Frailty General Practitioner

NHS Jobs; Godstone; Hybrid; GBP 12,000 - 15,000; Full time

Benefits offered by this job

NHS pension

27 days annual leave plus holidays

Employee Assistance Programme

Training and development opportunities

On-site parking

Job summary

South Tandridge Primary Care Network (PCN) seeks a Frailty General Practitioner to lead a frailty hub across multiple practices. You will triage frail patients, develop care plans, and work with a multidisciplinary team to prevent hospital admissions.

Role involves home visits, case oversight, and collaboration with Community Matrons, District Nurses, and GP Partners to improve patient care and outcomes within a mature PCN collaboration.

Qualifications

• Excellent communication skills (written and verbal).
• Strong IT skills and proficiency with MS Office.
• Experience or willingness to undertake clinical supervision/education.
• Knowledge of GP clinical systems EMIS and/or SystmOne.

Responsibilities

• Proactively triage and manage frail patients referred to the PCN frailty pathway.
• Lead MDT discussions and coordinate with Community Matrons, District Nurses and other services.
• Develop care plans for frail patients at risk of hospital admission.
• Provide clinical leadership to the frailty hub team and medical leadership to the wider community team.
• Support home visits and visits to care homes as appropriate.

Skills

Excellent communication

IT skills

MS Office

EMIS/SystmOne

Clinical supervision/education (desire

Education

Good standard of education

Tools

MS Office

EMIS

SystmOne

Job description

Salary: £11,500 per session per annum (employed) or up to £15,000 per session per annum if self-employed; Up to 5sessions per week

Contract Duration: Permanent or self-employed

Job Location: Practice sites across SouthTandridge PCN (Oxted Medical Practice, Pond Tail Surgery and Lingfield Surgery)with regular home visiting to frailty patients

In this role, a successful applicant will manage the PCNclinical frailty pathway (Hub) that all practices within this PCN can referinto. The post holder will provide a well-triaged frailty service and offercare in patients' homes, providing a high-quality patient experience and acollaborative way of working across the system to reduce unplanned admissions to hospital. The Frailty General Practitioner will beresponsible for providing clinical leadership to the frailty hub team andmedical leadership to the wider community team of Community Matrons, DistrictNurses, Pharmacists, etc. The PCN has worked together over several years and istherefore mature in its collaboration with member practices as well as externalprovider organisations. Our team of experienced clinical leads & GP Partners will provide regular supervision.

Main duties of the job

As a Frailty General Practitioner, you will be responsible for proactive triage and management of the PCNs frail patients who have been referred.

These referrals will come from a range of sources, including those proactively identified in-house. Management of this cohort includes developing care plans for patients at risk of hospital admission and using your clinical skills to diagnose and treat patients accordingly in order to improve their care. This will involve a holistic MDT approach to patient care, liaising with other professionals responsible for the patients care, referring to other teams as necessary, as well as liaising with secondary care, community care, social care, mental health services and other local providers.

About us

South Tandridge Primary Care Network (PCN) is a partnership of local GP surgeries working together to help people live healthier lives. The PCN is made up of Oxted Medical Practice, Pond Tail Surgery and Lingfield Surgery,with a population of approximately 35K. The PCN has worked together over several years and is therefore mature in its approach to collaboration with member practices and external providers, working alongside staff, patients, their families and carers, and the public to provide high-quality healthcare close to home.

You will also be supported by the wider DHC Federation and network of frailty GPs across our member PCNs. DHC is a supportive, local GP Federation which works hard to prioritise the healthcare needs of the community, as well as the well-being of its staff.

• Membership of the NHS pension scheme
• 27 days annual leave plus bank holidays, increasing with length of service
• Access to an Employee Assistance Programme
• Opportunities for training, development and career progression
• Some of our sites have free on-site parking subject to availability
• We aim to be an employer of choice and conduct annual staff satisfaction surveys

DHC actively encourage and promotes diversity, ensures all voices are heard and included and is committed to equal opportunities for all.

Job responsibilities

JOBSUMMARY

South Tandridge Primary Care Network (PCN) ismade up of the following Practices: Oxted Medical Practice, Pond TailSurgery and Lingfield Surgery,with a population of approximately 35K. The PCN hasworked together over several years and is therefore mature in its collaborationwith member practices as well as external provider organisations.

In this role, a successful applicant will managethe PCN clinical frailty pathway (Hub) that all practices within this PCN canrefer into. The aim is to offer care in the patients home in order to reduce unplannedadmissions and improve patient care. The Frailty General Practitioner will beresponsible for providing clinical leadership to the frailty hub team andproviding medical leadership to the wider community team of Community Matrons,District Nurses, Pharmacists, etc.

It is therefore desirable that you shouldalso have experience of or qualifications in clinical supervision/education,but not essential as training can be given. Populations are changing, andpatients are living longer with complex care needs. Having a frailty servicethat is well triaged aims to create a better patient experience, a better wayof working collaboratively and a reduction in unplanned admissions to hospital.

This service will be available up to 5sessions per week, with the expectation that coverage will be across theworking week, but flexible requests will be considered. Improved home visiting at scale will alsopotentially reduce pressure on A&E attendances, with the role of theFrailty General Practitioner providing oversight and clinical care to a cohortof patients as identified by the individual practices within the PCN. This rolewill include seeing patients in their own homes as well as visits to care homeswhere appropriate.

