The role is responsible forengaging, and supporting individuals, particularly those who are frail,elderly, or living with long-term or multiple conditions, coordinating,navigating, and personalising care across the health and care system. Therole is central to delivering NHS Englands personalised care model, improvingcontinuity of care and outcomes for people with complex needs.
To act as a single, consistent pointof contact for individuals, their families, and carers, ensuring timely accessto well-organised, person-centred support. Bringing together all elements ofan individuals assessed needs into a comprehensive personalised care andsupport plan, enabling joined up working across primary care, communityservices, voluntary sector, and wider system partners.
Working in close collaboration with GPs, practiceteams, and the wider multidisciplinary team, including social prescribing linkworkers and health and wellbeing coaches, ensuring individuals changing needs are identified early and responded to effectively.The role supports proactive care delivery, reduces fragmentation, andstrengthens communication across services.
Play a key role inempowering individuals to take an active role in their own health andwellbeing. This includes preparing people for shared decision-makingconversations, supporting understanding of health information, and facilitatingaccess to self-management education, peer support, and community-basedinterventions.
About us
For a second year in a row, Sunderland GP Alliance has been listed in The Sunday Times Best Places to Work and Better Health At Work - Gold Award, offering 33 days annual leave plus many other benefits
Sunderland GP Alliance is owned by the GP Practices of Sunderland and helps GPs work collaboratively for the benefit of patients and staff. We are a not-for-profit organisation, ensuring any surplus is reinvested back into better services for patients.
Sunderland GP Alliance runs three medical practices at New Silksworth Medical Practice, South Hylton Surgery and Monument Surgeries.
Job responsibilities
MAINDUTIES AND RESPONSIBILITIES
* Proactively identify people to support their personalised carerequirements, using the available decision support aids.
* Telephone triage all incoming referrals to bring together all of apersons identified care and support needs, and explore their options to meetthese via a single personalised care andsupport plan, or seamlessly refer cases, if necessary, to appropriateprofessionals.
* Help people to manage their needs, answering their queries andsupporting them to make appointments or to take up training and employment, andto access appropriate benefits where eligible.
* Support people to understand their level of knowledge, skills andconfidence when engaging with theirhealth and wellbeing, including through use of the Patient Activation Measure.
* Raise awareness of shared decision making and decision support tools,and assist people to be more prepared to have a shared decision makingconversation.
* Ensure that people have good quality information to help them makechoices about their care,
* Assist people to access self-management education courses, peer supportor interventions that support them in their health and wellbeing.
* Provide coordination and navigation for people and their carers acrosshealth and care services, alongside working closely with social prescribinglink workers, health and wellbeing coaches and other primary care roles.
* Maintain accurate records asrequired, including providing patient-related information for entering ClinicalReporting Systems, within the required time frame
* To be a point of contact for GPpractices, MDT and Social Prescribing Link Workers, as well as a direct linkfor the wider system across the city.
* Support the identification of patients for inclusion in MDTs withinPCNs.
* Support the collection of patient data for analysis of outcome measurefor service interpretation and growth
Role Specific Key Tasks
Education
* Promote social prescribing across the PCN, Health & SocialCare professionals and the wider system, including its role in self-management,addressing health inequalities and the wider determinants of health.
Referrals
* Receive and action referrals for social prescriptions via agreedsystems.
* Provide holistic, personcentredsupport by developing and reviewing personalised care plans, preparing peoplefor shared decisionmaking, and helping them manage their health andwellbeing.
* Work proactively with diversecommunities to ensure equal access to community, voluntary and statutoryservices, including selfmanagement and peer support.
* Follow up with individuals, gatherfeedback and outcomes, and contribute to service improvement within the PCN.
Community Asset Development
* Support the development andsustainability of community assets by working with VCSE organisations and localgroups to ensure accessible, inclusive resources that meet diverse health andwellbeing needs.
* Build strong partnerships withcommunity organisations to ensure safe, timely referrals and coordinatedsupport for individuals.
* Gather feedback from community partnersto understand capacity, gaps and opportunities, sharing insights with the PCNto inform service development.
Collaborative working
* Work as part of the PCNmultidisciplinary team, building strong relationships with GP practices, socialprescribing link workers, health coaches and other primary care professionalsto deliver coordinated, personalised support.
* Support effective communication withinthe MDT by sharing timely updates, acting as a key contact across practices andpartners, and ensuring smooth navigation for people with complex needs.
* Collaborate with VCSE organisations,local authority teams and community groups to improve access, reduceduplication and embed personalised care approaches across the system.
* Participate in MDT meetings, helpidentify individuals who may benefit from personalised care, and contribute toshared problem-solving and continuous improvement across the PCN and widercity.
Data Collection & Analysis
* Collect, record and analyse data to support personalised care andpopulation health management, capturing key information about individualsneeds, outcomes and experiences.
* Ensure accurate, timely documentation in clinical systems,following data protection and governance requirements.
* Analyse referral patterns, presenting needs and service use toidentify trends, inequalities and gaps, sharing insights to inform decision-making and service development.
* Gather qualitative feedback and lived experience stories to support continuous improvement andstrengthen community partnerships.
Professional Development
* Engage in ongoing professional development through supervision,training and skills development aligned with NHS Englands personalised careframework.
