GP with Extended Role in Frailty (2 Sessions on Wednesdays)GP Practice
Job summary
An exciting opportunity has arisen for a GP with a specialist interest in frailty to deliver two sessions per week on a Wednesday (Sorry we are unable to change the required day) within an integrated community-based service that launched 12 months ago. The team support the frail housebound population across Easington and Sedgefield. This role offers the chance to play a pivotal part in shaping and delivering proactive, person-centred care in collaboration with local stakeholders. The Proactive Service has recently launched which aims to bring joined-up, multidisciplinary support to patients to make a real difference in their health and wellbeing.
Please note, we are unable to offer sponsorship for a visa.
Main duties of the job
Conduct Comprehensive Geriatric Assessments (CGAs) remotely.
Perform medical, psychosocial, and medicines reviews,
including advanced care planning.
Manage diagnostic tests, communicate outcomes to GPs, and
provide follow-up reviews where necessary.
Make onward referrals to other specialties when appropriate.
Work within and support a multidisciplinary team (MDT)
including geriatricians, nurses, therapists, and social care professionals.
Lead and facilitate MDT clinical decision-making processes.
Supervise and support clinical staff.
Take a leadership role in the development and expansion of
frailty services.
Contribute to the development of clinical guidelines,
service pathways, and quality improvement initiatives.
Participate in research, clinical audit, and service
governance beyond revalidation requirements.
Communicate effectively with patients, carers, colleagues,
commissioners, and wider stakeholders.
Promote and implement innovative, remote care models and use
of digital health tools, including AI-based transcription.
Uphold clinical governance standards and practice within
national guidelines (e.g. NICE, GMC).
Take part in staff supervision, performance review,
appraisal, and professional development.
Demonstrate emotional resilience, professionalism, and
leadership under pressure and during service change.
About us
South Durham Health CiC is the managing agent for the 5
primary care networks (PCNs) in the Sedgefield and Easington localities. We
also hold a number of NHS contracts providing additional services to our
patient populations. We serve a combined patient population of 204,554 across
21 practices.
We are early adopters of the Integrated Neighbourhood Team
strategy and have already developed 2 Integrated Neighbourhood Teams (INTs)
aligned to our future work against NHS key strategies.
Details
Date posted
21 August 2026
Pay scheme
Other
Salary
£11,250 a session
no pdp attached
Contract
Fixed term
Duration
2 years
Working pattern
Part-time
Reference number
B0611-26-0018
Job locations
The Surgery
Ashmore Terrace
Wheatley Hill
County Durham
DH6 3NP
United Kingdom
Job description
Job responsibilities
The GPwER in Frailty will provide
evidence based, comprehensive, person centred and individualised medical care for older people, working
as part of a multidisciplinary team within community settings across South Durham
The role whilst demanding and challenging and also requiring the post holder to possess
the specialist frailty
knowledge required to support the medical management of complex and challenging
presentations of older frail people,
will prove extremely varied and rewarding to the post holder. This care will be provided through our
various community frailly workstreams
DUTIES & RESPONSIBILITIES
The post holder will work as part of
a multidisciplinary team, which includes Consultant Geriatricians, GPwERs,
nurses, therapists, social care, the third sector and care home staff, to
deliver high quality care and support for older people within the community. The post holder will contribute to service
development, guideline development, research opportunities, and governance
activities such as audit and quality improvement processes.
The post holder will be expected to
participate in the training and development of other members of the MDT and
wider healthcare community and assume a leadership role in the care of older
people in the community.
The post holder
will be expected
to work autonomously with peer review and personal development opportunities.
RESPONSIBILITY FOR PATIENT
CARE
Comprehensive Geriatric
Assessment (Remote)
The management of patients referred
into the service to include provision of medical,
psychosocial, medicines reviews and advanced care planning to patients in their own homes.
The communication of outcomes to the patient, their family and carers as well as their registered GP through the extended MDT.
To carry out reviews
of patients previously seen in
the service, when this is deemed clinically necessary.
To partake
in the supervision of staff including ANPs and Registrars
if and when the roles are integrated in to the service.
Filing and management of diagnostic tests requested through
the service.
