GP with Specialist Interest in Dementia & Frailty
Location: Sunderland (Neighbourhood-based) Sessions: 3 sessions + 0.375 CPD per week, working pattern to be agreed locally Salary: Actual Salary £39,164.06 per annum (WTE £104,437.50) – pending pay award
Contract type: 1 year fixed term
Benefits include: Working hours aligned to core General Practice hours
About the Role
We are seeking an enthusiastic and forward-thinking General Practitioner with a Specialist Interest in Dementia and Frailty to join our evolving neighbourhood health model in Sunderland.
The role will help support and shape the newly developed primary care memory clinics as part of our Neighbourhood Programme. This is a unique opportunity to shape a proactive, community-based model of care, supporting people to live well at home, reducing avoidable hospital admissions, and improving outcomes for some of our most vulnerable residents.
You will work across neighbourhood teams, bringing clinical expertise, leadership, and innovation to deliver joined-up, person-centred care in partnership with primary care, community services, mental health, social care and the voluntary sector.
Main duties of the job
Brief Responsibilities
- Deliver high-quality, patient-facing clinical care for people living with dementia, frailty and complex multimorbidity
- Undertake comprehensive clinical and cognitive assessments, contributing to timely and accurate diagnosis
- Develop, implement and review personalised care and management plans, including ongoing follow-up for complex cases
- Work as part of the Primary Care Memory Clinic and neighbourhood diagnostic pathways, supporting coordinated patient journeys
- Contribute to multidisciplinary team (MDT) discussions, shared decision-making and risk management
- Collaborate closely with GPs, community teams, specialists, social care and VCSE partners to provide joined-up care
- Undertake medication reviews, with a focus on polypharmacy and safe prescribing in line with specialist advice
- Provide continuity of post-diagnostic dementia and frailty care, including anticipatory care planning and carer support
- Deliver care across neighbourhood and community settings, supporting care closer to home
- Maintain high standards of clinical governance, record keeping and practice in line with NICE and local pathways
About us
For a second year in a row Sunderland GP Alliance has been listed in The Sunday Times Best Places to Work and Better Health At Work – Gold Award, offering 33 days annual leave and other benefits.
Sunderland GP Alliance is owned by the GP Practices of Sunderland and helps GPs work collaboratively for the benefit of patients and staff. We are a not-for-profit organisation, ensuring any surplus is reinvested back into better services for patients. By working together, our General Practice community is able to provide innovative services across the city, and work collectively with other key system partners. You’ll find great examples of this approach across our website including information on our Enhanced Access service, Clinical Pharmacist provision, and ECG service.
Job responsibilities
JOB PURPOSE
To provide high-quality, patient-facing clinical care for people living with frailty, dementia and complex multimorbidity, working as part of Sunderland’s neighbourhood multidisciplinary teams and Primary Care Memory Clinic model. To ensure patients receive appropriate assessment, diagnosis and ongoing care closer to home.
