About this role
Job summary
The post holder will work collaboratively with GP practices, secondary care, community services, voluntary organisations, and multidisciplinary teams to ensure patients receive timely interventions, appropriate information, emotional support, and access to the services they need.
Main duties of the job
Act as a named point of contact for patients throughout their cancer pathway. Provide regular check-ins with patients from diagnosis through treatment and into recovery or their transition to palliative care . Support patients in understanding their diagnosis, treatment plans, and available services. Coordinate care across primary care, hospital teams, community providers, social care, and voluntary organisations. Ensure patients do not feel lost within the healthcare system by helping them navigate appointments, referrals, investigations, and follow-up care. Monitor patient progress and identify concerns early, escalating where appropriate. Undertake holistic needs assessments at appropriate stages of the cancer pathway. Develop personalised care and support plans with patients and carers. Identify physical, psychological, emotional, financial, practical, and social needs. Review care plans regularly and adapt them according to changing patient needs. Support patients to maximise recovery following cancer treatment. Promote healthy lifestyle changes including physical activity, nutrition and weight management, smoking cessation, and emotional wellbeing. Encourage self-management and confidence in living with and beyond cancer. Signpost patients to rehabilitation programmes, wellbeing services, support groups, and community resources.
About us
COCO PCN is a collaborative partnership between three GP practices in West Surrey & Sussex: Chertsey Health Centre, Ottershaw Surgery and Crouch Oak Family Practice. We are a forward-thinking, community-focused PCN committed to delivering joined-up, proactive and personalised care closer to home.
We are passionate about developing and empowering our workforce. With two training practices, we actively promote learning, upskilling and knowledge-sharing across our teams. We aim to create a happy, supportive and knowledgeable workforce where colleagues feel valued, confident and empowered to contribute to improving our services and the care we provide. The Cancer Nurse will provide personalised, compassionate, and coordinated care to patients from the point of cancer diagnosis through treatment, recovery, rehabilitation. The role is designed to ensure that patients experience a seamless journey through health and care services by acting as a consistent point of contact, reducing fragmentation of care, and supporting patients to focus on their recovery and wellbeing.
Job description Job responsibilities
Key Responsibilities
Patient Care Coordination
Act as a named point of contact for patients throughout their cancer pathway. Provide regular check-ins with patients from diagnosis through treatment and into recovery or their transition to palliative care . Support patients in understanding their diagnosis, treatment plans, and available services. Coordinate care across primary care, hospital teams, community providers, social care, and voluntary organisations. Ensure patients do not feel lost within the healthcare system by helping them navigate appointments, referrals, investigations, and follow-up care. Monitor patient progress and identify concerns early, escalating where appropriate. Holistic Needs Assessment
Undertake holistic needs assessments at appropriate stages of the cancer pathway. Develop personalised care and support plans with patients and carers. Identify physical, psychological, emotional, financial, practical, and social needs. Review care plans regularly and adapt them according to changing patient needs. Recovery and Wellbeing
Support patients to maximise recovery following cancer treatment. Promote healthy lifestyle changes including physical activity, nutrition and weight management, smoking cessation, and emotional wellbeing. Encourage self-management and confidence in living with and beyond cancer. Signpost patients to rehabilitation programmes, wellbeing services, support groups, and community resources. Joined-Up Working
Work closely with GPs, practice nurses, specialist cancer teams, community nursing services, allied health professionals, social prescribing teams, mental health services, palliative care, and voluntary sector organisations. Have a clear understanding of their own professional competencies and limitations ie when to involve another clinician in the practice Facilitate communication between professionals to improve continuity of care. Participate in multidisciplinary team meetings where appropriate. Advocate for patients to ensure timely access to appropriate services. Clinical Support
Provide evidence-based advice within the scope of professional practice. Recognise deterioration or unmet needs and arrange appropriate intervention. Assessment to include identifying oncological emergencies. Support symptom management and treatment side effect monitoring where appropriate. Maintain accurate clinical documentation in accordance with organisational policies. Patient Education
Provide clear information regarding diagnosis, treatment, recovery, surveillance, and available support services. Empower patients and families to make informed decisions about their care. Provide emotional support throughout the cancer journey. Quality Improvement
Contribute to service development and continuous quality improvement. Support audits and data collection relating to cancer pathways and patient outcomes. Maintain accurate records and contribute to performance reporting where required.
Person Specification
Qualifications Essential
Essential Registered Nurse with current NMC registration. Demonstrable knowledge of cancer treatments for patients with cancer Experience within primary care, community nursing, oncology, or palliative care. Excellent communication and interpersonal skills. Experience of care coordination and multidisciplinary working. Ability to undertake holistic assessments. Ability to identify deterioration or potential oncological emergencies in telephone consultations and liaise appropriately with GP and secondary care. Knowledge of psychological impact of a cancer diagnosis especially within context of pre-existing mental health concerns or history of traumatic experiences Knowledge of cancer pathways and survivor-ship Ability to work independently while contributing effectively within a multidisciplinary team. Good organisational and time management skills. Competent IT skills and experience using electronic patient records.
Desirable
Cancer nursing qualification or relevant postgraduate study. Ability to discuss how treatments work and common side effects Advance communication skills training qualification Health coaching experience or qualification Experience in service development or quality improvement.
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.
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details Employer name Crouch Oak Family Practice
Address 45 Station Road
Addlestone
Surrey
KT15 2BH
United Kingdom
Employer's website http://crouchoak.nhs.uk/ (Opens in a new tab)