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The Enfield Integrated Proactive Care Service is an Enfield Community Services (ECS) Multi-Disciplinary Team (MDT) within the Royal Free London NHS Foundation Trust, operating under the North Middlesex University Hospital (NMUH) unit. The service provides coordinated, person-centred support and interventions for residents living with long-term health conditions and/or frailty, helping them to proactively manage their health and wellbeing through an integrated approach to care.

Working collaboratively with the local authority, acute hospital

trusts, primary care services, and the voluntary sector, the MDT delivers

integrated, person-centred care to Enfield residents who are registered with an Enfield GP, helping to improve health outcomes and support individuals to remain independent within their communities.

The successful candidate will join an ambitious and inclusive partnership that is helping to shape the future of integrated care in Enfield. Working closely with clinicians, community partners, and system leaders, you will play a key role in supporting residents through a more connected, preventative, and person-centred approach to care.

This role offers an exciting opportunity to further develop the Enfield Proactive Care Service Multi-Disciplinary Team (MDT) model and contribute to the design and delivery of an exemplary Integrated Neighbourhood Team (INT).

Main duties of the job

1 . Facilitating Access to Local Services

• Receive and process referrals from GPs and other members of the multidisciplinary team (MDT) for individual patients.
• Assess patients' needs in line with referral criteria and GP guidance, signposting them to appropriate health, social care, voluntary sector, and community services available within the borough.
• Support individuals to access services and activities that promote health, wellbeing, independence, and social inclusion, including both funded and self-funded options.
• Identify unpaid carers and assist them in accessing relevant support services and resources.
• Work collaboratively with volunteers, supporting their involvement and adhering to established procedures and best practices for volunteer engagement.
• Provide general information regarding potential benefit entitlements and refer individuals to specialist welfare advice services where appropriate.
• Develop personalised support plans outlining recommended services and access routes, ensuring relevant information is shared with GPs, carers, and other professionals involved in the individual's care.
• Maintain comprehensive knowledge of local services, community resources, and eligibility criteria, keeping up to date with service developments and changes.
• Promote awareness among GPs and healthcare professionals of the range of community-based services available and how these can be accessed.
  
  

The Enfield Integrated Proactive Care Service is an Enfield Community Services (ECS) Multi-Disciplinary Team (MDT) within the Royal Free London NHS Foundation Trust, operating under the North Middlesex University Hospital (NMUH) unit. The service provides coordinated, person-centred support and interventions for residents living with long-term health conditions and/or frailty, helping them to proactively manage their health and wellbeing through an integrated approach to care.

Working collaboratively with the local authority, acute hospital

trusts, primary care services, and the voluntary sector, the MDT delivers

integrated, person-centred care to Enfield residents who are registered with an Enfield GP, helping to improve health outcomes and support individuals to remain independent within their communities.

For further details / informal visits contact: Name: Nnamdi Igwe Job title: Proactive Care Lead Email address: nnamdi.igwe@nhs.net Telephone number: 07886345664