Job summary
Due to the continued development of our nursing services, we are seeking an experienced and highly motivated Long Term Conditions Nurse Lead to provide clinical leadership for the management of chronic disease and support the achievement of excellent patient outcomes.

The successful candidate will lead and develop our long-term conditions service, delivering high-quality care across a broad range of chronic diseases whilst supporting the practice in achieving Quality and Outcomes Framework (QOF) and enhanced service objectives.

This is an exciting opportunity for a skilled clinician who is passionate about preventative healthcare, patient education and improving outcomes for patients living with long-term conditions.

You will work collaboratively with GPs, pharmacists, HCAs, and the wider multidisciplinary team to deliver evidence-based care, identify opportunities for service improvement and support population health management.

Main duties of the job
Diabetes Management

• Lead diabetes care delivery within the practice.
• Undertake diabetes reviews and annual assessments.
• Support patients using oral agents, GLP-1 therapies and insulin.
• Initiate and titrate insulin where appropriately qualified.
• Interpret blood glucose data, HbA1c results and cardiovascular risk factors.
• Promote structured diabetes education and self-management.

Respiratory Disease Management

• Lead asthma and COPD services.
• Conduct annual reviews and optimise treatment in line with NICE guidance.
• Perform and interpret spirometry and FeNO testing.
• Support accurate diagnosis, monitoring and disease management.
• Deliver inhaler technique education and self-management support.

Cardiovascular Disease and Prevention

• Manage hypertension, CHD, stroke/TIA, atrial fibrillation and heart failure within scope of practice.
• Support lipid management and cardiovascular risk reduction.
• Optimise therapy in line with national and local guidance.
• Promote prevention and healthy lifestyle interventions.

Clinical Leadership

• Act as a clinical resource for long-term condition management.
• Support and mentor nursing and HCA colleagues.
• Contribute to audits, quality improvement and service development.
• Participate in MDT meetings and population health initiatives.

QOF and Quality Improvement

• Identify patients requiring review.
• Support achievement of QOF and enhanced service targets.
• Maintain accurate coding and high-quality records.
• Improve chronic disease outcomes and close care gaps.

About us
Overdale Medical Practice is a progressive, patient-focused GP practice serving approximately 12,000 patients in Derbyshire. We are committed to delivering high-quality, accessible primary care while embracing innovation, digital transformation and continuous improvement.

Our multidisciplinary team includes GPs, Advanced Nurse Practitioners, Practice Nurses, Pharmacists, Health Care Assistants, Care Coordinators and administrative colleagues who work closely together to provide outstanding care to our patients. We are proud of our supportive culture, commitment to professional development, and focus on delivering safe, evidence-based care.

At Overdale Medical Practice, we believe in delivering excellent patient care while supporting our staff to thrive professionally. We encourage innovation, value new ideas, and are committed to creating a positive workplace where every member of the team can make a meaningful contribution.

If you are an experienced clinician passionate about improving the lives of patients with long-term conditions, we would love to hear from you.

Job responsibilities
Clinical Care and Long-Term Condition Management.

• Lead the delivery and development of long-term condition management within the practice.
• Undertake comprehensive annual reviews, assessments and follow-up appointments for patients with chronic disease.
• Provide holistic, evidence-based care that supports prevention, early intervention, self-management and improved health outcomes.
• Work within agreed clinical protocols, national guidance, local pathways and professional scope of practice.
• Ensure care is personalised, inclusive and responsive to patient needs, preferences and health literacy.

Diabetes Management.

• Lead diabetes care within the practice, including annual reviews and ongoing monitoring.
• Assess, plan and evaluate care for patients using oral therapies, GLP-1 therapies and insulin.
• Initiate and titrate insulin where competent, appropriately trained and authorised to do so.
• Interpret and act on HbA1c results, blood glucose data, cardiovascular risk factors and other relevant investigations.
• Support structured education, lifestyle advice and self-management planning for patients with diabetes.

Respiratory Disease Management.

• Lead asthma and COPD services within the practice.
• Conduct annual reviews and optimise treatment in accordance with current clinical guidance and local pathways.
• Perform and interpret spirometry and FeNO testing where trained and competent.
• Support accurate diagnosis, monitoring and escalation of respiratory disease.
• Provide inhaler technique education, personalised action plans and self-management support.

Cardiovascular Disease and Prevention.

• Manage patients with hypertension, coronary heart disease, stroke/TIA, atrial fibrillation and heart failure within agreed scope of practice.
• Support lipid management, cardiovascular risk reduction and optimisation of therapy.
• Promote prevention, lifestyle interventions and shared decision-making.
• Identify patients at increased risk and support proactive review, monitoring and follow-up.

Clinical Leadership and Service Development.

• Act as a clinical resource for colleagues in relation to long-term condition management.
• Support, mentor and provide clinical guidance to nursing and HCA colleagues.
• Contribute to the development, review and implementation of clinical protocols, templates and practice processes.
• Participate in multidisciplinary team working, population health initiatives and case discussions where appropriate.
• Identify opportunities for service improvement and support implementation of change.

QOF, Audit and Quality Improvement.

• Work proactively to identify patients requiring review, monitoring or follow-up.
• Support achievement of QOF indicators, enhanced service requirements and local improvement priorities.
• Maintain accurate clinical coding, high-quality records and contemporaneous documentation.
• Contribute to clinical audits, searches, recall activity and quality improvement projects.
• Use data to identify care gaps, variation and opportunities to improve outcomes for patients with long-term conditions.

Professional Responsibilities.

• Maintain active NMC registration and work in accordance with the NMC Code.
• Work within own level of competence and seek support or escalate concerns where required.
• Maintain confidentiality, information governance standards and accurate patient records.
• Participate in appraisal, supervision, mandatory training and continuing professional development.
• Contribute to a positive, supportive and collaborative practice culture.
• Promote equality, diversity, inclusion and respectful care for patients and colleagues.

Person Specification
Skills
Essential

• Proficient in performing and interpreting spirometry.
• Proficient in performing and interpreting FeNO testing.
• Strong understanding of lipid modification and cardiovascular risk management.
• Ability to work autonomously and make complex clinical decisions.
• Excellent communication and patient education skills.
• High standard of clinical documentation and coding.

Desirable

• Independent prescribing qualification.
• Experience with insulin initiation and titration.
• Experience leading services or supervising colleagues.
• Knowledge of population health management and digital tools within primary care.

Experience
Essential

• Registered Nurse (NMC).
• Evidence of continued professional development.
• Significant experience managing long-term conditions within primary care.
• Demonstrable expertise in diabetes management.
• Experience supporting patients using insulin therapy.
• Experience managing asthma and COPD.
• Experience managing cardiovascular disease and hypertension.
• Experience working towards QOF targets and quality improvement initiatives.

Qualifications
Essential

• Registered Nurse (NMC).
• Evidence of continued professional development.

Desirable

• Independent Prescriber qualification or willingness to work towards this.

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.

UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).