Job description

Job responsibilities

Key duties and responsibilities

(Please note this is a list of options, it is not exhaustive, which options are deployed will be decided by the individual PCN, in conjunction with the clinical pharmacist and SEL GP Group). It is however mandated by NHS England that this role is patient-facing in nature.

1. Patient facing Clinical Medication Review

Undertake clinical medication reviews with patients and produce recommendations for senior clinical pharmacist, nurses and/or GP on prescribing and monitoring. These reviews could be cohort based, in care homes, polypharmacy or any other area required by the PCN, within the pharmacists competence. Home visits may be required.

2. Medicines quality improvement

Undertake clinical audits of prescribing in areas directed by the PCN, feedback the results and implement changes in conjunction with the relevant practice team.

Identify cohorts of patients at high risk of harm from medicines through computer searches. This might include risks that are patient related, medicine related, or both. Put in place changes to reduce the prescribing of these medicines to high-risk patient groups

3. Medicines safety

Implement changes to medicines that result from MHRA alerts, product withdrawal and other local and national guidance.

4. Management of common/minor/self-limiting ailments

Managing caseload of patients with common/minor/self-limiting ailments while working within a scope of practice and limits of competence. Signposting to community pharmacy and referring

to GPs or other healthcare professionals where appropriate.

5. Patient facing medicines support

Provide patient facing clinics for those with questions, queries and concerns about their

medicines in the practice.

6. Telephone medicines support

Provide a telephone help line for patients with questions, queries and concerns about their

medicines.

7. Management of medicines at change of care setting

Reconcile medicines following discharge from hospital or admission to intermediate care or care homes, including identifying and rectifying unexplained changes and working with patients and community pharmacists to ensure patients receive the medicines they need post discharge. Set up and manage systems to ensure continuity of medicines supply to high-risk groups of patients (e.g. those with medicine compliance aids or those in Care Homes).

8. Medicine information to practice staff and patients

Answer relevant medicine-related enquiries from GPs, other network staff, other healthcare teams (e.g. community pharmacy) and patients with queries about medicines. Suggest and recommend solutions. Providing follow up for patients to monitor the effect of any changes.

9. Drug monitoring

Ensure robust systems are in place for drug monitoring at each practice across the PCN, streamlining these where possible. Understand and apply the traffic light classifications for prescribing in the Leeds Health Economy.

10. Signposting

Ensure that patients are referred to the appropriate healthcare professional for the appropriate level of care within an appropriate period of time e.g. pathology results, common/minor ailments, acute conditions, long term condition reviews etc.

11. Repeat prescribing

Ensure each practice in the PCN has a robust repeat prescribing policy, and streamline these across the PCN where possible. You may be asked to contribute to the repeat prescribing reauthorisation process by reviewing patient requests for repeat prescriptions and reviewing medicines reaching review dates. Ensure patients have appropriate monitoring in place when required.

12. Service development

Contribute pharmaceutical advice for the development and implementation of new services that have medicinal components (e.g. advice on treatment pathways and patient information leaflets).

13. Information management

Analyse, interpret and present medicines data to highlight issues and risks to support decision making.

14. Education and Training

Provide education and training to primary healthcare team on therapeutics and medicines

optimisation.

15. Care Quality Commission

Work with the general practice teams to ensure the practices are compliant with CQC standards where medicines are involved.

16. Public health

Support public health campaigns. Provide specialist knowledge on all public health

programmes available to the general public.

17. Collaborative working arrangements

Work collaboratively with their PCN Clinical Director.

Participate in the PCN MDT.

Liaise with the Leeds GP Confederation Clinical Pharmacy team to benefit from peer support.

Liaise with CCG Medicines Commissioning colleagues on prescribing related matters to ensure consistency of patient care and benefit

Engage with the Leeds Practice Pharmacist and Technician Network and with the other SEL GP-employed pharmacists for peer support.

Foster and maintain strong links with all services across the PCN and neighbouring networks.

Explores the potential for collaborative working and takes opportunities to initiate and

sustain such relationships.

Liaises with other stakeholders as needed for the collective benefit of patients,including but not limited to :

Patients and their representatives

GP, nurses and other practice staff

Social prescribers, first contact physiotherapists, physicians associates and paramedics.

Community pharmacists and support staff

Locality / GP prescribing lead

Locality managers

Community nurses and other allied health professionals

Hospital staff with responsibilities for prescribing and medicines optimisation

18. Professional development

Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities.

Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.

Work with your line manager to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present.

Review yearly progress and develop clear plans to achieve results within priorities set by others. Participate in the delivery of formal education programmes.

Demonstrate an understanding of current educational policies relevant to working areas of practice and keep up to date with relevant clinical practice.

19. Research and Evaluation

Critically evaluate and review literature.

Identify where there is a gap in the evidence base to support practice.

Generate evidence suitable for presentations at practice and local level.

Apply research evidence base into the workplace.

20. Health and Safety/Risk Management

Must comply at all times with the Health and Safety policies, in particular following safe working procedures and reporting incidents using the organisations Incident Reporting Systems

Comply with the Data Protection Act (2018) and the Access to Health Records Act (1990).

21. Special working conditions

The post holder is required to travel independently between work sites and to attend meetings etc hosted by other agencies.

The post-holder will have contact with body fluids, i.e. wound exudates, urine etc while in clinical practice.

The post-holder is likely to need to visit patients in their own home.

22. Miscellaneous

Work as part of the team to seek feedback, continually improve the service and contribute to business planning.

Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.

Duties may vary from time to time, without changing the general character of the post or the level of responsibility.

23. Equality and Diversity

The post-holder must co-operate with all policies and procedures designed to ensure equality of employment. Co-workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc

24. Respect for Patient Confidentiality

The post-holder should respect patient confidentiality at all times and not divulge patient information unless sanctioned by the requirements of the role.

Person Specification

Personal Qualities & Attributes

Essential

• Commitment to reducing health inequalities and proactively working to reach people from all communities
• Demonstrates use of appropriate communication to gain the co-operation of relevant stakeholders (including patients, senior and peer colleagues, and other professionals, other NHS/private organisations, e.g. CCGs)
• Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary
• Ability to identify risk and assess/manage risk when working with individuals
• Able to work under pressure and meet deadlines
• Demonstrates accountability for delivering professional expertise and direct service provision

Desirable

• Demonstrates accountability for delivering professional expertise and direct service provision

Professional registration

Essential

• Mandatory registration with the General Pharmaceutical Council

Desirable

• Membership Primary Care Pharmacy Association (PCPA)
• Membership of the Royal Pharmaceutical Society

Other

Essential

• Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions
• Adaptable
• Evidence of being a great team-player
• Self Motivation
• Safeguarding and other mandatory training
• Immunisation status
• Access to own transport and ability to travel across the locality on a regular basis, including to visit people in their own homes

Experience

Essential

• Demonstrable experience as an established foundation-level pharmacist, demonstrated within a practice portfolio
• Experience and an awareness of the breadth of common acute and long-terms conditions that are likely to be seen in general practice
• Demonstrates ability to integrate general practice with community and hospital pharmacy teams and community groups
• Experience of partnership/collaborative working and of building relationships across a variety of organisations

Qualifications

Essential

• Qualifications & TrainingCompletion of an undergraduate degree in pharmacy and registration with the General Pharmaceutical Council
• Demonstrates and understanding of, and conforms to, relevant standards of practice.
• Follows professional and organisational policies/procedures relating to performance management

Desirable

• Holds or working towards an independent prescribing qualification
• Postgraduate Diploma in Clinical Pharmacy
• Successful completion of the CPPE General Practice Pharmacist Training Pathway

Skills and knowledge

Essential

• Demonstrable experience as an established foundation-level pharmacist, demonstrated within a practice portfolio
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities
• An appreciation of the nature of primary care prescribing, concepts of rational prescribing and strategies for improving prescribing
• Knowledge of IT systems, including ability to use word processing skills, emails and the internet to create simple plans and reports
• Able to obtain and analyse complex technical information.
• Able to gain acceptance for recommendations and influence/motivate/persuade the audience to comply with the recommendations/agreed course of action where there may be significant barriers
• Able to identify and resolve risk management issues according to policy/protocol.
• Understand the principles of research governance

Desirable

• Demonstrable experience as an established foundation-level pharmacist, demonstrated within a practice portfolio
• Able to plan, manage, monitor and review general medicine optimisation issues in core areas for long term conditions

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).

