About this role
Job summary
This is a new position and an exciting opportunity to support and work within the Epping Forest North Primary Care Network (PCN), which supports 6 GP practices across Epping, Ongar, Abridge and Waltham Abbey, with a registered population of circa 64,500.
Delivery of patient centre, integrated care, improving patient outcomes and providing continuity is at the heart of the PCN.
The post holder will work as part of an Integrated Neighbourhood Team within the Epping Forest North PCN to support complex patients through proactive care planning, enabling earlier intervention and prevention, reduction in escalation of need so improving outcomes for the local population
The post holder will demonstrate excellent communication and organisational skills, flexible in approach, able to exercise initiative and demonstrate consistently high standards of professionalism.
Main duties of the job
This is a new position which is seen as a critical and evolving post to support and work within the Epping Forest North PCN which supports six GP practices in Epping, Ongar, Abridge and Waltham Abbey. Delivery of patient centre, integrated care, improving patient outcomes and providing continuity is at the heart of the PCN.
This PCN has pockets of deprivation and inequalities and there are significant numbers of care homes within the PCN.
The post holder will demonstrate excellent organisational skills, must be flexible in approach, able to exercise initiative and demonstrate consistently high standards of professionalism. The post holder must at all times be aware of the need for confidentiality and integrity.
About us
Epping Forest North PCN is a group of 6 general practices working together, and in partnership with community, mental health, social care, pharmacy, hospital and voluntary services, to offer more personalised, coordinated health and social care to the people in our area. The member practices are:
Abridge Surgery (Abridge) High Street Surgery (Epping) Market Square Surgery (Waltham Abbey) Maynard Court Surgery (Waltham Abbey) Ongar Health Centre (Ongar) The Limes Medical Centre (Epping) Our vision is to provide compassionate, high-quality, joined-up care that puts patients first, delivering value by making the best use of our shared resources in a way that's sustainable for the future.
Our population spans Epping, Waltham Abbey, Ongar, Abridge and the surrounding forest-edge villages, a mix of market towns and rural West Essex communities.
Our team
Our Additional Roles Reimbursement Scheme (ARRS) team: clinical pharmacists, social prescribers, care coordinators, paramedics and physiotherapists, works across all six sites alongside GPs, nurses and practice staff, sharing resources and expertise.
Job description Job responsibilities
ROLE SUMMARY
This post will operate within the Epping North Primary Care Network supporting six local GP practices. As part of PCNs ambitious plans for transforming and developing primary care locally, the post holder will be expected to operate flexibly and collaboratively with all stakeholders. Care co-ordinators are personalised care roles.
The focus of the role will be to support population health management and to reflect local priorities and health inequalities and working within a multi-disciplinary team.
The role will support the delivery of personalised care for specific cohorts of patients by focusing on what matters to them, by co-ordinating and navigating care across the health and care system, helping patients make the right connections, with the right teams at the right time.
The role will work with specific cohorts of patients on a flexible and rolling programme with a key focus on frailty, but also working with other cohorts, for example, those with learning disabilities, mental illness or other physical health concerns.
The role will require working closely with GPs and other primary care professionals within the PCN to manage a caseload of identified patients through supporting patients in preparing for and or following up with patients post clinical care conversations they have with primary care professionals. The role will support the co-ordination of the patients journey through primary and community care, making sure that appropriate support is available to them and their careers, and ensuring that their changing needs are addressed.
The role will lead on coordinating wider support and activities including access to services, advice, information and health and care planning is timely.
KEY RESPONSIBILITIES
Proactively identify and work with a cohort of patients to support their personalised care requirements, using the available decision support aids.Target at risk populations where delivering vaccinations or other health and social care interventions may be difficult, committing to proactively supporting individuals who might miss this health intervention.Bring together all the patients identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with PCSP best practice.Help people to manage their needs, answering their queries and supporting them to make appointments.Support people to take up training and employment, and to access appropriate benefits where eligible.Raise awareness of shared decision-making and decision support tools and assist patients to be more prepared to have a shared decision-making conversation.Ensure that patients have good quality information to help them make choices about their care.Support patients to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through use of the Patient Activation Measure.Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing.Explore and assist patients to access personal health budgets where appropriate.Provide co-ordination and navigation for patients and their carers across health and care services, alongside working closely with social prescribing link workers, health and well-being coaches and other primary care roles.Assist patients and carers to optimise on-line services and support the deployment of new technologies.Support the co-ordination and delivery of MDTs within PCNs and facilitate referrals within the integrated neighbourhood team where appropriate.Minute/note-take for MDTs, ensuring clear actions and coordinated responses are captured.The post-holder is required to travel independently between practice sites (where applicable), and to attend meetings etc. hosted by other agencies.Any other duties commensurate to the role.
