GP with an Interest in Frailty, Integrated Neighbourhood Team @ Integrated Family Healthcare

Job summary

The GP with an Interest in Frailty is one of the three core roles in the INT team, alongside the MDT Coordinator and the Frailty Practitioner. Together they assess people on the AEAR list, carry out CGA and structured medication review, and build digital care and support plans, anticipatory care plans and treatment escalation plans. The GP and/or the Frailty Practitioner act as the team's clinical lead.

The role brings senior generalist expertise and the link to core general practice. It combines direct patient care with clinical leadership: supporting and developing colleagues from every organisation in the teamand helping the INT achieve a 10% reduction in avoidable emergency admissions for the cohort.

Main duties of the job

Proactive and preventative care

Use the AEAR list, ICT dashboards, local intelligence and clinical judgement to identify and prioritise people for proactive support.

Prioritise timely Comprehensive Geriatric Assessments (CGA) for the team's focus cohort where indicated, covering clinical, functional, frailty and mental health needs, and track progress.

Carry out structured medication reviews (SMR) with the team pharmacist, including deprescribing.

Develop digital personalised care and support plans (PCSP), with agreed actions, named responsibilities and review arrangements.

Lead anticipatory care planning (DNACPR, ReSPECT, LPA) and treatment escalation planning (TEP).

Focus on admission risks: falls, heart failure, flu/pneumonia and care home residents.

Hold clinical responsibility where needed and escalate when plans are not achieving intended outcomes.

Clinical careProvide clinical assessments in clinics, care homes and patients' homes.

Triage referrals from practices and the team, prioritising home and care home visits by need.

Respond to deterioration risks to prevent avoidable admissions and A&E attendances, linking with virtual wards, urgent community response and frailty support.

Support timely discharge and follow-up after hospital stays.

Prescribe safely in line with formularies and national guidance.

Make and follow up referrals to secondary care, community, mental health and social care services.

Maintain accurate, timely records in shared systems and code activity correctly.

About us

Working in our Integrated Neighbourhood Teams

INTs bring together GPs, community health, mental health, social care and voluntary sector partners to provide joined-up care, helping people stay well and independent at home.

The Sussex Neighbourhood Health core offer

Each INT covers around 30,00050,000 people within an Integrated Community Team (ICT). In 2026/27, the priority cohort is people on the Avoidable Emergency Admission Risk (AEAR) list, including those with complex multimorbidity and adults aged 65+ with frailty at highest risk of admission. Priorities include falls, heart failure, flu/pneumonia and care home residents. The aim is to reduce avoidable emergency admissions by 10%.

What the core offer includes

• Identifying people using the AEAR list, ICT dashboards and clinical judgement.
• Comprehensive Geriatric Assessments (CGA), falls assessments and structured medication reviews.
• Personalised care plans, anticipatory care planning (DNACPR, ReSPECT, LPA) and treatment escalation plans.
• MDT input, links with registered practices and shared records to track actions and outcomes.

The team and support

The core team comprises an MDT Coordinator, Frailty Practitioner and GP with an Interest in Frailty, supported by health and care partners. Each INT has named geriatrician, links to virtual wards, urgent community response, plus centralised training and support. Delivery and outcomes are reported through ICT and Neighbourhood Alliance governance.

Job description

Job responsibilities

GP with an Interest in Frailty

Integrated Neighbourhood Team (INT)

The GP with an Interest in Frailty is one of the three core roles within the Integrated Neighbourhood Team (INT), alongside the MDT Coordinator and Frailty Practitioner. The role combines senior generalist clinical expertise, direct patient care and clinical leadership to provide proactive, joined-up support for people at highest risk of avoidable emergency admission.

Working across primary care, community health, mental health, social care and voluntary sector services, the GP helps identify people at rising risk, coordinate timely assessment and develop personalised plans that support people to remain well and independent at home. The GP and/or Frailty Practitioner may act as the team's clinical lead.

The Integrated Neighbourhood Team

INTs bring together professionals from different organisations to work as one multidisciplinary team around a local population. Each INT covers approximately 30,00050,000 people within an Integrated Community Team (ICT).

The 2026/27 Year 1 cohort is drawn from the Avoidable Emergency Admission Risk (AEAR) list and includes people with high-complexity multimorbidity and adults aged 65 and over with frailty who are at highest risk of admission. Initial areas of focus are falls, congestive heart failure, flu/pneumonia and care home residents. The programme aims to achieve a 10% reduction in avoidable emergency admissions.

Comprehensive Geriatric Assessments (CGAs) for the focus cohort are the first priority. The INT's core offer also includes falls assessment, structured medication review, digital personalised care and support plans, anticipatory care planning, treatment escalation plans, proportionate MDT input and shared care records. Each person should have clear links with their registered practice, with actions and outcomes visible and followed through.

Key responsibilities

1. Proactive and preventative care

• Use the AEAR list, ICT dashboards, local intelligence and clinical judgement to identify and prioritise people who would benefit from proactive support.
• Prioritise and support timely Comprehensive Geriatric Assessments (CGA) for people in the team's focus cohort where clinically indicated. Assess clinical, functional, frailty and mental health needs, and monitor progress to ensure people are not missed.
• Work with the team pharmacist to undertake structured medication reviews (SMRs), including consideration of deprescribing.
• Develop digital personalised care and support plans (PCSPs), setting out agreed goals and actions, named responsibility and review arrangements.
• Lead anticipatory care planning, including discussions and documentation relating to DNACPR, ReSPECT and lasting power of attorney (LPA), as appropriate.
• Develop high-quality treatment escalation plans (TEPs) with patients, families and relevant professionals.
• Focus proactive interventions on the leading drivers of admission risk, including falls, congestive heart failure, flu/pneumonia and care home residents.
• Hold named clinical responsibility where needed and review, escalate or adapt care when a plan is not achieving its intended outcomes.

