PCN Complex Care Team Lead Nurse

APEX Primary Care Network

The closing date is 20 April 2025

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Job summary

APEX PCN is currently taking part in the NHSE national pilot to consider a proactive approach to meeting our patient needs. As part of this programme we are recruiting a fixed term Complex Care support team for our PCN population. This team will be assigned as a micro team to serve individual patient needs and take a consistent and personalised approach to patient care.

We are searching for a caring and motivated Lead Nurse with excellent clinical, organisational and communication skills to lead the co-ordination of the pilot team.

This is a hugely exciting opportunity for us to work closely with our identified patients through a proactive MDT approach.

Main duties of the job

This is a new role for the PCN, our ambition is to deliver a proactive, diverse and forward thinking service for the Complex Care patients within our PCN Community. The scope of the role will evolve and adapt according to the needs of the PCN and its patients as well as the skills and experience of the successful candidate. The ideal candidate will be motivated to lead the team and work closely with the PCN management and practices to drive our ambition.

The main purpose will be to provide and co-ordinate the Complex Care Service working across our PCN population. This includes leadership of the team and using clinical skills to undertake holistic assessments, health promotion, proactive work and reacting to acute visits.

You will perform an initial assessment with the identified patient cohort and continue to work with each patient based on their needs.

You will be expected to be an active member of the relevant MDT's, directing the care co-ordinator in the team and work in collaboration with the wider Complex Care Team/practices.

You will report into the PCN Manager and support the growth of the team and service.

About us

Apex Primary Care Network (PCN) is an innovative, enthusiastic and forward looking collaboration of GP practices looking after the health and wellbeing of our patients. Apex PCN consists of 4 practices which include The Woodland Medical Practice, Birchwood Medical Practice, Boultham Park Medical Practice and Richmond Medical Centre. Our PCN is committed to developing a skilled workforce that can maximise the delivery of safe, high quality and value for money healthcare services for the benefit of our local population.

Date posted

28 March 2025

Pay scheme

Other

Salary

Depending on experience

Contract

Fixed term

Duration

12 months

Working pattern

Full-time, Part-time

Reference number

A4325-25-0008

Job locations

Birchwood Medical Practice

Jasmin Road

Lincoln

Lincolnshire

LN6 0QQ


The Woodland Medical Practice

Jasmin Road

Lincoln

LN6 0QQ


Boultham Park Medical Practice

Boultham Park Road

Lincoln

LN6 7SS


Job description

Job responsibilities

Be the lead point of contact for the Complex Care team. Help build the service model with the PCN Manager. Reflect on what works and help implement change as necessary.

Lead the Complex Care Team members, supported by the PCN Manager and HR/Admin team. Provide Clinical supervision where appropriate.

Co-ordinate with the other service leads for the PCN to ensure a smooth process is formed to reduce duplication and improve efficiency. Working closely with the existing Frailty teams to ensure all strategic agenda's are achieved across the wide PCN.

Be the first point of contact to identified patients, performing an initial evaluation ie Comprehensive Assessments and personalised care plans.

Co-ordinate with the full Complex Care MDT to best action findings from the initial assessment.

Offer a holistic service to our Complex Care patients, developing where appropriate an on-going plan of care/support, with an emphasis on prevention and self-care.

Collaborative working with the practices to deliver ongoing priorities to our patients ie Comprehensive Assessments and personalised care plans.

Help reduce the patient footprint into General Practice.

Help reduce avoidable unplanned hospital admissions by improving services for vulnerable patients and those with complex physical or mental health needs, who are at high risk of hospital admissions or re-admissions.

Working with hospitals to ensure that practices receive timely information on when patients are admitted to hospital and when they are likely to be discharged from hospital and to plan better handover arrangements.

Conduct Acute visits to manage on the day demand and support the Practices, within scope of practice and competencies.

Ensure proactive care management- carrying out reviews of all unplanned GP appointments/OOH contacts, A&E admissions, re-admissions and A&E attendances for patients.

Ensuring follow up and coordination of patient care after discharge from hospital.

Taking responsibility for own development, learning and performance and demonstrating skills and activities to others in the team and ensure own educational commitment is at least sufficient to maintain revalidation requirements.

Job description

Job responsibilities

Be the lead point of contact for the Complex Care team. Help build the service model with the PCN Manager. Reflect on what works and help implement change as necessary.

Lead the Complex Care Team members, supported by the PCN Manager and HR/Admin team. Provide Clinical supervision where appropriate.

