Neighbourhood Frailty GP in Bognor Regis

An exciting opportunity has arisen for an experienced and enthusiastic GP to join Bognor Coastal Alliance (BCA) Primary Care Network as a Neighbourhood Frailty GP, playing a key role in the development of our Integrated Neighbourhood Frailty Team.

This is an opportunity to be part of an evolving approach to neighbourhood healthcare, supporting patients living with frailty, multiple long-term conditions and complex health needs through proactive, coordinated and personalised care.

Working alongside our Frailty Practitioner, MDT Coordinator and wider Integrated Neighbourhood Team (INT), you will provide senior clinical expertise, leadership and guidance to support early intervention, improve patient outcomes and reduce avoidable hospital admissions.

We are looking for a GP with a particular interest in frailty and complex patient management who is passionate about collaborative working, developing services and helping patients remain well and independent within their own communities.

*The role offers up to six sessions per week on a 12-month fixed-term contract, with flexibility for the sessions to be shared between more than one GP.

Main duties of the job

The Neighbourhood Frailty GP will provide clinical expertise and leadership within the Integrated Neighbourhood Frailty Team, supporting the identification, assessment and management of patients with frailty and complex health needs.

Key responsibilities include:

Undertaking Comprehensive Geriatric Assessments (CGA), structured medication reviews and anticipatory care planning.

Providing senior clinical assessment and management for patients in GP Practices, care homes and their own homes.

Developing personalised care and support plans to promote independence, prevent deterioration and reduce avoidable hospital admissions.

Providing clinical advice, guidance and support to the Frailty Practitioner, MDT Coordinator and wider multidisciplinary team.

Leading and contributing to multidisciplinary team meetings, complex case discussions and shared clinical decision-making.

Working collaboratively with GP Practices, community nursing, therapy services, mental health, social care and wider neighbourhood partners to ensure coordinated patient care.

Supporting effective clinical pathways, timely escalation and access to appropriate community and specialist services.

Contributing to the ongoing development, clinical governance and quality improvement of the Integrated Neighbourhood Frailty Team.

The role combines direct patient care with clinical leadership and multidisciplinary working, helping to establish a proactive, joined-up approach to frailty management across our local population.

About us

Bognor Coastal Alliance (BCA) Primary Care Network is an established partnership of three GP Practices: Grove House Surgery, Maywood Healthcare Centre and West Meads Surgery, collectively providing care to around 40,000 patients across Bognor Regis and the surrounding communities.

At BCA, we pride ourselves on being a supportive, collaborative and forward thinking network, with a strong commitment to delivering high quality, patient centred care. Our strength lies in our people, with a longstanding and experienced workforce who bring a wealth of knowledge, skills and expertise, alongside a genuine passion for making a positive difference to our patients.

We have developed a strong culture of teamwork and mutual support, where colleagues work closely across our Practices, sharing knowledge, ideas and best practice. We value our staff and strive to create a positive working environment where everyone feels supported, valued and encouraged to contribute.

As a progressive PCN, we continually look for opportunities to innovate, strengthen partnerships and develop services that respond to the changing needs of our population. Our developing Integrated Neighbourhood Frailty Team is an exciting example of this approach, bringing together expertise to deliver more proactive and personalised care.

Above all, we are a team that cares about our patients, our colleagues and the communities we serve, with a shared ambition to continually improve the care we provide.

Job responsibilities

The Neighbourhood Frailty GP willplay a key clinical role within the Integrated Neighbourhood Team (INT)/ PCN,contributing to the delivery of high-quality, proactive and personalised carefor patients living with frailty, multiple long-term conditions and complexhealth needs. The role will focus on improving patient outcomes, supportingindependence and reducing avoidable emergency hospital admissions through earlyintervention and coordinated multidisciplinary working.

Working alongside the Frailty Practitioner, MDT Coordinator and wider INT/ PCN Practice teams, the GP will provide senior clinical expertise, assessment and guidance to support the identification and management of patients at increased risk of deterioration. Responsibilities will include Comprehensive Geriatric Assessments (CGA), structured medication reviews, anticipatory care planning and the development of personalised care and support plans, with a particular focus on falls, heart failure, respiratory illness and care home residents.

