Job summaryTo provide proactive, high-quality care to frail, housebound and clinically vulnerable patients within the community as part of our Integrated Neighbourhood Team. The postholder will deliver long-term condition management, dementia and SMI health checks, and support care planning for patients with complex needs, including those with Learning Disabilities (LD).
This role supports the shift toward anticipatory and preventative care, reducing avoidable hospital admissions and improving quality of life for our most vulnerable populations.
Main duties of the job- Conduct home visits and community-based reviews for housebound and frail patients.
- Deliver long-term condition management (e.g. CHF, COPD, diabetes, hypertension).
- Lead or support anticipatory / future care planning and end-of-life discussions where appropriate.
- Undertake Dementia and Severe Mental Illness (SMI) annual health checks in line with QOF and PCN specifications.
- Support delivery of Learning Disability (LD) health assessments.
- Provide clinical leadership and support to the wider Integrated Neighbourhood Team (including nurses, AHPs, care coordinators and social prescribers).
- Work collaboratively with community and secondary care services to ensure continuity of care.
- Maintain accurate and timely clinical documentation in the relevant IT systems.
About usThe Brunel Primary Care Network consists of three Practices across Portsmouth; East Shore Partnership, The Lighthouse Group and University Surgery.
We have highly skilled and motivated teams working within our PCN, which consist of GP Partners, Salaried GP's, Advanced Nurse Practitioners, Pharmacists, Diabetes and Respiratory Nurse Specialists, Nurses, GP Assistant's and HCA's; who are supported by skilled administration teams.
We offer 6 weeks annual leave per annum plus Bank Holidays pro rata, an additional days paid leave allocated to you as a days birthday leave, automatic enrolment to a generous NHS Pension and free access to our Employee Assistance Programme.
Job responsibilitiesClinical Responsibilities- Conduct home visits and community-based reviews for housebound and frail patients.
- Deliver long-term condition management (e.g. CHF, COPD, diabetes, hypertension).
- Lead or support anticipatory / future care planning and end-of-life discussions where appropriate.
- Undertake Dementia and Severe Mental Illness (SMI) annual health checks in line with QOF and PCN specifications.
- Support delivery of Learning Disability (LD) health assessments.
- Provide clinical leadership and support to the wider Integrated Neighbourhood Team (including nurses, AHPs, care coordinators and social prescribers).
- Work collaboratively with community and secondary care services to ensure continuity of care.
- Maintain accurate and timely clinical documentation in the relevant IT systems.
Professional Responsibilities- Participate in clinical meetings, MDTs and case discussions.
- Engage in quality improvement initiatives related to frailty and proactive care.
- Commit to ongoing professional development and reflective practice.
- Adhere to GMC, CQC and safeguarding standards at all times.
Person SpecificationExperienceEssential- Experience in primary care / community care
- Working with vulnerable or complex patients
Desirable- Experience delivering LD or SMI health checks
- Anticipatory care / palliative care work
QualificationsEssential- GMC registered GP
- Eligible under ARRS within 2 years of CCT
Desirable- Additional frailty or geriatrics training
Personal AttributesEssential- Compassionate and patient-centred
- Reliable and well-organised
- Valid UK Driving licence and access to own vehicle for visits
Desirable- Interest in service development
Knowledge and SkillsEssential- Strong clinical assessment and decision-making skills
- Excellent communication and empathy
- Ability to work independently and within a team
Desirable- Familiarity with NHS Long-Term Plan priorities (frailty, population health)
- Experience in MDT / integrated team settings
- Quality improvement or audit involvement
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.Applicants must have current UK professional registration. For further information please see NHS Careers website. 
