Clinical Lead Nurse for Diabetes Neigbourhood Health Programme

Job summary

Are you an experienced diabetes clinical nurse specialist looking for a new challenge in integrated community diabetes care? A rare opportunity has arisen to join the Tier 2 Neighbourhood Support Team of the Diabetes Neighbourhood Health Programme a new, place-based, integrated model of diabetes care being delivered across south and east Leeds.

This role sits within the Tier 2 Neighbourhood Support Team, working alongside a Clinical Lead Nurse colleague, a Specialist Dietitian, a Specialist Pharmacist, a Specialist Podiatrist and a Registered Nurse development post. The team works into general practice across the initial Beeston and Middleton and Hunslet PCN footprint, and interfaces closely with the Tier 3 Clinical Oversight Group (Consultant Diabetologist, Consultant Pharmacist, Highly Specialist Pharmacist, Diabetes Matron and Clinical Psychologist) and specialist Tier 4 services at Leeds Teaching Hospitals.

Two posts are available. Working pattern: this is a 1.0 WTE post 37.5 hours per week based in the community across the multi-neighbourhood footprint, with flexibility in the working pattern to be agreed at appointment. There is genuine scope to shape how the Tier 2 nursing offer is delivered and evaluated over the three-year development period.

If you are motivated by working across tiers, driving equity into everyday clinical care, and contributing to a genuinely new model of care from the outset, we would love to hear from you.

Main duties of the job

You will hold a patient-facing caseload within the Year 1 cohort adults aged 18 to 67 living with diabetes and two or more other long-term conditions. Your focus is advanced diabetes nursing care in complex multimorbidity, working as an autonomous clinician within an experienced multidisciplinary team.

The day-to-day mix includes advanced clinical assessment and consultation, insulin and injectable initiation and titration, use of CGM and Flash Glucose Monitoring data for shared decision-making, joint visits with district nursing for assisted insulin, and delivery of structured education. There is a regular rhythm of Tier 2 MDT case discussion and weekly Tier 3 MDT participation, giving structured access to specialist opinion and peer learning.

Alongside the clinical caseload, you will play an active role in cascade education across Tier 1 and Tier 2 including quarterly joint clinics with Practice Diabetes Leads and delivery of TARGET education sessions. You will provide Advice and Guidance to primary care within tight response times, and contribute to service development, quality improvement and equity of diabetes nursing care as the model scales towards citywide delivery.

Active outreach and engagement with people in deprivation deciles 1 to 3 and named priority groups is a core expectation, not a bolt-on. This role suits someone who wants to work in a person-centred, trauma-informed way and build partnerships with community and third-sector delivery partners.

About us

South and East Leeds General Practice Group brings together general practices across the south and east of Leeds to deliver joined-up primary care, PCN services and integrated community programmes. As one of the hosting partners for the new Diabetes Neighbourhood Health Programme, we work in close partnership with Leeds Community Healthcare Trust, Leeds Teaching Hospitals Trust, West Yorkshire ICB and our neighbourhood Primary Care Networks to deliver a genuinely place-based model of care.

You will be joining a team that is comfortable with new ways of working, collaborative across professional and organisational boundaries, and committed to reducing health inequalities in some of the most under-served neighbourhoods in the city. The culture is honest about the challenges of complex multimorbidity, patient-centred in its everyday decision-making, and generous with peer support and shared learning.

We support flexible working, protected CPD time, professional supervision and access to formal advanced-practice development pathways. You will have regular clinical supervision, access to Tier 3 MDT mentorship, and structured opportunities to contribute to service evaluation, research and Year 2 business-case development.This role may expand to a wider geographical area in year 2 as the new service is rolled out across the City

Job responsibilities

The Clinical Lead Nurse for Diabetes is a senior clinical role within the Tier 2 Neighbourhood Support Team. The postholder holds a patient-facing caseload, delivering advanced diabetes nursing care in complex multimorbidity as an autonomous clinician. Responsibilities include insulin and injectable initiation and titration; use of CGM and Flash Glucose Monitoring data for titration; delivery of structured education; joint visits with district nursing for assisted insulin; contribution to the Tier 2 MDT and weekly Tier 3 MDT (combined with the LTHT community diabetes MDT); joint clinics with Practice Diabetes Leads; TARGET education across Tier 1; Advice and Guidance to primary care within 24-hour urgent and one-week routine SLAs; clinical leadership and supervision of nursing colleagues; and active outreach to people in deprivation deciles 1 to 3 and named priority groups. Contribution to service development, quality improvement and equity of diabetes care.

Purpose of the role

The Clinical Lead Nurse for Diabetes is a senior clinical role within the Tier 2 Neighbourhood Support Team of the Diabetes Neighbourhood Health Programme a new integrated model of care for adults aged 1867 with diabetes (any type) and two or more other long-term conditions, delivered across the Beeston and Middleton & Hunslet PCN footprint and expanding across the Multi-Neighbourhood over the three-year development period.

