GP – The Harbour Frailty Service

As part of the wider Healthcare of Older People (HOP) team, the post-holder will be based in The Harbour service at Newton Abbot Hospital, providing senior clinical decision-making and clinical leadership to enable people living with frailty to receive timely assessment, treatment and care closer to home. The role incorporates frailty coordination and telephone triage, Harbour @ Home (frailty virtual ward), same day emergency care (SDEC) with direct access to community hospital beds at Newton Abbot Hospital.

This post includes contributing to evening and weekend rotas.

• Be part of the frailty coordination function, providing clinical telephone triage to referrers including SWASFT, Primary Care, community teams, acute hospital wards, the Emergency Department and Acute Medical Unit (AMU), identifying the most appropriate way to meet the patient’s acute needs.
• Hold clinical responsibility and accountability for agreed patients while they are under the care of The Harbour
• Provide senior clinical decision-making and leadership to the multidisciplinary Harbour team and deputise for the GP Lead in their absence.
• Work across acute care, The Harbour and existing community services, particularly Urgent Community Response (UCR), accessing same-day interventions where appropriate.
• Work with intermediate care, Primary Care and the wider community multidisciplinary team.
• Deliver high-quality specialist assessment and intervention for older people living with frailty, using the principles of Comprehensive Geriatric Assessment (CGA).
• Use point-of-care testing, digital monitoring and other appropriate clinical support to facilitate care delivery
• Where appropriate, contribute to the training and supervision of other Harbour clinicians including trainee and qualified advanced clinical practitioners and resident doctors
• Contribute to service development, quality improvement, data evaluation and teaching.

Why Work With Us

The Harbour is Torbay and South Devon’s innovative frailty model located at Newton Abbot Hospital, supporting the NHS vision of moving care from acute hospitals into community settings and aligning with our organisational strategy to deliver more integrated, person-centred care closer to home.

It provides a single point of access for older people living with frailty, with patients triaged through a dedicated frailty clinical coordination service and directed to the most appropriate support.

Wherever possible, care will be provided at home or within community settings through services such as the Harbour at Home Virtual Ward, Harbour SDEC, Urgent Community Response and intermediate care, ensuring patients receive the right care in the right place, supported by
integrated health, social care and voluntary sector partners.

For patients requiring rapid assessment, diagnostics or specialist review, a Same Day Emergency Care (SDEC) and ambulatory care service will provide an alternative to attending Torbay Hospital.

Where hospital admission is required, inpatient beds will be available at Newton Abbot, with teams working proactively to support timely discharge and recovery closer to home.

Communication and working relationships

• Communicate effectively with patients, relatives and carers, supporting shared decision-making

and a person-centred approach to care and self-management.

• Provide telephone and virtual clinical advice to SWASFT, Primary Care, community teams and other referrers.
• Liaise with local GP practices, community matrons, district nurses, pharmacists, allied health professionals, hospital clinicians, IT providers and specialist acute teams.
• Provide specialist advice and clinical support to practitioners caring for patients in community settings.
• Ensure clear, accurate and contemporaneous records are made for every patient encounter.
• Understand the criteria and considerations for Harbour and acute medicine pathways
• Triage referrals, determine clinical suitability and accept agreed patients into The Harbour pathways.
• Apply senior autonomous clinical judgement when managing complexity, uncertainty and clinical risk in community settings.
• Undertake and contribute to Comprehensive Geriatric Assessment, medication review, deprescribing, anticipatory care planning and treatment escalation planning.
• Develop proactive management plans to prevent hospital admission and support earlier discharge.