Job summary At Hampstead Group Practice, located in the heart of NW3, we pride ourselves on being a warm, inclusive, and forward-thinking general practice that puts patient care and staff wellbeing at the forefront of everything we do. With a current list size of over 17,800 and growing, we are a dynamic, progressive practice committed to high-quality, patient-centred care. Main duties of the job To provide proactive and personalised care coordination for patients, working with clinical and administrative staff, community services, and patients families to ensure a smooth patient journey and help manage long-term conditions, frailty, and those at risk of hospital admission About us Youll be joining a well-established, supportive, and multidisciplinary team made up of 16 experienced and approachable GPs, highly skilled nurses, HCAs, pharmacists, care coordinators, and an efficient administrative support team. We value collaboration, mutual respect, and continuous improvement. Our team culture is friendly, inclusive, and collaborativewith regular team meetings, open communication, and a shared commitment to learning and innovation. Details Date posted 02 July 2025 Pay scheme Other Salary Depending on experience Contract Permanent Working pattern Full-time Reference number A2931-25-0005 Job locations The Hampstead Group Practice 75 Fleet Road London NW3 2QU Job description Job responsibilities Key Duties and Responsibilities: Act as a key point of contact for patients being supported through our specialist services (e.g., respiratory, diabetes, Bangladeshi clinic). Support patients in navigating the health and social care system, including booking appointments, arranging transport, and helping access community support. Coordinate care for patients with complex needs, ensuring their care plans are up-to-date and shared across services. Work closely with our team of GPs, nurses, social prescribers, and community teams to ensure continuity of care. Identify patients who may benefit from proactive care planning through data searches and multidisciplinary team discussions Additional Key Responsibilities: Be responsible for daily updating of patients on e-HealthScope Workflow and identifying potential gaps in care. Proactively prepare any actions prior to the MDT ensuring all relevant clinicians are present. To record patient interventions on relevant electronic database systems (e.g. EMIS Web) and contribute to report generation, analysis and production Follow up on all forward actions resulting from MDT discussions Be responsible for logging and making referrals To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the PCN Team and providing information to any member of the PCN Team in order to ease processes and communication in agreement with data protection protocol To be responsible for recording, reporting and producing evaluation reports which will include evaluation detailing effectiveness outcomes of new roles To be customer (patient, carer, GP) focused when representing the service To work collaboratively with other teams and services to maintain an effective and efficient service To offer appropriate support and guidance to patients and their families/carers To plan / organise work using own initiative, whilst being able to work as a valuable member of a team To have excellent IT skills, to include Microsoft Office, Outlook and Excel To undertake general office duties to support the role To work effectively as part of a team to provide cover for Care Coordination Teams when required and to be flexible regarding working hours to meet the needs of the service To ensure all electronic records are updated and complete within the agreed time-scale To use a range of verbal and non-verbal communication tools to communicate effectively with patients, carers and families and colleagues Provide coordination of and participate in relevant internal and external working groups and provide project advice, expertise and support where requested Support the PCN team as required Work with key personnel in the PCN to develop & support collective general practice projects including areas of federated working Work towards completing the appropriate training to deliver and support the Comprehensive Model for Personalised Care Work closely and in partnership with the Social Prescribing Link Worker(s) To participate in the review and appraisal process To carry out any other reasonable duties as requested by a manager to ensure quality of service To participate in any relevant training/courses/conferences Use clinical systems for record keeping, audit and evaluation Develop and implement data collection systems that will provide accurate and timely dat Job description Job responsibilities Key Duties and Responsibilities: Act as a key point of contact for patients being supported through our specialist services (e.g., respiratory, diabetes, Bangladeshi clinic). Support patients in navigating the health and social care system, including booking appointments, arranging transport, and helping access community support. Coordinate care for patients with complex needs, ensuring their care plans are up-to-date and shared across services. Work closely with our team of GPs, nurses, social prescribers, and community teams to ensure continuity of care. Identify patients who may benefit from proactive care planning through data searches and multidisciplinary team discussions Additional Key Responsibilities: Be responsible for daily updating of patients on e-HealthScope Workflow and identifying potential gaps in care. Proactively prepare any actions prior to the MDT ensuring all relevant clinicians are present. To record patient interventions on relevant electronic database systems (e.g. EMIS Web) and contribute to report generation, analysis and production Follow up on all forward actions resulting from MDT discussions Be responsible for logging and making referrals To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the PCN Team and providing information to any member of the PCN Team in order to ease processes and communication in agreement with data protection protocol To be responsible for recording, reporting and producing evaluation reports which will include evaluation detailing effectiveness outcomes of new roles To be customer (patient, carer, GP) focused when representing the service To work collaboratively with other teams and services to maintain an effective and efficient service To offer appropriate support and guidance to patients and their families/carers To plan / organise work using own initiative, whilst being able to work as a valuable member of a team To have excellent IT skills, to include Microsoft Office, Outlook and Excel To undertake general office duties to support the role To work effectively as part of a team to provide cover for Care Coordination Teams when required and to be flexible regarding working hours to meet the needs of the service To ensure all electronic records are updated and complete within the agreed time-scale To use a range of verbal and non-verbal communication tools to communicate effectively with patients, carers and families and colleagues Provide coordination of and participate in relevant internal and external working groups and provide project advice, expertise and support where requested Support the PCN team as required Work with key personnel in the PCN to develop & support collective general practice projects including areas of federated working Work towards completing the appropriate training to deliver and support the Comprehensive Model for Personalised Care Work closely and in partnership with the Social Prescribing Link Worker(s) To participate in the review and appraisal process To carry out any other reasonable duties as requested by a manager to ensure quality of service To participate in any relevant training/courses/conferences Use clinical systems for record keeping, audit and evaluation Develop and implement data collection systems that will provide accurate and timely dat Person Specification To have excellent IT skills, to include Microsoft Office, Outlook and Excel Essential Highly responsible, reliable, and organised Strong attention to detail with a commitment to accuracy Excellent communication and interpersonal skills Proven ability to work both independently and as part of a team Adaptable and willing to learn new systems and processes Proficient in the use of IT systems, particularly those related to healthcare or data management Discreet and professional, with a mature approach to handling sensitive information Experience Essential To have excellent IT skills, to include Microsoft Office, Outlook and Excel Qualifications Essential GCSE grade A to C in English and Maths Person Specification To have excellent IT skills, to include Microsoft Office, Outlook and Excel Essential Highly responsible, reliable, and organised Strong attention to detail with a commitment to accuracy Excellent communication and interpersonal skills Proven ability to work both independently and as part of a team Adaptable and willing to learn new systems and processes Proficient in the use of IT systems, particularly those related to healthcare or data management Discreet and professional, with a mature approach to handling sensitive information Experience Essential To have excellent IT skills, to include Microsoft Office, Outlook and Excel Qualifications Essential GCSE grade A to C in English and Maths Employer details Employer name Hampstead Group Practice Address The Hampstead Group Practice 75 Fleet Road London NW3 2QU Employer's website http://www.hampsteadgrouppractice.co.uk/ (Opens in a new tab) Employer details Employer name Hampstead Group Practice Address The Hampstead Group Practice 75 Fleet Road London NW3 2QU Employer's website http://www.hampsteadgrouppractice.co.uk/ (Opens in a new tab). Location : The Hampstead Group Practice, 75 Fleet Road, NW3 2QU London, United Kingdom