Specialist Dietitian for Diabetes Neighbourhood Health Programme

Job summary

Are you an experienced diabetes specialist dietitian 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 two Clinical Lead Nurses for Diabetes, 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.

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 dietetic offer is delivered and evaluated over the three-year development period.

If you are motivated by working across tiers, driving equity into everyday 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 specialist dietetic care in complex multimorbidity, particularly cardio-renal-metabolic disease, MAFLD, severe obesity and gastrointestinal disorders, working as an autonomous clinician within an experienced multidisciplinary team.

The day-to-day mix includes advanced dietetic assessment and consultation, delivery of structured diabetes education (DAFNE, Confidence with Carbohydrates, DESMOND or equivalent), targeted recruitment into the National Type 2 Path to Remission Programme (Xyla), carbohydrate counting and dose-adjustment support, cultural adaptation of dietary advice, and pre-conception or gestational diabetes dietetic input. There is a regular rhythm of Tier 2 MDT case discussion and weekly Tier 3 MDT participation.

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

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.

As your employer SEL GP offer a competitive salary, including the NHS Pension Scheme, annual leave, occupational sickness scheme and salary-sacrifice options. 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.

Job responsibilities

The Specialist Dietitian for Diabetes is the operational dietetic lead within the Tier 2 Neighbourhood Support Team. Responsibilities include specialist dietetic assessment and intervention in cardio-renal-metabolic multimorbidity, including CKD stages 3b to 5, heart failure, MAFLD, severe obesity and gastrointestinal disorders. The postholder delivers structured education (DAFNE, Confidence with Carbohydrates, DESMOND or equivalent), supports carbohydrate counting and dose adjustment for basal-bolus regimens, and targets recruitment to the National Type 2 Path to Remission Programme. Contributes to the Tier 2 MDT and the weekly Tier 3 MDT, provides Advice and Guidance to primary care within 24-hour urgent and one-week routine SLAs, delivers dietetic content in quarterly TARGET education, provides cultural adaptation of dietary advice for ethnic-specific patterns, supports pre-conception and gestational diabetes dietetic care, and contributes to quality improvement and equity of dietetic access.

Key duties and responsibilities

Specialist dietetic assessment and intervention in complex multimorbidity

Assess, plan, deliver and evaluate specialist dietetic care for adults on the Tier 2 caseload with diabetes and complex multimorbidity, working as an autonomous practitioner within a wider MDT.

Specialist dietetic intervention for complex co-morbidity including CKD stages 3b5, heart failure, MAFLD (metabolic-associated fatty liver disease), severe obesity, and gastrointestinal disorders.

Dietetic management of complex insulin regimens carbohydrate counting and dose adjustment for those on basal-bolus regimens, use of Continuous Glucose Monitoring and Flash Glucose Monitoring data to support decisions. Combination therapy support alongside dietetic intervention including SGLT2i, GLP-1 receptor agonists (subcutaneous and oral), and other pharmacotherapy in liaison with the Specialist Pharmacist.

Dietetic management of steroid-induced hyperglycaemia and hypoglycaemia risk reduction.

Reconciliation of dietetic plans following discharge from hospital or transfer from other services.

Type 2 remission and structured education

Targeted recruitment of eligible patients into the National Type 2 Diabetes Path to Remission Programme (Xyla in Leeds), including engagement with under-served communities.

Support and shape a proposed option to commission bespoke local Xyla-style sessions for underserved communities, in partnership with the Programme Manager and VCSE partners.

Good knowledge of the delivery of the Leeds Programme of structured education, DAFNE, and Confidence with Carbohydrates.

Delivery of DESMOND or equivalent Type 2 self-management education where relevant.

Adaptation of structured education for people with learning disability, sensory impairment or lower literacy in partnership with LD nursing and easy-read materials.

Cultural adaptation of dietary advice supporting ethnic-specific dietary patterns and food traditions across the diverse populations of south and east Leeds.

Lifestyle, physical activity and behaviour change

Resistance training advice alongside aerobic exercise not assumed within general lifestyle advice.

Behaviour-change consultation using recognised frameworks (Making Every Contact Count, motivational interviewing or equivalent).

Weight management dietetic input aligned with local pathways.

Pre-conception dietetic input for women planning pregnancy with diabetes, and gestational diabetes follow-up support with clear handover into the LTHT maternity team.

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 dietetic-related actions arising from MDT discussion.

