North & South Gloucestershire Primary Care Network

PCN Care Coordinator

The closing date is 16 September 2025

Job summary

North & South Gloucester Primary Care Network are looking to recruit a Care Coordinator to join our Living Well Team of Frailty Nurses, Social Prescribing Link Workers and Care Coordinators.

The hours for the post are from 21.5 up to 37.5 hours per week.

Career progression to the role of Advanced Care Coordinator and subsequent salary uplift would be available to the successful candidate after a qualifying period.

Our Care Coordinators play an important role within our Network to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

The successful candidate will be caring, dedicated and person-focussed, and will enjoy working with a wide range of people. They will have good written and verbal communication skills, and will be committed to providing people, their families and carers with high quality support, helping them to access the right services first time.

This role will be primarily based at The Alney Practice, either at the Cheltenham Road site or the branch surgery at Highnam, but on occasion their may be a requirement to work at other sites within the PCN, namely Brockworth Surgery, Churchdown Surgery, Hucclecote Surgery and Longlevens Surgery.

Experience of using EMIS and/or SystmOne is desirable.

Main duties of the job

The Care Coordinator role ensures patient health and care planning is timely, efficient and patient-centred. This is achieved by bringing together all the information about about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.

  • Provide coordination and navigation for people and their carers across health and care services, alongside working closely with the practice team and our Living Well Team.
  • With the support of the Practice and Network, proactively identify a cohort of people in need of anticipatory coordinated support, using local knowledge and population health intelligence.
  • Lead on the organisation, coordination and delivery of multi-disciplinary team meetings, including taking minutes and recording and following up actions.
  • Improve continuity of care by acting as a point of contact for people, their families and professionals.
  • Identify and manage a caseload of patients, carrying out home visits to complete/review Personalised Care and Support Plans, Me at my Best and What Matters to Me forms.
  • Ensure people have good quality information to help them make choices about their care and structure conversations using a coaching approach.

About us

North & South Gloucester (NSG) Primary Care Network (PCN) consists of five surgeries located around Gloucester The Alney Practice, Brockworth Surgery, Churchdown Surgery, Hucclecote Surgery and Longlevens Surgery. We are a growing PCN with over 58,000 patients and a PCN staff of over 40. We are passionate about developing and delivering excellent quality local services to meet the needs of our communities. We work closely together with a wide range of local providers, including acute trusts, social care, the voluntary and community sector, and patient participation groups to offer proactive, personalised, preventative, and co-ordinated health and social care to our local population.

Details

Date posted

21 August 2025

Pay scheme

Other

Salary

£25,361 a year WTE

Contract

Permanent

Working pattern

Full-time, Part-time

Reference number

A3666-25-0002

Job locations

The Alney Practice

16 Cheltenham Road

Gloucester

GL2 0LS


Job description

Job responsibilities

Care Coordinators play an important role within our PCN working closely with our GP practice teams, our PCN Living Well Team and wider health and social care and community colleagues. They identify and manage a caseload of specific patients, making sure the appropriate support is made available to them and their carers. This is achieved by bringing together all the information about a person's care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person. Care coordinators will set up and support MDT meetings and be the point of contact for the team. They will be involved with risk stratification, data searches, monitoring and evaluation of services.

The key responsibilities of the role are outlined below:

  • Provide coordination and navigation for people and their carers across health and care services, alongside working closely with our Living Well Team (Social Prescribing Link Workers, Frailty Nurses and Care Coordinators) and all members of our primary care teams.
  • With the support of the Practice and Network proactively identify a cohort of people in need of anticipatory coordinated support, using local knowledge and population health intelligence.
  • Lead the organisation, coordination and delivery of MDTs within the PCN - including producing the Agenda and taking minutes.
  • attend the MDTs, recording and following up actions within defined timescales agreed during the meeting.
  • Improve continuity of care by acting as a point of contact for people, families and professionals.
  • Bring together a person's identified care and support needs and explore their options to meet these into a single personalised care and support plan.
  • Ensure that people have good quality information to help them make choices about their care and structure conversations using a coaching approach.
  • Provide time, capacity and expertise to support people in preparing for or following up on clinical conversations with health professionals.
  • Work with members of the primary care teams to develop and implement data collection systems that will provide accurate and timely data to monitor and evaluate services.
  • Raise awareness within the PCN to shared decision making and decision support tools.
  • Raise of awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to shared decision making conversations.

Job description

Job responsibilities

Care Coordinators play an important role within our PCN working closely with our GP practice teams, our PCN Living Well Team and wider health and social care and community colleagues. They identify and manage a caseload of specific patients, making sure the appropriate support is made available to them and their carers. This is achieved by bringing together all the information about a person's care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person. Care coordinators will set up and support MDT meetings and be the point of contact for the team. They will be involved with risk stratification, data searches, monitoring and evaluation of services.

