Salaried GP Complex Care, Frailty and Care Homes

Care home medicine brings together some of the most rewarding parts of general practice: knowing people over time, making sense of complexity, supporting families and helping patients receive care that reflects what matters to them. At the One Weston Care Home Hub, GPs have the time, continuity and multidisciplinary support to do this work well.

THE OPPORTUNITY

We are looking for an experienced, compassionate GP to join our established Care Home Hub. This is complex, relationship-based general practice, not a narrow or routine care home role. You will hold an allocated caseload, allowing you to build continuity with residents, families and care home teams. You will also work alongside GPs, ACPs, nurses, pharmacists and colleagues in mental health. Clinical decisions are shared, different perspectives are valued.

WHAT MAKES THE ROLE DIFFERENT

• Meaningful clinical work. Time to understand the whole picture and make considered decisions, rather than repeatedly addressing isolated problems.
• A true MDT. Daily huddles, shared clinical thinking and specialist MDT support for palliative care, dementia, mental health.
• Continuity and a manageable workload. An allocated caseload, excellent administrative support and no ordinary practice workload.
• Time to support others. Dedicated space to provide clinical supervision, advice and feedback to ACPs and senior nurses within the MDT.

Main duties of the job

THE CLINICAL WORK

The role combines proactive and responsive care, with particular emphasis on advance care planning, palliative care, multimorbidity and diagnostic uncertainty. You will undertake holistic assessment, support treatment-escalation and ReSPECT planning, review residents whose health is changing, and help patients and families navigate difficult decisions with clarity and compassion.

The Hub also offers supported opportunities to build confidence in safeguarding, mental capacity and best-interest decision-making, learning disability, and the care of deteriorating people living with frailty. These are increasingly important capabilities for the future of general practice and neighbourhood health.

WHO THE ROLE WILL SUIT

You will be a confident generalist who values continuity, careful clinical reasoning and collaborative working. You should be able to provide clinical supervision to ACPs and senior nurses and be comfortable holding clinical responsibility while drawing appropriately on the team around you. Experience or a developing interest in palliative care, frailty or multimorbidity would be particularly welcome.

You do not need to arrive as a service-improvement expert or established clinical leader. For those who want it, there is scope to develop these capabilities through pathway improvement, teaching, quality improvement and the continued development of neighbourhood-based complex care. Mid-career GPs looking for their next challenge may find this job appeals.

About us

Pier Health Group is a GP-led super-partnership and Primary Care Network working across Weston-super-Mare to support high-quality, integrated care for a population of around 100,000 people. It brings together local practices and partners to develop services at neighbourhood and place level, with a strong focus on collaboration, innovation and improving care for people with complex needs.

The Care Home Hub is Pier Health's established at-scale care home service, based at 168 Locking Road, with roles employed by Pier Health and working as part of a multidisciplinary team across local care homes. The Hub was recognised nationally as a finalist in the 2023 HSJ Awards for Place-based Partnership and Integrated Care.

Job responsibilities

PURPOSE OF THE ROLE

The post holder will provide high-quality, relationship-based general practice to an allocated caseload of care home residents. The role combines continuity with proactive and responsive clinical care, allowing the GP to understand the whole picture and make considered decisions with residents, families and care home teams.

Working as a senior medical generalist within a true multidisciplinary team, the GP will focus particularly on advance care planning, palliative care, multimorbidity and diagnostic uncertainty. They will provide clinical supervision and decision support to ACPs and senior nurses while drawing on the complementary expertise of colleagues across pharmacy, community nursing, mental health and palliative care.

HOW THE ROLE WORKS

The GP holds an allocated caseload, supporting continuity with residents, families and care home teams. Each day begins with a whole-team check-in to share updates, discuss concerns, distribute work and identify the clinical lead for the day. Clinical work includes proactive reviews, ward rounds, comprehensive assessment, advance care planning, responsive assessment and family conversations. Time is built in for clinical supervision, peer learning, teaching, quality improvement and service development. Excellent administrative support enables clinicians to concentrate on clinical work and follow-through.

