About this role
Job summary
The MDT Relational Care Coordinator will support the proactive management of a cohort of patients with complex health and social care needs who have an established care plan. Working as part of a multidisciplinary team (MDT), the post holder will provide continuity, coordination, and relationship-based support to ensure patients receive timely, appropriate, and person centered care.
The role will focus on monitoring patient progress, identifying changes in needs, and facilitating appropriate escalation or de-escalation of care in collaboration with MDT colleagues.
Main duties of the job
1. Patient Care & Support
2. Care Coordination & Monitoring
3. Escalation & De-escalation
4. MDT Working
5. Holistic & Preventative Care
6. Safeguarding & Risk
7. Information Management & Quality
About us
Sutton Primary Care Networks is the collaborative vehicle for the four Sutton PCNs and the former Sutton GP Federation working together as a single entity. We are a Community Interest Company that aims to reinvest surpluses back into general practice and primary care for the benefit of our practices and the people who form the communities we serve.
Sutton has four PCNs whose boundaries are based on historical relationships and groupings of organisations. There are some similarities of residents health and care needs unique to a particular PCN, and many more needs that are shared across all four PCNs.
Our four PCN represent all 22 GP surgeries in Sutton. Their collective footprints cover all of the London Borough of Sutton and its residents who are able to access and benefit from the services and improvements offered by Primary Care Networks.
Primary Care Networks (PCNs) are a key part of the NHS Long Term Plan, with all general practices being required to be in a network by June 2019, and CCGs/Integrated Care Boards (ICBs) being required to commit recurrent funding to develop and maintain them.
The networks will have expanded neighbourhood teams which will comprise a range of staff such as GPs, pharmacists, district nurses, community geriatricians, dementia workers and Allied Health Professionals such as physiotherapists and podiatrists/chiropodists, joined by social care and the voluntary sector.
Job description Job responsibilities
1. Patient Care & Support
Act as a named point of contact for patients with complex care needs.
Develop and maintain effective, therapeutic relationships with patients and carers.
Provide person centred support to enable patients to actively engage with their care plans.
Support patients to navigate health, social care, and voluntary sector services.
2. Care Coordination & Monitoring
Monitor patients with established care plans through regular contact (telephone, digital, or face to face).
Identify changes in patient condition, wellbeing, or circumstances.
Ensure care plans are regularly reviewed and updated in collaboration with MDT members.
Maintain accurate, contemporaneous clinical records in line with organisational policies.
3. Escalation & De-escalation
Recognise early signs of deterioration, increased risk, or unmet needs and escalate appropriately.
Support timely intervention through MDT coordination to prevent avoidable deterioration or hospital admissions.
Identify opportunities for de-escalation where patient needs have stabilised, ensuring safe transition to lower levels of support.
Participate in risk stratification and case management processes.
4. MDT Working
Participate in regular MDT meetings, contributing updates on patient status and care planning.
Coordinate actions from MDT discussions and ensure follow-up.
Liaise effectively with GPs, nurses, social prescribers, pharmacists, community services, and secondary care.
Promote integrated, joined-up working across services.
5. Holistic & Preventative Care
Support a holistic approach addressing physical, mental, and social needs.
Signpost and refer patients to appropriate services, including social prescribing and community resources.
Encourage self-management and preventative health behaviours.
6. Safeguarding & Risk
Identify safeguarding concerns and take appropriate action in line with local policies.
Maintain awareness of risks associated with complex patient groups (e.g., frailty, long term conditions, mental health).
Escalate concerns promptly to appropriate professionals.
7. Information Management & Quality
Maintain accurate data entry and documentation within clinical systems.
Support service audits, reporting, and evaluation activities.
Contribute to continuous improvement initiatives within the PCN and MDT model.
Responsibility for Patient/Client Care
Responsible for coordinating care for a defined caseload of patients with complex needs.
Required to exercise judgement within defined parameters and escalate where necessary.
Ensures care remains aligned with agreed care plans and patient goals.
Policy & Service Development
Contribute to the development of MDT processes and care coordination pathways.
Implement local and national policies relevant to the role.
Responsibility for Information Resources
Accurate recording of patient interactions and care updates.
Compliance with GDPR, confidentiality, and information governance requirements.
Responsibility for Research & Development
Participate in audits and service evaluations.
Support evidence-based practice within MDT working.
Freedom to Act
Works within clearly defined protocols and procedures.
Exercises initiative within scope of role, escalating complex decisions to senior clinicians or MDT.
Person Specification
Qualifications Essential
NVQ Level 3/4 or equivalent experience in health, social care, or related field Evidence of continuous professional development
Desirable
Relevant degree or foundation degree Care coordination or health coaching qualification
Experience Essential
Experience working with individuals with complex or long-term conditions Experience of multidisciplinary or multi-agency working Experience of coordinating care or supporting caseload management Understanding of person centred care and relational approaches Awareness of health and social care systems Knowledge of safeguarding principles
Desirable
Experience within Primary Care or PCN environment Experience with risk stratification or case management Understanding of PCN structures and NHS priorities Knowledge of population health 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 Sutton Primary Care Networks
Address Thomas Wall Centre
52 Benhill Avenue
Sutton
Surrey
SM1 4DP
United Kingdom
Employer's website https://www.suttonpcns.co.uk/ (Opens in a new tab)