GP with an Interest in Frailty

South Downs Health and Care Ltd (SDHC); Eastbourne; On-site; GBP 75,000 - 110,000; Full time

Benefits offered by this job

NHS Pension

25 days holiday + bank holidays

Employee Assistance Programme

CycleScheme

Events (seasonal)

Hillbrow Health and Wellbeing Centre

Job summary

South Downs Health and Care (SDHC) invites a Salaried GP with an Interest in Frailty to join the Integrated Neighbourhood Team in Eastbourne. You will deliver senior clinical care for frailty, multimorbidity, and complex care needs within a supportive MDT, focusing on proactive and personalised care in the community.

The role emphasises CGA, structured medication reviews, advanced care planning, and leadership to colleagues across primary and community services.

Qualifications

• At least 2 years post-CCT in UK general practice; managing complex older patients and multimorbidity
• Frailty, care home, community or intermediate care roles; MDT leadership; clinical supervision or education

Responsibilities

• Undertake Comprehensive Geriatric Assessments (CGA) and structured medication reviews.
• Develop personalised care plans and advance care plans; treatment escalation plans.
• Lead MDT meetings and collaborate across primary care, community and hospital teams.
• Provide senior clinical leadership and supervision to Frailty Practitioners and colleagues.
• Support safe hospital discharge and timely follow-up after admissions

Skills

Geriatric assessment

Medication review

Advance care planning

Clinical governance

MDT leadership

Education

Diploma in Geriatric Medicine

Postgraduate qualification in frailty or palliative care

Tools

SystmOne

EMIS

Job description

South Downs Health and Care (SDHC) is seeking a compassionate, enthusiastic and motivated Salaried GP with an Interest in Frailty to join our Integrated Neighbourhood Team (INT) in Eastbourne.

This is an exciting opportunity to make a meaningful difference to the lives of older people and those living with frailty, helping them remain healthy, independent and supported within their communities.

Working as part of a supportive multidisciplinary team, you will provide expert clinical care to patients with frailty, multiple long-term conditions and complex health and social care needs. You will play a key role in delivering proactive, personalised care, preventing avoidable hospital admissions and improving patient outcomes.

You will work closely with Frailty Practitioners, community services, local GP practices and wider health and social care partners to ensure coordinated, patient-centred care.

We are looking for a GP who is passionate about older people's healthcare, enjoys collaborative working and is keen to contribute to the development of innovative community-based frailty services.

Main duties of the job

As a Salaried GP with an Interest in Frailty, you will provide senior clinical expertise within the Integrated Neighbourhood Team, supporting patients with frailty, multimorbidity and complex care needs.

Your main responsibilities will include:

Undertaking comprehensive clinical assessments in patients' homes, care homes and community settings.

Completing Comprehensive Geriatric Assessments (CGA) and supporting structured medication reviews.

Developing personalised care plans, advance care plans and treatment escalation plans.

Identifying patients at risk of deterioration and implementing proactive interventions to prevent avoidable hospital admissions.

Supporting safe hospital discharge and continuity of care.

Providing clinical leadership, guidance and advice to Frailty Practitioners and wider multidisciplinary colleagues.

Working collaboratively with GP practices, geriatricians, community services, mental health teams and social care partners.

Participating in multidisciplinary team meetings and complex case discussions.

Contributing to service development, clinical governance and quality improvement initiatives.

You will help deliver safe, effective and compassionate care that promotes independence, improves quality of life and supports patients to remain well within their communities.

About us

South Downs Health and Care GP Federation is a social enterprise. It was established in 2016 in service to shareholding/member GP practices in the areas of Eastbourne, Hailsham and Seaford. It now has extended membership within East Sussex. Our main purpose is to support GP practices in their task of providing patient care by enabling them to provide and invest in sustainable services by reducing the burden of their workload, maximising income opportunities and minimising their risks and liabilities.

We encourage our staff to take ownership and responsibility, to highlight concerns and feedback and to make an active contribution to their individual success as well as that of their team and the wider organisation. We operate a no-blame culture; by this we mean that everyone is held accountable but in an environment where the focus is on the learning that can be adopted and shared from instances where things havent gone so well.