Employer details

Employer name

South and East Leeds GP Group

Address

Hosted Employers address

1st Floor Park Edge Practice

Asket Drive

Leeds

West Yorkshire

LS14 1HX

United Kingdom

Employer's website

https://www.seleedsgpgroup.nhs.uk/ (Opens in a new tab)

Job description

Job responsibilities

Care Coordination and Patient Support

Act as a key point of contact for patients, carers and professionals involved in care.

Coordinate care for individuals with complex health, social care and psychological needs.

Support patients to understand their diagnosis, treatment options and available services.

Promote independence, self-management and improved quality of life.

Support patients to attend appointments and engage with health and care services.

Monitor wellbeing and identify changes in need, escalating appropriately.

Support individuals experiencing anxiety, low mood, loneliness, adjustment difficulties or distress.

Provide ongoing contact and support to reduce social isolation and improve engagement.

Carer and Family Support

Provide practical, emotional and informational support to carers and families.

Identify carers experiencing stress, burnout or social isolation.

Support access to carers assessments, respite services, benefits advice and peer support.

Provide information on dementia progression and coping strategies.

Promote carer wellbeing and resilience through ongoing engagement.

Service Navigation and Advocacy

Provide information, advice and signposting to health, social care, housing, welfare and voluntary sector services.

Support patients and carers to access appropriate services and overcome barriers.

Promote personalised care and shared decision-making.

Advocate on behalf of patients and carers where appropriate.

Multi-Disciplinary Team Working

Work collaboratively with GPs, Dementia Nurse, Care Coordinators, Social Prescribers, Community Nurses, Mental Health Practitioners, Social Workers and voluntary sector partners.

Participate in MDT meetings and case discussions as required.

Share relevant information in line with information governance requirements.

Contribute to coordinated, integrated care planning across services.

Safeguarding, Governance and Administration

Identify safeguarding concerns and escalate appropriately in line with procedures.

Support safeguarding processes and contribute to information gathering where required.

Maintain awareness of the Mental Capacity Act and Best Interest decision-making.

Maintain accurate, timely and confidential electronic patient records.

Support audits, data collection and service evaluation activities.

Ensure compliance with GDPR, confidentiality and information governance standards.

Contribute to continuous improvement of the Dementia Nurse Service and Frailty Team.

Attend supervision, mandatory training and team meetings.

Develop and maintain effective working relationships with partner organisations.

Promote equality, diversity, inclusion and person-centred care in all aspects of work.

Work within organisational policies and professional standards.

Undertake any other duties appropriate to the role.

Person Specification

Experience

Essential

• Experience in health, social care, community or voluntary sector services.
• Experience working with carers and families.
• Experience providing emotional and practical support.
• Experience of MDT working.

Desirable

• Experience supporting people with dementia, frailty or mental health needs.
• Experience of care coordination or case management.
• Experience using electronic patient record systems.

Qualifications

Essential

• GCSEs (or equivalent) including English and Maths.
• Care Certificate.
• Qualification in Health & Social Care, Mental Health or Dementia Care.

Desirable

• NVQ Level 3 in Health and Social Care, Mental Health, Dementia Care or equivalent experience.
• Safeguarding Adults Training.

Personal Attributes

Essential

• Please see attached for more information.

Desirable

• Please see attached for more information.

Knowledge

Essential

• Please see attached for more information.

Desirable

• Please see attached for more information.

Skills and Abilities

Essential

• Please see attached for more information.

Desirable

• Please see attached for more information.

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.

Employer details

Employer name

South and East Leeds GP Group

Address

Hosted Employers address

1st Floor Park Edge Practice

Asket Drive

Leeds

West Yorkshire

LS14 1HX

United Kingdom

Employer's website

https://www.seleedsgpgroup.nhs.uk/ (Opens in a new tab)

Job description

Job responsibilities

Purpose of the role

The Diabetes Matron is a Leeds system-wide senior nursing leadership post within the Tier 3 Clinical Oversight Group of the Diabetes Neighbourhood Health Programme a new integrated model of care for adults aged 1867 with diabetes (any type) and two or more other long-term conditions, delivered across the Beeston and Middleton & Hunslet PCN footprint and scaling across the multi-neighbourhood over the three-year development period.

The post-holder provides advanced clinical decision-making across atypical and complex diabetes presentations, contributes to the weekly Tier 3 MDT (combined with the existing LTHT community diabetes MDT), and provides clinical supervision to the Tier 2 Clinical Lead Nurses for Diabetes. The role sits alongside the Consultant Diabetologist, Consultant Pharmacist, Highly Specialist Pharmacist and Clinical Psychologist, forming the specialist backbone of the model.

This is not a ward-based Matron post it is a system-facing, MDT-embedded, senior nursing leadership role designed to work across organisational boundaries. The post-holder champions diabetes in wider long-term-conditions pathways, contributes to workforce and educational strategy across the Leeds diabetes nursing workforce, and drives service development, quality improvement and equity of diabetes nursing care across the neighbourhoods.

The post-holder is expected to demonstrate advanced practice competence across the four pillars set out by the Health Education England / NHS England multi-professional framework for advanced clinical practice clinical practice, leadership and management, education, and research. Expert clinical knowledge of diabetes is the primary requirement of the role and takes precedence over a formal Advanced Clinical Practitioner qualification. Applicants without a formal ACP qualification who can demonstrate the four pillars of advanced practice, together with expert diabetes knowledge, are strongly encouraged to apply.

Active engagement with people in deprivation deciles 13 and named priority groups (people with learning disability, serious mental illness, those homeless or vulnerably housed, those who smoke or use substances, adults living alone) is a core expectation of the role. The post-holder is expected to work in a person-centred, trauma-informed way with a working understanding of the wider social determinants of health.

Key duties and responsibilities

Advanced clinical practice and complex clinical decision-making

Provide advanced clinical assessment, examination and consultation for adults with complex or atypical diabetes presentations including suspected MODY, LADA, type 3c (pancreatic) diabetes, early-onset Type 2 and ketosis-prone Type 2.

Advanced nursing input to complex insulin regimen optimisation, hypoglycaemia unawareness work-up, steroid-induced hyperglycaemia in complex multimorbidity, and preparation for surgical procedures (pre-operative optimisation) for the working-age cohort.

Independent prescribing across the diabetes formulary within scope of practice, with clear escalation to the Consultant Diabetologist and Consultant Pharmacist for cases outside scope.

Advanced use of Continuous Glucose Monitoring and Flash Glucose Monitoring data for shared decision-making.

Advanced nursing input to sign-off of complex prescribing and management decisions escalated from Tier 2.

Utilises advanced specialist knowledge covering a range of procedures underpinned by relevant broad-based knowledge, experience and competence.

MDT leadership and step-up / step-down decisions

Weekly attendance and active contribution to the Tier 3 Clinical Oversight Group MDT, combined with the existing LTHT community diabetes MDT.

Leadership of step-up and step-down decisions across the tiers including Tier 4 to Tier 3 step-down for stable stage 4 CKD diabetic renal disease (from Year 2) and stable Type 1 not requiring ongoing technology adjustment (from Year 2).

Presenting cases, drafting shared care plans and taking responsibility for nursing-related actions arising from MDT discussion.

Named senior nursing point of contact for cases requiring specialist input across the multi-neighbourhood footprint.

