About this role
Job summary
We are seeking an enthusiastic and organised Care Coordinators with Clinical Skills to join the growing multi-disciplinary team within the North Wilts Border PCN. Building on our successful care coordination model, this role is key to delivering personalised, joined-up care for our patients.
As a Clinical Care Coordinator, you will work closely with PCN practices and a wide range of health professionals, including GPs, nurses, paramedics, pharmacists, social prescribers and Health and wellbeing coach and others. You will be responsible for coordinating access to services, information, and support ensuring that care is timely, efficient, and centred around the needs of each patient.
This is a vital role that contributes directly to:
Enhancing patient experience and outcomesPreventing avoidable hospital admissionsSupporting the NHS Long Term Plan and PCN priorities through integrated, person-centred careYou will act as a key point of contact, helping to bridge the gap between patients and clinical teams.Your work will help free up valuable clinical time while ensuring that patients feel informed, supported, and confident in managing their own health and wellbeing.
Main duties of the job
Clinical and Preventative Care Support
Coordinate and support Dementia Reviews, ensuring patients receive appropriate ongoing care and monitoring.Facilitate the completion and review of RESPECT forms (Recommended Summary Plan for Emergency Care and Treatment).Support the delivery of Learning Disability Annual Health Reviews.Coordinate and assist with Severe Mental Illness (SMI) Reviews.Undertake housebound patient blood pressure monitoring.Perform housebound ECGs where appropriate.Deliver phlebotomy services for housebound and eligible patients.Administer vaccinations and injections, including Vitamin B12 injections, in line with competency and organisational protocols.Support and deliver NHS Health Checks to promote preventative healthcare.Assist the Paramedic Team in conducting frailty assessments and comprehensive patient reviews.Care Coordination and Patient Support
Proactively identify patients requiring additional support and develop personalised care plans.Work collaboratively with GPs, nurses, paramedics, and MDT colleagues to coordinate effective, patient-centred care.Support patients, carers, and families by providing guidance, managing appointments, referrals, and follow-up care.Coordinate hospital discharges and liaise with social care, community services, care homes, and voluntary organisations.Organise MDT meetings, monitor actions, maintain accurate records, and promote self-management, wellbeing, and improved health outcomes across the PCN population.
About us
North Wilts Border PCN is a vibrant, forward-thinking Primary Care Network serving over 56,000 patients across North Wiltshire and the borders of Swindon. Our network brings together six GP practices
Malmesbury Primary Care Centre,New Court Surgery,Purton Surgery,Cricklade Surgery,The Tolsey Surgery, andTinkers Lane Surgery
To deliver integrated, patient-centred care. By working together, we provide more coordinated, accessible, and flexible services that go beyond traditional GP appointments.
Our multidisciplinary team consisting of GPs, paramedics, clinical pharmacists, care coordinators, social prescribing link workers, health & wellbeing coach and pharmacy technicians.
Together, we support patients medical, social, and wellbeing needs, ensuring holistic care across our network.
This is your chance to join a collaborative environment where innovation, teamwork, and patient care come first.
NOTE: Right to Work in the UK
Please note that we are unable to offer visa sponsorship for this role. Applicants MUST already have the right to work in the UK in order to be considered
What We Offer:
A supportive and inclusive team culture that is well-ledOpportunities for professional development and leadershipFlexible working arrangementsAccess to mentorship and clinical supervisionInvolvement in innovative projects and service developmentEmployee Assistant programmeNHS PensionCost coverage of an Enhanced DBSExcellent Induction25 days annual leave pro rata
Job description Job responsibilities
Primary Responsibilities
Develop and maintain a comprehensive directory of local services, including charities, community and voluntary sector organisations, and relevant private providers, ensuring up-to-date information is available for staff and service users. Deliver dedicated support to unpaid carers through carer clinics, offering guidance, signposting, emotional support, and assistance in accessing appropriate services or respite options. Coordinate safe and effective hospital discharge processes for patients under and over 75, ensuring timely follow-up care, medication reviews, and clear communication with families and community services. Manage referrals to Adult Social Care, liaising closely with social workers to ensure individuals receive timely assessments and appropriate care packages that meet their needs. Work collaboratively with community health teams, including District Nurses, Occupational Therapists, and Physiotherapists, to support holistic care planning and facilitate referrals for clinical or functional support. Engage Adult Social Care when issues of safeguarding or the need for a care assessment arise, ensuring concerns are escalated appropriately Build strong working relationships with care homes and teams supporting housebound patients to promote resident wellbeing, coordinate vaccinations, arrange social prescribing visits, and ensure effective communication between all involved providers. Arrange wheelchair assessments and referrals and support individuals in accessing appropriate mobility equipment and adaptations. Conduct and coordinate Dementia Reviews, including running assessment clinics, supporting carers, gathering input from GPs and community services, and ensuring follow-up actions are completed. Deliver NHS Health Check clinics, overseeing the full process from assessment to coordination of results, referrals, and lifestyle interventions to ensure effective follow-through for patients. Manage, monitor, and allocate LWT responsibilities across the team, ensuring timely completion, consistent documentation, and effective workflow coordination. Secondary Responsibilities
