PCN Frailty GP

The post holder will act as a clinical leader for our established Integrated Neighbourhood Team, providing senior clinical leadership, oversight and guidance to a dynamic multidisciplinary team of clinicians and healthcare professionals.

The team delivers a combination of proactive and reactive care, supporting patients living with frailty, complex health needs and those at risk of deterioration or hospital admission.

The GP will play a key role in supporting clinical decision-making, managing complexity and ensuring a coordinated, patient-centred approach to care.

The role will involve working closely with a diverse range of professionals across neighbourhood services, providing clinical leadership and contributing to multidisciplinary discussions and care planning.

An important aspect of the role will be helping to lead and develop our innovative neighbourhood model, supporting new ways of working and shaping the future delivery of integrated care across our PCN.

A really exciting opportunity

to join an ambitious, forward- thinking PCN at the cutting edge of Integrated

Neighbourhood Working, helping to shape and deliver the future of frailty care

and neighbourhood health.

To provide senior GP clinical input and leadership within the PCNs

Integrated Neighbourhood Team, supporting the delivery of high-quality,

coordinated care for people living with frailty and complex health needs

across our member practices.

To work as part of the PCNs hub model, providing clinical oversight

and management of patients identified through both proactive frailty pathways

and reactive INT services, supporting care to be delivered at neighbourhood

level and at scale.

To proactively identify, assess and manage patients at greatest risk

of deterioration, crisis or unplanned hospital admission, developing

personalised care plans and supporting patients to remain safely in their

usual place of residence wherever clinically appropriate.

To work closely with the wider multidisciplinary team, including

community nursing, pharmacy, care coordination, social care, secondary care

and other neighbourhood partners, ensuring a holistic and joined-up approach

to the management of frailty.

To build upon the learning and model developed through the NNHIP

pilot, supporting the transition of frailty and neighbourhood working into

business as usual and contributing to the ongoing development of the PCNs

Integrated Neighbourhood Team and Single Neighbourhood Health model.

To provide senior clinical leadership and input into

multidisciplinary team meetings, supporting coordinated decision-making

and care planning for patients living with frailty and complex needs.

Provide effective clinical triage and senior medical oversight for

patients referred to, or proactively identified by, the frailty and

Integrated Neighbourhood Team.

Proactively manage people living with frailty, complex multimorbidity

and those at increased risk of deterioration or hospital admission.

Undertake comprehensive and holistic clinical assessment, including

the principles of Comprehensive Geriatric Assessment where appropriate,

considering physical, psychological, functional and social needs.

Diagnose, investigate and treat patients within the scope of the role,

including prescribing in accordance with local and national guidance and

providing ongoing clinical monitoring where required.

Develop and review personalised care and support plans, including

anticipatory care planning and escalation planning, working with patients,

carers and the wider multidisciplinary team.

Support proactive management of frailty as part of the PCNs Single

Neighbourhood Health contract requirements, ensuring that proactive

interventions link effectively with the reactive Integrated Neighbourhood

Team service when a patient's needs change or they experience deterioration.

Undertake telephone, remote and face-to-face clinical assessment as

appropriate, including home visits and care home visits where clinical need

requires.

Support admission avoidance and timely community-based intervention,

enabling patients to remain safely at home wherever clinically appropriate

and helping to reduce unnecessary emergency department attendance and

hospital admission.

Provide senior clinical input into the management of patients

presenting through the reactive INT pathway, particularly where frailty,

multimorbidity or clinical complexity requires GP assessment or

decision-making.

Work collaboratively with clinicians and professionals across the

PCN's member practices, community services, secondary care, social care,

mental health services, voluntary sector and other neighbourhood partners.

Actively participate in, and where appropriate provide clinical

leadership to, multidisciplinary team meetings and case discussions relating

to frailty and complex patients.

Provide clinical leadership and support to the wider INT and frailty

team, promoting effective multidisciplinary working, shared decision-making

and appropriate clinical escalation.

Maintain accurate, timely and comprehensive clinical records and

ensure appropriate communication of assessments, care plans and clinical

decisions to the patient's registered practice and other professionals

involved in their care.

Contribute to the ongoing development, evaluation and improvement of

the PCN's frailty, INT and neighbourhood model, including pathway

development, clinical governance, audit, quality improvement and review of

outcomes.

Work autonomously within professional competencies while contributing

to agreed PCN and neighbourhood objectives, service standards and contractual

requirements, supporting the continued development of the NNHIP model into a sustainable

business-as-usual neighbourhood service.

Folkestone, Hythe & Rural Primary Care Network brings together seven GP practices serving a population of approximately 50,000 patients across a mixture of rural and urban communities.

Our member practices are Oaklands Health Centre, White House Surgery, Harbour Medical Practice, New Lyminge Surgery, Church Road Surgery, Sun Lane Surgery and Hawkinge and Elham Valley Practice.

Our population is diverse, covering communities with areas of significant deprivation alongside a high proportion of older patients and people living with frailty, multimorbidity and complex health needs.

We are an ambitious, progressive and forward-thinking organisation with a strong reputation for innovation, collaboration and developing new approaches to care.

Having participated in the national Neighbourhood Health Implementation Programme pilot, we have been at the forefront of Integrated Neighbourhood Working across Kent and Medway.

We have developed an established Integrated Neighbourhood Team, bringing together professionals from primary care, community health and wider partners to deliver more joined-up, proactive and responsive care.

We pride ourselves on creating a supportive and inclusive working environment where staff are valued, encouraged to contribute ideas and actively involved in service development.

This is an exciting time to join our PCN as we continue to build on our achievements and help shape the future of neighbourhood healthcare.

Experience

Essential: - 2 + years of working within GP practice; - Experience of working with vunerable / Frail patients; - Experience of running Multi-disiplinary meetings