General Practitioner - Hospital @ Home

South Tees Hospitals NHS Foundation Trust; Middlesbrough; On-site; GBP 70,000 - 90,000; Full time

Job summary

A leading healthcare provider in Middlesbrough seeks a lead decision maker to enhance their 'Hospital@Home' service. This role involves collaborating with multidisciplinary teams to provide patient-centered care, focusing on frailty management and proactive healthcare strategies. The successful candidate will play a vital role in delivering high-quality care at home, ensuring continuity and improving service delivery for vulnerable patients.

Qualifications

• Providing clinical, educational, and strategic support to the team.
• Collaborating with multidisciplinary teams to manage frailty.

Responsibilities

• Developing networks with key stakeholders.
• Conducting patient visits and ensuring continuity of care.

Skills

Clinical Decision-Making

Mentorship

Collaboration

Job description

We wish to appeal to GPs with a desire to be involved in developing home-delivered, patient-centred care, who strive to make a difference and influence future services.

The lead decision maker post holder will collaborate with our Lead GP and multidisciplinary team (MDT) to expand the ‘Hospital@Home’ service, a frailty virtual ward serving patients in Middlesbrough, Redcar and Cleveland, and partnering with North Tees for patients in Stockton and Hartlepool, integrating with the wider health and social care system.

Hospital@Home is a patient-centred care model emphasizing shared decision-making. An ongoing program aims to extend to more clinical pathways, allowing more patients to be cared for at home.

Main duties of the role

The Core Functions Of This Post Are

• Providing clinical, educational, and strategic support to the team, including clinical skills development and tutorials.
• Collaborating with Consultants and GPs in Older Person’s Medicine to establish an integrated frailty management system.
• Partnering with leadership teams for Community Nursing and Therapies to develop a reactive team responding to frailty crises, preventing unnecessary hospital admissions.
• Working with integrated neighbourhood teams, including primary care networks, to develop a proactive team preventing frailty crises.
• Facilitating and supporting early discharge for inpatients where appropriate.
• Contributing to the development of proactive care services.
• Providing senior clinical decision-making support to the team.
• Developing networks with key stakeholders.
• Offering pastoral support, mentorship, and educational training in frailty management to healthcare staff.
• Participating in daily ward/board rounds.
• Ensuring continuity of care with the same doctor for a run of about three days, with proper handovers for complex cases and out-of-hours staff.
• Discussing cases with visiting clinical staff.
• Conducting patient visits.

Our ambition is to become the preferred place for acutely ill, frail patients, with increased access to diagnostics and home interventions, fostering a collaborative, integrated approach to community healthcare rather than static bed-based care. We are also developing a proactive care strategy, with these post holders playing a key role, initially focusing on providing proactive care to the most complex and vulnerable patients to reduce avoidable health exacerbations and enhance care quality for older adults.

These senior clinicians will work within an MDT to deliver safe, high-quality care at patients’ homes, ensuring continuity and ongoing service improvement.

For further details or informal visits, contact:
Name: Dr Paul Williams
Job title: Clinical Director for Tees Community Service
Email: [e-mail]