Job summary
Are you looking for a challenging yet rewarding opportunity to make a positive impact on people lives?
Are you passionate about ensuring that individuals have access to the best opportunities and support to live their best lives?
Do you possess a strong determination, tenacity, and a collaborative, person-centred approach to improving outcomes for people?
Are you a person who is looking for autonomy and initiative within your role?
Are you looking for a role which by working together, we can make a difference in the lives of those who need it most?
First Coastal PCN has an exciting opportunity to recruit a HIU Lead to join the First Coastal PCN in the High Intensity Use Service. We are seeking an individual with the ability to connect with patients, whilst maintain clear boundaries in order to positively impact the behaviour and outcomes of those with the most complex medical and social needs.
Main duties of the job
In working with some of the most deprived communities in this area, it is crucial to understand and address the complex and unique needs that come with it. This role is not merely about fixing problems, but rather about listening and truly understanding the individuals we aim to support. Being open-minded and non-judgemental is key in building trust and rapport with those facing challenging circumstances. Patience is a virtue in this line of work, as progress may not happen as quickly as we hope. It is about embracing the individual's journey and moving at their pace, recognizing that this pace will vary for each person.
About us
First Coastal Primary Care Network is a group of seven practices who know they have a number of people in their community that need something different. For reasons we do not always understand people find themselves accessing urgent and emergency care and we need the right people with the right attitudes and skills to change this.
Details
Date posted
19 December 2025
Pay scheme
Other
Salary
£31,049 a year
Contract
Fixed term
Duration
18 months
Working pattern
Full-time, Part-time, Flexible working
Reference number
A3598-25-0001
Job locations
The Surgery
Main Road
Stickney
Boston
Lincolnshire
PE22 8AA
Merton Lodge Surgery
33 West Street
Alford
Lincolnshire
LN13 9HT
Health Centre
Church End
Old Leake
Boston
Lincolnshire
PE22 9LE
Spilsby Surgery
Simpson Street
Spilsby
Lincolnshire
PE23 5LG
Job description
Job responsibilities
Job Summary
A highly motivated, emotionally intelligent, and resilient person with leadership skills, whose drive is quality client care and who thrives off innovation. Lateral thinking, which is out of the box is encouraged to support this vulnerable client group.
The Objectives of the Service are
Identify those at greatest risk of A&E attendance and non-elective admissions.
Proactively work with a rolling cohort of HIU clients, really understanding what they need.
To coordinate wellbeing and connect with other services, enrolling them to help to get to the desired end.
Reducing 999 calls as a natural by-product (possibly ambulance and police).
Reducing A&E attendances and avoidable non-elective admissions
Drive equality and client voice.
Forming robust network of community health, social care, mental health and police to manage clients, creating true integrated working.
Providing a service driven by quality with positive human outcomes observed.
Act as a conduit to negotiate and de-escalate issues before a crisis occurs; a situation which has historically led to a destabilisation of their condition and resulting in a A&E attendance / 999 calls.
Improving communication and partnership working between those involved in client care 24/7.
Identify patterns and causal factors which trigger relapse behaviours in order to shape future commissioning of service and/or demand/capacity planning.
Empower clients to self-manage to enable sustainable discharge.
Expected Outcomes
The key outcomes that the proposed service will deliver are:
Impact positively on reducing the high intensity use of healthcare.
To support clients to flourish through sustaining job opportunities, reconnecting with families, improving well-being etc.
A new culture of 1:1 coaching as a medium to deliver sustainable change.
It is recognised that the latter two points of expected outcomes are more difficult to measure but they are essential outcomes if a culture change is to occur to lower the stigma associated with this cohort.
The post holder is responsible for creating an innovative way of supporting the reduction in high intensity use of A&E. They will facilitate discussions and advise colleagues as to how best practice might be adopted for future development of the service and oversee their delivery.
Lead in removing potential barriers and stigma associated with HIU to promote equality, diversity and safeguarding service wide.
The HIU Lead will act as an advocate for the client, guiding them through the complex journey and multi-faceted approach to encourage appropriate use of scheduled and unscheduled care services.
A further element of the role would be coordination, sharing and learning of the work with community-based staff to promote safe practice and sustainability.
The post is responsible for providing professional expertise to the outcome of the business processes for the Lincolnshire Integrated Commissioning Board, including report writing and presenting evaluation reports.