Escalation to Tier 4 for antenatal diabetes, bariatric pathway, high-risk foot MDT, 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 dietetic questions beyond the Tier 1 remit and short of MDT escalation.

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

Support Practice Diabetes Leads to cascade dietetic 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 including food-poverty and community food initiatives.

Quality, safety and improvement

Work to HCPC standards and the British Dietetic Association Standards of Proficiency; ensure practice is grounded in evidence-based theoretical and practical knowledge.

Identify cohorts of patients at high risk of nutritional 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 dietetic outcomes, remission rates, HbA1c, weight and lipid changes, 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 dietetic leadership within the Tier 2 Neighbourhood Support Team.

Provide supervision and mentorship to dietetic support workers, dietetic students and less experienced colleagues within scope.

Contribute to workforce development plans across Tier 1 and Tier 2 dietetic capability, in partnership with the senior dietetic lead in the wider Leeds diabetes dietetic pathway.

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

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

Service development

Contribute dietetic 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 dietetic 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 Tier 1 clinicians across the footprint.

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

Engage with the Leeds diabetes dietetic network, BDA Diabetes Specialist Group, and other diabetes special interest groups for peer support.

Liaise with LCH community diabetes teams, LTHT specialist diabetes services (including antenatal, bariatric and high-risk foot pathways), 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.

Continuing professional development, research and evaluation

Undertake continual personal and professional development and take an active role in developing the Tier 2 dietetic offer.

Access regular clinical supervision to work effectively with the complex issues the Tier 2 cohort presents.

Reflect on and evaluate own practice; identify areas of development by setting appropriate objectives via appraisal and clinical supervision.

Critically appraise and apply the evolving evidence base for diabetes and cardio-renal-metabolic dietetic care.

Contribute to the Programmes Year 1 evaluation and Year 2 business case.

Care Quality Commission, health and safety, and confidentiality

Work with the delivery partners to ensure practices and Programme delivery are compliant with CQC standards where dietetic input is involved.

Comply with Health and Safety policies, follow safe working procedures and report incidents through the organisation's Incident Reporting Systems.

Comply with the Data Protection Act (2018) and the Access to Health Records Act (1990); respect patient confidentiality at all times.

Understand and apply knowledge of the clinical role in safeguarding and incident management.

Special working conditions

The postholder will travel independently between practices and community sites across the Beeston and Middleton & Hunslet footprint, and to meetings hosted by other agencies.

Person specification

Personal Qualities & Attributes

Essential

• Commitment to reducing health inequalities and proactively working to reach people from all communities.
• Person-centred, trauma-informed approach with a working understanding of the wider social determinants of health.
• Ability to communicate with a wide range of colleagues from the NHS and other organisations and with patients including good written and oral communication skills.
• Recognises personal limitations and refers to more appropriate colleagues when necessary.
• Able to identify and assess / manage risk when working with individuals.
• Able to work under pressure and meet deadlines, managing unpredictable service demands.
• Accountability for delivering professional expertise and direct service provision.
• Emotional resilience, self-awareness, humility and curiosity.
• Willing to challenge and be challenged including consultants and GPs in the patients best interest.
• Reliability and integrity in a small MDT where the model depends on trust.
• Ability to organise, plan and prioritise on own initiative.
• Ability to work flexibly and enthusiastically within a team or on own initiative.
• Comfortable with the ambiguity of a new service willing to iterate, evaluate and adjust.
• Cultural competence for supporting ethnic-specific dietary patterns and adaptation.
• Positive and flexible attitude to dealing with change.

Desirable

• Leadership experience and previous experience of supervising or mentoring more junior staff or students.

Qualifications

Essential

• BSc (Hons) in Dietetics or equivalent professional dietetic degree.
• Postgraduate qualification in a specialist field (Diabetes, Renal, Obesity, MAFLD or Behaviour Change), or working towards.
• Must be willing to participate in any relevant training identified to develop skills required to carry out duties.
• Maintains a portfolio of CPD in line with HCPC standards.

Desirable

• Supporting Learning in Practice (SLIP), Practice Educator qualification or equivalent.
• Formal teaching qualification (PGCert HE or equivalent).
• Leadership or management qualification (ILM 3, NHS Leadership Academy or equivalent).
• Certified DAFNE, DESMOND, Confidence with Carbohydrates or Xyla Path to Remission educator.
• Formal training in health inequalities, trauma-informed care or behaviour-change approaches (Making Every Contact Count, motivational interviewing).

