Job summary
The MDT Clinician play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide co-ordination and navigation of care and support across health and care services.
Work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to people and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.
This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
The MDT Clinician role is intended to become an integral part of the PCNs multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.
Main duties of the job
To
support the delivery of personalised, proactive, and holistic care within the
Primary Care Network PCN, working as part of a multidisciplinary team MDT
Participate
in MDT meetings to support the development and implementation of integrated
care plans
Collaborate
with community teams, families, carers, and external partners to support
coordinated care delivery
Support
the delivery of necessary care to patients with frailty, complex needs, or
long-term conditions, focusing on prevention, early intervention, and reducing
avoidable hospital admissions.
Undertake
basic clinical assessments and observations under the supervision of a
registered healthcare professional
Support
the coordination and implementation of personalised care plans reflecting
patient preferences, goals, and needs
Carry
out home visits for assessment, monitoring, and delivery of care as appropriate
Promote
self-care, patient empowerment, and independence through education and coaching
approaches
About us
Sutton has a population of approximately 200,000 residents registered to 21 practices and there are currently 4 Primary Care Networks (PCNs); Carshalton, Cheam & South Sutton, Central Sutton and Wallington PCN; each serving a population of approximately 50,000 patients. PCNs form a key building block of the NHS long-term plan. Bringing general practices together to work at scale has been a policy priority for some years for a range of reasons, including improving the ability of practices to recruit and retain staff; to manage financial and estates pressures; to provide a wider range of services to patients and to more easily integrate with the wider health and care system. (The Kings Fund, Primary Care Networks Explained, 1.7.19)
Our Sutton PCNs are forward-looking, friendly and focused on providing a wide range of excellent healthcare services to patients in Sutton and the surrounding area.Our PCNs between them are led 9 PCN Clinical Directors. The PCNs work together as they see the benefits of working together in a larger GP partnership and are delighted to be realising some of those benefits now. Because of our scale, not only are we more resilient and efficient but we are able to invest in continuous quality improvement, enhanced care, new services and training and developing our workforce. We value the diversity of our colleagues and actively champion an inclusive culture and are committed to helping our colleagues achieve a work/life balance.
Job description
Job responsibilities
- Perform baseline physical observations during initial assessment home visit appointments and pre-assessment checks.
- Support holistic care needs assessments of patients to identify any unmet care needs.
- Refer patients to appropriate services that can assist with meeting outstanding care needs.
- Review and assess referral information as soon as the referral is received to establish clear goals and objectives.
- Ensure all additional information provided by an individual or their representatives is shared with the MDT in a timely manner.
- Participate in weekly referral triage meetings to assist in identifying appropriate referrals.
- Act as the direct line manager for the PAC MDT Coordinators, providing supervision, support and oversight of their day-to-day activities.
- Support the PAC MDT coordinators to ensure that GP/complex meetings are arranged, coordinated, and communicated, with all necessary information available in a timely manner.
- Participate in Complex MDT meetings and monthly PCN GP Meetings to communicate patient needs and establish clear actions for each party to aid the implementation of the patients care plan as required.
- Ensure all records are comprehensive, complete, available. Update patients records and universal care plan in timely manner to ensure coordinators and other service providers have access to any patient updates/progress.
- Contribute to final decision-making of MDT eligibility recommendations in a fair, inclusive, and impartial way, utilising clinical knowledge as required.
- Present yourself as an ambassador for the service and attend external practice/service meetings to promote the PAC MDT service when necessary.
- Collaborate with the team to ensure safe, efficient, and effective care, compatible with national clinical standards.
- Attend relevant MDT meetings as required.
- Ensure that all MDT clinical policies are fully adhered to.
Support the PAC MDT coordinators with arranging visits and managing clinicians' appointments and diaries
- Assist with undertaking non-clinical audits to ensure promote compliance with service policy.
- Participate in evaluating patient goals and outcomes to help guide ongoing care plans and support improvements within the service.
- Direct patients to suitable services and resources to support their empowerment and enable them to manage their own health.
- Must have a full, clean driving licence and access to a car for home visits
- Communication:
The post-holder should recognise the importance of effective communication within the team and will strive to:
- Promote effective communication and relationships within the nursing team
- Communicate effectively with other team members, including the Community Services, Social Services, INTS and Voluntary Organisations staffs as required.
