About this role
Job summary
Responsible to: Frailty Clinical Lead
Location: Sunderland (Neighbourhood-based)Sessions: 3 sessions + 0.375 CPD per week, working pattern to be agreed locallySalary: Actual Salary £39,164.06 per annum (WTE £104,437.50) - pending pay award
Contract type: 1 year fixed term
Benefits include:
NHS pension scheme
33 days holiday plus bank holidays (pro-rata)
Working hours aligned to core General Practice hours
About the Role
We are seeking an enthusiastic and forward-thinking General Practitioner with a Specialist Interest in Dementia and Frailty to join our evolving neighbourhood health model in Sunderland.
The role will help support and shape the newly developed primary care memory clinics as part of our Neighbourhood Programme. This is a unique opportunity to shape a proactive, community-based model of care, supporting people to live well at home, reducing avoidable hospital admissions, and improving outcomes for some of our most vulnerable residents.
You will work across neighbourhood teams, bringing clinical expertise, leadership, and innovation to deliver joined-up, person-centred care in partnership with primary care, community services, mental health, social care and the voluntary sector.
Main duties of the job
Brief Responsibilities
Deliver high-quality, patient-facing clinical care for people living with dementia, frailty and complex multimorbidity Undertake comprehensive clinical and cognitive assessments, contributing to timely and accurate diagnosis Develop, implement and review personalised care and management plans, including ongoing follow-up for complex cases Work as part of the Primary Care Memory Clinic and neighbourhood diagnostic pathways, supporting coordinated patient journeys Contribute to multidisciplinary team (MDT) discussions, shared decision-making and risk management Collaborate closely with GPs, community teams, specialists, social care and VCSE partners to provide joined-up care Undertake medication reviews, with a focus on polypharmacy and safe prescribing in line with specialist advice Provide continuity of post-diagnostic dementia and frailty care, including anticipatory care planning and carer support Deliver care across neighbourhood and community settings, supporting care closer to home Maintain high standards of clinical governance, record keeping and practice in line with NICE and local pathways
About us
For a second year in a row Sunderland GP Alliance has been listed in The Sunday Times Best Places to Work and Better Health At Work - Gold Award, offering 33 days annual leave and other benefits.
Sunderland GP Alliance is owned by the GP Practices of Sunderland and helps GPs work collaboratively for the benefit of patients and staff. We are a not-for-profit organisation, ensuring any surplus is reinvested back into better services for patients. By working together, our General Practice community is able to provide innovative services across the city, and work collectively with other key system partners. You'll find great examples of this approach across our website including information on our Enhanced Access service, Clinical Pharmacist provision, and ECG service.
Job description Job responsibilities
JOB PURPOSE
To provide high-quality, patient-facing clinical care for people living with frailty, dementia and complex multimorbidity, working as part of Sunderlands neighbourhood multidisciplinary teams and Primary Care Memory Clinic model. to ensure patients receive appropriate assessment, diagnosis and ongoing care closer to home.
This is a clinical role, focused on:
Direct patient care and assessment Supporting accurate and timely diagnosis Contributing to multidisciplinary decision-making Delivering ongoing management and follow-up for patients with dementia and frailty
The role contributes to Sunderlands neighbourhood ambitions by helping to ensure care is:
Coordinated and joined-up across services Delivered in community settings where possible Responsive to patient and carer needs
This role will bridge primary, community, and secondary care, improving system flow and integration
MAIN DUTIES AND RESPONSIBILITIES
Clinical Assessment & Patient Care
Provide face-to-face and remote clinical assessment for patients with:
Suspected dementia
Diagnosed dementia
Frailty and complex multimorbidity
Undertake:
Clinical history and examination
Cognitive assessment (as appropriate)
Initial investigations and interpretation
Develop and implement individualised care and management plans
Provide ongoing clinical review and follow-up, particularly for:
Patients with complex needs
Those at risk of deterioration
Contribution to the Dementia Diagnostic Pathway
Work as part of the Primary Care Memory Clinic / neighbourhood diagnostic pathway
Support:
Identification of patients with possible dementia
Initial assessment and appropriate referral into diagnostic services
Follow-up of patients post-diagnosis
Contribute to diagnostic processes alongside specialists, including:
Participation in MDT discussions
Providing relevant clinical information to support diagnostic decision-making
Ensure patients experience a clear and coordinated journey through the pathway
Improving diagnostic clarity and supporting timely decision-making within MDT settings
Working with Specialist Colleagues
Work collaboratively with:
Care of the Elderly Consultants
Specialist Dementia Nurses
Memory Assessment Services
PCN and Community Frailty Teams
Therapy services
Seek advice and input for:
Complex or uncertain cases