Co-ordinate with the other service leads for the PCN to ensure a smooth process is formed to reduce duplication and improve efficiency. Working closely with the existing Frailty teams to ensure all strategic agenda's are achieved across the wide PCN.

Be the first point of contact to identified patients, performing an initial evaluation ie Comprehensive Assessments and personalised care plans.

Co-ordinate with the full Complex Care MDT to best action findings from the initial assessment.

Offer a holistic service to our Complex Care patients, developing where appropriate an on-going plan of care/support, with an emphasis on prevention and self-care.

Collaborative working with the practices to deliver ongoing priorities to our patients ie Comprehensive Assessments and personalised care plans.

Help reduce the patient footprint into General Practice.

Help reduce avoidable unplanned hospital admissions by improving services for vulnerable patients and those with complex physical or mental health needs, who are at high risk of hospital admissions or re-admissions.

Working with hospitals to ensure that practices receive timely information on when patients are admitted to hospital and when they are likely to be discharged from hospital and to plan better handover arrangements.

Conduct Acute visits to manage on the day demand and support the Practices, within scope of practice and competencies.

Ensure proactive care management- carrying out reviews of all unplanned GP appointments/OOH contacts, A&E admissions, re-admissions and A&E attendances for patients.

Ensuring follow up and coordination of patient care after discharge from hospital.

Taking responsibility for own development, learning and performance and demonstrating skills and activities to others in the team and ensure own educational commitment is at least sufficient to maintain revalidation requirements.

Person Specification

Experience

Essential

  • Experience of leading a clinical team to meet objectives
  • Previous primary care experience
  • Experience with dealing with the needs of our Complex population
  • Experience of performing Holistic assessments
  • Experience of working with General Practice
  • Team working and lone working
  • Meeting deadlines
  • Prioritising workload

Desirable

  • Previous primary care experience.
  • Experience of clinical audit, evaluation research and implementation of evidence-based practice
  • Experience with home visits
  • Advanced Clinical Assessment skills

Qualifications

Essential

  • -Registered General Nurse

Desirable

  • Prescribing Qualification
  • Leadership Qualification

Additional

Essential

  • A sound understanding of the national and local health agenda
  • Willingness to undertake training at a higher level if necessary
  • Willingness to participate in clinical supervision and performance review
  • Awareness of the legal and ethical issues of the role
  • Excellent interpersonal and communication skills
  • Ability to work effectively in a multidisciplinary team as a key player
  • Information technology skills
Person Specification

Experience

Essential

  • Experience of leading a clinical team to meet objectives
  • Previous primary care experience
  • Experience with dealing with the needs of our Complex population
  • Experience of performing Holistic assessments
  • Experience of working with General Practice
  • Team working and lone working
  • Meeting deadlines
  • Prioritising workload

Desirable

  • Previous primary care experience.
  • Experience of clinical audit, evaluation research and implementation of evidence-based practice
  • Experience with home visits
  • Advanced Clinical Assessment skills

Qualifications

Essential

  • -Registered General Nurse

Desirable

  • Prescribing Qualification
  • Leadership Qualification

Additional

Essential

  • A sound understanding of the national and local health agenda
  • Willingness to undertake training at a higher level if necessary
  • Willingness to participate in clinical supervision and performance review
  • Awareness of the legal and ethical issues of the role
  • Excellent interpersonal and communication skills
  • Ability to work effectively in a multidisciplinary team as a key player
  • Information technology skills

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).

Employer details

Employer name

APEX Primary Care Network

Address

Birchwood Medical Practice

Jasmin Road

Lincoln

Lincolnshire

LN6 0QQ


Employer's website

https://www.birchwoodmedicalpractice.com/ (Opens in a new tab)

Employer details

Employer name

APEX Primary Care Network

Address

Birchwood Medical Practice

Jasmin Road

Lincoln

Lincolnshire

LN6 0QQ


Employer's website

https://www.birchwoodmedicalpractice.com/ (Opens in a new tab)

For questions about the job, contact:

PCN Business Manager

Sophie Robertson

sophie.robertson6@nhs.net

Date posted

28 March 2025

Pay scheme

Other

Salary

Depending on experience

Contract

Fixed term

Duration

12 months

Working pattern

Full-time, Part-time

Reference number

A4325-25-0008

Job locations

Birchwood Medical Practice

Jasmin Road

Lincoln

Lincolnshire

LN6 0QQ


The Woodland Medical Practice

Jasmin Road

Lincoln

LN6 0QQ


Boultham Park Medical Practice

Boultham Park Road

Lincoln

LN6 7SS


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