Job summary

An exciting opportunity has arisen for an experienced and enthusiastic GP to join Bognor Coastal Alliance (BCA) Primary Care Network as a Neighbourhood Frailty GP, playing a key role in the development of our Integrated Neighbourhood Frailty Team.

This is an opportunity to be part of an evolving approach to neighbourhood healthcare, supporting patients living with frailty, multiple long-term conditions and complex health needs through proactive, coordinated and personalised care.

Working alongside our Frailty Practitioner, MDT Coordinator and wider Integrated Neighbourhood Team (INT), you will provide senior clinical expertise, leadership and guidance to support early intervention, improve patient outcomes and reduce avoidable hospital admissions.

We are looking for a GP with a particular interest in frailty and complex patient management who is passionate about collaborative working, developing services and helping patients remain well and independent within their own communities.

*The role offers up to six sessions per week on a 12-month fixed-term contract, with flexibility for the sessions to be shared between more than one GP.

Main duties of the job

The Neighbourhood Frailty GP will provide clinical expertise and leadership within the Integrated Neighbourhood Frailty Team, supporting the identification, assessment and management of patients with frailty and complex health needs.

Key responsibilities include:

• Undertaking Comprehensive Geriatric Assessments (CGA), structured medication reviews and anticipatory care planning.
• Providing senior clinical assessment and management for patients in GP Practices, care homes and their own homes.
• Developing personalised care and support plans to promote independence, prevent deterioration and reduce avoidable hospital admissions.
• Providing clinical advice, guidance and support to the Frailty Practitioner, MDT Coordinator and wider multidisciplinary team.
• Leading and contributing to multidisciplinary team meetings, complex case discussions and shared clinical decision-making.
• Working collaboratively with GP Practices, community nursing, therapy services, mental health, social care and wider neighbourhood partners to ensure coordinated patient care.
• Supporting effective clinical pathways, timely escalation and access to appropriate community and specialist services.
• Contributing to the ongoing development, clinical governance and quality improvement of the Integrated Neighbourhood Frailty Team.

The role combines direct patient care with clinical leadership and multidisciplinary working, helping to establish a proactive, joined-up approach to frailty management across our local population.

About us

Bognor Coastal Alliance (BCA) Primary Care Network is an established partnership of three GP Practices: Grove House Surgery, Maywood Healthcare Centre and West Meads Surgery, collectively providing care to around 40,000 patients across Bognor Regis and the surrounding communities.

At BCA, we pride ourselves on being a supportive, collaborative and forward thinking network, with a strong commitment to delivering high quality, patient centred care. Our strength lies in our people, with a longstanding and experienced workforce who bring a wealth of knowledge, skills and expertise, alongside a genuine passion for making a positive difference to our patients.

We have developed a strong culture of teamwork and mutual support, where colleagues work closely across our Practices, sharing knowledge, ideas and best practice. We value our staff and strive to create a positive working environment where everyone feels supported, valued and encouraged to contribute.

As a progressive PCN, we continually look for opportunities to innovate, strengthen partnerships and develop services that respond to the changing needs of our population. Our developing Integrated Neighbourhood Frailty Team is an exciting example of this approach, bringing together expertise to deliver more proactive and personalised care.

Above all, we are a team that cares about our patients, our colleagues and the communities we serve, with a shared ambition to continually improve the care we provide.

Details

Date posted

05 November 2026

Pay scheme

Other

Salary

£12,000 a session £12,000 per session annually

Contract

Fixed term

Duration

12 months

Working pattern

Part-time, Job share, Flexible working

Reference number

A0952-26-0003

Job locations

225 Hawthorn Road

Bognor Regis

West Sussex

PO21 2UW

United Kingdom

West Meads Surgery

2-6 The Precinct

BOGNOR REGIS

West Sussex

PO21 5SB

United Kingdom

Grove House Surgery

80 Pryors Lane

BOGNOR REGIS

West Sussex

PO21 4JB

United Kingdom

Job description

Job responsibilities

The Neighbourhood Frailty GP will play a key clinical role within the Integrated Neighbourhood Team (INT)/ PCN, contributing to the delivery of high-quality, proactive and personalised care for patients living with frailty, multiple long-term conditions and complex health needs. The role will focus on improving patient outcomes, supporting independence and reducing avoidable emergency hospital admissions through early intervention and coordinated multidisciplinary working.

