GP – The Harbour Frailty Service

Communication and working relationships Communicate effectively with patients, relatives and carers, supporting shared decision-makingand 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.