Job summary

South Downs Health and Care (SDHC) is seeking a compassionate, enthusiastic and motivated Salaried GP with an Interest in Frailty to join our Integrated Neighbourhood Team (INT) in Eastbourne.

This is an exciting opportunity to make a meaningful difference to the lives of older people and those living with frailty, helping them remain healthy, independent and supported within their communities.

Working as part of a supportive multidisciplinary team, you will provide expert clinical care to patients with frailty, multiple long-term conditions and complex health and social care needs. You will play a key role in delivering proactive, personalised care, preventing avoidable hospital admissions and improving patient outcomes.

You will work closely with Frailty Practitioners, community services, local GP practices and wider health and social care partners to ensure coordinated, patient-centred care.

We are looking for a GP who is passionate about older people's healthcare, enjoys collaborative working and is keen to contribute to the development of innovative community-based frailty services.

Main duties of the job

As a Salaried GP with an Interest in Frailty, you will provide senior clinical expertise within the Integrated Neighbourhood Team, supporting patients with frailty, multimorbidity and complex care needs.

Your main responsibilities will include:

• Undertaking comprehensive clinical assessments in patients' homes, care homes and community settings.
• Completing Comprehensive Geriatric Assessments (CGA) and supporting structured medication reviews.
• Developing personalised care plans, advance care plans and treatment escalation plans.
• Identifying patients at risk of deterioration and implementing proactive interventions to prevent avoidable hospital admissions.
• Supporting safe hospital discharge and continuity of care.
• Providing clinical leadership, guidance and advice to Frailty Practitioners and wider multidisciplinary colleagues.
• Working collaboratively with GP practices, geriatricians, community services, mental health teams and social care partners.
• Participating in multidisciplinary team meetings and complex case discussions.
• Contributing to service development, clinical governance and quality improvement initiatives.

You will help deliver safe, effective and compassionate care that promotes independence, improves quality of life and supports patients to remain well within their communities.

About us

South Downs Health and Care GP Federation is a social enterprise. It was established in 2016 in service to shareholding/member GP practices in the areas of Eastbourne, Hailsham and Seaford. It now has extended membership within East Sussex. Our main purpose is to support GP practices in their task of providing patient care by enabling them to provide and invest in sustainable services by reducing the burden of their workload, maximising income opportunities and minimising their risks and liabilities.

We encourage our staff to take ownership and responsibility, to highlight concerns and feedback and to make an active contribution to their individual success as well as that of their team and the wider organisation. We operate a no-blame culture; by this we mean that everyone is held accountable but in an environment where the focus is on the learning that can be adopted and shared from instances where things havent gone so well.

Benefits of Working with SDHC

• NHS Pension Scheme with generous employer contributions
• 25 days holiday plus bank holidays, increasing in stages to 30 days holiday plus bank holidays after 5 years service (pro rata for part time hours)
• Employee Assistance Programme including access to counselling and support with legal and financial matters
• CycleScheme
• Christmas and summer events
• Discounted rate for membership of Hillbrow Health and Wellbeing Centre facilities

Details

Date posted

29 October 2026

Pay scheme

Other

Salary

£116,000 a year Pro-rata

Contract

Permanent

Working pattern

Part-time, Flexible working

Reference number

B0164-26-0005

Job locations

Hillbrow Health and Wellbeing

1 Denton Road

Eastbourne

East Sussex

BN20 7SS

United Kingdom

Job description

Job responsibilities

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.

Proactive and 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

One team: multi-organisation, multidisciplinary working

• 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
• Teach and develop colleagues and learners from all professions and organisations

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

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

Working across organisations

The core team brings together colleagues employed by different organisations, working collaboratively as one integrated team. Operationally it must function as one integrated team through collaborative working. Employment, line management and performance management responsibilities remain with the employing organisation, which retains its overarching responsibilities for the employee in accordance with the subcontract. Day-to-day priorities and the organisation of work are decided by the Integrated Neighbourhood Team (INT), with a work plan and timetable that are transparent and accessible to both the employing organisation and the team. Employees must look to the INT for their individual work-plan rather than to their employing organisation.

