An exciting opportunity has arisen for a GP with a specialist interest in frailty to deliver two sessions per week on a Monday within a new, integrated community-based service. The team supports the frail, housebound population across Easington and Sedgefield. This role offers the chance to play a pivotal part in shaping and delivering proactive, person-centred care in collaboration with local stakeholders. The Proactive Service has recently launched, aiming to bring joined-up, multidisciplinary support to patients to make a real difference in their health and wellbeing.
Please note, we are unable to offer sponsorship for a visa.
Main duties of the job
* Conduct Comprehensive Geriatric Assessments (CGAs) remotely.
* Perform medical, psychosocial, and medicines reviews, including advanced care planning.
* Manage diagnostic tests, communicate outcomes to GPs, and provide follow-up reviews where necessary.
* Make onward referrals to other specialties when appropriate.
* Work within and support a multidisciplinary team (MDT) including geriatricians, nurses, therapists, and social care professionals.
* Lead and facilitate MDT clinical decision-making processes.
* Supervise and support clinical staff.
* Take a leadership role in the development and expansion of frailty services.
* Contribute to the development of clinical guidelines, service pathways, and quality improvement initiatives.
* Participate in research, clinical audit, and service governance beyond revalidation requirements.
* Communicate effectively with patients, carers, colleagues, commissioners, and wider stakeholders.
* Promote and implement innovative, remote care models and use of digital health tools, including AI-based transcription.
* Uphold clinical governance standards and practice within national guidelines (e.g., NICE, GMC).
* Take part in staff supervision, performance review, appraisal, and professional development.
* Demonstrate emotional resilience, professionalism, and leadership under pressure and during service change.
About us
South Durham Health CiC manages five primary care networks in Sedgefield and Easington, serving a combined patient population of 204,554 across 21 practices. We are early adopters of the Integrated Neighbourhood Team strategy, having developed two Integrated Neighbourhood Teams aligned with NHS key strategies.
Job responsibilities
The GPwER in Frailty will provide evidence-based, comprehensive, person-centred, and individualised medical care for older people, working as part of a multidisciplinary team within community settings across South Durham. The role, demanding and challenging, requires specialist frailty knowledge to support the medical management of complex presentations of older frail individuals. This care will be delivered through our various community frailty workstreams.
The post involves working autonomously within a multidisciplinary team including consultant geriatricians, GPwERs, nurses, therapists, social care, third sector, and care home staff to deliver high-quality community care. The post holder will contribute to service development, guideline creation, research, and governance activities such as audits and quality improvement initiatives. Leadership in training and development of team members and the wider healthcare community is also expected, along with personal professional development opportunities.
Patient care responsibilities
Comprehensive Geriatric Assessment (Remote)
Manage patients referred into the service, including medical, psychosocial, medicines reviews, and advanced care planning in patients' homes. Communicate outcomes to patients, families, carers, and GPs via the MDT. Conduct follow-up reviews when clinically necessary, supervise staff including ANPs and Registrars, manage diagnostic tests, and support service expansion. Facilitate MDT decision-making and develop skills in AI-based transcription platforms.
Urgent Community Response
Provide CGA assessments with the MDT for patients suitable for review through the pathway, typically with multiple sub-acute issues requiring MDT support. The same principles of care as above apply.
Communication
Demonstrate excellent communication skills with patients, carers, colleagues, healthcare professionals, managers, commissioners, and media.
Analytical and organizational skills
Apply high-level clinical judgment and analytical skills in patient management, governance, and strategic service development. Maintain high personal organization to deliver clinical and managerial responsibilities, including planning service development and change management.
Physical skills
Maintain physical skills necessary for clinical practice, including hearing, vision, dexterity, mobility, and legibility.
Policy and service development
Contribute actively to daily operations and long-term service development, driving innovation and collaboration with organizations to meet local needs.
Resources and governance
Manage equipment and resources responsibly, ensure a secure environment, and participate in HR, information management, research, and quality activities.
Practice standards
Practice within organizational policies, national guidelines, and GMC ethical standards.
Service model principles
Deliver proactive, high-quality, patient-centred care using innovative remote models supported by a multidisciplinary team, engaging service users and their families, and continuously improving practice through education, feedback, and evidence-based approaches.
Person specification
* High-level clinical skills and ability to motivate multidisciplinary teams.
* Excellent communication and organizational skills, IT competency, and ability to work under pressure.
* Interest in research, teaching, and training.
* Qualifications: GMC registration, medical degree, teaching qualification, and ideally a Diploma in Geriatric Medicine or equivalent.
* Experience: supervising clinical staff, conducting audits, working with frail/older people, designing and delivering training, and familiarity with guidelines and clinical governance. Experience with SystmOne and Heidi Health is desirable.
Additional attributes
* Effective team player, adaptable, motivated, with integrity and a positive attitude to change.
Teaching & Training
* Ability to teach clinical skills and assess junior staff.
Disclosure
This post requires a DBS check as per legal and organizational policies.
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