Working alongside the Frailty Practitioner, MDT Coordinator and wider INT/ PCN Practice teams, the GP will provide senior clinical expertise, assessment and guidance to support the identification and management of patients at increased risk of deterioration. Responsibilities will include Comprehensive Geriatric Assessments (CGA), structured medication reviews, anticipatory care planning and the development of personalised care and support plans, with a particular focus on falls, heart failure, respiratory illness and care home residents.

The Neighbourhood Frailty GP will act as a key clinical point of contact for the INT, providing advice, clinical leadership and support with complex patient management, treatment decisions and appropriate escalation of care. Working collaboratively with the INT/ PCN Practices, community nursing, therapy services, social care and wider multidisciplinary colleagues, they will help ensure patients receive timely, coordinated care that meets their individual needs.

The Neighbourhood Frailty GP will also contribute to the ongoing development and effectiveness of the INT, supporting multidisciplinary discussions, strengthening clinical pathways and promoting consistent approaches to frailty management. Through clinical leadership, shared learning and quality improvement, the post-holder will help establish a sustainable, patient-centred service that supports the wider ambition of reducing avoidable hospital admissions and enabling patients to remain well and independent within their own homes.

Below are the core responsibilities of the Neighbourhood Frailty GP role. This list is not exhaustive and will be reviewed on an annual basis or sooner if deemed necessary. There may be times when the post-holder is required to carry out tasks outside of the list below to assist with the needs of the INT/ PCN:

Proactive & Preventative Care

• Use the AEAR list, ICT dashboards, local intelligence and clinical judgement to identify and prioritise people for proactive support
• Prioritise timely Comprehensive Geriatric Assessment (CGA) for everyone in the team's focus cohort where clinically indicated, covering clinical, functional, frailty and mental health review, and track progress so no one is missed
• Carry out structured medication reviews (SMR) with the team pharmacist, including deprescribing
• Develop digital personalised care and support plans (PCSP), with agreed actions, named responsibility and review arrangements
• Lead anticipatory care planning (DNACPR, ReSPECT, LPA) and high-quality treatment escalation planning (TEP)
• Focus on the leading drivers of admission risk: falls, congestive heart failure, flu/pneumonia and care home residents
• Hold named clinical responsibility where needed, and escalate when a plan is not achieving its intended outcomes

Clinical Care

• Provide senior clinical assessment in clinics, care homes and patients' homes
• Triage referrals from practices and the team, prioritising home and care home visits by need
• Respond to people at risk of deterioration to prevent avoidable admissions and A&E attendances, linking with virtual wards, urgent community response and acute frailty services
• Support safe, timely discharge and follow-up after hospital stays
• Prescribe safely in line with local formulary and national guidance
• Make and follow up referrals to secondary care, community, mental health and social care services
• Keep accurate, contemporaneous records in shared systems and code activity correctly

Multidisciplinary & Neighbourhood Working

• Promote a One Team approach to multidisciplinary and cross-organisational working, fostering strong relationships, shared responsibility and collaborative decision-making to deliver coordinated, patient-centred care across the INT
• Lead or contribute to INT and Practice MDT meetings and huddles, bringing a senior generalist view
• Build trusting working relationships across primary care, community, mental health, social care, hospital and voluntary sector colleagues
• Act as a clinical point of contact and source of advice for the team and local Practices
• Provide clinical supervision to team members such as physician associates, ACPs, paramedics and pharmacists where needed
• Teach and develop colleagues and learners from all professions and organisations when required