- Communicate effectively with patients, their families and carers
- Recognise peoples needs for alternative methods of communication and respond accordingly
- Work collaboratively with colleagues within and external to the PCN5.
- Personal/Professional Development:
Ensure all records are accurate, complete and permanent in line with national and organisational policy
Be aware of personal limitations in knowledge and practice and seek appropriate advice from clinical colleagues.
Monitor effectiveness of own clinical practice through audit and peer review.
Participate in continuing professional development opportunities to ensure that up-to-date evidence based knowledge and competence in aspects of the role is maintained.
Work collaboratively with all colleagues within and outside of the organisation.
To identify with the support of line manager appropriate areas of personal development.
To undertake training as required including mandatory and statutory training, core skills training and on-going developmental training. Assess own preferred learning methods and to adapt learning as required.
All staff have a responsibility to participate in the organisations appraisal scheme.
To actively participate in on-going one to one meetings with line manager to review development and performance.
To attend and participate in meetings as required.
To alert line manager and other team members to issues of quality and risk.
To assess own performance and take accountability for own actions.
To contribute to the effectiveness of the team by reflecting on own and teams performance and making suggestions to improve and enhance activities.
To work effectively with individuals in external agencies to meet patient needs.
Safeguarding Children and Adults
The PCNs are committed to safeguarding and promoting the welfare of children, young people (anyone under the age of 18) and adults. It expects all staff to share this commitment and act in such a way that safeguards and promotes the health and wellbeing of children, young people and adults.
- MDT clinicians must ensure that they are familiar with the signs and symptoms of abuse and know what to do if any such concerns are raised.
- Staff are expected to know about and how to follow safeguarding children and safeguarding adult policies.
- All employees working in at PCNs have a contractual right and a duty to raise genuine concerns they have with their employer about malpractice, patient safety, financial impropriety, or any other serious risks they consider to be in the public interest. PCNs have local policies in place that emphasise that it is safe and acceptable for staff to raise concerns.
Service Development
The MDT clinicians will:
- To work with the nursing, clinical and management teams to review the delivery of care within the evolving structure of MDT services.
- Identify areas of service development and provide support in implementing change within the MDT Nursing team
- Participate in audit where appropriate
Job description
Job responsibilities
- Perform baseline physical observations during initial assessment home visit appointments and pre-assessment checks.
- Support holistic care needs assessments of patients to identify any unmet care needs.
- Refer patients to appropriate services that can assist with meeting outstanding care needs.
- Review and assess referral information as soon as the referral is received to establish clear goals and objectives.
- Ensure all additional information provided by an individual or their representatives is shared with the MDT in a timely manner.
- Participate in weekly referral triage meetings to assist in identifying appropriate referrals.
- Act as the direct line manager for the PAC MDT Coordinators, providing supervision, support and oversight of their day-to-day activities.
- Support the PAC MDT coordinators to ensure that GP/complex meetings are arranged, coordinated, and communicated, with all necessary information available in a timely manner.
- Participate in Complex MDT meetings and monthly PCN GP Meetings to communicate patient needs and establish clear actions for each party to aid the implementation of the patients care plan as required.
- Ensure all records are comprehensive, complete, available. Update patients records and universal care plan in timely manner to ensure coordinators and other service providers have access to any patient updates/progress.
- Contribute to final decision-making of MDT eligibility recommendations in a fair, inclusive, and impartial way, utilising clinical knowledge as required.
- Present yourself as an ambassador for the service and attend external practice/service meetings to promote the PAC MDT service when necessary.
- Collaborate with the team to ensure safe, efficient, and effective care, compatible with national clinical standards.
- Attend relevant MDT meetings as required.
- Ensure that all MDT clinical policies are fully adhered to.
Support the PAC MDT coordinators with arranging visits and managing clinicians' appointments and diaries
- Assist with undertaking non-clinical audits to ensure promote compliance with service policy.
- Participate in evaluating patient goals and outcomes to help guide ongoing care plans and support improvements within the service.
- Direct patients to suitable services and resources to support their empowerment and enable them to manage their own health.
