Frailty General Practitioner

Salary: £11,500 per session per annum (employed) or up to £15,000 per session per annum if self-employed; Up to 5

sessions per week

Contract Duration: Permanent or self-employed

Job Location: Practice sites across South

Tandridge PCN (Oxted Medical Practice, Pond Tail Surgery and Lingfield Surgery)

with regular home visiting to frailty patients

In this role, a successful applicant will manage the PCN

clinical frailty pathway (Hub) that all practices within this PCN can refer

into. The post holder will provide a well-triaged frailty service and offer

care in patients' homes, providing a high-quality patient experience and a

collaborative way of working across the system to reduce unplanned admissions to hospital. The Frailty General Practitioner will be

responsible for providing clinical leadership to the frailty hub team and

medical leadership to the wider community team of Community Matrons, District

Nurses, Pharmacists, etc. The PCN has worked together over several years and is

therefore mature in its collaboration with member practices as well as external

provider organisations. Our team of experienced clinical leads & GP Partners will provide regular supervision.

Main duties of the job

As a Frailty General Practitioner, you will be responsible for proactive triage and management of the PCNs frail patients who have been referred.

These referrals will come from a range of sources, including those proactively identified in-house. Management of this cohort includes developing care plans for patients at risk of hospital admission and using your clinical skills to diagnose and treat patients accordingly in order to improve their care. This will involve a holistic MDT approach to patient care, liaising with other professionals responsible for the patients care, referring to other teams as necessary, as well as liaising with secondary care, community care, social care, mental health services and other local providers.

About us

South Tandridge Primary Care Network (PCN) is a partnership of local GP surgeries working together to help people live healthier lives. The PCN is made up of Oxted Medical Practice, Pond Tail Surgery and Lingfield Surgery, with a population of approximately 35K. The PCN has worked together over several years and is therefore mature in its approach to collaboration with member practices and external providers, working alongside staff, patients, their families and carers, and the public to provide high-quality healthcare close to home.

You will also be supported by the wider DHC Federation and network of frailty GPs across our member PCNs. DHC is a supportive, local GP Federation which works hard to prioritise the healthcare needs of the community, as well as the well-being of its staff.

Benefits:

• Competitive salaries
• Membership of the NHS pension scheme
• 27 days annual leave plus bank holidays, increasing with length of service
• Access to an Employee Assistance Programme
• Opportunities for training, development and career progression
• Some of our sites have free on-site parking subject to availability
• We aim to be an employer of choice and conduct annual staff satisfaction surveys

Details

Date posted

14 October 2026

Pay scheme

Other

Salary

£11,500 a session

Up to 5 sessions per week

Contract

Permanent

Working pattern

Part-time

Reference number

U0103-26-0068

Job locations

Pond Tail Surgery

Godstone Green

Godstone

Surrey

RH9 8DY

United Kingdom

Lingfield Surgery

East Grinstead Road

LINGFIELD

Surrey

RH7 6ER

United Kingdom

Oxted Health Centre

10 Gresham Road

OXTED

Surrey

RH8 0BQ

United Kingdom

Job responsibilities

JOB

SUMMARY

South Tandridge Primary Care Network (PCN) is

made up of the following Practices: Oxted Medical Practice, Pond Tail

Surgery and Lingfield Surgery, with a population of approximately 35K. The PCN has

worked together over several years and is therefore mature in its collaboration

with member practices as well as external provider organisations.

In this role, a successful applicant will manage

the PCN clinical frailty pathway (Hub) that all practices within this PCN can

refer into. The aim is to offer care in the patients home in order to reduce unplanned

admissions and improve patient care. The Frailty General Practitioner will be

responsible for providing clinical leadership to the frailty hub team and

providing medical leadership to the wider community team of Community Matrons,

District Nurses, Pharmacists, etc.

It is therefore desirable that you should

also have experience of or qualifications in clinical supervision/education,

but not essential as training can be given. Populations are changing, and

patients are living longer with complex care needs. Having a frailty service

that is well triaged aims to create a better patient experience, a better way

of working collaboratively and a reduction in unplanned admissions to hospital.