INT Frailty Team Clinical Practice & Collaboration

• Act as a clinical anchor for the INT Frailty Team, providing senior clinical expertise and guidance, bringing together clinical perspectives and supporting consistent, coordinated decision-making and patient-centred care
• Work closely with the Frailty Practitioner and MDT Coordinator to support the delivery of effective, proactive and personalised care for patients with frailty and complex health needs
• Promote effective communication, shared decision-making and collaborative working across the core team, ensuring a consistent approach to patient assessment, management and escalation
• Support opportunities for co-location with the Frailty Practitioner and wider team where practicable, strengthening working relationships and facilitating timely clinical discussions

Clinical Support & Supervision

• Clinical support and clinical supervision serve different but complementary purposes, and both have a role within the core team
• Provide accessible day-to-day clinical support to the Frailty Practitioner and wider INT team, including case discussions, raising concerns, exploring clinical options and agreeing appropriate next steps
• Act as a key source of clinical advice and expertise, supporting colleagues with complex patient management and informed clinical decision-making
• Ensure clinical discussions and advice informing patient care are appropriately documented, including the clinician consulted, in line with local record-keeping and information governance requirements
• Support reflective practice, shared learning and professional development across the multidisciplinary team
• Where specifically agreed, provide formal clinical supervision to the Frailty Practitioner, with protected time allocated within the GP's sessions and an agreed contribution to the practitioner's appraisal
• Ensure any formal supervision arrangements are documented through a written agreement, clearly defining responsibilities, escalation procedures, information-sharing arrangements and appropriate supervision records
• Maintain appropriate records of formal supervision and ensure these are shared with the employing organisation in accordance with agreed arrangements

Links to wider services

• Build and maintain strong working links with virtual wards, urgent community response and the wider ICT
• Develop clear routes to acute pathways and diagnostics, palliative and hospice care, specialist mental health, care home pathways, equipment and reablement, and housing
• Use warm transfers and direct clinician-to-clinician conversations to step people up or refer them on quickly
• Help the INT understand who to contact, how and when, so escalation is consistent across the team
• Work closely with the INT's named geriatrician on complex patients, through advice, joint review and shared decision-making

Working Across Community Organisations

• Work collaboratively with colleagues employed by different organisations, promoting a unified and integrated approach to patient care within the INT
• Operate within the INT's agreed working arrangements, with day-to-day priorities, responsibilities and work plans coordinated by the INT and communicated transparently with the employing organisation
• Recognise that employment, line management and performance management responsibilities remain with the employing organisation, in accordance with relevant contractual and subcontracting arrangements
• Follow the agreed INT work plan and timetable, ensuring alignment with the team's operational priorities and service objectives
• Maintain individual professional and clinical accountability for all clinical decisions, actions and omissions within the scope of the role, supported by the employing organisation's clinical governance arrangements
• Ensure collaborative working across organisational boundaries does not compromise individual clinical accountability or transfer responsibility for clinical decisions to other team members

Leadership, quality and governance

• Provide clinical leadership to the INT core team and help design and improve the local delivery of the core offer
• Take part in, and help deliver, the centralised training and support programme, including multiprofessional training and supervision in CGA, digital PCSPs, advance care planning and TEP
• Record decisions, action owners, timescales and outcomes to agreed MDT documentation standards in shared care records
• Contribute to activity and outcome reporting through ICT and Neighbourhood Alliance governance
• Take part in audit, quality improvement and evaluation of outcomes
• Follow clinical governance, safeguarding, information governance and CQC requirements of the employing organisation
• Raise and learn from incidents, complaints and significant events
• Maintain own professional development, appraisal and revalidation

