Frailty General Practitioner

The Methodist Church in Britain; Rotherham, Limpsfield; On-site; GBP 85,000 - 110,000; Full time

Benefits offered by this job

NHS pension

27 days annual leave

On-site parking

Job summary

South Tandridge Primary Care Network is seeking a Frailty General Practitioner to cover frailty hub responsibilities and clinical leadership across a community team. The role involves home visits to frail patients and care homes, triaging referrals, and coordinating with secondary and social care services.

The post requires DBS clearance and willingness to travel between sites; you will provide proactive care plans and contribute to reducing unplanned hospital admissions in the network.

Qualifications

• Good standard of education with excellent literacy and numeracy.
• Experience working with the general public in a healthcare setting.
• Understanding of community services and personalised care.
• Experience managing a complex administrative role.

Responsibilities

• Triage referred and proactively identified frail patients through the PCN frailty hub.
• Develop care plans for frail patients at risk of hospital admission.
• Diagnose and treat patients in their homes and care homes; lead frailty hub and medical leadership to the team.
• Lead discussions about patients at PCN and practice MDT meetings; liaise with secondary care and social care.
• Carry out frailty assessments, medication reviews and falls assessments; manage long-term conditions.

Skills

Frailty care

Home visits

Clinical leadership

MDT leadership

Education

GP qualification

Tools

EMIS

SystmOne

Job description

Frailty General Practitioner post with South Tandridge Primary Care Network, covering Oxted Medical Practice, Pond Tail Surgery and Lingfield Surgery, run by DHC, a GP federation. The role manages the network's frailty hub, triaging referred patients and providing clinical leadership to a community team of matrons, district nurses and pharmacists. Much of the work is home visiting to frail patients and care homes, aiming to cut unplanned hospital admissions. A DBS check is required and travel between sites is expected.

What the job involves

• Triage referred and proactively identified frail patients through the PCN frailty hub
• Develop care plans for frail patients at risk of hospital admission
• Diagnose and treat patients in their own homes and care homes
• Provide clinical leadership to the frailty hub team and medical leadership to the wider community team
• Lead discussions about patients at PCN-level and practice-level MDT meetings
• Liaise with secondary care, community care, social care, mental health services and other local providers
• Carry out in-depth frailty assessments, structured medication reviews and falls assessments
• Hold end-of-life care conversations and plan for changing care needs
• Manage long-term conditions and prescribe generically in line with local and national guidance
• Take telephone triage and prioritise home visits
• Process referrals, repeat prescriptions and other administration in a timely manner
• Keep accurate clinical records in line with good practice and policy

Qualifications

• Good standard of education, with excellent literacy and numeracy

Experience

• Experience working with the general public in a similar role, and in a healthcare setting
• Experience in NHS or primary care GP settings
• Understanding of community services and personalised care
• Experience managing a complex administrative role

Skills & knowledge

• Excellent written and oral communication, including listening
• Strong IT skills, including MS Office and databases
• Excellent administrative skills and time management in a fast-paced setting
• Proven problem-solving and analytical skills
• Adapting to changing service needs, with excellent patient care skills
• Maintaining confidentiality and following policies and procedures

Checks & eligibility

• Disclosure and Barring Service check

Other

• Willing and able to travel between sites and locations for meetings and training
• Caring, empathetic and motivated to achieve good patient outcomes
• Calm, confident and resilient under pressure
• Self-motivated, reliable and proactive, with integrity and good judgement

Nice to have

• Knowledge of GP clinical systems EMIS and/or TPP SystmOne
• Experience of leading MDT meetings in primary care
• Experience of or qualifications in clinical supervision or education

What’s offered

• Competitive salaries
• Membership of the NHS pension scheme
• 27 days annual leave plus bank holidays, increasing with length of service
• Employee Assistance Programme
• Opportunities for training, development and career progression
• Free on-site parking at some sites, subject to availability