- Working with our team of GPs, nurses, pharmacists and admin staff to co-ordinate annual health checks for chronic disease and long term conditions - Work directly with patients to offer support at home, and identify health care needs through a holistic assessment - Create annual care plans for patients (PCSP personalised care and support plan) - Alert our clinical team to any identified concerns including safeguarding issues - Support patients to use decision making aids, provide written information to support their health needs and signpost to other agencies that can help support them to maximise their health - Assist with lifestyle changes on a personal or population level. This might include running in house programs, or co-ordinating with local agencies to encourage patients to improve their lifestyle to improve their health and well being