NHS
We are searching for a Frailty Practitioner to join our Inner City PCN team. You will need to be a highly skilled practitioner responsible for delivering personalised care to individuals living with frailty in community settings.
The post holder will work closely with clinicians across the PCN practices and the PCN Leadership team.
You will be required to work across various locations in Gloucester. This will also include our Inner City PCN Surgeries Gloucester Health Access, Pavilion and St James Family Doctors, Severnside Medical Practice and Kingsholm Surgery.
Working Hours:
22.5 hours per week.
Closing Date:
19th January 2026
Interview Date:
28th January 2026 or 4th February 2026
Applications may close early depending on response.
Care Quality Commission requires us to have a complete employment history from the age of 16, including explanations for any gaps in employment.
Main duties of the job Deliver proactive, personalised care to individuals living with frailty in community settings.
Work autonomously within your scope of practice to assess, diagnose, treat, and manage patients.
Liaise with primary, secondary, social care and VCSE organisations, to ensure holistic management of frailty.
Work with people living with frailty in a collaborative way that focuses on what matters to them.
Contribute to service development to meet the needs of the PCN population.
Reports to (line manager)
Operationally: PCN Business Manager Clinically:
Clinical Directors
About us G DOC LTD is a unique, GP‑owned organisation; all GP surgeries in Gloucestershire are our shareholders. We operate with an not‑for‑profit ethos, ensuring every decision and service is focused on improving patient outcomes and reinvesting in local Primary Care across the county.
We directly manage several GP surgeries in Gloucester and the Forest of Dean, providing patient‑centred care to more than 45,000 patients. We value continuity of care and practice teams are at the heart of all we do. In addition to our surgeries, we deliver a range of county‑wide commissioned services designed to improve access, increase capacity, or provide specialist support. Our teams are committed to delivering sustainable, high‑quality primary care while fostering innovation and collaboration across the local health system.
By joining us, you'll be part of an organisation that puts people first supporting staff wellbeing, professional development, and a collaborative culture. You'll benefit from the stability, support, and career opportunities of a larger organisation, while still working in close‑knit, community‑focused teams.
Job responsibilities 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 a 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 patient’s 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
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 regulatory body and organisational NMP policy.
Working conditions
Primarily Gloucester‑based; 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.
Other
Disclosure Barring Service (DBS) enhanced check satisfactory.
Evidence of continuing professional development.
Ability to drive, current UK driving licence, and daily access to a vehicle.
Experience
Minimum 2 years post‑registration experience.
Experience in managing long‑term conditions.
Experience of working with older people.
Experience of General Practice.
Experience in managing end of life care.
Expertise in frailty identification and screening tools.
Experience of working effectively within MDTs or equivalent groups.
Experience of mentoring and supervising other clinicians.
Experience using remote monitoring tools.
Qualifications
Registered with relevant professional body (eg NMC, HCPC or equivalent).
MSc Advanced Clinical Practice or NMC/HCPC‑recognised equivalent.
Skills
Excellent communication and consultation skills.
Able to manage, monitor and review long‑term conditions.
Sound understanding of clinical governance and safeguarding.
Advanced assessment, diagnostic reasoning, and treatment planning skills.
Willing to become competent in use of SystmOne if not already.
Competent in the use of Office software.
Ability to follow policy and procedure.
Able to identify and resolve risk management issues according to policy or protocol.
Effective time management.
Ability to work as a team member and autonomously.
Good interpersonal skills.
Knowledge of QOF, enhanced services, and primary care targets.
Health coaching.
Competent in use of SystmOne.
Audit and research skills.
Teaching and mentoring skills.
Clear, polite telephone manner.
Polite and confident.
Flexible and cooperative.
Motivated.
High levels of integrity and loyalty.
Sensitive and empathetic in distressing situations.
Ability to work under pressure.
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 (formerly known as CRB) to check for any previous criminal convictions.
