GP Clinical Lead - Proactive Care ServiceNHS

Job summary

PLEASE INCLUDE WITH YOUR APPLICATION A COVERING LETTER EXPLAINING WHY YOU ARE INTERESTED IN THIS POSITION, AND WHAT MAKES YOU A GOOD FIT FOR THE ROLE.

PCS is a Monday-Friday keep-well service focused on earlier intervention before deterioration becomes crisis. The initial cohort will be predominantly PNG 10-11 patients, prioritised using recent hospital use and clinically validated. The service will provide active caseload management, including frailty review, falls assessment, medication optimisation and deprescribing, ReSPECT / care planning, CGA where needed, home or face-to-face review where clinically indicated, and coordinated access to wider health, social care and VCSE support.

The GP Clinical Lead will provide clinical leadership and oversight for the Berkshire West Proactive Care Service (PCS). The role will help mobilise, clinically govern and continually refine a new proactive care model for around 1,000 high-risk frail and complex patients across Berkshire West. The postholder will work closely with the frailty GP workforce, prescribing paramedics / advanced clinicians, care coordination team, Geriatrician Clinical Lead and wider system partners.

Main duties of the job

• 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.

Full responsibilities and deliverables are included in the job description.

Job description

KEY RESPONSIBILITIES AND DELIVERABLES

• 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.

ROLE BOUNDARIES

The GP Clinical Lead 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.

USE OF THE CLINICAL LEAD SESSION

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.
• Frailty GPs and 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.

PROFESSIONAL / GOVERNANCE RESPONSIBILITIES

• Work within GMC 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.

About us

The 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.

PCA 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.