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Job summary
This role is central to supporting the development of Integrated Neighbourhood Teams (INTs), which bring together professionals from across health, social care, and the voluntary sector to provide joined-up, person-centred care. Improving Health Limited (IHL) and Quay Health Solutions (QHS) GP Federations are working in partnership with Guys and St Thomas Foundation Trust to provide the integrator function for Integrated Neighbourhood Teams (INT) across Lambeth and Southwark. The Integrator partnership will actively support the transformative work of the development of neighbourhood health across the two boroughs, and is recruiting to posts within the newly created neighbourhoods. This role will be hosted by IHL or QHS on behalf of the Integrator but the postholder will be continuously working across organisational boundaries. We are seeking individuals who can work collaboratively with a range of stakeholders, embrace flexible and innovative ways of working, and commit to continuous improvement. This represents a significant cultural shift from a single-organisation focus to being part of a truly integrated team that places residents and communities at the heart of decision-making. Successful candidates will champion co-production, foster strong relationships with local partners, and help shape services that reduce health inequalities and improve outcomes for all.
Main duties of the job
The Neighbourhood Care Coordinator will act as the central point of contact for INT-eligible patients, coordinating their care within the Neighbourhood Integrated working model. The role will support proactive, personalised care for residents with complex needs, frailty, multiple long-term conditions, children and young people, and those who face barriers to accessing or engaging with services. The post holder will proactively identify and engage patients, undertake structured holistic reviews, capture patient goals and wider wellbeing needs, develop personalised care plans, coordinate access to clinical reviews and multidisciplinary team (MDT) meetings, and ensure agreed actions are followed through. In addition, they will support care coordination workflows, prioritisation and escalation processes, contribute to quality improvement activity, and provide supervision and support to care coordination colleagues.
About us
Quay Health Solutions CIC and Improving Health Limited, our two established GP federations in Southwark, are working in partnership with Guys and St Thomas' NHS Trust (GSTT) to provide the Integrator function for Southwark.
Integrators are organisations within each borough that will seek to provide the core infrastructure to support effective integrated neighbourhood team working as it develops, ensuring services are tailored to meet local community needs and operate smoothly across organisational boundaries. Their role is critical in creating cohesive, proactive, targeted, and sustainable services that place individuals and communities at the centre.
Southwark is a diverse borough made up of five neighbourhoods: Bermondsey & Rotherhithe, Borough, Peckham & Nunhead, Camberwell & Walworth, and Dulwich. Each neighbourhood has distinct population needs, requiring tailored approaches to health and care delivery.
Details
- Date posted: 25 August 2026
- Pay scheme: Other
- Salary: Depending on experience £32000 to £36000 a year (incl. inner London HCAS)
- Contract: Fixed term
- Duration: 12 months
- Working pattern: Full-time, Part-time, Job share, Flexible working
- Reference number: A0918-26-0023
- Job locations: Onsite - NHS Primary Care or Community Site, Within your assigned neighbourhood, Borough of Southwark, London, SE5 7JZ, United Kingdom
Job responsibilities
Key Responsibilities
Neighbourhood Care Coordination
Act as a senior point of contact for patients, carers, practices and partner organisations.
Proactively contact patients to understand their needs, priorities, goals and barriers to care.
Complete structured holistic reviews, capturing clinical, social and wider wellbeing factors and providing good quality written or verbal information to assist with choices about care.
Prepare for clinics by ensuring patient records are up to date and include any tests required by the clinic.
Follow up on post clinic tasks effectively (such as making referrals, multiple disciplinary team (MDT) meeting preparation etc).
Develop, record and coordinate personalised care plans in line with patient goals and local protocols.
Arrange any follow-ups, updating patient notes accordingly and pro-actively check these tasks have been completed.
Signpost or refer patients to appropriate health, social care, voluntary sector and community services.
Maintain accurate records, including Universal Care Plans and shared care records where appropriate.
Prioritise caseload activity and escalate risks, safeguarding concerns or clinical issues appropriately.
Provide guidance and day-to-day support to care coordination colleagues to share learning and best practice.
Ad-hoc neighbourhood tasks as and when services require this.
Support the CYP Programme by coordinating recalls for children and young people with tracer conditions, ensuring timely follow-up and accurate record keeping.
