Job responsibilities
Job Description
Job Purpose
Working closely with GP and nursing colleagues working in a multi-disciplinary team.
- To provide expert, evidence-based diabetes care across Stowhealth, in line with national guidance and local pathways
- To lead and support the management of adults with type 2 diabetes, with a particular focus on patients using, or being considered for, GLP-1 receptor agonists and related injectable therapies
- To work as part of the multidisciplinary team to improve glycaemic control, reduce complications and address health inequalities in people living with diabetes.
- To support education, training and clinical supervision of other nurses and primary care staff in diabetes management, including safe and appropriate use of GLP-1 therapies.
- Experience in managing patients with long term medical conditions and chronic disease management
Key Relationships
- GP's and GP partners
- Practice nurses and nurse associates
- Clinical pharmacists and pharmacy technicians
- Dietitians, podiatrists and other community specialists
- Secondary care diabetes teams
- PCN/ICS long term conditions leads
- Administrative and reception staff
Main duties and responsibilities
Clinical care
1.1 Provide specialist diabetes clinics, face to face, telephone and virtual for adults with type 2 diabetes, including
- complex or poorly controlled diabetes
- patients with multiple comorbidities e.g. CVD, CKD, obesity
- patients on, or being considered for, GLP1 receptor agonists and other injectable therapies.
1.2 Undertake comprehensive, holistic assessments including:
- glycaemic control HbA1c, SMBG/CGM data where available
- cardiovascular and renal risk
- weight, BMI and obesity related risk
- psychosocial factors, health literacy and self management capacity.
1.3 Develop, implement and reviewindividualised care plansin partnership with patients and carers, in line with national guidance e.g. NICE NG28, NG17, NG18, obesity and CVD guidance and local ICS pathways.
1.4 Provide expert advice on the initiation, titration and monitoring of diabetes therapies, including
- oral hypoglycaemic agents
- GLP1 receptor agonists e.g. initiation criteria, dose escalation, side effect management, stopping rules
- insulin and combination regimens, where within competence and local protocols.
1.5 Work closely with clinical pharmacists and GPs to supportstructured medication reviews, particularly for patients with complex polypharmacy, frailty, or high risk of hypoglycaemia.
1.6 Support delivery ofannual diabetes reviewsand QOF related activity, ensuring high quality, person centred care and accurate coding.
1.7 Recognise and act on red flag symptoms and complications e.g. DKA risk, acute foot problems, severe GI side effects from GLP1s, suspected pancreatitis, escalating appropriately to GPs or secondary care.
2. GLP1 and injectable therapy expertise
2.1 Act as thepractice PCN lead nursefor GLP1 receptor agonist therapy, including
- assessing eligibility in line with NICE and local formulary criteria
- counselling patients on benefits, risks, side effects and realistic expectations, including weight loss and cardiovascular benefits where applicable
- teaching injection technique, storage, disposal and adherence strategies
- monitoring response, tolerability and adherence, and recommending continuation or discontinuation in line with agreed protocols.
2.2 Provide specialist input intoweight management pathways, working with obesity services, dietitians and lifestyle programmes, ensuring appropriate and safe use of GLP1s where indicated.
2.3 Support antimicrobial stewardship and safe prescribing by ensuring GLP1 use is optimised and unnecessary or inappropriate prescribing is avoided, in collaboration with clinical pharmacists.
2.4 Contribute to the development, implementation and review oflocal protocols and guidelinesfor GLP1 and injectable therapy use in primary care.
3. Education, training and leadership
3.1 Provide formal and informaleducation and trainingfor
- practice nurses and HCAs e.g. foot checks, blood glucose monitoring, lifestyle advice
- GPs and other clinicians on practical aspects of GLP1 and injectable therapy use
- administrative staff on recall systems and patient communication.
3.2 Act as aclinical role model and mentor, supporting the development of general practice nurses towards enhanced practice in diabetes, in line with the Primary Care and General Practice Nursing Career and Core Capabilities Framework.
3.3 Participate in, and where appropriate lead,multidisciplinary meetingsand case discussions to support integrated, patient centred diabetes care.
3.4 Contribute toservice development and transformationworkstreams within the PCN/ICS, particularly around long term conditions, obesity and cardiovascular risk reduction.
4. Quality, audit and governance
4.1 Participate in clinical audit, quality improvement projects and data reviews related to:
- diabetes outcomes HbA1c, BP, lipids, weight, complications
- GLP1 prescribing, adherence, outcomes and safety
- QOF and enhanced service indicators.
4.2 Use audit findings and national guidance to update local protocols, patient pathways and educational materials.
4.3 Ensure all care is delivered in line with
- national and local clinical guidelines
- safeguarding policies
- infection prevention and control standards
- information governance and confidentiality requirements.
4.4 Maintain accurate, contemporaneous and comprehensive clinical records in the practice clinical system.
5. Professional development
5.1 Maintain up to date knowledge and skills in diabetes care, GLP1 and injectable therapies, obesity management and cardiovascular risk reduction through
- continuing professional development, CPD
- attendance at relevant courses, conferences and study days
- engagement with local diabetes networks and specialist teams.
5.2 Participate in annual appraisal and personal development planning, identifying learning needs and career progression opportunities, e.g. advanced practice, independent prescribing where appropriate.
5.3 Work within the NMC Code and scope of professional practice, recognising boundaries and seeking senior or specialist advice when required.
Person specification
Qualifications
- Registered Nurse Adult with current NMC registration.
- Post registration qualification in diabetes care e.g. diploma, degree module or equivalent experience.
- Evidence of ongoing CPD in diabetes and long term conditions.
- Desirable: Independent Nurse Prescriber or willingness to work towards this, subject to service need and employer support.
Experience
- Significant post registration experience in diabetes care in primary, community or secondary care.
- Demonstrable experience of managing complex type 2 diabetes, including patients with multiple comorbidities.
- Hands on experience initiating, titrating and monitoringGLP1 receptor agonistsand other injectable therapies, within protocols and under appropriate clinical supervision.
- Experience of working effectively within a multidisciplinary team.
- Experience of delivering patient education and staff training.
- Desirable - Experience in service development, audit and quality improvement.
Knowledge and skills
- In depth knowledge of
- type 2 diabetes pathophysiology and management
- national guidance e.g. NICE and local diabetes pathways
- indications, contraindications, side effects and monitoring requirements for GLP1 receptor agonists and other injectable therapies.
- Strong clinical assessment and decision making skills, with the ability to manage complex cases within agreed protocols.
- Excellent communication and consultation skills, including motivational interviewing and behaviour change techniques.
- Ability to teach and support patients in self management, including injection technique and lifestyle modification.
- Competence in using clinical IT systems, data extraction tools and recall systems.
- Understanding of health inequalities and the impact of social determinants on diabetes outcomes.
Personal attributes
- Compassionate, patient centred approach.
- Ability to work autonomously within scope of practice and as part of an MDT.
- Organised, with good time management and prioritisation skills.
- Commitment to continuous improvement and evidence based practice.