Lead the interface between the community Programme and Tier 4 specialist services at LTHT, working across the acute, community and primary care boundary.

Clinical supervision and workforce development

Provide clinical supervision to the two Tier 2 Band 7 Clinical Lead Nurses for Diabetes and to the Band 5 Registered Nurse development post.

Contribute to workforce development plans across Tier 1 and Tier 2 diabetes nursing capability, in partnership with the LCH Head of Nursing Development, LTHT nursing leadership and the wider Leeds diabetes nursing network.

Delivery of TARGET-style education to Practice Diabetes Leads and Tier 1 nursing colleagues on a quarterly cadence.

Practice supervisor / educator role for pre-registration and post-qualification nursing learners, including trainee ACPs and post-registration diabetes specialist courses.

Contribute to succession planning for advanced practice nursing in diabetes across the system, ensuring a fair and consistent development pathway for Diabetes Nurse Specialist colleagues.

Act as a role model, ensuring a professional service and image is maintained at all times.

System-wide leadership

Champion diabetes in wider long-term-conditions and neighbourhood-health pathways across Leeds, including the Leeds Proactive Care and Integrated Neighbourhood Health frameworks.

Provide senior nursing representation into system-wide diabetes forums, the Leeds ICB CaReMe Expert Reference Group and equivalent bodies.

Contribute to workforce and educational strategy across the Leeds diabetes nursing workforce.

Represent the Programme at local and regional clinical forums, including presentation, publication and submission for relevant awards.

Support LCH, LTHT and SEL GP in aligning practice and workforce across the diabetes pathway, ensuring the model reflects the Leeds system view rather than any single organisation.

Outreach, equity and engagement

Active engagement with people in deprivation deciles 13 and named priority groups people with learning disability, serious mental illness, those homeless or vulnerably housed, those with substance-use co-morbidity, adults living alone.

Liaison with mental health teams for patients with SMI and antipsychotic-induced metabolic disturbance.

Liaison with drug and alcohol services, homelessness services, and LD nursing colleagues.

Working in partnership with third-sector and asset-based community delivery partners as active collaborators, not downstream referrals.

Advocacy for equity of specialist access, addressing patterns of exclusion and disengagement in Tier 3 and Tier 4 attendance data.

Advice & Guidance and interface with primary care

Provide senior Advice and Guidance across the diabetes pathway, in partnership with the Tier 3 Consultant Diabetologist and Consultant Pharmacist.

Support quarterly joint clinics between Tier 2 and Practice Diabetes Leads, providing advanced nursing input as required.

Support Practice Diabetes Leads to cascade learning through practice clinical meetings.

Provide expert clinical opinion into primary care, community pharmacy, mental health, drug and alcohol and maternity services on complex diabetes cases.

Quality, safety and improvement

Work to NMC Code and advanced practice standards; ensure practice, and that of colleagues, is grounded in evidence-based theoretical and practical knowledge.

Lead and contribute to clinical audit across the Programme; feed back results and implement changes with the Tier 2 team, Practice Diabetes Leads and the Tier 3 Clinical Oversight Group.

Lead the implementation of changes to nursing practice that result from MHRA alerts, national guidance and local intelligence.

Contribute to the Programmes outcomes and evaluation framework, particularly on nursing-related outcomes, safety indicators, equity of access and specialist utilisation.

Lead complex clinical audit within the clinical area and support colleagues to contribute to audit and research activity relevant to the clinical area locally and nationally.

Comply with the organisations Infection Prevention and Control requirements, including bare below the elbows dress code.

Service development

Contribute senior nursing advice for the development and iteration of the Diabetes Neighbourhood Health Programme model including step-up / step-down criteria, pathway design, and operational standards.

Contribute to Year 2 business case development and Multi-Neighbourhood expansion planning.

Analyse, interpret and present nursing and outcomes data to highlight issues, opportunities and risks to support programme decision-making.

Propose and develop clinical policies and service developments that have impact on other disciplines, services or agencies.

Collaborative working relationships

Work collaboratively with the SEL GP senior clinical lead, Programme Manager, and the Tier 3 Clinical Oversight Group.

Maintain strong relationships with the LCH Head of Nursing Development, LTHT diabetes nursing leadership, SEL GP clinical leadership and the wider Leeds diabetes nursing network.

Maintain strong relationships with PCN Clinical Directors, Practice Diabetes Leads and practice nursing teams across the footprint.

Liaise with the Leeds ICB, community pharmacy, mental health services, drug and alcohol services, and VCSE partners as required.

Person Specification

Advanced practice — the four pillars

Essential

• Clinical practice expert-level clinical knowledge of diabetes across Type 1, Type 2, atypical presentations and complex multimorbidity; advanced clinical assessment and reasoning; autonomous clinical decision-making within scope of practice.
• Clinical practice advanced use of insulin regimen optimisation, CGM / Flash-informed titration, GLP-1 initiation and titration support; recognition of hypoglycaemia unawareness and appropriate work-up.
• Clinical practice non-medical prescribing (V300) or working towards, with clear understanding of scope and escalation.
• Leadership and management demonstrable clinical leadership at team and system level, able to influence and negotiate across professional and organisational boundaries.
• Leadership and management experience of leading service development, change management and workforce planning.
• Education demonstrable ability to provide clinical supervision and mentorship to Band 5, 6 and 7 diabetes nursing colleagues.
• Education experience of delivering teaching and cascade education, including via TARGET or equivalent forums.
• Education contribution to workforce and educational strategy across the Leeds diabetes nursing workforce; practice supervisor or educator recognition (or working towards).
• Research ability to critically appraise and apply the evolving evidence base for diabetes and cardio-renal-metabolic care.
• Research experience of leading or contributing to clinical audit, service evaluation and quality improvement projects.
• Research understanding of research governance and methodology; interest in contributing to research or service evaluation.

Desirable

• Formal ACP-level portfolio or e-portfolio aligned to the four pillars.
• Experience of contributing to national or regional guideline development or clinical research studies.

Experience

Essential

• Substantial post-registration experience as a Diabetes Nurse Specialist or equivalent diabetes-specialist nursing role.
• Advanced practice experience in complex diabetes case management, including atypical presentations (MODY, LADA, type 3c, early-onset Type 2, ketosis-prone Type 2). Practical experience of insulin regimen optimisation across all regimens, including CGM and Flash-informed titration.
• Practical experience of subcutaneous GLP-1 initiation and titration support.
• Experience of MDT working across community and acute care.
• Experience of clinical supervision and mentorship of Band 6 / 7 diabetes nursing colleagues.
• Experience of workforce development and education delivery.
• Experience of working with people affected by health inequalities.
• Experience of leading service development, quality improvement or clinical audit.
• Experience of supervising and managing other staff.

Desirable

• Experience of working in community or primary care based teams.
• Experience across the acute, community and primary care interface.
• Experience of pre-operative optimisation, hypoglycaemia unawareness work-up, or steroid-induced hyperglycaemia in complex cases.
• Experience of insulin pump, hybrid closed loop or CGM therapy at specialist level.
• Experience of leading complex clinical audit locally or nationally.
• Experience of research or contributing to national or regional guideline development.
• Experience of structured education delivery (DAFNE, DESMOND or equivalent) at educator level.

Qualifications

Essential

• Registered Nurse (Adult) with current NMC registration.
• Post-graduate learning to Masters level, or equivalent evidence of expert-level knowledge and specialist clinical practice.
• Recognised specialist diabetes qualification (Diabetes Specialist Practitioner course, Warwick, Leicester, Sheffield modules or equivalent).
• Demonstrable competence across the four pillars of advanced clinical practice (clinical practice, leadership and management, education, research).
• Independent Non-Medical Prescribing (V300), or working towards.
• Teaching, training or mentorship qualification or experience to an equivalent level.
• Maintains a portfolio of CPD in line with NMC standards.

