Primary Care Clinical Lead, Integrated Neighbourhood Team

Job description

Job responsibilities

Job Description

Role: Primary Care Clinical Lead, Integrated Neighbourhood Team (INT)

Neighbourhood: North Lambeth & Stockwell / Brixton & Herne Hill / Streatham / Clapham / Norwood

Contract: 12 Months Fixed Term Contract

Hours: 0.2 WTE (2 Sessions per week)

Responsible to: Neighbourhood Clinical Lead(s)

Accountable to: Integrator Delivery Board

Hosted by: Lambeth GP Federation

1. Context

This role is situated within the Lambeth Integrated Neighbourhood Team (INT) model, which is delivering a neighbourhood-based approach to health and care across Lambeth.

Integrated Neighbourhood Teams operate across five neighbourhoods:

• North Lambeth & Stockwell Multiple LTCs - Focus 2026/27
• Brixton & Herne Hill Frailty - Focus 2026/27
• Clapham Multiple LTCs - Focus 2026/27
• Streatham Multiple LTCs - Focus 2026/27
• Norwood CYP (with complex needs) Focus 2026/27

As part of the phased test and learn implementation of INTs, 3 clinical cohorts have been identified as priorities in 2026/27 Multiple Long-term Conditions (MLTC), Frailty and Children & Young People (CYP) with complex needs. Each Lambeth neighbourhood will focus on one clinical cohort during 2026/27 (please see above).

This role will contribute directly to clinical priorities of the INT programme, including:

• Embedding multidisciplinary team (MDT) working
• Strengthening workforce capability
• Improving data quality and digital maturity
• Delivering measurable improvements in outcomes
• Reducing health inequalities

2. Job Purpose

The Primary Care Clinical Lead will provide senior clinical leadership within the Integrated Neighbourhood Team, with responsibility for improving the quality, consistency and coordination of care for one of the clinical cohort priorities.

The role reflects the clinical complexity of care, including diagnostic uncertainty, multi-morbidity, polypharmacy and safeguarding considerations across the clinical cohorts. It requires a clinician able to practise autonomously at an advanced level, holding responsibility for undifferentiated presentations, clinical risk management, and longitudinal care across the primary care pathway.

The post holder will:

• Act as a clinical bridge across practices, Primary Care Networks (PCNs), Lambeth GP Federation, LGPPA and system partners
• Ensure general practice plays a central leadership role in neighbourhood care
• Support shift from reactive to proactive, preventative and personalised care

The role combines senior clinical leadership with service development, workforce support, and population health management. It requires an established clinician with extensive experience of managing complex patients in primary care, including responsibility for whole-person care, continuity across episodes, and clinical decision-making across organisational boundaries.

3. Key Responsibilities

3.1 Clinical Leadership and Service Delivery

• Provide senior clinical leadership across the neighbourhood
• Lead the development and delivery of integrated pathways
• Ensure consistent, high-quality clinical care across practices and partners within the Integrated Neighbourhood Team
• Support complex clinical decision-making, including risk and escalation

3.2 Multidisciplinary Team (MDT) Development

• Establish and embed high-functioning MDTs
• Ensure MDTs are structured, data-driven and focused on high-risk patients
• Promote a team of teams approach across:
• Primary care
• Community services
• Secondary care (including relevant consultants at Guys and St Thomas)
• Social care
• VCSE partners
• Ensure clear documentation, action tracking, and outcome monitoring

3.3 Practice and PCN Support

• Provide expert clinical advice and second opinions for complex cases
• Support preparation of cases for MDT discussion
• Advise on:
• Multi-morbidity management
• Polypharmacy and medication optimisation
• Anticipatory care planning
• Support safe and consistent clinical practice across the neighbourhood

3.4 Population Health Management and Digital Enablement

• Champion the use of population health management approaches
• Support risk stratification and proactive identification of frail patients
• Promote high-quality use of EMIS and digital tools, including:
• Accurate frailty coding (e.g. Clinical Frailty Score)
• Use of Ardens templates
• Universal Care Plans and anticipatory care plans
• Contribute to development and use of neighbourhood dashboards

