To support the delivery of high-quality patient care byassisting with arranging clinical monitoring, long-term condition management, medicines optimisation, and Quality and Outcomes Framework (QOF) requirements.The post holder will work closely with the clinical and pharmacy teams to identify patients requiring review, coordinate appointments, undertake patientfollow-up, and support the achievement of contractual and quality indicators.
Main duties of the job
Clinical Monitoring and Patient Follow-Up
Book, manage, and coordinate patient appointments, including targeted clinics such as blood pressure and pulse clinics for patients with coronary heart disease CHD and stroke.
Monitor patients requiring routine, mid-year, or annual reviews and follow up patients who do not attend appointments, including sending reminder and DNA letters.
Lead recall and oversee data collection booking bloods, ECGS, BP etc for medication monitoring as per Network protocols.
Follow up patients after discharge from hospital to ensure understanding of medication changes and assess whether further clinical review is required.
Issue, monitor, and action responses to clinical questionnaires, including heart failure and cholesterol monitoring tools e.g. Florey questionnaires.
Job responsibilities
QOF, IIF and Long-Term Condition Support
Support delivery of QOF and IIF indicators, including sending BP text messages, issuing patient invitations, and monitoring responses.
Identify patients requiring intervention through searches and monitoring systems and ensure appropriate follow-up is arranged.
Maintain accurate workload statistics and contribute to reporting requirements.
Cardiovascular Risk and Lifestyle Support
Identify patients with raised QRisk scores who are not prescribed lipid-lowering therapy, assess patient interest in treatment, arrange blood tests, and book follow-up appointments.
Undertake lifestyle discussions with patients with raised cholesterol where medication is not indicated, providing advice inline with local and national guidance.
Triage blood pressure-related tasks, calculate average home blood pressure HBPM readings, and escalates abnormal results to clinicians as appropriate.
Manage blood pressure monitor loans and ensure accurate recording of results.
Medicines Management and Pharmacy Support
Assist the pharmacy team with medicines optimisation tasks, including medication synchronisation.
Support Structured Medication Reviews SMRs by coordinating appointments and ensuring the necessary monitoring is complete beforehand.
Liaise with community pharmacies regarding new Nomad patients and medication queries.
Assist with the identification and management of polypharmacy patients through clinical searches, under the supervision of the pharmacy team.
Safety, Governance and Communication
Assist in actioning medicines safety alerts and medication recalls in line with practice and NHS guidance.
Discuss medication compliance issues with patients, provide appropriate support, and escalates concerns to the relevant clinician.
Maintain accurate and up to date patient records in accordance with practice policies and information governance standards.
Communicate effectively with patients, clinicians, pharmacy teams, and external services to ensure safe and coordinated care.
Professional Responsibilities
Work within own scope of practice and escalate clinical concerns appropriately.
Maintain confidentiality and comply with GDPR, Caldicott principles, and NHS policies.
Participate in training, appraisal, and continuous professional development.
Contribute to service improvement and support the efficient running of the practice, PCN.
This job description is not exhaustive and may be reviewed and amended in line with service needs.
Person Specification
Experience
* High level of written and verbal communication skills and the ability to communicate effectively both verbally and in writing, with people, their families, carers and other stakeholders
* Good working knowledge of Word, Excel, PowerPoint and Outlook
* Ability to maintain effective working relationships with all colleagues and to work flexibly and enthusiastically within a team or working under own initiative
* Ability to identify risk and assess and manage when working with individuals
* To promote collaborative working
* Ability to demonstrate personal accountability, resilience and work well under pressure
* Ability to organise, plan and prioritise under own initiative and when under pressure and meeting deadlines
* Knowledge of and ability to work to policies and procedures including confidentiality, safeguarding, information governance and health and safety
* Ability to actively listen, empathise and provide personalised support in a non-judgemental way, to inspire trust and confidence and motivate people to reach their potential
* Ability to provide a culturally sensitive service, supporting people from all backgrounds and communities, respecting lifestyle and diversity
* Commitment to reducing health inequalities and proactively working with to reach people from diverse communities
* Meets DBS reference standards and criminal records checks
* Willingness to work flexible hours when required to meet work demands
* Good Sense of Humour
Qualifications
* GCSE in English and Maths
* Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook
* Strong organisational skills including planning, prioritising, time management and record keeping
* Demonstrable commitment to professional and personal development
* Willing to travel across PCN sites if when required
* Experience of working in a healthcare setting
* Working knowledge of SystmOne
* Ability to work collaboratively, liaising with other stakeholders as needed for the collective benefit of patients including GPs, Practice Nurses, healthcare professionals and other PCN staff
Generic Responsibilites
* Health and Safety / Risk Management
* The post holder will be trained in and expected to use the personal security systems available within the practice
* To identify any risks involved in their work activities and undertake them in a way that manages the risks
* The post holder must comply at all times with the practices Health and Safety policies, in particular by following agreed safe working procedures and reporting clinical incidents using Significant Event Reporting system
* To use computers safely and appropriately
* Information Governance
* The practice is registered under the Data Protection Act 1984. The post holder will comply with the Data Protection Act and the Access to Health Records Act, the General Data Protection Regulations 2018 and the practice policies regarding information governance at all times. You must not at any time use the personal data held by the practice for a purpose not described in the Register entry or disclose such data to a third party. If you are in any doubt regarding what you should and should not do in connection with the Data Protection Act, then you must contact your line manager
* Confidentiality
* All dealings within the Practice remain strictly confidential and the post holder would be expected to maintain this confidentiality at all times. You will have access to confidential information relating to Practice business and to individuals. You are required to exercise due consideration in the way you use such information when carrying out your duties. Should you have any doubts regarding the use of information in carrying out your duties, you should seek advice from your line manager
* Equality and diversity
* The post holder must co-operate with all policies and procedures designed to ensure equality of employment and treatment in line the Practice Equal Opportunities Policy. Co-workers, patients and
* visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation or religion
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.
Depending on experience Between Band 3 and Band 4 depending on experience
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