Job description Job responsibilities The Neighbourhood Frailty GP will play a key clinical role within the Integrated Neighbourhood Team (INT)/ PCN, contributing to the delivery of high-quality, proactive and personalised care for patients living with frailty, multiple long-term conditions and complex health needs. The role will focus on improving patient outcomes, supporting independence and reducing avoidable emergency hospital admissions through early intervention and coordinated multidisciplinary working.Working alongside the Frailty Practitioner, MDT Coordinator and wider INT/ PCN Practice teams, the GP will provide senior clinical expertise, assessment and guidance to support the identification and management of patients at increased risk of deterioration. Responsibilities will include Comprehensive Geriatric Assessments (CGA), structured medication reviews, anticipatory care planning and the development of personalised care and support plans, with a particular focus on falls, heart failure, respiratory illness and care home residents.The Neighbourhood Frailty GP will act as a key clinical point of contact for the INT, providing advice, clinical leadership and support with complex patient management, treatment decisions and appropriate escalation of care. Working collaboratively with the INT/ PCN Practices, community nursing, therapy services, social care and wider multidisciplinary colleagues, they will help ensure patients receive timely, coordinated care that meets their individual needs.The Neighbourhood Frailty GP will also contribute to the ongoing development and effectiveness of the INT, supporting multidisciplinary discussions, strengthening clinical pathways and promoting consistent approaches to frailty management. Through clinical leadership, shared learning and quality improvement, the post-holder will help establish a sustainable, patient-centred service that supports the wider ambition of reducing avoidable hospital admissions and enabling patients to remain well and independent within their own homes.Below are the core responsibilities of the Neighbourhood Frailty GP role. This list is not exhaustive and will be reviewed on an annual basis or sooner if deemed necessary. There may be times when the post-holder is required to carry out tasks outside of the list below to assist with the needs of the INT/ PCN:Proactive & Preventative CareUse the AEAR list, ICT dashboards, local intelligence and clinical judgement to identify and prioritise people for proactive supportPrioritise timely Comprehensive Geriatric Assessment (CGA) for everyone in the team's focus cohort where clinically indicated, covering clinical, functional, frailty and mental health review, and track progress so no one is missedCarry out structured medication reviews (SMR) with the team pharmacist, including deprescribingDevelop digital personalised care and support plans (PCSP), with agreed actions, named responsibility and review arrangementsLead anticipatory care planning (DNACPR, ReSPECT, LPA) and high-quality treatment escalation planning (TEP)Focus on the leading drivers of admission risk: falls, congestive heart failure, flu/pneumonia and care home residentsHold named clinical responsibility where needed, and escalate when a plan is not achieving its intended outcomesClinical CareProvide senior clinical assessment in clinics, care homes and patients' homesTriage referrals from practices and the team, prioritising home and care home visits by needRespond to people at risk of deterioration to prevent avoidable admissions and A&E attendances, linking with virtual wards, urgent community response and acute frailty servicesSupport safe, timely discharge and follow-up after hospital staysPrescribe safely in line with local formulary and national guidanceMake and follow up referrals to secondary care, community, mental health and social care servicesKeep accurate, contemporaneous records in shared systems and code activity correctlyMultidisciplinary & Neighbourhood WorkingPromote a One Team approach to multidisciplinary and cross-organisational working, fostering strong relationships, shared responsibility and collaborative decision-making to deliver coordinated, patient-centred care across the INTLead or contribute to INT and Practice MDT meetings and huddles, bringing a senior generalist viewBuild trusting working relationships across primary care, community, mental health, social care, hospital and voluntary sector colleaguesAct as a clinical point of contact and source of advice for the team and local PracticesProvide clinical supervision to team members such as physician associates, ACPs, paramedics and pharmacists where neededTeach and develop colleagues and learners from all professions and organisations when requiredINT