£47,810 to £54,710 a year Pro Rata for PT hours
#J-18808-Ljbffr
The post holder will work closely with clinicians across the PCN practices and the PCN Leadership team.
You will be required to work across various locations in Gloucester. This will also include our Inner City PCN Surgeries Gloucester Health Access, Pavilion and St James Family Doctors, Severnside Medical Practice and Kingsholm Surgery.
Working Hours:
22.5 hours per week.
Closing Date:
19th January 2026
Interview Date:
28th January 2026 or 4th February 2026
Applications may close early depending on response.
Care Quality Commission requires us to have a complete employment history from the age of 16, including explanations for any gaps in employment.
Main duties of the job Deliver proactive, personalised care to individuals living with frailty in community settings.
Work autonomously within your scope of practice to assess, diagnose, treat, and manage patients.
Liaise with primary, secondary, social care and VCSE organisations, to ensure holistic management of frailty.
Work with people living with frailty in a collaborative way that focuses on what matters to them.
Contribute to service development to meet the needs of the PCN population.
Reports to (line manager)
Operationally: PCN Business Manager Clinically:
Clinical Directors
About us G DOC LTD is a unique, GP‑owned organisation; all GP surgeries in Gloucestershire are our shareholders. We operate with an not‑for‑profit ethos, ensuring every decision and service is focused on improving patient outcomes and reinvesting in local Primary Care across the county.
We directly manage several GP surgeries in Gloucester and the Forest of Dean, providing patient‑centred care to more than 45,000 patients. We value continuity of care and practice teams are at the heart of all we do. In addition to our surgeries, we deliver a range of county‑wide commissioned services designed to improve access, increase capacity, or provide specialist support. Our teams are committed to delivering sustainable, high‑quality primary care while fostering innovation and collaboration across the local health system.
By joining us, you'll be part of an organisation that puts people first supporting staff wellbeing, professional development, and a collaborative culture. You'll benefit from the stability, support, and career opportunities of a larger organisation, while still working in close‑knit, community‑focused teams.
Job responsibilities 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 a 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 patient’s 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
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 regulatory body and organisational NMP policy.
Working conditions
Primarily Gloucester‑based; 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.
Other
Disclosure Barring Service (DBS) enhanced check satisfactory.
Evidence of continuing professional development.
Ability to drive, current UK driving licence, and daily access to a vehicle.
Experience
Minimum 2 years post‑registration experience.
Experience in managing long‑term conditions.
Experience of working with older people.
Experience of General Practice.
Experience in managing end of life care.
Expertise in frailty identification and screening tools.
Experience of working effectively within MDTs or equivalent groups.
Experience of mentoring and supervising other clinicians.
Experience using remote monitoring tools.
Qualifications
Registered with relevant professional body (eg NMC, HCPC or equivalent).
MSc Advanced Clinical Practice or NMC/HCPC‑recognised equivalent.
Skills
Excellent communication and consultation skills.
Able to manage, monitor and review long‑term conditions.
Sound understanding of clinical governance and safeguarding.
Advanced assessment, diagnostic reasoning, and treatment planning skills.
Willing to become competent in use of SystmOne if not already.
Competent in the use of Office software.
Ability to follow policy and procedure.
Able to identify and resolve risk management issues according to policy or protocol.
Effective time management.
Ability to work as a team member and autonomously.
Good interpersonal skills.
Knowledge of QOF, enhanced services, and primary care targets.
Health coaching.
Competent in use of SystmOne.
Audit and research skills.
Teaching and mentoring skills.
Clear, polite telephone manner.
Polite and confident.
Flexible and cooperative.
Motivated.
High levels of integrity and loyalty.
Sensitive and empathetic in distressing situations.
Ability to work under pressure.
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 (formerly known as CRB) to check for any previous criminal convictions.
£47,810 to £54,710 a year Pro Rata for PT hours
#J-18808-Ljbffr