PCN Cardiometabolic Health NurseNHS

Job summary

Working with our forward-thinking PCN, this is a great opportunity for an experienced Registered Adult Nurse/Registered General Nurse to lead and coordinate our brand new Cardiometabolic Health Project. The role is initially for a fixed term of 6 months, which may be extended subject to funding and commissioner approval. The role is for a minimum of 22 hours per week, up to 37.5 per hours per week.

The job is primarily working with practices in the Forest of Dean (Blakeney, Coleford, Lydney, Yorkley and surrounding areas) and you will be required to travel independently between practices and occasionally G DOCs offices in Gloucester, and to attend meetings etc. hosted by other agencies throughout Gloucestershire

You will be required to be immunised in compliance with Green Book (link attached) and NHS recommendations for your role (unless medically exempt), including immunisations against Covid.

The Care Quality Commission requires us to have a complete employment history from the age of 16, including explanations for any gaps in employment.

Main duties of the job

The Cardiometabolic Health Nurse will lead and coordinate the identification, prevention, monitoring, and management of cardiometabolic disease across the Primary Care Network (PCN) population. The PCN has a particular focus on cardiometabolic disease associated with liver disease and on identifying unrecognised or under-treated liver disease.

The role involves both care of individual patients/groups of patients and population health management across the PCN.

The postholder will work collaboratively with GP practices, multidisciplinary teams, community providers, and secondary care services to improve outcomes for patients at risk of, or living with, cardiovascular disease, liver disease. hypertension, diabetes, chronic kidney disease, obesity, and related long-term conditions.

The role will focus on proactive population health management, reducing health inequalities, supporting quality improvement initiatives, and delivering evidence-based care aligned with NHS Long Term Plan objectives and local priorities.

Job description

Note: it is recognised that candidates are likely to have more advanced training and competencies in some clinical areas than others. The level of clinical responsibility will be adjusted accordingly. The role is a broad one and it is not expected that candidates will have specialist training in all the clinical components

Clinical Responsibilities

Undertake comprehensive cardiometabolic assessments for patients identified through risk stratification and population health management tools.

Deliver nursing interventions (within training and competencies) for patients with: Liver disease, Hypertension, Diabetes, Prediabetes, Hyperlipidaemia, Obesity, Chronic kidney disease, Cardiovascular disease.

Optimise cardiovascular risk factors in line with NICE guidance and local pathways.

Support medication reviews and treatment optimisation in conjunction with GPs, pharmacists, and prescribing clinicians.

Undertake and (within training and competencies) act on clinical investigations including blood pressure readings, ECGs, pathology test results

Develop personalised care plans in partnership with patients and carers, to include a ReSPECT plan, where relevant.

Ensure close multi-professional and multi-agency working, especially with other members of the local Integrated Neighbourhood Team(s), to facilitate the delivery of each patients PCSP

Promote self-management and lifestyle modification through health coaching techniques.

Refer patients appropriately to community, secondary care, and voluntary sector services.

Population Health and Prevention

Lead proactive case-finding programmes for patients at risk of cardiometabolic disease.

Support delivery of NHS Health Checks and cardiovascular prevention programmes.

Identify unwarranted variation in care and work with practices to improve outcomes.

Use population health data to target interventions for high-risk groups.

Support initiatives aimed at reducing health inequalities across the PCN population.

Contribute to screening and prevention campaigns.

Leadership and Service Development

Act as a clinical resource and subject matter expert for cardiometabolic health.

Support implementation of national and local cardiovascular disease prevention programmes.

Participate in the development of clinical pathways and protocols.

Contribute to quality improvement projects across the PCN.

Support achievement of Quality and Outcomes Framework (QOF), IIF, and locally commissioned service requirements.

Assist in evaluating service effectiveness and patient outcomes.

Multidisciplinary Working

Work collaboratively with General Practitioners, Practice Nurses, Clinical Pharmacists, Social Prescribing Link Workers, Health and Wellbeing Coaches, Dietitians, Community Services, Secondary Care Specialists

Participate in multidisciplinary team meetings and case discussions.

Provide education and support to practice staff regarding cardiometabolic care.

Information and Governance

Maintain accurate, contemporaneous patient records.

Ensure compliance with NMC Code, Data Protection legislation, Information Governance standards, Clinical governance requirements

Participate in audit, service evaluation, and reporting activities.

Maintain confidentiality at all times.

Professional Responsibilities

Maintain active NMC registration.

Participate in clinical supervision, appraisal, and revalidation.

Maintain continuing professional development relevant to cardiometabolic care.

Adhere to all organisational policies and procedures

General

Partnership Working: Build and maintain effective working relationships with GPs, acute and community hospitals, Adult Social Care, voluntary sector organisations, and other community services to deliver integrated care

Care Coordination: Ensure seamless transitions of care and continuity through proactive case management and liaison with all relevant stakeholders

MDT Coordination: Participate in MDT meetings, ensuring collaborative care planning and shared decision-making across system partners

Education and Training: Support the development of cardiometabolic medicine and skills for other practitioners, carers, and patients

Service Development: Contribute to the design, implementation, and evaluation of frailty pathways and services

Risk Management: Identify and manage clinical risks

Patient Advocacy: Promote shared decision-making and ensure care aligns with patients values, goals and what matters to them

Data and Audit: Collect and analyse data to support risk stratification and segmentation of the patient cohort, monitor outcomes and measure impact, support quality improvement and inform commissioning conversations.

See also the G DOC Ltd All Workers Job Description which applies to all G DOC employees.

About us

West Forest of Dean PCN is hosted by G DOC Ltd.

G DOC LTD is a unique, GP-owned organisation all GP surgeries in Gloucestershire are our shareholders. We operate with a not-for-profit ethos, ensuring every decision and service is focused on improving patient outcomes and reinvesting in local Primary Care across the county.

We directly manage several GP surgeries in Gloucester and the Forest of Dean, providing patient-centred care to more than 45,000 patients. We value continuity of care and practice teams are at the heart of all we do. In addition to our surgeries, we deliver a range of countywide commissioned services designed to improve access, increase capacity, or provide specialist support. Our teams are committed to delivering sustainable, high-quality primary care while fostering innovation and collaboration across the local health system.

By joining us, you'll be part of an organisation that puts people first, supporting staff wellbeing, professional development, and a collaborative culture. You'll benefit from the stability, support, and career opportunities of a larger organisation, while still working in close-knit, community-focused teams.