Clinical accountability for a practitioners own practice, including the clinical decisions they make and any actions or omissions within their responsibility, remains with the practitioner and is supported by the clinical governance arrangements of their employing organisation. Working alongside colleagues from other organisations does not, in itself, transfer that accountability to them.

Clinical support and clinical supervision

Clinical support and clinical supervision serve different but complementary purposes, and both have a role within the core team.

Clinical support is part of the teams day-to-day working arrangements. It includes discussing cases, raising concerns, considering clinical options and agreeing next steps. Practitioners can draw on the expertise of colleagues across the team, particularly the GP with an interest in frailty. Where a discussion informs a clinical decision, the practitioner records the relevant discussion and the clinician consulted in the patient record, in line with local documentation and information governance requirements.

Clinical supervision provides protected time for reflection on practice, learning and professional development. It is arranged through the employing organisation in accordance with its policies and professional requirements. Where supervision is provided by someone outside the employing organisation, this is agreed in advance and documented in a written supervision agreement setting out the respective roles, responsibilities and arrangements for escalation and information sharing. Brief records of supervision are shared with the employing organisation in accordance with the agreed arrangements.

Working with the frailty practitioner and the wider team

The GP with an interest in frailty provides a clinical anchor for the core team, helping to bring clinical perspectives together and support consistent, coordinated decision-making. The post holder is expected to be accessible to the frailty practitioner and other team members for day-to-day clinical support, including case discussion, advice on clinical decisions and agreement of appropriate next steps. Where practicable, co-location for part of the working week can help build relationships, support timely discussion and strengthen the teams approach to care.

Where the employing organisation and the ICT agree that the GP will also provide formal clinical supervision to the frailty practitioner, this is established through a written supervision agreement. The agreement sets out the respective responsibilities, with protected time identified within the GPs sessions and an agreed contribution to the practitioners appraisal. This is a specific, agreed addition to the role rather than an automatic expectation of the frailty GP post.

General responsibilities

These apply to every member of the INT.

• Equality, diversity and inclusion: treat patients, carers and colleagues fairly and with dignity and respect, and challenge discrimination on any protected characteristic
• Safeguarding: recognise and act on safeguarding concerns for adults and children, following local procedures
• Confidentiality and information governance: protect patient information and share it appropriately across organisations under agreed data-sharing arrangements
• Health, safety and lone working: take reasonable care of your own and others' safety, including during home visits
• Quality and continuous improvement: suggest and take part in improvements to how the team works
• Induction: complete induction with the employing organisation and the INT, including the practices you work with
• Professional conduct: follow the policies of the employing organisation and the standards of your professional body

Job description Job responsibilities 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.Proactive and 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 correctlyOne team: multi-organisation, multidisciplinary workingLead 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 pharmacistsTeach and develop colleagues and learners from all professions and organisationsLinks 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-makingLeadership, 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 revalidationWorking across organisationsThe core team brings together colleagues employed by different organisations, working collaboratively as one integrated team. Operationally it must function as one integrated team through collaborative working. Employment, line management and performance management responsibilities remain with the employing organisation, which retains its overarching responsibilities for the employee in accordance with the subcontract. Day-to-day priorities and the organisation of work are decided by the Integrated Neighbourhood Team (INT), with a work plan and timetable that are transparent and accessible to both the employing organisation and the team. Employees must look to the INT for their individual work-plan rather than to their employing organisation.Clinical accountability for a practitioners own practice, including the clinical decisions they make and any actions or omissions within their responsibility, remains with the practitioner and is supported by the clinical governance arrangements of their employing organisation. Working alongside colleagues from other organisations does not, in itself, transfer that accountability to them.Clinical support and clinical supervisionClinical support and clinical supervision serve different but complementary purposes, and both have a role within the core team.Clinical support is part of the teams day-to-day working arrangements. It includes discussing cases, raising concerns, considering clinical options and agreeing next steps. Practitioners can draw on the expertise of colleagues across the team, particularly the GP with an interest in frailty. Where a discussion informs a clinical decision, the practitioner records the relevant discussion and the clinician consulted in the patient record, in line with local documentation and information governance requirements.Clinical supervision provides protected time for reflection on practice, learning and professional development. It is arranged through the employing organisation in accordance with its policies and professional requirements. Where supervision is provided by someone outside the employing organisation, this is agreed in advance and documented in a written supervision agreement setting out the respective roles, responsibilities and arrangements for escalation and information sharing. Brief records of supervision are shared with the employing organisation in accordance with the agreed arrangements.Working with the frailty practitioner and the wider teamThe GP with an interest in frailty provides a clinical anchor for the core team, helping to bring clinical perspectives together and support consistent, coordinated decision-making. The post holder is expected to be accessible to the frailty practitioner and other team members for day-to-day clinical support, including case discussion, advice on clinical decisions and agreement of appropriate next steps. Where practicable, co-location for part of the working week can help build relationships, support timely discussion and strengthen the teams approach to care.Where the employing organisation and the ICT agree that the GP will also provide formal clinical supervision to the frailty practitioner, this is established through a written supervision agreement. The agreement sets out the respective responsibilities, with protected time identified within the GPs sessions and an agreed contribution to the practitioners appraisal. This is a specific, agreed addition to the role rather than an automatic expectation of the frailty GP post.General responsibilitiesThese apply to every member of the INT.Equality, diversity and inclusion: treat patients, carers and colleagues fairly and with dignity and respect, and challenge discrimination on any protected characteristicSafeguarding: recognise and act on safeguarding concerns for adults and children, following local proceduresConfidentiality and information governance: protect patient information and share it appropriately across organisations under agreed data-sharing arrangementsHealth, safety and lone working: take reasonable care of your own and others' safety, including during home visitsQuality and continuous improvement: suggest and take part in improvements to how the team worksInduction: complete induction with the employing organisation and the INT, including the practices you work withProfessional conduct: follow the policies of the employing organisation and the standards of your professional body

