Bank GP - Frailty & Proactive Home Visiting

Job summary
The Proactive Neighbourhood Care and Remote Monitoring service will support people living with frailty, complex needs and those who are housebound. The service will combine proactive home visiting, care coordination, remote monitoring and links into wider neighbourhood and Local Authority support.

Bank GPs will provide senior clinical assessment and decision-making for people living with frailty, complex needs and those who are housebound. The role will include planned home visits, remote review, care planning and support to the wider multidisciplinary team.

This role covers community and home visiting across the Berkshire West area.

Main duties of the job

• Undertake senior clinical assessment and management of patients in their own homes or remotely.
• Review complex presentations, medicines, long-term conditions and risks and agree proportionate plans.
• Provide clinical leadership and advice to frailty prescribers, the HCA and care coordinator.
• Support anticipatory care planning, ReSPECT and escalation planning where appropriate.
• Review remote monitoring information and make timely decisions about treatment, follow-up or onward referral.
• Work closely with registered practices and avoid duplication of existing care.
• Record all assessments and plans accurately on EMIS and communicate clearly with the patients usual GP.
• Contribute to clinical governance, audit and service improvement.

About us
The Primary Care Alliance CIC is a GP-led provider organisation delivering high-quality primary care services at scale across Berkshire West. Representing 36 member practices serving more than 580,000 residents, we work with general practice, Primary Care Networks, NHS Trusts, Local Authorities and the Integrated Care Board to deliver care closer to home.

Job responsibilities

• Undertake senior clinical assessment and management of patients in their own homes or remotely.
• Review complex presentations, medicines, long-term conditions and risks and agree proportionate plans.
• Provide clinical leadership and advice to frailty prescribers, the HCA and care coordinator.
• Support anticipatory care planning, ReSPECT and escalation planning where appropriate.
• Review remote monitoring information and make timely decisions about treatment, follow-up or onward referral.
• Work closely with registered practices and avoid duplication of existing care.
• Record all assessments and plans accurately on EMIS and communicate clearly with the patients usual GP.
• Contribute to clinical governance, audit and service improvement.

Person Specification
Experience
Essential

• Experience in general practice and autonomous management of complex patients.
• Confidence undertaking home visits and managing frailty and multimorbidity.
• Full UK driving licence and access to a suitable vehicle for work.
• Completion of required compliance and mandatory training.

Desirable

• Experience in care of older people, frailty, community services, virtual wards or proactive care.
• Experience of remote monitoring and multidisciplinary neighbourhood working.

Qualifications
Essential

• GMC registration and inclusion on the GP Register.
• Current licence to practise and appropriate medical indemnity.

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.
Applicants must have current UK professional registration.