Clinical Lead Nurse for Diabetes Neigbourhood Health Programme

You will hold a patient-facing

caseload within the Year 1 cohort adults aged 18 to 67 living with diabetes

and two or more other long-term conditions. Your focus is advanced diabetes

nursing care in complex multimorbidity, working as an autonomous clinician

within an experienced multidisciplinary team.

The day-to-day mix includes

advanced clinical assessment and consultation, insulin and injectable initiation

and titration, use of CGM and Flash Glucose Monitoring data for shared

decision-making, joint visits with district nursing for assisted insulin, and

delivery of structured education. There is a regular rhythm of Tier 2 MDT case

discussion and weekly Tier 3 MDT participation, giving structured access to

specialist opinion and peer learning.

Alongside the clinical caseload,

you will play an active role in cascade education across Tier 1 and Tier 2

including quarterly joint clinics with Practice Diabetes Leads and delivery of

TARGET education sessions. You will provide Advice and Guidance to primary care

within tight response times, and contribute to service development, quality

improvement and equity of diabetes nursing care as the model scales towards citywide

delivery.

Active outreach and engagement

with people in deprivation deciles 1 to 3 and named priority groups is a core

expectation, not a bolt-on. This role suits someone who wants to work in a

person-centred, trauma-informed way and build partnerships with community and

third-sector delivery partners.

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.

South and East Leeds General

Practice Group brings together general practices across the south and east of

Leeds to deliver joined-up primary care, PCN services and integrated community

programmes. As one of the hosting partners for the new Diabetes Neighbourhood

Health Programme, we work in close partnership with Leeds Community Healthcare

Trust, Leeds Teaching Hospitals Trust, West Yorkshire ICB and our neighbourhood

Primary Care Networks to deliver a genuinely place-based model of care.

You will be joining a team that

is comfortable with new ways of working, collaborative across professional and

organisational boundaries, and committed to reducing health inequalities in

some of the most under-served neighbourhoods in the city. The culture is honest

about the challenges of complex multimorbidity, patient-centred in its everyday

decision-making, and generous with peer support and shared learning.

We support flexible working,

protected CPD time, professional supervision and access to formal

advanced-practice development pathways. You will have regular clinical

supervision, access to Tier 3 MDT mentorship, and structured opportunities to

contribute to service evaluation, research and Year 2 business-case

development.This role may expand to a wider geographical

area in year 2 as the new service is rolled out across the City

Additional criteria

Experience

Qualifications