NMUH is part of the North Central London Integrated Care System (ICS), working in partnership with NHS trusts, ICB, local authorities, and VCSE organisations to improve patient experience and outcomes across interfaces. NMUH is now part of Royal free London Trust and is under the process of integration according to the clinical outcome model.
The post holder will provide senior clinical input and leadership within the Transfer of Care (ToC) Hub, supporting safe, timely and person-centred discharge in line with Home First, Discharge to Assess (D2A) pathways and the Criteria to Reside framework. Working under the direction of senior operational leads, the role will coordinate multidisciplinary and multi-agency discharge planning, reduce delayed transfers of care and improve patient flow
Provide senior clinical leadership for complex discharge planning within the Transfer of Care Hub.
Apply Home First, Discharge to Assess (D2A) pathways and Criteria to Reside consistently across wards.
Lead and support multidisciplinary discharge board rounds and escalation processes.
Coordinate complex discharges with Adult Social Care, CHC, housing and community services.
Ensure safe, person-centred discharge plans that meet safeguarding and infection control requirements.
Act as the senior point of contact for complex patient and family discussions.
Supervise and support Transfer of Care Hub staff and provide expert advice to ward teams.
Monitor discharge performance data and contribute to reducing delays and length of stay.
Escalate risks and capacity pressures impacting patient flow and site safety.
Contribute to service improvement, audits and implementation of discharge and interface standards.
Working for the Royal Free London NHS Foundation Trust offers the opportunity to be part of a large, integrated organisation committed to delivering safe, high-quality, patient-centred care across hospital and community settings. As part of the Royal Free group, North Middlesex University Hospital works within the North Central London Integrated Care System, promoting collaborative working across health, social care, and voluntary sector partners. In this role, staff are supported to demonstrate the Trust's values, contribute to service improvement, and play a key role in improving patient flow, reducing delays, and enhancing patient experience through effective discharge planning and integrated working.
JOB SUMMARY:
The post holder will provide senior clinical input and leadership within the Transfer of Care (ToC) Hub, supporting safe, timely and person-centred discharge in line with Home First, Discharge to Assess (D2A) pathways and the Criteria to Reside framework. Working under the direction of senior operational leads, the role will coordinate multidisciplinary and multi-agency discharge planning, reduce delayed transfers of care and improve patient flow.
Organisational Context
NMUH is part of the North Central London Integrated Care System (ICS), working in partnership with NHS trusts, ICB, local authorities, and VCSE organisations to improve patient experience and outcomes across interfaces. NMUH is now part of Royal free London Trust and is under the process of integration according to the clinical outcome model.
Key Relationships
* Internal: Wards and specialties, Site Operations & Flow, Pharmacy, Therapies (PT/OT), Frailty/Acute Medicine, Safeguarding, Community Nursing liaison, Discharge Lounge, Transport, Information/Business Intelligence.
* External: NCL ICB, Local Authority Adult Social Care, Housing and Homelessness teams, Community/Voluntary sector partners, Continuing Healthcare (CHC), Care Home providers, ICE hub for P2 units
Date of the JD review:
MAIN DUTIES AND RESPONSIBILITIES
1. CLINICAL RESPONSIBILITIES
2. 1.1 Act as a senior clinical resource for complex discharge planning and problem solving.
3. 1.2 Apply D2A and all pathways and Criteria to Reside consistently across wards.
4. 1.3 Ensure discharge plans are clinically safe, personalized and compliant with national guidance.
5. 1.4 Escalate risks and delays appropriately to senior operational leads
6. RESPONSIBILITY FOR PATIENTS
7. 2.1 Support and lead MDT board rounds focused on Estimated Date of Discharge (EDD).
8. 2.2 Ensure patients and families receive clear and timely information about discharge plans.
9. 2.3 Ensure safeguarding, homeless discharge and infection control requirements are met.
10. 2.4 Promote person-centred decision making and reasonable adjustments
11. 2.5 Lead and Support resolution of complex patient and family concerns.
12. RESPONSIBILITY FOR POLICY AND SERVICE DEVELOPMENT
13. 3.1 Support implementation of Trust and NCL ICS discharge policies.
14. 3.2 Contribute to audits of discharge documentation, safety netting and follow-up.
15. 3.3 Identify opportunities for pathway improvement and escalate recommendation
16. 3.4 Contribute to service improvement initiatives within the ToC Hub
17. 3.5 Support consistent application of interface standards
18. RESPONSIBILITY FOR FINANCIAL AND PHYSICAL RESOURCES
19. 4.1 Support efficient use of inpatient beds through timely discharge coordination.
20. 4.2 Facilitate effective use of the Discharge Lounge and transport services
21. 4.3 Support appropriate utilisation of commissioned discharge pathways
22. 4.4 Escalate capacity issues impacting patient flow
23. 4.5 Contribute to reducing delayed transfers of care
24. RESPONSIBILITY FOR LEADING AND MANAGING
25. 5.1 Provide day-to-day leadership and supervision of ToC Hub staff as required.