3.5 Proactive Care and Care Home Support

Lead development of proactive care models

Support delivery in:

o Care homes

o Extra care housing

o Housebound populations

Promote:

o Structured ward rounds

o Named GP models

o Regular review and care planning

Support identification and engagement of underserved populations

3.6 Workforce Development and Capability Building

• Design and deliver a neighbourhood training programme for one of the clinical cohorts
• Build workforce capability in:
• Comprehensive Geriatric Assessment (CGA)
• Medication optimisation
• Care home medicine
• Proactive care planning
• Provide mentorship and supervision to:
• GPs
• ARRS roles
• Nursing staff
• Allied health professionals

3.7 Partnership Working and System Leadership

• Work collaboratively across the Lambeth system
• Contribute to pathway development and service redesign
• Build strong relationships with:
• Secondary care
• Community services
• Mental health teams
• Social care
• VCSE organisations

3.8 Clinical Governance and Quality Improvement

• Ensure delivery aligns with LGPPA governance frameworks and INT SOPs
• Contribute to:
• Audit and evaluation
• Performance monitoring
• Quality improvement initiatives
• Ensure risks are identified, documented and escalated appropriately
• Support reporting to governance structures and the ICB

4. Key Deliverables

The postholder will be expected to:

• Establish a fully operational MDT model
• Increase identification and patient coding
• Improve uptake and quality of care planning (including UCPs)
• Deliver improvements in:
• Patient outcomes
• Continuity of care
• Care home support
• Contribute to reductions in:
• Avoidable hospital admissions
• Emergency department attendances
• Strengthen clinical capability across practices and teams

5. Person Specification

Essential

• Qualified General Practitioner with GMC registration and on Performers List
• Active clinical role in primary care (minimum 3-4 sessions per week)
• Experience in frailty, elderly care, and complex case management
• Experience of multidisciplinary working
• Clinical leadership or service development experience
• Strong competency in EMIS and digital clinical systems
• Understanding of integrated care systems and population health management
• Experience in teaching, mentoring or supervision

Desirable

• Experience working within Lambeth or South East London
• Experience in care home medicine / Enhanced Health in Care Homes
• Experience in quality improvement or service redesign

6. Governance and Accountability

The postholder will:

• Operate within Lambeth GP Federation governance frameworks
• Ensure transparency, accountability and compliance with policies
• Maintain high standards of documentation and decision-making
• Escalate risks appropriately through governance structures
• Comply with statutory and organisational requirements

7. Strategic Impact

This role is critical to:

• Successful delivery of the clinical cohort pathway within Lambeth INTs
• Shifting care towards prevention and community-based delivery
• Embedding population health and digital approaches
• Ensuring general practice leadership within integrated care

8. Additional Responsibilities

The post holder will comply with relevant organisational policies and procedures including:

Information governance and confidentiality

Equality, diversity and inclusion

Safeguarding responsibilities

Health and safety requirements

Risk management and governance processes

Review of Job Description

This job description outlines the key responsibilities of the role and may be reviewed periodically to reflect changes in programme priorities or organisational requirements.

Informal Enquiries

For an informal discussion about the role please contact:

Dr George Verghese Chair, Lambeth GP Provider Alliance Email: gverghese@nhs.net

Person Specification

Qualifications

Essential

• Person Specification
• Essential
• Qualified General Practitioner with GMC registration and on Performers List
• Active clinical role in primary care (minimum 3-4 sessions per week)
• Experience of multidisciplinary working
• Clinical leadership or service development experience
• Strong competency in EMIS and digital clinical systems
• Understanding of integrated care systems and population health
• management
• Experience in teaching, mentoring or supervision

Desirable

• Desirable
• Experience working within Lambeth or South East London
• Experience in care home medicine / Enhanced Health in Care Homes
• Experience in frailty, elderly care, and complex case management
• Experience in quality improvement or service redesign

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Lambeth GP Federation

Address

Akerman Health Centre

60 Patmos Road

London

SW9 6AF

Employer's website

https://www.lambethgpfederations.nhs.uk/ (Opens in a new tab)