Go to a more accessible version of this jobs board
Please wait, loading

Long term condition nurse/practitioner

Band 7 (indicative)

Main area
Population health management
Band 7 (indicative)
Fixed term: 12 months (secondment would also be considered)
Full time - 37.5 hours per week
Job ref
MCH House
£41,659 - £47,672 per annum
Salary period
06/12/2022 23:59

Do you want to be part of an award winning and dynamic social enterprise that:

  • is renowned for providing high quality care and is ranked ‘Good’ by the CQC;
  • is a for-better-profit organisation, reinvesting any surplus back into our health and care services and our local community;
  • is friendly, ambitious, welcomes innovation and rewards excellence;
  • offers superior benefits; everything you get in the NHS and more;
  • and whose achievements reflect the passion, dedication and commitment demonstrated by our staff across all services?

Our vision is to be a successful, vibrant, community interest company that benefits the communities we serve. So if you want be a part of this, we would love to hear from you.

Job overview

Population health management (PHM) is a partnership approach across the NHS, other public sector services including the voluntary sector and the public, all of which have a role to play in addressing the interdependent issues that affect people’s health and wellbeing. It is an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population by working together as a system.

The clinical lead for PHM  will proactively identify and manage treatment plans for patients at risk of developing a long-term conditions as identified through agreed risk stratification mechanisms (as appropriate). They will prescribe and review medication for therapeutic effectiveness, appropriate to patient needs and in accordance with evidence-based practice and national and practice protocols and formularies. The successful applicant will work with patients and their carers to support compliance with and adherence to prescribed treatments as well as provide information and advice on prescribed or over-the-counter medication on medication regimens, side-effects and interactions. They will support patients to adopt health promotion strategies that promote healthy lifestyles and apply principles of self-care.

Main duties of the job

  • Identify opportunities, and support GP practices and the local Health and Care Partnership (HCP) to reduce clinical variation and develop a culture of on-going improved care for patients with a focus on population health management.
  • Work under the direction of the Clinical Variation Programme Manager and as part of the Integrated Care Partnership Team.
  • Provide the data links to support the wider population health management work and as such is the critical link between Medway and Swale , individual practices, the Local Care Teams, local authority and the wider system.

Working for our organisation

So what else?

  • This is your chance to join a progressive and innovative service in a social enterprise that is patient and staff focused - you’ll even have the opportunity to become an MCH shareholder.
  • We encourage staff to get involved in exploring new ways of working and service development.
  • We’ll provide well established, in-service training, one to one supervision, and appraisals with regular support.
  • You’ll be able to develop your skills in a friendly and supportive team.

Would you like to work flexibly?  In the NHS, we are reminded every day of how important life is. As a flexible working friendly organisation, we want to be sure that you can work in a way that is best for us, for our patients and for you. Speak to us about how we might be able to accommodate a flexible working arrangement which will not mean sacrificing time for personal interests or family commitments. We aim to support you to work flexibly in a way that will suit you and us.

The small print

  • Informal visits can be arranged on request.
  • We will offer you the choice of two pension schemes; the NHS Pension scheme and the scottish widows group pension scheme.
  • MCH encourages all staff to be double COVID vaccinated to protect themselves, their colleagues, their family and their patients.

Detailed job description and main responsibilities

  1. Communication and relationship skills
  • To provide and receive highly complex, sensitive or contentious information where there may be significant barriers to acceptance which needs to be overcome by using a high level of interpersonal and communication skills.
  • Relationships will be critical to the success of the post. The post holder will pro-actively develop strong working relationships with GPs, Public Health and wider system colleagues to ensure that the objectives of the H&CP population health management programme are met.
  • There will be a responsibility to support partnership working with a wide range of stakeholders to promote integrated whole system delivery of safe, effective and personalised care and continuously seek to reduce clinical variation and improve quality outcomes for the Medway and Swale populations.
  • Ability to present highly complex, sensitive and/or contentious information in relation to population health management to a variety of audiences in terms of size and level.
  • To be able to appropriately deliver the key messages and deal with any contentious, hostile and difficult conversations across a wide breadth of communications.