26. 5.2 Support training and coaching of ward teams on D2A and interface standards
27. 5.3 Work collaboratively with external partners including Adult Social Care and CHC.
28. 5.4 Support staff induction and development
29. 5.5 Act as a role model for professional practice and Trust values
30. RESPONSIBILITY FOR INFORMATION RESOURCES
31. 6.1 Maintain accurate discharge data including EDD and Discharge Ready Dates.
32. 6.2 Contribute to ToC dashboards including DTOC and MOFD reporting
33. 6.3 Ensure accurate and timely documentation.
34. 6.4 Support data quality improvement
35. 6.5 Use data to inform escalation and improvement
36. RESPONSIBILITY FOR RESEARCH AND DEVELOPMENT
37. 7.1 Participate in service evaluation, quality improvement and learning activities.
38. 7.2 Support learning from incidents and feedback.
39. 7.3 Promote evidence-based discharge practice
40. 7.4 Maintain continuing professional development.
41. 7.5 Share learning within the team
GENERAL RESPONSIBILITIES
Infection Control
Infection control is everyone's responsibility. All staff, both clinical and non-clinical, are required to adhere to the Trust's Infection Prevention and Control policies and procedures and the Health Act Code of Practice for the prevention and control healthcare associated infections and make every effort to maintain high standards of infection control at all times thereby reducing the risk of Healthcare Associated infections.
It is the duty of every member of staff to take personal responsibility for the prevention and control of infection, as laid down in the Trust's policies and procedures which reflect the statutory requirements of the Hygiene Code.
* To work in close collaboration with the Infection Control Team.
* To ensure that monitoring of clinical practice is undertaken at the agreed frequency.
* To ensure that the ward environments are cleaned and maintained to the highest standards; ensuring that shortfalls are rectified or escalate as necessary.
* To ensure that all relevant monitoring data and issues are provided to the Directorate's Governance structures.
* To ensure that all staff are released to attend infection-related educational sessions and staff with specialist roles, e.g. link practitioners, are released to undertake their duties.
Health and Safety at Work
The post holder is required to:
* Take reasonable care for the health and safety of himself/herself and other people who may be affected by their actions or omissions at work.
* Co-operate with the employer in ensuring that all statutory and other requirements are complied with.
Confidentiality & Data Protection
The post holder has a responsibility to comply with the Data Protection Act and General Data Protection Regulation 2018 and maintain confidentiality of staff, patients and Trust business.
If you are required to process information, you should do so in a fair and lawful way, ensuring accuracy is maintained. You should hold information only for the specific registered purpose and not use or disclose it in any way incompatible with such a purpose.
You should disclose information only to authorised persons or organisations as instructed. Breaches of confidentiality in relation to information will result in disciplinary action, which may include dismissal. Employees are expected to comply with all Trust policies and procedures and to work in accordance of the Data Protection Act and General Data Protection Regulation 2018. For those posts where there is management or supervision of other staff it is the responsibility of that employee to ensure that their staff receive appropriate training (e.g. HISS induction, organising refresher sessions for staff when necessary.)
Conflict of Interest
The Trust is responsible for ensuring that the services for patients in its care meet the highest standards. Equally, it is responsible for ensuring that staff do not abuse their official position, to gain or benefit themselves, their family or friends.
Equality and Diversity
The Trust values equality and diversity in employment and in the services we provide. It is committed to promoting equality and diversity in employment and will keep under review our policies and procedures to ensure that the job-related needs of all staff working in the Trust are recognized. The Trust aims to ensure that all job applicants, employees or clients are treated fairly and valued equally regardless of sex, marital status, domestic circumstances, age, race, colour, disablement, ethnic or national origin, social background or employment status, sexual orientation, religion, beliefs, HIV status, gender reassignment, political affiliation or trade union membership. Selection for training and development and promotion will be based on the individual's ability to meet the requirements for the job.
You are responsible for ensuring that the Trust's policies, procedures and obligation in respect of promoting equality and diversity are adhered to in relation to both staff and services.
Vulnerable Groups
* To carry out responsibilities in such a way as to minimize risk of harm to children, young people and vulnerable adults and to promote their welfare in accordance with the Children Act 2004, Working Together to Safeguard Children and No Secrets guidance (DH 2000).
* To demonstrate an understanding of and adhere to the trust's child protection policies.
Smoke Free
The Trust implements a Smoke Free policy that applies to all staff. Staff are not allowed to smoke while wearing a recognizable Trust uniform or visible trust identification badge and not allowed to smoke anywhere on hospital grounds. Staff are not allowed to take additional breaks to smoke. They may smoke during designated breaks but only out of uniform and off site. Staff contravening this policy may be subject to disciplinary procedures .
Standards of dress
All staff are expected to abide by the Trust's guidance on standards of dress.
This job description outlines the current main responsibilities of the post. However, the duties of the post may change and develop over time and may therefore be amended in consultation with the post holder.