The Frailty General Practitioner will beresponsible for developing a care plan for frail patients at risk of hospitaladmission, using their clinical skills to diagnose and treat patientsaccordingly. This will involve liaising with other professionals responsiblefor the patients care, referring to other teams as necessary, as well asliaising with secondary care, community care, social care, mental healthservices and other local providers.

DUTIESAND RESPONSIBILITIES OF THE POST

The following arethe core responsibilities of the Frailty General Practitioner. There may be, onoccasion, a requirement to carry out other tasks; dependent upon factors suchas workload and staffing levels:

• Effective triageof referred and proactively identified patients to provide highly effectivemedical care to the entitled population in a timely fashion
• Proactivelymanaging the care of frail people alongside the Community Matron
• Genericprescribing adhering to local and national guidance
• Effectivemanagement of long-term conditions
• Processing ofadministration in a timely manner, including referrals, repeat prescriptionrequests and other associated administrative tasks
• Undertaketelephone triage and prioritise home visits accordingly
• Maintain accurateclinical records in conjunction with good practice, policy and guidance
• Workingcollaboratively across the PCN with all practices and partner organisations,and agencies
• Lead discussionabout patients at both PCN-level MDTs and at Practice-level MDTs
• Adhere to bestpractice recommended through clinical guidelines and the audit process
• Contribute to thesuccessful implementation of continuous improvement and quality initiativeswith the Practices and PCN
• Contributeeffectively to the development and maintenance of the PCN, including clinicalgovernance, training, financial management and HR
• Commit toself-learning and continuing professional development
• Support thepartners in achieving the strategic aims of the PCN
• Review and adhereto Practice/ PCN protocols and policies at all times
• Encourage collaborative working, liaising with allstaff regularly, promoting a culture of continuous improvement at all times

ORGANISATIONALPOSITION

The Frailty GP will report to the PCNClinical Director and Service Manager.

KEYPRINCIPLES OF THE FRAILTY GENERAL PRACTITIONER ROLE

• Proactive management of the frail population and people at the end oftheir life (65yrs+)
• Identification of the people most at risk of deterioration/hospitaladmission
• A multi-disciplinary team (MDT) approach to provide holistic care
• A defined caseload of people who have:
• An in-depth frailty assessments
• Structured medication reviews & falls assessments
• Quality conversations about end-of-life care
• Planning for when care needs change
• A personalised care plan agreed and enacted
• A key point of contact
• Proactive intervention to avoid hospital admission - linking with thereactive community service

INDIVIDUALRESPONSIBILITIES

• Adhere to DHC and GP Practicespolicies and procedures and any other relevant legislation
• Ensure mandatory training is upto date at all times
• Participate inregular supervision sessions and appraisals with yourline manager. Attend training and development activities as identifiedand participate in meetings as required
• Maintainadministration systems and workspaces in a clean and tidy fashion
• Maintain a goodworking knowledge of Health and Safety procedures and fire precautions, andoperate the correct procedures and participate in policy development and datacollection where appropriate
• Work flexibly tomeet the needs of patients
• Contribute to ongoing/newprojects as required
• To undertake any other duties appropriate tothe grade and purpose of the job as may be agreed by the post holder

WORKSETTING AND REVIEW

• The post holder will workautonomously to an agreed set of KPIs, targets and objectives.
• They will manage their own timeand case load, providing regular updates/progress reports to their line managerand to the GP practices they are based in.
• Participate in DHCs appraisaland review system.

This job descriptionrepresents an outline of the responsibilities of the post and is not intendedto be an exhaustive list of duties or tasks. It will change and develop in line with organisational needs and may beamended following agreement with the post-holder.

Person Specification

Other requirements

• Disclosure and barring service check.
• Willing and able to travel to other sites & locations to attend meetings and training events.

Skills

• Excellent communication skills (written and oral), including the ability to listen.
• Strong and confident IT skills, including MS Office and databases.
• Excellent administrative skills, working under own initiative at times.
• Effective time management skills, often in a fast-paced environment.
• Proven problem-solving and analytical skills.
• Ability to adapt to changing situations and changing needs of the service.
• Excellent patient care skills.
• Motivated to achieve good outcomes for patients.
• Able to follow policies and procedures effectively.
• Able to maintain confidentiality at all times.
• Knowledge of GP clinical systems EMIS and/or TPP SystmOne.

Personal Qualities

• Polite & confident, remaining calm under pressure.
• Caring, sensitive and empathetic sensitive to patients' life stages, concerns and problems.
• Self-motivated, reliable and dedicated.
• Excellent interpersonal skills.
• Motivated and proactive.
• Ability to use initiative and judgement.
• High levels of integrity and reliability.
• Ability to work under pressure.
• Confident, assertive and resilient.

Experience

• Experience working with the general public in a similar role.
• Experience working in a health care setting.
• Experience working in the NHS/Primary Care General Practice setting.
• Understanding of community services and personalised care.
• Experience in managing a complex administrative role.
• Experience of leading MDT Meetings in Primary Care.

Qualifications

• Good standard of education with excellent literacy and numeracy skills

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.

£11,500 a sessionUp to 5 sessions per week