Person Specification

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

Qualifications

Essential

• 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

Desirable

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

Skills, Knowledge and Abilities

Essential

• Experience in Comprehensive Geriatric Assessment; structured medication review; advance care planning conversations; clinical risk management
• Person-centred, proactive, empathetic in distressing situations; good judgement under pressure; committed to CPD
• Competent IT skills
• Collaborative across professional and organisational boundaries; supports and teaches others; works well autonomously and in a team

Desirable

• Quality improvement and audit leadership; population health and risk stratification tools
• Experience of integrated or multi-organisation teams; leading service change
• Interest in service development and system change
• SystmOne, EMIS

Other

Essential

• Full driving licence and access to a car; enhanced DBS check; occupational health clearance; flexibility to meet service needs

Person Specification 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 Qualifications Essential 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 Desirable Diploma in Geriatric Medicine or postgraduate qualification in frailty or palliative care Skills, Knowledge and Abilities Essential Experience in Comprehensive Geriatric Assessment; structured medication review; advance care planning conversations; clinical risk management Person-centred, proactive, empathetic in distressing situations; good judgement under pressure; committed to CPD Competent IT skills Collaborative across professional and organisational boundaries; supports and teaches others; works well autonomously and in a team Desirable Quality improvement and audit leadership; population health and risk stratification tools Experience of integrated or multi-organisation teams; leading service change Interest in service development and system change SystmOne, EMIS Other Essential Full driving licence and access to a car; enhanced DBS check; occupational health clearance; flexibility to meet service needs

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

South Downs Health and Care Ltd (SDHC)

Address

Hillbrow Health and Wellbeing

1 Denton Road

Eastbourne

East Sussex

BN20 7SS

United Kingdom

Employer's website

http://www.sdhc.org.uk/ (Opens in a new tab)

Employer details

Employer name

South Downs Health and Care Ltd (SDHC)

Address

Hillbrow Health and Wellbeing

1 Denton Road

Eastbourne

East Sussex

BN20 7SS

United Kingdom

Employer's website

http://www.sdhc.org.uk/ (Opens in a new tab)

Job summary

Interview dates: 17 and 18 November 2026.

South Downs Health and Care (SDHC) is seeking to appoint two experienced and motivated Frailty Practitioners to join our developing frailty service, working within the new Integrated Neighbourhood Team (INT) model.

These are exciting opportunities for skilled healthcare professionals who are passionate about delivering high-quality, person-centred care and improving outcomes for people living with frailty and complex health needs.

