Job description

Job responsibilities

SUMMARY:

The post holder is responsible for assisting the nurses, ensuring the delivery of safe and effective nursing services to the whole practice population. As a member of the clinical nursing team the post holder is responsible for his/her own practice, whilst being accountable to the senior trained nurse on duty.

Main duties/Responsibilities:

The post holder will work collaboratively with the general practice team to meet the needs of patients, supporting the delivery of policy and procedures whilst managing their own workload to deliver the practice priorities. Clinically, the focus of the role is to undertake clinical activities within the clinical team as requested. Eg. ECGs, health checks, dressings and wound care etc, as delegated by the practice nurse on duty and according to training and competencies. The role will also be evolving as the balance of care shifts from hospital to general practice.

The post holder will work collaboratively with the general practice team to meet the needs of patients, supporting the delivery of policy and procedures whilst managing their own workload to deliver the practice priorities. Clinically, the focus of the role is to undertake clinical activities within the clinical team as requested. Eg. ECGs, health checks, dressings and wound care etc, as delegated by the practice nurse on duty and according to training and competencies. The role will also be evolving as the balance of care shifts from hospital to general practice.

CLINICAL

• Support and monitor patients during nebulisation therapy
• Assist clinicians in minor surgery and coil fitting
• Perform basic dressing changes according to a nursing care plan
• Undertake Phlebotomy for individual patients.
• Undertake screening and diagnostic procedures, promoting and being involved in Health Education activity e.g. height, weight, BP.
• Processing of samples e.g. urine.
• Administer First Aid
• Receive and refer patients to trained nurses when appropriate
• Understand and adhere to the Policies and Procedures of the Practice
• Update the computer by coding activities appropriately and at the time of the consultation using templates where appropriate. Comply with computer based information requirements
• Ensure all items of equipment are maintained in good order, and ensure that all procedures for reporting hazards or unsafe equipment are known, understood and carried out by all staff in the nursing team
• Participate in a duty rota system within the clinical team to ensure the service requirements are met
• Ensure economical and careful use of property and resources within the clinical team are used economically and effectively, including ordering of dressings and other surgery equipment.
• Provide cover for colleagues by undertaking extra shifts when required.

COMMUNICATION

• Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment
• Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating
• Utilise communication skills to support patients to adhere to prescribed treatment regimen
• Anticipate barriers to communication and take action to improve communication
• Estimate and maintain effective communication with individuals and groups within the practice environment and with external stakeholders
• Act as an advocate when representing the patients and colleagues viewpoints to others

QUALITY

• Produce accurate, contemporaneous and complete records of patient consultation, consistent with legislation, policies and procedures
• Prioritise, organise and manage own workload in a manner that maintains and promotes quality
• Assess effectiveness of care delivery through self and peer review, benchmarking and formal evaluation
• In partnership with the clinical team, collaborate on improving the quality of health care, responding to local and national policies and initiatives as appropriate
• Support and participate in shared learning across the practice and wider organisation
• Participate in team meetings.

• Understand and apply legal policy that supports the identification of vulnerable and abused children and adults, being aware of statutory child/vulnerable adult health procedure and local guidance
• Work within policies relating to domestic violence, vulnerable adults, substance abuse and addictive behaviour, and refer as appropriate

PERSONAL AND PEOPLE DEVELOPMENT

• Take responsibility for own development, learning and performance participating in acting as a positive role model
• Encourage others to make realistic self-assessment of their application of knowledge and skills, challenging complacency and actions that are not in the interest of the public and/or users of services
• Participate in planning and implementing changes within the area of care and responsibility
• Contribute and participate in the development of local guidelines, protocols and standards
• Participate in the engagement of practice-based commissioning or similar initiatives
• Keep up-to-date with new developments locally and nationally identifying those that will enhance the teams work
• Ensure awareness of sources of support and guidance and provide information in an acceptable format to all patients, recognising any difficulties and referring to the trained nurse where appropriate.

