Rapid Response Team

The team provides urgent assessment, treatment and care within the person’s home in order to prevent ED attendance and/or hospital admission.

Hours: 8:00 to 20:00 (7 days a week, including bank holidays)

Link to our podcast here 

Our Referral Criteria

• Over 18 years old
• Resident in Tower Hamlets
• Acute illness or delirium
• Acute palliative care needs
• Exacerbation of behaviour or psychological symptoms of dementia   
• In crisis requiring intervention within 2 hours to stay safely at home/usual place of residence and avoid admission to an acute hospital

How GP can make referral

Telephone: 07710 066161

Once discussed with the team and accepted GP can refer through EMIS 

Use the template 'Single Point of Access CHS Referral TH CEG (RP) v5' and  complete relevant sections.

Save the consultation then the document named 'CHS SPA referral form TH CEG (RP) v2 will automatically open

Select the service and the rest of the form will be populated automatically. 

Save and close document and send via Accurx Accumail to thgpcg.spa@nhs.net 

Important: If you are unable to make contact with us please call SPA on 0300 033 5000

Tracheostomy Service Page

The service offers specialist advice and treatment to support the alerted airway patient, family, care givers and community teams with regard to the specialist management required for patients living in Tower Hamlets.

Please refer directly to Hannah McDonald on the email address below. 

Our Referral Criteria

Over 18 patients with an altered airway (tracheostomy or laryngectomy) living in Tower Hamlets 

Contact details to discuss and make referral: 

Email: Hannah.mcdonald3@nhs.net

Phone: 07917 599881 

The aim of the continence service is to promote continence, improve or achieve continence and to manage incontinence for any adult experiencing bladder/ bowel dysfunction. 

Our Referral Criteria 

• Over 18 years old
• Resident in Tower Hamlets
• Urinary and/or Faecal Incontinence 
• Please state whether the patient is housebound or able to attend appt in person at Mile End 

Exclusion Criteria 

• We do not offer our services to children, adults only please 
• Please visit Barts Health NHS Trust Community Services for more information on how to refer children for continence issues

How GP can make a referral

Gp can refer through EMIS using the template 'Single Point of Access CHS Referral TH CEG (RP) v5' and by completing relevant sections.

Save the consultation then the document named 'CHS SPA referral form TH CEG (RP) v2 will automatically open

Select the service and the rest of the form will be populated automatically. 

Save and close document and send via Accurx Accumail to thgpcg.spa@nhs.net 

Pad Prescription Only Required:

If patients need to re-order their pad please ask them to call 0800 030 44 66.

If discharged from the NHS supply chain, please ask the patient to call the continence service 0207 771 5795

Contact details to discuss a referral

Telephone: 0207 771 5795

Email: elft.th.continence.service@nhs.net

Important: If you are unable to make contact with us please call SPA on 0300 033 5000

We complete a holistic multidisciplinary assessment for patients with long term complex physical or mental health needs to see if they qualify for free social care arranged and funded solely by the NHS. 

NHS continuing healthcare can be provided in a variety of settings outside hospital, such as in the patient's own home or in a care home.

Our Referral Criteria 

• Over 18 years old
• Resident in Tower Hamlets
• Known to London Borough Tower Hamlets Social Services and/or have a Community health team involved in their care
• Have a condition which requires ongoing and prolonged care 
• Urgent/ Fast track referral is for patients whose condition is rapidly deteriorating and may be entering the terminal stage

Exclusion Criteria 

• Children under the age 18
• Patients with a registered GP not in Tower Hamlets 
• Patients undergoing rehabilitation who have not yet met their goals
• Patients who are medically unwell or waiting further investigations or specialist assessments to be completed 
• Patients in acute hospital setting 

How GP can make a referral

Routine

Please complete CHC checklist and referral form and send via email elft.thchc@nhs.net 

Urgent (Fast Track)

Please complete CHC Fast track pathway tool and referral form and send via email elft.thchc@nhs.net 

Fast Track can only be completed by registered nurse or doctor

Contact details to discuss a referral

Telephone: 0207 771 5680/5675 (Monday to Friday 0900- 1700 not bank holidays, no out of hour service available)

Email: elft.thchc@nhs.net

Macmillan Cancer Care Navigation

We offer personalised coordination and navigation support for people with cancer who:

• Have very complex health and social care needs
• Are vulnerable and isolated
• Need proactive ongoing support close to home
• Live in Tower Hamlets and are aged 18 years and over.