To
support expansion and development of the service over time
Support and
facilitate MDT decision making in your role as the senior clinical leader
Complete onward
referrals to other specialties when appropriate
Develop skills in the use of AI based transcription platforms
Urgent Community
Response
Provide a CGA assessment with the rest of the MDT team for
patient deemed suitable for review through the Urgent Community Response
Pathway. This not a same day assessment pathway assessment.
The patients will likely have multiple sub acute issues
that requires support and facilitation through an MDT approach.
The same approach is to be give to this patient group as
outlined above.
COMMUNICATION
The post holder will be required to
demonstrate excellent communication skills when working with patients, carers,
members of the public, primary and secondary care colleagues, allied health
care professionals, managers up to chief executive level, commissioners and the
media.
ANALYTICAL TASKS
High
level clinical judgement based on experience and clinical guidance is expected in patient management. High level analytical skills
will also be required in the day to day operational management, governance and
in strategic service development.
PLANNING AND ORGANISATIONAL SKILLS
The
post will require a high level
of personal organisation to deliver clinical and managerial
responsibilities. Specifically, at service
level, the post holder will have to plan and organise service
development and change in areas of responsibility.
Strategically, the post holder will require being a self-starter and taking
personal responsibility for the development, organisation and delivery of service development in line with the needs of the contracted population.
PHYSICAL SKILLS
The physical skills requiring to be sustained
are those required to achieve the CCT/CESR
in their speciality
e.g. hearing, vision and dexterity for minor procedures, mobility and legible handwriting.
POLICY AND SERVICE DEVELOPMENT IMPLEMENTATION
The post
holder will actively contribute to both the day-to-day operations and the
long-term development of the service, working closely with clinical and
management teams. Internally, this will involve driving innovation to create a
forward-thinking, cost-effective, and patient-focused service that makes use of
new technologies and the expertise of a multidisciplinary team, in partnership
with statutory and third-sector organisations. Externally, the role will
include collaborating with members of the multidisciplinary team to ensure
services meet the specific needs of the local population
RESPONSIBILITIES FOR FINANCIAL
AND PHYSICAL RESOURCES
The
post holder will have a personal duty of
care in relation to equipment
and resources and to maintain
a secure working environment.
RESPONSIBILITIES FOR HUMAN RESOURCES
The post holder may take part in managing, supervising, coordinating,
teaching, training, and supporting employees, students, trainees, and others in
similar roles. They will be responsible for planning and assigning work, as
well as reviewing and assessing completed tasks.
They will also participate in personal development supervision to
enhance their skills and clinical practice, and will complete appraisal and
revalidation processes as required.
RESPONSIBILITIES FOR INFORMATION RESOURCES
The post holder will be responsible
for the development and safe storage of person centred health care assessments,
plans and electronic care records. The
post holder may also be responsible for the managing and safe storage of
electronic staff records, for example clinical supervision records.
RESPONSIBILITIES FOR RESEARCH AND DEVELOPMENT
The post holder will be expected to participate in
Quality and audit activity, beyond the minimum required for revalidation, to
assure service quality and patient safety.
FREEDOM TO ACT
The post holder will be expected to
practice within the policies, procedures and guidelines of the organisation and
service, and national bodies such as NICE, The Royal College of General
Practice.
S/he must practice
within the ethical boundaries
of Good Medical Practice
as laid down by the GMC.
CARE OF OLDER PEOPLE,
SERVICE MODEL:
The service model includes the following key principles:
OUR ETHOS:
The ethos
of the service is to proactively deliver innovative, high-quality care to the
local populations of Sedgefield and Easington, with the goal of enhancing the
quality of life for the most frail and vulnerable individuals. This care is
patient-centered and evidence-based, ensuring that every action is aimed at
improving the lives of those we serve. Professionals working within this
service are encouraged to feel supported, engaged, and motivated to provide the
highest standard of care.
ENGAGEMENT AND INVOLVEMENT:
We actively engage with our service
users and their families and carers and will utilise feedback from engagement
activities to inform service development.
SERVICE USER FEEDBACK
The Integrated
frailty service will support patient feedback through patient survey and
friends and family opportunities.
SERVICE DELIVERY:
Our service model will combine
clinical and cost effectiveness by providing access to a skilled and
multiprofessional workforce. Care will be delivered in an innovative remote
model where technology is used to enable remote working with the support of the
MDT team.
IMPROVING PRACTICE:
Providing education and support to primary care organisations, constituent practices and
Other primary care providers to raise the general standard
and consistency of care of the older person
across primary care.
