About the Role
As a General Practitioner in the Care Management Service (CMS), you will provide clinical leadership and expertise within multidisciplinary neighbourhood teams, supporting the delivery of proactive care to patients with complex health and social care needs.
You will work collaboratively with clinicians, care coordinators, community teams, social care professionals and voluntary sector partners to identify opportunities to improve outcomes, reduce avoidable hospital utilisation and enhance patient experience.
In this role, you will have the opportunity to utilise your clinical expertise beyond traditional general practice, influencing system-wide care delivery and helping to shape innovative models of integrated care.
Key Responsibilities
- Provide clinical leadership and oversight within multidisciplinary team meetings.
- Support identification, assessment and management of patients at high risk of unplanned healthcare utilisation.
- Contribute to development, review and optimisation of personalised care and support plans.
- Collaborate with clinicians, care coordinators, community teams, social care professionals and voluntary sector partners to identify opportunities to improve outcomes, reduce avoidable hospital utilisation and enhance patient experience.
- Deliver proactive care to patients with complex health and social care needs.
- Deliver regular clinical and social support, ensuring timely access to appropriate services and interventions.
- Provide responsive care and escalation support to prevent health crises and avoidable hospital admissions.
- Support effective discharge planning and reduce risk of hospital readmissions.
- Coordinate care across organisational boundaries to improve patient outcomes and experience.
Background
The CMS operates across Suffolk's fourteen Integrated NHS Teams, building on early adopter programmes and a flexible “test, learn and develop” approach. It brings together professionals from health, social care, community services and the voluntary sector to deliver coordinated, person-centred care.
As part of the NHS Long Term Plan and the development of Integrated Care Systems, the CMS supports a shift from reactive healthcare towards prevention, early intervention and personalised care, affirming the NHS's ambition to transform care through neighbourhood-based models.
Organisation
The Care Management Service is supported by Suffolk GP Federation CIC, a not‑for‑profit community interest company that supports primary care across Suffolk, North East Essex and beyond.
Care Management Service employer: Cardiff and Vale University Health Board
Cardiff and Vale University Health Board is an exceptional employer, offering a supportive environment for aspiring nephrologists. With a focus on professional development, extensive training, and opportunities for research and teaching, employees can thrive in their careers while contributing to meaningful patient care in a vibrant community. The work culture promotes collaboration and innovation, making it an ideal place for those looking to make a significant impact in healthcare.
Contact Details:
Cardiff and Vale University Health Board Recruitment Team