This service will be available up to 5

sessions per week, with the expectation that coverage will be across the

working week, but flexible requests will be considered. Improved home visiting at scale will also

potentially reduce pressure on A&E attendances, with the role of the

Frailty General Practitioner providing oversight and clinical care to a cohort

of patients as identified by the individual practices within the PCN. This role

will include seeing patients in their own homes as well as visits to care homes

where appropriate.

The Frailty General Practitioner will be

responsible for developing a care plan for frail patients at risk of hospital

admission, using their clinical skills to diagnose and treat patients

accordingly. This will involve liaising with other professionals responsible

for the patients care, referring to other teams as necessary, as well as

liaising with secondary care, community care, social care, mental health

services and other local providers.

DUTIES

AND RESPONSIBILITIES OF THE POST

The following are

the core responsibilities of the Frailty General Practitioner. There may be, on

occasion, a requirement to carry out other tasks; dependent upon factors such

as workload and staffing levels:

• Effective triage

of referred and proactively identified patients to provide highly effective

medical care to the entitled population in a timely fashion

• Proactively

managing the care of frail people alongside the Community Matron

• Generic

prescribing adhering to local and national guidance

• Effective

management of long-term conditions

• Processing of

administration in a timely manner, including referrals, repeat prescription

requests and other associated administrative tasks

• Undertake

telephone triage and prioritise home visits accordingly

• Maintain accurate

clinical records in conjunction with good practice, policy and guidance

• Working

collaboratively across the PCN with all practices and partner organisations,

and agencies

• Lead discussion

about patients at both PCN-level MDTs and at Practice-level MDTs

• Adhere to best

practice recommended through clinical guidelines and the audit process

• Contribute to the

successful implementation of continuous improvement and quality initiatives

with the Practices and PCN

• Accept delegated

responsibility

• Contribute

effectively to the development and maintenance of the PCN, including clinical

governance, training, financial management and HR

• Commit to

self-learning and continuing professional development

• Support the

partners in achieving the strategic aims of the PCN

• Review and adhere

to Practice/ PCN protocols and policies at all times

• Encourage collaborative working, liaising with all

staff regularly, promoting a culture of continuous improvement at all times

ORGANISATIONAL

POSITION

The Frailty GP will report to the PCN

Clinical Director and Service Manager.

KEY

PRINCIPLES OF THE FRAILTY GENERAL PRACTITIONER ROLE

• Proactive management of the frail population and people at the end of

their life (65yrs+)

• Identification of the people most at risk of deterioration/hospital

admission

• A multi-disciplinary team (MDT) approach to provide holistic care
• A defined caseload of people who have:
• An in-depth frailty assessments
• Structured medication reviews & falls assessments
• Quality conversations about end-of-life care
• Planning for when care needs change
• A personalised care plan agreed and enacted
• A key point of contact
• Proactive intervention to avoid hospital admission - linking with the

reactive community service

INDIVIDUAL

RESPONSIBILITIES

• Adhere to DHC and GP Practices

policies and procedures and any other relevant legislation

• Ensure mandatory training is up

to date at all times

• Participate in

regular supervision sessions and appraisals with your

line manager. Attend training and development activities as identified

and participate in meetings as required

• Maintain

administration systems and workspaces in a clean and tidy fashion

• Maintain a good

working knowledge of Health and Safety procedures and fire precautions, and

operate the correct procedures and participate in policy development and data

collection where appropriate

• Work flexibly to

meet the needs of patients

• Contribute to ongoing/new

projects as required

• To undertake any other duties appropriate to

the grade and purpose of the job as may be agreed by the post holder

WORK

SETTING AND REVIEW

• The post holder will work

autonomously to an agreed set of KPIs, targets and objectives.

• They will manage their own time

and case load, providing regular updates/progress reports to their line manager

and to the GP practices they are based in.

