PCN Frailty GP in Hythe

A really exciting opportunity to join an ambitious, forward- thinking PCN at the cutting edge of Integrated Neighbourhood Working, helping to shape and deliver the future of frailty care and neighbourhood health. To provide senior GP clinical input and leadership within the PCNs Integrated Neighbourhood Team, supporting the delivery of high-quality, coordinated care for people living with frailty and complex health needs across our member practices. To work as part of the PCNs hub model, providing clinical oversight and management of patients identified through both proactive frailty pathways and reactive INT services, supporting care to be delivered at neighbourhood level and at scale. To proactively identify, assess and manage patients at greatest risk of deterioration, crisis or unplanned hospital admission, developing personalised care plans and supporting patients to remain safely in their usual place of residence wherever clinically appropriate. To work closely with the wider
multidisciplinary team, including community nursing, pharmacy, care coordination, social care, secondary care and other neighbourhood partners, ensuring a holistic and joined-up approach to the management of frailty. To build upon the learning and model developed through the NNHIP pilot, supporting the transition of frailty and neighbourhood working into business as usual and contributing to the ongoing development of the PCNs Integrated Neighbourhood Team and Single Neighbourhood Health model. To provide senior clinical leadership and input into multidisciplinary team meetings, supporting coordinated decision-making and care planning for patients living with frailty and complex needs. Key Tasks and Responsibilities Provide effective clinical triage and senior medical oversight for patients referred to, or proactively identified by, the frailty and Integrated Neighbourhood Team. Proactively manage people living with frailty, complex multimorbidity and those at increased risk of
deterioration or hospital admission. Undertake comprehensive and holistic clinical assessment, including the principles of Comprehensive Geriatric Assessment where appropriate, considering physical, psychological, functional and social needs. Diagnose, investigate and treat patients within the scope of the role, including prescribing in accordance with local and national guidance and providing ongoing clinical monitoring where required. Develop and review personalised care and support plans, including anticipatory care planning and escalation planning, working with patients, carers and the wider multidisciplinary team. Support proactive management of frailty as part of the PCNs Single Neighbourhood Health contract requirements, ensuring that proactive interventions link effectively with the reactive Integrated Neighbourhood Team service when a patient's needs change or they experience deterioration. Undertake telephone, remote and face-to-face clinical assessment as appropriate,
including home visits and care home visits where clinical need requires. Support admission avoidance and timely community-based intervention, enabling patients to remain safely at home wherever clinically appropriate and helping to reduce unnecessary emergency department attendance and hospital admission. Provide senior clinical input into the management of patients presenting through the reactive INT pathway, particularly where frailty, multimorbidity or clinical complexity requires GP assessment or decision-making. Work collaboratively with clinicians and professionals across the PCN's member practices, community services, secondary care, social care, mental health services, voluntary sector and other neighbourhood partners. Actively participate in, and where appropriate provide clinical leadership to, multidisciplinary team meetings and case discussions relating to frailty and complex patients. Provide clinical leadership and support to the wider INT and frailty team, promoting
effective multidisciplinary working, shared decision-making and appropriate clinical escalation. Maintain accurate, timely and comprehensive clinical records and ensure appropriate communication of assessments, care plans and clinical decisions to the patient's registered practice and other professionals involved in their care. Contribute to the ongoing development, evaluation and improvement of the PCN's frailty, INT and neighbourhood model, including pathway development, clinical governance, audit, quality improvement and review of outcomes. Work autonomously within professional competencies while contributing to agreed PCN and neighbourhood objectives, service standards and contractual requirements, supporting the continued development of the NNHIP model into a sustainable business-as-usual neighbourhood service.

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