Working alongside GPs with a specialist interest in frailty, Community Geriatricians and a wider multidisciplinary team, you will play an important role in developing a proactive, coordinated approach to care that supports patients to remain safe, well and independent within their own homes.

As part of an evolving integrated care model, you will have the opportunity to contribute to service development, strengthen collaborative working across organisational boundaries and help shape the delivery of frailty services within the local community.

Main duties of the job

As a Frailty Practitioner, you will use advanced clinical assessment and decision-making skills to assess, manage and coordinate care for patients living with frailty and complex long-term conditions.

Key responsibilities will include

• Undertaking comprehensive clinical and holistic assessments, including Comprehensive Geriatric Assessments (CGAs).
• Developing and implementing personalised care and treatment plans in partnership with patients, carers and multidisciplinary colleagues.
• Proactively managing patients with complex needs, supporting early intervention and preventing unnecessary hospital admissions.
• Working closely with GPs, Community Geriatricians, community nursing teams, social care professionals and other healthcare providers.
• Supporting safe and timely hospital discharge and reducing the risk of readmission.
• Providing specialist clinical advice and guidance to patients, carers and professional colleagues.
• Undertaking medication reviews and prescribing independently within professional competencies.
• Supporting the delivery of integrated frailty pathways, including collaboration with Frailty Virtual Ward and urgent community services.
• Contributing to clinical governance, quality improvement and ongoing service development.

About us

South Downs Health and Care GP Federation is a social enterprise. It was established in 2016 in service to shareholding/member GP practices in the areas of Eastbourne, Hailsham and Seaford. It now has extended membership within East Sussex. Our main purpose is to support GP practices in their task of providing patient care by enabling them to provide and invest in sustainable services by reducing the burden of their workload, maximising income opportunities and minimising their risks and liabilities.

We encourage our staff to take ownership and responsibility, to highlight concerns and feedback and to make an active contribution to their individual success as well as that of their team and the wider organisation. We operate a no-blame culture; by this we mean that everyone is held accountable but in an environment where the focus is on the learning that can be adopted and shared from instances where things havent gone so well.

Benefits of Working with SDHC

• NHS Pension Scheme with generous employer contributions
• 25 days holiday plus bank holidays, increasing in stages to 30 days holiday plus bank holidays after 5 years service (pro rata for part time hours)
• Employee Assistance Programme including access to counselling and support with legal and financial matters
• CycleScheme
• Christmas and summer events
• Discounted rate for membership of Hillbrow Health and Wellbeing Centre facilities

Details

Date posted

26 October 2026

Pay scheme

Other

Salary

£49,719 a year

Contract

Permanent

Working pattern

Full-time, Flexible working

Reference number

B0164-26-0004

Job locations

Hillbrow Health and Wellbeing

1 Denton Road

Eastbourne

East Sussex

BN20 7SS

United Kingdom

Job description

Job responsibilities

As a Frailty Practitioner, you will use advanced clinical assessment and decision-making skills to assess, manage and coordinate care for patients living with frailty and complex long-term conditions.

Main Duties

Clinical

Within the core Frailty Practitioner community team:

To use advanced clinical skills and expert knowledge to assess the physical and psychosocial needs of those living with frailty, instigating treatment based on best available evidence in order to stabilise the individuals condition, prevent admission and maintain independence appropriate to that person.

To work flexibly across community localities covered by Eastbourne ICT. You will need to have your own car transport.

To agree a personal management plan with the patient, ideally with inclusion of carers, relatives and other appropriate health care professionals. This will be based on a full assessment of medical, nursing and basic social care needs.

To use advanced clinical skills and expert knowledge to identify changes in the patients condition, analysing and interpreting complex health problems and associated scenarios.

To work with patients to identify problems from their perspective and develop holistic management plans.

To negotiate and agree with clients, carers, community nurse teams and other care professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate.

To work across professional and organisational boundaries, identifying areas for skill and knowledge development applying these to individual practice with the aim of providing continuity and high-quality patient centred care.

To enable clients and carers to manage their medications in conjunction with GPs, pharmacists and other relevant clinical staff, including medication reviews as part of initial assessments and ongoing patient reviews.

To provide expert clinical care and health promotion.