Frailty Team Clinical Practice & CollaborationAct as a clinical anchor for the INT Frailty Team, providing senior clinical expertise and guidance, bringing together clinical perspectives and supporting consistent, coordinated decision-making and patient-centred careWork closely with the Frailty Practitioner and MDT Coordinator to support the delivery of effective, proactive and personalised care for patients with frailty and complex health needsPromote effective communication, shared decision-making and collaborative working across the core team, ensuring a consistent approach to patient assessment, management and escalationSupport opportunities for co-location with the Frailty Practitioner and wider team where practicable, strengthening working relationships and facilitating timely clinical discussionsClinical Support & SupervisionClinical support and clinical supervision serve different but complementary purposes, and both have a role within the core teamProvide accessible day-to-day clinical support to the Frailty Practitioner and wider INT team, including case discussions, raising concerns, exploring clinical options and agreeing appropriate next stepsAct as a key source of clinical advice and expertise, supporting colleagues with complex patient management and informed clinical decision-makingEnsure clinical discussions and advice informing patient care are appropriately documented, including the clinician consulted, in line with local record-keeping and information governance requirementsSupport reflective practice, shared learning and professional development across the multidisciplinary teamWhere specifically agreed, provide formal clinical supervision to the Frailty Practitioner, with protected time allocated within the GP's sessions and an agreed contribution to the practitioner's appraisalEnsure any formal supervision arrangements are documented through a written agreement, clearly defining responsibilities, escalation procedures, information-sharing arrangements and appropriate supervision recordsMaintain appropriate records of formal supervision and ensure these are shared with the employing organisation in accordance with agreed arrangementsLinks to wider servicesBuild and maintain strong working links with virtual wards, urgent community response and the wider ICTDevelop clear routes to acute pathways and diagnostics, palliative and hospice care, specialist mental health, care home pathways, equipment and reablement, and housingUse warm transfers and direct clinician-to-clinician conversations to step people up or refer them on quicklyHelp the INT understand who to contact, how and when, so escalation is consistent across the teamWork closely with the INT's named geriatrician on complex patients, through advice, joint review and shared decision-makingWorking Across Community Organisations Work collaboratively with colleagues employed by different organisations, promoting a unified and integrated approach to patient care within the INT Operate within the INT's agreed working arrangements, with day-to-day priorities, responsibilities and work plans coordinated by the INT and communicated transparently with the employing organisation Recognise that employment, line management and performance management responsibilities remain with the employing organisation, in accordance with relevant contractual and subcontracting arrangements Follow the agreed INT work plan and timetable, ensuring alignment with the team's operational priorities and service objectives Maintain individual professional and clinical accountability for all clinical decisions, actions and omissions within the scope of the role, supported by the employing organisation's clinical governance arrangements Ensure collaborative working across organisational boundaries does not compromise individual clinical accountability or transfer responsibility for clinical decisions to other team membersLeadership, quality and governanceProvide clinical leadership to the INT core team and help design and improve the local delivery of the core offerTake part in, and help deliver, the centralised training and support programme, including multiprofessional training and supervision in CGA, digital PCSPs, advance care planning and TEPRecord decisions, action owners, timescales and outcomes to agreed MDT documentation standards in shared care recordsContribute to activity and outcome reporting through ICT and Neighbourhood Alliance governanceTake part in audit, quality improvement and evaluation of outcomesFollow clinical governance, safeguarding, information governance and CQC requirements of the employing organisationRaise and learn from incidents, complaints and significant eventsMaintain own professional development, appraisal and revalidation

