Long Term Condition Nurse Lead

Clinical Care and Long-Term Condition Management. Lead the delivery and development of long-term condition management within the practice. Undertake comprehensive annual reviews, assessments and follow-up appointments for patients with chronic disease. Provide holistic, evidence-based care that supports prevention, early intervention, self-management and improved health outcomes. Work within agreed clinical protocols, national guidance, local pathways and professional scope of practice. Ensure care is personalised, inclusive and responsive to patient needs, preferences and health literacy. Diabetes Management. Lead diabetes care within the practice, including annual reviews and ongoing monitoring. Assess, plan and evaluate care for patients using oral therapies, GLP-1 therapies and insulin. Initiate and titrate insulin where competent, appropriately trained and authorised to do so. Interpret and act on HbA1c results, blood glucose data, cardiovascular risk factors and other relevant investigations. Support structured education, lifestyle advice and self-management planning for patients with diabetes. Respiratory Disease Management. Lead asthma and COPD services within the practice. Conduct annual reviews and optimise treatment in accordance with current clinical guidance and local pathways. Perform and interpret spirometry and FeNO testing where trained and competent. Support accurate diagnosis, monitoring and escalation of respiratory disease. Provide inhaler technique education, personalised action plans and self-management support. Cardiovascular Disease and Prevention. Manage patients with hypertension, coronary heart disease, stroke/TIA, atrial fibrillation and heart failure within agreed scope of practice. Support lipid management, cardiovascular risk reduction and optimisation of therapy. Promote prevention, lifestyle interventions and shared decision-making. Identify patients at increased risk and support proactive review, monitoring and follow-up. Clinical Leadership and Service Development. Act as a clinical resource for colleagues in relation to long-term condition management. Support, mentor and provide clinical guidance to nursing and HCA colleagues. Contribute to the development, review and implementation of clinical protocols, templates and practice processes. Participate in multidisciplinary team working, population health initiatives and case discussions where appropriate. Identify opportunities for service improvement and support implementation of change. QOF, Audit and Quality Improvement. Work proactively to identify patients requiring review, monitoring or follow-up. Support achievement of QOF indicators, enhanced service requirements and local improvement priorities. Maintain accurate clinical coding, high-quality records and contemporaneous documentation. Contribute to clinical audits, searches, recall activity and quality improvement projects. Use data to identify care gaps, variation and opportunities to improve outcomes for patients with long-term conditions. Professional Responsibilities. Maintain active NMC registration and work in accordance with the NMC Code. Work within own level of competence and seek support or escalate concerns where required. Maintain confidentiality, information governance standards and accurate patient records. Participate in appraisal, supervision, mandatory training and continuing professional development. Contribute to a positive, supportive and collaborative practice culture. Promote equality, diversity, inclusion and respectful care for patients and colleagues. Qualifications and Experience Essential. Registered Nurse with current NMC registration. Evidence of continued professional development relevant to long-term condition management. Significant experience managing long-term conditions within primary care or a comparable clinical setting. Demonstrable expertise in diabetes care, including supporting patients using insulin therapy. Experience managing asthma, COPD, hypertension and cardiovascular disease. Experience working with QOF targets, recall systems, clinical coding and quality improvement activity. Ability to work autonomously and make safe, complex clinical decisions within scope of practice. Excellent communication, consultation and patient education skills. Desirable. Independent Prescribing qualification or willingness to work towards this. Experience initiating and titrating insulin. Competence in performing and interpreting spirometry and FeNO testing. Experience leading services, supervising colleagues or supporting clinical education. Knowledge of population health management, digital tools and data-driven improvement in primary care. Key Skills and Attributes Strong clinical knowledge of long-term condition management and preventative healthcare. Confident, compassionate and patient-centred approach to care. Ability to prioritise workload, manage time effectively and respond to changing clinical demand. High standard of clinical documentation, coding and attention to detail. Ability to work collaboratively within a multidisciplinary team. Commitment to learning, service improvement and improving patient outcomes. Working Relationships.The post holder will work closely with GP Partners, salaried GPs, Advanced Nurse Practitioners, Practice Nurses, HCAs, pharmacists, care coordinators, administrative teams and wider community or specialist services to support coordinated care for patients with long-term conditions. Key Performance Indicators. Achievement and maintenance of relevant QOF indicators and enhanced service requirements for long-term conditions, in line with practice targets. Timely completion of annual reviews and follow-up appointments for patients with diabetes, asthma, COPD, hypertension and cardiovascular disease. Reduction in avoidable care gaps through proactive recall, monitoring and review of patients with long-term conditions. Accurate and consistent clinical coding, documentation and use of agreed templates to support safe care and reliable reporting. Evidence of appropriate medicines optimisation, escalation and referral within scope of practice and agreed clinical pathways. Delivery of high-quality patient education, self-management support and personalised care planning. Contribution to clinical audit, quality improvement projects and service development activity relating to long-term condition care. Effective clinical leadership, supervision and support for nursing and HCA colleagues involved in chronic disease management. Positive feedback from patients and colleagues, with concerns, complaints or incidents responded to appropriately and used for learning. Compliance with mandatory training, NMC professional requirements, practice policies, information governance and safeguarding responsibilities. Review of Job Description. This job description is intended to outline the main duties and responsibilities of the role. It is not exhaustive and may be reviewed and amended in consultation with the post holder to reflect the changing needs of the practice, patients and wider primary care services. Job