South Kerrier INT GP Frailty LeadGP Practice

Job summary 12 month fixed term contact

The South Kerrier Integrated Neighbourhood Team (INT) are seeking a forward thinking GP !

This role would suit a GP who is interested in supporting people with frailty to live and die well in the South Kerrier community and those who live in care homes. If you are a GP who is passionate about personalised care and has expertise in tolerating uncertainty to support people to live and die well in line with their wishes, then this role will be perfect for you!

The post holder will work alongside the INT Clinical Lead and INT Frailty Lead to provide GP input into the frailty model that is being collaborated designed in the South Kerrier area. The role will sit across the South Kerrier area and will therefore be required to work collaboratively with the 4 GP practices in the area, as well as NHS partners, Cornwall Council, voluntary sector providers and independent sector colleagues.

We will consider flexible working arrangements including sessions ranging from 4 sessions to 6 sessions per week.

Main duties

The main duties of this role are as follows but are not limited to:

·        Attend and contribute to frailty multi-disciplinary team (MDT) meetings

·        Assist the frailty led nurse to co-design and develop a comprehensive frailty service for the South Kerrier population

·        Act as the clinical conduit between primary, community and secondary care

·        Assist practices in the management of complex frail patients, linking with the named accountable GP for the patient

Commence and lead work on the ‘hospital pull’ list reviewing previous day admission data to consider a prompt and effective discharge wherever possible
Provide a clinical lead role to facilitate collaborative working with hospital geriatricians and colleagues developing key relationships and understanding of patients need to support an integrated approach to care planning

About us

The South Kerrier Integrated Neighbourhood Team (INT) support a diverse and vibrant population of more than 33,000 people across communities including Helston, Carleen, Coverack, Constantine and the surrounding rural areas. We are a collaborative, community rooted team bringing together colleagues from health, social care, the voluntary sector and independent providers to deliver joined up, person centred care.

Our shared purpose is simple: to help people live well, stay well, and receive the right support at the right time. By working as one team across organisational boundaries, we aim to reduce fragmentation, improve access to care, and strengthen the resilience of our local communities.

A key focus for our INT is enhancing the support available for people living with frailty. This includes proactive identification of those who may benefit from early intervention, as well as responsive, coordinated care, during periods of crisis or following events such as hospital admissions., We work closely with primary care, community services, social care teams and voluntary sector partners to ensure that individuals and their families feel support, informed and empowered.

We are a team that values innovation, collaboration and compassion. Whether we are redesigning pathways, supporting neighbourhood initiatives or working directly with individuals in their home, we are committed to improving outcomes and delivery care that reflects the strengths and needs of our community.