Desirable

• Full Masters degree in Advanced Clinical Practice or formal Advanced Clinical Practitioner qualification.
• Formal teaching qualification (PGCert HE or equivalent).
• Leadership or management qualification (NHS Leadership Academy, Nye Bevan or equivalent).
• Formal training in health inequalities, trauma-informed care or behaviour-change approaches.

Additional criteria

Essential

• Advanced clinical assessment and consultation skills.
• Confident advanced practice decision-making within scope, with clear understanding of when to escalate.
• In-depth knowledge of diabetes across Type 1, Type 2, atypical presentations and complex multimorbidity.
• Confident with SGLT2i, GLP-1, insulin regimen selection, CGM / Flash data interpretation and complex prescribing.
• Demonstrable understanding of the wider determinants of health and their impact on outcomes.
• Person-centred and trauma-informed approach to consultations.
• Strong system-wide leadership presence able to influence and negotiate across professional and organisational boundaries.
• Ability to develop and lead complex clinical audit within the clinical area. Excellent verbal and written communication skills across clinical and non-clinical audiences.
• Emotional resilience, self-awareness, humility and curiosity.
• Willingness to challenge and be challenged, including consultants and GPs, in the patients best interest.
• Comfortable with the ambiguity of a new service and willing to iterate, evaluate and adjust.
• Confident with digital consultation, MDT tools and asynchronous working.
• Access to own transport and ability to travel across the multi-neighbourhood footprint.
• Meets DBS reference standards.
• Up-to-date mandatory training and immunisation status.

Desirable

• Awareness of the Leeds Proactive Care and Integrated Neighbourhood Health frameworks.
• Understanding of NHS commissioning and business case development.
• Demonstrable interest in continuing to develop the advanced practice profile in diabetes nursing at system level.

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).

Employer details

Employer name

South and East Leeds GP Group

Address

Hosted Employers address

1st Floor Park Edge Practice

Asket Drive

Leeds

West Yorkshire

LS14 1HX

United Kingdom

Employer's website

https://www.seleedsgpgroup.nhs.uk/ (Opens in a new tab)

Job description

Job responsibilities

The Clinical Lead Nurse for Diabetes is a senior clinical role within the Tier 2 Neighbourhood Support Team. The postholder holds a patient-facing caseload, delivering advanced diabetes nursing care in complex multimorbidity as an autonomous clinician. Responsibilities include insulin and injectable initiation and titration; use of CGM and Flash Glucose Monitoring data for titration; delivery of structured education; joint visits with district nursing for assisted insulin; contribution to the Tier 2 MDT and weekly Tier 3 MDT (combined with the LTHT community diabetes MDT); joint clinics with Practice Diabetes Leads; TARGET education across Tier 1; Advice and Guidance to primary care within 24-hour urgent and one-week routine SLAs; clinical leadership and supervision of nursing colleagues; and active outreach to people in deprivation deciles 1 to 3 and named priority groups. Contribution to service development, quality improvement and equity of diabetes care.

Purpose of the role

The Clinical Lead Nurse for Diabetes is a senior clinical role within the Tier 2 Neighbourhood Support Team of the Diabetes Neighbourhood Health Programme a new integrated model of care for adults aged 1867 with diabetes (any type) and two or more other long-term conditions, delivered across the Beeston and Middleton & Hunslet PCN footprint and expanding across the Multi-Neighbourhood over the three-year development period.

The role is patient-facing, holds an active caseload within the Tier 2 cohort, and delivers advanced diabetes nursing care across injectable therapy, structured education and complex multimorbidity. The postholder is a core participant in the Tier 2 MDT and the weekly Tier 3 MDT (combined with the existing LTHT community diabetes MDT), provides Advice and Guidance to primary care, leads joint clinics with the Practice Diabetes Lead in each footprint practice, and drives workforce development across Tier 1 and Tier 2 through quarterly TARGET education.

Active outreach and engagement with deprivation deciles 13 and named priority groups (people with learning disability, serious mental illness, those homeless or vulnerably housed, those who smoke or use substances, adults living alone) is a core expectation of the role. The postholder is expected to work in a person-centred, trauma-informed way, with a working understanding of the wider social determinants of health.

Key duties and responsibilities

Advanced diabetes nursing and injectable therapy

Advanced clinical assessment and consultation with patients on the Tier 2 caseload, including remote and asynchronous consultation.

Insulin initiation, titration and ongoing management across all regimens basal, biphasic, basal-bolus including remote support by phone and asynchronous tools.

Subcutaneous GLP-1 receptor agonist initiation, titration and ongoing management (oral GLP-1 and GLP-1 / GIP formulations are prescribed at Tier 1).

Use of Continuous Glucose Monitoring (CGM) and Flash Glucose Monitoring data for titration, escalation and shared decision-making.

Joint visits with district nursing for patients requiring assisted insulin administration.

Delivery of structured diabetes education DAFNE, DESMOND, Confidence with Carbohydrates or equivalent, and pre-conception / pre-pregnancy education where relevant.

Non-Medical Prescribing within scope of practice (post-holders holding V300); clear escalation to Tier 2 Pharmacist or Tier 3 Consultant colleagues for complex prescribing decisions.

Recognition of and appropriate response to acute deterioration, including sick-day rules education, hypo unawareness identification and referral to Tier 3 or Tier 4 as required.

Care coordination and complex multimorbidity

Holding and managing an active caseload within the Tier 2 cohort, with responsibility for planning, delivering and evaluating patient-centred nursing care.

Care coordination across the Tier 2 team who holds the patient list, how follow-up cadence is decided, and how patients move safely between tiers.

Contribution to the Tier 2 approach to cardio-renal-metabolic multimorbidity, working alongside the Specialist Pharmacist, Specialist Dietitian, Specialist Podiatrist and Registered Nurse development post.

Recognition of psychological, social and mental health needs affecting engagement and self-management with liaison into mental health, learning disability, homelessness and substance-use services.

Reconciliation of care following discharge from hospital or transfer from other services, working with community pharmacy and hospital teams to ensure continuity.

MDT participation and clinical decision-making

Active participation in the Tier 2 MDT fortnightly for complex / high-risk cases and 812 weekly for moderate-risk cases.

Weekly attendance and active contribution to the Tier 3 Clinical Oversight Group MDT, combined with the existing LTHT community diabetes MDT.

Presenting cases, drafting shared care plans and taking responsibility for nursing-related actions arising from MDT discussion.

Escalation to Tier 4 for pump / hybrid closed loop, DKA / HHS follow-up, high-risk foot MDT, antenatal diabetes and other specialist pathways as required.

Advice & Guidance and joint clinics with primary care

Provide Advice and Guidance to primary care within agreed SLAs 24 hours for urgent enquiries, one week for routine for clinical questions beyond the Tier 1 remit and short of MDT escalation.

Lead quarterly joint clinics with the Practice Diabetes Lead in each footprint practice, on the model described in the Programme Education, Training and Support Plan.

Deliver nursing content within the quarterly TARGET education sessions for Practice Diabetes Leads, cascading learning into wider practice teams.

Support Practice Diabetes Leads to cascade learning through practice clinical meetings.

Outreach, equity and engagement

Active recruitment and engagement from deprivation deciles 13, with DNA monitoring and proactive approaches to reduce DNAs.

Outreach to named priority groups people with learning disability, serious mental illness, those homeless or vulnerably housed, those with substance-use co-morbidity, adults living alone.

Flexible appointment access including evening, digital and asynchronous options; home visits where clinically indicated.

Liaison with mental health teams for patients with SMI and antipsychotic-induced metabolic disturbance.

Liaison with drug and alcohol services and homelessness services.

Workplace engagement and reasonable-adjustment support via Healthy Working Lives.

Working in partnership with third-sector and asset-based community delivery partners as active collaborators, not downstream referrals.

Nursing quality, safety and improvement

Work to NMC Code and professional standards; ensure practice, and that of colleagues, is grounded in evidence-based theoretical and practical knowledge.