Main Purpose of Job
To provide holistic one-to-one-person centred support for people aged 18 and over who have high dependency on emergency services and who are frequent visitors/callers of A&E, the Urgent Care Centre and East Midlands Ambulance Service.
To meet and collaborate with identified MDT partners to identify, discuss, and prioritise appropriate referrals from the patient cohort list.
To work and collaborate with the voluntary and community sector, including Community Connector and wider Partnerships, to help identify appropriate referral destinations and to explore opportunities to meet gaps in services and activities.
To ensure effective record keeping and storage of patient data to demonstrate outputs and outcomes which is compliant with GDPR.
To actively contribute as a member of a well-established social prescribing team and Neighbourhood network team who support the most vulnerable in society, contributing to the response to Population Health Management and Health Inequalities.
Key Tasks and Responsibilities
1.To provide holistic one-to-one-person centred support for people aged 18 and over who have high dependency on emergency services and who are frequent visitors/ callers of A&E, the Urgent Care Centre and East Midlands Ambulance Service.
Carry out the role of a facilitator, broker, sign poster, community connector and navigator, acting as an enabler between the voluntary and community sector, patients, GPs and health clinicians, and social care.
Provide support to patients, generally in their own homes, up to 3-4 months to help direct and connect them to alternative sources of non-medical support services and activities.
Offer a personalised approach to sensitively uncover the real reasons for them calling 999 or presenting frequently at A&E/UCC.
During client visits undertake an assessment to gather baseline data and to identify the support needs and actions.Generating personalised care and support or wellbeing plans, which may include risk management.
Ensure support actions agreed with the patient are carried out by the service. Support areas could include making referrals into a range of services provided by the voluntary, statutory or private sector, help with non-means tested benefit form filling e.g. Personal Independent Payments, Attendance Allowance, housing forms etc, distributing food bank vouchers, identifying suitable volunteering opportunities, connecting people into peer to peer led activities, initially taking patients to services if their confidence is low etc.
Once support has been provided carry out a final assessment
2. To work and collaborate with the voluntary and community sector to help identify appropriate referral destinations and to explore opportunities to meet gaps in services and activities.
Keep abreast of a wide range of support services on offer in the voluntary and community sector through undertaking research, making connections with organisations and groups and by using a range of local online directories and Community Connectors.
Build and maintain positive relationships with a wide range of voluntary and community sector providers.
When gaps is services and activities are identified discuss and raise these with the team and if required liaise with voluntary organisations and Community Connector to help identify solutions.
3.To ensure effective record keeping and storage of patient data to demonstrate outputs and outcomes which is compliant with GDPR.
Ensure all patient records and actions are entered onto our record keeping systems.
Ensure GDPR requirements are adhered to in relation to data management.
When required, support in gathering any data required for working out cost savings to the wider health and social care sector as a result of the service interventions.
4.To actively contribute as a member of a well-established Neighbourhood team who support the most vulnerable in society.
Actively contribute to team meetings, away days, planning activities and reflective practice activities.
Share progress, learning and challenges within the existing Integrated Plus social prescribing team.
Share ideas about how the service could develop and evolve.
5. Minimum Qualifications, Knowledge, Training and Experience Required for the Post
No formal qualifications required but must have high emotional intelligence and resilience, be win-win negotiators and be brave enough to change the culture around high intensity use of services. Needs to shine and connect well in interviews to demonstrate these skills.
It would be desirable for applicant to have experience in working in person centred roles, social prescribing and skills linked with some of our most vulnerable groups, housing, drug and alcohol etc or care and support co-ordination.
General Duties
Financial and Physical Resources
Responsible for advising on the commissioning and streamlining of services to support project delivery as well as highlighting gaps in service provision for high intensity use of health.
Interpret and produce quarterly quality and financial reports.
Provide advice and prepare strategic reports and briefings for directors and stakeholders.
Constantly strive for providing quality care for HIU by addressing any underlying issues.
Constantly strive to provide value for money and greater efficiency in the use of unscheduled care services and to contribute to how they operate in recurrent financial balance for future years.
Human Resources
The post holder will be responsible for colleague development and knowledge in this area of expertise.
Work to manage confidential information about an individuals wellbeing and capability development.
Information Resources
Present complex information about the project, initiatives and service providers to a wide range of stakeholders in a formal setting.