- Must have a full, clean driving licence and access to a car for home visits
- Communication:
The post-holder should recognise the importance of effective communication within the team and will strive to:
- Promote effective communication and relationships within the nursing team
- Communicate effectively with other team members, including the Community Services, Social Services, INTS and Voluntary Organisations staffs as required.
- Communicate effectively with patients, their families and carers
- Recognise peoples needs for alternative methods of communication and respond accordingly
- Work collaboratively with colleagues within and external to the PCN5.
- Personal/Professional Development:
Ensure all records are accurate, complete and permanent in line with national and organisational policy
Be aware of personal limitations in knowledge and practice and seek appropriate advice from clinical colleagues.
Monitor effectiveness of own clinical practice through audit and peer review.
Participate in continuing professional development opportunities to ensure that up-to-date evidence based knowledge and competence in aspects of the role is maintained.
Work collaboratively with all colleagues within and outside of the organisation.
To identify with the support of line manager appropriate areas of personal development.
To undertake training as required including mandatory and statutory training, core skills training and on-going developmental training. Assess own preferred learning methods and to adapt learning as required.
All staff have a responsibility to participate in the organisations appraisal scheme.
To actively participate in on-going one to one meetings with line manager to review development and performance.
To attend and participate in meetings as required.
To alert line manager and other team members to issues of quality and risk.
To assess own performance and take accountability for own actions.
To contribute to the effectiveness of the team by reflecting on own and teams performance and making suggestions to improve and enhance activities.
To work effectively with individuals in external agencies to meet patient needs.
Safeguarding Children and Adults
The PCNs are committed to safeguarding and promoting the welfare of children, young people (anyone under the age of 18) and adults. It expects all staff to share this commitment and act in such a way that safeguards and promotes the health and wellbeing of children, young people and adults.
- MDT clinicians must ensure that they are familiar with the signs and symptoms of abuse and know what to do if any such concerns are raised.
- Staff are expected to know about and how to follow safeguarding children and safeguarding adult policies.
- All employees working in at PCNs have a contractual right and a duty to raise genuine concerns they have with their employer about malpractice, patient safety, financial impropriety, or any other serious risks they consider to be in the public interest. PCNs have local policies in place that emphasise that it is safe and acceptable for staff to raise concerns.
Service Development
The MDT clinicians will:
- To work with the nursing, clinical and management teams to review the delivery of care within the evolving structure of MDT services.
- Identify areas of service development and provide support in implementing change within the MDT Nursing team
- Participate in audit where appropriate
Person Specification
Experience
Essential
- Minimum of 2 years experience working as a Health Care Assistant
- Experience in a primary care, GP surgery, or community health setting
- Experience working in a multidisciplinary team (MDT)
- Experience conducting clinical observations and holistic assessments
- Understanding of protocols and clinical guidelines
- Ability to manage change
- Understanding of developing MDT Services
- Ability to support patients to change lifestyle
- Good understanding of clinical governance
Desirable
- Motivational interviewing/coaching
- Experience with patients with long-term conditions, frailty, or complex needs
- Experience with undertaking home visits
- Experience with proactive care pathways or anticipatory care planning
- Previous experience of using EMIS
- Experience line managing or supervising junior staff
Motivational & Personal Characteristics
Essential
- Ability to work effectively with other members of the team and other partners and agencies.
- Commitment to on-going personal and professional development
- Maintaining clinical practice and further developing competence and performance.
- To keep up to date and adhere to current legislation as appropriate
- Commitment to working in the NHS and improving the care given to patients and the health outcomes for deprived or traditionally hard to reach members of the local community.
- Self-motivated with a flexible and proactive approach
- Ability to organise and prioritise workload
- Ability to work flexibly to meet service needs
- Commitment to provide effective and high quality service
- Ability to work in a multi-professional team and across boundaries and develop good working relationships with team members
- Values and respects the different cultures and beliefs of patients and colleagues.
Desirable
- Ability to be self-directed
- Innovator
Qualifications
Essential
- NVQ Level 3 in Health and Social Care/Care Certificate or equivalent
- Previous experience working as a HCA or HCSW
- Evidence of appropriate continuing professional development and education to maintain up to date knowledge
Desirable
- Foundation degree or Associate Practitioner qualification
- Leadership/supervisory training
- Training in coaching, motivational interviewing, or care navigation
Skills, Abilities & Knowledge Required
Essential
- MDT Clinical skills
- Awareness of the structure and working of a GP Surgery
- Effective time management skills
- Good communication skills
- Ability to analyse and understand information arising from patient assessments.
