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JOB SUMMARY 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 35K. 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 5 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 POSTThe 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 fashionProactively managing the care of frail people alongside the Community MatronGeneric prescribing adhering to local and national guidanceEffective management of long-term conditionsProcessing of administration in a timely manner, including referrals, repeat prescription requests and other associated administrative tasksUndertake telephone triage and prioritise home visits accordinglyMaintain accurate clinical records in conjunction with good practice, policy and guidanceWorking collaboratively across the PCN with all practices and partner organisations, and agenciesLead discussion about patients at both PCN-level MDTs and at Practice-level MDTsAdhere to best practice recommended through clinical guidelines and the audit processContribute to the successful implementation of continuous improvement and quality initiatives with the Practices and PCNAccept delegated responsibilityContribute effectively to the development and maintenance of the PCN, including clinical governance, training, financial management and HRCommit to self-learning and continuing professional developmentSupport the partners in achieving the strategic aims of the PCNReview and adhere to Practice/ PCN protocols and policies at all timesEncourage collaborative working, liaising with all staff regularly, promoting a culture of continuous improvement at all timesORGANISATIONAL POSITIONThe Frailty GP will report to the PCN Clinical Director and Service Manager.KEY PRINCIPLES OF THE FRAILTY GENERAL PRACTITIONER ROLEProactive management of the frail population and people at the end of their life (65yrs+)Identification of the people most at risk of deterioration/hospital admissionA multi-disciplinary team (MDT) approach to provide holistic careA defined caseload of people who have:An in-depth frailty assessmentsStructured medication reviews & falls assessmentsQuality conversations about end-of-life carePlanning for when care needs changeA personalised care plan agreed and enactedA key point of contactProactive intervention to avoid hospital admission - linking with the reactive community serviceINDIVIDUAL RESPONSIBILITIESAdhere to DHC and GP Practices policies and procedures and any other relevant legislationEnsure mandatory training is up to date at all timesParticipate in regular supervision sessions and appraisals with your line manager.Attend training and development activities as identified and participate in meetings as requiredMaintain administration systems and workspaces in a clean and tidy fashionMaintain 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 appropriateWork flexibly to meet the needs of patientsContribute to ongoing/new projects as requiredTo undertake any other duties appropriate to the grade and purpose of the job as may be agreed by the post holderWORK SETTING AND REVIEWThe 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.

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