Facilitating and encouraging the
spread of good practice from within primary care across the whole health and
social care community.
Working with general practitioners,
pharmacists, primary care nurses, social workers, mental health nurses,
specialist community nurses and other health care staff such that current best
practice is implemented within effective pathways within primary care.
This
job description is not meant to be exhaustive. It describes the main duties and
responsibilities of the post. It may be subject to change in the light
of developing organisational and service needs and
wherever possible change will follow consultation with the post holder
Job description
Job responsibilities
The GPwER in Frailty will provide
evidence based, comprehensive, person centred and individualised medical care for older people, working
as part of a multidisciplinary team within community settings across South Durham
The role whilst demanding and challenging and also requiring the post holder to possess
the specialist frailty
knowledge required to support the medical management of complex and challenging
presentations of older frail people,
will prove extremely varied and rewarding to the post holder. This care will be provided through our
various community frailly workstreams
DUTIES & RESPONSIBILITIES
The post holder will work as part of
a multidisciplinary team, which includes Consultant Geriatricians, GPwERs,
nurses, therapists, social care, the third sector and care home staff, to
deliver high quality care and support for older people within the community. The post holder will contribute to service
development, guideline development, research opportunities, and governance
activities such as audit and quality improvement processes.
The post holder will be expected to
participate in the training and development of other members of the MDT and
wider healthcare community and assume a leadership role in the care of older
people in the community.
The post holder
will be expected
to work autonomously with peer review and personal development opportunities.
RESPONSIBILITY FOR PATIENT
CARE
Comprehensive Geriatric
Assessment (Remote)
The management of patients referred
into the service to include provision of medical,
psychosocial, medicines reviews and advanced care planning to patients in their own homes.
The communication of outcomes to the patient, their family and carers as well as their registered GP through the extended MDT.
To carry out reviews
of patients previously seen in
the service, when this is deemed clinically necessary.
To partake
in the supervision of staff including ANPs and Registrars
if and when the roles are integrated in to the service.
Filing and management of diagnostic tests requested through
the service.
To
support expansion and development of the service over time
Support and
facilitate MDT decision making in your role as the senior clinical leader
Complete onward
referrals to other specialties when appropriate
Develop skills in the use of AI based transcription platforms
Urgent Community
Response
Provide a CGA assessment with the rest of the MDT team for
patient deemed suitable for review through the Urgent Community Response
Pathway. This not a same day assessment pathway assessment.
The patients will likely have multiple sub acute issues
that requires support and facilitation through an MDT approach.
The same approach is to be give to this patient group as
outlined above.
COMMUNICATION
The post holder will be required to
demonstrate excellent communication skills when working with patients, carers,
members of the public, primary and secondary care colleagues, allied health
care professionals, managers up to chief executive level, commissioners and the
media.
ANALYTICAL TASKS
High
level clinical judgement based on experience and clinical guidance is expected in patient management. High level analytical skills
will also be required in the day to day operational management, governance and
in strategic service development.
PLANNING AND ORGANISATIONAL SKILLS
The
post will require a high level
of personal organisation to deliver clinical and managerial
responsibilities. Specifically, at service
level, the post holder will have to plan and organise service
development and change in areas of responsibility.
Strategically, the post holder will require being a self-starter and taking
personal responsibility for the development, organisation and delivery of service development in line with the needs of the contracted population.
PHYSICAL SKILLS
The physical skills requiring to be sustained
are those required to achieve the CCT/CESR
in their speciality
e.g. hearing, vision and dexterity for minor procedures, mobility and legible handwriting.
POLICY AND SERVICE DEVELOPMENT IMPLEMENTATION
The post
holder will actively contribute to both the day-to-day operations and the
long-term development of the service, working closely with clinical and
management teams. Internally, this will involve driving innovation to create a
forward-thinking, cost-effective, and patient-focused service that makes use of
new technologies and the expertise of a multidisciplinary team, in partnership
with statutory and third-sector organisations. Externally, the role will
include collaborating with members of the multidisciplinary team to ensure
services meet the specific needs of the local population
RESPONSIBILITIES FOR FINANCIAL
AND PHYSICAL RESOURCES
The
post holder will have a personal duty of
care in relation to equipment
and resources and to maintain
a secure working environment.