TEAMWORKING

• Understand own role and scope in the organisation and identify how this may develop over time
• Work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working
• Ensure clear understanding and utilisation of referral mechanisms within the practice
• Accept delegation from nurses, prioritise own workload and ensure effective time-management strategies are embedded in own practice
• Work effectively with others to clearly define values, direction and policies impacting upon care delivery
• Participate in team activities that create opportunities to improve patient care
• Participate in and support local projects as agreed with the practice management team

MANAGEMENT OF RISK

• Manage and assess risk within the areas of responsibility, ensuring adequate measures are in place to protect staff and patients
• Monitor work areas and practices to ensure they are safe and free from hazards and conform to health, safety and security legislation, policies, procedures and guidelines
• Undertake mandatory and statutory training
• Apply infection control measures within the practice according to local and national guidelines
• Apply policies that reduce environmental health risks, are culturally sensitive and increase access to health care for all
• Participate in the local implementation strategies that are aligned to the values and culture of general practice

ADDITIONAL RESPONSIBILITY

• Attend training courses identified as essential or beneficial to the role and take responsibility for identifying own learning needs.
• Ensure all significant events are reported.
• Maintain records of specific adverse incidents, complaints and near misses.

Person Specification

Qualifications

Essential

• Experience of working in a healthcare environment
• Educated to GCSE Standard or Equivalent
• Demonstrates a basic understanding of the needs of the patient and the role of the HCA
• Willing to develop clinical skills and competency relevant to the role e.g phlebotomy skills

Desirable

• Has completed recognised course in Phlebotomy
• NVQ Level 3
• Awareness of local and national health policy
• Awareness of issues within the wider health economy
• Emis Web experience

Experience

Essential

• Minimum of two years experience in health care setting

Desirable

• Experience of working in General Practice

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

Star Lane Medical Centre

Address

121 Star Lane

Canning Town

Newham

E16 4QH

United Kingdom

Employer's website

https://www.starlanemedicalcentre.nhs.uk (Opens in a new tab)

Job description

Job responsibilities

• Greeting and Assisting Patients: They are the first point of contact for patients, greeting them and assisting with their needs, whether in person or over the phone
• Appointment Management: Scheduling and managing appointments for patients, including handling cancellations and rescheduling.
• Telephone and Email Management: Answering calls and emails, directing them to the appropriate staff, and taking messages when necessary.
• Administrative Support: Providing administrative support to doctors and nurses, including filing patient records, processing repeat prescriptions, and managing patient referrals.
• Handling Patient Enquiries: Addressing patient enquiries efficiently and courteously, whether they are about appointments, prescriptions, or general practice information.
• Maintaining Records: Ensuring that patient records are up-to-date and accurately filed.
• Building Security: Ensuring the security of the practice premises, including opening and closing the surgery.

Person Specification

Qualifications

Essential

• A good standard of GCSEs, particularly in English and Maths, is preferred

Experience

Essential

• Previous experience in a customer service or administrative role.
• Strong literacy, numeracy, and IT skills are essential.
• Good communication, organizational, and customer service skills.
• Friendly, patient, and understanding, with the ability to work accurately and methodically.
• The ability to handle stressful situations and deal with upset or angry patients.

Desirable

• Experience specifically in a healthcare setting, such as another GP practice.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

Star Lane Medical Centre

Address

121 Star Lane

Canning Town

Newham

E16 4QH

United Kingdom

Employer's website

https://www.starlanemedicalcentre.nhs.uk (Opens in a new tab)

Job description

Job responsibilities

Role Purpose

The MDT Coordination, Clinical Care Coordination and Integrated Care Manager will support South One PCN to deliver high quality, proactive, and integrated care for patients with long-term conditions (LTCs).

The postholder will:

• Coordinate and optimise Multi-Disciplinary Team (MDT) working
• Provide clinical care coordination across pathways

The role ensures effective delivery of the LTC Proactive Care and Quality and Outcomes Framework (QOF) through jointed-up, person-centred, and data-informed care, improving outcomes and reducing health inequalities.

