Salaried GP Complex Care, Frailty and Care Homes

PURPOSE OF THE ROLE The post holder will provide high-quality, relationship-based general practice to an allocated caseload of care home residents. The role combines continuity with proactive and responsive clinical care, allowing the GP to understand the whole picture and make considered decisions with residents, families and care home teams. Working as a senior medical generalist within a true multidisciplinary team, the GP will focus particularly on advance care planning, palliative care, multimorbidity and diagnostic uncertainty. They will provide clinical supervision and decision support to ACPs and senior nurses while drawing on the complementary expertise of colleagues across pharmacy, community nursing, mental health and palliative care. HOW THE ROLE WORKS The GP holds an allocated caseload, supporting continuity with residents, families and care home teams. Each day begins with a whole-team check-in to share updates, discuss concerns, distribute work and identify the clinical lead for the day. Clinical work includes proactive reviews, ward rounds, comprehensive assessment, advance care planning, responsive assessment and family conversations. Time is built in for clinical supervision, peer learning, teaching, quality improvement and service development. Excellent administrative support enables clinicians to concentrate on clinical work and follow-through. Key responsibilities The responsibilities below describe the core of the role; they are intended to support good judgement, not replace it. RELATIONSHIP-BASED CLINICAL CARE Provide proactive and responsive GP assessment for care home residents, using face-to-face, telephone, video and other appropriate formats. Undertake holistic assessment, identify and prioritise problems, and devise personalised management plans that use the skills of the MDT effectively. Maintain continuity with residents, families and care home teams, taking responsibility for follow-through and ongoing management. Lead advance care planning and treatment-escalation conversations, producing clear, realistic care plans and ReSPECT documentation in keeping with the wishes of residents and families. Assess acute deterioration and diagnostic uncertainty, arranging and interpreting investigations in a way that is proportionate to frailty, likely benefit and agreed treatment escalation. SENIOR CLINICAL DECISION SUPPORT AND SUPERVISION Provide senior medical input for complex decisions and act as clinical lead of the day when allocated. Hold clinical responsibility for decisions concerning the GP's patients while drawing appropriately on the skills and perspectives of the MDT. Provide clinical supervision, advice, feedback and case discussion for ACPs, senior nurses, students and other members of the team. Contribute to a learning culture through significant-event review, case-based discussion, teaching and reflective practice. MULTIDISCIPLINARY AND PARTNERSHIP WORKING Lead or participate in specialist MDTs for palliative care, dementia and mental health, and other complex-care needs. Work closely with care home staff and managers, pharmacists, community nurses, hospice colleagues, mental health teams, geriatricians and hospital services. Undertake structured medication review alongside pharmacy colleagues and support clinically appropriate prescribing and deprescribing. Provide outreach support where a complex case, a care home under pressure or a safeguarding concern would benefit from senior GP input. CLINICAL GOVERNANCE, SAFETY AND PROFESSIONAL PRACTICE Promote adult safeguarding and apply the Mental Capacity Act, including best-interest decision-making, with support from colleagues where appropriate. Maintain timely, accurate clinical records and use agreed coding, templates and personalised care-planning standards. Prescribe safely and in accordance with the BNSSG formulary where clinically appropriate, working with the pharmacy team. Support delivery of relevant QOF, local enhanced service and contractual requirements without allowing process measures to displace person-centred care. Take part in audit, quality improvement, significant-event learning and other clinical-governance activity. DEVELOPMENT OFFER The role is designed for a confident generalist who wants to deepen meaningful clinical practice. The Hub offers supported opportunities to build capability in safeguarding, mental capacity and best-interest decision-making, learning disability, dementia and mental health, and the care of deteriorating people living with frailty. These are increasingly important capabilities for general practice and neighbourhood health. For those who want it, there is also scope to develop teaching, pathway improvement, quality improvement and clinical leadership. Career and personal development are supported through protected learning time, peer discussion and regular one-to-one conversations with the team