RESPONSIBILITIES FOR HUMAN RESOURCES
The post holder may take part in managing, supervising, coordinating,
teaching, training, and supporting employees, students, trainees, and others in
similar roles. They will be responsible for planning and assigning work, as
well as reviewing and assessing completed tasks.
They will also participate in personal development supervision to
enhance their skills and clinical practice, and will complete appraisal and
revalidation processes as required.
RESPONSIBILITIES FOR INFORMATION RESOURCES
The post holder will be responsible
for the development and safe storage of person centred health care assessments,
plans and electronic care records. The
post holder may also be responsible for the managing and safe storage of
electronic staff records, for example clinical supervision records.
RESPONSIBILITIES FOR RESEARCH AND DEVELOPMENT
The post holder will be expected to participate in
Quality and audit activity, beyond the minimum required for revalidation, to
assure service quality and patient safety.
FREEDOM TO ACT
The post holder will be expected to
practice within the policies, procedures and guidelines of the organisation and
service, and national bodies such as NICE, The Royal College of General
Practice.
S/he must practice
within the ethical boundaries
of Good Medical Practice
as laid down by the GMC.
CARE OF OLDER PEOPLE,
SERVICE MODEL:
The service model includes the following key principles:
OUR ETHOS:
The ethos
of the service is to proactively deliver innovative, high-quality care to the
local populations of Sedgefield and Easington, with the goal of enhancing the
quality of life for the most frail and vulnerable individuals. This care is
patient-centered and evidence-based, ensuring that every action is aimed at
improving the lives of those we serve. Professionals working within this
service are encouraged to feel supported, engaged, and motivated to provide the
highest standard of care.
ENGAGEMENT AND INVOLVEMENT:
We actively engage with our service
users and their families and carers and will utilise feedback from engagement
activities to inform service development.
SERVICE USER FEEDBACK
The Integrated
frailty service will support patient feedback through patient survey and
friends and family opportunities.
SERVICE DELIVERY:
Our service model will combine
clinical and cost effectiveness by providing access to a skilled and
multiprofessional workforce. Care will be delivered in an innovative remote
model where technology is used to enable remote working with the support of the
MDT team.
IMPROVING PRACTICE:
Providing education and support to primary care organisations, constituent practices and
Other primary care providers to raise the general standard
and consistency of care of the older person
across primary care.
Facilitating and encouraging the
spread of good practice from within primary care across the whole health and
social care community.
Working with general practitioners,
pharmacists, primary care nurses, social workers, mental health nurses,
specialist community nurses and other health care staff such that current best
practice is implemented within effective pathways within primary care.
This
job description is not meant to be exhaustive. It describes the main duties and
responsibilities of the post. It may be subject to change in the light
of developing organisational and service needs and
wherever possible change will follow consultation with the post holder
Person Specification
Practical & Intellectual skills
Essential
High level of clinical skills.
Ability to motivate and develop the multi-disciplinary team,
High level of communication skills. Good organisational skills.IT
competency Ability to make good clear concise medical notes, both computerised and manual
Able to work under pressure and within an ever changing environment Ability to balance service and personal objectives.
Desirable
Interest in research
Qualifications
Essential
Full and current unrestricted GMC (UK) registration on the GP Register A medical degree qualification
Desirable
A teaching qualification
e.g. post graduate diploma in post graduate education A post
Graduate qualification in older peoples care,
e.g. Diploma Geriatric Medicine or willing to work towards
Experience
Essential
Experience of supervising clinical staff to
Experience of continuing professional development.
Evidence of attendance at courses or self directed learning to meet learning gaps
identified through the professional development plan and through annual appraisal
Experience of conducting clinical audit
Desirable
1 year plus General Practice experience unless trainee has indicated additional skills to support appropriate experience in the field.
Diploma in Elderly Medicine.
Experience or formal qualifications or working with frail/ older people
Experience of designing, organising, teaching and training healthcare professionals and teaching patients.
Knowledge & Understanding
Essential
Up to date knowledge of all the latest guidelines and evidence in older peoples medicine.
Understand the importance of evidence based practice and clinical eectiveness
Understanding of clinical governance
Sound clinical knowledge.
Ability to use the evidence base and clinical audit to support decision-making
Desirable
Experience of SystmOne,
Experience of Heidi health
Practical & Intellectual skills
Essential
High level of clinical skills.
