PCN Salaried GP - Integrated Neighbourhood Care

proactive, holistic care to frail, housebound and clinically vulnerable

patients.

closely with the wider Integrated Neighbourhood Care multidisciplinary

team, including nurses, pharmacists, social prescribers and other

community professionals.

the management of patients with complex and multiple long-term

conditions, frailty and other vulnerabilities.

same-day acute visiting appointments as part of the Brunel Acute

Visiting Service.

clinical oversight and support for the outreach service for homeless

patients across three local hostels, working alongside our Health

Inclusion Team and wider multidisciplinary services.

admission avoidance and appropriate management of patients in their usual

place of residence wherever clinically appropriate.

to the ongoing development and improvement of the PCN's proactive care and

acute visiting services.

home visits and community-based reviews for housebound and frail patients.

long-term condition management (e.g. CHF, COPD, diabetes, hypertension).

or support anticipatory / future care planning and end-of-life discussions

where appropriate.

Dementia and Severe Mental Illness (SMI) annual health checks in line with

QOF and PCN specifications.

delivery of Learning Disability (LD) health assessments.

clinical leadership and support to the wider Integrated Neighbourhood Team

(including nurses, AHPs, care coordinators and social prescribers).

collaboratively with community and secondary care services to ensure

continuity of care.

accurate and timely clinical documentation in the relevant IT systems.

in clinical meetings, MDTs and case discussions.

in quality improvement initiatives related to frailty and proactive care.

to ongoing professional development and reflective practice.

to GMC, CQC and safeguarding standards at all times.

Our INT

service aims to provide a coordinated approach to supporting patients with

complex needs, with a particular focus on prevention, early intervention and

admission avoidance.

element of the role offers an opportunity to work within a flexible and

multidisciplinary model, helping to improve access to primary care and reduce

barriers to healthcare for patients who may otherwise struggle to engage with

traditional services.

arrangements.

salary dependent on experience.

opportunity to work across three practices within Brunel PCN.

varied role combining proactive care, acute visiting and Health

Inclusion outreach.

opportunity to work closely with an established multidisciplinary team.

for professional development and service development.

opportunity to contribute to and shape the future development of Integrated

Neighbourhood Care within Brunel PCN.

Experience

Essential: - Experience in primary care / community care; - Working with vulnerable or complex patients

Desirable: - Experience delivering LD or SMI health checks; - Anticipatory care / palliative care work

Qualifications

Essential: - GMC registered GP; - Eligible under ARRS within 2 years of CCT

Desirable: - Additional frailty or geriatrics training

Personal Attributes

Essential: - Compassionate and patient-centred; - Reliable and well-organised; - Valid UK Driving licence and access to own vehicle for visits

Desirable: - Interest in service development

Knowledge and Skills

Essential: - Strong clinical assessment and decision-making skills; - Excellent communication and empathy; - Ability to work independently and within a team