The Neighbourhood Frailty GP will act as a key clinical point of contact for the INT, providing advice, clinical leadership and support with complex patient management, treatment decisions and appropriate escalation of care. Working collaboratively with the INT/ PCN Practices, community nursing, therapy services, social care and wider multidisciplinary colleagues, they will help ensure patients receive timely, coordinated care that meets their individual needs.

The Neighbourhood Frailty GP will also contribute to the ongoing development and effectiveness of the INT, supporting multidisciplinary discussions, strengthening clinical pathways and promoting consistent approaches to frailty management. Through clinical leadership, shared learning and quality improvement, the post-holder will help establish a sustainable, patient-centred service that supports the wider ambition of reducing avoidable hospital admissions and enabling patients to remain well and independent within their own homes.

Below are thecore responsibilities of the Neighbourhood Frailty GP role. This list is not exhaustive and will bereviewed on an annual basis or sooner if deemed necessary. There may be timeswhen the post-holder is required to carry out tasks outside of the list belowto assist with the needs of the INT/ PCN:

Proactive & Preventative Care

• Usethe AEAR list, ICT dashboards, local intelligence and clinical judgement toidentify and prioritise people for proactive support
• Prioritisetimely Comprehensive Geriatric Assessment (CGA) for everyone in the team'sfocus cohort where clinically indicated, covering clinical, functional, frailtyand mental health review, and track progress so no one is missed
• Carryout structured medication reviews (SMR) with the team pharmacist, includingdeprescribing
• Developdigital personalised care and support plans (PCSP), with agreed actions, namedresponsibility and review arrangements
• Leadanticipatory care planning (DNACPR, ReSPECT, LPA) and high-quality treatmentescalation planning (TEP)
• Focuson the leading drivers of admission risk: falls, congestive heart failure,flu/pneumonia and care home residents
• Holdnamed clinical responsibility where needed, and elevate when a plan is notachieving its intended outcomes

Clinical Care

• Providesenior clinical assessment in clinics, care homes and patients' homes
• Triagereferrals from practices and the team, prioritising home and care home visitsby need
• Respondto people at risk of deterioration to prevent avoidable admissions and A&Eattendances, linking with virtual wards, urgent community response and acutefrailty services
• Supportsafe, timely discharge and follow-up after hospital stays
• Prescribesafely in line with local formulary and national guidance
• Makeand follow up referrals to secondary care, community, mental health and socialcare services
• Keepaccurate, contemporaneous records in shared systems and code activity correctly

Multidisciplinary & NeighbourhoodWorking

• Promotea One Team approach to multidisciplinary and cross-organisational working,fostering strong relationships, shared responsibility and collaborativedecision-making to deliver coordinated, patient-centred care across the INT
• Leador contribute to INT and Practice MDT meetings and huddles, bringing a seniorgeneralist view
• Buildtrusting working relationships across primary care, community nursing, mental health,social care, hospital and voluntary sector colleagues
• Actas a clinical point of contact and source of advice for the team and localPractices
• Provideclinical supervision to team members such as physician associates, ACPs,paramedics and pharmacists where needed
• Teachand develop colleagues and learners from all professions and organisations whenrequired

INTFrailty Team Clinical Practice & Collaboration

• Actas a clinical anchor for the INT Frailty Team, providing senior clinicalexpertise and guidance, bringing together clinical perspectives and supportingconsistent, coordinated decision-making and patient-centred care
• Workclosely with the Frailty Practitioner and MDT Coordinator to support thedelivery of effective, proactive and personalised care for patients withfrailty and complex health needs
• Promoteeffective communication, shared decision-making and collaborative workingacross the core team, ensuring a consistent approach to patient assessment,management and escalation
• Supportopportunities for co-location with the Frailty Practitioner and wider teamwhere practicable, strengthening working relationships and facilitating timelyclinical discussions

ClinicalSupport & Supervision

• Clinicalsupport and clinical supervision serve different but complementary purposes,and both have a role within the core team
• Provideaccessible day-to-day clinical support to the Frailty Practitioner and widerINT team, including case discussions, raising concerns, exploring clinicaloptions and agreeing appropriate next steps
• Actas a key source of clinical advice and expertise, supporting colleagues withcomplex patient management and informed clinical decision-making
• Ensureclinical discussions and advice informing patient care are appropriatelydocumented, including the clinician consulted, in line with localrecord-keeping and information governance requirements
• Supportreflective practice, shared learning and professional development across themultidisciplinary team
• Wherespecifically agreed, provide formal clinical supervision to the FrailtyPractitioner, with protected time allocated within the GP's sessions and anagreed contribution to the practitioner's appraisal
• Ensureany formal supervision arrangements are documented through a written agreement,clearly defining responsibilities, escalation procedures, information-sharingarrangements and appropriate supervision records
• Maintainappropriate records of formal supervision and ensure these are shared with theemploying organisation in accordance with agreed arrangements