The key responsibilities of the role are outlined below:

  • Provide coordination and navigation for people and their carers across health and care services, alongside working closely with our Living Well Team (Social Prescribing Link Workers, Frailty Nurses and Care Coordinators) and all members of our primary care teams.
  • With the support of the Practice and Network proactively identify a cohort of people in need of anticipatory coordinated support, using local knowledge and population health intelligence.
  • Lead the organisation, coordination and delivery of MDTs within the PCN - including producing the Agenda and taking minutes.
  • attend the MDTs, recording and following up actions within defined timescales agreed during the meeting.
  • Improve continuity of care by acting as a point of contact for people, families and professionals.
  • Bring together a person's identified care and support needs and explore their options to meet these into a single personalised care and support plan.
  • Ensure that people have good quality information to help them make choices about their care and structure conversations using a coaching approach.
  • Provide time, capacity and expertise to support people in preparing for or following up on clinical conversations with health professionals.
  • Work with members of the primary care teams to develop and implement data collection systems that will provide accurate and timely data to monitor and evaluate services.
  • Raise awareness within the PCN to shared decision making and decision support tools.
  • Raise of awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to shared decision making conversations.

Person Specification

Qualifications

Essential

  • Good standard of education with 5 GCSE's or equivalent.
  • Good IT skills, especially a working knowledge of MS Office (Word, Excel, Powerpoint and Outlook).
  • Commitment to continuing professional development, including the Personalised Care Institute Course(s).

Desirable

  • Further education qualifications or Degree level education.
  • Training in health coaching/motivational interviewing or equivalent.

Skills and Attributes

Essential

  • Able to work independently and proactively.
  • Be able to manage multiple demands and prioritise appropriately.
  • Ability to seek solutions and solve problems using your own initiative.
  • Adaptability, flexibility and the ability to cope with uncertainty and change.
  • Be able to focus in a busy work environment.
  • Demonstrate a strong desire to improve performance and make a difference by focusing on goals.
  • Work in a confidential manner and maintain the trust of colleagues and patients.
  • Excellent time keeping.

Experience

Essential

  • Experience of working in the NHS (preferably in Primary Care) or for a private care provider. This could be in a clinical or non-clinical role.
  • Experience in working and communicating with multiple stakeholders.

Desirable

  • Experience and understanding of evaluating and measuring the performance of health services.
  • Experience in using clinical IT systems, in particular EMIS Web.
  • A good understanding of the health and social care environment and the roles and responsibilities within it.
  • Knowledge of existing referral pathways to local health, social care and voluntary organisations.

Communication

Essential

  • Excellent interpersonal and communication skills.
  • Ability and confidence to handle difficult conversations.
  • Ability to structure conversations using a coaching approach based on what matters to the person.
  • Be able to talk to a wide range of professionals appropriately.
  • Ability to nurture key relationships and maintaining networks.
Person Specification

Qualifications

Essential

  • Good standard of education with 5 GCSE's or equivalent.
  • Good IT skills, especially a working knowledge of MS Office (Word, Excel, Powerpoint and Outlook).
  • Commitment to continuing professional development, including the Personalised Care Institute Course(s).

Desirable

  • Further education qualifications or Degree level education.
  • Training in health coaching/motivational interviewing or equivalent.

Skills and Attributes

Essential

  • Able to work independently and proactively.
  • Be able to manage multiple demands and prioritise appropriately.
  • Ability to seek solutions and solve problems using your own initiative.
  • Adaptability, flexibility and the ability to cope with uncertainty and change.
  • Be able to focus in a busy work environment.
  • Demonstrate a strong desire to improve performance and make a difference by focusing on goals.
  • Work in a confidential manner and maintain the trust of colleagues and patients.
  • Excellent time keeping.

Experience

Essential

  • Experience of working in the NHS (preferably in Primary Care) or for a private care provider. This could be in a clinical or non-clinical role.
  • Experience in working and communicating with multiple stakeholders.

Desirable

  • Experience and understanding of evaluating and measuring the performance of health services.
  • Experience in using clinical IT systems, in particular EMIS Web.
  • A good understanding of the health and social care environment and the roles and responsibilities within it.
  • Knowledge of existing referral pathways to local health, social care and voluntary organisations.

Communication

Essential

  • Excellent interpersonal and communication skills.
  • Ability and confidence to handle difficult conversations.
  • Ability to structure conversations using a coaching approach based on what matters to the person.
  • Be able to talk to a wide range of professionals appropriately.
  • Ability to nurture key relationships and maintaining networks.

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

North & South Gloucestershire Primary Care Network

Address

The Alney Practice

16 Cheltenham Road

Gloucester

GL2 0LS


Employer's website

https://www.brockworthsurgery.nhs.uk (Opens in a new tab)

Employer details

Employer name

North & South Gloucestershire Primary Care Network

Address

The Alney Practice

16 Cheltenham Road

Gloucester

GL2 0LS


Employer's website

https://www.brockworthsurgery.nhs.uk (Opens in a new tab)

Employer contact details

For questions about the job, contact:

PCN Operations Manager

Debbie Hope-Hill

debbie.hope-hill@nhs.net

07917240915

Details

Date posted

21 August 2025

Pay scheme

Other

Salary

£25,361 a year WTE

Contract

Permanent

Working pattern

Full-time, Part-time

Reference number

A3666-25-0002

Job locations

The Alney Practice

16 Cheltenham Road

Gloucester

GL2 0LS


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