• Participate in DHCs appraisal

and review system.

This job description

represents an outline of the responsibilities of the post and is not intended

to be an exhaustive list of duties or tasks. It will change and develop in line with organisational needs and may be

amended following agreement with the post-holder.

Job responsibilities

JOB

SUMMARY

South Tandridge Primary Care Network (PCN) is

made up of the following Practices: Oxted Medical Practice, Pond Tail

Surgery and Lingfield Surgery, with a population of approximately 35K. The PCN has

worked together over several years and is therefore mature in its collaboration

with member practices as well as external provider organisations.

In this role, a successful applicant will manage

the PCN clinical frailty pathway (Hub) that all practices within this PCN can

refer into. The aim is to offer care in the patients home in order to reduce unplanned

admissions and improve patient care. The Frailty General Practitioner will be

responsible for providing clinical leadership to the frailty hub team and

providing medical leadership to the wider community team of Community Matrons,

District Nurses, Pharmacists, etc.

It is therefore desirable that you should

also have experience of or qualifications in clinical supervision/education,

but not essential as training can be given. Populations are changing, and

patients are living longer with complex care needs. Having a frailty service

that is well triaged aims to create a better patient experience, a better way

of working collaboratively and a reduction in unplanned admissions to hospital.

This service will be available up to 5

sessions per week, with the expectation that coverage will be across the

working week, but flexible requests will be considered. Improved home visiting at scale will also

potentially reduce pressure on A&E attendances, with the role of the

Frailty General Practitioner providing oversight and clinical care to a cohort

of patients as identified by the individual practices within the PCN. This role

will include seeing patients in their own homes as well as visits to care homes

where appropriate.

The Frailty General Practitioner will be

responsible for developing a care plan for frail patients at risk of hospital

admission, using their clinical skills to diagnose and treat patients

accordingly. This will involve liaising with other professionals responsible

for the patients care, referring to other teams as necessary, as well as

liaising with secondary care, community care, social care, mental health

services and other local providers.

DUTIES

AND RESPONSIBILITIES OF THE POST

The following are

the core responsibilities of the Frailty General Practitioner. There may be, on

occasion, a requirement to carry out other tasks; dependent upon factors such

as workload and staffing levels:

• Effective triage

of referred and proactively identified patients to provide highly effective

medical care to the entitled population in a timely fashion

• Proactively

managing the care of frail people alongside the Community Matron

• Generic

prescribing adhering to local and national guidance

• Effective

management of long-term conditions

• Processing of

administration in a timely manner, including referrals, repeat prescription

requests and other associated administrative tasks

• Undertake

telephone triage and prioritise home visits accordingly

• Maintain accurate

clinical records in conjunction with good practice, policy and guidance

• Working

collaboratively across the PCN with all practices and partner organisations,

and agencies

• Lead discussion

about patients at both PCN-level MDTs and at Practice-level MDTs

• Adhere to best

practice recommended through clinical guidelines and the audit process

• Contribute to the

successful implementation of continuous improvement and quality initiatives

with the Practices and PCN

• Accept delegated

responsibility

• Contribute

effectively to the development and maintenance of the PCN, including clinical

governance, training, financial management and HR

• Commit to

self-learning and continuing professional development

• Support the

partners in achieving the strategic aims of the PCN

• Review and adhere

to Practice/ PCN protocols and policies at all times

• Encourage collaborative working, liaising with all

staff regularly, promoting a culture of continuous improvement at all times

ORGANISATIONAL

POSITION

The Frailty GP will report to the PCN

Clinical Director and Service Manager.

