Clinical Lead-Leatherhead PCN – Surrey Downs H&C

Detailed job description and main responsibilities

Operational Delivery

1. Support the delivery of the benefits and KPIs relating to the PCN and as part of the relevant GP Federation sub-contracting requirements

2. Hold responsibility for advising and development of strategies to support in relation to the clinical quality, safety and governance of contracted services.

3. Support the Lead GP by ensuring the development of new ways of working, continuous improvement and accelerated delivery of the benefits of place-based care and PCN

4. Build and maintain strong relationships with stakeholders to ensure the delivery of the benefits and KPIs.

5. Support the Implementation of local arrangements for clinical performance management (including dashboards) and report on a regular basis to the GP Federation and wider constituent practices, including the identification and mitigation of risks.

6. Participate in regular meetings within the PCN and Federation including those involving wider stakeholders

7. Provide clinical leadership to the PCN team including day to day advice in relation to complex patient care and assessment of individual patient circumstances as appropriate.

Development and transformation of services

1. Develop Surrey Downs Health and Care organisational culture demonstrating agreed values and behaviours.

2. Build strong relationships with local practices and wider partners, supporting ways of working which will both maximise the impact of the Alliance in relation to adult community services and the potential of the wider impact of place-based care through the PCN model.

3. Build processes with people as partners in the co-design and co-production of services leading to empowerment of people and involvement in decision making.

4. Support the introduction of new ways of working and cross-competencies including ensuring processes are in place to develop practice.

5. Work collaboratively with health and social care partners to achieve optimal care for people as close to their home as possible.

6. Lead the introduction of new pathways and ways of working, taking the lead for ensuring successful local mobilisation and benefits realisation.

7. Embed service improvement methodology and a culture of continuous improvement.

Working across the Partnership

1. Represent the PCN and Federation in relation to service and pathway development for community services including taking the lead for identified projects across the Alliance.

2. Support the Partnership Board and the Director of Community Services in relation to delivery of overall benefits and KPIs and service development.

3. In all activities undertaken, adhere to the Code of Conduct for relevant healthcare professional body.

Clinical Lead for PCN Community Hub: Core Responsibilities

To work across organisational & professional boundaries as part of Surrey Downs Health & Care community service to provide clinical care and leadership and to co-ordinate the treatment, care, management and empowerment of individual patients. 

To liaise pro-actively and work collaboratively with all health, social care and voluntary sector providers, primary and secondary care professionals, palliative care services, patients, carers and commissioners

To act as a source of specialist clinical knowledge and expertise to GPs, nurses and allied health professionals within the integrated community multi-speciality provider service.

To act as a source of knowledge and advise for community matrons and district nurses, to aid proactive case management of patient with LTC/EOLC needs in order to promote self-management, prevent further deterioration in health and facilitate a speedy and safe discharge from acute and community hospitals

To provide clinical leadership and supervision to a team of band 7 community Nurses/Matrons and therapists

Key relationships & pathways

Urgent Care Pathways

• Community Medical Team
• Community Multi Speciality Providers
• Rapid Response
• Rehabilitation Teams
• Out of Hours District Nursing teams

Complex Care Pathways

• Community Matrons and associated professionals such as Mental Health Practitioners, Dementia Practitioners and Domiciliary Physiotherapy services.
• Community Hospice, Home Nursing service and End of Life Care Team.
• Acute Hospital Discharge Liaison Teams

Planned Care Pathways

• District Nursing.
• Specialist nursing teams including, Tissue Viability, Heart Failure, Respiratory Service.
• Community Dietician
• Phlebotomy Service
• Multi-disciplinary discharge teams

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