Highlight exceptions and risks ensuring mitigating action can be taken to keep the programme on track.
Draft reports summarising status on issues, client outcomes, and providing progress reports for the Clinical Commissioning Group / ICB.
Collate as required, qualitative and quantitative information and lead appropriate analysis to develop robust business cases.
Analyse, interpret and present data to highlight issues, risks and support decision making within the niche of HIU.
Job description
Job responsibilities
Job Summary
A highly motivated, emotionally intelligent, and resilient person with leadership skills, whose drive is quality client care and who thrives off innovation. Lateral thinking, which is out of the box is encouraged to support this vulnerable client group.
The Objectives of the Service are
Identify those at greatest risk of A&E attendance and non-elective admissions.
Proactively work with a rolling cohort of HIU clients, really understanding what they need.
To coordinate wellbeing and connect with other services, enrolling them to help to get to the desired end.
Reducing 999 calls as a natural by-product (possibly ambulance and police).
Reducing A&E attendances and avoidable non-elective admissions
Drive equality and client voice.
Forming robust network of community health, social care, mental health and police to manage clients, creating true integrated working.
Providing a service driven by quality with positive human outcomes observed.
Act as a conduit to negotiate and de-escalate issues before a crisis occurs; a situation which has historically led to a destabilisation of their condition and resulting in a A&E attendance / 999 calls.
Improving communication and partnership working between those involved in client care 24/7.
Identify patterns and causal factors which trigger relapse behaviours in order to shape future commissioning of service and/or demand/capacity planning.
Empower clients to self-manage to enable sustainable discharge.
Expected Outcomes
The key outcomes that the proposed service will deliver are:
Impact positively on reducing the high intensity use of healthcare.
To support clients to flourish through sustaining job opportunities, reconnecting with families, improving well-being etc.
A new culture of 1:1 coaching as a medium to deliver sustainable change.
It is recognised that the latter two points of expected outcomes are more difficult to measure but they are essential outcomes if a culture change is to occur to lower the stigma associated with this cohort.
The post holder is responsible for creating an innovative way of supporting the reduction in high intensity use of A&E. They will facilitate discussions and advise colleagues as to how best practice might be adopted for future development of the service and oversee their delivery.
Lead in removing potential barriers and stigma associated with HIU to promote equality, diversity and safeguarding service wide.
The HIU Lead will act as an advocate for the client, guiding them through the complex journey and multi-faceted approach to encourage appropriate use of scheduled and unscheduled care services.
A further element of the role would be coordination, sharing and learning of the work with community-based staff to promote safe practice and sustainability.
The post is responsible for providing professional expertise to the outcome of the business processes for the Lincolnshire Integrated Commissioning Board, including report writing and presenting evaluation reports.
Main Purpose of Job
To provide holistic one-to-one-person centred support for people aged 18 and over who have high dependency on emergency services and who are frequent visitors/callers of A&E, the Urgent Care Centre and East Midlands Ambulance Service.
To meet and collaborate with identified MDT partners to identify, discuss, and prioritise appropriate referrals from the patient cohort list.
To work and collaborate with the voluntary and community sector, including Community Connector and wider Partnerships, to help identify appropriate referral destinations and to explore opportunities to meet gaps in services and activities.
To ensure effective record keeping and storage of patient data to demonstrate outputs and outcomes which is compliant with GDPR.
To actively contribute as a member of a well-established social prescribing team and Neighbourhood network team who support the most vulnerable in society, contributing to the response to Population Health Management and Health Inequalities.
Key Tasks and Responsibilities
1.To provide holistic one-to-one-person centred support for people aged 18 and over who have high dependency on emergency services and who are frequent visitors/ callers of A&E, the Urgent Care Centre and East Midlands Ambulance Service.
Carry out the role of a facilitator, broker, sign poster, community connector and navigator, acting as an enabler between the voluntary and community sector, patients, GPs and health clinicians, and social care.
Provide support to patients, generally in their own homes, up to 3-4 months to help direct and connect them to alternative sources of non-medical support services and activities.
Offer a personalised approach to sensitively uncover the real reasons for them calling 999 or presenting frequently at A&E/UCC.
During client visits undertake an assessment to gather baseline data and to identify the support needs and actions.Generating personalised care and support or wellbeing plans, which may include risk management.