KEY

PRINCIPLES OF THE FRAILTY GENERAL PRACTITIONER ROLE

• Proactive management of the frail population and people at the end of

their life (65yrs+)

• Identification of the people most at risk of deterioration/hospital

admission

• A multi-disciplinary team (MDT) approach to provide holistic care
• A defined caseload of people who have:
• An in-depth frailty assessments
• Structured medication reviews & falls assessments
• Quality conversations about end-of-life care
• Planning for when care needs change
• A personalised care plan agreed and enacted
• A key point of contact
• Proactive intervention to avoid hospital admission - linking with the

reactive community service

INDIVIDUAL

RESPONSIBILITIES

• Adhere to DHC and GP Practices

policies and procedures and any other relevant legislation

• Ensure mandatory training is up

to date at all times

• Participate in

regular supervision sessions and appraisals with your

line manager. Attend training and development activities as identified

and participate in meetings as required

• Maintain

administration systems and workspaces in a clean and tidy fashion

• Maintain a good

working knowledge of Health and Safety procedures and fire precautions, and

operate the correct procedures and participate in policy development and data

collection where appropriate

• Work flexibly to

meet the needs of patients

• Contribute to ongoing/new

projects as required

• To undertake any other duties appropriate to

the grade and purpose of the job as may be agreed by the post holder

WORK

SETTING AND REVIEW

• The post holder will work

autonomously to an agreed set of KPIs, targets and objectives.

• They will manage their own time

and case load, providing regular updates/progress reports to their line manager

and to the GP practices they are based in.

• Participate in DHCs appraisal

and review system.

This job description

represents an outline of the responsibilities of the post and is not intended

to be an exhaustive list of duties or tasks. It will change and develop in line with organisational needs and may be

amended following agreement with the post-holder.

Person Specification

Other requirements

Essential

• Disclosure and barring service check.
• Willing and able to travel to other sites & locations to attend meetings and training events.

Skills

Essential

• Excellent communication skills (written and oral), including the ability to listen.
• Strong and confident IT skills, including MS Office and databases.
• Excellent administrative skills, working under own initiative at times.
• Effective time management skills, often in a fast-paced environment.
• Proven problem-solving and analytical skills.
• Ability to adapt to changing situations and changing needs of the service.
• Excellent patient care skills.
• Motivated to achieve good outcomes for patients.
• Able to follow policies and procedures effectively.
• Able to maintain confidentiality at all times.

Desirable

• Knowledge of GP clinical systems EMIS and/or TPP SystmOne.

Personal Qualities

Essential

• Polite & confident, remaining calm under pressure.
• Caring, sensitive and empathetic sensitive to patients' life stages, concerns and problems.
• Self-motivated, reliable and dedicated.
• Excellent interpersonal skills.
• Motivated and proactive.
• Ability to use initiative and judgement.
• High levels of integrity and reliability.
• Ability to work under pressure.
• Confident, assertive and resilient.

Experience

Essential

• Experience working with the general public in a similar role.
• Experience working in a health care setting.
• Experience working in the NHS/Primary Care General Practice setting.
• Understanding of community services and personalised care.
• Experience in managing a complex administrative role.

Desirable

• Experience of leading MDT Meetings in Primary Care.

Qualifications

Essential

• Good standard of education with excellent literacy and numeracy skills

Person Specification

Other requirements

Essential

• Disclosure and barring service check.
• Willing and able to travel to other sites & locations to attend meetings and training events.

Skills

Essential

• Excellent communication skills (written and oral), including the ability to listen.
• Strong and confident IT skills, including MS Office and databases.
• Excellent administrative skills, working under own initiative at times.
• Effective time management skills, often in a fast-paced environment.
• Proven problem-solving and analytical skills.
• Ability to adapt to changing situations and changing needs of the service.
• Excellent patient care skills.
• Motivated to achieve good outcomes for patients.
• Able to follow policies and procedures effectively.
• Able to maintain confidentiality at all times.

Desirable

• Knowledge of GP clinical systems EMIS and/or TPP SystmOne.

Personal Qualities

Essential

• Polite & confident, remaining calm under pressure.
• Caring, sensitive and empathetic sensitive to patients' life stages, concerns and problems.
• Self-motivated, reliable and dedicated.
• Excellent interpersonal skills.
• Motivated and proactive.
• Ability to use initiative and judgement.
• High levels of integrity and reliability.
• Ability to work under pressure.
• Confident, assertive and resilient.

