About this role
Job summary
This is a new role funded by the Launceston and Tamar Valley Integrated Neighbourhood Team (INT). The post holder will be employed by Launceston Medical Centre while working with the wider neighbourhood to develop and implement a frailty model of care, incorporating a proactive care test and learn project and improving coordination across the INT.
The role combines clinical frailty work with service development, collaboration and clinical leadership. As the project develops, the balance of duties may vary to reflect the stage of implementation and learning.
The Frailty Test and Learn is an 18-month project aiming to improve care for people living with frailty. It will focus on early identification, proactive support and better coordination across services, with the intention of improving outcomes for people while reducing avoidable use of acute hospital care.
The project will primarily focus on people aged 65 and over living with moderate to severe frailty.
The two principal goals of the test and learn are to -
Reduce non-elective admissions to acute hospitals for the identified cohort.
Reduce length of stay and bed days within acute settings for the identified cohort through a system-wide, co-designed pull model supporting earlier discharge.
The post holder will be part of the Launceston and Tamar Valley INT frailty team and will contribute actively to the co-design, implementation and evaluation of this project.
Main duties of the job
As the role sits within a developing neighbourhood frailty model, responsibilities will evolve with the project. Expected responsibilities include -
Spend time with organisations and professionals within the INT frailty team to understand their roles, capacity, pathways and workload.
Build effective working relationships across organisations and help identify and reduce barriers to collaboration.
Work with the INT to improve coordination of frailty care across the neighbourhood and reduce duplication between services.
Collaborate with system partners in the development of the pull model intended to support earlier and safer discharge from acute care.
Take an active role in overseeing implementation of the Frailty Test and Learn within Launceston Medical Centre, working closely with the social prescribing team, Health Hub, managers and other relevant staff.
Contribute to the evaluation of the project, including clinical governance, quality improvement, learning, service outcomes and changes required as the model develops.
About us
Launceston Medical Centre is a large dispensing practice providing care to around 19,000 patients in and around Devon and Cornwall.
We enjoy working from modern, purpose-built premises. The partners and staff have a shared belief in the delivery of high quality, traditional and personal family healthcare. Our patients enjoy good access to care, and we have a strong ethos to recognise their needs when driving forward patient services. It is important to the partners to treat our staff well. We are proud to be a teaching Practice. To promote a multi-disciplinary team approach, we share our premises with other providers including mental health services and social prescribers.
Job description Job responsibilities
The clinical element of the role will focus predominantly on proactive frailty care and medical input where GP expertise adds value within the wider multidisciplinary model.
Review the clinical records of patients identified through agreed IT, population-health or risk-stratification processes to assess suitability for proactive frailty intervention.
Undertake face-to-face or telephone reviews where required. These will mainly be proactive appointments agreed through the co-design of the test and learn and are likely to include medication review, falls assessment, long-term condition review and assessment of complex multimorbidity.
Provide medical review for selected same-day or more complex frailty presentations where a medical problem has been identified and the patients usual GP is not available to provide continuity.
Routine urgent and first-contact care will continue to be managed through the Practices established access and duty arrangements. Requests from the wider INT for medical assessment or appointments would ordinarily enter through these usual routes.
Provide medical supervision, advice and support to members of the Launceston Medical Centre team involved in the Frailty Test and Learn, for example the social prescriber, frailty nurse and care coordinator, within appropriate professional and governance arrangements.
Provide medical advice to the wider INT team where appropriate, supporting shared clinical decision-making and escalation.
Contribute medical expertise to holistic assessment, personalised care planning and comprehensive geriatric assessment undertaken across the multidisciplinary team.
Undertake and support structured medication review and appropriate deprescribing, balancing clinical guidance, treatment burden, safety, quality of life and patient priorities.
Contribute to advance care planning, treatment escalation planning and end-of-life discussions where medical input is required.
