Job summary
The objective of this role is to improve the health andwellbeing of patients within our network through improved screening, holisticassessment identifying and implementing a proactive approach to the managementof cancer conditions and those in remission from Cancer. This will entail amixture of clinics, home visits, research, project management and developmentas directed.
The post holder will work collaboratively with the generalpractice, other stakeholders and the wider Primary Care Network team as well asat Place level to meet the needs of patients, support the delivery of PCNobjectives, act as a role model to junior staff and demonstrate a caring andcompassionate attitude.
The post holder is expected to makeclinical and professional autonomous decisions on a daily basis. Provideclinical and professional advice to the multidisciplinary team. Analysis andassessment of patient condition to establish the continuing care plan.
Working within their scope of practice and professionalboundaries, the post holder will provide high quality care to the presentingpatient including:
Consultation and history taking, physicalassessment and examination, recording and interpretation of observations/investigations,recognising red flags and need for escalation of care, propose treatment plansand reduce admissions to hospital.
They will also demonstrate safe and competentclinical decision-making according to policies, procedures, local and nationalguidelines.
They will communicate effectively and workcollaboratively with the general practice, wider PCN team and other health andsocial care providers.
They will act professionally, according to therequirements of their regulatory body, adhere to confidentiality, and recordappropriate, accurate and contemporaneous notes.
Take a lead on the development of this rolefocussing on improving cancer screening uptake, improved experiences forpatients on a cancer pathway, support patients through treatment processes andensure advanced care planning, MCCR, RESPECT forms and PPC are implemented inan appropriate time frame.
Work with member practices to understand theirpopulation needs and develop good working relationships to support patients, toreduce crisis situations, improve screening uptake and support patients toremain in their preferred place of care. Ultimately improving Cancer careacross our PCN practice population.
Detailed responsibilities
Clinical
Identify and coordinate the implementation andevaluation of treatment/interventions and care for patients with complex needs.
Assess patient needs from a physiological and psychologicalperspective, and plan clinical care accordingly.
Liaise with wider MDT and support the managementof both acute and chronic conditions, integrating both drug- and non-drug-basedtreatment methods into a management plan.
Review medication for therapeutic effectiveness,appropriate to patient needs and in accordance with evidence-based practice andnational and practice protocols, and within scope of practice.
Work with patients to support compliance withand adherence to prescribed treatments.
Prioritise health problems and interveneappropriately to assist the patient in complex, urgent or emergency situations,including initiation of effective emergency care.
Support the completion of Advanced care planningwhere appropriate including My care choice register, RESPECT forms and PPCdocumentation.
Support practices with cancer patients that mayrapidly decline and facilitate the right services to meet the patients needs.
Work with other MDT to provide a holisticapproach to the management of individuals needs for example referral to socialprescribers or occupational therapists.
Ensure accurate and legible notes of allconsultations and treatments are recorded promptly in the patients notes onSystmOne/EMIS.
To maintain infection control standards invaried and challenging environments in line with the organisations infectioncontrol policy and procedural guidance.
To ensure the safety of patients, relatives, andcolleagues and to report all incidents and near misses in line with the riskmanagement policy.
To remain up to date with all mandatorytraining.
To maintain up-to-date knowledge of safeguardingadult and children guidance to ensure that those at risks of abuse/sufferingabuse are identified and the necessary process to protect them is followed.
To meet responsibilities as an employee as setout in the organisations corporate and clinical policies.
Leadership
Take responsibility for own continuingprofessional developmental learning, participate in self-evaluation and refection.
Lead in the development of this role, focussingon the needs of the practice population. Working with other stakeholders toeducate our population re cancer screening programmes and improving uptake ofthese.
Develop the robust cancer care reviews withinthe practices ensuring the same quality is being delivered across ourpopulation. Including development of resource pack for all to refer to.
Leading on Patient education events for healthpromotion.
Be a role model for PCN and practice staff, promotingeffective cancer care and supporting new ways of working.
Take a lead on Cancer care in the widerdevelopment of the PCN and local and National agenda.
Research
Assist in clinical audit processes, supportingdemonstration and analysis of Cancer care outcomes.
Engage and evaluate peer, patient, and serviceevaluations.