To support the governance team/Chief Corporate Officer in the management of serious incidents and root cause analysis, sharing learnt outcomes and best practice with clinical staff.

Use expert knowledge and skill as a non-medical prescriber to independently prescribe within the individual practitioners areas of prescribing competency.

Develop prescribing clinical management plans as appropriate in partnership with GP colleagues.

Work to the NMC and HCPC codes of practice and maintain professional registration.

Care co-ordinator

To anticipate medical, care and social support needs of those living with frailty, developing appropriate management plans and referring to other services or professionals when required.

To regularly review patient care pathways with community nurse colleagues and the wider Integrated Locality Adult Teams, preventing duplication of work and promoting service efficiency.

Make direct referrals and order investigations as necessary ensuring medical records are written in accordance with SDHC and regulatory body policy.

To be responsible and accountable for the caseload and liaising with other professionals in all settings to optimise continuity of care as appropriate.

To establish contact when patients are admitted to in-patient facilities in order to provide relevant health and social care data, facilitate consistency of care and discharge planning.

To be a key part of the multidisciplinary and agency team, acting as care co-ordinator for individual patients and working closely with the MDT Co-ordinator.

To work collaboratively and in partnership with other clinicians to offer appropriate advice to all professions on care practices, delivery and service development to ensure efficient and effective team approach.

To maintain a high profile within the locality and ensure the service is easily accessible to patients, families, carers and health professionals in relation to those living with frailty.

Work with colleagues to lead on development, implementation and evaluation of protocols, policies and integrated care pathways consistent with local and national policies, standards and current research, facilitating changes in practice which improve clinical outcomes and meet the needs of patients and carers.

In conjunction with other health care professionals develops and regularly reviews patient information using a variety of mediums that consider cultural diversity and communication difficulties in line with SDHC policy and guidance.

Education and research

To work with patients living with frailty and their carers to identify changes in their condition and abilities that may precipitate an acute exacerbation or deterioration in condition and advise on relevant actions.

To critically evaluate and interpret evidence-based research findings from diverse sources making informed judgements on implications for changing and developing services and clinical practice.

To continually evaluate and audit the quality and effectiveness of the service and make alterations in conjunction with the manager as appropriate.

To identify gaps in services to support patient care and participate in resolution with the wider Eastbourne Healthcare System.

To contribute to the wider development of frailty practice through publishing, presenting and networking locally and nationally.

To contribute to business planning, development and clinical governance processes, ensuring sustained effective and efficient service delivery.

To participate in locality health education initiatives to ensure both staff and the wider public have a greater understanding of the health promotion and self care agenda.

Communication skills

To effectively communicate within the SDHC and ICT team; to a variety of health professionals, users and carers, to provide the best outcomes for clients.

To provide the interface for individual patients between hospital, primary, community and social care settings.

To maintain a high level of performance and be goal and outcome focussed when faced with opposition or when working under conditions of pressure.

To keep accurate contemporaneous documentation and management plans using the single assessment process and participate in integrated documentation.

Comprehensive and effective use of communication skills, oral and written, to communicate with patients, their supporters and other professionals, including the communication of highly sensitive and complex information about their condition.

To prepare patients and their families for changes in condition, and support choice about end-of-life care.

To use IM&T support systems to obtain effective feedback on progress of clients and service performance.

In collaboration with Integrated Locality Adult Team colleagues, regularly attend locality MDT meetings to provide Frailty Practitioner representation. To attend VMT meetings when requested.

Finance and business management

Ensure an appropriate understanding of the services financial structure and accounts and provide an informed analytical perspective of the budgets for which the post holder supports.

Support the Chief Operating Officer to meet agreed targets within the locality and when required represent the team in SDHC/ICT business.

Support the Chief Operating Officer in preparation of business cases for both internal and external agencies and funding.

Health, safety and security

Support the Frailty GP to implement approved changes in response to legislation and the changing needs of the population.

Support clinical leads, service leads and senior staff to respond and implement action that provides health, safety and security for workforce and users.

Represent the team as required including attendance at meetings and committees when required.

Responsible for undertaking personal risk assessments on any work area that directly affects the way in which they work, for example office space, patient homes or any other building. To complete desk and ergonomic and associated risk assessments prior to working from their own home.

