Complex Care GP

Somerset NHS Foundation Trust; Yeovil; On-site; GBP 65,000 - 90,000; Part time

Benefits offered by this job

Flexible working options

NHS pension scheme

Generous annual leave

Career development

Blue Light Card

Job summary

Somerset NHS Foundation Trust in Yeovil is recruiting a Complex Care GP to join the Yeovil Complex Integrated Care Team, helping shape integrated healthcare across Somerset. The role focuses on patients with multiple long‑term conditions, frailty, frequent hospital admissions and polypharmacy, delivering proactive, personalised care across primary, community and secondary care.

This permanent post offers 8 PAs per week, Monday to Friday 08:30‑16:30 with no on‑call commitment, and opportunities

Qualifications

• Experience in General Practice or General Medicine with elderly care competencies.
• GMC registration with license to practice on GP Performers list.
• Eligibility for Specialist register via CCT (within 6 months of interview).

Responsibilities

• Participate in multidisciplinary huddles within GP practices, providing specialist advice and supporting clinical decision‑making for patients with complex needs.
• Attend secondary care meetings to review patients identified by hospital teams.
• Support safe discharge of patients with highly complex needs from hospital into community settings.
• Contribute to hospital and community MDT meetings, safeguarding discussions and Best Interest meetings as required.
• Manage a caseload of patients with complex health needs, developing personalised care plans and Treatment Escalation Plans (TEPs).
• Undertake face‑to‑face consultations, extended assessments and home visits where clinically appropriate.
• Prescribe safely and effectively in accordance with national guidance and local formularies.
• Work with GP practices and MDTs to identify patients needing additional input and coordinated support.
• Maintain accurate patient records using clinical systems.
• Prioritise workload while maintaining professional accountability and delivering high‑quality care.
• Ensure oversight of an active caseload to promote continuity and safe outcomes.

Education

MBBS & MRCP. MRCGP or equivalent

Job description

Join Somerset Foundation Trust as a Complex Care GP in Yeovil

We are looking for an enthusiastic and motivated Complex Care GP to join the Yeovil Complex Integrated Care Team and help shape the future of integrated healthcare across Somerset.

This rewarding role focuses on supporting patients with the most complex healthcare needs, including multiple long-term conditions, frailty, frequent hospital admissions, psychological challenges and polypharmacy.

You will play a key role in delivering proactive, personalised care that improves outcomes and reduces health inequalities for some of our most vulnerable patients.

Working across primary, community and secondary care, you will help strengthen continuity of care and build effective partnerships with Primary Care Networks, neighbourhood teams and hospital services, ensuring patients receive seamless, coordinated support.

This is a permanent position, working 8 Programmed Activities (PAs) per week, Monday to Friday, 08:30 to 16:30, with no on-call commitment currently required.

If you are passionate about integrated care, multidisciplinary working and making a real difference to patients with complex needs, this is an excellent opportunity to join a forward-thinking team at the forefront of innovative healthcare delivery.

Main duties of the job

Participate in multidisciplinary "huddles" within GP practices, providing specialist advice and supporting clinical decision‑making for patients with complex needs.

Attend secondary care meetings to review patients identified by hospital teams.

Support the safe discharge of patients with highly complex needs from hospital into community settings.

Contribute to hospital and community multidisciplinary team (MDT) meetings, safeguarding discussions and Best Interest meetings as required.

Manage a caseload of patients with complex health needs, frailty and multiple long-term conditions, developing personalised care plans, disease‑specific management plans and Treatment Escalation Plans (TEPs).

Undertake face‑to‑face consultations, extended assessments and home visits where clinically appropriate.

Prescribe safely and effectively in accordance with national guidance, local formularies and best practice standards.

Work proactively with GP practices and multidisciplinary teams to identify patients who would benefit from additional clinical input and coordinated support.

Maintain accurate, timely and comprehensive patient records using appropriate clinical systems.

Prioritise and manage workload effectively while maintaining professional accountability and delivering high‑quality patient care.

Ensure effective oversight of an active caseload, promoting continuity, safety and excellent patient outcomes.

About us

At Somerset NHS Foundation Trust, we're committed to supporting our employees with a range of benefits designed to enhance your professional and personal life. We offer:

• Flexible working options to help you balance work and life
• NHS pension scheme for long‑term financial security
• Generous annual leave allowance to recharge and relax
• A strong focus on career development to help you grow and achieve your potential

Additionally, you'll gain access to our Blue Light Card, unlocking exclusive discounts on shopping, dining, and leisure activities, as well as NHS‑specific perks to support you both inside and outside of work.

We are proud to foster a diverse, skilled, and inclusive workforce, and we encourage applications from all backgrounds.

Why Somerset? Somerset offers the perfect blend of idyllic countryside, outstanding areas of natural beauty, and breathtaking coastlines, with vibrant cities like Bristol, Bath, and Exeter just a short drive away - and only two hours to London.

The region is home to excellent educational facilities, and with affordable housing compared to other parts of the country, it's a great place to build both your career and your future.

Somerset truly has it all - the peaceful countryside and cosmopolitan city life, with something for everyone to enjoy.

Job responsibilities

About the Service

The Complex Care Service operates across South Somerset and consists of four multidisciplinary teams working in partnership with GP practices across local Primary Care Networks. Each team includes a GP, Complex Care Nurse or Advanced Clinical Practitioner, and a Key Worker, delivering proactive, integrated care within neighbourhood services.

Working closely with District Nursing, Older Persons Mental Health Services, Community Rehabilitation, Hospital@Home, Rapid Response teams and Adult Social Care, the service supports patients with the most complex health and care needs.

The team provides:

• Comprehensive Geriatric Assessments (CGA), exploring physical, psychological, functional, social and environmental factors affecting health and wellbeing.
• Holistic, personalised care and support planning.
• Structured Medication Reviews.
• Development of disease-specific escalation plans, Treatment Escalation Plans (TEPs) and Resuscitation Orders where appropriate.
• Coordination of care across primary, community, secondary and social care services.
• Partnership working with voluntary and community organisations to strengthen local support networks and improve patient outcomes.

The service complements, rather than replaces, the care provided by a patient's registered GP. The length of our involvement is determined by individual patient needs and the complexity of coordination required across services.

At Somerset Foundation Trust, we remain committed to our five leadership pillars, ensuring that even during periods of pressure we continue to deliver compassionate, collaborative and high‑quality care. By joining our organisation, you will be expected to embody these values and contribute to delivering outstanding care for our patients and communities.

Person Specification

Qualifications

• MBBS & MRCP. MRCGP or equivalent
• Full GMC registration with a licence to practice on GP Performers list
• Entry on the GMC Specialist register via
• CCT ( Proposed CCT date must be within 6 months of the interview date)
• An Appropriate Higher General Medicine Qualification

Experience

• Competencies in General Practice or General Medicine and Elderly care at consultant level.
• Experience with a special interest in Complex care that will compliment the skill mix in the existing team in the service.

Additional Criteria

• Undertake travel across the locality to deliver care in a range of community settings, including patients' homes, GP practices, care homes, and other healthcare environments.
• Be able to safely and independently access a variety of properties and locations, some of which may present challenges relating to mobility, access, or the physical environment.
• Possess the physical capability to undertake community visits, including carrying clinical equipment and navigating stairs, uneven surfaces, and other environmental obstacles where required.
• Hold a valid driving licence and have access to a suitable vehicle to fulfil the travel requirements of the role, where applicable.
• Maintain the ability to work effectively in a range of clinical and non‑clinical settings whilst ensuring personal safety and adherence to lone working policies and procedures.

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.