The care coordination service aims to keeps patients with complex health and care needs well at home.

You can access this service if you:

  • Are over 18 years old, have a GP in Ealing and live within 1 mile of the borough
  • Need help to find your way around different health and social care services
  • Have one or more long term conditions, for example, diabetes, asthma, chronic obstructive pulmonary disease (COPD), coronary vascular disease, Alzheimer’s disease or dementia.

Your care coordinator will:

  • Work closely with your GP, carers and family to ensure you receive the best possible care
  • Help you understand and get the best out of the health and social care system
  • Bring together the different services involved in your care, where needed
  • Help you communicate effectively with health and social care professionals involved in your care
  • Work closely with GPs’ social prescribing link workers who can help you access support from a range of local voluntary organisations.

We provide care at GP locations across Ealing’s 8 primary care networks (PCNs). PCNs are networks of GP practices and each PCN has a named care coordinator.

You may be referred for care coordination by your GP or another healthcare professional.

In some cases, we may offer you support proactively if we’ve identified that you have a range of health and/or care needs from information available to us about your use of health and care services.  

Referral forms are available to GPs on SystmOne – a clinical system for clinicians and other healthcare professionals. These forms should be sent to 

For more information, please contact the community referral hub on 0300 1234 544 or email