GP with Extended Role in Frailty (GPwER)

Job responsibilities

Responsibilities:

Communication and engagement with system partners

Work with a wide range of professionals, including GPs, social workers, community nurses, physiotherapists and occupational therapists and acute frailty teams to encourage identification of patients and referral to the service.

Ensure a robust assessment process for confirming suitability for the service.

Support in accepting referrals from all health and care staff who approach the service, including GPs, social workers and community nurses.

Actively promote the service to professionals across the health and care system.

Proactive identification of patient and carer need

Support in proactively identifying patients who may benefit from the Enhanced Frailty Service.

Work with health and care professionals to identify individuals who may benefit from support.

Work with Internal and external stakeholders to deliver a seamless transition between Acute and the community.

Ensure patients have a Comprehensive Frailty Assessment (CFA) and an anticipatory care plan in place.

Consider and respond to the wider holistic needs of the patient and their carer to provide tailored, personalised support.

Provide case management and care navigation to support patients to remain in a community setting.

Planned multi-disciplinary care and support

Provide planned care and support as required, including medically prescribed clinical treatments, personal care, end of life care and wider health and social care as needed.

Ensure there is regular multi-disciplinary communication (including weekly huddles, touchpoint meetings and regular formal MDTs) to discuss caseload, review patients holistically and decide how best to care for the patient;

Put mechanisms in place to review patients regularly, track outcomes, and provide on-going support as required.

Responsive multi-disciplinary care and support

Ensure there is joint working with the Rapid Response Service and wider health and social care services to deliver the right care in the right place at the right time.

Put mechanisms in place to review patients who have needed unplanned, reactive care, to ensure patients and their carers receive the support and care they need to stay well.

Integrated working

Act as a building block, co-operating with other service providers to form a growing integrated care team.

Use reflective working and continuous improvement practices to support service delivery.

Work with other health and care providers to share information, jointly plan care and provide a streamlined, integrated service.

Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance through weekly touchpoint meetings.

Provide advice and guidance to GPs and wider teams.

This list is not exhaustive.

Please also refer to the attached job description for Additional Information.

Qualifications

Essential

• Full Registration with the GMC
• JCTGP/PMETB CCT
• BLS or higher
• Child Safeguarding
• Adult Safeguarding
• Satisfactory current appraisal

Desirable

• MRCGP
• Specialist older adult qualifications
• Postgraduate Diplomas (e.g. DGM, DRCOG)
• Management/Leadership qualifications

Personal Qualifications

Essential

• Good communication and interpersonal skills
• Proven and demonstrable leadership skills
• Demonstrate initiative, motivation and ability to put things into practice
• Calm under pressure
• High professional standards
• Committed to quality improvement

Desirable

• Due to the nature of our work, all posts are deemed to require Enhanced Disclosure clearance

Skills & Knowledge

Essential

• Use of EMIS Web
• Experience and knowledge within the speciality or related field
• Able to promote equality, diversity and rights
• Ability to participate and facilitate partnership working with other health care organisations
• Fully aware of health and safety issues

Desirable

• Formal presentation skills

Experience

Essential

• Post registration primary care experience
• Relevant clinical experience with older adult patients
• Experience working as a GPwSI (GPwER)

Desirable

• Involvement in research
• Experience in change management
• Evidence of management experience / training
• Understanding of budgets and finance

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).