Key responsibilities

The responsibilities below describe the core of the role; they are intended to support good judgement, not replace it.

RELATIONSHIP-BASED CLINICAL CARE

• Provide proactive and responsive GP assessment for care home residents, using face-to-face, telephone, video and other appropriate formats.
• Undertake holistic assessment, identify and prioritise problems, and devise personalised management plans that use the skills of the MDT effectively.
• Maintain continuity with residents, families and care home teams, taking responsibility for follow-through and ongoing management.
• Lead advance care planning and treatment-escalation conversations, producing clear, realistic care plans and ReSPECT documentation in keeping with the wishes of residents and families.
• Assess acute deterioration and diagnostic uncertainty, arranging and interpreting investigations in a way that is proportionate to frailty, likely benefit and agreed treatment escalation.

SENIOR CLINICAL DECISION SUPPORT AND SUPERVISION

• Provide senior medical input for complex decisions and act as clinical lead of the day when allocated.
• Hold clinical responsibility for decisions concerning the GP's patients while drawing appropriately on the skills and perspectives of the MDT.
• Provide clinical supervision, advice, feedback and case discussion for ACPs, senior nurses, students and other members of the team.
• Contribute to a learning culture through significant-event review, case-based discussion, teaching and reflective practice.

MULTIDISCIPLINARY AND PARTNERSHIP WORKING

• Lead or participate in specialist MDTs for palliative care, dementia and mental health, and other complex-care needs.
• Work closely with care home staff and managers, pharmacists, community nurses, hospice colleagues, mental health teams, geriatricians and hospital services.
• Undertake structured medication review alongside pharmacy colleagues and support clinically appropriate prescribing and deprescribing.
• Provide outreach support where a complex case, a care home under pressure or a safeguarding concern would benefit from senior GP input.

CLINICAL GOVERNANCE, SAFETY AND PROFESSIONAL PRACTICE

• Promote adult safeguarding and apply the Mental Capacity Act, including best-interest decision-making, with support from colleagues where appropriate.
• Maintain timely, accurate clinical records and use agreed coding, templates and personalised care-planning standards.
• Prescribe safely and in accordance with the BNSSG formulary where clinically appropriate, working with the pharmacy team.
• Support delivery of relevant QOF, local enhanced service and contractual requirements without allowing process measures to displace person-centred care.
• Take part in audit, quality improvement, significant-event learning and other clinical-governance activity.

DEVELOPMENT OFFER

The role is designed for a confident generalist who wants to deepen meaningful clinical practice. The Hub offers supported opportunities to build capability in safeguarding, mental capacity and best-interest decision-making, learning disability, dementia and mental health, and the care of deteriorating people living with frailty. For those who want it, there is also scope to develop teaching, pathway improvement, quality improvement and clinical leadership. Career and personal development are supported through protected learning time, peer discussion and regular one-to-one conversations with the team leader.

Person Specification

Experience

• Experienced GP generalist
• Holistic assessment and management of complexity
• Safe community risk-holding and sound clinical judgement
• Current evidence-based practice
• Able to clinically supervise ACPs and senior nurses
• Experience of multidisciplinary working
• Able to give clear advice, constructive feedback and appropriate challenge
• Compassionate communication with residents and families
• Able to work with care home staff, managers and partner organisations
• Experience in palliative care, frailty, multimorbidity or care homes
• Teaching, educational supervision or team-development experience
• Experience influencing or improving care beyond an individual clinical encounter
• Interest in quality improvement, pathway development or neighbourhood health

Qualifications

• Qualifications and registration: MRCGP or equivalent
• GMC registration
• Adult safeguarding level 3
• Diploma of Geriatric Medicine, MRCP or a BGS Frailty Module completion
• Palliative Care interest or experience

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.

Depending on experience IRO £11-11,400 per session per annum.