description Job responsibilities Clinical Care and Long-Term Condition Management. Lead the delivery and development of long-term condition management within the practice. Undertake comprehensive annual reviews, assessments and follow-up appointments for patients with chronic disease. Provide holistic, evidence-based care that supports prevention, early intervention, self-management and improved health outcomes. Work within agreed clinical protocols, national guidance, local pathways and professional scope of practice. Ensure care is personalised, inclusive and responsive to patient needs, preferences and health literacy. Diabetes Management. Lead diabetes care within the practice, including annual reviews and ongoing monitoring. Assess, plan and evaluate care for patients using oral therapies, GLP-1 therapies and insulin. Initiate and titrate insulin where competent, appropriately trained and authorised to do so. Interpret and act on HbA1c results, blood glucose data, cardiovascular risk factors and other relevant investigations. Support structured education, lifestyle advice and self-management planning for patients with diabetes. Respiratory Disease Management. Lead asthma and COPD services within the practice. Conduct annual reviews and optimise treatment in accordance with current clinical guidance and local pathways. Perform and interpret spirometry and FeNO testing where trained and competent. Support accurate diagnosis, monitoring and escalation of respiratory disease. Provide inhaler technique education, personalised action plans and self-management support. Cardiovascular Disease and Prevention. Manage patients with hypertension, coronary heart disease, stroke/TIA, atrial fibrillation and heart failure within agreed scope of practice. Support lipid management, cardiovascular risk reduction and optimisation of therapy. Promote prevention, lifestyle interventions and shared decision-making. Identify patients at increased risk and support proactive review, monitoring and follow-up. Clinical Leadership and Service Development. Act as a clinical resource for colleagues in relation to long-term condition management. Support, mentor and provide clinical guidance to nursing and HCA colleagues. Contribute to the development, review and implementation of clinical protocols, templates and practice processes. Participate in multidisciplinary team working, population health initiatives and case discussions where appropriate. Identify opportunities for service improvement and support implementation of change. QOF, Audit and Quality Improvement. Work proactively to identify patients requiring review, monitoring or follow-up. Support achievement of QOF indicators, enhanced service requirements and local improvement priorities. Maintain accurate clinical coding, high-quality records and contemporaneous documentation. Contribute to clinical audits, searches, recall activity and quality improvement projects. Use data to identify care gaps, variation and opportunities to improve outcomes for patients with long-term conditions. Professional Responsibilities. Maintain active NMC registration and work in accordance with the NMC Code. Work within own level of competence and seek support or escalate concerns where required. Maintain confidentiality, information governance standards and accurate patient records. Participate in appraisal, supervision, mandatory training and continuing professional development. Contribute to a positive, supportive and collaborative practice culture. Promote equality, diversity, inclusion and respectful care for patients and colleagues. Qualifications and Experience Essential. Registered Nurse with current NMC registration. Evidence of continued professional development relevant to long-term condition management. Significant experience managing long-term conditions within primary care or a comparable clinical setting. Demonstrable expertise in diabetes care, including supporting patients using insulin therapy. Experience managing asthma, COPD, hypertension and cardiovascular disease. Experience working with QOF targets, recall systems, clinical coding and quality improvement activity. Ability to work autonomously and make safe, complex clinical decisions within scope of practice. Excellent communication, consultation and patient education skills. Desirable. Independent Prescribing qualification or willingness to work towards this. Experience initiating and titrating insulin. Competence in performing and interpreting spirometry and FeNO testing. Experience leading services, supervising colleagues or supporting clinical education. Knowledge of population health management, digital tools and data-driven improvement in primary care. Key Skills and Attributes Strong clinical knowledge of long-term condition management and preventative healthcare. Confident, compassionate and patient-centred approach to care. Ability to prioritise workload, manage time effectively and respond to changing clinical demand. High standard of clinical documentation, coding and attention to detail. Ability to work collaboratively within a multidisciplinary team. Commitment to learning, service improvement and improving patient outcomes. Working Relationships.The post holder will work closely with GP Partners, salaried GPs, Advanced Nurse Practitioners, Practice Nurses, HCAs, pharmacists, care coordinators, administrative teams and wider community or specialist services to support coordinated care for patients with long-term conditions. Key Performance Indicators. Achievement and maintenance of relevant QOF indicators and enhanced service requirements for long-term conditions, in line with practice targets. Timely completion of annual reviews and follow-up appointments for patients with diabetes, asthma, COPD, hypertension and cardiovascular disease. Reduction in avoidable care gaps through proactive recall, monitoring and review of patients with long-term conditions. Accurate and consistent clinical coding, documentation and use of agreed templates to support safe care and reliable reporting. Evidence of appropriate medicines optimisation, escalation and referral within scope of practice and agreed clinical pathways. Delivery of high-quality patient education, self-management support and personalised care planning. Contribution to clinical audit, quality improvement projects and service development activity relating to long-term condition care. Effective clinical leadership, supervision and support for nursing and HCA colleagues involved in chronic disease management. Positive feedback from patients and colleagues, with concerns, complaints or incidents responded to appropriately and used for learning. Compliance with mandatory training, NMC professional requirements, practice policies, information governance and safeguarding responsibilities. Review of Job Description. This job description is intended to outline the main duties and responsibilities of the role. It is not exhaustive and may be reviewed and amended in consultation with the post holder to reflect the changing needs of the practice, patients and wider primary care services.