Job summary
Please note, this role is advertised by One Wight Health - GP Federation, on behalf of Central & West Primary Care Network.
Central & West PCN will be the employer for this post.
Hours: Full time 37.5 per week
Salary: Band 7 - 8a according to experience
Central & West PCN is seeking an experienced and
motivated Advanced Nurse Practitioner (ANP) or Advanced Health Practitioner
(AHP) to join our new Proactive Care Service, delivering against the Hampshire
& Isle of Wight Integrated Care Board (HIOW ICB) Proactive Care 2025/26
specification.
This is a key role supporting the frail and multimorbid
population across Newport Health Centre, Cowes Medical Centre, and Brookside
Health Centre. The postholder will work as part of a multi-disciplinary
Integrated Neighbourhood team to identify, assess, case manage, and support
patients with moderate to severe frailty. The aim is to improve independence,
personalise care, reduce avoidable hospital admissions, and enhance patient
experience.
Main duties of the job
The ANP/AHP will provide advanced clinical assessment, comprehensive frailty reviews, and proactive case management. They will work collaboratively with GPs, pharmacists, therapists, social prescribers, community teams and voluntary sector partners to ensure integrated, person-centred care.
- The postholder will be based across the three PCN practices, with some home visiting and community-based work.
- Flexible working is required, including participation in some Saturday sessions.
- Travel between sites is expected.
Should the service need to change or adapt due to different ongoing needs within the PCN/practices, there is an expectation the candidate would be able to work alongside other AHPs in line with usual expectations of work in primary care. This balance of work and future adjustment will remain at the discretion of the employer and will be discussed in advance with the candidate should a change be required.
About us
Central & West PCN serves around 54,000
patients across Newport Health Centre, Cowes Medical Centre and Brookside
Health Centre. We are committed to collaborative, innovative models of care
that respond to the changing needs of our ageing population. Our Proactive Care
Service is at the heart of our response to the HIOW Frailty Signature
Move embedding prevention, personalised care, and integrated neighbourhood
working as core elements of modern primary care.
Job description
Job responsibilities
Clinical and Case Management
- Review and manage a cohort of frail patients, working with practices to allocate patients to the caseload and clinically review their suitability for the service.
- Undertake comprehensive frailty assessments covering medical, functional, psychological and social domains using identified frameworks and templates.
- Develop and regularly review personalised care and support plans with patients and carers, ensuring their goals and preferences are central.
- Act as named clinician and care coordinator for a defined caseload, ensuring continuity and timely interventions.
- Provide advanced clinical assessment, diagnosis and treatment for patients, working within professional scope of practice.
- Prescribe and deprescribe appropriately (where qualified), contributing to structured medication reviews with pharmacists and GPs.
- Actively manage and monitor patients to prevent deterioration, escalating to appropriate services where required.
- Facilitate Advance Care Planning conversations, supporting documentation and sharing of ACPs across care settings.
- Facilitate DNR and End of Life conversations and paperwork.
Integrated Working and MDT Leadership
- Work as part of the PCNs operational frailty MDT, meeting at least monthly to review complex cases.
- Collaborate closely with GPs, community nurses, therapists, pharmacists, social prescribers, mental health and voluntary sector colleagues.
- Contribute clinical expertise to MDT discussions and proactive care planning.
- Develop and maintain strong relationships with community, mental health and acute services to ensure seamless transitions of care.
- Participate in additional proactive care clinics or home visits where required to support service coverage which may occur outside normal working days.
Service Development and Quality
- Contribute to the development and implementation of the PCNs Proactive Care Plan in line with the HIOW specification and Frailty Signature Move.
- Support innovation and local adaptation to meet the needs of the PCNs population while delivering the core functions of the service.
- Participate in service evaluation, audits and quality improvement projects to evidence outcomes and continuous improvement.
- Support monitoring and reporting against shared KPIs, including care planning coverage, medication reviews, MDT activity, and reductions in unplanned admissions.
- Ensure practice and data recording align with agreed templates and coding standards to support evaluation and health equity monitoring.
Professional Leadership and Development
- Maintain professional registration (NMC or HCPC) and work within relevant regulatory frameworks.
- Engage in ongoing clinical supervision, peer review, and appraisal processes.
