We are seeking to recruit an experienced Chronic Disesases Practice Nurse at our highly successful, recently rated CQC outstanding, 14,000 patient practice in Dorking.
Hours for this post:
* 25 hours up to 37.5 hours a week
We are a friendly practice, with a supportive GP Partnership and a hardworking large supportive nursing team to our patient population.
Main duties of the job
To lead and deliver a high-quality, evidence-based chronic diseases service for the practice population. The postholder will manage a defined caseload of adults living with long-term conditions such as respiratory disease, diabetes and hypertension, providing assessment, treatment, education, and ongoing review to optimise care, prevent complications, and support self-management.
They will work collaboratively with GPs, practice nurses, healthcare assistants, and allied health professionals to ensure safe, consistent, and coordinated care across the patient journey. The postholder will also act as a clinical resource within the practice, contributing to the professional development of colleagues and the continuous improvement of chronic disease management care with approximately 20% of the role to include general practice nursing duties.
About us
Medwyn Surgery is a well-established GP practice located in the heart of Dorking, Surrey, serving a growing patient population of over 14,000. Our mission is to deliver the highest standard of primary healthcare, encompassing not only medical treatment but also comprehensive health information, community engagement, and fostering strong doctor-patient relationships.
Operating from the purpose-built Medwyn Centre on Reigate Road, our facility, completed in 2006, offers a modern and accessible environment for both patients and staff. The Centre houses a range of services, including Medwyn Surgery, physiotherapy and podiatry services, community health staff, conference and meeting facilities, a pharmacy, audiometry services, and a variety of services provided by sessional medical practitioners.
The Centre is fully accessible, featuring step-free access, wheelchair-friendly facilities, an induction loop, and a disabled toilet. Additional amenities include CCTV for security, comfort cooling, and automated check‑in and patient calling systems, all contributing to a comfortable and efficient healthcare environment.
Medwyn Surgery offers a full range of Enhanced Services to our patients, ensuring comprehensive care that meets the diverse needs of our community. We provide Improved Access appointments every weekday evening and on Saturdays, accommodating patients who require flexibility in scheduling their healthcare visits.
Job responsibilities
KEY RESPONSIBILITIES
Clinical Patient Care & Management
Maintain a defined caseload of patients with chronic disease (such as respiratory diseases, diabetes, hypertension, cardiovascular disease etc) and deliver ongoing assessment, monitoring, review, and follow‑up.
Undertake complex assessments (clinical history, physical exam, risk stratification, complication screening) and develop individualised care plans.
Monitor and interpret relevant investigations (e.g HbA1c, lipids, renal function, peak flow test, etc).
Initiate, titrate, adjust and monitor various chronic disease medications in line with agreed protocols and prescribing qualifications.
Provide structured education for newly diagnosed and existing patients.
Conduct group and one‑to‑one education and support sessions to promote behaviour change and adherence.
Identify, assess, and refer patients with complications as appropriate.
Provide telephone, virtual, or in‑person follow‑up as clinically required.
Undertake home visits where necessary (e.g. housebound patients) for assessment, treatment, or education.
Ensure continuity of care and coordinate with secondary care and community services to support integrated chronic disease management.
Clinical Leadership & Service Development
Lead and direct the coordination of the various chronic disease clinics within the practice, including scheduling, patient recall, and quality assurance.
Develop, implement, and review local pathways, policies, and protocols in chronic disease care.
Audit and monitor the various chronic disease care metrics (QOF indicators, IIF, local targets, and clinical outcomes) and drive improvement initiatives.
Act as a specialist resource and mentor for practice staff (GPs, nurses, HCAs), providing expert advice, support, and supervision.
Deliver or facilitate in‑house training sessions and case‑based discussions to enhance team competence in chronic disease care.
Contribute to the planning and delivery of health promotion and prevention programmes (e.g. obesity management, smoking cessation etc).
Liaise closely with local various chronic disease networks, community teams, and secondary care providers to promote continuity and best practice.
Support implementation of new technologies to support chronic disease management.
Lead or contribute to quality improvement projects, audits, and service redesign initiatives aligned with local and national priorities.
Professional and Quality Assurance Duties
Maintain up‑to‑date knowledge of national and various local chronic disease guidance (NICE, local ICs pathways) and ensure clinical compliance.
Maintain accurate, contemporaneous, and professional clinical records in accordance with NMC and practice standards.
Participate in practice clinical governance processes, including risk management, incident review, and medicines safety.
Undertake regular audits and contribute to service evaluation, research, and outcome measurement.
Participate in and support CQC, or other relevant quality frameworks as required.