Identify cohorts of patients at high risk of harm through structured searches (EMIS / SystmOne) and act on findings.

Contribute to clinical audit within the Tier 2 caseload and across the Programme; feed back results and implement changes with the Tier 2 team, Practice Diabetes Leads and the Tier 3 Clinical Oversight Group.

Contribute to the Programme's outcomes and evaluation framework, particularly on nursing-related outcomes, safety indicators and equity of access.

Comply with the organisations Infection Prevention and Control requirements, including bare below the elbows dress code.

Leadership, supervision and workforce development

Provide clinical leadership on diabetes nursing practice within the Tier 2 Neighbourhood Support Team.

Provide supervision and mentorship to the Registered Nurse development post, and to less experienced colleagues within scope.

Act as a role model to all staff, ensuring a professional service and image is maintained at all times.

Contribute to workforce development plans across Tier 1 and Tier 2 nursing, in partnership with the Tier 3 Diabetes Matron and the wider Tier 3 group.

Practice supervisor / educator role for pre-registration and post-qualification nursing learners as required.

Effective and efficient use of clinical resources (staff, supplies) within own sphere of responsibility.

Service development

Contribute nursing advice for the development and iteration of the Diabetes Neighbourhood Health Programme model including step-up / step-down criteria, pathway design, and operational standards.

Contribute to Year 2 and Multi-Neighbourhood expansion planning.

Analyse, interpret and present nursing and outcomes data to highlight issues, opportunities and risks to support programme decision-making.

Collaborative working relationships

Work collaboratively with the Tier 2 clinical lead, Programme Manager, and the Tier 3 Clinical Oversight Group.

Maintain strong relationships with PCN Clinical Directors, Practice Diabetes Leads and practice nursing teams across the footprint.

Liaise with the Leeds ICB, LCH, LTHT and neighbouring GP federations for consistency of patient care.

Engage with the Leeds diabetes nursing network and other diabetes special interest groups for peer support.

Liaise with LCH community diabetes teams, LTHT specialist diabetes services, community pharmacy, mental health services, drug and alcohol services, and VCSE partners as required.

Foster and maintain strong links with all services across the multi-neighbourhood footprint.

Please see attached job description for more info

Person Specification

Additional criteria

Essential

• Advanced clinical assessment and consultation skills.
• Highly specialist knowledge of diabetes across Type 1, Type 2, atypical presentations and complex multimorbidity.
• Confident with SGLT2i, GLP-1, insulin regimen selection and use of CGM or Flash data for shared decision-making.
• Autonomous within scope of practice, with clear understanding of when to escalate to Tier 3.
• Excellent verbal and written communication skills, including complex or potentially distressing conversations with patients and families.
• Demonstrable understanding of the wider determinants of health and their impact on communities.
• Demonstrable commitment to reducing health inequalities and proactively reaching under-served populations.
• Person-centred and trauma-informed approach to consultations.
• Ability to plan, manage, monitor and review nursing care for a long-term-conditions cohort.
• Ability to influence, motivate and negotiate across professional and organisational boundaries.
• Clinical leadership presence and ability to role-model professional standards.
• Willingness to challenge and be challenged, including consultants and GPs, in the patient's best interest.
• Comfortable with the ambiguity of a new service, and willing to iterate, evaluate and adjust.
• Confident with digital consultation, MDT tools and asynchronous working.
• Emotional resilience, self-awareness, humility and curiosity.
• Access to own transport and ability to travel across the multi-neighbourhood footprint.
• Meets DBS reference standards.
• Up-to-date mandatory training and immunisation status.

Desirable

• Awareness of the Leeds Proactive Care and Integrated Neighbourhood Health frameworks.
• Understanding of NHS commissioning, business-case development and the wider system architecture.
• Interest in contributing to research, service evaluation or Year 2 business-case development.

Experience

Essential

• Substantial post-registration experience as a Diabetes Nurse Specialist or equivalent diabetes-specialist nursing role.
• Practical experience of insulin regimen optimisation across all regimens (basal, biphasic, basal-bolus).
• Practical experience of subcutaneous GLP-1 initiation, titration and ongoing management.
• Experience of joint working with district nursing for assisted insulin administration.
• Experience of MDT working across community and acute care.
• Experience of delivering structured diabetes education (DAFNE, DESMOND, Confidence with Carbohydrates or equivalent).
• Experience of clinical supervision and mentorship of junior nursing colleagues.
• Experience of working with people affected by health inequalities.
• Experience of contributing to service development, quality improvement or clinical audit.
• Experience of leadership in practice, including day-to-day team leadership and delegation.

Desirable

• Experience of working across the acute, community and primary care interface.
• Experience of CGM, Flash Glucose Monitoring and insulin pump technology.
• Experience of leading or contributing to clinical audit and quality improvement projects.
• Experience of contributing to research or service evaluation.
• Working experience of EMIS and SystmOne clinical systems.
• Experience of change management or new-service implementation.

Qualifications

Essential

• Registered Nurse (Adult) with current NMC registration.
• Post-graduate learning to Master's level or equivalent.
• Independent Non-Medical Prescribing (V300), or working towards.
• Recognised specialist diabetes course or qualification (Diabetes Specialist Practitioner course, Warwick, Leicester, Sheffield modules, or equivalent).
• Teaching, training or mentorship qualification, or experience to an equivalent level.
• Maintains a portfolio of CPD in line with NMC standards.

Desirable

• Full Master's degree in Advanced Clinical Practice.
• Formal teaching qualification (PGCert HE or equivalent).
• Leadership or management qualification (NHS Leadership Academy or equivalent).
• Formal training in health inequalities, trauma-informed care, or behaviour-change approaches such as Making Every Contact Count.

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).

Employer details

Employer name

South and East Leeds GP Group

Address

Hosted Empolyers address

1st Floor Park Edge Practice

Asket Drive

Leeds

West Yorkshire

LS14 1HX

United Kingdom

Employer's website

https://www.seleedsgpgroup.nhs.uk/ (Opens in a new tab)

Job description

Job responsibilities

The Specialist Dietitian for Diabetes is the operational dietetic lead within the Tier 2 Neighbourhood Support Team. Responsibilities include specialist dietetic assessment and intervention in cardio-renal-metabolic multimorbidity, including CKD stages 3b to 5, heart failure, MAFLD, severe obesity and gastrointestinal disorders. The postholder delivers structured education (DAFNE, Confidence with Carbohydrates, DESMOND or equivalent), supports carbohydrate counting and dose adjustment for basal-bolus regimens, and targets recruitment to the National Type 2 Path to Remission Programme. Contributes to the Tier 2 MDT and the weekly Tier 3 MDT, provides Advice and Guidance to primary care within 24-hour urgent and one-week routine SLAs, delivers dietetic content in quarterly TARGET education, provides cultural adaptation of dietary advice for ethnic-specific patterns, supports pre-conception and gestational diabetes dietetic care, and contributes to quality improvement and equity of dietetic access.

Key duties and responsibilities

Specialist dietetic assessment and intervention in complex multimorbidity

Assess, plan, deliver and evaluate specialist dietetic care for adults on the Tier 2 caseload with diabetes and complex multimorbidity, working as an autonomous practitioner within a wider MDT.

Specialist dietetic intervention for complex co-morbidity including CKD stages 3b5, heart failure, MAFLD (metabolic-associated fatty liver disease), severe obesity, and gastrointestinal disorders.

Dietetic management of complex insulin regimens carbohydrate counting and dose adjustment for those on basal-bolus regimens, use of Continuous Glucose Monitoring and Flash Glucose Monitoring data to support decisions. Combination therapy support alongside dietetic intervention including SGLT2i, GLP-1 receptor agonists (subcutaneous and oral), and other pharmacotherapy in liaison with the Specialist Pharmacist.

Dietetic management of steroid-induced hyperglycaemia and hypoglycaemia risk reduction.