The role is patient-facing, holds an active caseload within the Tier 2 cohort, and delivers advanced diabetes nursing care across injectable therapy, structured education and complex multimorbidity. The postholder is a core participant in the Tier 2 MDT and the weekly Tier 3 MDT (combined with the existing LTHT community diabetes MDT), provides Advice and Guidance to primary care, leads joint clinics with the Practice Diabetes Lead in each footprint practice, and drives workforce development across Tier 1 and Tier 2 through quarterly TARGET education.

Active outreach and engagement with deprivation deciles 13 and named priority groups (people with learning disability, serious mental illness, those homeless or vulnerably housed, those who smoke or use substances, adults living alone) is a core expectation of the role. The postholder is expected to work in a person-centred, trauma-informed way, with a working understanding of the wider social determinants of health.

Key duties and responsibilities

Advanced diabetes nursing and injectable therapy

Advanced clinical assessment and consultation with patients on the Tier 2 caseload, including remote and asynchronous consultation.

Insulin initiation, titration and ongoing management across all regimens basal, biphasic, basal-bolus including remote support by phone and asynchronous tools.

Subcutaneous GLP-1 receptor agonist initiation, titration and ongoing management (oral GLP-1 and GLP-1 / GIP formulations are prescribed at Tier 1).

Use of Continuous Glucose Monitoring (CGM) and Flash Glucose Monitoring data for titration, escalation and shared decision-making.

Joint visits with district nursing for patients requiring assisted insulin administration.

Delivery of structured diabetes education DAFNE, DESMOND, Confidence with Carbohydrates or equivalent, and pre-conception / pre-pregnancy education where relevant.

Non-Medical Prescribing within scope of practice (post-holders holding V300); clear escalation to Tier 2 Pharmacist or Tier 3 Consultant colleagues for complex prescribing decisions.

Recognition of and appropriate response to acute deterioration, including sick-day rules education, hypo unawareness identification and referral to Tier 3 or Tier 4 as required.

Care coordination and complex multimorbidity

Holding and managing an active caseload within the Tier 2 cohort, with responsibility for planning, delivering and evaluating patient-centred nursing care.

Care coordination across the Tier 2 team who holds the patient list, how follow-up cadence is decided, and how patients move safely between tiers.

Contribution to the Tier 2 approach to cardio-renal-metabolic multimorbidity, working alongside the Specialist Pharmacist, Specialist Dietitian, Specialist Podiatrist and Registered Nurse development post.

Recognition of psychological, social and mental health needs affecting engagement and self-management with liaison into mental health, learning disability, homelessness and substance-use services.

Reconciliation of care following discharge from hospital or transfer from other services, working with community pharmacy and hospital teams to ensure continuity.

MDT participation and clinical decision-making

Active participation in the Tier 2 MDT fortnightly for complex / high-risk cases and 812 weekly for moderate-risk cases.

Weekly attendance and active contribution to the Tier 3 Clinical Oversight Group MDT, combined with the existing LTHT community diabetes MDT.

Presenting cases, drafting shared care plans and taking responsibility for nursing-related actions arising from MDT discussion.

Escalation to Tier 4 for pump / hybrid closed loop, DKA / HHS follow-up, high-risk foot MDT, antenatal diabetes and other specialist pathways as required.

Advice & Guidance and joint clinics with primary care

Provide Advice and Guidance to primary care within agreed SLAs 24 hours for urgent enquiries, one week for routine for clinical questions beyond the Tier 1 remit and short of MDT escalation.

Lead quarterly joint clinics with the Practice Diabetes Lead in each footprint practice, on the model described in the Programme Education, Training and Support Plan.

Deliver nursing content within the quarterly TARGET education sessions for Practice Diabetes Leads, cascading learning into wider practice teams.

Support Practice Diabetes Leads to cascade learning through practice clinical meetings.

Outreach, equity and engagement

Active recruitment and engagement from deprivation deciles 13, with DNA monitoring and proactive approaches to reduce DNAs.

Outreach to named priority groups people with learning disability, serious mental illness, those homeless or vulnerably housed, those with substance-use co-morbidity, adults living alone.

Flexible appointment access including evening, digital and asynchronous options; home visits where clinically indicated.

Liaison with mental health teams for patients with SMI and antipsychotic-induced metabolic disturbance.

Liaison with drug and alcohol services and homelessness services.

Workplace engagement and reasonable-adjustment support via Healthy Working Lives.

Working in partnership with third-sector and asset-based community delivery partners as active collaborators, not downstream referrals.

Nursing quality, safety and improvement

Work to NMC Code and professional standards; ensure practice, and that of colleagues, is grounded in evidence-based theoretical and practical knowledge.

Identify cohorts of patients at high risk of harm through structured searches (EMIS / SystmOne) and act on findings.

Contribute to clinical audit within the Tier 2 caseload and across the Programme; feed back results and implement changes with the Tier 2 team, Practice Diabetes Leads and the Tier 3 Clinical Oversight Group.

Contribute to the Programme's outcomes and evaluation framework, particularly on nursing-related outcomes, safety indicators and equity of access.

Comply with the organisations Infection Prevention and Control requirements, including bare below the elbows dress code.

Leadership, supervision and workforce development

Provide clinical leadership on diabetes nursing practice within the Tier 2 Neighbourhood Support Team.