Engage in continuing professional development (CPD) and reflective practice to maintain and develop specialist competence.
Maintain professional registration and if applicable independent prescribing qualification.
Adhere to the NMC Code, professional boundaries, and practice policies including confidentiality, data protection, and safeguarding.
KEY RESPONSIBILITIES ADMINISTRATIVE
Accurately record all consultations, care plans, and interventions on the clinical system.
Ensure appropriate coding to support QOF and local enhanced service reporting.
Maintain and review diabetes registers, ensuring systematic recall and proactive management.
Contribute to data collection, audits, and reporting for clinical and performance monitoring.
Participate in the review and development of practice policies and standard operating procedures.
Attend and contribute to clinical meetings, case reviews, and multidisciplinary discussions.
KEY RESPONSIBILITIES PROFESSIONAL
Professional Registration
Be professionally accountable for nursing practice in accordance with the NMC Code.
Maintain active NMC registration and up‑to‑date professional knowledge.
Participate in annual appraisal and maintain a personal development plan.
Attend relevant training, study days, and clinical supervision sessions to maintain and enhance clinical competence.
Recognise and work within scope of professional practice, seeking advice and support when required.
CONFIDENTIALITY
Patients entrust sensitive information to the practice, which must be handled with the utmost confidentiality.
Information relating to patients, carers, colleagues, or the business of the practice must not be disclosed to unauthorised persons and must be processed in line with data protection legislation.
All staff must comply with the Practice Confidentiality Policy and the NMC Code regarding confidentiality.
SAFEGUARDING
Demonstrate commitment to safeguarding and promoting the welfare of children, young people, and vulnerable adults.
Follow practice safeguarding procedures and attend appropriate training.
The post holder will be required to undergo an enhanced DBS check.
EQUALITY AND DIVERSITY
Uphold the principles of equality, diversity, and human rights in all patient and team interactions.
Deliver care that is respectful of privacy, dignity, and cultural or individual needs.
Promote a non‑judgemental and inclusive environment for patients and colleagues.
PERSONAL / PROFESSIONAL DEVELOPMENT
Participate in an annual performance review and maintain an up‑to‑date record of CPD.
Take responsibility for personal learning, reflective practice, and skill development.
Contribute to the training and supervision of student nurses, medical students, or other trainees within the practice.
COMMUNICATION
Communicate effectively with patients, carers, colleagues, and partner organisations.
Use motivational interviewing, shared decision‑making, and other techniques to support engagement and self‑management.
Recognise the need for alternative methods of communication and adapt accordingly.
Contribute to effective communication across the multidisciplinary team.
OTHER DUTIES
Undertake any other duties commensurate with the role as required by the Partners or Lead Nurse.
Actively participate in reviewing systems, suggesting and implementing improvements to enhance quality of care and patient experience.
Person Specification
Experience
* Experience with chronic disease management such as respiratory, diabetes, hypertension
* Experience of working autonomously
* Experience of infection prevention and control measures
Personal Qualities
* Effective time management (planning and organising)
* Ability to follow legal, ethical and professional policies/local policies/procedures and codes of conduct
* Knowledge of IT systems including the ability to use word processing skills, emails and the internet
* Understand the requirement for PGDs and associated policy
* Ability to use own initiative, discretion, and sensitivity
* Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
* Ability to identify risk and assess/manage risk when working with individuals
* Ability to work as a team member and autonomously
* Good interpersonal and organisational skills
* Sensitive and empathetic in distressing situations
* Commitment to ongoing professional development
* Clear, polite telephone manner
* Occupational Health clearance
* Meet the requirements and produce evidence for professional revalidation
* Evidence of CPD commensurate with the role
* Demonstrate personal accountability, emotional resilience and work well under pressure
Clinical Knowledge and Skills
* Ability to work within own scope of practice and understand when to refer to GPs
* Good clinical system IT knowledge and an ability to record accurate clinical notes
* Ability to communicate complex and sensitive information effectively with people by telephone, email and face to face
* Understanding of safeguarding adults and children
* Understanding and knowledge of healthcare provision in GP surgeries, QOF and enhanced service
* Effectively able to communicate and understand the needs of the patient
* Broad knowledge of clinical governance
* Awareness of issues within the wider health arena and knowledge of health promotion strategies
* Knowledge of public health issues in the local area
* Knowledge of national standards that inform general practice (NSF NICE guidelines)
Qualifications
* Registered General Nurse Qualification in Chronic Disease Management
* Evidence or working at relevant level of practice required for this post
* Mentor or teaching qualification
* Non‑Medical Prescriber
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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