  1. Knowledge, training and experience
  • Hold a Degree in a health/Management related subject or hold a professional qualification in data analysis or be able to evidence experience of health service management including change management, or be able to demonstrate relevant equivalent experience.
  • Experience of working in a primary care setting.
  • Knowledge and understanding of the primary care computer information systems is desirable
  • Experience of leading, co-ordinating and managing practice improvement projects, including the on-going monitoring and evaluating of any changes, using evidence-based project management approach.
  • Good organisational skills and experience or knowledge of service improvement methodology, diagnostic tools and delivering on improvement plans.
  • Experience in leading the development of performance monitoring/data collection systems and embedding the usage throughout organisations, including acute and community settings.
  • Experience of analysing and interpreting data sets.
  • Experience of producing written briefings and reports including text and graphics and having formatted them to a high standard.
  • Highly developed interpersonal skills with ability to relate effectively with staff at all levels.
  • Evidence of continuing professional development.


  1. Analytical and judgement skills
  • Lead work under the guidance of the Director of HCP Delivery to establish timely and robust data collection and sharing processes for information required to support the delivery of the population health management programme and reduce unwarranted clinical variation.
  • Ability to undertake detailed analysis of complex and wide-ranging data sets.
  • To be able to make judgements through comprehensive interpretation and present detailed verbal and written interpretation of data, with recommendations of actions required to a wide variety of audiences.
  • Ability to act with discretion and understand the need for confidentiality.
  • Understanding complex data or information and using judgement skills to formulate solutions, recommending/deciding on the best course of action/treatment.


  1. Planning and organisational skills
  • Required to plan and organise a broad range of complex activities, some of which are on-going, and which require the formulation and adjustment of plans or strategies i.e. coordinate and manage complex clinical variation reduction plans in collaboration with GPs, practice staff and wider system colleagues positively impacting on quality outcomes for patients.
  • Ensure robust governance arrangements are in place for the planning, presentation and progression of the key operational, performance, quality and risk objectives in line with the HCPs operating plan and strategic developments.
  • As part of the wider HCP team contribute towards the development of the on-going quality agenda.
  • Be responsible for the planning, organisation and prioritisation of own workload without direct supervision and meet required deadlines for completion.
  • Areas of the role where planning and organisational skills are required, this may be planning clinical or non-clinical activities meetings, diary management, conferences, strategic planning etc.
  • This should include short- and long-term planning responsibilities and the specific involvement of the post holder.



  1. Physical skills
  • Advanced keyboard skills for producing presentations, reports, spreadsheets and correspondence using Microsoft Office Suite IT packages and applications.
  • Driving between practices and base.


  1. Responsibility for patient / client care
  • Provides specialised advice to general practice, primary care teams and local care teams to reduce clinical variation and improve care for patients.
  • Respect the confidence of patients, clients and their carer’s and abide by the Code of Conduct and Caldecott requirements for confidentiality at all times.
  • Complying with the Data Protection Act in all respects, with particular relevance to the protection and use of patient information.
  • Maintain HCP and patient records (both paper and electronic) in accordance with approved policies to facilitate clinical care and effective administration

Full JD can be found in the attachments 


Person specification


Essential criteria
  • demonstration in application and at interview
Desirable criteria
  • demonstration in application and at interview


Essential criteria
  • demonstration in application and at interview
Desirable criteria
  • demonstration in application and at interview

communication and relationships

Essential criteria
  • demonstration in application and at interview
Desirable criteria
  • demonstration in application and at interview

MCH Values

Essential criteria
  • caring and compassionate, deliver quality and value, working in partnership

Employer certification / accreditation badges

Armed Forces CovenantApprenticeships logoNo smoking policyCare quality commission - GoodWorkplace Wellbeing Charter LogoDisability confident committedStep into health

Applicant requirements

You must have appropriate UK professional registration.

This post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service.

Documents to download

Apply online now

Further details / informal visits contact

nikki teesdale
Job title
Director of Delivery Medway and Swale H&CP
Email address
Telephone number

If you have problems applying, contact

MCH House
Bailey Drive
Gillingham Business Park