Experience

Essential

• Experience working with the general public in a similar role.
• Experience working in a health care setting.
• Experience working in the NHS/Primary Care General Practice setting.
• Understanding of community services and personalised care.
• Experience in managing a complex administrative role.

Desirable

• Experience of leading MDT Meetings in Primary Care.

Qualifications

Essential

• Good standard of education with excellent literacy and numeracy skills

Disclosure and Barring Service Check

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.

UK Registration

Applicants must have current UK professional registration. For further information please see

NHS Careers website .

Additional information

Disclosure and Barring Service Check

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.

UK Registration

Applicants must have current UK professional registration. For further information please see

NHS Careers website .

Employer details

Employer name

Dorking Healthcare Ltd.

Address

Pond Tail Surgery

Godstone Green

Godstone

Surrey

RH9 8DY

United Kingdom

Employer's website

https://dhcclinical.co.uk/ (Opens in a new tab)

Employer details

Employer name

Dorking Healthcare Ltd.

Address

Pond Tail Surgery

Godstone Green

Godstone

Surrey

RH9 8DY

United Kingdom

Employer's website

https://dhcclinical.co.uk/ (Opens in a new tab)

Job responsibilities

JOB

SUMMARY

South Tandridge Primary Care Network (PCN) is

made up of the following Practices: Oxted Medical Practice, Pond Tail

Surgery and Lingfield Surgery, with a population of approximately 35K. The PCN has

worked together over several years and is therefore mature in its collaboration

with member practices as well as external provider organisations.

In this role, a successful applicant will manage

the PCN clinical frailty pathway (Hub) that all practices within this PCN can

refer into. The aim is to offer care in the patients home in order to reduce unplanned

admissions and improve patient care. The Frailty General Practitioner will be

responsible for providing clinical leadership to the frailty hub team and

providing medical leadership to the wider community team of Community Matrons,

District Nurses, Pharmacists, etc.

It is therefore desirable that you should

also have experience of or qualifications in clinical supervision/education,

but not essential as training can be given. Populations are changing, and

patients are living longer with complex care needs. Having a frailty service

that is well triaged aims to create a better patient experience, a better way

of working collaboratively and a reduction in unplanned admissions to hospital.

This service will be available up to 5

sessions per week, with the expectation that coverage will be across the

working week, but flexible requests will be considered. Improved home visiting at scale will also

potentially reduce pressure on A&E attendances, with the role of the

Frailty General Practitioner providing oversight and clinical care to a cohort

of patients as identified by the individual practices within the PCN. This role

will include seeing patients in their own homes as well as visits to care homes

where appropriate.

The Frailty General Practitioner will be

responsible for developing a care plan for frail patients at risk of hospital

admission, using their clinical skills to diagnose and treat patients

accordingly. This will involve liaising with other professionals responsible

for the patients care, referring to other teams as necessary, as well as

liaising with secondary care, community care, social care, mental health

services and other local providers.

DUTIES

AND RESPONSIBILITIES OF THE POST

The following are

the core responsibilities of the Frailty General Practitioner. There may be, on

occasion, a requirement to carry out other tasks; dependent upon factors such

as workload and staffing levels:

