GP with an Interest in Frailty

NHS Jobs; Eastbourne; On-site; GBP 85,000 - 105,000; Full time

Job summary

NHS Jobs in Eastbourne is seeking a GP with an interest in frailty to join the Integrated Care Team. The post provides clinical leadership, working across primary care, community and hospital services.

You will conduct CGA, structured medication reviews, develop digital care plans, and lead multidisciplinary teams to reduce avoidable admissions. This role combines patient care with system leadership and teaching to colleagues from different organisations.

Responsibilities

• Provide senior clinical assessment in clinics, care homes and patients' homes
• Triage referrals and prioritise home and care home visits by need
• Carry out CGA and structured medication reviews with the team pharmacist
• Develop digital personalised care and support plans (PCSP) with agreed actions
• Lead anticipatory care planning and treatment escalation planning
• Build strong working links across primary care, community, hospital and social care

Skills

Clinical leadership

Geriatrics knowledge

Team collaboration

Job description

The GP with an Interest in Frailty is one of the three core roles in the INT team, alongside the MDT Coordinator and the Frailty Practitioner. Together they assess people on the AEAR list, carry out CGA and structured medication review, and build digital care and support plans, anticipatory care plans and treatment escalation plans. The GP and/or the Frailty Practitioner act as the team's clinical lead. The role brings senior generalist expertise and the link to core general practice. It combines direct patient care with clinical leadership: supporting and developing colleagues from every organisation in the team, and helping the INT achieve a 10% reduction in avoidable emergency admissions for the cohort.

Proactive and preventative care

• Use the AEAR list, ICT dashboards, local intelligence and clinical judgement to identify and prioritise people for proactive support
• Prioritise timely Comprehensive Geriatric Assessment (CGA) for everyone in the team's focus cohort where clinically indicated, covering clinical, functional, frailty and mental health review, and track progress so no one is missed
• Carry out structured medication reviews (SMR) with the team pharmacist, including deprescribing
• Develop digital personalised care and support plans (PCSP), with agreed actions, named responsibility and review arrangements
• Lead anticipatory care planning (DNACPR, ReSPECT, LPA) and high-quality treatment escalation planning (TEP)
• Focus on the leading drivers of admission risk: falls, congestive heart failure, flu/pneumonia and care home residents
• Hold named clinical responsibility where needed, and escalat when a plan is not achieving its intended outcomes

Clinical care

• Provide senior clinical assessment in clinics, care homes and patients' homes
• Triage referrals from practices and the team, prioritising home and care home visits by need
• Respond to people at risk of deterioration to prevent avoidable admissions and A&E attendances, linking with virtual wards, urgent community response and acute frailty services
• Support safe, timely discharge and follow-up after hospital stays
• Prescribe safely in line with local formulary and national guidance
• Make and follow up referrals to secondary care, community, mental health and social care services
• Keep accurate, contemporaneous records in shared systems and code activity correctly

One team: multi-organisation, multidisciplinary working

• Lead or contribute to INT and practice MDT meetings and huddles, bringing a senior generalist view
• Build trusting working relationships across primary care, community, mental health, social care, hospital and voluntary sector colleagues
• Act as a clinical point of contact and source of advice for the team and local practices
• Provide clinical supervision to team members such as physician associates, ACPs, paramedics and pharmacists
• Teach and develop colleagues and learners from all professions and organisations
• Links to wider services
• Build and maintain strong working links with virtual wards, urgent community response and the wider ICT
• Develop clear routes to acute pathways and diagnostics, palliative and hospice care, specialist mental health, care home pathways, equipment and reablement, and housing
• Use warm transfers and direct clinician-to-clinician conversations to step people up or refer them on quickly
• Help the INT understand who to contact, how and when, so escalation is consistent across the team
• Work closely with the INT's named geriatrician on complex patients, through advice, joint review and shared decision-making
• Leadership, quality and governance Provide clinical leadership to the INT core team and help design and improve the local delivery of the core offer
• Take part in, and help deliver, the centralised training and support programme, including multiprofessional training and supervision in CGA, digital PCSPs, advance care planning and TEP
• Record decisions, action owners, timescales and outcomes to agreed MDT documentation standards in shared care records
• Contribute to activity and outcome reporting through ICT and Neighbourhood Alliance governance
• Take part in audit, quality improvement and evaluation of outcomes
• Follow clinical governance, safeguarding, information governance and CQC requirements of the employing organisation
• Raise and learn from incidents, complaints and significant events
• Maintain own professional development, appraisal and revalidation

Clinical support and clinical supervision

Clinical support and clinical supervision serve different but complementary purposes, and both have a role within the core team. Clinical support is part of the teams day-to-day working arrangements. It includes discussing cases, raising concerns, considering clinical options and agreeing next steps. Practitioners can draw on the expertise of colleagues across the team, particularly the GP with an interest in frailty. Where a discussion informs a clinical decision, the practitioner records the relevant discussion and the clinician consulted in the patient record, in line with local documentation and information governance requirements. Clinical supervision provides protected time for reflection on practice, learning and professional development. It is arranged through the employing organisation in accordance with its policies and professional requirements. Where supervision is provided by someone outside the employing organisation, this is agreed in advance and documented in a written supervision agreement setting out the respective roles, responsibilities and arrangements for escalation and information sharing. Brief records of supervision are shared with the employing organisation in accordance with the agreed arrangements.

Working with the frailty practitioner and the wider team

The GP with an interest in frailty provides a clinical anchor for the core team, helping to bring clinical perspectives together and support consistent, coordinated decision-making. The post holder is expected to be accessible to the frailty practitioner and other team members for day-to-day clinical support, including case discussion, advice on clinical decisions and agreement of appropriate next steps. Where practicable, co-location for part of the working week can help build relationships, support timely discussion and strengthen the teams approach to care. Where the employing organisation and the ICT agree that the GP will also provide formal clinical supervision to the frailty practitioner, this is established through a written supervision agreement. The agreement sets out the respective responsibilities, with protected time identified within the GPs sessions and an agreed contribution to the practitioners appraisal. This is a specific, agreed addition to the role rather than an automatic expectation of the frailty GP post.

General responsibilities

• Equality, diversity and inclusion: treat patients, carers and colleagues fairly and with dignity and respect, and challenge discrimination on any protected characteristic
• Safeguarding: recognise and act on safeguarding concerns for adults and children, following local procedures
• Confidentiality and information governance: protect patient information and share it appropriately across organisations under agreed data-sharing arrangements
• Health, safety and lone working: take reasonable care of your own and others' safety, including during home visits
• Quality and continuous improvement: suggest and take part in improvements to how the team works
• Induction: complete induction with the employing organisation and the INT, including the practices you work with
• Professional conduct: follow the policies of the employing organisation and the standards of your professional body