Salaried Frailty General Practitioner

NHS Jobs; Launceston; Vor Ort; GBP 60.000 - 80.000; Vollzeit

Zusammenfassung

Cornwall Partnership Foundation NHS Trust is seeking a clinician to lead proactive frailty care within a multidisciplinary team at Launceston Medical Centre. The role emphasizes medical input, holistic assessment and risk-stratified reviews to support frailty pathways and person-centred care.

The post holder will contribute to structured medication reviews, care planning and escalation decisions, including home visits when GP assessment is clinically necessary, while working with social

Aufgaben

• Review clinical records of patients identified through agreed IT, population-health or risk-stratification processes to assess suitability for proactive frailty intervention.
• Undertake face-to-face or telephone reviews where required, including medication review, falls assessment, long-term condition review and assessment of complex multimorbidity.
• Provide medical review for selected same-day or more complex frailty presentations where a medical problem has been identified and the patient’s usual GP is not available to provide continuity.
• Support medical supervision, advice and governance within the multidisciplinary team and contribute to holistic assessment and personalised care planning.
• Undertake and support structured medication review and appropriate deprescribing, balancing clinical guidance, treatment burden, safety and quality of life.
• Contribute to advance care planning, treatment escalation planning and end-of-life discussions where medical input is required.
• Undertake home visits where GP assessment is clinically necessary, while coordinating with the wider multidisciplinary team and community services.
• Maintain accurate contemporaneous clinical records and complete referrals, prescribing, results and other administration arising directly from the post holder’s clinical work.
• Recognise safeguarding, mental capacity issues and other risks associated with frailty and vulnerability.
• Attend regular multidisciplinary meetings with daily/weekly/monthly MDT structures.

Jobbeschreibung

The clinical element of the role will focus predominantly on proactive frailty care and medical input where GP expertise adds value within the wider multidisciplinary model. Review the clinical records of patients identified through agreed IT, population-health or risk-stratification processes to assess suitability for proactive frailty intervention. Undertake face-to-face or telephone reviews where required. These will mainly be proactive appointments agreed through the co-design of the test and learn and are likely to include medication review, falls assessment, long-term condition review and assessment of complex multimorbidity. Provide medical review for selected same-day or more complex frailty presentations where a medical problem has been identified and the patients usual GP is not available to provide continuity. Routine urgent and first-contact care will continue to be managed through the Practices established access and duty arrangements. Requests from the wider INT for medical assessment or appointments would ordinarily enter through these usual routes. Provide medical supervision, advice and support to members of the Launceston Medical Centre team involved in the Frailty Test and Learn, for example the social prescriber, frailty nurse and care coordinator, within appropriate professional and governance arrangements. Provide medical advice to the wider INT team where appropriate, supporting shared clinical decision-making and escalation. Contribute medical expertise to holistic assessment, personalised care planning and comprehensive geriatric assessment undertaken across the multidisciplinary team. Undertake and support structured medication review and appropriate deprescribing, balancing clinical guidance, treatment burden, safety, quality of life and patient priorities. Contribute to advance care planning, treatment escalation planning and end-of-life discussions where medical input is required. Undertake home visits where GP assessment is clinically necessary, while working closely with the wider multidisciplinary team and community services to avoid duplication of work. Maintain accurate contemporaneous clinical records and complete referrals, prescribing, results and other administration arising directly from the post holders clinical work within agreed timescales. Recognise and respond appropriately to safeguarding concerns, mental capacity issues, carer strain, self-neglect and other risks associated with frailty and vulnerability. MULTIDISCIPLINARY WORKING The post holder will attend regular multidisciplinary meetings as required. The anticipated structure is: Daily MDT focused on urgent care and admission avoidance. Weekly MDT focused on proactive care and patients within the Frailty Test and Learn project. Monthly MDT discussion of patients requiring input from the wider team, including specialist geriatric input where available. The exact frequency and format of MDT working may change as the project develops. CLINICAL LEADERSHIP The post holder will act as Frailty Lead GP within Launceston Medical Centre. Drawing on their experience of working with the wider INT, they will provide clinical advice, education and support to the Launceston Medical Centre team and help develop effective frailty pathways within the Practice and neighbourhood. INDICATIVE JOB PLAN The final job plan will be agreed with the successful applicant and may vary depending on the progress and evolution of the INT project. The initial anticipated four-session job plan is: 0.5 session MDT activity. 1.5 sessions project co-design, collaboration, pathway development and implementation. 2 clinical sessions face-to-face appointments and/or telephone reviews as required, predominantly proactive care, with some capacity potentially reserved for same-day or complex frailty patients requiring medical review. The balance between these elements will be reviewed as the test and learn develops, ensuring that the role remains aligned with the aims of the project and the needs of the wider INT. GENERAL RESPONSIBILITIES Work in accordance with Launceston Medical Centre policies and procedures and contribute to their review and development where relevant to the frailty service. Attend relevant internal and external clinical, multidisciplinary and service-development meetings, representing the Practice and contributing to the wider INT where required. Maintain relevant clinical knowledge and skills through continuing professional development and annual appraisal, including current evidence and guidance relating to frailty and complex care. Work within GMC standards of good medical practice and maintain positive, collaborative relationships across primary, community, secondary and social care.

Cornwall Partnership Foundation NHS Trust