Benefits of Working with SDHC

• NHS Pension Scheme with generous employer contributions
• 25 days holiday plus bank holidays, increasing in stages to 30 days holiday plus bank holidays after 5 years service (pro rata for part time hours)
• Employee Assistance Programme including access to counselling and support with legal and financial matters
• CycleScheme
• Christmas and summer events
• Discounted rate for membership of Hillbrow Health and Wellbeing Centre facilities

Job responsibilities

The GP with an Interest in Frailty is oneof the three core roles in the INT team, alongside the MDT Coordinator and theFrailty Practitioner. Together they assess people on the AEAR list, carry outCGA and structured medication review, and build digital care and support plans,anticipatory care plans and treatment escalation plans. The GP and/or theFrailty Practitioner act as the team's clinical lead.

The role brings senior generalist expertiseand the link to core general practice. It combines direct patient care withclinical leadership: supporting and developing colleagues from everyorganisation in the team, and helping the INT achieve a 10% reduction inavoidable emergency admissions for the cohort.

Proactiveand preventative care

• Use the AEAR list, ICTdashboards, local intelligence and clinical judgement to identify andprioritise people for proactive support
• Prioritise timely ComprehensiveGeriatric Assessment (CGA) for everyone in the team's focus cohort whereclinically indicated, covering clinical, functional, frailty and mental healthreview, and track progress so no one is missed
• Carry out structured medicationreviews (SMR) with the team pharmacist, including deprescribing
• Develop digital personalisedcare and support plans (PCSP), with agreed actions, named responsibility andreview arrangements
• Lead anticipatory care planning(DNACPR, ReSPECT, LPA) and high-quality treatment escalation planning (TEP)
• Focus on the leading drivers ofadmission risk: falls, congestive heart failure, flu/pneumonia and care homeresidents
• Hold named clinicalresponsibility where needed, and elevate when a plan is not achieving itsintended outcomes
• Provide senior clinicalassessment in clinics, care homes and patients' homes
• Triage referrals from practicesand the team, prioritising home and care home visits by need
• Respond to people at risk ofdeterioration to prevent avoidable admissions and A&E attendances, linkingwith virtual wards, urgent community response and acute frailty services
• Support safe, timely dischargeand follow-up after hospital stays
• Prescribe safely in line withlocal formulary and national guidance
• Make and follow up referrals tosecondary care, community, mental health and social care services
• Keep accurate, contemporaneous records in shared systems and code activity correctly

Oneteam: multi-organisation, multidisciplinary working

• Lead or contribute to INT andpractice MDT meetings and huddles, bringing a senior generalist view
• Build trusting workingrelationships across primary care, community, mental health, social care,hospital and voluntary sector colleagues
• Act as a clinical point ofcontact and source of advice for the team and local practices
• Provide clinical supervision toteam members such as physician associates, ACPs, paramedics and pharmacists
• Teach and develop colleaguesand learners from all professions and organisations
• Build and maintain strongworking links with virtual wards, urgent community response and the wider ICT
• Develop clear routes to acutepathways and diagnostics, palliative and hospice care, specialist mentalhealth, care home pathways, equipment and reablement, and housing
• Use warm transfers and directclinician-to-clinician conversations to step people up or refer them on quickly
• Help the INT understand who tocontact, how and when, so escalation is consistent across the team
• Work closely with the INT'snamed geriatrician on complex patients, through advice, joint review and shared decision-making

Leadership, quality and governance

• Provide clinical leadership tothe INT core team and help design and improve the local delivery of the coreoffer
• Take part in, and help deliver,the centralised training and support programme, including multiprofessionaltraining and supervision in CGA, digital PCSPs, advance care planning and TEP
• Record decisions, actionowners, timescales and outcomes to agreed MDT documentation standards in sharedcare records
• Contribute to activity andoutcome reporting through ICT and Neighbourhood Alliance governance
• Take part in audit, qualityimprovement and evaluation of outcomes
• Follow clinical governance,safeguarding, information governance and CQC requirements of the employingorganisation
• Raise and learn from incidents,complaints and significant events
• Maintain own professionaldevelopment, appraisal and revalidation

Working across organisations

The core team brings together colleaguesemployed by different organisations, working collaboratively as one integratedteam. Operationally it must function as one integrated team throughcollaborative working. Employment, line management and performance managementresponsibilities remain with the employing organisation, which retains itsoverarching responsibilities for the employee in accordance with thesubcontract. Day-to-day priorities and the organisation of work are decided bythe Integrated Neighbourhood Team (INT), with a work plan and timetable thatare transparent and accessible to both the employing organisation and the team.Employees must look to the INT for their individual work-plan rather than totheir employing organisation.