2. Clinical assessment and care

• Provide senior clinical assessment in clinics, care homes and patients' homes, according to clinical need.
• Triage referrals from local practices and the INT, prioritising home and care home visits according to need and risk.
• Respond to people at risk of deterioration, taking appropriate action to prevent avoidable hospital admissions and A&E attendances.
• Work closely with virtual wards, urgent community response and acute frailty services to coordinate timely assessment, intervention and escalation.
• Support safe and timely discharge from hospital, including appropriate follow-up and coordination with community and primary care services.
• Prescribe safely in accordance with the local formulary and national guidance.
• Make and follow up referrals to secondary care, community, mental health and social care services, ensuring appropriate communication and continuity.
• Maintain accurate, contemporaneous clinical records in shared systems and ensure activity is coded correctly.

3. Multidisciplinary working and clinical leadership

• Lead or contribute to INT and practice MDT meetings and huddles, bringing a senior generalist perspective to shared decisions and care planning.
• Build effective working relationships across primary care, community services, mental health, social care, hospitals and voluntary sector partners.
• Act as a clinical point of contact and source of advice for INT colleagues and local practices.
• Provide clinical supervision, advice and support to team members, and contribute to teaching and developing colleagues and learners from different professions and organisations.
• Work as part of one integrated team, sharing information and decisions appropriately rather than acting solely as a representative of the employing organisation.
• Support the MDT Coordinator and Frailty Practitioner, helping the core team work effectively and deliver the INT's agreed priorities.

4. Links with wider services and pathways

• Build and maintain strong links with virtual wards, urgent community response and the wider Integrated Community Team.
• Work closely with the INT's named geriatrician on complex patients, using advice, joint reviews and shared decision-making where appropriate.
• Develop and maintain clear routes into acute pathways and diagnostics, palliative and hospice care, specialist mental health, care home pathways, equipment, reablement and housing services.
• Use warm transfers and direct clinician-to-clinician communication to ensure people are stepped up or referred on promptly when their needs change.
• Help the wider team understand which services to contact, how to access them and when escalation is required, supporting consistent practice across the INT.

5. Leadership, quality and service development

• Provide clinical leadership to the INT core team and contribute to the design, development and improvement of local delivery of the Sussex Neighbourhood Health core offer.
• Take part in and help deliver the centralised training and support programme, including multidisciplinary training and supervision in CGA, digital personalised care and support plans, advance care planning and treatment escalation planning.
• Ensure MDT decisions, action owners, timescales and outcomes are recorded in line with agreed documentation standards and shared care record requirements.
• Contribute to activity and outcome reporting through ICT and Neighbourhood Alliance governance arrangements.
• Participate in audit, quality improvement and evaluation to assess impact and improve the service.
• Work in accordance with the employing organisation's clinical governance, safeguarding, information governance and CQC requirements.
• Raise and learn from incidents, complaints and significant events, supporting a culture of safety and continuous improvement.
• Maintain own professional development, appraisal and revalidation.

General responsibilities

• Treat patients, carers and colleagues fairly and with dignity and respect, promoting equality, diversity and inclusion.
• Recognise and act on safeguarding concerns involving adults and children, following local procedures.
• Maintain confidentiality and protect patient information, sharing it appropriately under agreed information governance and data-sharing arrangements.
• Take reasonable care of personal and others' health and safety, including when undertaking lone working and home visits.
• Contribute to continuous improvement in how the INT operates and delivers care.
• Complete induction with the employing organisation and the INT, including induction to the practices with which the role works.
• Follow the policies and procedures of the employing organisation and the standards of the relevant professional body.

Role details

Employer: Primary care host organisation: Sussex Integrated Health, a host GP federation, PCN or practice (to be confirmed for each INT).

Sessions: To be agreed locally for each area.

Pay: £12,500 per session.

Contract: Permanent.

Base: The relevant neighbourhood/INT, with work across practices, care homes, community settings and patients' homes.

Accountable to: Employing organisation's Clinical Director.

Clinical supervisor: A named clinician working within the INT.

Annual leave: 30 days pro rata, agreed with the clinical supervisor.

Working relationships: INT members across primary care, community, mental health, social care and voluntary sector services.

Person Specification

Qualifications

Essential

• MRCGP or equivalent; CCT in general practice
• Full GMC registration with a licence to practice; NHS England Performers List; appropriate indemnity; right to work in the UK
• At least 2 years post-CCT in UK general practice; managing complex older patients and multimorbidity; medicines management
• Experience in Comprehensive Geriatric Assessment; structured medication review; advance care planning conversations; clinical risk management
• Collaborative across professional and organisational boundaries; supports and teaches others; works well autonomously and in a team
• Person-centred, proactive, empathetic in distressing situations; good judgement under pressure; committed to CPD
• Competent IT skills
• Full driving licence and access to a car; enhanced DBS check; occupational health clearance; flexibility to meet service needs

Desirable

• Diploma in Geriatric Medicine or postgraduate qualification in frailty or palliative care
• Clinical or Educational Supervisor Training
• Frailty, care home, community or intermediate care roles; MDT leadership; clinical supervision or education
• Quality improvement and audit leadership; population health and risk stratification tools
• Experience of integrated or multi-organisation teams; leading service change
• Interest in service development and system change
• SystmOne, EMIS

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

Integrated Family Healthcare

Address

Marlborough House, 19-21 Warrior Square

St. Leonards on Sea

East Sussex

TN37 6BG

United Kingdom

Employer's website

https://www.ifhfederation.org/ (Opens in a new tab)