- Maintain and develop advanced practice skills, including frailty assessment and management, ACP facilitation, and population health approaches.
- Provide mentorship and support to colleagues and students, contributing to the development of the PCN workforce.
- Contribute to a positive, collaborative and learning culture within the Integrated Neighbourhood team.
Job description
Job responsibilities
Clinical and Case Management
- Review and manage a cohort of frail patients, working with practices to allocate patients to the caseload and clinically review their suitability for the service.
- Undertake comprehensive frailty assessments covering medical, functional, psychological and social domains using identified frameworks and templates.
- Develop and regularly review personalised care and support plans with patients and carers, ensuring their goals and preferences are central.
- Act as named clinician and care coordinator for a defined caseload, ensuring continuity and timely interventions.
- Provide advanced clinical assessment, diagnosis and treatment for patients, working within professional scope of practice.
- Prescribe and deprescribe appropriately (where qualified), contributing to structured medication reviews with pharmacists and GPs.
- Actively manage and monitor patients to prevent deterioration, escalating to appropriate services where required.
- Facilitate Advance Care Planning conversations, supporting documentation and sharing of ACPs across care settings.
- Facilitate DNR and End of Life conversations and paperwork.
Integrated Working and MDT Leadership
- Work as part of the PCNs operational frailty MDT, meeting at least monthly to review complex cases.
- Collaborate closely with GPs, community nurses, therapists, pharmacists, social prescribers, mental health and voluntary sector colleagues.
- Contribute clinical expertise to MDT discussions and proactive care planning.
- Develop and maintain strong relationships with community, mental health and acute services to ensure seamless transitions of care.
- Participate in additional proactive care clinics or home visits where required to support service coverage which may occur outside normal working days.
Service Development and Quality
- Contribute to the development and implementation of the PCNs Proactive Care Plan in line with the HIOW specification and Frailty Signature Move.
- Support innovation and local adaptation to meet the needs of the PCNs population while delivering the core functions of the service.
- Participate in service evaluation, audits and quality improvement projects to evidence outcomes and continuous improvement.
- Support monitoring and reporting against shared KPIs, including care planning coverage, medication reviews, MDT activity, and reductions in unplanned admissions.
- Ensure practice and data recording align with agreed templates and coding standards to support evaluation and health equity monitoring.
Professional Leadership and Development
- Maintain professional registration (NMC or HCPC) and work within relevant regulatory frameworks.
- Engage in ongoing clinical supervision, peer review, and appraisal processes.
- Maintain and develop advanced practice skills, including frailty assessment and management, ACP facilitation, and population health approaches.
- Provide mentorship and support to colleagues and students, contributing to the development of the PCN workforce.
- Contribute to a positive, collaborative and learning culture within the Integrated Neighbourhood team.
Person Specification
Qualifications
Essential
- Registered Nurse or Allied Health Professional with current NMC or HCPC registration.
- Masters level qualification in Advanced Clinical Practice or equivalent experience.
Desirable
- Independent Prescriber (V300)
Knowledge and skills
Essential
- Excellent communication and MDT working skills.
- Commitment to population health approaches and reducing health inequalities.
- Ability to work across multiple sites.
Experience
Essential
- Demonstrable experience in autonomous clinical assessment and management of complex patients.
Desirable
- Experience working within PCNs or Integrated Neighbourhood models.
- Experience with frailty assessments and proactive case management.
- Experience in service development or QI projects.
- Experience leading or contributing to MDTs.
- Familiarity with SystmOne.
Person Specification
Qualifications
Essential
- Registered Nurse or Allied Health Professional with current NMC or HCPC registration.
- Masters level qualification in Advanced Clinical Practice or equivalent experience.
Desirable
- Independent Prescriber (V300)
Knowledge and skills
Essential
- Excellent communication and MDT working skills.
- Commitment to population health approaches and reducing health inequalities.
- Ability to work across multiple sites.
Experience
Essential
- Demonstrable experience in autonomous clinical assessment and management of complex patients.
Desirable
- Experience working within PCNs or Integrated Neighbourhood models.
- Experience with frailty assessments and proactive case management.
- Experience in service development or QI projects.
- Experience leading or contributing to MDTs.
- Familiarity with SystmOne.
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