This is a clinical role, focused on:
- Direct patient care and assessment
- Supporting accurate and timely diagnosis
- Contributing to multidisciplinary decision-making
- Delivering ongoing management and follow-up for patients with dementia and frailty
The role contributes to Sunderland’s neighbourhood ambitions by helping to ensure care is:
- Coordinated and joined-up across services
- Delivered in community settings where possible
- Responsive to patient and carer needs
This role will bridge primary, community, and secondary care, improving system flow and integration
Clinical Assessment & Patient Care
Provide face-to-face and remote clinical assessment for patients with:
- Diagnosed dementia
- Frailty and complex multimorbidity
Undertake:
- Clinical history and examination
- Cognitive assessment (as appropriate)
- Initial investigations and interpretation
- Develop and implement individualised care and management plans
- Provide ongoing clinical review and follow-up, particularly for patients with complex needs
Contribution to the Dementia Diagnostic Pathway
Work as part of the Primary Care Memory Clinic / neighbourhood diagnostic pathway
Support:
- Identification of patients with possible dementia
- Initial assessment and appropriate referral into diagnostic services
- Follow-up of patients post-diagnosis
- Contribution to diagnostic processes alongside specialists, including participation in MDT discussions and providing relevant clinical information to support diagnostic decision-making
- Ensure patients experience a clear and coordinated journey through the pathway
- Improving diagnostic clarity and supporting timely decision-making within MDT settings
Working with Specialist Colleagues
Work collaboratively with:
- Care of the Elderly Consultants
- Specialist Dementia Nurses
- Memory Assessment Services
- PCN and Community Frailty Teams
- Therapy services
Seek advice and input for:
- Complex or uncertain cases
- Medication management
- Diagnostic clarification
Contribute to shared care, ensuring recommendations from specialist colleagues are implemented and followed up in primary care
Multidisciplinary Team Working
Participate in regular MDT meetings within the neighbourhood model
Contribute to case discussions, shared care planning and risk management
Work alongside:
- Frailty Teams
- Community nurses
- Allied health professionals
- VCSE colleagues
Medication Review & Management
Undertake medication reviews for patients with dementia and frailty
Support safe prescribing and monitoring of treatment effectiveness and side effects, with adjustments in line with specialist advice
Pay particular attention to polypharmacy
Ongoing Dementia & Frailty Care
Provide continuity of care for patients following diagnosis
Support management of behavioural and psychological symptoms and carer support in collaboration with wider team
Contribute to anticipatory care planning, including deterioration planning
Neighbourhood-Based Working
Deliver care within a neighbourhood model, including GP practices, community settings and care homes where appropriate
Support the aim of providing care closer to home, reducing the need for hospital-based care
Work flexibly across settings to meet patient need
Clinical Governance & Good Practice
Maintain accurate, timely and appropriate clinical records
Work in line with NICE guidance, information governance standards, audit and clinical governance processes
Training & Development
Fully participates in training and development and engages in a programme of ongoing support and feedback to maximise the benefit of the training and development plan.
Confidentiality
In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.
Information relating to patients, carers, colleagues, other healthcare workers or the business of the Practice may only be divulged to authorised persons in accordance with the Alliance policies and procedures relating to confidentiality, and the protection of personal and sensitive data.
Health & Safety
The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the Practice Health & Safety Policy.
Identifying the risk involved in work activities and undertaking such activities in a way that manages those risks.
Using appropriate infection control procedures particularly those relating to needlestick injuries, maintaining work areas in a tidy and safe way and free from hazards.
Ensuring that all accidents or dangerous accidents are reported and investigated, and follow up action taken where necessary.
Maintain training in line with local policies.
Equality and Diversity
The post-holder will support the quality, diversity and rights of patients, carers and colleagues to include acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with current legislation.
Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rights.
Quality
The post-holder will strive to maintain quality within the Practice, alert the Frailty Clinical Lead to issues of quality and risk, assess own performance and take accountability for own actions, contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team’s performance, work effectively with individuals in other agencies to meet patients needs, and effectively manage own time, workload and resources.
Communication
The post-holder should recognise the importance of effective communication within the team and will strive to communicate effectively with other team members, patients and carers, recognise peoples needs for alternative methods of communication and respond accordingly.
Person Specification
Qualifications
- Full registration with the GMC with licence to practise
- Inclusion on the NHS Performers List
Experience
- Experience of working as a GP in primary care
- Experience in the assessment and management of older adults, including frailty and/or dementia
- Experience managing patients with complex needs and multimorbidity
- Experience of medication review and prescribing in older people
- Experience contributing to multidisciplinary team (MDT) working, including case discussions and shared care planning
- Knowledge of dementia assessment, diagnosis and management
- Knowledge of frailty syndromes and holistic care of older adults
- Knowledge of multimorbidity and polypharmacy
- Demonstrable interest in dementia care or older peoples health
- Experience working with memory services, community geriatrics, mental health services for older people
- Experience supporting patients in care homes, community or home-based settings
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 to check for any previous criminal convictions.
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