How can we help?

Our navigators:

• Have personalised conversations to assess people's wider support needs
• Co-produce a care plan with the person, focusing on their needs
• Coordinate care and support with other professionals as a team around the person - including the GP and hospital teams
• Provide people access to urgent information, advice and support in the community
• Enable people to take control, be independent and manager their health.

How GP can make referral 

Gp can refer through EMIS using the template 'Single Point of Access CHS Referral TH CEG (RP) v5' and by completing relevant sections.

Save the consultation then the document named 'CHS SPA referral form TH CEG (RP) v2 will automatically open

Select the service and the rest of the form will be populated automatically. 

Save and close document and send via Accurx Accumail to thgpcg.spa@nhs.net 

Contact details for GP to discuss referral 

Email: elft.macmillan-carenavigation@nhs.net 

Telephone: 0300 033 5000

*Patients can self refer to this service through this email or telephone contact*

Care Navigation

The Care Navigation service provides support and coordination for patients who have complex health and social care needs as well as patients and carers who are struggling to navigate the health and social care system. 

The Care Navigator will undertake a home visit and carry out an holistic assessment. The patient will be asked about their health and social care needs and other issues such as housing, safety and financial concerns.  

Our Referral Criteria

• High intensity user of acute services who do not meet criteria for social care intervention
• Frequent visits to GP and/or request for home visit
• Complex care needs including end of life care
• Patients who self-neglect or at risk of neglect and hard to engage
• Patients who could be taught to self manage
• Patients with social issues that impact on health eg environmental or housing issues
• Any patient with cancer diagnosis who would benefit from holistic care navigation - see separate service 

How GP can make referral 

Gp can refer through EMIS using the template 'Single Point of Access CHS Referral TH CEG (RP) v5' and by completing relevant sections.

Save the consultation then the document named 'CHS SPA referral form TH CEG (RP) v2 will automatically open

Select the service and the rest of the form will be populated automatically. 

Save and close document and send via Accurx Accumail to thgpcg.spa@nhs.net 

Contact details for GP to discuss referral 

Email: f.colley@nhs.net 

Phone: SPA on 0300 033 5000 and ask for the Care Navigation Service 

*Patients can self refer to this service through this email or telephone contact*

Our Referral Criteria

• Housebound patients
• Insulin treatment, Enoxaparin injections, Eye drops, Pain patches, B12 injections, EPO injections, Warfarin monitoring, IV antibiotic therapy
• Wound care, Negative Pressure (VAC) Dressings, Leg Ulcers, Pressure Ulcer Management, Pressure Relieving Equipment, Lymph-oedema management, palliative care/end of life care
• Drain site care, chemo disconnection/PICC line care 
• Bowel care - enema/suppositry
• Re-catheterization 
• Blood tests if patients on active case load -form and bottles need to be in patients property 

How GP can make a referral 

Gp can refer through EMIS using the template 'Single Point of Access CHS Referral TH CEG (RP) v5' and by completing relevant sections.

Save the consultation then the document named 'CHS SPA referral form TH CEG (RP) v2 will automatically open

Select the service and the rest of the form will be populated automatically. 

Save and close document and send via Accurx Accumail to thgpcg.spa@nhs.net 

Contact details for GP to discuss referral 

Phone: 0300 033 5000 and request for call to pass to Triage and Assessment Team

Email: elft.triageandassessment@nhs.net 

Our District Nurses welcome referrals for patients in the last year of life for holistic assessment and care planning. We also welcome urgent referrals for those patients in the last few days of life to alleviate symptoms and provide support. 