Key Duties and Responsibilities (LTC Proactive Care QOF Aligned)

MDT Coordination and Delivery

• Coordinate and support regular, structured MDT meetings for South One PCN, ensuring alignment with LTC Proactive Care QOF requirements.
• Organise MDTs at practice, neighbourhood, PCN, RPN or Borough levels as locally determined.
• Ensure MDT meetings are focused on high-need patients and result in clear actions, ownership, and follow-up.
• Maintain consistent MDT processes, agendas, case selection, documentation, and tracking outcomes.

Clinical Care Coordination

• Coordinate care for patients discussed within MDTs, ensuring timely follow-up of agreed actions and interventions.
• Act as a central point of coordination between primary care community services, social care, and voluntary sector partners.
• Support navigation of patients through complex care pathways, improving continuity and reducing fragmentation of care.
• Ensure personalised care plans or implemented, reviewed, and updated in collaboration with MDT members.
• Identify gaps in care and escalate concerns appropriately to clinical leads.
• Supports proactive management of patients at risk of deterioration, admission, or poor outcomes.

Identification and Proactive Management of LTC Patients

• Support identification and prioritisation of patients with multiple LTCs, frailty, or high risk.
• Ensure MDT discussions focus on high-risk and complex cohorts in line with QOF indicators.
• Facilitate development and review of proactive, personalised care plans

Person-Centred and Integrated Care

• Enable MDTs to deliver holistic, person-centred care planning covering physical, mental, and social needs.
• Promote shared decision making and continuity of care.
• Ensure MDT actions translate into coordinated and effective care delivery across South One PCN.

Effective MDT Working and Professional Collaboration

• Facilitate collaboration between primary care, community services, social care, and voluntary sector organisations.
• Ensure appropriate professional representation within MDTs .
• Promote Integrated ways of working to reduce duplication and improve patient experience.

Health Inequalities and Targeted Support

• Ensure MDT And care coordination activity targets patients with health inequalities or barriers to access.
• Support production of on warranted variation across the South one PCN population.
• Align work with prevention, early intervention, and neighbourhood priorities.

Quality, Outcomes and Continuous Improvement

• Monitor MDT activity and care coordination effectively against LTC proactive care quote indicators.
• Support collection of evidence demonstrating improvement in patient outcomes and service delivery.
• Use data, feedback column and learning to drive continuous improvement.

Governance, Reporting and Assurance

• Support delivery assurance for the LTC Proactive Care QOF within South One PCN.
• Provide reporting to PCN leadership, RPN, and ICB.
• Act as a key point of contact for MDT and care coordination-related performance matters.

Person Specification

Qualifications

Essential

• Educated to degree level or equivalent experience in relevant field (e.g. healthcare management, public health, nursing, allied health professional, or social care)
• Evidence of continuous professional development relevant to integrated care, care coordination, or service delivery
• Strong working knowledge of NHS systems, primary care, or community care environments

Desirable

• Professional modification in a health or social care discipline (e.g. nursing, AHP, social work)
• Training or certification and quality improvement methodologies (e.g QI, PD SA, Lean)
• knowledge or training related to long-term condition management, population health, or integrated care
• Understanding of LTC Proactive Care or similar NHS frameworks

Experience

Essential

• Experience working in a PCN setting.
• Knowledge of LTC Proactive Care QOF or similar frameworks.
• Experience in quality improvement methodologies.
• Understanding of population health approaches.

Desirable

• Effective and DTS delivering proactive, coordinated care.
• Strong clinical care coordination improvement patient pathways and experience.
• Improved outcomes for patients with long term conditions.
• Reduction in health inequalities across the PCN population.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

Star Lane Medical Centre

Address

South One PCN

121 Star Lane

Canning Town

Newham

E16 4QH

United Kingdom

Employer's website

https://www.starlanemedicalcentre.nhs.uk (Opens in a new tab)