Undertake home visits where GP assessment is clinically necessary, while working closely with the wider multidisciplinary team and community services to avoid duplication of work.
Maintain accurate contemporaneous clinical records and complete referrals, prescribing, results and other administration arising directly from the post holders clinical work within agreed timescales.
Recognise and respond appropriately to safeguarding concerns, mental capacity issues, carer strain, self-neglect and other risks associated with frailty and vulnerability.
MULTIDISCIPLINARY WORKING
The post holder will attend regular multidisciplinary meetings as required. The anticipated structure is:
Daily MDT focused on urgent care and admission avoidance.
Weekly MDT focused on proactive care and patients within the Frailty Test and Learn project.
Monthly MDT discussion of patients requiring input from the wider team, including specialist geriatric input where available.
The exact frequency and format of MDT working may change as the project develops.
CLINICAL LEADERSHIP
The post holder will act as Frailty Lead GP within Launceston Medical Centre. Drawing on their experience of working with the wider INT, they will provide clinical advice, education and support to the Launceston Medical Centre team and help develop effective frailty pathways within the Practice and neighbourhood.
INDICATIVE JOB PLAN
The final job plan will be agreed with the successful applicant and may vary depending on the progress and evolution of the INT project. The initial anticipated four-session job plan is:
0.5 session MDT activity.
1.5 sessions project co-design, collaboration, pathway development and implementation.
2 clinical sessions face-to-face appointments and/or telephone reviews as required, predominantly proactive care, with some capacity potentially reserved for same-day or complex frailty patients requiring medical review.
The balance between these elements will be reviewed as the test and learn develops, ensuring that the role remains aligned with the aims of the project and the needs of the wider INT.
GENERAL RESPONSIBILITIES
Work in accordance with Launceston Medical Centre policies and procedures and contribute to their review and development where relevant to the frailty service.
Attend relevant internal and external clinical, multidisciplinary and service-development meetings, representing the Practice and contributing to the wider INT where required.
Maintain relevant clinical knowledge and skills through continuing professional development and annual appraisal, including current evidence and guidance relating to frailty and complex care.
Work within GMC standards of good medical practice and maintain positive, collaborative relationships across primary, community, secondary and social care.
Person Specification
Professional Skills Essential
Up-to-date clinical knowledge relevant to frailty, multimorbidity and complex care Ability to provide proactive medical assessment and clinical decision-making for patients with frailty and complex needs within a multidisciplinary model Ability to contribute medical expertise to holistic assessment and personalised care planning undertaken by the wider team Ability to balance evidence-based medicine, clinical risk, treatment burden and patient choice Excellent communication skills, including sensitive conversations with patients and families Ability to work effectively across organisational and professional boundaries Ability to support, advise and supervise other members of the multidisciplinary team within appropriate governance arrangements Excellent digital and clinical record-keeping skills
Desirable
Experience of clinical leadership or supporting other clinicians Ability to use population-health or risk-stratification tools Experience of integrated neighbourhood or multidisciplinary service development
Qualifications Essential
Qualified GP Inclusion on the GMC Register Eligibility to practise independently in the UK Evidence of continuing professional development
Desirable
MRCGP Relevant qualification or training in frailty, geriatrics, palliative care or complex care
Experience Essential
Experience of working as a General Practitioner Experience of managing older people with frailty, multimorbidity or complex care needs Experience of autonomous clinical decision-making and clinical risk management Experience of multidisciplinary working across organisational boundaries
Desirable
Experience of contributing to comprehensive geriatric assessment within a multidisciplinary team Experience of community, care-home, palliative or end-of-life care Experience of service development, pathway redesign or test-and-learn / quality-improvement projects Experience of SystmOne
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).
Employer details Employer name Launceston Medical Centre
Address Landlake Road
Launceston
Cornwall
PL15 9HH
United Kingdom
Employer's website http://www.launcestonmedicalcentre.co.uk/ (Opens in a new tab)