PCN - Community GP - Ageing Well

Job responsibilities

1. Leading a clinical team to provide proactive and reactive general medical services to the housebound population, including those in are homes, in collaboration with registered practices where appropriate;

2. Leading and coordinating across organisations;

3. Promote and deliver a multi-skilled team response that includes GP Acute Home Visits, holistic assessment, care, pro-active follow up and care planning;

4. Develop and deliver an efficient, high quality, multi-disciplinary Acute Home Visiting and Community Urgent Response Service to people who have an urgent need that is best provided in their own home, or wherever they call home;

5. Ensure that the Acute Home Visiting and Community Rapid Response Service that supports and links well to system infrastructure provided at a bigger scale e.g. Acute Hospitals, 999, 111, Ambulance services;

6. Ensure Acute Home Visiting and Community Urgent Response Service that links well to routine and proactive services;

7. Developing expertise within the community for improving the lives of people living with frailty;

8. Promoting the use of supportive, non-statutory services to support self-care and social prescribing agendas;

9. Maximise best care in the patient’s own home in order to reduce the need for hospital or care home admissions;

10. Ensure that the care and support people receive is based on their wishes, preferences and aspirations, particularly towards the end of their lives;

11. Provide medical expertise in the management of older people living with frailty in the defined community. To support ACP’s and wider MDT members working in the community by:

· Providing Senior GP clinical triage for all Acute Home Visit requests to determine the urgency and type of response needed, according to clinical need.

• Regular debrief sessions for patients on their caseload.
• Lead and support the ACPs in their role in the MDT
• Deliver formal and informal education for the ACPs during clinical interactions
• Advising on complex clinical situations including;

• Complex prescribing decisions,

• Where there are difficult clinical risk decisions.

• Where there is disagreement between professionals, patients or their carers.

• Diagnosis is uncertain

• Identification of end of life is difficult;

12. Liaison with GPs and frailty unit when needed;

13. Chairs and Contribute to multidisciplinary meetings/rounds;

14. Contribute to the development and implementation of new care pathways, systems and processes to support the service delivery;

15. Contribute towards the development and implementation of new standards, policies and procedures;

16. Advise local GP practices within the defined population to implement effective multidisciplinary working for people with frailty;

17. Contribute to CPD programmes for the members of the ageing well team:

• Clinical Mentorship/educational supervision of the team members including GP Registrars, Trainee ACPs, First contact practitioners;

18. Ensure contemporaneous notes are recorded and clinical tasks are updated and completed within the agreed timescales;

19. To work collaboratively with other teams and services to maintain an effective and efficient service;

20. Participate in quality improvements and innovations, e.g. audits, significant events analysis and development of protocols and new services.

Experience

Essential

• Experience and evidence of an interest in care of the Elderly
• Understanding of adult safeguarding and Deprivation of liberty procedures
• Experience of multidisciplinary working
• Experience of senior clinical triage for the Acute Home Visiting to determine the urgency and type of response needed, according to clinical need.

Desirable

• Knowledge and experience of carrying out Comprehensive Geriatric Assessment
• Experience of medical education/clinical supervision
• Experience of using SystmOne or another clinical device
• Experience of working in a multi-disciplinary team.
• Evidence of leadership development

Qualifications

Essential

• A vocationally trained and accredited GP
• Current registration with GMC
• On the GP performers list

Desirable

• MRCGP
• Recognised qualification in Care of the Elderly
• Recognised qualification in medical education/clinical supervision

Skills and Abilities

Essential

• The ability to understand the competencies of others and support them to work within and at the top of those competencies. Also, to recognise and act when others are going beyond their competency.
• Ability to work effectively and provide leadership across traditional organisational and professional boundaries.
• Ability to demonstrate leadership skills within a multidisciplinary team.
• Excellent organisational and communication skills.
• Ability to work effectively as a member of a team.
• Ability to work effectively with colleagues, patients and external organisations.
• Ability to triage patients in order of clinical need.
• Effective communication, verbally and in writing.
• Full driving license required as travelling required for the role.
• Committed to the development of integrated community teams.

Desirable

• Leadership of service delivery / change

Aptitude and Personal Qualities

Essential

• Flexible, supportive, collaborative.
• Recognise the benefits of multiagency & multidisciplinary team working.
• Ability to work as part of a multi-disciplinary team.
• Willingness to contribute to and participate in a peer support group.

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. For further information please see NHS Careers website (opens in a new window).