GP Clinical Lead - Proactive Care Service

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.