Bethnal Green Health Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this. At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to requires improvement.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice maintained up-to-date patient assessments and ensured staff understood individuals’ current health and care needs. Vulnerable patients were prioritised, with annual health checks offered to those with learning disabilities. There were 24 patients on the learning disability register. Of those 24 patients, 66.67% of patients had their annual health check carried out in 2025. The practice had 87 carers on its register which represented 1.37% of the practice population.

In the main, staff followed prescribing protocols and guidance to ensure assessments were up-to-date and people’s care needs were routinely reviewed. However, from our review of patients with long-term health conditions patients with potential diagnoses of diabetes were being missed for appropriate review and follow up. The management of these patients was not always in line with national guidelines. We found one patient had not had appropriate follow up when their last two readings confirmed a diagnosis of diabetes. Patients were therefore at risk of diabetic complications. We raised this concern with the leaders who informed us they had taken immediate action to contact the patient.

A clinical search identified 52 patients suffering from asthma who have had 2 or more courses of rescue steroids in the last 12 months. We found all patients were reviewed following asthma exacerbations and patients had up-to-date asthma reviews recorded and all appeared to have been managed well.

For the monitoring of patients with hypothyroidism, there were 22/242 patients with hypothyroidism who have not had TFT monitoring for 18 months: Our review of 5 patients found all required blood tests had been appropriately identified and arranged by the practice.

A clinical search of patients with diabetic retinopathy who’s latest HbA1c was >75mmol/l identified 144/709. We reviewed 5 patient records and found patients had been seen and followed up and treatment adjusted.

A clinical search identified 12/43 patients with CKD 4 or 5 who had not had anurea and electrolytes blood test in the last 9 months. We looked at 5 patient records and found monitoring was up to date and there were no concerns.

Patient Survey, was generally higher or in line with local and national averages. 616 surveys were sent out, and 118 responses were received (19% completion rate). Of those who responded, 87% of respondents felt their needs were met during their last general practice appointment. Feedback from the 2025 National GP Patient Survey showed that 96% of patients felt the healthcare professional they saw had all the information they needed about them during their last appointment.

Patients with urgent needs were triaged by a clinician for early assessment to help avoid admission to secondary care. Carers’ needs were also assessed to support their wellbeing and ability to provide safe care. Reception staff used digital flags in care records to identify specific needs, such as longer appointments or translation support. During health reviews, staff assessed people’s health, care and wellbeing needs. Clinical staff used templates to guide comprehensive care reviews and could refer people with social needs, such as isolation or housing issues, to a social prescriber.

The practice did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. Staff told us they had access to up-to-date evidence-based guidance and legislation. However, clinical records we saw demonstrated care was not always provided in line with current guidance. For example, information had not been placed on patient records to ensure that it was safe to continue to prescribe and that the patient received timely care and treatment. Staff had not always followed escalation protocols which set out the process, or action to be taken if patients did not respond to appointment invites or failed to attend appointments.

The practice worked well across teams and services to support people. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. There were systems in place to support the effective assessment and treatment of patients with more complex needs. Clinicians attended monthly Integrated care meetings to discuss patients with complex needs.

Leaders told us the practice participated in the local Primary Care Network (PCN), where they collaborated on shared service delivery and quality improvement initiatives.

Staff supported people to manage their health and wellbeing. They focused on prevention and early intervention to help reduce future care needs. Staff identified health risks such as end-of-life needs, frailty, carer responsibilities and supported national health priorities, including smoking cessation and obesity reduction. Staff referred patients to the PCN social prescriber who contacted patients with complex needs or who were vulnerable to ensure their needs were being met. Staff told us patients had access to a community mental health specialist nurse. The practice held bi-monthly mental health meetings, providing a forum for discussing the mental health needs of the patient population and sharing learning across the clinical team. Leaders reported that the PCN was working across 4 Tower Hamlets communities to reduce health inequalities and prevent long-term conditions.

Data from the 2025 National GP patient survey showed that 63% of people felt they received enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses. This was above the local average (61%) and lower than the national average (69%). The provider shared data which showed the Bethnal Green Health Centre scored the highest for overall experience of the service across the four GP Practices in the PCN.

The provider had processes to monitor people’s care and treatment to continuously improve it. Although there was a system in place to recall patients for long-term health condition reviews, processes for reviewing the uptake of patient monitoring needed strengthening. Results from our clinical searches showed a small number of patients had not received relevant blood tests prior to a review or prescriptions being issued.

The provider submitted clinical audits they had carried out to improve outcomes for patients. Findings from audits were shared with staff to help identify further areas for improvement in outcomes for patients.

The practice did not meet the WHO target of 95% for five childhood immunisation indicators (01/04/2024–31/03/2025). It provided evidence of actions to improve uptake, including working with the linked health visitor to better engage parents and guardians. Unverified data showed improvement across all five indicators over the past 12 months. When a child does not attend (DNA), parents or guardians are contacted to rearrange the appointment.

The practice reported that the PCN provided cervical screening clinics at the extended access hub. It used a recall system and text messages with a self‑booking link to encourage attendance. Reviewed data showed low cervical screening uptake among younger patients (25–49 years, under 70%) and older patients (50–64 years, under 80%). However, unverified data demonstrated recent improvement towards national targets for both patient cohorts.

The practice told people about their rights around consent and respected these when delivering person-centred care and treatment. Staff understood and applied legislation relating to consent. However, we found 3 members of clinical staff whose files we reviewed did not have a record of up-to-date training in the Mental Capacity Act. Capacity and consent were clearly recorded.

We reviewed a sample of patients Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. We found recording of conversations with, and decisions agreed with the patient, their families and representativeswas inconsistent. We observed 2 patients did not have a DNACPR form documented in their records. It was not clear whether decisions about CPR would be reviewed at the appropriate interval. Where staff were able to show us a DNACPR decision, we saw they were made in line with relevant legislation.