PCN Cardiometabolic Health Nurse

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.

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.

Job description

Job

responsibilities

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.

Person Specification

Qualifications

Essential Registered Adult Nurse/Registered General Nurse or other qualification recognised by the NMC as equivalent Current registration with Nursing & Midwifery Council Current level 3 safeguarding training or willing & able to undertake level 3 safeguarding training Desirable Post-graduate training in a relevant subject, e.g. liver disease, diabetes, cardiovascular disease, other long-term conditions or public/population health.

Personal qualities Essential Polite and confident Flexible and cooperative Motivated High levels of integrity and loyalty Demonstrates empathy, respect and kindness in all interactions Collaborative and able to work effectively across disciplines and organisations to deliver joined-up care Person centred (Prioritises the individuals needs, preferences, and dignity) Innovative: Seeks out and applies evidence-based practices and new models of care Takes responsibility for clinical decisions and service outcomes Engages in continuous professional development and reflective practice Promotes equality, diversity, and cultural competence in care delivery Able to use own initiative but also know when to seek assistance Ability to work under pressure Other Essential Disclosure Barring Service (DBS) enhanced check satisfactory Evidence of continuing professional development An ability to drive, current UK driving licence. and daily access to a vehicle Experience Essential Minimum of 2 years post-registration experience Clinical experience of long-term condition management Understanding of cardiometabolic disease and associated risk factors Understanding of health inequalities and personalised care Experience of undertaking clinical assessments and care planning Experience working within multidisciplinary teams Experience using clinical systems and electronic patient records.

Desirable Understanding of population health management approaches Experience working within a Primary Care Network or other multi-provider system Experience of population health management Experience leading quality improvement projects Experience of clinical audit and service evaluation Experience of delivering contractual requirements e.g.

KPIs, QOF, PCN DES Skills Essential Excellent communication skills, written and oral Strong IT skills Advanced clinical assessment and diagnostic skills, particularly in geriatric and frailty syndromes Knowledge of national standards that inform practices e.g. NICE guidelines Expertise in frailty identification and screening tools e.g.

Clinical Frailty Scale, eFI.

Knowledge of clinical and information governance as appropriate to role Sound understanding of long-term condition management, rehabilitation and end-of-life care Proven ability to work effectively within MDTs and across organisational boundaries Understanding of personalised care, wider determinants of health and equality, diversity and inclusion Ability to engage with and enable people, families and carers using health coaching approaches Ability to enable efficient multi-agency working with practitioners across the system adopting a team of teams approach, especially with the local Integrated Neighbourhood Team Competence in using digital health records and remote monitoring tools Competent, or willing to become competent, in use of SystmOne Competent in the use of Office and Outlook Ability to follow policy and procedure Able to identify and resolve risk management issues according to policy or protocol Ability to assess, implement and evaluate a programme of care Effective time management - planning and organising Ability to work as a team member and autonomously Good interpersonal skills Desirable Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders