Specialist Dietitian for Diabetes Neighbourhood Health ProgrammeNHS
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.
Job description
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.
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.