Ensure that the risks identified are escalated as per SDHC policy.

To ensure that any assessments undertaken are documented and reported in line with SDHC policy.

Quality, clinical governance and clinical audit

Identify appropriate audits and assist in delivering these.

To be an active part of the team developing quality outcomes and providing support in delivering these.

To develop with the Frailty Practitioners & GPs a robust process for ensuring clinical governance is integrated in day-to-day work.

To support the development of quality indicators and acknowledge the quality monitoring of clinical record keeping within the team.

Participate in the collection of data to achieve the targets.

Equality, diversity and rights

Ensure that the team provides an appropriate staffing to reflect the diversity of the population and ensure equal opportunities.

The post holder will ensure that equal opportunities policies are upheld.

Ensure that monitoring of service delivery includes access by minority groups.

Patient and public involvement

SDHC has a statutory duty to ensure that patients, clients and members of the public are consulted and involved in decisions about local health service developments. The post holder will work with relevant staff to ensure this happens.

Job description Job responsibilities As a Frailty Practitioner, you will use advanced clinical assessment and decision-making skills to assess, manage and coordinate care for patients living with frailty and complex long-term conditions.Main DutiesClinicalWithin the core Frailty Practitioner community team: To use advanced clinical skills and expert knowledge to assess the physical and psychosocial needs of those living with frailty, instigating treatment based on best available evidence in order to stabilise the individuals condition, prevent admission and maintain independence appropriate to that person. To work flexibly across community localities covered by Eastbourne ICT. You will need to have your own car transport. To agree a personal management plan with the patient, ideally with inclusion of carers, relatives and other appropriate health care professionals. This will be based on a full assessment of medical, nursing and basic social care needs. To use advanced clinical skills and expert knowledge to identify changes in the patients condition, analysing and interpreting complex health problems and associated scenarios. To work with patients to identify problems from their perspective and develop holistic management plans. To negotiate and agree with clients, carers, community nurse teams and other care professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate. To work across professional and organisational boundaries, identifying areas for skill and knowledge development applying these to individual practice with the aim of providing continuity and high-quality patient centred care. To enable clients and carers to manage their medications in conjunction with GPs, pharmacists and other relevant clinical staff, including medication reviews as part of initial assessments and ongoing patient reviews. To provide expert clinical care and health promotion. To support the governance team/Chief Corporate Officer in the management of serious incidents and root cause analysis, sharing learnt outcomes and best practice with clinical staff. Use expert knowledge and skill as a non-medical prescriber to independently prescribe within the individual practitioners areas of prescribing competency. Develop prescribing clinical management plans as appropriate in partnership with GP colleagues. Work to the NMC and HCPC codes of practice and maintain professional registration.Care co-ordinator To anticipate medical, care and social support needs of those living with frailty, developing appropriate management plans and referring to other services or professionals when required. To regularly review patient care pathways with community nurse colleagues and the wider Integrated Locality Adult Teams, preventing duplication of work and promoting service efficiency. Make direct referrals and order investigations as necessary ensuring medical records are written in accordance with SDHC and regulatory body policy. To be responsible and accountable for the caseload and liaising with other professionals in all settings to optimise continuity of care as appropriate. To establish contact when patients are admitted to in-patient facilities in order to provide relevant health and social care data, facilitate consistency of care and discharge planning. To be a key part of the multidisciplinary and agency team, acting as care co-ordinator for individual patients and working closely with the MDT Co-ordinator. To work collaboratively and in partnership with other clinicians to offer appropriate advice to all professions on care practices, delivery and service development to ensure efficient and effective team approach. To maintain a high profile within the locality and ensure the service is easily accessible to patients, families, carers and health professionals in relation to those living with frailty. Work with colleagues to lead on development, implementation and evaluation of protocols, policies and integrated