Complex Care GPNHS

Job summary

Join Somerset Foundation Trust as a Complex Care GP in Yeovil

We are looking for an enthusiastic and motivated Complex Care GP to join the Yeovil Complex Integrated Care Team and help shape the future of integrated healthcare across Somerset.

This rewarding role focuses on supporting patients with the most complex healthcare needs, including multiple long-term conditions, frailty, frequent hospital admissions, psychological challenges and polypharmacy.

You will play a key role in delivering proactive, personalised care that improves outcomes and reduces health inequalities for some of our most vulnerable patients.

Working across primary, community and secondary care, you will help strengthen continuity of care and build effective partnerships with Primary Care Networks, neighbourhood teams and hospital services, ensuring patients receive seamless, coordinated support.

This is a permanent position, working 8 Programmed Activities (PAs) per week, Monday to Friday, 08:30 to 16:30, with no on-call commitment currently required.

If you are passionate about integrated care, multidisciplinary working and making a real difference to patients with complex needs, this is an excellent opportunity to join a forward-thinking team at the forefront of innovative healthcare delivery.

We look forward to receiving your application

Main duties of the job

Participate in multidisciplinary "huddles" within GP practices, providing specialist advice and supporting clinical decision-making for patients with complex needs.

Attend secondary care meetings to review patients identified by hospital teams.

Support the safe discharge of patients with highly complex needs from hospital into community settings.

Contribute to hospital and community multidisciplinary team (MDT) meetings, safeguarding discussions and Best Interest meetings as required.

Manage a caseload of patients with complex health needs, frailty and multiple long-term conditions, developing personalised care plans, disease-specific management plans and Treatment Escalation Plans (TEPs).

Undertake face-to-face consultations, extended assessments and home visits where clinically appropriate.

Prescribe safely and effectively in accordance with national guidance, local formularies and best practice standards.

Work proactively with GP practices and multidisciplinary teams to identify patients who would benefit from additional clinical input and coordinated support.

Maintain accurate, timely and comprehensive patient records using appropriate clinical systems.

Prioritise and manage workload effectively while maintaining professional accountability and delivering high-quality patient care.

Ensure effective oversight of an active caseload, promoting continuity, safety and excellent patient outcomes.

Job description

About the Service

The Complex Care Service operates across South Somerset and consists of four multidisciplinary teams working in partnership with GP practices across local Primary Care Networks. Each team includes a GP, Complex Care Nurse or Advanced Clinical Practitioner, and a Key Worker, delivering proactive, integrated care within neighbourhood services.

Working closely with District Nursing, Older Persons Mental Health Services, Community Rehabilitation, Hospital@Home, Rapid Response teams and Adult Social Care, the service supports patients with the most complex health and care needs.

The team provides:

• Comprehensive Geriatric Assessments (CGA), exploring physical, psychological, functional, social and environmental factors affecting health and wellbeing.
• Holistic, personalised care and support planning.
• Structured Medication Reviews.
• Development of disease-specific escalation plans, Treatment Escalation Plans (TEPs) and Resuscitation Orders where appropriate.
• Coordination of care across primary, community, secondary and social care services.
• Partnership working with voluntary and community organisations to strengthen local support networks and improve patient outcomes.

The service complements, rather than replaces, the care provided by a patient's registered GP. The length of our involvement is determined by individual patient needs and the complexity of coordination required across services.

At Somerset Foundation Trust, we remain committed to our five leadership pillars, ensuring that even during periods of pressure we continue to deliver compassionate, collaborative and high-quality care. By joining our organisation, you will be expected to embody these values and contribute to delivering outstanding care for our patients and communities.

About us

At Somerset NHS Foundation Trust, we're committed to supporting our employees with a range of benefits designed to enhance your professional and personal life. We offer:

• Flexible working options to help you balance work and life
• NHS pension scheme for long-term financial security
• Generous annual leave allowance to recharge and relax
• A strong focus on career development to help you grow and achieve your potential

Additionally, you'll gain access to our Blue Light Card, unlocking exclusive discounts on shopping, dining, and leisure activities, as well as NHS-specific perks to support you both inside and outside of work.

We are proud to foster a diverse, skilled, and inclusive workforce, and we encourage applications from all backgrounds.

Why Somerset? Somerset offers the perfect blend of idyllic countryside, outstanding areas of natural beauty, and breathtaking coastlines, with vibrant cities like Bristol, Bath, and Exeter just a short drive away - and only two hours to London.

The region is home to excellent educational facilities, and with affordable housing compared to other parts of the country, it's a great place to build both your career and your future.

Somerset truly has it all - the peaceful countryside and cosmopolitan city life, with something for everyone to enjoy.