GP with an Interest in Frailty, Integrated Neighbourhood Team
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.

Main duties of the job

• Use the AEAR list, ICT dashboards, local intelligence and clinical judgement to identify and prioritise people for proactive support.
• Prioritise timely Comprehensive Geriatric Assessments (CGA) for the team's focus cohort where indicated, covering clinical, functional, frailty and mental health needs, and track progress.
• Carry out structured medication reviews (SMR) with the team pharmacist, including deprescribing.
• Develop digital personalised care and support plans (PCSP), with agreed actions, named responsibilities and review arrangements.
• Lead anticipatory care planning (DNACPR, ReSPECT, LPA) and treatment escalation planning (TEP).
• Focus on admission risks: falls, heart failure, flu/pneumonia and care home residents.
• Hold clinical responsibility where needed and escalate when plans are not achieving intended outcomes.
• Provide clinical assessments in clinics, care homes and patients' homes.
• Triage referrals from practices and the team, prioritising home and care home visits by need.
• Respond to deterioration risks to prevent avoidable admissions and A&E attendances, linking with virtual wards, urgent community response and frailty support.
• Support timely discharge and follow-up after hospital stays.
• Prescribe safely in line with formularies and national guidance.
• Make and follow up referrals to secondary care, community, mental health and social care services.
• Maintain accurate, timely records in shared systems and code activity correctly.

About us
INTs bring together GPs, community health, mental health, social care and voluntary sector partners to provide joined-up care, helping people stay well and independent at home.

Details
Salary: £12,500 a session
Contract: Permanent
Working pattern: Part-time
Reference number: B0301-26-0012
Closing date: 31 January 2027

Role details
Employer: Integrated Family Healthcare, Marlborough House, 19-21 Warrior Square, St. Leonards on Sea, East Sussex, TN37 6BG

Essential qualifications and experience

• 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
• At least 2 years post-CCT in UK general practice; managing complex older patients and multimorbidity; medicines management
• Experience in Comprehensive Geriatric Assessment; structured medication review; advance care planning conversations; clinical risk management
• Full driving licence and access to a car; enhanced DBS check; occupational health clearance; flexibility to meet service needs

Desirable

• Diploma in Geriatric Medicine or postgraduate qualification in frailty or palliative care
• Clinical or Educational Supervisor Training
• Frailty, care home, community or intermediate care roles; MDT leadership; clinical supervision or education
• Quality improvement and audit leadership; population health and risk stratification tools
• Experience of integrated or multi-organisation teams; leading service change
• SystmOne, EMIS

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 to check for any previous criminal convictions.

UK Registration
Applicants must have current UK professional registration. For further information please see the NHS Careers website (opens in a new window).

Contact: Jon Merrick, lily.wadmore@nhs.net, 07498367647

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