Advanced Clinical Practitioner for Proactive Care & Clinical Lead in Leeds

Cross Gates Primary Care Network is seeking an experienced, forward thinking Advanced Clinical Practitioner to lead our Proactive Care Team and help shape the next phase of neighbourhood health in East Leeds. This is a senior Band 8a level role combining expert advanced clinical practice with clinical leadership, operational management, service development and system partnership working.

The postholder will work alongside the PCN Clinical Director, GP Lead and PCN Manager to develop a coordinated, preventative and population based model of care. The role will be central to redesigning how the PCN works with community, mental health, social care, local organisations and the voluntary sector.

The PCN Proactive Care Team supports people at greatest risk of deterioration, avoidable hospital admission with a strong focus on frailty, multimorbidity and complex health and social care needs.

Main duties of the job

• The Proactive Care Advanced Clinical Practitioner & Clinical Lead will provide clinical leadership and operational management of the PCN Proactive Care Team while undertaking advanced clinical practice.
• The role leads delivery of proactive care, Enhanced Health in Care Homes, frailty pathways, personalised care planning and multidisciplinary working.
• The PCN provides enhanced proactive care to residents across four care homes, delivering ward rounds, multidisciplinary reviews, acute assessment, anticipatory care planning and proactive case management.
• The wider programme will expand proactive care across the PCN population using a population health management approach to identify and prioritise patients.
• The postholder will independently assess, diagnose, treat and prescribe for patients with complex needs in care homes, patients' homes and community settings.
• As Clinical Lead, they will manage and develop the proactive care nursing team, provide clinical supervision, drive service improvement, and ensure delivery of agreed outcomes and integrated neighbourhood working.

About us

Cross Gates PCN brings together Colton Mill and The Grange Medical Centre, Keystone GP Partnership and Family Doctors, working across six sites and serving approximately 33,000 patients. Our proactive care model is built around multidisciplinary working and strong relationships with neighbourhood partners.

The PCN Proactive Care Team includes the GP Lead for Proactive Care, Specialist Proactive Care Nurse, Mental Health / Dementia Specialist Nurse, PCN Nurse, Nurse Associate, Clinical Care Coordinators and Clinical Pharmacists. The team works closely with practice GPs, ACPs, Nursing Teams and Pharmacists alongside a Geriatrician, Community Matron, Neighbourhood Teams, Respiratory and Cardiology Specialist, Linking Leeds, Adult Social Care, Housing, the Local Care Partnership and third-sector organisations.

Key responsibilities of the Role

• Provide expert advanced clinical practice for people living with frailty, multimorbidity, complex needs and high risk of deterioration or avoidable hospital admission.
• Lead the clinical and operational delivery of the PCN Proactive Care Team and ensure safe, effective and coordinated working across PCN practices and community settings.
• Lead implementation and delivery of the Proactive Care Programmes, including cohort identification, holistic assessment, personalised care planning, named care coordination and outcome monitoring.
• Lead care home Enhanced Health in Care Homes activity, ward rounds and MDT working in collaboration with practice GPs, ACPs, care home teams, pharmacists and community services.
• Develop Cross Gates PCNs neighbourhood health model by strengthening integration, coordination and communication between primary care, community services, mental health, social care, public health, housing and the voluntary sector.
• Use population health management and clinical judgement to target those with greatest unmet need and address health inequalities and wider determinants of health.
• Promote prevention, early intervention and proactive care to reduce deterioration, crisis, unnecessary use of reactive services and avoidable hospital admission.

