GP - Care Management ServiceNHS
Job summary
Provide clinical leadership and oversight within multidisciplinary team meetings.
Support the identification, assessment and management of patients at high risk of unplanned healthcare utilisation.
Contribute to the development, review and optimisation of personalised care and support plans.
Main duties of the job
As a General Practitioner within the Care Management Service, you will provide clinical leadership and expertise within multidisciplinary neighbourhood teams, supporting the delivery of proactive care to patients with complex health and social care needs.
You will work collaboratively with clinicians, care coordinators, community teams, social care professionals and voluntary sector partners to identify opportunities to improve outcomes, reduce avoidable hospital utilisation and enhance patient experience.
This role offers an opportunity to utilise your clinical expertise beyond traditional general practice, influencing system-wide care delivery and helping to shape innovative models of integrated care.
You will need to be a local GP and be aware of local pathways.
Job description
We are seeking enthusiastic and forward-thinking General Practitioners to join our Care Management Service (CMS), an established multidisciplinary service supporting some of Suffolk's most vulnerable residents.
The Care Management Service provides criteria-led, proactive care planning and support for individuals identified as being at high risk of generating significant demand for urgent and emergency healthcare services.
The service operates across Suffolk's fourteen INTs and continues to evolve through a flexible "test, learn and develop" approach, building upon early adopter programmes and the agreed service model. The CMS brings together professionals from across health, social care, community services and the voluntary sector to deliver coordinated, person-centred care.
The primary functions of the service are to:
- Develop proactive, personalised care plans in collaboration with patients, their registered GP practice and wider multidisciplinary teams.
- Provide regular clinical and social support, ensuring timely access to appropriate services and interventions.
- Deliver responsive care and escalation support to prevent health crises and avoidable hospital admissions.
- Support effective discharge planning and reduce the risk of hospital readmissions.
- Coordinate care across organisational boundaries to improve patient outcomes and experience.
This role sits at the heart of the NHS's ambition to transform healthcare through neighbourhood-based models of care.
The NHS Long Term Plan and the development of Integrated Care Systems have placed increasing emphasis on delivering more care closer to home, improving population health, reducing health inequalities and supporting people to live independently within their communities. Integrated Neighbourhood Teams are central to this vision, bringing together primary care, community services, mental health services, social care and voluntary sector partners to provide joined-up, proactive care.
The Care Management Service is a key enabler of this transformation. By identifying individuals at greatest risk of deterioration and working proactively to address their health and social care needs, CMS supports the shift from reactive healthcare towards prevention, early intervention and personalised care.
As a CMS GP, you will play a vital role in delivering this vision, helping shape the future of community-based healthcare across Suffolk.
About us
Suffolk GP Federation CIC is a not-for-profit community interest company. Our main purpose is to support Primary Care across Suffolk including support with working collaboratively and at scale. We also deliver a portfolio of NHS services across Suffolk and North East Essex, including Podiatry, Ultrasound, Public Health & Diagnostics as well as urgent Care Services including the Out of Hours face-to-face Service in Suffolk.