Neighbourhood Frailty GP

The Neighbourhood Frailty GP will provide clinical expertise and leadership within the Integrated Neighbourhood Frailty Team, supporting the identification, assessment and management of patients with frailty and complex health needs.

The role combines direct patient care with clinical leadership and multidisciplinary working, helping to establish a proactive, joined-up approach to frailty management across our local population.

play a key clinical role within the Integrated Neighbourhood Team (INT)/ PCN,

contributing to the delivery of high-quality, proactive and personalised care

for patients living with frailty, multiple long-term conditions and complex

health needs. The role will focus on improving patient outcomes, supporting

independence and reducing avoidable emergency hospital admissions through early

intervention and coordinated multidisciplinary working.

Working alongside the Frailty Practitioner, MDT Coordinator and wider INT/ PCN Practice teams, the GP will provide senior clinical expertise, assessment and guidance to support the identification and management of patients at increased risk of deterioration. Responsibilities will include Comprehensive Geriatric Assessments (CGA), structured medication reviews, anticipatory care planning and the development of personalised care and support plans, with a particular focus on falls, heart failure, respiratory illness and care home residents.

The Neighbourhood Frailty GP will act as a key clinical point of contact for the INT, providing advice, clinical leadership and support with complex patient management, treatment decisions and appropriate escalation of care. Working collaboratively with the INT/ PCN Practices, community nursing, therapy services, social care and wider multidisciplinary colleagues, they will help ensure patients receive timely, coordinated care that meets their individual needs.

The Neighbourhood Frailty GP will also contribute to the ongoing development and effectiveness of the INT, supporting multidisciplinary discussions, strengthening clinical pathways and promoting consistent approaches to frailty management. Through clinical leadership, shared learning and quality improvement, the post-holder will help establish a sustainable, patient-centred service that supports the wider ambition of reducing avoidable hospital admissions and enabling patients to remain well and independent within their own homes.

Below are the

core responsibilities of the Neighbourhood Frailty GP role. This list is not exhaustive and will be

reviewed on an annual basis or sooner if deemed necessary. There may be times

when the post-holder is required to carry out tasks outside of the list below

to assist with the needs of the INT/ PCN:

the AEAR list, ICT dashboards, local intelligence and clinical judgement to

identify and prioritise people for proactive support

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

out structured medication reviews (SMR) with the team pharmacist, including

deprescribing

digital personalised care and support plans (PCSP), with agreed actions, named

responsibility and review arrangements

anticipatory care planning (DNACPR, ReSPECT, LPA) and high-quality treatment

escalation planning (TEP)

