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Integrated Care

Coordinated and enhanced care for people with multiple health problems


This is a NEW and ADDITIONAL service to your usual GP care plus enhanced services for people recently discharged from or at risk of admission to hospital. If you are eligible for this service then we may have already contacted you or will be doing so soon.


Usual GP care looks after you when you are sick and offers routine checks for the major diseases like diabetes, heart disease or COPD. Patient feedback, both locally and nationally, says that people with lots of health problems want coordinated care with a focus on quality of life:



“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me.”


We are developing these new integrated care services to meet this need.


We are offering:

  • Extra time with your GP or practice nurse to understand how your problems affect your life and to work with you to find services and supports that could help you and your family
  • A named lead clinician within the practice who will really get to know about you and your family
  • Ensuring that your information gets to the right place at the right time so you don’t have to keep giving the same information
  • Planning for the future- what you can do to manage flare ups and what you would like to happen if you become very ill.
  • Checking that family and friends helping you with everyday life (carers) also get offered support.


The GP community is working hand in hand with other providers of care locally to strengthen partnership working, this includes:


  • London Borough of Tower Hamlets: social and continuing health care services
  • Carers Centre
  • Community and voluntary resources such as Age UK, LinkAge plus teams and Health Trainers
  • Barts Health: community health services, GP out of hours and health care of the elderly
  • ELFT: dementia team, joint work into Barts Health (RAID team) and community mental health services
  • Drug and Alcohol services
  • St Joseph’s Hospice and community palliative care teams

Full details about your legal protections to ensure confidentiality are below


In order for us to deliver this service we must have your permission to share information about you across different organisations. This is ALWAYS done in a way that meets the legal requirements- we will share only what a service provider needs to know in order to deliver a service and we can do so only with your consent.


We are also developing a care navigator role and the administrative staff supporting you in this way will have access to relevant information such as which health professionals are looking after you.


This is a new approach and so we will have to monitor to see what is working best. This means some information about you: for example hospital admissions and attendances, will be tracked by our administrative staff but they will NOT be able to identify you personally


In addition you may be contacted for feedback on how the service is working for you.




SHARING INFORMATION WITH YOUR FAMILY/ CARERS :Normally we are not able to give anyone else in your family information about your health, but some people are happy for us to share information with members of their family or other carers to enable them to provide support to you effectively.


SOCIAL CARE INFORMATION: Some of you will already have assessments from social care or be needing them in the future and we are seeking consent to share relevant information so you do not need to repeat yourself.


COORDINATE MY CARE DATABASE: This is an across London database sharing health information about people at the end of their life in order to improve communication


If you are unsure about any of this or would like to discuss it further before making a decision, please speak to your usual clinician or any member of the practice team

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