Frailty General Practitioner

As a Frailty General Practitioner, you will be responsible for proactive triage and management of the PCNs frail patients who have been referred.

These referrals will come from a range of sources, including those proactively identified in-house. Management of this cohort includes developing care plans for patients at risk of hospital admission and using your clinical skills to diagnose and treat patients accordingly in order to improve their care. This will involve a holistic MDT approach to patient care, 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.

We screen and shortlist suitable candidates as applications are received. We reserve the right to close this vacancy early and without notice if we fill the position. Therefore, we encourage early applications to avoid disappointment.

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.

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.

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

of referred and proactively identified patients to provide highly effective

medical care to the entitled population in a timely fashion

managing the care of frail people alongside the Community Matron

prescribing adhering to local and national guidance

management of long-term conditions

administration in a timely manner, including referrals, repeat prescription

requests and other associated administrative tasks

telephone triage and prioritise home visits accordingly

clinical records in conjunction with good practice, policy and guidance

collaboratively across the PCN with all practices and partner organisations,

and agencies

about patients at both PCN-level MDTs and at Practice-level MDTs

practice recommended through clinical guidelines and the audit process

successful implementation of continuous improvement and quality initiatives

with the Practices and PCN

responsibility

effectively to the development and maintenance of the PCN, including clinical

governance, training, financial management and HR

self-learning and continuing professional development

partners in achieving the strategic aims of the PCN

to Practice/ PCN protocols and policies at all times

staff regularly, promoting a culture of continuous improvement at all times

POSITION

The Frailty GP will report to the PCN

Clinical Director and Service Manager.

their life (65yrs+)

admission

reactive community service

policies and procedures and any other relevant legislation

to date at all times

regular supervision sessions and appraisals with your

line manager. Attend training and development activities as identified

and participate in meetings as required

administration systems and workspaces in a clean and tidy fashion

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

meet the needs of patients

projects as required

the grade and purpose of the job as may be agreed by the post holder

autonomously to an agreed set of KPIs, targets and objectives.

and case load, providing regular updates/progress reports to their line manager

and to the GP practices they are based in.

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.

South Tandridge Primary Care Network (PCN) is a partnership of local GP surgeries working together to help people live healthier lives. The PCN is made up of 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 approach to collaboration with member practices and external providers, working alongside staff, patients, their families and carers, and the public to provide high-quality healthcare close to home.

You will also be supported by the wider DHC Federation and network of frailty GPs across our member PCNs. DHC is a supportive, local GP Federation which works hard to prioritise the healthcare needs of the community, as well as the well-being of its staff.

DHC actively encourage and promotes diversity, ensures all voices are heard and included and is committed to equal opportunities for all.

Other requirements

Essential: - Disclosure and barring service check.; - Willing and able to travel to other sites & locations to attend meetings and training events.

Skills

Desirable: - Knowledge of GP clinical systems EMIS and/or TPP SystmOne.

Personal Qualities

Experience

Desirable: - Experience of leading MDT Meetings in Primary Care.

Qualifications

Essential: - Good standard of education with excellent literacy and numeracy skills