Ensure support actions agreed with the patient are carried out by the service. Support areas could include making referrals into a range of services provided by the voluntary, statutory or private sector, help with non-means tested benefit form filling e.g. Personal Independent Payments, Attendance Allowance, housing forms etc, distributing food bank vouchers, identifying suitable volunteering opportunities, connecting people into peer to peer led activities, initially taking patients to services if their confidence is low etc.
Once support has been provided carry out a final assessment
2. To work and collaborate with the voluntary and community sector to help identify appropriate referral destinations and to explore opportunities to meet gaps in services and activities.
Keep abreast of a wide range of support services on offer in the voluntary and community sector through undertaking research, making connections with organisations and groups and by using a range of local online directories and Community Connectors.
Build and maintain positive relationships with a wide range of voluntary and community sector providers.
When gaps is services and activities are identified discuss and raise these with the team and if required liaise with voluntary organisations and Community Connector to help identify solutions.
3.To ensure effective record keeping and storage of patient data to demonstrate outputs and outcomes which is compliant with GDPR.
Ensure all patient records and actions are entered onto our record keeping systems.
Ensure GDPR requirements are adhered to in relation to data management.
When required, support in gathering any data required for working out cost savings to the wider health and social care sector as a result of the service interventions.
4.To actively contribute as a member of a well-established Neighbourhood team who support the most vulnerable in society.
Actively contribute to team meetings, away days, planning activities and reflective practice activities.
Share progress, learning and challenges within the existing Integrated Plus social prescribing team.
Share ideas about how the service could develop and evolve.
5. Minimum Qualifications, Knowledge, Training and Experience Required for the Post
No formal qualifications required but must have high emotional intelligence and resilience, be win-win negotiators and be brave enough to change the culture around high intensity use of services. Needs to shine and connect well in interviews to demonstrate these skills.
It would be desirable for applicant to have experience in working in person centred roles, social prescribing and skills linked with some of our most vulnerable groups, housing, drug and alcohol etc or care and support co-ordination.
General Duties
Financial and Physical Resources
Responsible for advising on the commissioning and streamlining of services to support project delivery as well as highlighting gaps in service provision for high intensity use of health.
Interpret and produce quarterly quality and financial reports.
Provide advice and prepare strategic reports and briefings for directors and stakeholders.
Constantly strive for providing quality care for HIU by addressing any underlying issues.
Constantly strive to provide value for money and greater efficiency in the use of unscheduled care services and to contribute to how they operate in recurrent financial balance for future years.
Human Resources
The post holder will be responsible for colleague development and knowledge in this area of expertise.
Work to manage confidential information about an individuals wellbeing and capability development.
Information Resources
Present complex information about the project, initiatives and service providers to a wide range of stakeholders in a formal setting.
Highlight exceptions and risks ensuring mitigating action can be taken to keep the programme on track.
Draft reports summarising status on issues, client outcomes, and providing progress reports for the Clinical Commissioning Group / ICB.
Collate as required, qualitative and quantitative information and lead appropriate analysis to develop robust business cases.
Analyse, interpret and present data to highlight issues, risks and support decision making within the niche of HIU.
Person Specification
Qualifications
Desirable
- Motivational interviewing
- Personalised Care Institute e-learning modules PCSP, shared decision making or equivalent
Experience
Essential
- Experience of supporting vulnerable adults in a person centred way
- Experience of working in the voluntary and community sector
- You have the ability to work sensitively in difficult emotional circumstances with empathy, compassion, respect and understanding.
- Knowledge of asset/strength-based recovery models and approaches
- Experience of case load management.
- You will be able to cooperate with a range of health professionals, voluntary sector providers and people around the range of possibilities that might be available enabling service provision to be more holistic to improve mental health and wellbeing of vulnerable people.
- You are a person who is willing to go the extra mile for a person to ensure they get the right care and support. You are passionate about making a difference to peoples lives
- You possess a strong and practical understanding of safeguarding policy and practice and are up to date with current legislation.
- Excellent communication and interpersonal skills.
- Experience of working in teams
- Experience of collaborative working
- Knowledge and understanding of equality and diversity
- Knowledge and understanding of GDPR
- You can plan, prioritise and carry out your work in a flexible way. You are accustomed to working on your own and in teams.