Ability to motivate and develop the multi-disciplinary team.
High level of communication skills.
Good organisational skills.
IT competency
Ability to make good clear concise medical notes, both computerised and manual
Able to work under pressure and within an ever changing environment
Ability to balance service and personal objectives.
Desirable
Interest in research
Attitude & Behaviour
Essential
Sensitive to the needs of others and has an awareness and responsiveness to other peoples feelings and needs
Excellent command of the English Language both verbal and written
Values differences: regards people as individuals and appreciates the value of diversity in the workplace Able to work as part of a team, cooperating to work together and in conjunction with others and willing to help and assist wherever possible and appropriate.
Able to develop, establish and maintain positive relationships with others both internal and external to the organisation.
Able to work under pressure, dealing with peaks and troughs in workload.
Positive attitude to dealing with change; flexible and adaptable, willing to change and accept change and to explore new ways of doing things and approaches.
Highly motivated, enthusiastic and reliable.
Has a strong degree of personal integrity; able to adhere to standards of conduct based on a sense of right and wrong and be dependable and reliable.
Demonstrates values consistent with those of the organisation.
Ability and willingness to adopt a flexible approach to work on the occasions it may be required.
Teaching & Training experience
Essential
Ability to teach clinical skills to medical and nursing staff and other disciplines. The ability to appraise junior doctors and other staff
Person Specification
Practical & Intellectual skills
Essential
High level of clinical skills.
Ability to motivate and develop the multi-disciplinary team,
High level of communication skills. Good organisational skills.IT
competency Ability to make good clear concise medical notes, both computerised and manual
Able to work under pressure and within an ever changing environment Ability to balance service and personal objectives.
Desirable
Interest in research
Qualifications
Essential
Full and current unrestricted GMC (UK) registration on the GP Register A medical degree qualification
Desirable
A teaching qualification
e.g. post graduate diploma in post graduate education A post
Graduate qualification in older peoples care,
e.g. Diploma Geriatric Medicine or willing to work towards
Experience
Essential
Experience of supervising clinical staff to
Experience of continuing professional development.
Evidence of attendance at courses or self directed learning to meet learning gaps
identified through the professional development plan and through annual appraisal
Experience of conducting clinical audit
Desirable
1 year plus General Practice experience unless trainee has indicated additional skills to support appropriate experience in the field.
Diploma in Elderly Medicine.
Experience or formal qualifications or working with frail/ older people
Experience of designing, organising, teaching and training healthcare professionals and teaching patients.
Knowledge & Understanding
Essential
Up to date knowledge of all the latest guidelines and evidence in older peoples medicine.
Understand the importance of evidence based practice and clinical eectiveness
Understanding of clinical governance
Sound clinical knowledge.
Ability to use the evidence base and clinical audit to support decision-making
Desirable
Experience of SystmOne,
Experience of Heidi health
Practical & Intellectual skills
Essential
High level of clinical skills.
Ability to motivate and develop the multi-disciplinary team.
High level of communication skills.
Good organisational skills.
IT competency
Ability to make good clear concise medical notes, both computerised and manual
Able to work under pressure and within an ever changing environment
Ability to balance service and personal objectives.
Desirable
Interest in research
Attitude & Behaviour
Essential
Sensitive to the needs of others and has an awareness and responsiveness to other peoples feelings and needs
Excellent command of the English Language both verbal and written
Values differences: regards people as individuals and appreciates the value of diversity in the workplace Able to work as part of a team, cooperating to work together and in conjunction with others and willing to help and assist wherever possible and appropriate.
Able to develop, establish and maintain positive relationships with others both internal and external to the organisation.
Able to work under pressure, dealing with peaks and troughs in workload.
Positive attitude to dealing with change; flexible and adaptable, willing to change and accept change and to explore new ways of doing things and approaches.
Highly motivated, enthusiastic and reliable.
Has a strong degree of personal integrity; able to adhere to standards of conduct based on a sense of right and wrong and be dependable and reliable.
Demonstrates values consistent with those of the organisation.
Ability and willingness to adopt a flexible approach to work on the occasions it may be required.
Teaching & Training experience
Essential
Ability to teach clinical skills to medical and nursing staff and other disciplines. The ability to appraise junior doctors and other staff
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).