Advanced Clinical Practitioner for Proactive Care & Clinical Lead

Overview

In this senior role you will lead Cross Gates PCN’s Proactive Care Team, delivering advanced clinical practice and clinical leadership to reduce frailty and avoidable hospital admissions. You’ll drive population health approaches, coordinate care across primary, community and voluntary sector partners, and shape neighbourhood health with a focus on prevention and early intervention. The position blends hands-on clinical work with service development and MDT leadership to improve outcomes for high-risk patients.

Responsibilities

• Provide expert advanced clinical practice for frailty, multimorbidity, and high-risk patients in care homes and community settings
• Lead clinical and operational delivery of the Proactive Care Team with safe, coordinated working across PCN practices
• Drive Proactive Care Programmes, including cohort identification, holistic assessment, personalised care planning and outcome monitoring
• Oversee Enhanced Health in Care Homes activities, ward rounds, and MDT collaboration with GPs, ACPs, care home teams and community services
• Strengthen neighbourhood health model through integration and communication with primary care, community services, mental health, social care, housing and voluntary sector
• Apply population health management to target unmet need and address health inequalities
• Promote prevention and early intervention to reduce deterioration and hospital admissions
• Lead supervision, governance, and workforce development for the proactive care team
• Chair and clinically lead proactive care and care home MDTs; foster integrated neighbourhood working across partners
• Pilot and oversee delivery of Proactive Care Programmes, including data quality and contractual requirements

Key requirements

• Significant post-registration experience with autonomous practice at advanced level
• Experience managing whole episodes of care for complex patients in community or primary care
• Experience with frailty, multimorbidity and older people in community settings
• Experience undertaking home visits and care-home reviews or ward rounds
• Experience Anticipatory care planning, personalised care planning and shared decision-making
• Multidisciplinary and multi-agency working across health, social care and voluntary sector
• Experience leading a clinical team, operational management, supervision and workforce development
• Experience leading service redesign, transformation, or quality improvement
• Experience using data and outcomes to monitor and drive improvement
• Desirable: experience in PCNs, Enhanced Health in Care Homes, population health management
• Knowledge of governance, safeguarding, Mental Capacity Act, consent, information governance
• Digital literacy with Microsoft 365 and clinical systems like SystmOne and/or EMIS

• Collaborative leadership
• Effective communication
• Strategic thinking
• Advanced clinical assessment and management of complex care
• Independent prescribing and medication optimisation
• Frailty and polypharmacy management

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