PCN Frailty Practitioner
| Posting date: | 06 January 2026 |
|---|---|
| Salary: | £47,810.00 to £54,710.00 per year |
| Additional salary information: | £47810.00 - £54710.00 a year |
| Hours: | Full time |
| Closing date: | 19 January 2026 |
| Location: | Gloucester, GL1 2TZ |
| Company: | NHS Jobs |
| Job type: | Permanent |
| Job reference: | A0782-26-0000 |
Summary
Duties specific to role With a focus on prevention, the role is pivotal in the delivery of the NHSE Proactive Care Framework at PCN level for people living with moderate or severe frailty, working collaboratively with multi-agency multi-disciplinary teams (MDTs) and system partners to enhance independence and quality of life and in turn reduce the risk of unplanned hospital admissions. Case Identification: Use eFI/ Personal Proactive Whiteboard to identify list of potential patients living with moderate or severe frailty, supported by sub-cohort analysis, with the aim of identifying the highest risk patients Holistic Assessment: Provide support to administrators to ensure the self-assessment questionnaire process is carried out effectively and to a high-quality standard Triage potential patients to determine which will receive a comprehensive geriatric assessment (CGA) Determine what action to take with those patients who do not receive a CGA and ensure those actions are undertaken Undertake CGAs as determined for relevant patients, inputting information into the digital template and ensuring they are given a Rockwood Score. Draw in clinical support as required from the PCN Frailty Teams GP with an interest in Frailty for those patients with a higher acuity of need. Personalised Care and Support Planning: Ensure a Personalised Care and Support Plan (PCSP) is produced and agreed with the relevant patient and any carer/family, along with a ReSPECT plan Coordinated and Multi Professional Working: Ensure close multi-professional and multi-agency working, especially with other members of the local Integrated Neighbourhood Team(s), to facilitate the delivery of each patients PCSP Continuity of Care including reviews Work with rest of the frailty team to ensure regular review of patients take place as planned and agreed according to the individual needs of the person and /or following trigger events such as hospital admission. Dementia Co-diagnosis Determine the frequency of MDT meetings, depending on demand; keep under regular review Support the Frailty Team Care Navigator to ensure all post MDT meetings are carried out in a timely and effective manner Other Clinical Within competencies and training: Undertake comprehensive assessment, diagnosis, and treatment of patients with undifferentiated and undiagnosed problems, both acute and chronic. Prescribe and review medication in accordance with national and local prescribing guidelines. Order and interpret investigations to inform clinical decision-making. Identify and manage long-term conditions, health promotion, and disease prevention strategies. Recognise and respond to medical emergencies and deteriorating patients. General Leadership: Provide leadership and support to the Frailty Care Navigator Clinical Leadership: Provide clinical assessment, diagnosis, and case management of people living with frailty in the community using agreed standardised tools and templates. Responsible for Frailty Care Navigator, managing caseloads and ensuring the appropriate allocation of personnel and tasks to team members Partnership Working: Build and maintain effective working relationships with GPs, acute and community hospitals, Adult Social Care, voluntary sector organisations, and other community services to deliver integrated care Care Coordination: Ensure seamless transitions of care and continuity through proactive case management and liaison with all relevant stakeholders MDT Coordination: Lead and participate in MDT meetings, ensuring collaborative care planning and shared decision-making across system partners Education and Training: Support the development of frailty awareness and skills for other practitioners, carers, and patients Service Development: Contribute to the design, implementation, and evaluation of frailty pathways and services Risk Management: Identify and manage clinical risks, including falls, polypharmacy, and cognitive decline Patient Advocacy: Promote shared decision-making and ensure care aligns with patients values, goals and what matters to them Data and Audit: Collect and analyse data to: support risk stratification and segmentation of the patient cohort, enable use of the Personalised Proactive Whiteboard for care coordination, monitor outcomes and measure impact, support quality improvement and inform commissioning conversations. Professional Maintain professional registration with the appropriate regulatory body (eg NMC/HCPC). Engage in clinical supervision and maintain an up-to-date professional portfolio. Participate in continuing professional development and annual appraisal. Non-medical prescribing/independent prescribing (if applicable) As a qualified non-medical prescriber (NMP)/independent prescriber (IP), prescribing will be undertaken within the scope of practice of the prescriber and in accordance with their professional code of conduct as set out by their own regulatory bodies and organisational NMP policy. Working conditions The job is primarily Gloucester-based, but you will be required to travel independently between services in Gloucestershire and, occasionally, in other areas of the UK. Frequent, prolonged VDU use Time-pressured environment High levels of accuracy and attention to detail essential at all times Exposure to distressing situations and written material Contact with body fluids, i.e. wound exudates; urine etc. while in clinical practice. Uniform/scrubs to be worn as agreed with line manager The job description for all G DOC workers also forms part of your job description.