Community Gp

Community General Practitioner

ARCH (Alfreton, Ripley, Crich and Heanor) Primary Care Network

Are you passionate about frailty?

Are you keen to work across traditional health and social care boundaries?

ARCH PCN is seeking a Community GP to support our multi-disciplinary and multi-agency team of professionals to provide effective, efficient and high-quality healthcare to our housebound patients and patients in care or residential facilities across the PCN footprint.

We are looking for GP cover on a Monday, Thursday (essential) and Friday.

This is an exciting opportunity to be at the forefront of the delivery of our Ageing Well model of care, part of Team Up! Derbyshire. The role will operate across the traditional health and social care organisational boundaries, including with our GP practice partners, to help clinically lead the service on a day to day basis. The aim for the service is to ultimately provide a holistic approach to our acute home visiting service, enhanced care into care homes and enhanced routine care for older people with frailty for patients with multifaceted health problems.

To lead the clinical team on the day we are looking for a Community General Practitioner with a strong interest in working with people with frailty and who aspires to promote a continuous improvement approach to leading and delivering responsive, safe, patient-centred and effective care. The successful candidate will work alongside other clinicians delivering responsive clinical pathways for seamless working, challenge traditional ways of working and proactively support individuals within the team to develop the necessary skills, competencies and expertise needed to deliver the service.

About Amber Valley Health

This post will be hosted by Amber Valley Health - the umbrella organisation for ARCH PCN. ARCH PCN consists of 9 GP practices (91,000 patients) across the PCN area of Alfreton, Ripley, Crich and Heanor. The PCN is committed to improving the care of patients in the local geographical area and sustaining General Practice.

Amber Valley Health offers the NHS pension scheme.

• Provide day-to-day clinical leadership to provide proactive and reactive general medical services to the housebound population, including those in are homes, in collaboration with registered practices where appropriate;
• Promote and deliver a multi-skilled team response that includes GP Acute Home Visits, holistic assessment, care, pro-active follow up and care planning;
• Contribute to the development of the Acute Home Visiting and Community Urgent Response Service.
• Deliver an efficient, high quality, multi-disciplinary Acute Home Visiting and Community Urgent Response Service to people who have an urgent need that is best provided in their own home, or wherever they call home;
• Ensure that the Acute Home Visiting and Community Rapid Response Service that supports and links well to system infrastructure provided at a bigger scale e.g. Acute Hospitals, 99, 111, Ambulance services;
• Ensure Acute Home Visiting and Community Urgent Response Service that links well to routine and proactive services;
• Developing expertise within the community for improving the lives of people living with frailty;
• Promoting the use of supportive, non-statutory services to support self-care and social prescribing agendas;
• Maximize best care in the patients own home in order to reduce the need for hospital or care home admissions;
• Ensure that the care and support people receive is based on their wishes, preferences and aspirations, particularly towards the end of their lives;
• Provide medical expertise in the management of older people living with frailty in the defined community. To support ACPs and wider MDT members working in the community by:

• Providing Senior GP clinical triage for all Acute Home Visit requests to determine the urgency and type of response needed, according to clinical need.
• Regular debrief sessions for patients on their caseload.
• Lead and support the ACPs in their role in the MDT.
• Deliver formal and informal education for the ACPs during clinical interactions.
• Advising on complex clinical situations including:
• Complex prescribing decisions,
• Where there are difficult clinical risk decisions.
• Where there is disagreement between professionals, patients or their carers.
• Diagnosis is uncertain.
• Identification of end of life is difficult.

• Liaison with GPs and frailty unit when needed;
• Lead and engage in MDT and other team meetings, and…