GP Clinical Lead - Proactive Care Service

clinical leadership for PCS and act as the principal clinical lead for the

service.

Delivery Officer, Medical Director and operational team to support safe

mobilisation and implementation of the service.

Full responsibilities and deliverables are included in the job description.

Provide senior

clinical leadership for PCS and act as the principal clinical lead for the

service.

Work with the Chief

Delivery Officer, Medical Director and operational team to support safe

mobilisation and implementation of the service.

Lead development and

maintenance of clinical SOPs, inclusion / exclusion criteria, caseload

processes, escalation pathways and step-down arrangements.

Provide clinical

oversight of the frailty GP and prescribing clinician workforce and support

consistent, proportionate clinical decision making.

Support complex case

discussion and provide a pragmatic escalation route for clinicians where GP

clinical leadership is required.

Work with the

Geriatrician Clinical Lead to ensure specialist geriatric input is accessible

for complex frailty, multimorbidity, polypharmacy, functional / cognitive

decline and recurrent hospital use.

Oversee the clinical

approach to frailty assessment, falls, medication optimisation / deprescribing,

ReSPECT, CGA and disease optimisation.

Support a clear

caseload management model, including intensity of follow-up, review after

deterioration or discharge, and safe step-down when patients are stable.

Help ensure PCS works

around general practice rather than creating parallel ownership or avoidable

actions back to practices.

Lead clinical

induction, supervision, case-based learning and development for the PCS

clinical workforce.

Provide clinical

leadership on governance, incidents, significant events, quality improvement

and learning.

Help shape practical

interfaces with UCR, SDEC, acute geriatrics, community services, primary care,

Adult Social Care and VCSE partners.

Contribute to

evaluation of the service, including interpretation of outcome data, matched

comparator findings and refinement of the model at 3-, 6-, 9- and 12-month

review points.

Promote a

test-and-learn culture and make evidence-based recommendations on what should

continue, change, scale or stop.

is not the operational Service Manager and is not expected to hold every

patient clinically. Frailty GPs remain the senior clinical decision makers for

the patients they are managing. The Clinical Lead provides service-level

clinical leadership, governance, escalation support and consistency across the

model. The Geriatrician Clinical Lead provides specialist geriatric expertise

alongside, rather than replacing, GP clinical leadership.

The exact use of the

session will be agreed with the successful GP and may evolve through

mobilisation. It is expected to include a mix of:

clinical leadership /

governance review

complex case

discussion and clinician support

SOP, pathway and

service development

clinical induction,

supervision and case-based learning

selected partner /

MDT discussions where clinical leadership is needed

review of incidents,

quality and evaluation data

support to refine

cohort, caseload and step-down arrangements

ACCOUNTABILITY / WHAT SUCCESS LOOKS LIKE

The service launches

with clear and safe clinical SOPs, escalation routes and governance

arrangements.

prescribing clinicians are supported to work consistently and at the top of

their capability.

Patients receive

active follow-up and appropriate step-down rather than remaining indefinitely

on the caseload.

Clinical hand-offs to

general practice, UCR, SDEC, acute and community services are clear and

proportionate.

Clinical incidents

and learning are reviewed promptly and used to improve the service.

Outcome data are

interpreted proportionately and used to refine the model through the first

year.

PCS develops as a

credible, safe and integrated proactive care offer across Berkshire West.

standards, professional guidance and PCA clinical governance arrangements.

Maintain appropriate

safeguarding, information governance, confidentiality and clinical safety

standards.

Maintain appropriate

professional indemnity / cover for the agreed engagement model.

Participate in

relevant appraisal / CPD requirements through the substantive employer or

agreed contractual arrangement.

Identify and manage

potential conflicts of interest transparently.

Demonstrate collaborative

system leadership across primary care, acute, community, social care and VCSE

partners.

Primary Care Alliance (PCA) is the collaborative voice of general practice

across the Berkshire West Place within the Thames Valley Integrated Care

System. We bring together GP practices and Primary Care Networks (PCNs) to work

at scale, enabling innovation, influencing system change, and delivering

services that meet the needs of our local populations.

plays a vital role in shaping the future of primary care by strengthening

partnerships, developing the workforce, and ensuring general practice is a

central and equal partner in integrated care. As a community interest company,

PCA supports primary care sustainability, equity, and improved outcomes for

patients across Reading, Wokingham, and West Berkshire.

Experience

Qualifications

Desirable: - Additional qualification / training in frailty, older people, leadership or service development