ADDITIONAL DUTIES
In addition to the above duties, you will also be expected to perform the below key activities in line with your job role;
Complete mandatory training in line with PCN policy and proceduresTo participate in the staff appraisal process and to undertake for any staff you manage To keep yourself updated on all matters relating to PCN policyTo provide management supervision where appropriateParticipate in learning and teaching opportunities with other healthcare professionals and learnersEQUAL OPPORTUNITIES STATEMENT
The PCN operates an Equal Opportunities Policy and expects staff to have a commitment to equal opportunity in relation to employment, development, training and service delivery.
GENERAL DATA PROTECTION REGULATION 2018
The General Data Protection Regulation (2018) is to ensure compliance with all PCN policies, and those procedures relevant to the area of work.
The PCN will always seek to process your personal data in accordance with its obligations and your rights.
The GDPR requires that personal data shall be;
Processed Lawfully, fairly and in a transparent manner in relation to individuals;
Collected for specified, explicit and legitimate purposes and not further processed in a manner that is incompatible with those purposes; further processing for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes shall not be incompatible with the initial purpose;
Adequate, relevant and limited to what is necessary in relation to the purposes for which they are processed;
Kept in a form which permits identification of data subjects for no longer than is necessary for the purposes for which the personal data are processed; personal data may be stored for longer periods insofar as the personal data will be processed solely for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes subject to implementation of the appropriate technical and organisational measures required by the GDPR in order to safeguard the rights and freedoms of individuals; and
Processed in a manner that ensures appropriate security of the personal data, including protection against unauthorised or unlawful processing and against accidental loss, destruction or damage, using appropriate, technical or organisational measures.
All employees must adhere to the PCNs Policy on the Protection and Use of Personal Information which provides guidance on the use and disclosure of information. The PCN also has a range of policies for the use of computer equipment and computer-generated information. These policies detail the employees legal obligations and include references to current legislation. Copies of the Policy on the Protection and Use of Personal Information and other Information Technology are available at PCN member practices.
CONFIDENTIALITY
Your attention is drawn to the confidential nature of information collected and used throughout the NHS. The unauthorised use or disclosure of patient, staff or other personal information is a dismissible offence. The unauthorised disclosure of information could also result in a prosecution for an offence, or action for civil damages, under the General Data Protection Regulation.
You are required to observe the strictest confidence regarding any Confidential Information relating to work of the PCN, its patients/clients and its employees.
Confidential Information includes but is not limited to information relating to the PCN received by you in the course of your employment with the PCN or its predecessors, information relating to patients, personnel information, budgeting and financial information and information in respect of which the PCN owes a duty of confidentiality to a third party.
You are required not to disclose any Confidential Information either during or after your employment with the PCN, unless expressly authorised to do so by the PCN or required in the proper performance of your duties or as required by law.
This obligation will cease only when such information comes into the public domain other than through unauthorised disclosure by you.
Failure to comply with these requirements could result in action being taken under the PCNs Conduct/Disciplinary Policy and Procedure.
This obligation is without prejudice to the law concerning protected disclosures in the Public Interest Disclosure Act 1998 (the so-called Whistleblowers Act).
SAFEGUARDING DUTY
It is the responsibility of the post holder to be aware of and follow the legislation and guidance regarding Safeguarding Children and Adults.
INFORMATION TECHNOLOGY
It is the responsibility of the post holder to have a level of IT competence relevant to their job role and will be expected to continue to keep their skills up to date as part of their Continuing Professional Development.
CHANGES TO THIS JOB DESCRIPTION
Post holders have a responsibility to discuss any significant job changes with their line manager at the time the change occurs and agree any permanent substantial change.
On appointment within the PCN staff may be allocated to a specific area of care. It is however PCN policy to allocate staff to other areas of work within the PCN from time to time where this is in the interest of the individual and / or the service.
The Job Description does not purport to be an exhaustive list of duties and responsibilities. The post holder will be expected to undertake additional duties as the requirements of the post change.
Person Specification
Experience Essential
Advanced experience of using Word, Excel and PowerPoint, including the ability to use word processing skills, e-mails and the internet to create simple plans and reports. Ability to distil information, maintain effective records and prioritise and co-ordinate actions. Creative problem solver, willing to search for hard-to-find information. Ability to read large amounts of information and extract the salient points, to analyse data and report on findings. Access to own transport and ability to travel across the locality on a regular basis.
Desirable
Knowledge of the personalised care approach. Knowledge of General Practice clinical systems such as EMIS and SystmOne.
Qualifications Essential
Diploma/HNC Level or relevant experience. NVQ Level 2 Business Administration or relevant experience. Demonstrable commitment to professional and personal development.
Desirable
Training in motivational coaching and interviewing or equivalent experience.
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 Epping Forest North PCN
Address 57 Fyfield Road
Chipping Ongar
CM5 0AL
United Kingdom
Employer's website https://www.eppingforestnorthpcn.co.uk/ (Opens in a new tab)