Medication management
Diagnostic clarification
Contribute to shared care, ensuring recommendations from specialist colleagues are implemented and followed up in primary care
Multidisciplinary Team Working
Participate in regular MDT meetings within the neighbourhood model
Contribute to: Case discussions, Shared care planning and Risk management
Work alongside:
General Practitioners
Frailty Teams
Community nurses
Allied health professionals
Mental health practitioners
Social care colleagues
VCSE colleagues
Medication Review & Management
Undertake medication reviews for patients with dementia and frailty
Support:
Safe prescribing
Monitoring of treatment effectiveness and side effects
Adjustments in line with specialist advice
Pay particular attention to:
Polypharmacy
Psychotropic medication use
Ongoing Dementia & Frailty Care
Provide continuity of care for patients following diagnosis
Support:
Care planning
Management of behavioural and psychological symptoms
Carer support (in collaboration with wider team)
Contribute to anticipatory care planning, including:
Future care preferences
Deterioration planning
Neighbourhood-Based Working
Deliver care within a neighbourhood model, including:
GP practices
Community settings
Care homes (where appropriate)
Support the aim of providing care closer to home, reducing the need for hospital-based care
Work flexibly across settings to meet patient need
Clinical Governance & Good Practice
Maintain accurate, timely and appropriate clinical records
Work in line with:
NICE guidance
Local dementia pathways
Information governance standards
Participate in:
Audit (as required)
Clinical governance processes
Training & Development
Fully participates in training and development
Engages in a programme of ongoing support and feedback to maximise the benefit of the training and development plan.
Confidentiality
In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.
Information relating to patients, carers, colleagues, other healthcare workers or the business of the Practice may only be divulged to authorised persons in accordance with the Alliance policies and procedures relating to confidentiality, and the protection of personal and sensitive data.
Health & Safety
The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the Practice Health & Safety Policy to include:
Identifying the risk involved in work activities and undertaking such activities in a way that manages those risks.
Using appropriate infection control procedures particularly those relating to needlestick injuries, maintaining work areas in a tidy and safe way and free from hazards.
Ensuring that all accidents or dangerous accidents are reported and investigated, and follow up action taken where necessary.
Maintain training in line with local policies.
Equality and Diversity
The post-holder will support the quality, diversity and rights of patients, carers and colleagues to include:
Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with current legislation.
Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rights.
Quality
The post-holder will strive to maintain quality within the Practice, and will:
Alert the Frailty Clinical Lead to issues of quality and risk.
Assess own performance and take accountability for own actions, either directly or under supervision.
Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhanced the teams performance.
Work effectively with individuals in other agencies to meet patients needs.
Effectively manage own time, workload and resources.
Communication
The post-holder should recognise the importance of effective communication within the team and will strive to:
Communicate effectively with other team members.
Communicate effectively with patients and carers.
Recognise peoples needs for alternative methods of communication and respond accordingly.
The employer is Sunderland GP Alliance and the post-holder is expected to comply with the Alliances employment policies and procedures.
Person Specification
Qualifications Essential
MBBS (or equivalent medical qualification) Practising General Practitioner Full registration with the GMC with licence to practise Inclusion on the NHS Performers List
Experience Essential
EXPERIENCE AND KNOWLEDGE Experience of working as a GP in primary care Experience in the assessment and management of older adults, including frailty and/or dementia Experience managing patients with complex needs and multimorbidity Experience of medication review and prescribing in older people Experience contributing to multidisciplinary team (MDT) working, including case discussions and shared care planning Knowledge of: -Dementia assessment, diagnosis and management -Frailty syndromes and holistic care of older adults -Multimorbidity and polypharmacyDemonstrable interest in dementia care or older peoples health Experience of working with: -Memory services -Community geriatrics -Mental health services for older people Experience supporting patients in: -Care homes -Community or home-based settings
Desirable
Demonstrable interest in dementia care or older peoples health Experience of working with: -Memory services -Community geriatrics -Mental health services for older people Experience supporting patients in: -Care homes -Community or home-based settings
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 Sunderland GP Alliance
Address North East BIC
Wearfield
Sunderland
Tyne and Wear
SR5 2TA
United Kingdom
Employer's website https://www.sunderlandgpalliance.co.uk/ (Opens in a new tab)