- You know how to use a range of software to produce written documents, spreadsheets, presentations. You can effectively manage communication by email, and you are comfortable using collaborative online tools (for example WhatsApp, Twitter, Facebook, using text editors such as Word/Pages and other message apps.
- Adaptability, flexibility and ability to cope with uncertainty and change
- Demonstrate ability to work in a busy environment; ability to deal with both urgent and important tasks and to prioritise effectively whilst also supporting others
- Excellent time keeping and prioritisation skills
- Flexibility to work outside of core office hours
- Disclosure Barring Service (DBS) check
- Access to own transport and ability to travel across the PCN locality on a regular basis
Desirable
- Experience of providing social prescribing interventions
- Knowledge of health and social care
- Local knowledge of the voluntary and community sector
- Ability to use Microsoft 365
- Specific Aptitudes Awareness of equality and valuing diversity principles Understanding of Confidentiality and Data Protection Act
- Continued commitment to improve skills and ability in new areas of work
- Able to undertake the demands of the post with reasonable adjustments if required
- Ability to work from home on some occasions where tasks allow
Person Specification
Qualifications
Desirable
- Motivational interviewing
- Personalised Care Institute e-learning modules PCSP, shared decision making or equivalent
Experience
Essential
- Experience of supporting vulnerable adults in a person centred way
- Experience of working in the voluntary and community sector
- You have the ability to work sensitively in difficult emotional circumstances with empathy, compassion, respect and understanding.
- Knowledge of asset/strength-based recovery models and approaches
- Experience of case load management.
- You will be able to cooperate with a range of health professionals, voluntary sector providers and people around the range of possibilities that might be available enabling service provision to be more holistic to improve mental health and wellbeing of vulnerable people.
- You are a person who is willing to go the extra mile for a person to ensure they get the right care and support. You are passionate about making a difference to peoples lives
- You possess a strong and practical understanding of safeguarding policy and practice and are up to date with current legislation.
- Excellent communication and interpersonal skills.
- Experience of working in teams
- Experience of collaborative working
- Knowledge and understanding of equality and diversity
- Knowledge and understanding of GDPR
- You can plan, prioritise and carry out your work in a flexible way. You are accustomed to working on your own and in teams.
- You know how to use a range of software to produce written documents, spreadsheets, presentations. You can effectively manage communication by email, and you are comfortable using collaborative online tools (for example WhatsApp, Twitter, Facebook, using text editors such as Word/Pages and other message apps.
- Adaptability, flexibility and ability to cope with uncertainty and change
- Demonstrate ability to work in a busy environment; ability to deal with both urgent and important tasks and to prioritise effectively whilst also supporting others
- Excellent time keeping and prioritisation skills
- Flexibility to work outside of core office hours
- Disclosure Barring Service (DBS) check
- Access to own transport and ability to travel across the PCN locality on a regular basis
Desirable
- Experience of providing social prescribing interventions
- Knowledge of health and social care
- Local knowledge of the voluntary and community sector
- Ability to use Microsoft 365
- Specific Aptitudes Awareness of equality and valuing diversity principles Understanding of Confidentiality and Data Protection Act
- Continued commitment to improve skills and ability in new areas of work
- Able to undertake the demands of the post with reasonable adjustments if required
- Ability to work from home on some occasions where tasks allow
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.
Employer details
Employer name
First Coastal PCN
Address
The Surgery
Main Road
Stickney
Boston
Lincolnshire
PE22 8AA
Employer's website
https://www.mariscomedicalpractice.com/ (Opens in a new tab)
Employer details
Employer name
First Coastal PCN
Address
The Surgery
Main Road
Stickney
Boston
Lincolnshire
PE22 8AA
Employer's website
https://www.mariscomedicalpractice.com/ (Opens in a new tab)
Employer contact details
For questions about the job, contact:
Details
Date posted
19 December 2025
Pay scheme
Other
Salary
£31,049 a year
Contract
Fixed term
Duration
18 months
Working pattern
Full-time, Part-time, Flexible working
Reference number
A3598-25-0001
Job locations
The Surgery
Main Road
Stickney
Boston
Lincolnshire
PE22 8AA
Merton Lodge Surgery
33 West Street
Alford
Lincolnshire
LN13 9HT
Health Centre
Church End
Old Leake
Boston
Lincolnshire
PE22 9LE
Spilsby Surgery
Simpson Street
Spilsby
Lincolnshire
PE23 5LG