care pathways consistent with local and national policies, standards and current research, facilitating changes in practice which improve clinical outcomes and meet the needs of patients and carers. In conjunction with other health care professionals develops and regularly reviews patient information using a variety of mediums that consider cultural diversity and communication difficulties in line with SDHC policy and guidance.Education and research To work with patients living with frailty and their carers to identify changes in their condition and abilities that may precipitate an acute exacerbation or deterioration in condition and advise on relevant actions. To critically evaluate and interpret evidence-based research findings from diverse sources making informed judgements on implications for changing and developing services and clinical practice. To continually evaluate and audit the quality and effectiveness of the service and make alterations in conjunction with the manager as appropriate. To identify gaps in services to support patient care and participate in resolution with the wider Eastbourne Healthcare System. To contribute to the wider development of frailty practice through publishing, presenting and networking locally and nationally. To contribute to business planning, development and clinical governance processes, ensuring sustained effective and efficient service delivery. To participate in locality health education initiatives to ensure both staff and the wider public have a greater understanding of the health promotion and self care agenda.Communication skills To effectively communicate within the SDHC and ICT team; to a variety of health professionals, users and carers, to provide the best outcomes for clients. To provide the interface for individual patients between hospital, primary, community and social care settings. To maintain a high level of performance and be goal and outcome focussed when faced with opposition or when working under conditions of pressure. To keep accurate contemporaneous documentation and management plans using the single assessment process and participate in integrated documentation. Comprehensive and effective use of communication skills, oral and written, to communicate with patients, their supporters and other professionals, including the communication of highly sensitive and complex information about their condition. To prepare patients and their families for changes in condition, and support choice about end-of-life care. To use IM&T support systems to obtain effective feedback on progress of clients and service performance. In collaboration with Integrated Locality Adult Team colleagues, regularly attend locality MDT meetings to provide Frailty Practitioner representation. To attend VMT meetings when requested.Finance and business management Ensure an appropriate understanding of the services financial structure and accounts and provide an informed analytical perspective of the budgets for which the post holder supports. Support the Chief Operating Officer to meet agreed targets within the locality and when required represent the team in SDHC/ICT business. Support the Chief Operating Officer in preparation of business cases for both internal and external agencies and funding.Health, safety and security Support the Frailty GP to implement approved changes in response to legislation and the changing needs of the population. Support clinical leads, service leads and senior staff to respond and implement action that provides health, safety and security for workforce and users. Represent the team as required including attendance at meetings and committees when required. Responsible for undertaking personal risk assessments on any work area that directly affects the way in which they work, for example office space, patient homes or any other building. To complete desk and ergonomic and associated risk assessments prior to working from their own home. Ensure that the risks identified are escalated as per SDHC policy. To ensure that any assessments undertaken are documented and reported in line with SDHC policy.Quality, clinical governance and clinical audit Identify appropriate audits and assist in delivering these. To be an active part of the team developing quality outcomes and providing support in delivering these. To develop with the Frailty Practitioners & GPs a robust process for ensuring clinical governance is integrated in day-to-day work. To support the development of quality indicators and acknowledge the quality monitoring of clinical record keeping within the team. Participate in the collection of data to achieve the targets.Equality, diversity and rights Ensure that the team provides an appropriate staffing to reflect the diversity of the population and ensure equal opportunities. The post holder will ensure that equal opportunities policies are upheld. Ensure that monitoring of service delivery includes access by minority groups.Patient and public involvement SDHC has a statutory duty to ensure that patients, clients and members of the public are consulted and involved in decisions about local health service developments. The post holder will work with relevant staff to ensure this happens.

