Neighbourhood Health PractitionerNHS

Job summary

Shape the Future of Neighbourhood Health

Are you an experienced Nurse Prescriber looking for an opportunity to work differently?

We are seeking a highly motivated Neighbourhood Health Practitioner (Prescriber) to join our developing Neighbourhood Health Team and play a key role in delivering the NHS vision of providing more proactive, personalised care closer to home through integrated neighbourhood services. This role supports the NHS neighbourhood health model, which aims to improve outcomes through multidisciplinary working, prevention, population health management and reducing health inequalities.

This is an exciting opportunity for an Enhanced Nurse who is passionate about complex care management, clinical leadership and integrated working across health, social care and community services.

Main duties of the job

As a Neighbourhood Health Practitioner, you will work autonomously across primary care and community settings, providing advanced clinical assessment, diagnosis, treatment and prescribing for patients with complex health needs.

You will have a pivotal leadership role within our Neighbourhood Multidisciplinary Team (MDT), providing clinical oversight for patients identified through population health management, risk stratification, frailty pathways and proactive case management.

Working closely with Care Coordinators, GPs, community services, social care, mental health teams and voluntary sector partners, you will help ensure patients receive coordinated, person-centred care that improves outcomes and reduces avoidable hospital admissions.

What You'll Be Doing

Providing expert clinical assessment, diagnosis, treatment and prescribing.

Leading clinical discussions within neighbourhood MDT meetings.

Providing clinical oversight of patients with complex and multiple long-term conditions.

Supporting proactive management of frailty, multimorbidity and high-intensity service users.

Providing clinical support and supervision to Care Coordinators managing complex patient cohorts.

Developing and reviewing personalised care and treatment plans.

Using population health intelligence to identify patients requiring early intervention.

Reducing health inequalities through proactive, community-based care.

Leading quality improvement initiatives and service development projects.

Job description

The Neighbourhood Health Practitioner (Prescriber) is an Enhanced Nurse working autonomously within a multidisciplinary neighbourhood health team to deliver proactive, person-centred, population-focused care for individuals, families and communities.

The post holder will support delivery of the NHS Neighbourhood Health model through the provision of enhanced clinical assessment, diagnosis, treatment, prescribing, care coordination, prevention, health promotion and long-term condition management. The role will contribute to reducing health inequalities, improving population health outcomes, supporting independence and delivering care closer to home through integrated working with primary care, community services, social care, mental health services and voluntary sector partners.

As an Independent Prescriber, the post holder will provide expert clinical leadership, oversight and management of patients with complex health needs, ensuring coordinated care, effective MDT working and timely intervention to improve outcomes and reduce avoidable hospital admissions.

The post holder will provide clinical leadership and oversight of the Neighbourhood MDT, supporting Care Coordinators and other members of the multidisciplinary team to deliver proactive, coordinated care for patients with complex needs.

Key responsibilities

Clinical Practice

Undertake comprehensive assessment, diagnosis, treatment and review of patients presenting with acute, chronic and complex health needs.

Independently prescribe medicines and treatments within professional competence and scope of practice.

Develop, implement and evaluate personalised care and treatment plans.

Deliver enhanced specialist nursing care within areas of expertise including:

o Wound care

o Diabetes

o Respiratory disease

o Cardiovascular disease

o Dementia

o Women's health

o Public health

o Population health management

Manage individuals with multiple long-term conditions, frailty and complex care needs.

Undertake home visits and community-based assessments as appropriate.

Support anticipatory care planning, personalised care and shared decision-making.

Identify and respond appropriately to safeguarding concerns.

Neighbourhood MDT Clinical Leadership and Care Coordination Oversight

Provide clinical leadership within neighbourhood multidisciplinary team (MDT) meetings.

Lead clinical discussions relating to risk stratification, population health management, frailty, complex care and proactive case management.

Act as the lead clinician for patients identified through neighbourhood MDT processes, ensuring appropriate assessment, diagnosis, treatment, prescribing and follow-up.

Maintain clinical oversight of patients requiring coordinated multidisciplinary interventions.

Provide clinical oversight of care plans developed through MDT discussions to ensure they remain clinically appropriate, person-centred and outcome focused.

Ensure agreed MDT actions are implemented, monitored and evaluated.

Provide professional and clinical support to Care Coordinators managing patients with complex health, frailty and social care needs.

Support Care Coordinators to identify clinical deterioration, escalating risk and safeguarding concerns, ensuring timely review and intervention.

Act as a readily accessible clinical resource for Care Coordinators and wider neighbourhood team members.

Lead multidisciplinary reviews for patients with complex needs, multimorbidity, frailty and high healthcare utilisation.

Support continuity of care through ongoing clinical oversight of patients discussed through neighbourhood MDT processes.

Promote integrated working across primary care, community services, mental health services, social care and voluntary sector organisations.

Contribute to reducing avoidable admissions and improving patient outcomes through proactive neighbourhood-based care.

Population Health and Neighbourhood Health Development

Support the development and delivery of neighbourhood-based models of care.

Use population health intelligence and risk stratification tools to identify patients requiring proactive intervention.

Contribute to reducing health inequalities and improving access to services for underserved populations.

