GP with a Special Interest in Frailty - complex frailty assessment

NHS; Rotherham; On-site; GBP 80,000 - 100,000; Full time

Job summary

A prominent National Health Service in the United Kingdom is seeking a GP with a Special Interest in Frailty to undertake complex frailty assessments across Rotherham Community Services. The role involves comprehensive patient reviews, coordination with various health professionals, and contributing to advancements in patient care for those facing advanced frailty. Candidates must have GMC registration and a postgraduate qualification in Geriatric Medicine. This position emphasizes collaboration within a multi-disciplinary team and aims to enhance patient outcomes.

Qualifications

• Full registration and a licence to practise with the GMC.
• Eligible to be included on the Specialist register.
• Evidence of appraisal/revalidation and ongoing CPD.

Responsibilities

• Conduct comprehensive reviews of primary and secondary care records.
• Identify patients using the Eclipse risk stratification tool.
• Engage in advance care planning including completion of ReSPECT documentation.

Skills

Strong clinical consultation skills (telephone / video)

Ability to work autonomously and collaboratively

IT proficiency, including electronic records

Experience managing undifferentiated presentations

Education

MBChB or equivalent primary medical qualification

Postgraduate qualification in Geriatric Medicine

Tools

Eclipse risk stratification tool

Electronic Patient Records (SystmOne, Meditech)

Job description

GP with a Special Interest in Frailty - complex frailty assessment

We have a fixed-term opportunity (12 months) for a GP with a Special Interest (GPwSI) to support an innovative Complex Frailty Assessment model across Rotherham Community Services. This follows initial pilot work commenced in early 2025.

The post focuses on risk stratification, comprehensive assessment, and coordination for people living with advanced frailty and/or those in the last year of life. Reviews will be undertaken remotely using primary and secondary care electronic records and the Eclipse risk stratification tool, with telephone-based patient/carer contact and potential for ongoing support if indicated. Each review will generate a Comprehensive Assessment to be shared with the patient/carer and relevant health and social care professionals.

The aim is to improve care for people with advanced frailty, including polypharmacy review, falls/continence/nutrition assessment, and Advance Care Planning (ACP) (including ReSPECT). Early outcomes have shown reduced UECC/hospital attendances and improvements in mortality and patient experience; this phase will consolidate delivery and evaluation. You will work closely with the Quality Improvement Team on data collection and future service development.

You will join a multi-professional team aligned with Community Physician, Hospital at Home, Community Matrons, District Nursing, Rapid Response, and partner services across Primary, Secondary, Social Care, and Mental Health.

Secretarial support is provided.

Main duties of the job

• Patient identification using the Eclipse risk stratification tool.
• Comprehensive review of primary and secondary care records (including recent investigations, UECC/hospital attendances, and admissions).
• Telephone-based reviews with the patient and/or carer - particularly in severe frailty or where the patient lacks capacity to participate.
• Focus on community-dwelling older people (including care home residents).
• Correspondence to primary/secondary care and social care (as appropriate) to align and/or rationalise ongoing medical review and support.
• Advance Care Planning, including completion of ReSPECT documentation.
• Polypharmacy review and medicines optimisation with support from medicines management.
• Liaison with Falls, Continence, Hospital at Home, Community Matrons, and Primary/Secondary Care clinicians.
• Data collection for quality improvement and service evaluation.

About us

The Rotherham NHS Foundation Trust (TRFT) is a combined acute and community Trust serving our local population of around 270,000 people. Our vision is to always act the right way and be proud to provide exceptional healthcare to the communities of Rotherham.

As a Trust we are on a journey to excellence and our people and culture are at the heart of everything we do for patients. In the latest NHS Staff Survey, we are the second most improved Trust in England for would you recommend the Trust as a place to work? and were one of the most improved for staff engagement overall.

But dont just take our word for it each year hundreds of colleagues receive nominations for our Excellence and Proud awards, showcasing our brilliant people and recognising their achievements. Our people make a difference to the lives of patients every day and we are proud of the improvements we are making.

