Frailty General Practitioner

South Tandridge PCN, part of the Dorking Healthcare GP Federation, is made up of Oxted Medical Practice, Pond Tail Surgery, and Lingfield Surgery with a population of approximately 30,000 patients.

This PCN has worked together over several years and is therefore mature in its collaboration with member practices as well as external provider organisations.

This project aims to create a frailty clinical pathway (Hub) that all practices within this PCN can refer into. The aim is to offer care in the patients' homes, with the avoidance of unplanned admissions.

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 Matron, District Nurses, Pharmacists etc. within the South Tandridge Primary Care Network (PCN).

Main duties of the job

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 attendance 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.

The Frailty General Practitioner will be responsible for developing a care plan for patients at risk of hospital admission, using your 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.

Job responsibilities

JOB SUMMARY

South Tandridge Primary Care Network (PCN) is made up of the following Practices: Oxted Medical Practice, Pond Tail Surgery and Lingfield Surgery with a population of approximately 30K. This PCN has worked together over several years and is therefore mature in its collaboration with member practices as well as external provider organisations.

This project aims to create a frailty clinical pathway (Hub) that all practices within this PCN can refer into. The aim is to offer care in the patients home, with the avoidance of unplanned admissions. 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 Matron, District Nurses, Pharmacists etc.

This service will be available up to 5 sessions per week with the expectation that coverage 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.

The Frailty General Practitioner will be responsible for developing a care plan for patients at risk of hospital admission, using your 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.

DUTIES AND RESPONSIBILITIES OF THE POST

• The delivery of highly effective medical care to the entitled population
• Proactively managing the care of frail people [defined by those with 3 LTCs and recent hospital admission] managed by Community Matrons and Frailty GP at PCN level and provide a rapid response if a patient was in crisis (via the community response/Home visiting GP)
• Generic prescribing adhering to local and national guidance
• Effective management of long-term conditions
• Processing of administration in a timely manner, including referrals, repeat prescription requests and other associated administrative tasks
• Undertake telephone triage and prioritise home visits accordingly
• Maintain accurate clinical records in conjunction with good practice, policy and guidance
• Working collaboratively across the PCN with all practices and partner organisations and agencies
• Lead discussion about patients at both PCN level MDTs and at Practice level MDTs
• Adhere to best practice recommended through clinical guidelines and the audit process
• Contribute to the successful implementation of continuous improvement and quality initiatives with the Practices and PCN
• Contribute effectively to the development and maintenance of the practice including clinical governance, training, financial management and HR
• Commit to self-learning and instil an ethos of continuing professional development
• Support the training of clinical/medical students from all clinical disciplines
• Support the partners in achieving the strategic aims of the PCN
• Review and adhere to Practice/ PCN protocols and policies at all times
• Encourage collaborative working, liaising with all staff regularly, promoting a culture of continuous improvement at all times

KEY PRINCIPLES OF THE FRAILTY GENERAL PRACTITIONER ROLE

Proactive management of the frail population and people at the end of their life (65yrs+)

• Identification of the people most at risk of deterioration/hospital admission
• Consistency and coverage across the week (M-F)
• A multi-disciplinary team (MDT) approach to provide holistic care
• A defined caseload of people who have:
• in-depth assessments, medication/falls reviews
• quality conversations about end-of-life care
• Planning for when care needs change
• A care plan agreed and enacted
• A key point of contact
• Proactive intervention to avoid hospital admission - linking with the reactive community service

INDIVIDUAL RESPONSIBILITIES

• Adhere to DHC and GP Practices policies and procedures and any other relevant legislation
• Participate in regular supervision sessions and appraisals with your line manager. Attend training and development activities as identified and participate in meetings as required
• Maintain administration systems and workspace used in a clean and tidy condition
• Maintain a good 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
• Work flexibly to meet the needs of clients
• Ensure mandatory training is up to date at all times
• Contribute to ongoing/new projects as required
• To undertake any other duties appropriate to the grade and purpose of the job as may be agreed by the post holder

WORK SETTING AND REVIEW

• The post holder will work autonomously to an agreed set of targets and objectives.
• They will manage their own time and case load, providing regular updates/progress reports to their line manager and to the GP practices they are based in.
• Participate in DHCs appraisal 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.

Person Specification

Qualifications

• Good standard of education with excellent literacy and numeracy skills

Experience

• Experience working with the general public in a similar role
• Experience working in a health care setting
• Experience working in the NHS/Primary Care General Practice setting
• Understanding of community services and personalised care
• Experience of managing a complex administrative role
• Experience of leading MDT Meetings in Primary Care

Skills

• Excellent communication skills (written and oral) including the ability to listen
• Strong and confident IT skills including MS Office and databases
• Excellent administrative skills working under own initiative at times
• Effective time management skills, often in a fast-paced environment
• Proven problem solving and analytical skills
• Ability to adapt to changing situations and changing needs of the service
• Excellent customer care skills
• Motivated to achieve good outcomes for patients
• Able to follow policies and procedures effectively
• Able to maintain confidentiality at all times
• Knowledge of GP clinical systems EMIS TPP SystmOne

Personal Qualities

• Polite & confident with good customer care skills remaining calm under pressure
• Caring, sensitive and empathetic sensitive to patients' life stages, concerns and problems.
• Self-motivated, reliable and dedicated
• Excellent interpersonal skills
• Motivated and proactive
• Ability to use initiative and judgement
• High levels of integrity and loyalty
• Ability to work under pressure
• Confident, assertive and resilient

Other requirements

• Disclosure and barring service check
• Willing and able to travel to other sites & locations to attend meetings and training events

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Depending on experience £9,000 per weekly session per year, up to 5 sessions available