PCN Matron/ACP & Clinical Lead for Proactive Care

Cross Gates Primary Care Ltd; Leeds; On-site; GBP 58,000 - 65,000; Full time

Job summary

Cross Gates Primary Care Network is seeking an experienced PCN Matron/Clinical Lead for Proactive Care to lead the Proactive Care Team across East Leeds. The role combines senior clinical leadership with service development, improving outcomes for frailty and complex health needs.

You will develop new ways of working, build partnerships with GPs, nurses and social care, and use population health approaches to drive preventative care across four care homes and the wider PCN population.

Qualifications

• Advanced clinical practice with senior leadership.
• Experience with frailty and complex care planning.
• Experience leading clinical teams and service transformation.

Responsibilities

• Provide expert advanced clinical practice for frailty, multimorbidity and high-risk patients.
• Lead clinical and operational delivery of the Proactive Care Team across settings.
• Deliver proactive care programmes, including cohort identification and outcome monitoring.
• Lead Enhanced Health in Care Homes activity and MDT working.
• Strengthen partnerships across primary care, community services and social care.

Skills

Advanced clinical practice

Team leadership

Population health

Care coordination

Frailty knowledge

Data analysis

Multidisciplinary working

Clinical governance

Stakeholder engagement

Microsoft 365

Education

Master's in ACP

Teaching qualification

Leadership qualification

Postgraduate frailty care

Tools

EMIS

SystmOne

Microsoft 365

Job description

PCN Matron/ACP & Clinical Lead for Proactive Care

Are you an experienced Advanced Clinical Practitioner or Matron who is passionate about improving care for people with frailty, complex needs and long-term conditions? We are looking for a PCN Matron & Clinical Lead for Proactive Care to lead our established Proactive Care Team and help shape the future of neighbourhood health across East Leeds. This is a unique opportunity to combine expert clinical practice with leadership, service development and innovation, working with a wide range of partners to create truly joined-up, preventative care. If you are motivated by improving outcomes, reducing health inequalities and leading positive change, we would love to hear from you.

Main duties of the job

This senior role combines advanced clinical practice with team leadership and service development. You will support patients with complex health and social care needs across care homes, patients' homes and community settings, while providing leadership to an established multidisciplinary proactive care team. You will help develop new ways of working, build strong partnerships across health, social care and voluntary services, and use data and population health approaches to improve outcomes for local people.

About us

Cross Gates Primary Care Network serves approximately 33,000 patients across six sites through Colton Mill and The Grange Medical Centre, Keystone GP Partnership and Family Doctors. We are a friendly, ambitious and forward-thinking organisation with a strong culture of teamwork, innovation and shared learning. Our Proactive Care Team works alongside GPs, nurses, pharmacists, care coordinators, community services, social care and voluntary sector partners to deliver personalised, integrated care. We value collaboration, professional development and staff wellbeing, offering the opportunity to be part of a supportive team that is genuinely shaping the future of neighbourhood health in East Leeds.

Job responsibilities

Job Title: PCN Matron & Clinical Lead for Proactive Care

Band: Equivalent to NHS Agenda for Change Band 8a

Hours: Full Time (37.5 hours per week)

Hosted by: Cross Gates Primary Care Ltd

Line Manager: PCN Business Manager

Professionally Accountable To: PCN Clinical Director

Base: Cross Gates PCN practices and community settings across East Leeds, including care homes and patients' homes.

Job Summary

The PCN Matron & Clinical Lead for Proactive Care will provide senior clinical leadership and operational oversight for the PCN Proactive Care Team while maintaining a substantial advanced clinical practice role. The postholder will lead delivery of the PCN Proactive Care model, Enhanced Health in Care Homes activity, frailty work, proactive case management, personalised care planning and multidisciplinary working.

Working closely with the PCN Clinical Director, GP Lead and PCN leadership team, the postholder will help develop a coordinated, preventative and population-based model of care that improves outcomes for people living with frailty, multimorbidity and complex health and social care needs.

The role supports proactive care delivery across four care homes and leads the continued development of proactive care services across the wider PCN population through a population health management approach.

Main Duties and Responsibilities

• Provide expert advanced clinical practice for people living with frailty, multimorbidity, complex needs and at high risk of deterioration or avoidable hospital admission.
• Lead the clinical and operational delivery of the PCN Proactive Care Team across practice and community settings.
• Deliver and develop proactive care programmes, including cohort identification, holistic assessment, personalised care planning and outcome monitoring.
• Lead Enhanced Health in Care Homes activity, care home ward rounds and multidisciplinary team working.
• Strengthen integration and partnership working across primary care, community services, mental health, social care, housing and voluntary sector organisations.
• Use population health management approaches to identify patients with the greatest unmet need and address health inequalities.
• Promote prevention, early intervention and proactive care to reduce avoidable deterioration and hospital admissions.
• Independently assess, diagnose, treat and prescribe for patients with complex, undifferentiated and deteriorating presentations.
• Lead and support multidisciplinary team meetings, clinical decision-making and neighbourhood health initiatives.
• Provide clinical supervision, workforce development, quality improvement and service transformation leadership.

Working Relationships

The postholder will work closely with GPs, Advanced Clinical Practitioners, Nursing Teams, Clinical Pharmacists, Care Coordinators, Community Services, Adult Social Care, Mental Health Services, Housing Services, Linking Leeds, the Local Care Partnership and voluntary sector organisations.

About the Service

Cross Gates Primary Care Network brings together Colton Mill and The Grange Medical Centre, Keystone GP Partnership and Family Doctors, serving approximately 33,000 patients across six sites in East Leeds. The proactive care model is built around multidisciplinary working, integrated neighbourhood care and strong partnerships across the local health and care system.

Professional Responsibilities

• Maintain professional registration, advanced clinical competence and continuing professional development.
• Comply with information governance, data protection and confidentiality requirements.
• Maintain safeguarding knowledge and practice relating to adults and children.
• Promote equality, diversity, inclusion and culturally competent care.
• Comply with health and safety, infection prevention and lone working requirements.

Person Specification

Experience

• Advanced clinical practice experience.
• Experience managing complex patients autonomously.
• Experience working with frailty and older people.
• Experience of home visits and/or care home reviews.
• Experience of personalised care planning.
• Experience of multidisciplinary working.
• Experience leading clinical teams.
• Experience leading service improvement or transformation.
• Experience using data, audit or outcome measures to improve services.
• Experience working in a Primary Care Network or integrated neighbourhood team.
• Experience of Enhanced Health in Care Homes.
• Experience of population health management.
• Experience of reporting to commissioners or system partners.

Knowledge and Skills

• Advanced clinical assessment and decision-making skills.
• Knowledge of frailty, multimorbidity and complex care.
• Knowledge of anticipatory care planning and admission avoidance.
• Knowledge of proactive care and population health management.
• Knowledge of clinical governance and safeguarding.
• Ability to lead multidisciplinary teams and partnerships.
• Ability to use data to support service improvement.
• Strong communication and stakeholder engagement skills.
• Proficient in Microsoft 365 and clinical systems (EMIS/SystmOne)
• Knowledge of proactive care frameworks and neighbourhood health models.

Qualifications

• Registered NMC or HCPC professional.
• Master's degree in Advanced Clinical Practice (or equivalent).
• Advanced clinical assessment qualification.
• Evidence of continuing professional development.
• Leadership qualification or equivalent senior leadership experience.
• Teaching, mentorship or clinical supervision qualification.
• Postgraduate qualification in frailty, older people's care, long-term conditions or palliative care.

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.

£57,528 to £64,750 a yearEquivalent to AFC band 8a