Reconciliation of dietetic plans following discharge from hospital or transfer from other services.

Type 2 remission and structured education

Targeted recruitment of eligible patients into the National Type 2 Diabetes Path to Remission Programme (Xyla in Leeds), including engagement with under-served communities.

Support and shape a proposed option to commission bespoke local Xyla-style sessions for underserved communities, in partnership with the Programme Manager and VCSE partners.

Good knowledge of the delivery of the Leeds Programme of structured education, DAFNE, and Confidence with Carbohydrates.

Delivery of DESMOND or equivalent Type 2 self-management education where relevant.

Adaptation of structured education for people with learning disability, sensory impairment or lower literacy in partnership with LD nursing and easy-read materials.

Cultural adaptation of dietary advice supporting ethnic-specific dietary patterns and food traditions across the diverse populations of south and east Leeds.

Lifestyle, physical activity and behaviour change

Resistance training advice alongside aerobic exercise not assumed within general lifestyle advice.

Behaviour-change consultation using recognised frameworks (Making Every Contact Count, motivational interviewing or equivalent).

Weight management dietetic input aligned with local pathways.

Pre-conception dietetic input for women planning pregnancy with diabetes, and gestational diabetes follow-up support with clear handover into the LTHT maternity team.

MDT participation and clinical decision-making

Active participation in the Tier 2 MDT fortnightly for complex / high-risk cases and 812 weekly for moderate-risk cases.

Weekly attendance and active contribution to the Tier 3 Clinical Oversight Group MDT, combined with the existing LTHT community diabetes MDT.

Presenting cases, drafting shared care plans and taking responsibility for dietetic-related actions arising from MDT discussion.

Escalation to Tier 4 for antenatal diabetes, bariatric pathway, high-risk foot MDT, and other specialist pathways as required.

Advice & Guidance and joint clinics with primary care

Provide Advice and Guidance to primary care within agreed SLAs 24 hours for urgent enquiries, one week for routine for dietetic questions beyond the Tier 1 remit and short of MDT escalation.

Support quarterly joint clinics with the Practice Diabetes Lead in each footprint practice, on the model described in the Programme Education, Training and Support Plan.

Deliver dietetic content within the quarterly TARGET education sessions for Practice Diabetes Leads, cascading learning into wider practice teams.

Support Practice Diabetes Leads to cascade dietetic learning through practice clinical meetings.

Outreach, equity and engagement

Active recruitment and engagement from deprivation deciles 13, with DNA monitoring and proactive approaches to reduce DNAs.

Outreach to named priority groups people with learning disability, serious mental illness, those homeless or vulnerably housed, those with substance-use co-morbidity, adults living alone.

Flexible appointment access including evening, digital and asynchronous options; home visits where clinically indicated.

Liaison with mental health teams for patients with SMI and antipsychotic-induced metabolic disturbance.

Liaison with drug and alcohol services and homelessness services.

Workplace engagement and reasonable-adjustment support via Healthy Working Lives.

Working in partnership with third-sector and asset-based community delivery partners as active collaborators, not downstream referrals including food-poverty and community food initiatives.

Quality, safety and improvement

Work to HCPC standards and the British Dietetic Association Standards of Proficiency; ensure practice is grounded in evidence-based theoretical and practical knowledge.

Identify cohorts of patients at high risk of nutritional harm through structured searches (EMIS / SystmOne) and act on findings.

Contribute to clinical audit within the Tier 2 caseload and across the Programme; feed back results and implement changes with the Tier 2 team, Practice Diabetes Leads and the Tier 3 Clinical Oversight Group.

Contribute to the Programme's outcomes and evaluation framework, particularly on dietetic outcomes, remission rates, HbA1c, weight and lipid changes, and equity of access.

Comply with the organisations Infection Prevention and Control requirements, including bare below the elbows dress code.

Leadership, supervision and workforce development

Provide dietetic leadership within the Tier 2 Neighbourhood Support Team.

Provide supervision and mentorship to dietetic support workers, dietetic students and less experienced colleagues within scope.

Contribute to workforce development plans across Tier 1 and Tier 2 dietetic capability, in partnership with the senior dietetic lead in the wider Leeds diabetes dietetic pathway.

Practice supervisor / educator role for pre-registration and post-qualification dietetic learners as required.

Act as a role model, ensuring a professional service and image is maintained at all times.

Service development

Contribute dietetic advice for the development and iteration of the Diabetes Neighbourhood Health Programme model including step-up / step-down criteria, pathway design and operational standards.

Contribute to Year 2 and Multi-Neighbourhood expansion planning.

Analyse, interpret and present dietetic and outcomes data to highlight issues, opportunities and risks to support programme decision-making.

Collaborative working relationships

Work collaboratively with the Tier 2 clinical lead, Programme Manager, and the Tier 3 Clinical Oversight Group. Maintain strong relationships with PCN Clinical Directors, Practice Diabetes Leads and Tier 1 clinicians across the footprint.

Liaise with the Leeds ICB, LCH, LTHT and neighbouring GP federations for consistency of patient care.

Engage with the Leeds diabetes dietetic network, BDA Diabetes Specialist Group, and other diabetes special interest groups for peer support.

Liaise with LCH community diabetes teams, LTHT specialist diabetes services (including antenatal, bariatric and high-risk foot pathways), community pharmacy, mental health services, drug and alcohol services, and VCSE partners as required.

Foster and maintain strong links with all services across the multi-neighbourhood footprint.

Continuing professional development, research and evaluation

Undertake continual personal and professional development and take an active role in developing the Tier 2 dietetic offer.

Access regular clinical supervision to work effectively with the complex issues the Tier 2 cohort presents.

Reflect on and evaluate own practice; identify areas of development by setting appropriate objectives via appraisal and clinical supervision.

Critically appraise and apply the evolving evidence base for diabetes and cardio-renal-metabolic dietetic care.

Contribute to the Programmes Year 1 evaluation and Year 2 business case.

Care Quality Commission, health and safety, and confidentiality

Work with the delivery partners to ensure practices and Programme delivery are compliant with CQC standards where dietetic input is involved.

Comply with Health and Safety policies, follow safe working procedures and report incidents through the organisation's Incident Reporting Systems.

Comply with the Data Protection Act (2018) and the Access to Health Records Act (1990); respect patient confidentiality at all times.

Understand and apply knowledge of the clinical role in safeguarding and incident management.

Special working conditions

The postholder will travel independently between practices and community sites across the Beeston and Middleton & Hunslet footprint, and to meetings hosted by other agencies.

Person Specification

Personal Qualities & Attributes

Essential

• Commitment to reducing health inequalities and proactively working to reach people from all communities.
• Person-centred, trauma-informed approach with a working understanding of the wider social determinants of health.
• Ability to communicate with a wide range of colleagues from the NHS and other organisations and with patients including good written and oral communication skills.
• Recognises personal limitations and refers to more appropriate colleagues when necessary.
• Able to identify and assess / manage risk when working with individuals.
• Able to work under pressure and meet deadlines, managing unpredictable service demands.
• Accountability for delivering professional expertise and direct service provision.
• Emotional resilience, self-awareness, humility and curiosity.
• Willing to challenge and be challenged including consultants and GPs in the patients best interest.
• Reliability and integrity in a small MDT where the model depends on trust.
• Ability to organise, plan and prioritise on own initiative.
• Ability to work flexibly and enthusiastically within a team or on own initiative.
• Comfortable with the ambiguity of a new service willing to iterate, evaluate and adjust.
• Cultural competence for supporting ethnic-specific dietary patterns and adaptation.
• Positive and flexible attitude to dealing with change.

Desirable

• Leadership experience and previous experience of supervising or mentoring more junior staff or students.

Qualifications

Essential

• BSc (Hons) in Dietetics or equivalent professional dietetic degree.
• Postgraduate qualification in a specialist field (Diabetes, Renal, Obesity, MAFLD or Behaviour Change), or working towards.
• Must be willing to participate in any relevant training identified to develop skills required to carry out duties.
• Maintains a portfolio of CPD in line with HCPC standards.

