Specialist and Hospital Coordination

Chronic Disease Management, Complex Care Management and Shared Care in our local Community

Our GPs manage many long term conditions for patients in the Johnstown Medical Centre. We also share patient’s Medical Care with different hospital clinics and specialists.

Some people have many complex conditions together and are on complex medications. This is now called Complex Care management. As medical Generalists, our GPs have become used to judging what is suitable to be managed at GP surgery level and what parts are better managed at Hospital Out-Patient level. We invest much time and effort to keep our service up to date. Our GPs aim to keep people independent in their own community.

Examples of Chronic Disorders that we GPs manage by ourselves or in Shared Care with specialists include:


  • High Blood Pressure and Cholesterol,
  • Heart Failure
  • Angina or patients after Heart Attacks or Angioplasty or By-pass surgery
  • Atrial Fibrillation or other heart rhythm disturbances

Oncology/Cancer Care

  • Monitoring, assessing and following up of Cancer patients

Common examples include – Breast, Prostate, Colon, Skin, Lung and Ovarian diseases

Endocrine/Glandular disorders

  • Thyroid disorders
  • Diabetes Mellitus, Type 2 more than Type 1
  • Other Hormonal problems

Chronic Pain Syndromes

  • Many Pain disorders need joint monitoring by your GP and the Pain Clinic specialists

Common examples include – Chronic Back, Neck and Facial pain disorders


  • Asthma
  • COPD (Chronic Bronchitis / Emphysema disorders)
  • Bronchiectasis

Rheumatology/Joint diseases

  • Shoulders, Hips and Knee Pains disorders
  • Low Back disorders
  • Osteoarthritis (wear and tear arthritis)
  • Other joint diseases e.g. Rheumatoid and Psoriatic Arthropathies and other inflammatory arthropathies


  • Parkinson’s Disorder
  • Headaches disorders particularly Migraine, Muscle Contraction/Tension Headaches and Chronic Daily Headaches
  • Epilepsy
  • Multiple Sclerosis
  • Other Degenerative Neurological disorders


  • RecurrentKidney Infections
  • Bladder Frequency/ Urgency or Incontinence disorders
  • monitoring of Kidney function/ Chronic Renal Failure


  • Inflammatory Bowel disorders (Crohn’s Disease and Ulcerative Colitis)
  • Irritable Bowel syndrome


  • Eczema
  • Psoriasis
  • Skin infections
  • Review of moles and pigmented skin lesions
  • Sun Damaged Skin/ Paricularly Recurrent scaly skin lesion/ pre-cancerous skin conditions
  • Assessment of possible Skin Cancers

Psychological Medicine

  • Chronic Anxiety disorder
  • Low Mood Disorders / Depression
  • Bipolar Mood Disorders
  • Chronic Psychotic disorders, e.g. Schizophrenia

Elderly Medicine

  • Monitoring the Frail Elderly
  • Monitoring Memory disorders / Cognitive Impairments / Dementia
  • Monitoring Falls and Blackouts risks