Our Advanced Care Planning team are available to support our district nurses in the community.

MAAR Charts

For help with completing MAAR charts please look at the St Joseph’s Clinical Guidelines. If you are still unsure and need advice call St Joseph’s on 0300 30 30 400

For more detailed information a WEBINAR hosted by St Joseph’s Hospice is available.

Our Referral Criteria 

• Over 18 year old
• Housebound
• In the last year of life (For help in identifying use SPICT tool) or
• In last few days of life 

*GP can consider a separate referral to St Joseph's  for complex end of life patients or for end of life patients with young children for access to specialist support or we can refer directly if we feel this is appropriate for any patient on our caseload*

How GP can make a referral 

Gp can refer through EMIS using the template 'Single Point of Access CHS Referral TH CEG (RP) v5' and by completing relevant sections.

Save the consultation then the document named 'CHS SPA referral form TH CEG (RP) v2 will automatically open

Select the service and the rest of the form will be populated automatically. 

Save and close document and send via Accurx Accumail to thgpcg.spa@nhs.net 

Contact details for GP to discuss referral 

Phone: 0300 033 5000 and request for call to pass to Triage and Assessment Team

Email: elft.triageandassessment@nhs.net 

We support and work closely with the community staff in identifying and managing patients with mental health concerns. 

The integrated care mental health liaison team was introduced to improve links between community health teams, GP and secondary mental health services. We provide mental health assessment and interventions to people not known to other secondary mental health services. 

Each locality has a Community Mental Health Nurse who can undertake joint assessment with CHS staff, provide short term interventions and attend meetings with GP teams. We provide information on whether a patient is known to mental health services and support joint working between CHS and mental health services. Mental health nurses are also based in the rapid response team. 

Our referral criteria 

• Mental health concerns in patients with multiple co-morbidities (frailty) not known to the secondary mental health services (patents do not need a mental health or dementia diagnosis)
• Patients with increased confusion
• Exacerbation of behavioural/psychological symptoms of dementia

How GP can make a routine referral 

Gp can refer through EMIS using the template 'Single Point of Access CHS Referral TH CEG (RP) v5' and by completing relevant sections.

Save the consultation then the document named 'CHS SPA referral form TH CEG (RP) v2 will automatically open

Select the service and the rest of the form will be populated automatically. 

Save and close document and send via Accurx Accumail to thgpcg.spa@nhs.net 

How GP can make or discuss an urgent referral 

Telephone: 07710 066 161 (8am - 7pm) 

Important: If you are unable to make contact with us please call SPA on 0300 033 5000

Contact details for GP to discuss routine referral

Telephone: 0300 033 5000 and ask for Triage and Assessment team 

Email: elft.triageandassessment@nhs.net

Other useful contacts for our GP Teams:

Our Referral Criteria

• Housebound patients
• Transfer issues - bed/bath, chair and inability to stand for prolonged periods
• Functional and environmental assessment 
• Equipment assessment with clear goals of rehabilitation 

Exclusion Criteria 

• We do not accept referrals for equipment only with no rehabilitation goals
• Separate referral has to be sent to social services: Tower Hamlets Connect enquiry@towerhamletsconnect.org or call 0300 303 6070 for major adaptation eg wet floor shower, stair lift

How GP can make a referral 

Gp can refer through EMIS using the template 'Single Point of Access CHS Referral TH CEG (RP) v5' and by completing relevant sections.

Save the consultation then the document named 'CHS SPA referral form TH CEG (RP) v2 will automatically open

Select the service and the rest of the form will be populated automatically. 

