Diabetes Matron Neighbourhood Health Programme in Leeds

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 18-67 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. 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 1-3 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 1-3 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.