Gp With An Interest In Frailty

Job summary South Downs Health and Care (SDHC) is seeking a compassionate, enthusiastic and motivated Salaried GP with an Interest in Frailty to join our Integrated Neighbourhood Team (INT) in Eastbourne. This is an exciting opportunity to make a meaningful difference to the lives of older people and those living with frailty, helping them remain healthy, independent and supported within their communities. Working as part of a supportive multidisciplinary team, you will provide expert clinical care to patients with frailty, multiple long-term conditions and complex health and social care needs. You will play a key role in delivering proactive, personalised care, preventing avoidable hospital admissions and improving patient outcomes. You will work closely with Frailty Practitioners, community services, local GP practices and wider health and social care partners to ensure coordinated, patient-centred care. We are looking for a GP who is passionate about older people's healthcare, enjoys collaborative working and is keen to contribute to the development of innovative community-based frailty services. As a Salaried GP with an Interest in Frailty, you will provide senior clinical expertise within the Integrated Neighbourhood Team, supporting patients with frailty, multimorbidity and complex care needs. Your main responsibilities will include: Undertaking comprehensive clinical assessments in patients' homes, care homes and community settings. Completing Comprehensive Geriatric Assessments (CGA) and supporting structured medication reviews. Developing personalised care plans, advance care plans and treatment escalation plans. Identifying patients at risk of deterioration and implementing proactive interventions to prevent avoidable hospital admissions. Supporting safe hospital discharge and continuity of care. Providing clinical leadership, guidance and advice to Frailty Practitioners and wider multidisciplinary colleagues. Working collaboratively with GP practices, geriatricians, community services, mental health teams and social care partners. Participating in multidisciplinary team meetings and complex case discussions. Contributing to service development, clinical governance and quality improvement initiatives. You will help deliver safe, effective and compassionate care that promotes independence, improves quality of life and supports patients to remain well within their communities. About us South Downs Health and Care GP Federation is a social enterprise. It was established in 2016 in service to shareholding/member GP practices in the areas of Eastbourne, Hailsham and Seaford. It now has extended membership within East Sussex. Our main purpose is to support GP practices in their task of providing patient care by enabling them to provide and invest in sustainable services by reducing the burden of their workload, maximising income opportunities and minimising their risks and liabilities. We encourage our staff to take ownership and responsibility, to highlight concerns and feedback and to make an active contribution to their individual success as well as that of their team and the wider organisation. We operate a no-blame culture; by this we mean that everyone is held accountable but in an environment where the focus is on the learning that can be adopted and shared from instances where things have not gone so well. Benefits of Working with SDHC NHS Pension Scheme with generous employer contributions 25 days holiday plus bank holidays, increasing in stages to 30 days holiday plus bank holidays after 5 years service (pro rata for part time hours) Employee Assistance Programme including access to counselling and support with legal and financial matters CycleScheme Christmas and summer events Discounted rate for membership of Hillbrow Health and Wellbeing Centre facilities Closing date 20 November 2026 Working pattern Part-time, Flexible working Contract Permanent Location Hillbrow Health and Wellbeing, 1 Denton Road, Eastbourne, East Sussex, BN20 7SS Job responsibilities 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 team, and helping the INT achieve a 10% reduction in avoidable emergency admissions for the cohort. 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 Assessment (CGA) for everyone in the team's focus cohort where clinically indicated, covering clinical, functional, frailty and mental health review, and track progress so no one is missed Carry out structured medication reviews (SMR) with the team pharmacist, including deprescribing Develop digital personalised care and support plans (PCSP), with agreed actions, named responsibility and review arrangements Lead anticipatory care planning (DNACPR, ReSPECT, LPA) and high-quality treatment escalation planning (TEP) Focus on the leading drivers of admission risk: falls, congestive heart failure, flu/pneumonia and care home residents Hold named clinical responsibility where needed, and elevate when a plan is not achieving its intended outcomes Clinical care Provide senior clinical assessment in clinics, care homes and patients' homes Triage referrals from practices and the team, prioritising home and care home visits by need Respond to people at risk of deterioration to prevent avoidable admissions and A managing complex older patients and multimorbidity; medicines management Desirable: Frailty, care home, community or intermediate care roles; MDT leadership; clinical supervision or education Qualifications Essential: MRCGP or equivalent; CCT in general practice Full GMC registration with a licence to practise; NHS England Performers List; appropriate indemnity; right to work in the UK Desirable: Diploma in Geriatric Medicine or postgraduate qualification in frailty or palliative care Skills, Knowledge and Abilities Essential: Experience in Comprehensive Geriatric Assessment; structured medication review; advance care planning conversations; clinical risk management Person-centred, proactive, empathetic in distressing situations; good judgement under pressure; committed to CPD Competent IT skills Collaborative across professional and organisational boundaries; supports and teaches others; works well autonomously and in a team Desirable: 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 Other Essential: Full driving licence and access to a car; enhanced DBS check; occupational health clearance; flexibility to meet service needs 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: South Downs Health and Care Ltd (SDHC) Employer's website: http://www.sdhc.org.uk/ Questions about the job: Fiona Collins, Chief Operating Officer, sdhc.humanresources@nhs.net