How to develop and maintain a role in frailty

Required:

• Primary Medical Qualification from UK or overseas
• MRCGP or equivalent route to UK general practice (e.g., Certificate of Eligibility for GP Registration)
• Full GMC registration with licence to practise on NHS performers list.

Optional:

• Diploma in Geriatric Medicine

Core capabilities and competencies will have already been achieved in the MRCGP training. To highlight capabilities that are particularly relevant to the extended role, we have taken the five areas of capability described in the RCGP curriculum as a starting point. These are based around the GMC's generic professional capabilities' framework. We build on these capabilities in relation to the extended role.

The five areas of capability for frailty framework

Caring for the whole person and the wider community

• may provide or oversee enhanced care in care homes/support living facilities
• may lead end of life/palliative care team
• may lead an integrated care team providing urgent community response
• is a frailty/complect care GP
• manages or leads a team managing complex care / acute frailty / patients
• may oversee rehabilitation wards
• leads proactive anticipator care.

Working well in organisations and systems of care

• may undertake assessments independently or may be with other members of the team.
• may manage complex care patients in the community on behalf of their GP. Or may support a GP in managing frail patients with long term conditions
• communicate and build relationships on an individual, multi-professional and team basis with all levels of staff
• enables collective responsibility
• work autonomously
• overseeing management, reporting, and analysis
• may provide a link between acute geriatrician-led frailty services and GP

Knowing yourself and relating to others

• change management
• driving performance / performance management
• motivating and inspiring
• coaching and decision-making
• collaboration and partnership working
• influencing, negotiating, compassionate leadership, mentoring
• communication and team building.

Managing frailty, complex and long-term care

• provide face-to-face consultations with patients requiring GP input and provide extended appointments and/or home visits
• understands clinical governance and professionals' accountability
• provides a comprehensive assessment of a person's needs in an extended consultation
• settings for assessments can vary from the patient’s home, care home, surgery, or hospital setting
• shares relevant information amongst teams involved in the person's care in dedicated time
• manages patients with frailty and or/complex care needs in extended appointments
• may support GPs to manage frail patients with long-term conditions. Develop disease-specific care plans and treatment escalation plans. Manage these patients on behalf of their registered GPs.

Applying clinical knowledge and skills

• shared decision-making
• managing risk
• uses a biopsychosocial approach
• coordinates care.

View the above information as diagrams (PDF file, 178 KB).

In this section, we describe GP leadership in the extended role, highlighting aspects of leadership that are particularly relevant to the Frailty extended role. We refer to the domains of the RCGP Leadership Capabilities Framework, as follows:

Demonstrating personal qualities

Given this is a team-based role, it is particularly important that the Frailty GPwER understands their own team working style and can develop their own values and behaviours in a team setting. The need for the Frailty GPwER to demonstrate compassionate leadership qualities, and act as a motivator, teacher and role model to individuals in a multi-professional team, is important.

The Frailty GPwER is:

• an experienced medical doctor who can manage risk and biopsychosocial complexities well
• able and willing to teach others (not necessarily with a formal education qualification but utilising recognised skills)
• able to hold the values of the team
• a compassionate leader
• able to coach individuals and teams
• non-judgmental
• respected and respectful
• able to demonstrate extensive and high level of working knowledge regarding ethical and legal frameworks, including the Mental Capacity Act.

Some of these abilities can be developed through specific training, whereas others are innate.

Working with others

Typically, the complex care team is characterised by collective responsibility, with recognition that everyone brings different skills, and an acceptance that each team member leads on certain aspects where their skills are required for the task (“leadership by all”). This requires trust amongst team members, a strong sense of value and shared mutual respect. The Frailty GPwER will uphold these values.

They demonstrate compassionate leadership within the wider multidisciplinary (MDT), including when running an MDT meeting.

Managing services

Considering the complex needs of the patient population, the Frailty GPwER needs to be an experienced medical doctor who is skillful in managing risk and understanding biopsychosocial complexities.

Improving services

The Frailty GPwER must be effective in breaking down barriers to care, building relationships across/between teams and addressing poor communication between sectors that disadvantage the experience of people with complex needs.

They provide medical leadership in managing risk and complexity and resolve competing priorities through shared decision-making. It is necessary for the GPwER to promote a culture of openness and learning where everyone feels able to ask questions and make suggestions for service improvement.

Setting direction

The establishment of a Complex Care or Frailty Team or Service requires strong leadership, the willingness to try something new and the ability to learn from mistakes and achieve positive outcomes.

This section explains how a GP can develop the skills, knowledge, and experience to undertake the extended role. This includes acquisition of core knowledge and skills relevant to the extended role. A GPwER should have an appropriate balance of practical and theoretical knowledge in relation to their extended role.

Training roles and opportunities are changing rapidly and currently vary in different areas. Opportunities available include Foundation training posts, integrated GP training posts in frailty and/or complex care and other relevant Fellowships.

Shadowing any pre-existing complex care or frailty roles in place or in other services such as falls clinic, memory clinic, older persons, community mental health, and adult social care, can be valuable.

The opportunities above can enhance attitudes, skills, and knowledge in respect to:

• person centred care and shared decision-making
• team working allowing collective responsibility across different professions and organisations/boundaries
• collaborative working and building relationships and mutual trust
• running a multi-professional meeting
• compassionate leadership
• ability to develop effective working relationships on an individual, multi-professional and team basis with all levels of staff
• ability to communicate effectively
• understanding of clinical governance and the individual responsibilities it implies.

The RCGP's position is that GPs are expert medical generalists and, as such, do not need formal accreditation in enhanced roles for which they have been trained. However, where formal accreditation is desired by a GP, programmes that offer accreditation should be made available.

As for all doctors, GPs are required by the GMC to recognise and work within the limits of their competence and should refer to the GMC's Good medical practice for a description of what it means to be a good doctor. It is worth noting that employers and service commissioners may have specific requirements relating to the provision of a GPwER service.

The evidence that a GPwER is keeping their requisite knowledge and skills up to date and maintaining their competencies should be reviewed through the GPwER's annual whole scope of practice appraisal. This should form part of the discussion of all external roles and include quality improvement activity such as case analysis and audit. This has replaced any need for periodic re-accreditation.

The RCGP would expect that, for a GP to describe themselves as a GPwER, at least some ‘core’ general practice should be maintained. This is because as a GP they bring important additional skills in practising holistically and dealing with complexity and uncertainty to their GPwER role. However, we acknowledge that some frailty doctors (those who have trained as GPs) may have stopped general practice altogether. For such doctors, appraisals may be delivered through the acute trust.

Where there is a need for a GPwER to demonstrate at their annual appraisal that they remain safe, competent and up to date in their core general practice role, they may wish to utilise the Academy of Medical Royal Colleges' factors for consideration template (external PDF).