Job summary
The South Kerrier Integrated Neighbourhood Team (INT) are seeking a forward thinking GP !

This role would suit a GP who is interested in supporting people with frailty to live and die well in the South Kerrier community and those who live in care homes. If you are a GP who is passionate about personalised care and has expertise in tolerating uncertainty to support people to live and die well in line with their wishes, then this role will be perfect for you!

The post holder will work alongside the INT Clinical Lead and INT Frailty Lead to provide GP input into the frailty model that is being collaborated designed in the South Kerrier area. The role will sit across the South Kerrier area and will therefore be required to work collaboratively with the 4 GP practices in the area, as well as NHS partners, Cornwall Council, voluntary sector providers and independent sector colleagues.

We will consider flexible working arrangements including sessions ranging from 4 sessions to 6 sessions per week.

Main duties of the job
The Frailty General Practitioner will be responsible for the following (there may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels):

• Attend and contribute to frailty multi-disciplinary (MDT) meetings
• Assist the frailty lead to co-design and develop a comprehensive frailty service for the South Kerrier population
• Act as the clinical conduit between primary, community and secondary care
• Assist practices in the management of complex frail patients, linking with the named accountable GP for the practice
• Commence and lead work on the hospital pull list reviewing previous day admission data to consider a prompt and effective discharge wherever possible
• provide a clinical lead role to facilitate collaborative working with hospital geriatricians and colleagues developing key relationships and understanding of patients need to support an integrated approach to care planning

About us
The South Kerrier Integrated Neighbourhood Team (INT) support a diverse and vibrant population of more than 33,000 people across communities including Helston, Carleen, Coverack, Constantine and the surrounding rural areas. We are a collaborative, community rooted team bringing together colleagues from health, social care, the voluntary sector and independent providers to deliver joined up, person centred care.

Our shared purpose is simple: to help people live well, stay well, and receive the right support at the right time. By working as one team across organisational boundaries, we aim to reduce fragmentation, improve access to care, and strengthen the resilience of our local communities.

A key focus for our INT is enhancing the support available for people living with frailty. This includes proactive identification of those who may benefit from early intervention, as well as responsive, coordinated care, during periods of crisis or following events such as hospital admissions., We work closely with primary care, community services, social care teams and voluntary sector partners to ensure that individuals and their families feel support, informed and empowered.

We are a team that values innovation, collaboration and compassion. Whether we are redesigning pathways, supporting neighbourhood initiatives or working directly with individuals in their home, we are committed to improving outcomes and delivery care that reflects the strengths and needs of our community.

Job responsibilities
Equality, Diversity & Inclusion
A good attitude and positive action towards ED&I create an environment where all individuals are able to achieve their full potential. Creating such an environment is important for three reasons: it improves operational effectiveness, it is morally the right thing to do, and it is required by law.

Patients and their families have the right to be treated fairly and be routinely involved in decisions about their treatment and care. They can expect to be treated with dignity and respect and will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Patients have a responsibility to treat other patients and our staff with dignity and respect.

Staff have the right to be treated fairly in recruitment and career progression. Staff can expect to work in an environment where diversity is valued, and equality of opportunity is promoted. Staff will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Staff have a responsibility to ensure that you treat our patients and their colleagues with dignity and respect.

Safety, Health, Environment and Fire
The INT is committed to supporting and promoting opportunities for staff to maintain their health, well-being and safety. You have a duty to take reasonable care of health and safety at work for you, your team and others, and to cooperate with employers to ensure compliance with health and safety requirements. All personnel are to comply with the Health and Safety at Work Act 1974, Environmental Protection Act 1990, Environment Act 1995, Fire Precautions (workplace) Regulations 1999 and other statutory legislation.

Confidentiality
This INT is committed to maintaining an outstanding confidential service. Patients entrust and permit us to collect and retain sensitive information relating to their health and other matters, pertaining to their care. They do so in confidence and have a right to expect all staff will respect their privacy and maintain confidentiality at all times. It is essential that if, the legal requirements are to be met, and the trust of our patients is to be retained that all staff protect patient information and provide a confidential service.

Quality and Continuous Improvement
The INT will continually strive to improve work processes which deliver health care with improved results across all areas of our service provision. We will promote a culture of continuous improvement, where everyone counts and staff are permitted to make suggestions and contributions to improve our service delivery and enhance patient care.

Collaborative Working
All staff are to recognise the significance of collaborative working. Teamwork is essential in multidisciplinary environments. Effective communication is essential, and all staff must ensure they communicate in a manner which enables the sharing of information in an appropriate manner.

Delivery
The project will initially concentrate on those frail patients who have been admitted to hospital and will look at opportunities to review the patients care and consider how the INT frailty team and support a timely and safe discharge for the patient, looking at maximise resources within community so that patients can return to their preferred place of care. It is anticipated that this initial work stream will be established within 3 months of the being in post. Alongside this work will be undertaken to review hospital discharges of frail patients to ensure that the wrap around care and needs of the patient are met, in order to prevent a re-admission.

One this is an established process with daily MDT and mapped resource next steps will be to look at proactive care and disease monitoring to ensure that patients stay well and are able to manage their own health within our community.

Person Specification
Qualifications
Essential

• Qualified GP
• Vocational Training Certificate, or equivalent JCPTGP
• General Practitioner Certificate of Completion of Training

Desirable

• MRCGP
• Diploma in Geriatric Medicine a grant toward completing this qualification can be given
• Recognised qualifications for GP registrar training

Clinical Knowledge
Essential

• Outstanding level of clinical knowledge and skills commensurate with that of an experienced GP
• Understands the importance of evidence based practice and clinical effectiveness

Desirable

• Knowledge of the current issues facing primary care and the wider NHS

Personal Qualities
Essential

• Polite and confident
• Flexible and cooperative
• Motivated & forward thinker
• Problem solver with the ability to process information accurately and effectively, interpreting data as required
• High levels of integrity and loyalty
• Sensitive and empathetic in distressing situations
• Ability to work under pressure
• Effectively able to communicate and understand the needs of the patient
• Commitment to ongoing professional development
• Effectively utilises resources
• Punctual and committed to supporting the team effort
• A demonstrable commitment to professional development
• Evidence of recent self directed learning or development
• Ability to use own judgement, resourcefulness, and common sense
• Observance of strict confidentiality

Experience
Essential

• Experience of working in a primary care environment
• Experience of continued professional development
• Experience of effective multi-disciplinary team MDT working across sectors

Desirable

• Experience of GP QOF system and clinical audit
• Two years as a salaried GP or locum
• Experience of medicines management
• Experience of ICB, ICS initiatives
• General understanding of the GMS contract

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).

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.