Detailed job description and main responsibilities

Job Description subject to AFC consistency checking process

Key Result Areas & Performance:
1.    Provide clinical and strategic leadership for the for the core INT team developing the service to meet the needs of the PCNs and wider Lewisham INT model of care.
2.    To deliver patient facing care and conduct multi-morbidity reviews to improve outcomes for patients with complex needs or provide support before needs become acute. 
3.    To provide line management of and supervision to the core INT team, including clinical pharmacist prescribers and caseworkers to ensure effective teamwork and delivery of the programme’s goals. 
4.    To lead and participate in clinical audit to support evaluation of service delivery and inform improvement. 
5.    To work in closely with other members of the core INT team including link workers, key workers, health equity team, GPs and community groups, linking with clinicians and staff within other community and secondary teams within both health and social care to ensure a holistic and multidisciplinary approach to care maintained.
6.    Provide medicines management expertise and support to patients, other clinical and none-clinical staff as part of the INT model of care.
7.    To promote appropriate evidence-based and cost-effective prescribing and advice on de-prescribing where appropriate.
8.    Provide highly specialist medicines management support and training for GPs, nurses and other members of the multi-disciplinary team caring for patients with multi-morbidity in all settings 
9.    To lead on the development of protocols in collaboration with key stakeholders as necessary to support service delivery.

Service Development
1.    To lead on the development and refinement of service delivery models within the INT programme alongside relevant commissioning and programme leads, to support effective delivery of activity across all PCNs/ Neighbourhoods. 
2.    To work closely with colleagues and leads to promote and embed the role of the INT into local pathways of care.
3.    To communicate with other service leads within the community setting to ensure the INT model works effectively with existing services within primary care to achieve better outcomes for patients. 
4.    To plan actions to continuously improve the quality of services provided to ensure a quality improvement approach is taken to medication optimisation and any service development or re-design. 
5.    To evaluate with the programme leads, outcome measures associated with the INT service and the resource requirements for any change or service development required. 

Clinical Services & Patient Care
1.    To act as a clinical role model to and provide direct clinical supervision to clinical prescribing pharmacists in the INT team to ensure a high-quality service is developed which improves outcomes through the provision of a patient-centred approach to the safe and clinically cost-effective use of medicines.
2.    To provide clinical leadership on medicines optimisation in the context of multi-morbidity across the core and wider team setting. 
3.    To conduct patient facing and telephone consultations to review patients with complex multi-morbidity focusing on optimisation of cardiovascular disease management and improving long-term outcomes.  
4.    To collaborate with multidisciplinary teams (MDTs) to develop and implement individualised care plans.
5.    To provide clinical advice and support to other members on the INT, including complex scenarios to ensure a high standard of patient care. 
6.    To manage complex and non-routine medicines management problems identified in patients under the INT service, making onward referrals when needed. 
7.    To demonstrate an intuitive grasp of situations based on knowledge, expertise and understanding and to make decisions about drug therapy with limited information. 
8.    To work with colleagues to facilitate robust communication and onward referral pathways to support seamless care for patients managed by the INT service where complex medicines and/or other needs are identified. 
9.    To ensure efficient transfer of information related to complex medicines management needs across care interfaces and reconcile information received to ensure the safe care for patients with complex medicines management needs.
10.    To work as an independent prescriber and review medication to ensure that patients medicines are optimised for safety, effectiveness and cost-efficiency. in line with competency and agreed scope of practice as approved by the relevant Trust governance process.

Information & Data Management
1.    To develop quantitative and qualitative performance measures, co-ordinate their use and be involved in disseminating, acting on and sharing learning from information gathered.
2.    To co-ordinate the design, collection and evaluation of clinical audit data and participate in research projects improve the quality of care and inform best practices. 
3.    To utilise available information from audits, national guidelines, and benchmarking data to influence practice and implement improvement in service delivery  
4.    To work closely with PCNs ensuring seamless integration of patient data for improved care co-ordination. 

Staff Management and Education and Training
1.    To line manage the Clinical Prescribers with overall management of all core team members within the INT, providing supervision, guidance and support to ensure effective teamwork and delivery of goals. This will include matrix working with PCN clinical leads and business managers to effectively manage and co-ordinate team members and support appraisals, objective setting, and management of sickness absence.
2.    To ensure the team’s activities align with the wider objectives of the INT programme, fostering a culture of collaboration and excellence.
3.    To oversee the personal and professional development of team members and identify the training needs and develop strategies to meet those needs.
4.    To identify and lead the design and delivery of education and training around the INT service including medicines optimisation in multimorbidity and cost-effective prescribing, to colleagues and more widely across the system. Training delivery will range from small communications to formal presentations. 
5.    To participate and contribute to clinical training programmes for trainee professionals across Lewisham where exposure to the INT model would aid learning and practice. 
6.    To evaluate and ensure continuous development of own professional knowledge and competencies by attendance at in house/external training programmes, appropriate self- education 
  
Financial
1.    To support the service lead manage the delegated staff budget for relevant aspects of the INT service and ensure that pay expenditure is maintained within allocated targets.
2.    To support and advise relevant leads and GP / primary care prescribers on delivering relevant local QIPP, QoF and local targets in relation to medicines optimisation.
3.    To provide medicines advice regarding the use of cost-effective drugs across the primary and secondary care interface to the relevant stakeholders.
4.    To provide a value for money service to contribute to reduction of medicines related readmission of patients with complex medicines management needs by optimising management and communication about medicines across care interfaces.
5.    Support the delivery of targets in the general practice setting in relation to medicines optimisation within the quality and outcomes framework and enhanced services in defined areas of multimorbidity 

Research & Development
1.    To be responsible for shaping and participating in research and development within the INT service.  
2.    To encourage and co-ordinate clinical audit in medicines optimisation and multimorbidity within the workstream setting and collaborate with partners to publish the results 
3.    To develop initiatives in the delivery of medicines optimisation within the INT model of care and develop quality standards for clinical effectiveness.
4.    To develop working relationship and research links with academic units to promote collaboration in practice and research around medicines optimisation in multimorbidity.

Communications and Relationships
1.    To communicate clearly and sensitively about patient medicines management issues both internal and external to the Trust and in the PCN setting.
2.    To communicate and collaborate with the multidisciplinary healthcare team including doctors, nurses, pharmacists and social care professionals on a daily basis to address the complex needs of patients with multimorbidity. 
3.    To communicate complex and sensitive medication/ health carer elated issues to patients and relatives - including history taking, medication review and counselling, and overcoming barriers to understanding and communication such as language, hearing, visual or cognitive difficulties.  Tact and persuasive skills are required when negotiating with patients to improve adherence with medication/ advice, with empathy and re-assurance necessary to address patient concerns.  Communication may be either verbal in the form of face-to-face contact, over the telephone or in written form.
4.    To work closely with key leads of other services within primary care to develop robust referral pathways that support an improved outcomes for patients.
5.    To act as a link between primary and secondary care, facilitating smoother transitions for patients and promoting integrated care pathways.