Save and close document and send via Accurx Accumail to thgpcg.spa@nhs.net 

Contact details for GP to discuss referral 

Phone: 0300 033 5000 request for call to pass to Triage and Assessment team 

Email: elft.triageandassessment@nhs.net  

Our Referral Criteria

• Housebound patients
• Mobility/mobility aid assessment
• Falls assessment, falls prevention
• Stairs assessment 

Exclusion criteria

• New/ recent strokes, Parkinson's. Motor Neurone Disease, Huntington's Disease and other progressive degenerative neuro conditions 
• We do not accept referrals for wheelchair assessments 

How GP can make a referral 

Gp can refer through EMIS using the template 'Single Point of Access CHS Referral TH CEG (RP) v5' and by completing relevant sections.

Save the consultation then the document named 'CHS SPA referral form TH CEG (RP) v2 will automatically open

Select the service and the rest of the form will be populated automatically. 

Save and close document and send via Accurx Accumail to thgpcg.spa@nhs.net 

Contact details for GP to discuss referral 

Phone: 0300 033 5000 request for call to pass to Triage and Assessment Team 

Email: elft.triageandassessment@nhs.net 

Our District Nursing team care for housebound patients with pressure ulcers supported by Pressure Ulcer Improvement Facilitators (PUIF).

The PUIF are a team of three nurses who specialise in pressure ulcer prevention and management. They support the community teams by providing specialist evidence based wound care advice and support for patients with category 3, category 4 and unstageable pressure ulcers. Also for those patients with category 2 and suspected deep tissue injury that does not respond to treatment after two weeks. 

Our Referral Criteria 

• Housebound
• Pressure Ulcer
• Not in a nursing home 

Non - housebound patients with complex wounds or ulcers and Nursing home patients with pressure ulcers should be referred to Accelerate >>  

How GP can make a referral 

You can refer housebound patients with pressure ulcers to our District Nurses through EMIS using the template 'Single Point of Access CHS Referral TH CEG (RP) v5' via Accurx Accumail to thgpcg@nhs.net 

Contact details for GP to discuss patients 

Phone: 0300 033 5000 and request for call to pass to Triage and Assessment Team

Email: elft.triageandassessment@nhs.net for any patients with ulcers or elft.puifteam@nhs.net if patient known to our specialist nurses 

Important: If your enquiry is urgent please call SPA on 0300 033 5000 and ask for the triage and assessment team. 

Tower Hamlets Foot Health Service

We can help with a range of conditions which affect foot health such as diabetics with foot complications, circulatory conditions or congenital deformity. Routine nail care, callous and corns will not be treated.

Our Urgent Referral Criteria and Referral information

Daily Emergency Clinic 8:30 am prompt Monday-Friday, excl Bank Holidays.

Patients can self-refer to our Emergency Clinic for blisters and sores, discharging and infected wounds, inflamed areas such as acute ingrowing toenails

Mon-Fri (excluding bank holidays) at Mile End Hospital, Foot Health Department. To ensure treatment service users must be present at 8.30am.

Service users should please bring their NHS Number for speedy registration for care

Departmental opening hours are 8.30 am - 5.00 pm (Routine daily clinics start at 9:30am post emergency clinic)

Out of hours please contact NHS 111

Our Routine Referral Criteria

• Diabetics with complications affecting their feet (Not painful neuropathy)
• Peripheral arterial disease patients
• Peripheral sensory neuropathy
• Rheumatoid arthritis affecting tissue viability
• Lymphoedema affecting tissue viability with active or previous ulcer
• Significant foot deformity and congenital foot issue requiring footwear 
• Previous ulcers requiring foot protection 
• Diagnosed mental health issues & learning disability affecting ability to self foot care
• Diagnosed dementia unable to self foot care 

Exclusion Criteria 

Top five not accepted foot health referrals:
1. Diabetics with painful peripheral neuropathy or burning sensation to feet
2. Anyone with a verruca or fungal infection
3. People with rheumatoid arthritis affecting their feet requiring musculoskeletal
assessment or insole therapy
4. People with plantar fasciitis, heel pain, digital deformities or bunions
5. Anyone requiring an internal or external heel raise for a leg length discrepancy

How GP can make a routine referral 

Through EMIS using the template 'Single Point of Access CHS Referral TH CEG (RP) v5' and by completing relevant sections.

