Primary Care Clinical Lead: Long Term Conditions

Job summary

City & Hackney Place-Based Partnership is seeking an experienced and passionate primary care clinician to join our clinical leadership team.

We are recruiting for a Primary Care Clinical Lead: Long Term Conditions who will help shape the future of integrated neighbourhood working across one of London's most diverse and dynamic health systems.

This role is funded through ICB Integrated Care Transformation funds and hosted by City & Hackney Integrated Primary Care (IPC). Whilst based within the IPC, post holders work on behalf of the City & Hackney Place-Based Partnership as a whole, providing clinical leadership that spans primary, community, secondary and social care and the voluntary sector.

Main duties of the job

Building on City & Hackney's long history of successful collaboration between primary and secondary care, public health and clinical effectiveness organisations, this role provides primary care clinical leadership across the long term conditions agenda at Place. The post holder will use data, education and clinical evidence to support the development of approaches that improve the quality and consistency of LTC management across neighbourhoods, and will provide the primary care voice in system-wide work on pathways, service design and transformation.

About You

• Currently practise within the City & Hackney footprint
• Have experience working across organisational and professional boundaries
• Are passionate about integrated neighbourhood working and reducing health inequalities
• Can influence and build effective relationships across complex systems
• Bring strategic thinking alongside a strong understanding of frontline primary care

About us

Clinical leadership is at the heart of delivering the best possible outcomes for our population in City & Hackney. These roles exist to ensure that the voice of experienced, practising clinicians runs through everything we do, connecting the work of operational and managerial leads, partners across the system, and the patients and communities we serve. As our partnership continues to develop and our neighbourhood model matures, sustained clinical leadership is not a support function; it is a core ingredient of success. These posts are designed to provide that leadership, ensuring that what we plan, and deliver is clinically credible, grounded in the reality of practice, and genuinely shaped by the needs and experiences of local people.

Job responsibilities

The post holder will provide clinical leadership across the following areas, with the precise scope agreed in partnership with the Chief Medical Officer and shaped by local intelligence:

Population Health and Proactive Care

Provide clinical leadership for the development and implementation of a proactive, neighbourhood-based approach to long term conditions management, including risk stratification, personalised care planning and case finding

Support PCN Clinical Directors and neighbourhood teams to use population health data to identify and act on unmet need and unwarranted variation in LTC outcomes across their registered populations

Contribute to the development and ongoing refinement of the LTC primary care contract and related enhanced service specifications

Promote and support improvement in clinical coding to ensure that disease registers accurately reflect local need

Pathway Development and Clinical Standards

Provide clinical input into the design and development of integrated LTC pathways, spanning primary care, community services and secondary care, with a focus on reducing fragmentation and improving the patient experience

Responsible for supporting the development, review and maintenance of new and existing relevant pathways on our website

Contribute to the development of education and clinical development programmes for primary care teams on LTC management, drawing on best practice from within and beyond City & Hackney

Work with medicines optimisation teams and provider collaboratives to improve outcomes and reduce harm in LTC populations

Support the identification and spread of innovation in LTC management, including digital tools, remote monitoring and supported self-management

Reducing Health Inequalities

Maintain a consistent focus on health inequalities across the LTC agenda, supporting targeted approaches to improve outcomes for populations who face the greatest barriers to care

Work with the Population Health Hub and partners in public health, local government and the voluntary sector to address the wider determinants of LTC outcomes

Neighbourhood Model Development

Work with Neighbourhoods to ensure that LTC management is a core function of the neighbourhood model, with clear clinical governance and accountability

Supporting, engaging and participating, in the development/codesign of neighbourhood group consultation clinics

Support the engagement of PCN Clinical Directors and practices in neighbourhood-level MDTs and care coordination processes for people with complex LTC needs

Building Trusted Relationships with Partners and Communities

Success in this role is dependent on having strong relationships with patients, service users, carers and their representative organisations, partners, staff, clinicians and local communities.

Please see the attached Job Description and Person Specification for further information.

Person Specification

Core Requirements

Essential

• We are seeking experienced GPs or other primary care clinicians with a track record of working across organisational boundaries and contributing to system-level improvement
• Current clinical practice in primary care within the City & Hackney footprint
• Experience of working across organisational and professional boundaries in a partnership or system context
• Understanding of integrated neighbourhood working, population health approaches and health inequalities
• Ability to influence without direct authority and to build trusted relationships with diverse stakeholders
• Commitment to co-production and to placing the voice of residents and service users at the centre of service change
• Capacity to operate strategically within the time commitment of two sessions per week, identifying priorities and working through others
• Familiarity with NHS governance, contracting and programme management frameworks relevant to their area
• Knowledge of the long term conditions landscape and population health approaches to proactive care, with experience of quality improvement or service development in primary care or at a 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).

Applicants must have current UK professional registration.

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