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NHS Jobs; Godstone; On-site; GBP 90,000 - 110,000; Full time

Job summary

South Tandridge Primary Care Network (PCN) seeks a Frailty General Practitioner to lead the frailty hub, delivering care at patients' homes and in care homes across the PCN. You will work with Community Matrons, District Nurses, Pharmacists and other teams to develop care plans and reduce unnecessary hospital admissions.

You will provide clinical leadership, undertake triage and supervise colleagues, with flexibility for up to five sessions per week and a focus on improving patient experience

Qualifications

• Experience delivering frailty care and home visits.
• Clinical leadership and supervision experience desirable.
• Ability to work across PCN partners and external teams.

Responsibilities

• Triage referred and proactively identified patients to provide timely medical care.
• Coordinate with Community Matron and wider PCN teams.
• Generic prescribing in line with local and national guidelines.
• Manage long-term conditions effectively.
• Handle admin tasks including referrals and prescriptions.
• Perform telephone triage and prioritize home visits.
• Maintain accurate clinical records and comply with policy.
• Lead discussions at PCN and Practice MDTs and contribute to governance.
• Support quality initiatives and professional development.
• Commit to ongoing learning and development.

Skills

Triage

Frailty care

Long-term conditions

Clinical governance

MDT collaboration

Self-learning

Education

Clinical supervision/education

Job description

JOB SUMMARY South Tandridge Primary Care Network (PCN) is made up of the following Practices: Oxted Medical Practice, Pond Tail Surgery and Lingfield Surgery, with a population of approximately 35K. The PCN has worked together over several years and is therefore mature in its collaboration with member practices as well as external provider organisations. In this role, a successful applicant will manage the PCN clinical frailty pathway (Hub) that all practices within this PCN can refer into. The aim is to offer care in the patients home in order to reduce unplanned admissions and improve patient care. The Frailty General Practitioner will be responsible for providing clinical leadership to the frailty hub team and providing medical leadership to the wider community team of Community Matrons, District Nurses, Pharmacists, etc. It is therefore desirable that you should also have experience of or qualifications in clinical supervision/education, but not essential as training can be given. Populations are changing, and patients are living longer with complex care needs. Having a frailty service that is well triaged aims to create a better patient experience, a better way of working collaboratively and a reduction in unplanned admissions to hospital. This service will be available up to 5 sessions per week, with the expectation that coverage will be across the working week, but flexible requests will be considered. Improved home visiting at scale will also potentially reduce pressure on A&E attendances, with the role of the Frailty General Practitioner providing oversight and clinical care to a cohort of patients as identified by the individual practices within the PCN. This role will include seeing patients in their own homes as well as visits to care homes where appropriate. The Frailty General Practitioner will be responsible for developing a care plan for frail patients at risk of hospital admission, using their clinical skills to diagnose and treat patients accordingly. This will involve liaising with other professionals responsible for the patients care, referring to other teams as necessary, as well as liaising with secondary care, community care, social care, mental health services and other local providers.

DUTIES AND RESPONSIBILITIES OF THE POST

The following are the core responsibilities of the Frailty General Practitioner. There may be, on occasion, a requirement to carry out other tasks; dependent upon factors such as workload and staffing levels:

• Effective triage of referred and proactively identified patients to provide highly effective medical care to the entitled population in a timely fashion
• Proactively managing the care of frail people alongside the Community Matron
• Generic prescribing adhering to local and national guidance
• Effective management of long-term conditions
• Processing of administration in a timely manner, including referrals, repeat prescription requests and other associated administrative tasks
• Undertake telephone triage and prioritise home visits accordingly
• Maintain accurate clinical records in conjunction with good practice, policy and guidance
• Working collaboratively across the PCN with all practices and partner organisations, and agencies
• Lead discussion about patients at both PCN-level MDTs and at Practice-level MDTs
• Adhere to best practice recommended through clinical guidelines and the audit process
• Contribute to the successful implementation of continuous improvement and quality initiatives with the Practices and PCN
• Accept delegated responsibility
• Contribute effectively to the development and maintenance of the PCN, including clinical governance, training, financial management and HR
• Commit to self-learning and continuing professional development
• Support the partners in achieving the strategic aims of the PCN
• Review and adhere to Practice/ PCN protocols and policies at all times
• Encourage collaborative working, liaising with all staff regularly, promoting a culture of continuous improvement at all times

ORGANISATIONAL POSITION

The Frailty GP will report to the PCN Clinical Director and Service Manager.

KEY PRINCIPLES OF THE FRAILTY GENERAL PRACTITIONER ROLE

• Proactive management of the frail population and people at the end of their life (65yrs+)
• Identification of the people most at risk of deterioration/hospital admission
• A multi-disciplinary team (MDT) approach to provide holistic care
• A defined caseload of people who have:
  • An in-depth frailty assessments
  • Structured medication reviews & falls assessments
  • Quality conversations about end-of-life care
  • Planning for when care needs change
  • A personalised care plan agreed and enacted
  • A key point of contact
  • Proactive intervention to avoid hospital admission - linking with the reactive community service

INDIVIDUAL RESPONSIBILITIES

• Adhere to DHC and GP Practices policies and procedures and any other relevant legislation
• Ensure mandatory training is up to date at all times
• Participate in regular supervision sessions and appraisals with your line manager.
• Attend training and development activities as identified and participate in meetings as required
• Maintain administration systems and workspaces in a clean and tidy fashion
• Maintain a good working knowledge of Health and Safety procedures and fire precautions, and operate the correct procedures and participate in policy development and data collection where appropriate
• Work flexibly to meet the needs of patients
• Contribute to ongoing/new projects as required
• To undertake any other duties appropriate to the grade and purpose of the job as may be agreed by the post holder

WORK SETTING AND REVIEW

The post holder will work autonomously to an agreed set of KPIs, targets and objectives. They will manage their own time and case load, providing regular updates/progress reports to their line manager and to the GP practices they are based in. Participate in DHCs appraisal and review system. This job description represents an outline of the responsibilities of the post and is not intended to be an exhaustive list of duties or tasks. It will change and develop in line with organisational needs and may be amended following agreement with the post-holder.