Outline of the Post

• Advanced Clinical Practice
• Independently assess, examine, investigate, diagnose and treat patients with complex, undifferentiated, acute and deteriorating presentations in care homes and patients homes.
• Prescribe, deprescribe and optimise medicines within professional scope, evidence based guidance and local pathways.
• Manage frailty, multimorbidity, polypharmacy, cognitive decline, dementia, long term conditions and complex social circumstances using a holistic, person centred approach.
• Lead care home ward rounds, urgent home visits, proactive frailty reviews, anticipatory care planning and escalation planning, working closely with practice clinical teams.
• Recognise deterioration early, coordinate timely intervention and maximise safe alternatives to hospital where clinically appropriate.
• Actively support the planning and delivery of seasonal vaccination programmes for care home, housebound and proactive care cohorts, working with Clinical Care Coordinators and PCN clinicians to improve uptake, prevent avoidable illness and reduce the risk of deterioration and hospital admission.
• Proactive Care and Population Health
• Use population data, practice intelligence and clinical judgement to identify and prioritise people at greatest risk of deterioration or avoidable admission.
• Ensure holistic assessment, personalised care planning, named care coordination and appropriate step-up and step-down of support for the proactive care cohort.
• Target people with greatest unmet need and address wider determinants including housing, debt, isolation, carer pressures and barriers to accessing care.
• Embed early intervention, self-management, health coaching, social prescribing and community support to help people maintain independence and wellbeing.
• Clinical Leadership and Team Management
• Provide visible senior clinical leadership for the PCN Proactive Care Team and act as an expert resource for complex clinical and professional decision-making.
• Lead the day to day clinical and operational management of the proactive care team, including workload, caseloads, job planning and delivery against priorities.
• Provide clinical supervision, appraisal support, mentoring and workforce development, ensuring staff work within competency, professional and governance frameworks.
• Lead clinical governance, risk management, incident learning, safeguarding, audit and continuous improvement across the service.
• MDT and Neighbourhood Working
• Chair and clinically lead proactive care and care home MDTs, ensuring clear ownership, timely actions, escalation and follow-up.
• Build effective working relationships across primary care, geriatric medicine, LCH community services, respiratory and cardiology teams, mental health, Adult Social Care, Linking Leeds, Housing, the Local Care Partnership and voluntary/community organisations.
• Support the PCN Clinical Director, GP Lead and PCN Manager to develop neighbourhood health and represent the PCN in relevant partnership forums.
• Service Development and Delivery
• Lead delivery of the Proactive Care Programmes / Pilots, including service standards, coding, data quality and contractual requirements.
• Oversee delivery of care home enhanced care, ward rounds, proactive reviews and coordinated MDT support.
• Monitor agreed activity and outcomes, including proactive care numbers, unplanned care use and patient experience.
• Lead pathway redesign and service development across prevention, proactive and reactive care, testing new ways of working and integrating specialist support into neighbourhood teams.
• Communication, Education and Professional Practice
• Communicate complex and sensitive information effectively, facilitate shared decision making and influence across organisational boundaries.
• Provide teaching, mentorship, promote evidence based practice and support research, service evaluation and quality improvement.
• Maintain advanced clinical competence, CPD, supervision, appraisal and professional registration, revalidation requirements, and practise in line with relevant legislation, professional standards and organisational policies.

Person Specification

Experience

• Significant post-registration experience, including substantial autonomous practice at an advanced clinical level.
• Demonstrable experience managing complete episodes of care for undifferentiated, complex and deteriorating patients, including diagnosis, investigation, treatment and referral.
• Experience working with frailty, multimorbidity, complex needs and/or older people in community or primary care settings.
• Experience undertaking home visits and/or care-home clinical reviews or ward rounds.
• Experience of anticipatory care planning, personalised care planning and shared decision-making.
• Significant experience of multidisciplinary and multi-agency working across health, social care and/or voluntary sector boundaries.
• Experience leading a clinical team, including operational management, supervision, performance management and workforce development.
• Experience leading service redesign, transformation, quality improvement or pathway development.
• Experience using data, audit and outcome measures to monitor service performance and drive improvement.

Knowledge and Skills

• Expert knowledge of advanced clinical practice, clinical reasoning, differential diagnosis and management of complexity.
• Strong knowledge of frailty, multimorbidity, polypharmacy, dementia/cognitive impairment, falls, functional decline and common long-term conditions.
• Knowledge of anticipatory care planning, end-of-life care, treatment escalation planning and admission avoidance.
• Understanding of proactive care, prevention, early intervention, personalised care and the principles of neighbourhood health.
• Understanding of population health management, health inequalities and wider determinants of health including housing, debt and social isolation.
• Knowledge of clinical governance, safeguarding, Mental Capacity Act, consent, information governance and risk management.
• Ability to chair complex MDTs, synthesise multidisciplinary information, allocate actions and maintain clinical oversight.
• Ability to analyse service data, identify trends, evaluate outcomes and translate findings into improvement actions.
• Ability to lead change, influence stakeholders, negotiate across organisational boundaries and build effective partnerships.
• Excellent written and verbal communication skills, including presentation of complex information to clinical and non-clinical audiences.
• High level digital literacy, including Microsoft 365 and clinical systems such as SystmOne and/or EMIS.

Qualifications

• Current registration with an appropriate UK professional regulator (e.g. NMC or HCPC) relevant to the applicants advanced clinical practice role.
• Masters degree in Advanced Clinical Practice, or equivalent masters-level advanced practice qualification demonstrating the four pillars of advanced practice.
• Independent non-medical prescribing qualification with current prescribing competence.
• Advanced clinical assessment / physical examination qualification at postgraduate or masters level.
• Evidence of substantial continuing professional development relevant to frailty, multimorbidity, complex care and advanced practice.
• Leadership or management qualification, or evidence of equivalent senior leadership experience.

Personable Attributes

• Visible and credible clinical leader who demonstrates accountability, integrity and sound professional judgement.
• Able to work autonomously while recognising limits of competence and escalating appropriately.
• Collaborative leadership style with the ability to enable shared decision-making and empower multidisciplinary teams.
• Strong organisational skills with the ability to manage competing clinical, operational and strategic priorities.
• Resilient, adaptable and able to lead effectively through uncertainty and service change.
• Commitment to person-centred care, prevention, health inequalities and improving outcomes for people with complex needs.
• Commitment to learning, reflective practice, clinical supervision and continuous improvement.