leader. Job description Job responsibilities PURPOSE OF THE ROLE The post holder will provide high-quality, relationship-based general practice to an allocated caseload of care home residents. The role combines continuity with proactive and responsive clinical care, allowing the GP to understand the whole picture and make considered decisions with residents, families and care home teams. Working as a senior medical generalist within a true multidisciplinary team, the GP will focus particularly on advance care planning, palliative care, multimorbidity and diagnostic uncertainty. They will provide clinical supervision and decision support to ACPs and senior nurses while drawing on the complementary expertise of colleagues across pharmacy, community nursing, mental health and palliative care. HOW THE ROLE WORKS The GP holds an allocated caseload, supporting continuity with residents, families and care home teams. Each day begins with a whole-team check-in to share updates, discuss concerns, distribute work and identify the clinical lead for the day. Clinical work includes proactive reviews, ward rounds, comprehensive assessment, advance care planning, responsive assessment and family conversations. Time is built in for clinical supervision, peer learning, teaching, quality improvement and service development. Excellent administrative support enables clinicians to concentrate on clinical work and follow-through. Key responsibilities The responsibilities below describe the core of the role; they are intended to support good judgement, not replace it. RELATIONSHIP-BASED CLINICAL CARE Provide proactive and responsive GP assessment for care home residents, using face-to-face, telephone, video and other appropriate formats. Undertake holistic assessment, identify and prioritise problems, and devise personalised management plans that use the skills of the MDT effectively. Maintain continuity with residents, families and care home teams, taking responsibility for follow-through and ongoing management. Lead advance care planning and treatment-escalation conversations, producing clear, realistic care plans and ReSPECT documentation in keeping with the wishes of residents and families. Assess acute deterioration and diagnostic uncertainty, arranging and interpreting investigations in a way that is proportionate to frailty, likely benefit and agreed treatment escalation. SENIOR CLINICAL DECISION SUPPORT AND SUPERVISION Provide senior medical input for complex decisions and act as clinical lead of the day when allocated. Hold clinical responsibility for decisions concerning the GP's patients while drawing appropriately on the skills and perspectives of the MDT. Provide clinical supervision, advice, feedback and case discussion for ACPs, senior nurses, students and other members of the team. Contribute to a learning culture through significant-event review, case-based discussion, teaching and reflective practice. MULTIDISCIPLINARY AND PARTNERSHIP WORKING Lead or participate in specialist MDTs for palliative care, dementia and mental health, and other complex-care needs. Work closely with care home staff and managers, pharmacists, community nurses, hospice colleagues, mental health teams, geriatricians and hospital services. Undertake structured medication review alongside pharmacy colleagues and support clinically appropriate prescribing and deprescribing. Provide outreach support where a complex case, a care home under pressure or a safeguarding concern would benefit from senior GP input. CLINICAL GOVERNANCE, SAFETY AND PROFESSIONAL PRACTICE Promote adult safeguarding and apply the Mental Capacity Act, including best-interest decision-making, with support from colleagues where appropriate. Maintain timely, accurate clinical records and use agreed coding, templates and personalised care-planning standards. Prescribe safely and in accordance with the BNSSG formulary where clinically appropriate, working with the pharmacy team. Support delivery of relevant QOF, local enhanced service and contractual requirements without allowing process measures to displace person-centred care. Take part in audit, quality improvement, significant-event learning and other clinical-governance activity. DEVELOPMENT OFFER The role is designed for a confident generalist who wants to deepen meaningful clinical practice. The Hub offers supported opportunities to build capability in safeguarding, mental capacity and best-interest decision-making, learning disability, dementia and mental health, and the care of deteriorating people living with frailty. These are increasingly important capabilities for general practice and neighbourhood health. For those who want it, there is also scope to develop teaching, pathway improvement, quality improvement and clinical leadership. Career and personal development are supported through protected learning time, peer discussion and regular one-to-one conversations with the team leader.