Person Specification

Skills

Essential

• Exceptional written and oral communication skills (including polite and professional telephone manner)
• Competent IT literacy, including clinical systems such as TPP SystmOne as well as MS Office and email
• Excellent negotiation, interpersonal and influential skills
• Able to efficiently plan and prioritise tasks and workflow
• Possess lead and ambassadorial skills
• Ability to apply evidence based researched into Pharmacy work and strategy
• Self-autonomous but able to work within teams
• Able to follow but also develop policy and procedures were deemed as necessary
• Capable to identify and resolve risk management issues in accordance with PCN and Practice standards
• Demonstrates commitment to continual service and process improvement
• Confident in the collection, analysis and presentation of data

Experience

Essential

• At least 2 years post-CCT in UK general practice; managing complex older patients and multimorbidity; medicines management

Desirable

• Frailty, care home, community or intermediate care roles; MDT leadership; clinical supervision or education

Other requirements

Essential

• Disclosure Barring Service (DBS) check
• The right to work in the UK
• Full Driving Licence
• Occupational Health Clearance
• Flexibility to meet service needs

Eligibility

Essential

• Full GMC registration with a licence to practise; NHS England

Qualifications

Essential

• MRCGP or equivalent; CCT in general practice

Desirable

• Diploma in Geriatric Medicine or postgraduate qualification in frailty or palliative care

Clinical Skills

Essential

• Experience in Comprehensive Geriatric Assessment; structured medication review; advance care planning conversations; clinical risk management

Desirable

• Quality improvement and audit leadership; population health and risk stratification tools

Personal Qualities

Essential

• Collaborative across professional and organisational boundaries; supports and teaches others; works well autonomously and in a team
• Positive and confident persona
• Approachable and supportive towards colleagues and patients (able to empathise in difficult/ distressing situations)
• Able to use initiative and problem solve
• Resilient and able to operate in a calm professional manner during busy and high demand periods
• Flexible and cooperative dependant on the needs of the INT/ PCN/ Practice
• Highly motivated and focused
• Willing to learn and develop

Desirable

• Experience of integrated or multi-organisation teams; leading service change

Person Specification Skills Essential Exceptional written and oral communication skills (including polite and professional telephone manner) Competent IT literacy, including clinical systems such as TPP SystmOne as well as MS Office and email Excellent negotiation, interpersonal and influential skills Able to efficiently plan and prioritise tasks and workflow Possess lead and ambassadorial skills Ability to apply evidence based researched into Pharmacy work and strategy Self-autonomous but able to work within teams Able to follow but also develop policy and procedures were deemed as necessary Capable to identify and resolve risk management issues in accordance with PCN and Practice standards Demonstrates commitment to continual service and process improvement Confident in the collection, analysis and presentation of data Experience Essential At least 2 years post-CCT in UK general practice; managing complex older patients and multimorbidity; medicines management Desirable Frailty, care home, community or intermediate care roles; MDT leadership; clinical supervision or education Other requirements Essential Disclosure Barring Service (DBS) check The right to work in the UK Full Driving Licence Occupational Health Clearance Flexibility to meet service needs Eligibility Essential Full GMC registration with a licence to practise; NHS England Qualifications Essential MRCGP or equivalent; CCT in general practice Desirable Diploma in Geriatric Medicine or postgraduate qualification in frailty or palliative care Clinical Skills Essential Experience in Comprehensive Geriatric Assessment; structured medication review; advance care planning conversations; clinical risk management Desirable Quality improvement and audit leadership; population health and risk stratification tools Personal Qualities Essential Collaborative across professional and organisational boundaries; supports and teaches others; works well autonomously and in a team Positive and confident persona Approachable and supportive towards colleagues and patients (able to empathise in difficult/ distressing situations) Able to use initiative and problem solve Resilient and able to operate in a calm professional manner during busy and high demand periods Flexible and cooperative dependant on the needs of the INT/ PCN/ Practice Highly motivated and focused Willing to learn and develop Desirable Experience of integrated or multi-organisation teams; leading service change

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).

Additional information 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).

Employer details

Employer name

Maywood Surgery

Address

225 Hawthorn Road

Bognor Regis

West Sussex

PO21 2UW

United Kingdom

Employer's website

https://www.maywoodsurgery.com/ (Opens in a new tab)

Employer details

Employer name

Maywood Surgery

Address

225 Hawthorn Road

Bognor Regis

West Sussex

PO21 2UW

United Kingdom

Employer's website

https://www.maywoodsurgery.com/ (Opens in a new tab)