All of our 5,100 colleagues are key to our improvement journey and we are continuing to improve our services by upholding the Trusts values of Ambitious, Caring and Together. If you are passionate about making a difference, then please apply to join us on our journey to excellence.

Job responsibilities

The Department

The Rotherham NHS Foundation Trust is a combined acute and community provider serving Rotherham and South Yorkshire. We deliver care at home, in the community and in hospital with an innovative, forward thinking approach. Over 4,500 staff work across Rotherham Hospital and multiple community settings. We are committed to diversity and inclusion, encourage flexible working and welcomes applications from all communities.

The Post

We have a fixed term opportunity (12 months) for a GP with a Special Interest (GPwSI) in Geriatrics to support an innovative Complex Frailty Assessment model across Rotherham Community Services. This follows initial pilot work commenced in early 2025.

General

• In conjunction with Consultant and Senior colleagues, to provide a service in Complex Frailty Assessment.
• Assessments will be completed using online risk stratification tools (Eclipse) and Electronic Patient Records SystmOne, Meditech, Sepia and/or The Yorkshire and Humber Care Record.
• Assessments will be based on combined electronic frailty index with other determinants of severe frailty e.g. dementia, falls, sarcopenia, delirium.
• Assessments will involve phone calls with either patients and or their carers depending on mental capacity and ability.
• Letters will be generated (supported by Copilot, AI) and sent to the patient or carers, GP as well as relevant multidisciplinary partners e.g. therapy, nursing, continence, social work, mental health, etc.
• Your work will be integrated with the community physician team in Rotherham.
• Assessments will be based on the principles of Comprehensive Geriatric Assessments.
• Assessments will include discussions relating to Emergency Care Planning and Resuscitation (ReSPECT).
• Training and support will be available to doctors.
• Administration support will be available.
• If you do not have access to a laptop, one will be provided.
• A phone if required will be provided.

Person Specification

Qualifications

• Full registration and a licence to practise with the GMC.
• Please confirm your GMC Registration number
• Eligible to be included on the Specialist register - CCT expected within 6 months of interview date
• Or
• Evidence of CESR application submission and within 6 months of obtaining Specialist Registration via CESR.
• MBChB or equivalent primary medical qualification.
• Listed on the NHS England Medical Performers List and/or GMC Specialist Register (as appropriate to role).
• Evidence of appraisal/revalidation and ongoing CPD.
• Postgraduate qualification in Geriatric Medicine (e.g., MSc) or other relevant higher qualification.

Clinical Skills

• Strong clinical consultation skills (telephone / video and in person home visits in defined circumstances)
• Ability to rapidly review, assimilate and document clinical information
• Experience managing undifferentiated presentations and remote patient management
• Knowledge of developing clinical quality assurance and evidence based practice
• IT proficiency, including electronic records, remote consultation platforms and data handling
• Knowledge of relevant NICE, local and national pathways / guidelines
• Ability to work autonomously and collaboratively, co-ordinating programmes of care
• Ability to maintain and monitor high standards of care and safety

Research and Audit

• Evidence of audit and the implementation of change following the audit
• Evidence of audit and/or quality improvement activities
• Relevant research published in peer review journal

Management Skills

• Demonstrate effective team working skills.
• Time management and organisational ability. An example may be they have developed and run training programmes.
• Proven knowledge of systems and process of NHS or equivalent.
• Sense of understanding and commitment to corporate responsibility.
• Commitment to and understanding of their responsibility to the organisation.
• Excellent communication with people of all backgrounds.
• Strong commitment to high quality clinical services and team working.
• Resilient and able to work under pressure and at pace when required.

Education and Teaching

• Able to provide learning and development to other professionals (e.g. case based teaching, supervision and mentoring)

Experience

• Experience working as a General Practitioner
• Case management experience in older people / frailty or complex multi-morbidity
• Willingness to mentor and support other clinicians
• Evidence of continuing professional development
• Experience as a GP lead for Older people, Proactive Care or Care Homes
• Recognised roles in clinical education
• Awareness of primary and secondary care pathways relevant to frailty / older people

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.