on the leading drivers of admission risk: falls, congestive heart failure,

flu/pneumonia and care home residents

named clinical responsibility where needed, and escalate when a plan is not

achieving its intended outcomes

senior clinical assessment in clinics, care homes and patients' homes

referrals from practices and the team, prioritising home and care home visits

by need

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

safe, timely discharge and follow-up after hospital stays

safely in line with local formulary and national guidance

and follow up referrals to secondary care, community, mental health and social

care services

accurate, contemporaneous records in shared systems and code activity correctly

a One Team approach to multidisciplinary and cross-organisational working,

fostering strong relationships, shared responsibility and collaborative

decision-making to deliver coordinated, patient-centred care across the INT

or contribute to INT and Practice MDT meetings and huddles, bringing a senior

generalist view

trusting working relationships across primary care, community, mental health,

social care, hospital and voluntary sector colleagues

as a clinical point of contact and source of advice for the team and local

clinical supervision to team members such as physician associates, ACPs,

paramedics and pharmacists where needed

and develop colleagues and learners from all professions and organisations when

required

as a clinical anchor for the INT Frailty Team, providing senior clinical

expertise and guidance, bringing together clinical perspectives and supporting

consistent, coordinated decision-making and patient-centred care

closely with the Frailty Practitioner and MDT Coordinator to support the

delivery of effective, proactive and personalised care for patients with

frailty and complex health needs

effective communication, shared decision-making and collaborative working

across the core team, ensuring a consistent approach to patient assessment,

management and escalation

opportunities for co-location with the Frailty Practitioner and wider team

where practicable, strengthening working relationships and facilitating timely

clinical discussions

support and clinical supervision serve different but complementary purposes,

and both have a role within the core team

accessible day-to-day clinical support to the Frailty Practitioner and wider

INT team, including case discussions, raising concerns, exploring clinical

options and agreeing appropriate next steps

as a key source of clinical advice and expertise, supporting colleagues with

complex patient management and informed clinical decision-making

clinical discussions and advice informing patient care are appropriately

documented, including the clinician consulted, in line with local

record-keeping and information governance requirements

reflective practice, shared learning and professional development across the

multidisciplinary team

specifically agreed, provide formal clinical supervision to the Frailty

Practitioner, with protected time allocated within the GP's sessions and an

agreed contribution to the practitioner's appraisal

any formal supervision arrangements are documented through a written agreement,

clearly defining responsibilities, escalation procedures, information-sharing

arrangements and appropriate supervision records

appropriate records of formal supervision and ensure these are shared with the

employing organisation in accordance with agreed arrangements

Links to wider services

and maintain strong working links with virtual wards, urgent community response

and the wider ICT

clear routes to acute pathways and diagnostics, palliative and hospice care,

specialist mental health, care home pathways, equipment and reablement, and

housing

warm transfers and direct clinician-to-clinician conversations to step people

up or refer them on quickly

the INT understand who to contact, how and when, so escalation is consistent

across the team

closely with the INT's named geriatrician on complex patients, through advice,

joint review and shared decision-making

Work

collaboratively with colleagues employed by different organisations, promoting

a unified and integrated approach to patient care within the INT

Operate

within the INT's agreed working arrangements, with day-to-day priorities,

responsibilities and work plans coordinated by the INT and communicated

transparently with the employing organisation

Recognise

that employment, line management and performance management responsibilities

remain with the employing organisation, in accordance with relevant contractual

and subcontracting arrangements

Follow

the agreed INT work plan and timetable, ensuring alignment with the team's

operational priorities and service objectives

individual professional and clinical accountability for all clinical decisions,

actions and omissions within the scope of the role, supported by the employing

organisation's clinical governance arrangements

collaborative working across organisational boundaries does not compromise

individual clinical accountability or transfer responsibility for clinical

decisions to other team members

Leadership,

quality and governance

clinical leadership to the INT core team and help design and improve the local

delivery of the core offer

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

decisions, action owners, timescales and outcomes to agreed MDT documentation

standards in shared care records

to activity and outcome reporting through ICT and Neighbourhood Alliance

governance

part in audit, quality improvement and evaluation of outcomes

clinical governance, safeguarding, information governance and CQC requirements

of the employing organisation

and learn from incidents, complaints and significant events

and revalidation

Bognor Coastal Alliance (BCA) Primary Care Network is an established partnership of three GP Practices: Grove House Surgery, Maywood Healthcare Centre and West Meads Surgery, collectively providing care to around 40,000 patients across Bognor Regis and the surrounding communities.

At BCA, we pride ourselves on being a supportive, collaborative and forward thinking network, with a strong commitment to delivering high quality, patient centred care. Our strength lies in our people, with a longstanding and experienced workforce who bring a wealth of knowledge, skills and expertise, alongside a genuine passion for making a positive difference to our patients.

We have developed a strong culture of teamwork and mutual support, where colleagues work closely across our Practices, sharing knowledge, ideas and best practice. We value our staff and strive to create a positive working environment where everyone feels supported, valued and encouraged to contribute.

As a progressive PCN, we continually look for opportunities to innovate, strengthen partnerships and develop services that respond to the changing needs of our population. Our developing Integrated Neighbourhood Frailty Team is an exciting example of this approach, bringing together expertise to deliver more proactive and personalised care.

Above all, we are a team that cares about our patients, our colleagues and the communities we serve, with a shared ambition to continually improve the care we provide.

Skills

Experience

Essential: - At least 2 years post-CCT in UK general practice; managing complex older patients and multimorbidity; medicines management

Desirable: - Frailty, care home, community or intermediate care roles; MDT leadership; clinical supervision or education

Other requirements

Eligibility

Essential: - Full GMC registration with a licence to practise; NHS England

Qualifications

Essential: - MRCGP or equivalent; CCT in general practice

Desirable: - Diploma in Geriatric Medicine or postgraduate qualification in frailty or palliative care

Clinical Skills

Essential: - Experience in Comprehensive Geriatric Assessment; structured medication review; advance care planning conversations; clinical risk management

Desirable: - Quality improvement and audit leadership; population health and risk stratification tools

Personal Qualities

Desirable: - Experience of integrated or multi-organisation teams; leading service change