Bank General Practitioner; GP – Care Management Service; CMS

Location: Suffolk (Neighbourhood-Based Working Across Integrated Neighbourhood Teams)

Hours: Flexible / Sessional / Part-Time Opportunities Available

Suffolk GP Federation is committed to delivering innovative, high-quality services that improve health outcomes and support the sustainability of primary and community care. Working in partnership with Primary Care Networks, Integrated Neighbourhood Teams (INTs), community providers, local authorities, acute trusts and voluntary sector organisations, we are transforming the way care is delivered across Suffolk.

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.

You will need to be a local GP and be aware of local pathways.

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 INT’s 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.

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.

• 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.