Job descriptionThe Advanced ClinicalPractitioner (ACP) will provide autonomous, patient-centred clinical care to housebound patients across Huntingdon Primary Care Network. The role has a strong focus on proactive long‑term condition (LTC) management, personalised care planning, and supporting some of our most complex and vulnerable patients within their own homes. The post holder will undertake comprehensive clinical assessments, diagnosis, treatment, prescribing, monitoring and review of patients with long‑term conditions, ensuring care is delivered in line with local and national clinical guidelines. They will maintain an ongoing caseload of patients requiring regular clinical intervention, providing continuity of care and working collaboratively with patients, carers and the wider multidisciplinary team. Main duties of the job A key responsibility of the role will be the delivery of annual long‑term condition reviews for housebound patients during their birth month, helping to improve disease management, reduce health inequalities and ensure patients receive timely, proactive care. The ACP will work closely with other teams, and other partner organisations to coordinate care and improve patient outcomes. The successful candidate will be an autonomous clinician with advanced assessment and decision‑making skills, able to manage clinical complexity, identify deterioration, initiate appropriate investigations and referrals, and exercise professional judgement within their scope of practice. The role requires excellent organisational, communication and digital skills. The post holder will utilise a range of digital systems including SystmOne, Accurx, Microsoft Office applications, Outlook and Teams to support clinical care, communication, service delivery and accurate record keeping. The ACP will play a key role in improving access to care, supporting continuity, reducing avoidable hospital admissions and helping patients to remain well and independent within their own homes. Due to the nature of the role, the ACP will work extensively with frail, vulnerable and housebound patients and will have a significant responsibility for recognising, assessing and escalating safeguarding concerns. About us Huntingdon PCNs vision is to bring GP practices together with other local services to provide the best care in the right place. This role will support Huntingdon PCN which covers four GP Practices and has a patient population of 47,000 patients. Our values are: * Integrity– We promise to conduct ourselves with the utmost integrity, staying open and honest with colleagues and patients. * Empathy– We strive to take perspective of and feel emotions of another person, taking action to alleviate stress and pain of others showing kindness and care in our approach. Putting ourselves in other peoples shoes, both patients and colleagues, establishing an empathetic connection. * Empowerment– We seek to champion positive relationships and build trust whilst empowering others. Job responsibilities Why Join Huntingdon PCN? * Work autonomously across four progressive GP practices serving 47,000 patients. * Be part of a supportive multidisciplinary team including GPs, pharmacists, physiotherapists and social prescribers. * Opportunity to shape and develop ACP services across the network. * Protected CPD and clinical supervision. * Involvement in service development, quality improvement and leadership initiatives. * Supportive culture focused on innovation, learning and patient‑centred care. The ACP will contribute to: * Supporting continuity of care. * Reducing unnecessary secondary care referrals. * Improving patient experience and outcomes. * Improving patient access. * Reducing avoidable GP appointments. Key Responsibilities Clinical Care * Undertake comprehensive clinical assessments in patients homes. * Deliver annual long‑term condition reviews for housebound patients within their birth month. * Assess, diagnose, treat, prescribe and review patients within scope of practice. * Develop personalised care plans in partnership with patients and carers. * Provide holistic care considering physical, psychological and social needs. * Identify safeguarding concerns and take appropriate action in line with local policy. * Support admission avoidance and early intervention where deterioration is identified. * Refer appropriately to community, secondary care and voluntary sector services. * Assessment of capacity in accordance with the Mental Capacity Act. * Participate in Best Interest decision‑making processes where capacity is lacking. * Promote preventive healthcare interventions including vaccinations, health promotion and lifestyle advice. * Identify and address gaps in routine preventative care. * Undertake medication reviews and support medicines optimisation in collaboration with GPs, pharmacists, patients and carers. * Identify and manage risks associated with polypharmacy and complex medication regimes. * Monitor treatment effectiveness, side effects and adherence to prescribed therapies. * Assess and manage patients living with frailty, multiple co‑morbidities and complex healthcare