GP with an Interest in FrailtyNHS

Job summary

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.

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 escalate 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

Working across organisations

The core team brings together colleagues employed by different organisations, working collaboratively as one integrated team. Operationally it must function as one integrated team through collaborative working. Employment, line management and performance management responsibilities remain with the employing organisation, which retains its overarching responsibilities for the employee in accordance with the subcontract. Day-to-day priorities and the organisation of work are decided by the Integrated Neighbourhood Team (INT), with a work plan and timetable that are transparent and accessible to both the employing organisation and the team. Employees must look to the INT for their individual work-plan rather than to their employing organisation.

Clinical accountability for a practitioners own practice, including the clinical decisions they make and any actions or omissions within their responsibility, remains with the practitioner and is supported by the clinical governance arrangements of their employing organisation. Working alongside colleagues from other organisations does not, in itself, transfer that accountability to them.

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

These apply to every member of the INT.

• 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

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