• Effective triage

of referred and proactively identified patients to provide highly effective

medical care to the entitled population in a timely fashion

• Proactively

managing the care of frail people alongside the Community Matron

• Generic

prescribing adhering to local and national guidance

• Effective

management of long-term conditions

• Processing of

administration in a timely manner, including referrals, repeat prescription

requests and other associated administrative tasks

• Undertake

telephone triage and prioritise home visits accordingly

• Maintain accurate

clinical records in conjunction with good practice, policy and guidance

• Working

collaboratively across the PCN with all practices and partner organisations,

and agencies

• Lead discussion

about patients at both PCN-level MDTs and at Practice-level MDTs

• Adhere to best

practice recommended through clinical guidelines and the audit process

• Contribute to the

successful implementation of continuous improvement and quality initiatives

with the Practices and PCN

• Accept delegated

responsibility

• Contribute

effectively to the development and maintenance of the PCN, including clinical

governance, training, financial management and HR

• Commit to

self-learning and continuing professional development

• Support the

partners in achieving the strategic aims of the PCN

• Review and adhere

to Practice/ PCN protocols and policies at all times

• Encourage collaborative working, liaising with all

staff regularly, promoting a culture of continuous improvement at all times

ORGANISATIONAL

POSITION

The Frailty GP will report to the PCN

Clinical Director and Service Manager.

KEY

PRINCIPLES OF THE FRAILTY GENERAL PRACTITIONER ROLE

• Proactive management of the frail population and people at the end of

their life (65yrs+)

• Identification of the people most at risk of deterioration/hospital

admission

• A multi-disciplinary team (MDT) approach to provide holistic care
• A defined caseload of people who have:
• An in-depth frailty assessments
• Structured medication reviews & falls assessments
• Quality conversations about end-of-life care
• Planning for when care needs change
• A personalised care plan agreed and enacted
• A key point of contact
• Proactive intervention to avoid hospital admission - linking with the

reactive community service

INDIVIDUAL

RESPONSIBILITIES

• Adhere to DHC and GP Practices

policies and procedures and any other relevant legislation

• Ensure mandatory training is up

to date at all times

• Participate in

regular supervision sessions and appraisals with your

line manager. Attend training and development activities as identified

and participate in meetings as required

• Maintain

administration systems and workspaces in a clean and tidy fashion

• Maintain a good

working knowledge of Health and Safety procedures and fire precautions, and

operate the correct procedures and participate in policy development and data

collection where appropriate

• Work flexibly to

meet the needs of patients

• Contribute to ongoing/new

projects as required

• To undertake any other duties appropriate to

the grade and purpose of the job as may be agreed by the post holder

WORK

SETTING AND REVIEW

• The post holder will work

autonomously to an agreed set of KPIs, targets and objectives.

• They will manage their own time

and case load, providing regular updates/progress reports to their line manager

and to the GP practices they are based in.

• Participate in DHCs appraisal

and review system.

This job description

represents an outline of the responsibilities of the post and is not intended

to be an exhaustive list of duties or tasks. It will change and develop in line with organisational needs and may be

amended following agreement with the post-holder.

Other requirements

Essential

• Disclosure and barring service check.
• Willing and able to travel to other sites & locations to attend meetings and training events.

Skills

Essential

• Excellent communication skills (written and oral), including the ability to listen.
• Strong and confident IT skills, including MS Office and databases.
• Excellent administrative skills, working under own initiative at times.
• Effective time management skills, often in a fast-paced environment.
• Proven problem-solving and analytical skills.
• Ability to adapt to changing situations and changing needs of the service.
• Excellent patient care skills.
• Motivated to achieve good outcomes for patients.
• Able to follow policies and procedures effectively.
• Able to maintain confidentiality at all times.

Desirable

• Knowledge of GP clinical systems EMIS and/or TPP SystmOne.

Personal Qualities

Essential

• Polite & confident, remaining calm under pressure.
• Caring, sensitive and empathetic sensitive to patients' life stages, concerns and problems.
• Self-motivated, reliable and dedicated.
• Excellent interpersonal skills.
• Motivated and proactive.
• Ability to use initiative and judgement.
• High levels of integrity and reliability.
• Ability to work under pressure.
• Confident, assertive and resilient.

Experience

Essential

• Experience working with the general public in a similar role.
• Experience working in a health care setting.
• Experience working in the NHS/Primary Care General Practice setting.
• Understanding of community services and personalised care.
• Experience in managing a complex administrative role.

Desirable

• Experience of leading MDT Meetings in Primary Care.

Qualifications

Essential

• Good standard of education with excellent literacy and numeracy skills