MDT and Partnership Working
Work with the neighbourhood primary care team to identify cohorts of patients who are eligible for neighbourhood services. In Southwark we currently have 3 priority areas: frailty, multiple long term conditions and children & young people but as neighbourhood services expand, additional priority areas will be identified.
Prepare, coordinate and refer appropriate cases for MDT discussion.
Track MDT actions and escalate delays or unresolved issues.
Work with the MDT to ensure consistent, patient-centered support across the INT pathway.
Collaborate with primary care, mental health, nursing teams, community services, social care, and voluntary sector partners.
Support safe information sharing and improvements to neighbourhood pathways.
Help to embed the MDT approach across the neighbourhood.
Collaborate with administrative teams to support the organisation, coordination and smooth running of MDT meetings.
Build strong relationships with local partners and help shape the services to improve outcomes for all.
Service Improvement
Support daily workflow, caseload prioritisation and task allocation.
Build and maintain effective relationships with neighbourhood practices, Primary Care Network (PCN), existing practice-based primary care co-ordinators and neighbourhood teams.
Provide coaching and support to colleagues.
Contribute to SOPs, templates and pathway improvements.
Support audit, reporting and quality improvement activity by collating patient data to help inform future service decisions.
Identify key themes, escalate and report service risks, challenges and improvement opportunities to the INT Manager
Resident Engagement and Support
Build trusting relationships to understand patient needs, priorities and barriers.
Use motivational interviewing and goal-setting techniques to support engagement in the INT programme.
Encourage and empower patients to take an active role in their health and care planning.
Support patients with low health and digital literacy, communication needs or complex social circumstances.
Promote self-management, prevention and access to community support.
Support patients to access and manage their Universal Care Plans through the NHS App including signposting to digital inclusion and support services.
Person specification
Experience
Essential
- Previous experience in a health or social care setting.
- At least 12 months' experience in an administrative role.
- Experience of care coordination.
- Experience working with people with complex needs.
- Experience using clinical, case management or shared care record systems.
- Experience working closely with clinical professionals as part of a multidisciplinary team.
- Experience communicating directly with patients, service users and/or carers.
Desirable
- Experience working in primary care.
- Experience of the Quality and Outcomes Framework (QOF) and/or Enhanced Services.
- Experience supporting frail older people and those living with complex needs.
- Experience working with people with long-term conditions.
- Experience working with children and young people.
- Experience analysing data and producing reports to support service improvement.
- Line management, supervision or coaching experience.
- Experience using motivational interviewing and developing personalised care plans.
Qualifications
Essential
- GCSE Grade A to C in English and Maths
- Level 3 qualification or equivalent relevant experience
Desirable
- Level 4 qualification or equivalent relevant experience
Knowledge and Skills
Essential
- Demonstrable ability to use motivational interviewing, goal-setting and personalised care approaches to support behaviour change and improve patient outcomes.
- Ability to build effective working relationships and work collaboratively across organisational and professional boundaries.
- Excellent verbal and written communication skills, with the ability to engage a wide range of stakeholders and adapt communication to different audiences.
- Strong minute-taking skills, including the ability to capture key discussions, decisions and actions, and produce clear, concise summaries.
- Excellent organisational skills, with the ability to manage and prioritise a varied workload, coordinate multiple tasks, and ensure actions are followed through to completion.
- Good IT skills, including proficiency in Microsoft Office applications and the ability to learn and use digital healthcare systems.
- Sound judgement and the ability to identify, assess and escalate safeguarding risks appropriately.
- Good knowledge and understanding of consent, confidentiality, information governance and data protection requirements (including GDPR).
Desirable
- Knowledge of medical terminology.
- Experience navigating EMIS and maintaining accurate patient records including coding.
- Familiarity with AccuRx, Consultant Connect, Ardens or similar clinical systems.
- Understanding of Universal Care Plans and personalised care planning.
Values and Behaviours
Essential
- Passionate about neighbourhood working and collaborative care across organisational boundaries.
- Committed to person-centred care and reducing health inequalities.
- Works collaboratively, contributes positively to team culture.
- Demonstrates compassion, professionalism and accountability in all aspects of their work.
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Applying for this NHS job
This advert is for Neighbourhood Care Coordinator with Quay Health Solutions CIC in Onsite - NHS Primary Care or Community Site, United Kingdom. It is listed as a Administrative and IT role. The advertised salary is Negotiable. The contract type is Fixed-Term. The application deadline is 06 Sep 2026.
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