General Practitioner (GP) - Community Frailty Service (5 sessions)
An exciting opportunity has arisen for an experienced General Practitioner/Community Geriatrician with a special interest in frailty and/or palliative care to join the Retford and Villages PCN, working closely with the Bassetlaw Integrated Neighbourhood Team. The role is centered around supporting patients in the most deprived areas of the community.
This post is a new role but will work in tandem with our existing community-based frailty service, aiming to provide proactive, person-centred care for individuals living with frailty across our local area within the Retford & Villages Primary Care Network (PCN).
Main duties of the job
Main objectives
* Provide high-quality, community-based care to patients identified as living with frailty, particularly for those residing in areas of high deprivation.
* Work as part of a multidisciplinary team (MDT), including community nursing, social care, therapy, secondary care, and voluntary sector colleagues, building relationships within the Integrated Neighbourhood Team.
* Contribute to anticipatory care planning, care home support, and end-of-life care.
* Participate in MDT meetings and care reviews to ensure a holistic approach to patient needs.
* Support early identification of frailty and offer timely interventions to maintain independence and reduce hospital admissions.
About us
Retford & Villages PCN comprises 5 General Practices including Riverside Health Partnership, Kingfisher Family Practice, Crown House Surgery, Tuxford Medical Centre, and North Leverton Surgery. With a patient population of nearly 60,000 people, we are the largest of the three PCNs in Bassetlaw. The area we cover is largely rural. Retford and Villages PCN is a collaborative and progressive network, committed to improving the health and wellbeing of our local population. You'll work within a strong network of practices and be supported by the wider Bassetlaw Integrated Neighbourhood Team—a model of partnership working that includes primary care, community services, and local authorities.
We value innovation, teamwork, and compassionate care. This role offers the chance to shape services and be part of an ambitious team making real change on the ground.
Please note that this is a community-based role where the ability to travel is essential. The role will involve visiting patients (in their homes/care homes) plus administration, meetings, training, etc. (based across PCN Practices/remote working TBC).
The Employer for this role will be Fidelium Health Limited (Riverside are a part of the PCN but your contract will be with Fidelium Health Limited).
We are unable to offer sponsorship for this role.
Job responsibilities
Main objectives
* Provide high-quality, community-based care to patients identified as living with frailty, particularly for those residing in areas of high deprivation.
* Work as part of a multidisciplinary team (MDT), including community nursing, social care, therapy, secondary care, and voluntary sector colleagues, building relationships within the Integrated Neighbourhood Team.
* Contribute to anticipatory care planning, care home support, and end-of-life care.
* Participate in MDT meetings and care reviews to ensure a holistic approach to patient needs.
* Support early identification of frailty and offer timely interventions to maintain independence and reduce hospital admissions.
Job Description
Clinical Duties:
* Provide direct patient care for frail individuals, including comprehensive geriatric assessments, medication reviews, and advance care planning.
* Lead or participate in regular multidisciplinary team (MDT) meetings.
* Contribute to and oversee the development of personalised care and support plans.
* Work closely with care coordinators, practice administration teams, community nurses, therapists, social care teams, and the voluntary sector to ensure holistic care.
* Support early identification and stratification of patients living with frailty.
* Manage end-of-life care planning and delivery in line with patient wishes and national guidance.
* Actively engage with PCN colleagues and Bassetlaw Integrated Neighbourhood Team to improve pathways and care models.
* Contribute to audit, quality improvement initiatives, and service development.
* Participate in local frailty-related learning and development activities.
Leadership & Education:
* Share knowledge and expertise with colleagues, including mentoring and training where appropriate.
* Help develop the clinical skillset of wider team members in managing frailty and palliative care.
Person Specification
Experience
* Experience in primary care and/or community settings.
* Demonstrable experience or interest in frailty and/or palliative care.
* Experience in integrated care systems or multidisciplinary work.
* Experience in care home medicine or complex case management.
Qualifications
* GMC-registered GP/Community Geriatrician with license to practice.
* Additional training in frailty, geriatrics, or palliative care.
Skills
* Excellent clinical reasoning and decision-making.
* Strong communication, team-working, and interpersonal skills.
* Ability to work effectively within an MDT.
* Organised and efficient work ethic.
* Proficient use of clinical systems (Systmone, EMIS, and related digital systems).
* Teaching or mentoring experience.
Values
* Commitment to community-based, patient-centred care.
* Compassionate, person-centred, and proactive approach to care.
* Takes responsibility for professional development, learning, and performance.
* Commitment to equality, diversity, and inclusion.
* Commitment to service innovation and development in primary care.
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.
Retford & Villages PCN Geographical Area
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