Job summary
In this role, the successful applicant will manage the PCN clinical frailty pathway (Hub) that all practices within this PCN can refer into. The post holder will provide a well-triaged frailty service and offer care in patients’ homes, providing a high-quality patient experience and a collaborative way of working across the system to reduce unplanned admissions to hospital.
The Frailty General Practitioner will be responsible for providing clinical leadership to the frailty hub team and medical leadership to the wider community team of Community Matrons, District Nurses, Pharmacists, etc. The PCN has worked together over several years and is therefore mature in its collaboration with member practices as well as external provider organisations. Our team of experienced clinical leads & GP partners will provide regular supervision.
Job location
Practice sites across South Tandridge PCN (Oxted Medical Practice, Pond Tail Surgery and Lingfield Surgery) with regular home visiting to frailty patients.
Main duties of the job
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.
Responsibilities
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 35,000. 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 five 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.
The Frailty General Practitioner will be 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.
Duties 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 as workload and staffing levels:
- Effective triage of referred and proactively identified patients to provide highly effective medical care to the entitled population in a timely fashion
- Proactively managing the care of frail people alongside the Community Matron
- 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
- Accept delegated responsibility
- Contribute effectively to the development and maintenance of the PCN, including clinical governance, training, financial management and HR
- Commit to self-learning and continuing professional development
- 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
Organisational position
The Frailty GP will report to the PCN Clinical Director and Service Manager.
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
- A multi-disciplinary team (MDT) approach to provide holistic care
- A defined caseload of people who have:
- An in-depth frailty assessments
- Structured medication reviews & falls assessments
- Quality conversations about end-of-life care
- Planning for when care needs change
- A personalised 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
- Ensure mandatory training is up to date at all times
- 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 workspaces in a clean and tidy fashion
- 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 patients
- 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 KPIs, 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.
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.
UK Registration
Applicants must have current UK professional registration.
Requirements
Other requirements
Essential
- Disclosure and barring service check
- Willing and able to travel to other sites & locations to attend meetings and training events
Skills
Essential
- 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 patient care skills
- Motivated to achieve good outcomes for patients
- Able to follow policies and procedures effectively
- Able to maintain confidentiality at all times
Desirable
Knowledge of GP clinical systems EMIS and/or TPP SystmOne
Personal qualities
Essential
- Polite & confident, 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 reliability
- Ability to work under pressure
- Confident, assertive and resilient
Experience
Essential
- 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 in managing a complex administrative role
Desirable
- Experience of leading MDT Meetings in Primary Care
Qualifications
Essential
- Good standard of education with excellent literacy and numeracy skills
About us
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 35,000. 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.
Benefits
- Competitive salaries
- Membership of the NHS pension scheme
- 27 days annual leave plus bank holidays, increasing with length of service
- Access to an Employee Assistance programme
- Opportunities for training, development and career progression
- Some of our sites have free on-site parking subject to availability
- We aim to be an employer of choice and conduct annual staff satisfaction surveys
- DHC actively encourage and promotes diversity, ensures all voices are heard and included and is committed to equal opportunities for all