PCN Salaried GPNHS

Job summary

To provide proactive, high-quality care to frail, housebound and clinically vulnerable patients within the community as part of our Integrated Neighbourhood Team. The postholder will deliver long-term condition management, dementia and SMI health checks, and support care planning for patients with complex needs, including those with Learning Disabilities (LD).

This role supports the shift toward anticipatory and preventative care, reducing avoidable hospital admissions and improving quality of life for our most vulnerable populations.

Main duties of the job

• Conduct home visits and community-based reviews for housebound and frail patients.
• Deliver long-term condition management (e.g. CHF, COPD, diabetes, hypertension).
• Lead or support anticipatory / future care planning and end-of-life discussions where appropriate.
• Undertake Dementia and Severe Mental Illness (SMI) annual health checks in line with QOF and PCN specifications.
• Support delivery of Learning Disability (LD) health assessments.
• Provide clinical leadership and support to the wider Integrated Neighbourhood Team (including nurses, AHPs, care coordinators and social prescribers).
• Work collaboratively with community and secondary care services to ensure continuity of care.
• Maintain accurate and timely clinical documentation in the relevant IT systems.

Job description

Clinical Responsibilities

• Conduct home visits and community-based reviews for housebound and frail patients.
• Deliver long-term condition management (e.g. CHF, COPD, diabetes, hypertension).
• Lead or support anticipatory / future care planning and end-of-life discussions where appropriate.
• Undertake Dementia and Severe Mental Illness (SMI) annual health checks in line with QOF and PCN specifications.
• Support delivery of Learning Disability (LD) health assessments.
• Provide clinical leadership and support to the wider Integrated Neighbourhood Team (including nurses, AHPs, care coordinators and social prescribers).
• Work collaboratively with community and secondary care services to ensure continuity of care.
• Maintain accurate and timely clinical documentation in the relevant IT systems.

Professional Responsibilities

• Participate in clinical meetings, MDTs and case discussions.
• Engage in quality improvement initiatives related to frailty and proactive care.
• Commit to ongoing professional development and reflective practice.
• Adhere to GMC, CQC and safeguarding standards at all times.

About us

The Brunel Primary Care Network consists of three Practices across Portsmouth; East Shore Partnership, The Lighthouse Group and University Surgery.

We have highly skilled and motivated teams working within our PCN, which consist of GP Partners, Salaried GP's, Advanced Nurse Practitioners, Pharmacists, Diabetes and Respiratory Nurse Specialists, Nurses, GP Assistant's and HCA's; who are supported by skilled administration teams.

We offer 6 weeks annual leave per annum plus Bank Holidays pro rata, an additional days paid leave allocated to you as a days birthday leave, automatic enrolment to a generous NHS Pension and free access to our Employee Assistance Programme.