Work alongside practice teams to streamline care for patients with complex or long-term needs, aiming to smooth their journey through the system and accelerate access to appropriate support. Use agreed clinical criteria and population health management tools to flag individuals who would benefit from coordinated care, ensuring proactive rather than reactive support. Respond to patient queries and provide clear, accessible information that helps them understand and manage their health and care plans. Arrange patient appointments as needed and promote vaccination uptake among eligible groups to support prevention and early intervention. Tailor support to each person's priorities, ensuring care is sensitive to cultural background, personal values, disabilities and long-term conditions Coordinate transitions between different parts of the health and care system, ensuring referrals are timely and that patients move smoothly between services without gaps in support. Hold a defined caseload and act as a consistent point of contact for patients across primary care, community services, secondary care and care home environments Oversee referrals to clinical and non-clinical services, maintaining effective communication with internal healthcare teams and wider partner organisations. Provide calm, practical support to people who feel overwhelmed or uncertain about navigating the care system, helping them build confidence and reduce distress. Address health inequalities through focused work with priority groups, including people with multiple health needs or those at higher risk of poor outcomes.
Person Specification
Skills and Attributes Essential
Able to work independently and proactively. Be able to manage multiple demands and prioritise appropriately. Ability to seek solutions and solve problems using your own initiative. Adaptability, flexibility and the ability to cope with uncertainty and change. Be able to focus in a busy work environment. Demonstrate a strong desire to improve performance and make a difference by focusing on goals. Work confidentially and maintain the trust of colleagues and patients. Excellent time keeping.
Desirable
Excellent interpersonal and communication skills. Ability and confidence to handle difficult conversations. Ability to structure conversations using a coaching approach based on what matters to the person. Be able to talk to a wide range of professionals appropriately. Ability to nurture key relationships and maintain networks.
Experience Essential
Experience of working in a primary care setting /GP practice - either in a clinical or non-clinical role Experience in working and communicating with multiple stakeholders. Experience in managing patient caseload Experience of working in health or social care settings without direct supervision Experience of organising and prioritising own workload Demonstrates awareness of limits to knowledge base
Desirable
Experience and understanding of evaluating and measuring the performance of health services. Experience in using clinical IT systems, in particular Systmone. A good understanding of the health and social care environment and the roles and responsibilities within it. Knowledge of existing referral pathways to local health, social care and voluntary organisations.
Attitude & Behaviour Essential
Displays care, compassion, sensitivity and responsiveness to other people's feelings and needs. Able to work as part of a team, co-operating to work together and in conjunction with others and willing to help and assist wherever possible and appropriate, appreciating the value of diversity in the workplace. Able to develop, establish and maintain positive relationships with others both internal and external to the organisation and with patients and their carers. Able to work under pressure, dealing with peaks and troughs in workload. Highly motivated and reliable. Demonstrates values consistent with those of North Wilts Border PCN
Desirable
Positive and flexible attitude to dealing with change; able to respond to the changing needs of the patient in an appropriate and timely manner. Willing to change and accept change and to explore new ways of doing things and approaches. Has a strong degree of personal integrity. Able to adhere to standards of conduct based on a culture of equality and fairness
Qualifications Essential
Good standard of education with 5 GCSE's or equivalent. NVQ Level 3 in Health & Social Care Good IT skills, especially a working knowledge of MS Office (Word, Excel, PowerPoint and Outlook). Commitment to continuing professional development, including the Personalised Care Institute Course(s).
Desirable
Qualified in Phlebotomy Blood pressure taking Experience with vital observations Experience in long-term condition management
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.
Employer details Employer name North Wilts Border PCN Ltd Company
Address Malmesbury Primary Care Center
Priory Way
Burton Hill
Malmesbury
Wiltshire
SN16 0FB
United Kingdom
Employer's website https://northwiltsborderpcn.nhs.uk/ (Opens in a new tab)