Desirable

• Supporting Learning in Practice (SLIP), Practice Educator qualification or equivalent.
• Formal teaching qualification (PGCert HE or equivalent).
• Leadership or management qualification (ILM 3, NHS Leadership Academy or equivalent).
• Certified DAFNE, DESMOND, Confidence with Carbohydrates or Xyla Path to Remission educator.
• Formal training in health inequalities, trauma-informed care or behaviour-change approaches (Making Every Contact Count, motivational interviewing).

Skills and knowledge

Essential

• Detailed theoretical and clinical dietetic knowledge appropriate to diabetes, multimorbidity and cardio-renal-metabolic disease.
• Highly specialist knowledge of diabetes across Type 1, Type 2, atypical presentations and complex multimorbidity.
• Confident with carbohydrate counting, dose adjustment for insulin regimens and use of CGM / Flash data.
• Knowledge of Type 2 remission pathways (Xyla) and structured education programmes.
• Understanding of the wider determinants of health and their impact on communities, including food access and food poverty.
• Autonomous within scope of practice and knows when to escalate.
• Excellent verbal, non-verbal and written communication skills, including complex or potentially distressing conversations with patients and families and managing conflict when appropriate.
• Advanced consultation skills and shared decision-making with people whose lives are shaped by health inequalities.
• Confident with EMIS / SystmOne, digital consultation modes, MDT tools and asynchronous working.
• Able to plan, manage, monitor and review dietetic care for a long-term-conditions cohort.
• Able to obtain and analyse complex clinical and outcomes information.
• Complex analytical and creative problem solving in unpredictable situations.
• Workload management including delegation and day-to-day team leadership.

Desirable

• Understanding of research governance and quality improvement methodology.
• Awareness of the Leeds Proactive Care and Integrated Neighbourhood Health frameworks.

Professional Registration

Essential

• Mandatory registration with the Health and Care Professions Council (HCPC) as a Dietitian.

Desirable

• Membership of the British Dietetic Association (BDA).
• Membership of the BDA Diabetes Specialist Group.

Experience

Essential

• Substantial post-registration dietetic experience in diabetes and multimorbidity.
• Experience of dietetic management of Type 1 and Type 2 diabetes including insulin regimens and carbohydrate counting.
• Experience of dietetic management in CKD stages 3b5, heart failure, MAFLD or severe obesity.
• Experience of delivering structured diabetes education (DAFNE, DESMOND, Confidence with Carbohydrates or equivalent).
• Experience of MDT working across community and acute care.
• Experience of supervising and delegating to other members of staff, dietetic support workers or students.
• Experience of contributing to service development, quality improvement or clinical audit.
• Experience of working with people affected by health inequalities.

Desirable

• Experience of practice-based, PCN-based or community-based dietetic delivery.
• Experience of the National Type 2 Diabetes Path to Remission Programme (Xyla) delivery or referral.
• Experience of gestational diabetes and pre-conception dietetic care.
• Experience of behaviour-change consultation using recognised frameworks.
• Experience of delivering dietetic education to Tier 1 clinicians (nurses, GPs, HCAs).
• Working experience of EMIS and SystmOne clinical systems.
• Experience of contributing to research or service evaluation.

Experience

Essential

• Substantial post-registration dietetic experience in diabetes and multimorbidity.
• Experience of dietetic management of Type 1 and Type 2 diabetes including insulin regimens and carbohydrate counting.
• Experience of dietetic management in CKD stages 3b5, heart failure, MAFLD or severe obesity.
• Experience of delivering structured diabetes education (DAFNE, DESMOND, Confidence with Carbohydrates or equivalent).
• Experience of MDT working across community and acute care.
• Experience of supervising and delegating to other members of staff, dietetic support workers or students.
• Experience of contributing to service development, quality improvement or clinical audit.
• Experience of working with people affected by health inequalities.

Desirable

• Experience of practice-based, PCN-based or community-based dietetic delivery.
• Experience of the National Type 2 Diabetes Path to Remission Programme (Xyla) delivery or referral.
• Experience of gestational diabetes and pre-conception dietetic care.
• Experience of behaviour-change consultation using recognised frameworks.
• Experience of delivering dietetic education to Tier 1 clinicians (nurses, GPs, HCAs).
• Working experience of EMIS and SystmOne clinical systems.
• Experience of contributing to research or service evaluation.

Other

Essential

• Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions.
• Adaptable.
• Works effectively independently and as a team player.
• Self-motivated.
• Up to date with safeguarding and other mandatory training.
• Up to date immunisation status.
• Ability to work in different locations across the footprint and to help provide cover for absent colleagues; ability to take part in an extended working day in line with the models flexible-access commitment.
• Access to own transport and ability to travel across the multi-neighbourhood footprint, including home visits.

Desirable

• .

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).

Employer details

Employer name

South and East Leeds GP Group

Address

Hosted Employers address

1st Floor Park Edge Practice

Asket Drive

Leeds

West Yorkshire

LS14 1HX

United Kingdom

Employer's website

https://www.seleedsgpgroup.nhs.uk/ (Opens in a new tab)

Job description

Job responsibilities

Key duties and responsibilities

Care coordination patient tracking and pathway

Maintain the Tier 2 caseload tracker in real time, ensuring every patient on the pathway has a named clinician, an agreed follow-up plan and an accurate risk stratification recorded.

Process new referrals into Tier 2 from primary care, from the existing LCH community waiting-list triage, and as step-down from Tier 4 within agreed SLAs (24 hours acknowledgement for urgent referrals; one week for routine).

Process step-up referrals from Tier 2 into Tier 3 MDT discussion and into Tier 4 specialist pathways, ensuring the correct information accompanies each referral.

Book patients into structured education courses (DAFNE, Confidence with Carbohydrates, DESMOND or equivalent) and into the National Type 2 Path to Remission Programme (Xyla).

Track patient movement through step-up and step-down decisions, ensuring the caseload tracker reflects each transition accurately.

Escalate concerns to the Tier 2 clinical lead when a patient appears to have fallen out of the pathway, has repeated DNAs, or is showing signs of clinical deterioration.

Care coordination patient contact and engagement

Act as a named point of contact for patients on the Tier 2 caseload for practical queries about appointments, transport, interpreters, reasonable adjustments and referral progress.

Coordinate patient communication letters, SMS, phone and digital in line with patient preference and accessibility needs.

Undertake proactive DNA follow-up phoning patients who miss appointments, understanding the barrier, and rebooking rather than discharging where clinically appropriate.

Support outreach to deprivation deciles 13 and named priority groups, working alongside VCSE partners, care navigators and community connectors.

Arrange interpreters, easy-read information and other reasonable adjustments for patients with additional communication needs.

Signpost patients to VCSE and community delivery partners for wider wellbeing, food access, welfare and social support.

MDT and joint-clinic coordination

Coordinate the Tier 2 MDT fortnightly for complex / high-risk cases and 812 weekly for moderate cases including diary invitations, agenda preparation, case-list circulation and minute-taking, and follow-up of MDT actions.

Coordinate the Tier 2 team's contribution to the weekly Tier 3 Clinical Oversight Group MDT, combined with the existing LTHT community diabetes MDT.

Coordinate quarterly joint clinics between the Tier 2 team and the Practice Diabetes Lead in each footprint practice booking clinic slots, sharing case lists in advance and following up on actions.

Coordinate the quarterly TARGET education sessions for Practice Diabetes Leads room booking, attendance, materials and evaluation returns.

Administrative support to the clinical team

Diary management for the Tier 2 team including the Clinical Lead Nurses, Specialist Pharmacist, Specialist Dietitian, Specialist Podiatrist and the Nurse development post.

Correspondence drafting and processing letters to patients, GPs, hospital colleagues and partner agencies; preparing standard letter templates.