Use research and evidence-based practice toshare ideas for improvements and efficiencies.
Educational
Act as a role model to peers and positivelyrepresent your profession, organisation, and NHS.
Operate as an effective member of the PCN team.
Support and educate patients to adopt healthpromotion strategies that promote healthy lifestyles and apply principles ofself-care.
Take responsibility for maintaining a record ofown continuing professional development.
Identify and communicate learning, training, anddevelopment needs.
To recognise and understand the roles andresponsibilities of individuals working in the wider PCN.
Communication
Liaise and interact with multi-professionalteams across organisational boundaries, including primary care, social servicesand secondary care providers according to patient needs and appropriate carepathways.
Maintain communication with all healthcareprofessionals and outside agencies to ensure seamless, patient-centre serviceprovision.
Ensure effective communication so that thepatient receives the appropriate level of care and wherever possible to avoidunnecessary hospital admission.
Communicate effectively with other team members.
Communicate effectively with patients andcarers, recognising their needs for alternative methods of communication.
Positively communicate advice and guidance abouthealth promotion and lifestyle change.
Delicately and empathetically discuss sensitivetopics.
Health, safety and security
Adopt a risk-assessment approach to allactivities.
Report perceived risks to the appropriate,responsible person.
Adhere to the lone-worker policy.
Ensure patient records are recorded and stored safelyaccording to policy.
Ensure that patient identifiable information,laptops, and smartcards are transported in line with the information governancepolicy.
Quality
Alert the Clinical Lead/other team members toissues of quality and risk in the care of patients.
Ensure own actions are high quality andconsistent with clinical governance.
Practice in accordance with agreed standards ofcare.
Enable patients to access appropriateprofessionals in the team.
Ensure stock items under your control arereplenished or reported, as appropriate.
Be aware of practice-specific policies andprocedures.
Demonstrate effective time and work-loadmanagement.
Equality and diversity
Act in ways that recognises and respectspatients choices and wishes.
Respect the privacy, dignity, needs and beliefsof patients and carers.
Understand basic legal and communication issuesregarding abuse, violence, vulnerable adults, substance abuse and addictivebehaviours.
Information processes
Record daily activities and informationundertaken in an accurate and timely fashion using IT, as appropriate.
Maintain accurate and contemporaneous electronicpatient records on SystmOne/EMIS.
Maintain the confidentiality of sensitiveinformation relating to patients, relatives, staff and the practice.
Maintain accurate and contemporaneous electronicpatient records on SystmOne/EMIS.
Omit patient-identifiable information, asappropriate when sharing data.
This JD is not intended to be an exhaustive list ofactivities but rather an outline of the main areas of responsibility. The roleis likely to evolve to meet the changing needs of the service.
Person Specification
Qualifications
Essential
1. Essential
2. Registration with the Nursing & Midwifery council
3. Be able to carry out the duties of this post
4. Minimum 3 years post registration experience
5. Evidence advanced clinical skills and knowledge
6. Demonstrate understanding of personalised care approach
7. Demonstrate management of patients with complex needs
8. Knowledge of public health issues relating to the local population
9. Knowledge/understanding of the Primary Care Network Direct Enhanced Service, local ICB vision/values and how primary care fits in with the NHS Long Term Plan
10. Good understanding of current issues within in the wider NHS
11. Demonstrates professional pride.
12. Able to manage own time and prioritise work effectively.
13. Able to work well with others and deal with the challenges of ever changing and demanding situations.
14. Excellent communication skills
15. Ability to manage high pressure situations clinical crisis
16. Willingness to work flexibly in order to deliver clinically effective and cost-effective healthcare.
17. Evidence/demonstration of the sound clinical knowledge of a wide range of long-term/chronic conditions
18. Understanding of the Quality Outcome & Investment and Impact Framework (QoF & IIF)
19. Willingness to learn and develop.
20. Act as an autonomous practitioner whilst working within their scope of practice.
Desirable
21. Desirable
22. Be education to degree level or higher.
23. Good working knowledge of SystmOne/EMIS
24. Independent or supplementary prescribing qualification
25. Core knowledge of the anatomy, physiology and pathophysiology relating to chronic disease and illness
26. Holistic assessment Degree or MSC
27. Experience within a leadership and management role