Job Description

The GPwER in Frailty will provide evidence based, comprehensive, person centred and individualised medical care for older people, working as part of a multidisciplinary team within community settings across South Durham The role whilst demanding and challenging and also requiring the post holder to possess the specialist frailty knowledge required to support the medical management of complex and challenging presentations of older frail people, will prove extremely varied and rewarding to the post holder. This care will be provided through our various community frailly workstreams DUTIES & RESPONSIBILITIES The post holder will work as part of a multidisciplinary team, which includes Consultant Geriatricians, GPwERs, nurses, therapists, social care, the third sector and care home staff, to deliver high quality care and support for older people within the community. The post holder will contribute to service development, guideline development, research opportunities, and governance activities such as audit and quality improvement processes. The post holder will be expected to participate in the training and development of other members of the MDT and wider healthcare community and assume a leadership role in the care of older people in the community.



The post holder will be expected to work autonomously with peer review and personal development opportunities. RESPONSIBILITY FOR PATIENT CARE Comprehensive Geriatric Assessment (Remote) The management of patients referred into the service to include provision of medical, psychosocial, medicines reviews and advanced care planning to patients in their own homes. The communication of outcomes to the patient, their family and carers as well as their registered GP through the extended MDT. To carry out reviews of patients previously seen in the service, when this is deemed clinically necessary.



To partake in the supervision of staff including ANPs and Registrars if and when the roles are integrated in to the service. Filing and management of diagnostic tests requested through the service. To support expansion and development of the service over time Support and facilitate MDT decision making in your role as the senior clinical leader Complete onward referrals to other specialties when appropriate Develop skills in the use of AI based transcription platforms Urgent Community Response Provide a CGA assessment with the rest of the MDT team for patient deemed suitable for review through the Urgent Community Response Pathway. This not a same day assessment pathway assessment.



The patients will likely have multiple sub acute issues that requires support and facilitation through an MDT approach. The same approach is to be give to this patient group as outlined above. COMMUNICATION The post holder will be required to demonstrate excellent communication skills when working with patients, carers, members of the public, primary and secondary care colleagues, allied health care professionals, managers up to chief executive level, commissioners and the media. ANALYTICAL TASKS High level clinical judgement based on experience and clinical guidance is expected in patient management.



High level analytical skills will also be required in the day to day operational management, governance and in strategic service development. PLANNING AND ORGANISATIONAL SKILLS The post will require a high level of personal organisation to deliver clinical and managerial responsibilities. Specifically, at service level, the post holder will have to plan and organise service development and change in areas of responsibility. Strategically, the post holder will require being a self-starter and taking personal responsibility for the development, organisation and delivery of service development in line with the needs of the contracted population.



PHYSICAL SKILLS The physical skills requiring to be sustained are those required to achieve the CCT/CESR in their speciality e.g. hearing, vision and dexterity for minor procedures, mobility and legible handwriting. POLICY AND SERVICE DEVELOPMENT IMPLEMENTATION The post holder will actively contribute to both the day-to-day operations and the long-term development of the service, working closely with clinical and management teams. Internally, this will involve driving innovation to create a forward-thinking, cost-effective, and patient-focused service that makes use of new technologies and the expertise of a multidisciplinary team, in partnership with statutory and third-sector organisations.



Externally, the role will include collaborating with members of the multidisciplinary team to ensure services meet the specific needs of the local population RESPONSIBILITIES FOR FINANCIAL AND PHYSICAL RESOURCES The post holder will have a personal duty of care in relation to equipment and resources and to maintain a secure working environment. RESPONSIBILITIES FOR HUMAN RESOURCES The post holder may take part in managing, supervising, coordinating, teaching, training, and supporting employees, students, trainees, and others in similar roles. They will be responsible for planning and assigning work, as well as reviewing and assessing completed tasks. They will also participate in personal development supervision to enhance their skills and clinical practice, and will complete appraisal and revalidation processes as required.



RESPONSIBILITIES FOR INFORMATION RESOURCES The post holder will be responsible for the development and safe storage of person centred health care assessments, plans and electronic care records. The post holder may also be responsible for the managing and safe storage of electronic staff records, for example clinical supervision records. RESPONSIBILITIES FOR RESEARCH AND DEVELOPMENT The post holder will be expected to participate in Quality and audit activity, beyond the minimum required for revalidation, to assure service quality and patient safety. FREEDOM TO ACT The post holder will be expected to practice within the policies, procedures and guidelines of the organisation and service, and national bodies such as NICE, The Royal College of General Practice.



S/he must practice within the ethical boundaries of Good Medical Practice as laid down by the GMC. CARE OF OLDER PEOPLE, SERVICE MODEL: The service model includes the following key principles: OUR ETHOS: The ethos of the service is to proactively deliver innovative, high-quality care to the local populations of Sedgefield and Easington, with the goal of enhancing the quality of life for the most frail and vulnerable individuals. This care is patient-centered and evidence-based, ensuring that every action is aimed at improving the lives of those we serve. Professionals working within this service are encouraged to feel supported, engaged, and motivated to provide the highest standard of care.

ENGAGEMENT AND INVOLVEMENT:

We actively engage with our service users and their families and carers and will utilise feedback from engagement activities to inform service development. SERVICE USER FEEDBACK The Integrated frailty service will support patient feedback through patient survey and friends and family opportunities. SERVICE DELIVERY: Our service model will combine clinical and cost effectiveness by providing access to a skilled and multiprofessional workforce. Care will be delivered in an innovative remote model where technology is used to enable remote working with the support of the MDT team.

IMPROVING PRACTICE:

Providing education and support to primary care organisations, constituent practices and Other primary care providers to raise the general standard and consistency of care of the older person across primary care. Facilitating and encouraging the spread of good practice from within primary care across the whole health and social care community. Working with general practitioners, pharmacists, primary care nurses, social workers, mental health nurses, specialist community nurses and other health care staff such that current best practice is implemented within effective pathways within primary care. This job description is not meant to be exhaustive.



It describes the main duties and responsibilities of the post. It may be subject to change in the light of developing organisational and service needs and wherever possible change will follow consultation with the post holder