Specialist Practice Nurse Long Term Conditions

Work clinically to provide highly skilled evidence based long term condition management to patients as an essential part of the health care provided by the local GP Practices within the Federation / PCN.

Work flexibly; the exact nature of your sessions / clinics can be developed according to your skills and experience. However you will need to be able to work with minimal supervision and be competent to undertake comprehensive health checks for a range of clients and be skilled in the management of one or more long term conditions (e.g. Asthma, COPD, Diabetes).

Provide assessment and nursing care, advice and information to patients and carers within the Long Term Condition clinics at the Surrey Heath Hub or alternative Practice setting.

Work under the direction of the Clinical Services Manager, Clinical Team Leader or Clinical Director, using skills and knowledge as a registered nurse.,

• To hold responsibility for delivery of Long Term Condition management clinics for a defined cohort of patients and undertake holistic assessments of patients, including those with complex health needs, make a nursing diagnosis, and develop appropriate plans of care with clear timelines for evaluation.


• To be responsible for assessing, diagnosing, implementing, planning and reviewing care needs for patients in the cohort(s) in partnership with patients, carers and multi-professional teams, in line with local policies and procedures, local commissioned service requirements and best practice guidance.


• To support and participate in staff training and development to ensure delivery of high quality evidence based nursing care and clinical competence.


• To work with the wider multidisciplinary team in a proactive way with the aim of preventing hospital admission and reduce GP contact.


• To demonstrate clinical expertise and competence within the specialty and work autonomously, managing own allocated clinics independently.


• Develop effective relationships with the SHCPL Team and the practice teams. Work as part of the multi-disciplinary team (MDT).


• Communicate effectively with team members, patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating.
  
  We are Surrey Heath Community Providers Limited, which is a federation of 7 GP practices across 10 sites, covering a population of over 103,000 patients across Surrey Heath. We began in 2016 and now employ around 200 members of staff across our head office sites, and our primary care and unplanned care services.


As a GP Federation, we are proud to represent our member practices and to champion primary care by working with local general practice and system partners in the provision of community-based healthcare services. We are dedicated to providing safe and compassionate care to our patients across our range of primary care and unplanned healthcare services in Surrey Heath, and believe in continuous commitment to quality service delivery and positive patient outcomes.

Patients are at the heart of everything we do, and we pride ourselves in ensuring our patients feel safe, supported, communicated with and respected, at a time when they may be feeling vulnerable. Our vision is to provide high quality, seamless health care that enables people to lead healthier lives, whilst feeling supported and cared for.