needs. * Contribute to frailty reviews and personalised care planning. Caseload Management * Independently prioritise and manage a defined caseload of housebound patients with complex and ongoing healthcare needs. * Maintain oversight of patient reviews, follow‑up actions and care planning requirements. * Monitor clinical outcomes and identify patients requiring escalation or additional support. * Maintain continuity of care through regular review, monitoring and coordination of services. * Coordinate care with GPs, District Nursing Teams, Community Services and other healthcare professionals. * Manage referrals, investigations and onward care to ensure timely intervention and follow‑up. * Identify patients at risk of deterioration, hospital admission or safeguarding concerns and coordinate appropriate support. * Ensure patients on the caseload receive timely reviews, interventions and ongoing monitoring in line with clinical need and PCN objectives. * Maintain accurate caseload records, ensuring actions, reviews and outcomes are documented appropriately. * Regularly review caseload complexity, clinical priorities and service demand to support effective workload management. Multidisciplinary Working * Work collaboratively with GP practices, District Nursing Teams and community services. * Participate in multidisciplinary team meetings and clinical discussions. * Liaise with care homes, carers and family members where appropriate. * Support patients with palliative and end‑of‑life care needs in collaboration with GPs, District Nursing Teams and specialist services. * Act as an advocate for patients requiring support from multiple agencies. * Support colleagues through clinical supervision and shared learning. * Participate in advance care planning, treatment escalation discussions and future care planning with patients, carers and other professionals. * Liaise closely with District Nursing Teams regarding patient management, treatment plans and escalation of concerns. * Work collaboratively with Community Nursing, Community Rehabilitation, Social Prescribers, Pharmacists, Frailty Teams, Adult Social Care and Voluntary Services. * Participate in multidisciplinary meetings to support coordinated patient care. Digital Systems and Technology * Maintain accurate and contemporaneous clinical records using SystmOne. * Utilise Accurx to communicate with patients and healthcare professionals. * Use Microsoft Outlook, Teams, Word and Excel effectively to support service delivery. * Monitor and manage clinical tasks, referrals and communications through digital systems. * Produce reports, audit data and outcome measures as required. * Ensure compliance with information governance, data protection and confidentiality standards. * Demonstrate confidence and competence in using a range of digital healthcare technologies. Leadership and Education * Act as a clinical role model across Huntingdon PCN. * Support the education, training and development of colleagues and learners where appropriate. * Provide clinical supervision, mentorship and support to members of the multidisciplinary team. * Promote reflective practice, continuous learning and evidence‑based care. * Contribute to workforce development and sharing of best practice across the PCN. * Support the implementation of service improvements and new ways of working. Operational Responsibilities Daily activities may include: * Reviewing the clinical ledger and patient caseload. * Reviewing patient records ahead of visits, including vaccination status, allergies and outstanding actions. * Managing referrals and recording outcomes. * Responding to clinical tasks, emails and TeamNet actions. * Completing home visits and joint visits with colleagues where required. * Completing referrals to other services and agencies. * Maintaining clinical equipment and stock. * Ensuring all clinical records and documentation are completed on the day of patient contact. * Providing clinical support and supervision to colleagues where appropriate. Weekly and monthly responsibilities include: * Clinical supervision sessions. * Caseload reviews. * Stock management and equipment checks. * Audit activity and quality improvement projects. * Mandatory training and CPD. * One‑to‑one meetings and service development discussions. * Review and implementation of policies and procedures. Quality Improvement * Participate in clinical audit, quality improvement and service evaluation activities. * Contribute to the development of policies, pathways and clinical procedures. * Use outcome data to improve service delivery and patient care. * Support the implementation of evidence‑based practice. Safeguarding Responsibilities * Act as a safeguarding advocate for vulnerable patients, ensuring their safety, wellbeing and rights are protected. * Identify, assess and respond appropriately to safeguarding concerns including abuse, neglect, self‑neglect, domestic abuse, exploitation, hoarding, financial abuse and carer breakdown. * Undertake holistic assessments of patients within their home environment, recognising factors that may place individuals at risk. * Recognise early signs of