* Work with line managers to review performance, identify learningneeds and set development goals.
* Maintain uptodateknowledge of local services, community resources and system developments, andcomplete all required organisational training.
* Participate in reflective practice, peer learning and knowledgesharing to support consistent, highqualitypersonalised care across the MDT.
Service Development
* Contribute to the ongoing improvement of personalised careservices by identifying gaps, opportunities and innovations with MDT colleaguesand community partners.
* Use feedback, data and lived-experienceinsights to support responsive, person-centredservice design and reduce health inequalities.
* Participate in quality improvement, business planning and coproduction of new initiatives.
* Promote consistent practice across PCNs through shared learning,collaboration and championing approaches that improve access, experience andoutcomes.
Leadership
* Demonstrate leadership by supporting the development and deliveryof high quality personalised care acrossthe PCN.
* Act as a role model for person-centred,strengths based and community connected practice.
* Share learning, offer guidance and contribute to innovation,problem solving and service development.
* Uphold organisational values, promote equality and inclusion, andhelp foster a positive, supportive working culture.
Other
* Undertake additional duties consistent with the role and respondflexibly to service needs and organisational priorities.
* Support team resilience by adapting to changing demands andassisting colleagues when required.
* Adhere to all organisational policies, including confidentiality,safeguarding, information governance and professional conduct.
* Carry out any reasonable tasks requested by management thatcontribute to high quality personalised care andeffective service delivery.
Confidentiality
* In the performance of the dutiesoutlined in this job description, the post-holder may have access toconfidential information relating to patients and their carers, Practice staffand other healthcare workers. All suchinformation from any source is to be regarded as strictly confidential.
* Information relating to patients,carers, colleagues, other healthcare workers or the business of the Alliancemay only be divulged to authorized persons in accordance with the Alliancespolicies and procedures relating to confidentiality, and the protection ofpersonal and sensitive data.
Health & Safety
* Thepost-holder will assist in promoting and maintaining their own and othershealth, safety and security as defined in the Alliances Health & SafetyPolicy to include:
* Identifying the risk involved inwork activities and undertaking such activities in a way that manages thoserisks.
* Ensuring that all accidents ordangerous accidents are reported and investigated and follow up action takenwhere necessary.
Equality and Diversity
* Thepost-holder will support the quality, diversity and rights of patients, carersand colleagues to include:
* Acting in a way that recognizesthe importance of peoples rights, interpreting them in a way that isconsistent with current legislation.
* Respecting the privacy, dignity,needs and beliefs of patients, carers and colleagues.
* Behaving in a manner which iswelcoming to and of the individual, is non-judgemental and respects theircircumstances, feelings, priorities and rights.
Quality
Thepost-holder will strive to maintain quality within the Alliance, and will:
* Alert other team members to issuesof quality and risk.
* Assess own performance and takeaccountability for own actions, either directly or under supervision.
* Contribute to the effectiveness ofthe team by reflecting on own and team activities and making suggestions onways to improve and enhanced the teams performance.
* Work effectively with individualsin other agencies to meet patients needs.
* Effectively manage own time,workload and resources.
Communication
Thepost-holder should recognize the importance of effective communication withinthe team and will strive to:
* Communicate effectively with otherteam members.
* Communicate effectively withpatients and carers.
* Recognise peoples needs foralternative methods of communication and respond accordingly.
Person Specification
Experience
* Ability to competently use technology and IT systems including word processing, email and the internet to create simple personalised plans with individuals
* Experience of supporting people, their families and carers in a paid or unpaid capacity
* Experience of working in a community setting
* Experience of handling confidential information.
* Experience of collecting and recording information and data
* Ability to identify risk to self and others, Identifying and reporting safeguarding incidents
* Experience of working in or with voluntary organisations or groups in a paid or unpaid capacity
* Experience of working collaboratively with different organisations, building trust, confidence and partnerships
* Extensive knowledge of local services within a Sunderland locality through either living or working within one of the wider Sunderland settings.
* Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work
Motivation and Skills
* Prioritise and work to deadlines.
* Work effectively and collaboratively as part of a team but also autonomously.
* High level and adaptable communication skills across a range individuals of all ages, backgrounds and cultures with varying social and emotional needs
* Able to respond to challenges with resilience and manage situations calmly and professionally.
* Passionate advocate for digital transformation in Primary Care
* Promote and maintain good working relationships with a variety of external partners.
* Keep accurate records of discussions and clearly replicate discussions in writing
* Work on own initiative but within constraints of the role
* Provide motivational coaching with the ability to inspire trust and confidence
* Confident and comfortable with difficult situations
* Able to work under pressure and emotionally resilient
* Able to think creatively and use initiative to develop solutions to problems.
* Ability to support the development of small voluntary led groups
* Understanding the impact of economic and environmental factors on people's health and wellbeing
Other
* Understands the principles of equality and diversity.
* A firm commitment to CPD
* Full UK driving licence with use of own car
* Ability to travel across Sunderland if required
* Meet DBS standards and Criminal Record checks
Qualifications
* Demonstrable commitment to personal and professional development
* Proficient in the use of Microsoft Office applications.
* PCI Accredited Tailored
* qualification in Care coordination (can be arranged if not in place)
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.
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