Skills and knowledge

Essential

• Detailed theoretical and clinical dietetic knowledge appropriate to diabetes, multimorbidity and cardio-renal-metabolic disease.
• Highly specialist knowledge of diabetes across Type 1, Type 2, atypical presentations and complex multimorbidity.
• Confident with carbohydrate counting, dose adjustment for insulin regimens and use of CGM / Flash data.
• Knowledge of Type 2 remission pathways (Xyla) and structured education programmes.
• Understanding of the wider determinants of health and their impact on communities, including food access and food poverty.
• Autonomous within scope of practice and knows when to escalate.
• Excellent verbal, non-verbal and written communication skills, including complex or potentially distressing conversations with patients and families and managing conflict when appropriate.
• Advanced consultation skills and shared decision-making with people whose lives are shaped by health inequalities.
• Confident with EMIS / SystmOne, digital consultation modes, MDT tools and asynchronous working.
• Able to plan, manage, monitor and review dietetic care for a long-term-conditions cohort.
• Able to obtain and analyse complex clinical and outcomes information.
• Complex analytical and creative problem solving in unpredictable situations.
• Workload management including delegation and day-to-day team leadership.

Desirable

• Understanding of research governance and quality improvement methodology.
• Awareness of the Leeds Proactive Care and Integrated Neighbourhood Health frameworks.

Professional Registration

Essential

• Mandatory registration with the Health and Care Professions Council (HCPC) as a Dietitian.

Desirable

• Membership of the British Dietetic Association (BDA).
• Membership of the BDA Diabetes Specialist Group.

Experience

Essential

• Substantial post-registration dietetic experience in diabetes and multimorbidity.
• Experience of dietetic management of Type 1 and Type 2 diabetes including insulin regimens and carbohydrate counting.
• Experience of dietetic management in CKD stages 3b5, heart failure, MAFLD or severe obesity.
• Experience of delivering structured diabetes education (DAFNE, DESMOND, Confidence with Carbohydrates or equivalent).
• Experience of MDT working across community and acute care.
• Experience of supervising and delegating to other members of staff, dietetic support workers or students.
• Experience of contributing to service development, quality improvement or clinical audit.
• Experience of working with people affected by health inequalities.

Desirable

• Experience of practice-based, PCN-based or community-based dietetic delivery.
• Experience of the National Type 2 Diabetes Path to Remission Programme (Xyla) delivery or referral.
• Experience of gestational diabetes and pre-conception dietetic care.
• Experience of behaviour-change consultation using recognised frameworks.
• Experience of delivering dietetic education to Tier 1 clinicians (nurses, GPs, HCAs).
• Working experience of EMIS and SystmOne clinical systems.
• Experience of contributing to research or service evaluation.

Experience

Essential

• Substantial post-registration dietetic experience in diabetes and multimorbidity.
• Experience of dietetic management of Type 1 and Type 2 diabetes including insulin regimens and carbohydrate counting.
• Experience of dietetic management in CKD stages 3b5, heart failure, MAFLD or severe obesity.
• Experience of delivering structured diabetes education (DAFNE, DESMOND, Confidence with Carbohydrates or equivalent).
• Experience of MDT working across community and acute care.
• Experience of supervising and delegating to other members of staff, dietetic support workers or students.
• Experience of contributing to service development, quality improvement or clinical audit.
• Experience of working with people affected by health inequalities.

Desirable

• Experience of practice-based, PCN-based or community-based dietetic delivery.
• Experience of the National Type 2 Diabetes Path to Remission Programme (Xyla) delivery or referral.
• Experience of gestational diabetes and pre-conception dietetic care.
• Experience of behaviour-change consultation using recognised frameworks.
• Experience of delivering dietetic education to Tier 1 clinicians (nurses, GPs, HCAs).
• Working experience of EMIS and SystmOne clinical systems.
• Experience of contributing to research or service evaluation.

Other

Essential

• Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions.
• Adaptable.
• Works effectively independently and as a team player.
• Self-motivated.
• Up to date with safeguarding and other mandatory training.
• Up to date immunisation status.
• Ability to work in different locations across the footprint and to help provide cover for absent colleagues; ability to take part in an extended working day in line with the models flexible-access commitment.
• Access to own transport and ability to travel across the multi-neighbourhood footprint, including home visits.

Desirable

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