Clinical accountability for apractitioners own practice, including the clinical decisions they make and anyactions or omissions within their responsibility, remains with the practitionerand is supported by the clinical governance arrangements of their employingorganisation. Working alongside colleagues from other organisations does not,in itself, transfer that accountability to them.

Clinical support and clinical supervision

Clinical support and clinical supervisionserve different but complementary purposes, and both have a role within thecore team.

Clinical support is part of the teamsday-to-day working arrangements. It includes discussing cases, raisingconcerns, considering clinical options and agreeing next steps. Practitionerscan draw on the expertise of colleagues across the team, particularly the GPwith an interest in frailty. Where a discussion informs a clinical decision,the practitioner records the relevant discussion and the clinician consulted inthe patient record, in line with local documentation and information governancerequirements.

Clinical supervision provides protectedtime for reflection on practice, learning and professional development. It isarranged through the employing organisation in accordance with its policies andprofessional requirements. Where supervision is provided by someone outside theemploying organisation, this is agreed in advance and documented in a writtensupervision agreement setting out the respective roles, responsibilities andarrangements for escalation and information sharing. Brief records of supervisionare shared with the employing organisation in accordance with the agreedarrangements.

Working with the frailty practitioner and the wider team

The GP with an interest in frailty providesa clinical anchor for the core team, helping to bring clinical perspectivestogether and support consistent, coordinated decision-making. The post holderis expected to be accessible to the frailty practitioner and other team membersfor day-to-day clinical support, including case discussion, advice on clinicaldecisions and agreement of appropriate next steps. Where practicable,co-location for part of the working week can help build relationships, supporttimely discussion and strengthen the teams approach to care.

Where the employing organisation and theICT agree that the GP will also provide formal clinical supervision to thefrailty practitioner, this is established through a written supervisionagreement. The agreement sets out the respective responsibilities, withprotected time identified within the GPs sessions and an agreed contributionto the practitioners appraisal. This is a specific, agreed addition to therole rather than an automatic expectation of the frailty GP post.

General responsibilities

These apply to every member of the INT.

• Equality, diversity and inclusion: treatpatients, carers and colleagues fairly and with dignity and respect, andchallenge discrimination on any protected characteristic
• Safeguarding: recognise and act onsafeguarding concerns for adults and children, following local procedures
• Confidentiality and information governance: protect patient information and share it appropriately acrossorganisations under agreed data-sharing arrangements
• Health, safety and lone working: takereasonable care of your own and others' safety, including during home visits
• Quality and continuousimprovement: suggest and take part in improvementsto how the team works
• Induction: complete induction with theemploying organisation and the INT, including the practices you work with
• Professional conduct: follow thepolicies of the employing organisation and the standards of your professionalbody

Person Specification

Experience

• At least 2 years post-CCT in UK general practice; managing complex older patients and multimorbidity; medicines management
• Frailty, care home, community or intermediate care roles; MDT leadership; clinical supervision or education

Qualifications

• Full GMC registration with a licence to practise; NHS England Performers List; appropriate indemnity; right to work in the UK
• Diploma in Geriatric Medicine or postgraduate qualification in frailty or palliative care

Skills, Knowledge and Abilities

• Experience in Comprehensive Geriatric Assessment; structured medication review; advance care planning conversations; clinical risk management
• Person-centred, proactive, empathetic in distressing situations; good judgement under pressure; committed to CPD
• Collaborative across professional and organisational boundaries; supports and teaches others; works well autonomously and in a team
• Quality improvement and audit leadership; population health and risk stratification tools
• Experience of integrated or multi-organisation teams; leading service change
• Interest in service development and system change
• SystmOne, EMIS

Other

• Full driving licence and access to a car; enhanced DBS check; occupational health clearance; flexibility to meet service needs

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.