Promote prevention, self-management, health education and wellbeing.

Support early intervention and prevention initiatives across neighbourhood populations.

Contribute to the development of integrated pathways that improve outcomes and patient experience.

Personalised Care and Patient Support

Empower individuals to manage their own health and wellbeing wherever appropriate.

Support treatment adherence through education, coaching and personalised care approaches.

Work collaboratively with carers and families involved in patient care.

Signpost and refer patients to appropriate community, voluntary sector and personalised care services.

Provide holistic support to individuals with complex physical, mental health and social care needs.

Leadership, Education and Service Improvement

Act as a senior clinical role model within the neighbourhood team.

Provide mentorship, supervision and support to registered nurses, nursing associates, healthcare support workers, apprentices and students.

Contribute to workforce development and succession planning.

Support implementation of evidence-based practice and national clinical standards.

Lead or contribute to quality improvement initiatives, clinical audits and service evaluation.

Support service redesign and innovation to improve patient outcomes and experience.

Participate in reflective practice and clinical supervision.

Maintain own professional development and support colleagues with learning and development activities.

Lead patient Clinical Education sessions and community outreach sessions.

Communication

Communicate effectively across a wide range of channels and with a wide range of individuals, the public, health, and social care professionals, maintaining the focus of communication on delivering and improving health and care services.

Demonstrate those inter-personal skills that promote clarity, compassion, empathy, respect, and trust.

Contribute to team success and challenge others constructively.

Communicate with individuals, carers, and other visitors in a courteous and helpful manner, whilst being mindful that there may be barriers to understanding.

Report to appropriate registered care professional information received from the individuals, carers, and members of the team.

Ensure all patient related information is treated sensitively and always adhere to the principals of confidentiality.

Report any accidents or incidents and raise any concerns as per organisational policy.

Ensure clear, concise, accurate and legible records and all communication is maintained in relation to care delivered adhering to local and national guidance.

Ensure ability to manage electronic records system taking cognisance of need to protect access (ID, passwords, swipe cards).

Health, safety, and security

• Use the personal security systems within the workplace according to practice guidelines.
• Identify the risks involved in work activities and undertake them in a way that manages the risks.

Quality

• Alert other team members to issues of quality and risk in the care of patients.
• Ensure own actions are consistent with clinical governance systems.
• Practice in accordance with agreed standards of care.
• Enable patients to access appropriate professionals in the team.
• Know the practice's policies, especially the whistle-blowing policy, available in the practice staff handbook.
• Be able to manage your own time effectively.

Equality and diversity

• Act in ways that recognise the importance of people's rights, interpreting them in a way that is consistent with procedures.
• Respect the privacy, dignity, needs and beliefs of patients and carers.
• Understand basic legal and communication issues regarding child abuse, family violence, vulnerable adults, substance abuse and addictive behaviour.

Information processes

• Record information and activities undertaken with patients and carers in an accurate and timely fashion using manual or computer systems as appropriate.
• Maintain confidentiality or information relating to patients, relatives, staff, and the practice.
• Maintain accurate and contemporaneous electronic patient records on SystmOne.
• Take the necessary precautions when transmitting information.

Duties and Responsibilities:

• Attend annual updates and mandatory training as required.
• Maintain necessary requirements to support NMC revalidation.
• Highlight any gaps in knowledge/training needs to their line manager to allow them the opportunity to offer support to fulfil the duties of this post.

Act in a manner that safeguards children and/or vulnerable adults as applicable to the role.

• Work in line with organisational policies and procedural guidelines.

Clinical governance

Maintain accurate, contemporaneous and legally compliant clinical records.

Ensure all care is delivered in accordance with NMC standards, organisational policies and clinical governance requirements.

Participate in incident reporting, risk management and learning from events.

Maintain patient confidentiality and comply with information governance requirements.

Ensure safe management and transportation of patient-identifiable information and smartcards.

Complete all mandatory training and maintain professional competencies.

Maintain compliance with NMC revalidation requirements.

Work in accordance with safeguarding policies and procedures for children and adults.

Promote equality, diversity and inclusion in all aspects of practice.

About us

Rayleigh and District Primary Care Network (PCN) is made up of 6 surgeries who have 56,437 registered patients. Our vision is to work in partnership with our colleagues and patients to provide the best primary care services in the community.

Why join us?

Join a dynamic and supportive network of local GP practices committed to providing high-quality, patient-centred care.

• Be part of a forward-thinking team that embraces new ideas and technologies to improve patient care.
• Work in a collaborative and nurturing environment where your professional growth is encouraged.
• Make a real difference in the lives of our patients and the wider community.
• Work as part of a wider multidisciplinary clinical team made up of clinical pharmacists, paramedics, nurse associates, pharmacy technicians and many more!

All of our PCN staff are employed by GP Healthcare Alliance (GPHA). GPHA values staff and can offer:

• NHS pension;
• A supportive and friendly working environment;
• Flexible working hours;
• Peer support;
• Support with training and development;
• 38 days annual leave per year, including bank holidays (pro rota);
• Reimbursement for parking and travel expenses for attending meetings/off site sessions.