- Ability to assess patients risk effectively and safely
- Management of patients with complex needs
- Ability to remain calm and professional in an emergency
- Ability to work as part of a multidisciplinary team
- Ability to electronically maintain accurate and or written records
- Understanding of primary care infection control
- Understanding of safeguarding principles
- Understanding of evidence based practice
- Ability to work within a confidentiality policy
- Assist in undertaking clinical audits
- Understanding of Equality Acts 2010
- Good IT skills
Desirable
- Willingness to participate in clinical supervision and performance review
- Willingness to undertake training at a higher level if necessary
- Work within a multicultural environment
- Awareness of clinical governance issues in primary care
- Familiarity with national policies (e.g. NHS 10 Year Plan)
- Understanding of social prescribing and integrated neighbourhood teams
- Knowledge of the Universal Care Plan (UCP)
- Recognises and understands the important of chronic disease management and rehabilitation in the community
- Understanding of local & national health policy
Person Specification
Experience
Essential
- Minimum of 2 years experience working as a Health Care Assistant
- Experience in a primary care, GP surgery, or community health setting
- Experience working in a multidisciplinary team (MDT)
- Experience conducting clinical observations and holistic assessments
- Understanding of protocols and clinical guidelines
- Ability to manage change
- Understanding of developing MDT Services
- Ability to support patients to change lifestyle
- Good understanding of clinical governance
Desirable
- Motivational interviewing/coaching
- Experience with patients with long-term conditions, frailty, or complex needs
- Experience with undertaking home visits
- Experience with proactive care pathways or anticipatory care planning
- Previous experience of using EMIS
- Experience line managing or supervising junior staff
Motivational & Personal Characteristics
Essential
- Ability to work effectively with other members of the team and other partners and agencies.
- Commitment to on-going personal and professional development
- Maintaining clinical practice and further developing competence and performance.
- To keep up to date and adhere to current legislation as appropriate
- Commitment to working in the NHS and improving the care given to patients and the health outcomes for deprived or traditionally hard to reach members of the local community.
- Self-motivated with a flexible and proactive approach
- Ability to organise and prioritise workload
- Ability to work flexibly to meet service needs
- Commitment to provide effective and high quality service
- Ability to work in a multi-professional team and across boundaries and develop good working relationships with team members
- Values and respects the different cultures and beliefs of patients and colleagues.
Desirable
- Ability to be self-directed
- Innovator
Qualifications
Essential
- NVQ Level 3 in Health and Social Care/Care Certificate or equivalent
- Previous experience working as a HCA or HCSW
- Evidence of appropriate continuing professional development and education to maintain up to date knowledge
Desirable
- Foundation degree or Associate Practitioner qualification
- Leadership/supervisory training
- Training in coaching, motivational interviewing, or care navigation
Skills, Abilities & Knowledge Required
Essential
- MDT Clinical skills
- Awareness of the structure and working of a GP Surgery
- Effective time management skills
- Good communication skills
- Ability to analyse and understand information arising from patient assessments.
- Ability to assess patients risk effectively and safely
- Management of patients with complex needs
- Ability to remain calm and professional in an emergency
- Ability to work as part of a multidisciplinary team
- Ability to electronically maintain accurate and or written records
- Understanding of primary care infection control
- Understanding of safeguarding principles
- Understanding of evidence based practice
- Ability to work within a confidentiality policy
- Assist in undertaking clinical audits
- Understanding of Equality Acts 2010
- Good IT skills
Desirable
- Willingness to participate in clinical supervision and performance review
- Willingness to undertake training at a higher level if necessary
- Work within a multicultural environment
- Awareness of clinical governance issues in primary care
- Familiarity with national policies (e.g. NHS 10 Year Plan)
- Understanding of social prescribing and integrated neighbourhood teams
- Knowledge of the Universal Care Plan (UCP)
- Recognises and understands the important of chronic disease management and rehabilitation in the community
- Understanding of local & national health policy
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).
Additional information
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).
