Job description
Learn about the role, responsibilities and what the employer is looking for.
Conditions you'll manage: Your caseload will span the full breadth of LTC in primary care, including: Diabetes (Type 1 and Type 2) - annual reviews, HbA1c monitoring, foot and eye referral pathways Hypertension - BP monitoring, cardiovascular risk assessment, and documented recommendations for GP-authorised medication adjustment Chronic Obstructive Pulmonary Disease (COPD) - spirometry interpretation, exacerbation management, inhaler review Asthma asthma reviews, PAAP updates, step-up/step-down under GP oversight Chronic Kidney Disease (CKD) - eGFR and ACR monitoring, medication safety reviews, referral pathways Atrial Fibrillation (AF) - anticoagulation monitoring, stroke risk assessment, and liaison with the prescribing GP on rate or anticoagulation management Heart Failure - monitoring, titration of medications under GP supervision, coordination with community cardiology Frailty - comprehensive geriatric assessment, falls risk, polypharmacy review Dementia - annual reviews, carer support, advance care planning Mental Health (SMI register) - physical health checks, metabolic monitoring Obesity and metabolic syndrome - lifestyle management, weight management pathway referrals Hypothyroidism and other endocrine conditions - monitoring and medication review Care home & community visiting: This role includes a regular care home and community visiting commitment - a valued part of how we provide continuity for our most vulnerable patients. Home and care home visits are structured and planned; they are not for acute or undifferentiated presentations, which are triaged and managed by a GP first. Undertake regular structured ward rounds at our linked care homes, supported by GP clinical leads, focusing on LTC review, medication safety, and personalised care planning Conduct anticipatory care planning and RESPECT conversations as part of planned care home visits, working alongside the palliative care team and GP lead Carry out planned home visits for housebound patients for routine LTC reviews and vaccinations; Work within the Enhanced Health in Care Homes (EHCH) framework, contributing to personalised care and support plans Build relationships with care home staff and community nurses to ensure joined-up, person-centred care This is an exceptional opportunity for a PA who wants to develop real expertise in the care of older people and those with complex needs. Your clinical supervisor will be a named GP. You will benefit from: Peer support from clinical colleagues across the practice A clear escalation pathway to our On the Day Hub for urgent or complex clinical decisions at all times Participation in our whole-team clinical meetings and significant event review We are committed to making this role work for you - we want our PA colleague to thrive, develop and stay with us for the long term.