PCN Diabetic Specialist Nurse in Hitchin

The Specialist Nurse will be an experienced and compassionate clinician who will play a key role in managing Hitchin and Whitwell patients with diabetes mellitus and pre-diabetes. Patients with co-existing cardiovascular disease (CVD) and chronic kidney disease (CKD) will be of particular focus. You will work with practice and PCN staff and the wider multi-disciplinary team to deliver excellent, patient-facing care, aiming to improve patient experience and their outcomes. Diabetes is a condition in which good blood sugar control can reduce the risk of the many associated potential complications. There are overlaps with the care of CVD and CKD, for example with good blood pressure control. You will be an experienced prescribing nurse who is passionate about diabetes care, promoting self-management and patient empowerment while confidently adding and adjusting medication as required.

This post is part of the Additional Roles Reimbursement Scheme (ARRS) for Primary Care Networks (PCNs).

Main duties of the job

• With support from the practice and PCN teams, you will undertake holistic diabetic, CVD and CKD Quality Outcomes Framework and Enhanced Commissioning Framework reviews, including taking and recording clinical observations, completing care planning documents, implementing evidence-based interventions, prescribing and monitoring medication, and offering practical advice and emotional support to patients and, where appropriate, their carer.
• You will be aware of local support services and be able to refer and signpost into these as appropriate.
• You will work collaboratively with partners to support patients, primary care and the wider health and social care system.
• We aim for this role to be key to the development of Neighbourhood cardio-renal-metabolic multi-disciplinary team working.

About us

H&W Health Ltd is a company providing services for Hitchin and Whitwell Primary Care Network (HWPCN). HWPCN was the Hertfordshire and West Essex PCN of the Year in 2024. PCNs build on existing primary care services and enable new and innovative approaches to improve patient care and access to services. HWPCN covers approximately 47,000 patients from four local GP surgeries. We are a dynamic and forward-thinking PCN, with a team of ARRS including clinical pharmacists, physiotherapists, social prescribing link workers, health & wellbeing coaches and care coordinators, supported by an operations manager, a business manager and a clinical director. We facilitate our PCN staff to integrate into practice teams and pride ourselves on providing a friendly and supportive working environment. Hitchin is a market town in Hertfordshire with excellent schools and transport links.

Job responsibilities

Primary Responsibilities

• Deliver comprehensive diabetes care and management in accordance with national guidelines (e.g., NICE, QOF).
• Conduct structured diabetes reviews including assessment, monitoring, and adjustment of treatment plans.
• Provide education and self-management support to patients with diabetes and pre-diabetes.
• Initiate and titrate insulin or non-insulin therapies in accordance with clinical protocols and independent prescribing rights.
• Support patients to manage devices such as continuous blood glucose monitoring equipment and insulin pumps.
• Identify patients at risk of diabetes-related complications and implement appropriate interventions.
• Collaborate with GPs and multidisciplinary teams to deliver patient-centred care.
• Provide support and training to primary care staff in diabetes management.
• Undertake CVD and CKD reviews in conjunction with diabetic reviews and take these co-morbidities into account with management plan.
• Contribute to the development and delivery of Neighbourhood cardio-renal-metabolic multi-disciplinary teams.
• Maintain accurate and timely clinical documentation in patient records.
• Participate in patient recall systems and help ensure achievement of QOF and IIF targets related to diabetes.

Secondary Responsibilities

• Participate in practice audits as requested by the audit lead.
• Participate in local quality improvement initiatives to enhance service delivery and patient care.
• Participate in the review of significant and near-miss events applying a structured approach i.e. root cause analysis (RCA).

This list is not exhaustive and there may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload, staffing levels and the needs of the business.

Generic Responsibilities

Confidentiality

All staff are required to respect the confidentiality of all H&W Health, HWPCN and Practice business and the business of the staff, residents, patients and general public which they may learn in the execution of their duties.

Data Protection

All staff are expected to adhere to the current laws regarding data protection.

Health and Safety

All staff are expected:

• To carry out the duties placed on employees by the Health and Safety at Work Act 1974, Environmental Protection Act 1990, Environment Act 1995, Fire Precautions (workplace) Regulations 1999 and other statutory legislation.
• To take reasonable care for the Health and Safety of themselves and of other persons who may be affected by their acts or omissions at work.
• To co-operate with their employer as far as is necessary to meet the requirements of the legislation.
• Not to intentionally or recklessly interfere with or misuse anything provided in the interest of health, safety or welfare in the pursuance of any relevant statutory provision.

Equality and Diversity

You must uphold the PCN commitment that all people will be valued regardless of their economic circumstances, disability, race, age, gender, sexual orientation, religion or belief, transgender status, pregnancy, maternity, partnership or marital status.

All staff are expected:

• To have a commitment to identifying and minimising risk, report all incidents and any risks which need to be assessed.
• To always comply with the Practices/PCNs/Company's Health and Safety policies.
• To follow agreed safe working practices and report any incidents or concerns to the practice manager, PCN director and senior clinic pharmacist.

Professional Registration

All qualified/professional staff are required to keep professionally registered and updated in accordance with the requirements of the relevant Code of Practice and to follow guidance issued by their professional body.

Policies and Procedures

The post holder is expected to comply with all relevant PCN policies, procedures and guidelines.

Quality & Continuous Improvement (CI)

All staff are expected to strive for continuous improvement and to raise ideas and concerns with their line manager.

Learning and Development

All staff will be required to partake and complete a company induction and mandatory training, as well as participating in PCN training activities.

All staff are expected:

• To recognise the significance of collaborative working.
• To communicate in a manner which enables the sharing of information appropriately and professionally.

Professional Conduct

Staff are required to dress appropriately for their role.

Leave

Staff are encouraged to use all of their annual leave entitlement.

Person Specification

Experience

• Experience of working in a primary care environment.
• Extensive experience in managing diabetes mellitus, including initiation and monitoring of insulin.
• Experience of managing patients with cardiovascular disease.
• Experience of managing patients with chronic kidney disease.
• Experience of using SystmOne.
• Experience of working in multi-disciplinary teams.

Other requirements

• Flexibility to work outside of core office hours.
• Occupational Health Clearance.
• Clean current driving licence and access to own vehicle.
• Project lead as required.

Personal Qualities

• Polite and confident.
• Flexible and cooperative.
• Motivated, forward thinker.
• Problem solver with the ability to process information accurately and effectively, interpreting data as required.
• High levels of integrity and loyalty.
• Sensitive and empathetic in distressing situations.
• Ability to work under pressure / in stressful situations.
• Effectively able to communicate and understand the needs of the patient.
• Commitment to ongoing professional development.
• Punctual and committed to supporting the team effort.

Qualifications

• Current registration with the Nursing and Midwifery Council.
• Recognised nursing qualification to degree level or equivalent.

Skills

• Excellent communication skills (written and oral).
• Clear, polite telephone manner.
• Competent in the use of Office and Outlook.
• Effective time management (Planning & Organising).
• Ability to work as a team member and autonomously.
• Excellent interpersonal skills.
• Problem solving & analytical skills.
• Ability to follow clinical policy and procedure.
• Experience with audit and able to lead audit programmes.
• Experience with clinical risk management.

Clinical Knowledge & Skills

Excellent level of clinical knowledge and skills.

Other requirements

• Flexibility to work outside of core office hours.
• Occupational Health Clearance.
• Clean current driving licence and access to own vehicle.
• Project lead as required.

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.

£46,000 to £50,000 a year pa WTE depending on experience.