Preparation and formatting of clinical, education, service-development and quality-improvement documents.

Meeting support beyond MDT arranging team meetings, workshop days, service planning and workforce meetings; taking and circulating minutes.

Interface with SEL GP corporate services on HR, payroll, procurement and IT queries on behalf of the Tier 2 team.

Ordering supplies, room bookings, travel arrangements and expenses management for the Tier 2 team.

Cover for absent colleagues within the wider SEL GP administrative team where required.

Digital, data and records

Accurate and timely data entry into EMIS and SystmOne, in line with the Programme's data-quality standards and the specification cohort criteria.

Maintain the Tier 2 caseload tracker workbook and support the Programme Manager to generate weekly and monthly reports.

Support the Programme's outcomes and evaluation framework by preparing structured search outputs, dashboards and reports for the Tier 2 team.

Compliance with the Data Protection Act (2018), the Access to Health Records Act (1990) and SEL GP's information-governance policies.

Compliance with Caldicott principles for confidentiality and information sharing.

Attend digital training as required and act as a super-user for administrative aspects of EMIS / SystmOne within the Tier 2 team.

Communication and liaison

Answer telephone and digital enquiries into the Tier 2 team from patients, primary care, hospital colleagues and VCSE partners escalating clinical queries appropriately.

Provide a welcoming, respectful and inclusive first point of contact for the Tier 2 team.

Liaise closely with practice administrative teams at each Tier 1 practice, and with LTHT and LCH administrative teams for interfaces at Tier 4.

Support the Tier 2 team's engagement with VCSE partners diary coordination, minute-taking and follow-up.

Communicate complex or sensitive information with tact, discretion and empathy, adapting language and format to the audience.

Team support and quality improvement

Contribute to team meetings, service reviews and continuous improvement activity within the Tier 2 team.

Contribute to quality improvement projects and clinical audit identifying searchable cohorts, running structured searches, preparing data and presenting findings alongside clinical colleagues.

Provide induction support for new team members on Tier 2 administrative and care-coordination processes.

Support the delivery of the Programme's Year 1 evaluation and Year 2 business-case preparation.

Suggest improvements to administrative and care-coordination processes based on day-to-day experience.

Care Quality Commission, health and safety, and confidentiality

Work with the delivery partners to ensure Programme administrative activity is compliant with CQC standards.

Comply with Health and Safety policies, follow safe working procedures and report incidents through the organisations Incident Reporting Systems.

Comply with the Data Protection Act (2018) and the Access to Health Records Act (1990); respect patient confidentiality at all times.

Understand and apply the safeguarding role appropriate to a senior administrative role recognising concerns and escalating to a clinical colleague or safeguarding lead.

Continuing personal and professional development

Undertake continual personal and professional development, including mandatory training and any additional training identified through appraisal.

Take up development opportunities aligned to your role for example NVQ Level 3 in Business Administration or Customer Service, Care Certificate elements relevant to care coordination, or apprenticeship pathways towards senior administration or care-coordination roles.

Access regular supervision and support the Programme's supervision and reflective-practice culture.

Special working conditions

The post-holder will be based in the community across the Beeston and Middleton & Hunslet footprint, with occasional travel between practices, community sites and system-partner offices.

Working days may include periods of concentrated administrative work, telephone contact with patients and structured MDT / clinic support.

The post-holder may experience occasional distressing conversations for example when contacting patients in difficult social circumstances, or when discussing missed appointments or clinical concerns and will be supported through structured supervision.

Person Specification

Other requirements

Essential

• Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions.
• Adaptable.
• Works effectively independently and as a team player.
• Self-motivated.
• Up to date with safeguarding and other mandatory training.
• Up to date immunisation status.
• Ability to work in different locations across the footprint and to help provide cover for absent colleagues; ability to take part in an extended working day in line with the models flexible-access commitment.
• Access to own transport or reliable means to travel across the multi-neighbourhood footprint.

Skills and knowledge

Essential

• Excellent written and verbal communication skills, adapting to a wide range of audiences.
• Excellent organisational skills; able to plan, prioritise and manage a varied workload.
• Competent IT skills including Microsoft Office (Word, Excel, PowerPoint, Outlook, Teams).
• Ability to accurately enter, extract and interpret patient information from clinical systems.
• Understanding of the principles of confidentiality, information governance, safeguarding and Caldicott principles.
• Understanding of the wider determinants of health and their impact on communities.
• Ability to remain calm, respectful and professional in emotionally challenging situations.
• Ability to work autonomously within scope, escalating clinical or safeguarding concerns appropriately.
• Attention to detail and accuracy in data entry, correspondence and record keeping.
• Ability to gain acceptance for recommendations and to influence colleagues to comply with agreed processes.

Desirable

• Understanding of the Leeds Proactive Care and Integrated Neighbourhood Health frameworks.
• Understanding of quality improvement methodology.

Qualifications

Essential

• GCSE English and Mathematics at Grade C / 4 or above (or equivalent).
• NVQ Level 3 in Business Administration, Customer Service, Health and Social Care, or equivalent qualification or equivalent experience.
• Willing to undertake any relevant training identified to develop skills required to carry out duties, including safeguarding, information-governance and digital training.

Desirable

• Care Certificate.
• Additional qualification or training in care coordination, health navigation, patient experience or equivalent role.
• ECDL, Microsoft Office Specialist or equivalent digital-skills qualification.
• Formal training in health inequalities, trauma-informed care or behaviour-change approaches such as Making Every Contact Count.
• Foundation-degree level study or apprenticeship pathway relevant to health administration or care coordination.

Experience

Essential

• Substantial experience in an administrative or care-coordination role in the NHS, general practice, social care or a comparable setting.
• Experience of working with clinical or administrative systems such as EMIS, SystmOne or equivalent.
• Experience of telephone and digital contact with patients or service users, including handling sensitive or difficult conversations.
• Experience of arranging meetings, taking accurate minutes and following up actions.
• Experience of maintaining accurate records and trackers, and generating reports from them.
• Experience of working alongside a clinical multidisciplinary team.
• Experience of working with people affected by health inequalities.
• Experience of work involving diary management, correspondence and general office administration.

Desirable

• Experience of care coordination, patient tracking or pathway management in a clinical setting.
• Experience of working with VCSE, community or asset-based partners.
• Experience of contributing to quality improvement, clinical audit or service evaluation.
• Experience of preparing dashboards, reports or presentations for a team.
• Experience of supporting or supervising new or less experienced staff.

Personal Qualities & Attributes

Essential

• Commitment to reducing health inequalities and proactively working to reach people from all communities.
• Person-centred, trauma-informed approach with a working understanding of the wider social determinants of health.
• Ability to communicate with a wide range of colleagues from the NHS and other organisations, and with patients and their families including good written and oral communication skills.
• Recognises personal limitations and refers to more appropriate colleagues when necessary.
• Able to work under pressure and meet deadlines, managing unpredictable service demands.
• Emotional resilience, self-awareness, humility and curiosity.
• Reliability and integrity in a small MDT where the model depends on trust and close working relationships.
• Ability to organise, plan and prioritise on own initiative with minimal supervision.
• Ability to work flexibly and enthusiastically within a team or on own initiative.
• Comfortable with the ambiguity of a new service willing to iterate, evaluate and adjust.
• Positive and flexible attitude to change; able to respond to changing needs in an appropriate and timely manner.
• Genuine empathy for people whose lives are shaped by health inequalities.
• Cultural competence for supporting patients across the diverse populations of south and east Leeds.
• Confident to challenge and to be challenged in the patients best interest.

Desirable

• .

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.

Employer details

Employer name

South and East Leeds GP Group

Address

Hosted Employers address

1st Floor Park Edge Practice

Asket Drive

Leeds

West Yorkshire

LS14 1HX

United Kingdom

Employer's website

https://www.seleedsgpgroup.nhs.uk/ (Opens in a new tab)