Overview
In this role you will provide clinical leadership for a housebound and frailty-focused population within ARCH PCN. You will work across health and social care boundaries as part of a multidisciplinary team to deliver proactive home-based care and enhanced routine services for older people. You focus on frailty, complex care planning and reducing hospital admissions, while supporting urgent response pathways and ACPs. This is a mission-driven opportunity within the Ageing Well program to shape care delivery in the community. You will collaborate with practice partners and cross-functional teams to improve outcomes for frail patients.
Pay / Benefits
- NHS pension scheme
Responsibilities
- Provide day-to-day clinical leadership for housebound/general medical services; collaborate with registered practices
- Promote a multi-skilled team approach including Acute Home Visits, holistic assessment, follow-up and care planning
- Develop Acute Home Visiting and Community Urgent Response Service
- Deliver efficient, high-quality Acute Home Visiting/Community Urgent Response in patients' homes
- Ensure integration with system infrastructure (hospitals, 999, 111, ambulance) and routine services
- Develop expertise in frailty to improve lives in the community
- Promote self-care and social prescribing through non-statutory supports
- Maximize in-home care to reduce hospital/care home admissions
- Align care with patient wishes and end-of-life preferences
- Provide senior GP clinical triage for Acute Home Visits and support MDTs
- Lead and support ACPs in MDT, including mentoring and education
- Advise on complex prescribing and risk decisions in difficult clinical scenarios
- Liaise with GPs and frailty unit as needed
- Lead MDT meetings and quality improvement activities
- Contribute to new care pathways, standards and procedures
- Advise practices on multidisciplinary working for frailty
- Support CPD and mentorship within Ageing Well team
- Ensure accurate contemporaneous notes and timely task completion
- Collaborate with other teams to maintain efficient service
- Participate in audits and quality improvement initiatives
Key requirements
- Experience and interest in care of the elderly
- Understanding of adult safeguarding and DoLs procedures
- Experience of multidisciplinary working
- Experience of senior clinical triage for Acute Home Visiting
- Current GMC registration and GP on performers list
- Desirable: MRCGP, Care of the Elderly qualification, medical education/clinical supervision
- Full driving licence
- Strong leadership in multi-disciplinary settings
- Excellent organisational and communication skills
- Flexible
- Collaborative
- Team-oriented
- SystmOne or alternative clinical device
- Triage and risk assessment
- Complex prescribing decisions
Community GP employer: National Health Service
Betsi Cadwaladr University Health Board is an exceptional employer, offering a supportive and collaborative work environment for healthcare professionals in North Wales. With a commitment to employee development and a focus on compassionate care, staff have access to continuous professional development opportunities and the chance to make a meaningful impact in both acute and community paediatrics. The Health Board's integrated approach ensures that employees are part of a dynamic team dedicated to improving health outcomes for the local population.