deterioration in physical, mental or social wellbeing and initiate appropriate interventions. * Work closely with Adult Social Care, Community Services, District Nursing Teams, General Practice teams and other partner organisations to support safeguarding activity. * Raise safeguarding referrals and concerns in accordance with local procedures and legislation. * Participate in safeguarding investigations, strategy meetings and multidisciplinary discussions where appropriate. * Ensure safeguarding concerns, actions and outcomes are documented accurately within clinical records. * Contribute to Mental Capacity Act assessments and Best Interest decision‑making processes where appropriate. * Promote patient autonomy whilst balancing risks and safeguarding responsibilities. * Support carers and families where safeguarding concerns or care needs have been identified. * Maintain up‑to‑date safeguarding knowledge through mandatory training and continuing professional development. * Provide advice and support to colleagues regarding safeguarding concerns and escalation pathways. * Contribute to the development of a culture where safeguarding is recognised as everyones responsibility. Professional & PCN Policies * The post holder must comply with all national, statutory, legislative, professional and local policy. * The post holder should proactively contribute to improve local policy and any changes to improve service or protocols. * To be responsible for the application in practice of the PCNs policies and procedures and the limits of the authority and responsibility the post holder has within these. * To operate within the PCNs standing financial instructions and their application to financial and physical resources. Person Specification Skills * Excellent verbal and written communication skills * Ability to communicate effectively with patients, carers, colleagues and external agencies * Strong clinical reasoning and decision‑making skills * Ability to work safely and effectively as a lone practitioner in community settings. * Ability to recognise clinical deterioration and escalate appropriately * Ability to recognise and assess safeguarding concerns appropriately * Ability to work autonomously and manage clinical risk * Ability to manage and prioritise an independent caseload * Excellent organisational and time management skills * Ability to analyse and interpret information and present findings clearly * Ability to build and maintain effective professional relationships * Digital competency including use of Microsoft Outlook, Teams, Word and Excel * Competent use of SystmOne or equivalent clinical system * Competent use of Accurx or similar digital consultation platform * Ability to confidently navigate, manage and utilise electronic patient records, digital workflows and reporting systems. * Experience supporting colleagues through supervision, coaching or mentorship Qualifications * Educated to Masters degree level in a relevant clinical discipline * Registered with appropriate professional body (NMC, HCPC, etc.) * Significant post‑registration clinical experience demonstrating advanced practice capability * Experience working with vulnerable adults, frailty, complex care or community‑based patient populations * Experience managing a clinical caseload autonomously * Experience of multidisciplinary team working across organisational boundaries * Level 3 Safeguarding Adults and Children training (or willingness to undertake) * Evidence of ongoing Continuing Professional Development (CPD) * Experience conducting home visits and community‑based assessments * Teaching, mentorship or clinical supervision qualification * Experience within General Practice or Primary Care Knowledge * Working at Masters level and demonstrating the four pillars of Advanced Clinical Practice * Knowledge of medicines optimisation and polypharmacy management * Advanced clinical assessment, diagnostic and treatment skills * Understanding of long‑term condition management and personalised care planning * Knowledge of safeguarding legislation, processes and referral pathways * Understanding of the Mental Capacity Act and Best Interest decision‑making processes * Knowledge of frailty, complex care and proactive care approaches * Knowledge of digital healthcare systems and electronic patient records * Evidence of participation in audit, quality improvement or service development activities * Experience of using SystmOne * Knowledge of local community services and referral pathways Personal Qualities & Attributes * Ability to reflect upon and share best practice with peers * Compassionate and patient‑centred approach to care * Commitment to reducing health inequalities and improving access to care * Ability to work collaboratively within multidisciplinary teams * Proactive and self‑motivated approach to problem solving * Adaptable and resilient when managing competing priorities * Commitment to continuous learning and professional development * Professional, approachable and able to work with integrity 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. 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