Provide supervision and mentorship to the Registered Nurse development post, and to less experienced colleagues within scope.

Act as a role model to all staff, ensuring a professional service and image is maintained at all times.

Contribute to workforce development plans across Tier 1 and Tier 2 nursing, in partnership with the Tier 3 Diabetes Matron and the wider Tier 3 group.

Practice supervisor / educator role for pre-registration and post-qualification nursing learners as required.

Effective and efficient use of clinical resources (staff, supplies) within own sphere of responsibility.

Service development

Contribute nursing advice for the development and iteration of the Diabetes Neighbourhood Health Programme model including step-up / step-down criteria, pathway design, and operational standards.

Contribute to Year 2 and Multi-Neighbourhood expansion planning.

Analyse, interpret and present nursing and outcomes data to highlight issues, opportunities and risks to support programme decision-making.

Collaborative working relationships

Work collaboratively with the Tier 2 clinical lead, Programme Manager, and the Tier 3 Clinical Oversight Group.

Maintain strong relationships with PCN Clinical Directors, Practice Diabetes Leads and practice nursing teams across the footprint.

Liaise with the Leeds ICB, LCH, LTHT and neighbouring GP federations for consistency of patient care.

Engage with the Leeds diabetes nursing network and other diabetes special interest groups for peer support.

Liaise with LCH community diabetes teams, LTHT specialist diabetes services, community pharmacy, mental health services, drug and alcohol services, and VCSE partners as required.

Foster and maintain strong links with all services across the multi-neighbourhood footprint.

Please see attached job description for more info

Person specification

Additional criteria

Essential

• Advanced clinical assessment and consultation skills.
• Highly specialist knowledge of diabetes across Type 1, Type 2, atypical presentations and complex multimorbidity.
• Confident with SGLT2i, GLP-1, insulin regimen selection and use of CGM or Flash data for shared decision-making.
• Autonomous within scope of practice, with clear understanding of when to escalate to Tier 3.
• Excellent verbal and written communication skills, including complex or potentially distressing conversations with patients and families.
• Demonstrable understanding of the wider determinants of health and their impact on communities.
• Demonstrable commitment to reducing health inequalities and proactively reaching under-served populations.
• Person-centred and trauma-informed approach to consultations.
• Ability to plan, manage, monitor and review nursing care for a long-term-conditions cohort.
• Ability to influence, motivate and negotiate across professional and organisational boundaries.
• Clinical leadership presence and ability to role-model professional standards.
• Willingness to challenge and be challenged, including consultants and GPs, in the patient's best interest.
• Comfortable with the ambiguity of a new service, and willing to iterate, evaluate and adjust.
• Confident with digital consultation, MDT tools and asynchronous working.
• Emotional resilience, self-awareness, humility and curiosity.
• Access to own transport and ability to travel across the multi-neighbourhood footprint.
• Meets DBS reference standards.
• Up-to-date mandatory training and immunisation status.

Desirable

• Awareness of the Leeds Proactive Care and Integrated Neighbourhood Health frameworks.
• Understanding of NHS commissioning, business-case development and the wider system architecture.
• Interest in contributing to research, service evaluation or Year 2 business-case development.

Experience

Essential

• Substantial post-registration experience as a Diabetes Nurse Specialist or equivalent diabetes-specialist nursing role.
• Practical experience of insulin regimen optimisation across all regimens (basal, biphasic, basal-bolus).
• Practical experience of subcutaneous GLP-1 initiation, titration and ongoing management.
• Experience of joint working with district nursing for assisted insulin administration.
• Experience of MDT working across community and acute care.
• Experience of delivering structured diabetes education (DAFNE, DESMOND, Confidence with Carbohydrates or equivalent).
• Experience of clinical supervision and mentorship of junior nursing colleagues.
• Experience of working with people affected by health inequalities.
• Experience of contributing to service development, quality improvement or clinical audit.
• Experience of leadership in practice, including day-to-day team leadership and delegation.

Desirable

• Experience of working across the acute, community and primary care interface.
• Experience of CGM, Flash Glucose Monitoring and insulin pump technology.
• Experience of leading or contributing to clinical audit and quality improvement projects.
• Experience of contributing to research or service evaluation.
• Working experience of EMIS and SystmOne clinical systems.
• Experience of change management or new-service implementation.

Qualifications

Essential

• Registered Nurse (Adult) with current NMC registration.
• Post-graduate learning to Master's level or equivalent.
• Independent Non-Medical Prescribing (V300), or working towards.
• Recognised specialist diabetes course or qualification (Diabetes Specialist Practitioner course, Warwick, Leicester, Sheffield modules, or equivalent).
• Teaching, training or mentorship qualification, or experience to an equivalent level.
• Maintains a portfolio of CPD in line with NMC standards.

Desirable

• Full Master's degree in Advanced Clinical Practice.
• Formal teaching qualification (PGCert HE or equivalent).
• Leadership or management qualification (NHS Leadership Academy or equivalent).
• Formal training in health inequalities, trauma-informed care, or behaviour-change approaches such as Making Every Contact Count.