Save the consultation then the document named 'CHS SPA referral form TH CEG (RP) v2 will automatically open

Select the service and the rest of the form will be populated automatically. 

Save and close document and send via Accurx Accumail to thgpcg.spa@nhs.net 

Self referral Non-NHS Footcare Providers:  

Download the Non NHS Provider List for routine foot and nail care and non eligible issues

Contact details for GP to discuss referral 

Telephone: 0207 771 5775

Email: elft.thchsfoothealth@nhs.net

Important: If you are unable to make contact with us please call SPA on 0300 033 5000

Frailty Assessment Team

The Older Person's Clinic offers advice, guidance, investigations, treatment, and onward referrals if needed. It is based at RLH and includes ELFT and Bart's Health Colleagues, including a RLH geriatrician. 

The purpose of the clinic is to improve outcomes for older adults by reducing avoidable hospitalization, providing comprehensive old age assessment, plan individually tailored interventions and support patients to be cared for in their own home/communities.

Our Referral Criteria

• resident of Tower Hamlets London
• over 65 years old
• has multidisciplinary needs:
• Physical frailty
• Deteriorating complex co morbidities
• Recurrent emergency attendances
• Polypharmacy
• Difficulty with managing ADL`s
• Mobility problems
• Multiple falls
• Cognitive and mood issues

How GP can make a referral 

GPs can refer their patients or ask for advice through advice and guidance via e-referral service. Search for 'Older Peoples Services' and 'RLH' 

If GP needs to refer someone under the age of 65 they can email their referral bhnt.opc@nhs.net

Contact details for GP to discuss referral 

Telephone: Call 0207 377 7000 and ask for "Geriatrician of the Day" on 45799 available via switchboard at the Royal London Hospital. This is available Mon-Fri 9am-5pm and Sat and Sun 9am-3pm  

Email: Through Advice and Guidance E-referral service 

Long COVID Service

The Long COVID Service are a therapy led service and their work with patients is primarily virtual. 

The service will provide an initial assessment and then decide on the most appropriate therapy pathway. This may involve in-house therapeutic options or onward referral to other support services. Whilst the service has medical input, it is a therapy led service and primarily staffed by AHP’s.

Our Referral Criteria

• Symptom/s lasting over 12 weeks since initial COVID infection
• At least one symptom such as brain fog, fatigue, breathlessness, anxiety, muscle ache, difficulty concentrating/memory loss/confusion, loss of smell or taste, headache, sleeping issues, fast heart rate 
• Please complete tests including FBC/CRP/ESR/LFT and do CXR (if breathlessness or respiratory changes) and refer if within normal ranges 

How GP can make a referral 

Referrals are accepted from the GP only and need to be sent via EMIS/Email using the Long COVID referral form

Contact details for GP to discuss referral 

Telephone: 0207 909 3676

Email: longcovid.elft@nhs.net

The support offered by the NMHTs range from professional input directly from NMHT staff (similar to the erstwhile Community Mental health teams or CMHTs e.g. for SMI) to those offered within primary care e.g. via ARRS Mental Health Practitioners and Primary Care Nurses.

The offer includes access to a multidisciplinary team assessments, brief treatment and longer term complex care in order to meet peoples’ recovery goals. This may also include signposting (working closely with voluntary sector partners, local authorities, substance misuse services etc.) and ongoing referrals to specialist mental health services (e.g. Older Adults mental health services, Early Intervention psychosis, Perinatal psychiatry, etc.) or clinics (e.g. for Neurodiversity assessments) or other resources e.g. therapy (e.g. Complex Emotional Needs) or educational or self-help groups (Disordered Eating).

Direct referrals can be made to specialist community teams - Perinatal Mental Health Team, Early Intervention Service and Autism Service using the relevant separate referral form on Resource Publisher, EMIS: