Chronic Diseases Practice Nurse
| Posting date: | 29 April 2026 |
|---|---|
| Salary: | £43,914.92 to £49,956.64 per year |
| Additional salary information: | £43914.92 - £49956.64 a year |
| Hours: | Full time |
| Closing date: | 13 May 2026 |
| Location: | Dorking, RH4 1SD |
| Company: | NHS Jobs |
| Job type: | Permanent |
| Job reference: | A2589-26-0004 |
Summary
KEY RESPONSIBILITIES 1. Clinical Patient Care & Management Maintain a defined caseload of patients with chronic disease (such as respiratory diseases, diabetes, hypertension, cardiovascular disease etc) and deliver ongoing assessment, monitoring, review, and follow-up. Undertake complex assessments (clinical history, physical exam, risk stratification, complication screening) and develop individualised care plans. Monitor and interpret relevant investigations (e.g HbA1c, lipids, renal function, peak flow test, etc.). Initiate, titrate, adjust and monitor various chronic disease medications in line with agreed protocols and prescribing qualifications. Educate patients in self-management e.g inhaler technique, blood glucose monitoring, diet etc Provide structured education for newly diagnosed and existing patients. Conduct group and one-to-one education and support sessions to promote behaviour change and adherence. Identify, assess, and refer patients with complications as appropriate. Provide telephone, virtual, or in-person follow-up as clinically required. Undertake home visits where necessary (e.g. housebound patients) for assessment, treatment, or education. Ensure continuity of care and coordinate with secondary care and community services to support integrated chronic disease management. 2. Clinical Leadership & Service Development Lead and direct the coordination of the various chronic disease clinics within the practice, including scheduling, patient recall, and quality assurance. Develop, implement, and review local pathways, policies, and protocols in chronic disease care. Audit and monitor the various chronic disease care metrics (QOF indicators, IIF, local targets, and clinical outcomes) and drive improvement initiatives. Act as a specialist resource and mentor for practice staff (GPs, nurses, HCAs), providing expert advice, support, and supervision. Deliver or facilitate in-house training sessions and case-based discussions to enhance team competence in chronic disease care. Contribute to the planning and delivery of health promotion and prevention programmes (e.g. obesity management, smoking cessation etc). Liaise closely with local various chronic disease networks, community teams, and secondary care providers to promote continuity and best practice. Support implementation of new technologies to support chronic disease management. Lead or contribute to quality improvement projects, audits, and service redesign initiatives aligned with local and national priorities. 3. Professional and Quality Assurance Duties Maintain up-to-date knowledge of national and various local chronic disease guidance (NICE, local ICS pathways) and ensure clinical compliance. Maintain accurate, contemporaneous, and professional clinical records in accordance with NMC and practice standards. Participate in practice clinical governance processes, including risk management, incident review, and medicines safety. Undertake regular audits and contribute to service evaluation, research, and outcome measurement. Participate in and support CQC, or other relevant quality frameworks as required. Engage in continuing professional development (CPD) and reflective practice to maintain and develop specialist competence. Maintain professional registration and if applicable independent prescribing qualification. Adhere to the NMC Code, professional boundaries, and practice policies including confidentiality, data protection, and safeguarding. KEY RESPONSIBILITIES ADMINISTRATIVE Accurately record all consultations, care plans, and interventions on the clinical system. Ensure appropriate coding to support QOF and local enhanced service reporting. Maintain and review diabetes registers, ensuring systematic recall and proactive management. Contribute to data collection, audits, and reporting for clinical and performance monitoring. Participate in the review and development of practice policies and standard operating procedures. Attend and contribute to clinical meetings, case reviews, and multidisciplinary discussions. KEY RESPONSIBILITIES PROFESSIONAL Professional Registration Be professionally accountable for nursing practice in accordance with the NMC Code. Maintain active NMC registration and up-to-date professional knowledge. Participate in annual appraisal and maintain a personal development plan. Attend relevant training, study days, and clinical supervision sessions to maintain and enhance clinical competence. Recognise and work within scope of professional practice, seeking advice and support when required. CONFIDENTIALITY Patients entrust sensitive information to the practice, which must be handled with the utmost confidentiality. Information relating to patients, carers, colleagues, or the business of the practice must not be disclosed to unauthorised persons and must be processed in line with data protection legislation. All staff must comply with the Practice Confidentiality Policy and the NMC Code regarding confidentiality. SAFEGUARDING Demonstrate commitment to safeguarding and promoting the welfare of children, young people, and vulnerable adults. Follow practice safeguarding procedures and attend appropriate training. The post holder will be required to undergo an enhanced DBS check. EQUALITY AND DIVERSITY Uphold the principles of equality, diversity, and human rights in all patient and team interactions. Deliver care that is respectful of privacy, dignity, and cultural or individual needs. Promote a non-judgemental and inclusive environment for patients and colleagues. PERSONAL / PROFESSIONAL DEVELOPMENT Participate in an annual performance review and maintain an up-to-date record of CPD. Take responsibility for personal learning, reflective practice, and skill development. Contribute to the training and supervision of student nurses, medical students, or other trainees within the practice. COMMUNICATION Communicate effectively with patients, carers, colleagues, and partner organisations. Use motivational interviewing, shared decision-making, and other techniques to support engagement and self-management. Recognise the need for alternative methods of communication and adapt accordingly. Contribute to effective communication across the multidisciplinary team. OTHER DUTIES Undertake any other duties commensurate with the role as required by the Partners or Lead Nurse. Actively participate in reviewing systems, suggesting and implementing improvements to enhance quality of care and patient experience.