Links to wider services

• Buildand maintain strong working links with virtual wards, urgent community responseand the wider ICT
• Developclear routes to acute pathways and diagnostics, palliative and hospice care,specialist mental health, care home pathways, equipment and reablement, andhousing
• Usewarm transfers and direct clinician-to-clinician conversations to step peopleup or refer them on quickly
• Helpthe INT understand who to contact, how and when, so escalation is consistentacross the team
• Workclosely with the INT's named geriatrician on complex patients, through advice,joint review and shared decision-making

Working Across Community Organisations

• Workcollaboratively with colleagues employed by different organisations, promotinga unified and integrated approach to patient care within the INT
• Operatewithin the INT's agreed working arrangements, with day-to-day priorities,responsibilities and work plans coordinated by the INT and communicatedtransparently with the employing organisation
• Recognisethat employment, line management and performance management responsibilitiesremain with the employing organisation, in accordance with relevant contractualand subcontracting arrangements
• Followthe agreed INT work plan and timetable, ensuring alignment with the team'soperational priorities and service objectives
• Maintainindividual professional and clinical accountability for all clinical decisions,actions and omissions within the scope of the role, supported by the employingorganisation's clinical governance arrangements
• Ensurecollaborative working across organisational boundaries does not compromiseindividual clinical accountability or transfer responsibility for clinicaldecisions to other team members

Leadership,quality and governance

• Provideclinical leadership to the INT core team and help design and improve the localdelivery of the core offer
• Takepart in, and help deliver, the centralised training and support programme,including multiprofessional training and supervision in CGA, digital PCSPs,advance care planning and TEP
• Recorddecisions, action owners, timescales and outcomes to agreed MDT documentationstandards in shared care records
• Contributeto activity and outcome reporting through ICT and Neighbourhood Alliancegovernance
• Takepart in audit, quality improvement and evaluation of outcomes
• Followclinical governance, safeguarding, information governance and CQC requirementsof the employing organisation
• Raiseand learn from incidents, complaints and significant events
• Maintain own professional development, appraisaland revalidation

Person Specification

Skills

• Exceptional written and oral communication skills (including polite and professional telephone manner)
• Competent IT literacy, including clinical systems such as TPP SystmOne as well as MS Office and email
• Excellent negotiation, interpersonal and influential skills
• Able to efficiently plan and prioritise tasks and workflow
• Possess lead and ambassadorial skills
• Ability to apply evidence based researched into Pharmacy work and strategy
• Self-autonomous but able to work within teams
• Able to follow but also develop policy and procedures were deemed as necessary
• Capable to identify and resolve risk management issues in accordance with PCN and Practice standards
• Demonstrates commitment to continual service and process improvement
• Confident in the collection, analysis and presentation of data

Experience

• At least 2 years post-CCT in UK general practice; managing complex older patients and multimorbidity; medicines management
• Frailty, care home, community or intermediate care roles; MDT leadership; clinical supervision or education

Other requirements

• The right to work in the UK
• Full Driving Licence
• Occupational Health Clearance
• Flexibility to meet service needs
• Full GMC registration with a licence to practise; NHS England

Qualifications

• Diploma in Geriatric Medicine or postgraduate qualification in frailty or palliative care

Clinical Skills

• Experience in Comprehensive Geriatric Assessment; structured medication review; advance care planning conversations; clinical risk management
• Quality improvement and audit leadership; population health and risk stratification tools

Personal Qualities

• Collaborative across professional and organisational boundaries; supports and teaches others; works well autonomously and in a team
• Positive and confident persona
• Approachable and supportive towards colleagues and patients (able to empathise in difficult/ distressing situations)
• Able to use initiative and problem solve
• Resilient and able to operate in a calm professional manner during busy and high demand periods
• Flexible and cooperative dependant on the needs of the INT/ PCN/ Practice
• Highly motivated and focused
• Willing to learn and develop
• Experience of integrated or multi-organisation teams; leading service change

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.

£12,000 a session£12,000 per session annually