Person Specification

Experience

Essential

• Experience of working as an autonomous practitioner
• Case management experience
• Working with older people living with frailty and/or complex conditions
• Working with adults with long term conditions, in particular COPD, heart failure, type 2 diabetes
• Good understanding of working in partnership with statutory and non statutory agencies to support patient centred care
• Multi-disciplinary and multi-agency working
• Proven extensive experience of working with older people

Desirable

• Experience in a Community setting
• Experience of working between other health and social care organisations and settings
• Experience of interpreting microbiology and pathology results
• Experience of managing acute patients
• Use of IT systems, including MS Teams, SystmOne, NerveCentre

Qualifications

Essential

• RN first level nurse (Adults) or Allied Health Professional eligible to become an Independent Prescriber
• Bachelors degree
• Case management experience
• Teaching and Assessing qualification
• Non-medical independent prescriber or supplementary prescribing, or willingness to commence training within 12 months of coming into post
• Advanced physical assessment module, or willingness to commence training within 12 months of coming into post
• Evidence of continuing professional development in a relevant area of specialist practice to masters equivalent level
• Registered with NMC and/or HCPC

Desirable

• Relevant post-graduate or masters level degree

Skills, Knowledge and Abilities

Essential

• Able to demonstrate effective leadership and organisational skills
• Advanced clinical decision-making skills to support patient centred care
• Advanced physical assessment skills
• Good knowledge of anatomy and physiology
• Up to date working knowledge of both local and national policy issues pertinent to frail older people, i.e. legislation and disease management
• Extensive experience in working with adults and older people, including frail older people
• Evidence of ability to maintain and monitor high standards of care
• Ability to communicate complex clinical patient presentations to medical colleagues, in particular GPs in Primary Care
• Evidence of ability to direct and co-ordinate complex programmes of care working autonomously and collaboratively across organisational boundaries
• Ability to communicate effectively in a variety of settings across organisational boundaries and with the general public
• Evidence of the ability to work in a changing, stressful situation
• Ability to adapt to working in challenging environments to manage complex patient centred care

Desirable

• Experience of contributing to the development of new services
• Experience of working through cycles of change, including at times of pressure, embracing and implementing change to provide high quality health outcomes
• Ability to influence and manage a variety of change management programmes

Other

Essential

• Must be mobile for regular travel and able to travel between base and client homes within a reasonable timeframe and cost
• Enhanced DBS Disclosure
• Reliable work record

Person Specification Experience Essential Experience of working as an autonomous practitioner Case management experience Working with older people living with frailty and/or complex conditions Working with adults with long term conditions, in particular COPD, heart failure, type 2 diabetes Good understanding of working in partnership with statutory and non statutory agencies to support patient centred care Multi-disciplinary and multi-agency working Proven extensive experience of working with older people Desirable Experience in a Community setting Experience of working between other health and social care organisations and settings Experience of interpreting microbiology and pathology results Experience of managing acute patients Use of IT systems, including MS Teams, SystmOne, NerveCentre Qualifications Essential RN first level nurse (Adults) or Allied Health Professional eligible to become an Independent Prescriber Bachelors degree Case management experience Teaching and Assessing qualification Non-medical independent prescriber or supplementary prescribing, or willingness to commence training within 12 months of coming into post Advanced physical assessment module, or willingness to commence training within 12 months of coming into post Evidence of continuing professional development in a relevant area of specialist practice to masters equivalent level Registered with NMC and/or HCPC Desirable Relevant post-graduate or masters level degree Skills, Knowledge and Abilities Essential Able to demonstrate effective leadership and organisational skills Advanced clinical decision-making skills to support patient centred care Advanced physical assessment skills Good knowledge of anatomy and physiology Up to date working knowledge of both local and national policy issues pertinent to frail older people, i.e. legislation and disease management Extensive experience in working with adults and older people, including frail older people Evidence of ability to maintain and monitor high standards of care Ability to communicate complex clinical patient presentations to medical colleagues, in particular GPs in Primary Care Evidence of ability to direct and co-ordinate complex programmes of care working autonomously and collaboratively across organisational boundaries Ability to communicate effectively in a variety of settings across organisational boundaries and with the general public Evidence of the ability to work in a changing, stressful situation Ability to adapt to working in challenging environments to manage complex patient centred care Desirable Experience of contributing to the development of new services Experience of working through cycles of change, including at times of pressure, embracing and implementing change to provide high quality health outcomes Ability to influence and manage a variety of change management programmes Other Essential Must be mobile for regular travel and able to travel between base and client homes within a reasonable timeframe and cost Enhanced DBS Disclosure Reliable work record

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

South Downs Health and Care Ltd (SDHC)

Address

Hillbrow Health and Wellbeing

1 Denton Road

Eastbourne

East Sussex

BN20 7SS

United Kingdom

Employer's website

http://www.sdhc.org.uk/ (Opens in a new tab)

Employer details

Employer name

South Downs Health and Care Ltd (SDHC)

Address

Hillbrow Health and Wellbeing

1 Denton Road

Eastbourne

East Sussex

BN20 7SS

United Kingdom

Employer's website

http://www.sdhc.org.uk/ (Opens in a new tab)