Job summary
Are you a clinician with a passion for frailty care and integrated working? Do you want to make a measurable difference by preventing frailty progression, reducing unnecessary hospital admissions, and supporting early, safe discharge?
Coastal PCN is seeking an experienced and motivated Frailty Lead Clinician to lead the development of a rapidly responsive frailty service operating at Integrated Neighbourhood Team (INT) level.
Main duties of the job
The Role
You will:
- Provide clinical leadership for frailty across the PCN
- Build and lead a responsive MDT using existing INT team members
- Prevent frailty deterioration through proactive, data-led care
- Reduce avoidable admissions and long hospital stays
- Enable early discharge and improve system flow
This role works closely with the PCN Clinical Director, INT Lead, acute and community partners, and the wider ICS and working across the four Practice sites.
We Are Looking For
- A registered clinician with experience and interest in frailty
- Someone confident working across organisational boundaries
- A leader who can influence, innovate, and build strong MDT relationships
- Experience in admission avoidance, discharge planning, or integrated care is highly desirable
What We Offer
- Opportunity to shape and lead frailty care across a PCN
- Flexible sessional working
- Strong system support and alignment with ICS priorities
- The chance to deliver real, measurable improvements for frail patients
About us
Coastal Primary Care Network is an NHS collaboration between 4 GP surgeries. We provide quality NHS healthcare services to our patients and aim to support and connect with our local community.
Our surgeries are located in St Agnes, Perranporth, Carnon Downs, and Chacewater. We all work together to give our patients a choice over where they visit, who they see and the services available.
Practices in our network are:
- Chacewater Health Centre
- St Agnes Surgery
- Perranporth Surgery
- Carnon Downs Surgery
Our mission to work collaboratively to provide sustainable, high quality primary care.
The Coastal Primary Care Network (PCN) has just over 29,200 patients and is rural in character but flanked by the beautiful north coast of Cornwall. We are very close to the main hospital, Royal Cornwall Hospital Treliske and we have the highest numbers of over-65s population for any PCN in the county.
The practices in this PCN have commenced a programme to create stronger links between the four practices plus the wider health and social care community.
- The aim is to create a more sustainable and resilient PCN servicing the needs of its patients and ensuring the best possible care.
- The model in which we operate is around creating closer integration with community nursing teams, social prescribing and coordinated frailty management.
Job description
Job responsibilities
Job Title
Frailty Lead Clinician Integrated Neighbourhood Team (INT)
Location
Coastal Primary Care Network (PCN), Cornwall (Operating at Integrated Neighbourhood Team level)
Accountable to
PCN Clinical Director
PCN Board Integrated Neighbourhood Team (INT) Steering Group
Professional Accountability
To relevant professional body (GMC / NMC / HCPC)
Contract
Sessional / Fixed-term (subject to funding approval) Sessions to be agreed (anticipated 2 sessions per week)
Job Purpose
The Frailty Lead Clinician will provide clinical leadership and strategic direction for frailty services across Coastal PCN, working at Integrated Neighbourhood Team (INT) level. The postholder will lead the development of a rapidly responsive frailty team, utilising existing INT workforce and community partners to:
- Prevent or slow frailty progression
- Reduce avoidable acute hospital admissions
- Enable early, safe discharge from acute care
- Improve flow for frail patients across the system
The role directly responds to system data demonstrating that acute pressures are driven by long-stay frailty patients and No Criteria to Reside (NCTR) occupancy rather than ED demand, and that integrated, proactive frailty care offers the greatest opportunity for impact.
Key Responsibilities
Clinical Leadership & Oversight
- Act as the clinical lead for frailty within Coastal PCN and the INT
- Provide clinical oversight and supervision to frailty practitioners, care coordinators, and advanced practitioners
- Support proactive and anticipatory clinical decision-making for frail patients
- Ensure high-quality, person-centred, evidence-based frailty care
Frailty Prevention & Proactive Identification
- Lead early identification of frailty and those at risk of deterioration
- Use population health tools (e.g. BRAVE AI) to stratify and prioritise cohorts
- Promote comprehensive geriatric assessment (CGA), anticipatory care planning, and medicines optimisation
- Reduce frailty progression through MDT-led proactive interventions
Admission Avoidance
- Develop and strengthen frailty-at-the-front-door and community alternatives to admission
- Support same-day assessment and decision-making pathways
- Reduce avoidable conveyance and admissions by rapid INT response
- Work with GPs, ambulance services, community teams, and acute services to manage frailty crises in community settings where appropriate
Early and Safe Discharge
- Lead frailty input into discharge planning from the earliest point of admission
- Reduce long length of stay, stranded and super-stranded frail patients
- Actively reduce No Criteria to Reside (NCTR) occupancy
- Work closely with discharge teams, therapy services, social care, and community hospitals to improve patient flow
- Promote seven-day working and therapy input for frail patients where required
Team Development & INT Working
- Build and lead a rapidly responsive frailty team operating at INT level
- Utilise existing INT team members across health, social care, mental health, and VCSE partners
- Develop clear escalation, communication, and response pathways for frailty leads
- Foster a strong MDT culture with shared accountability and rapid decision-making
Service Development & Quality Improvement
- Map current frailty services across Coastal PCN and identify gaps, duplication, and opportunities
- Support development of frailty hubs and neighbourhood-based models of care
- Lead or contribute to pathway redesign across prevention, admission avoidance, discharge, and reablement
- Support audits and evaluation, including:
- Acute admission rates
- Length of stay and NCTR reduction
- Community service utilisation
- Polypharmacy reduction
- Patient outcomes and experience
System Leadership & Collaboration
- Represent frailty services at PCN, neighbourhood, and ICS meetings
- Work closely with acute trusts, community providers, local authorities, and VCSE organisations
- Align local frailty work with GIRFT, SAMIT, and ICS priorities
- Work collaboratively with the INT Lead and PCN Clinical Director to progress integrated neighbourhood working
Job description
Job responsibilities
Job Title
Frailty Lead Clinician Integrated Neighbourhood Team (INT)
Location
Coastal Primary Care Network (PCN), Cornwall (Operating at Integrated Neighbourhood Team level)
Accountable to
PCN Clinical Director
PCN Board Integrated Neighbourhood Team (INT) Steering Group
Professional Accountability
To relevant professional body (GMC / NMC / HCPC)
Contract
Sessional / Fixed-term (subject to funding approval) Sessions to be agreed (anticipated 2 sessions per week)
Job Purpose
The Frailty Lead Clinician will provide clinical leadership and strategic direction for frailty services across Coastal PCN, working at Integrated Neighbourhood Team (INT) level. The postholder will lead the development of a rapidly responsive frailty team, utilising existing INT workforce and community partners to:
- Prevent or slow frailty progression
- Reduce avoidable acute hospital admissions
- Enable early, safe discharge from acute care
- Improve flow for frail patients across the system
The role directly responds to system data demonstrating that acute pressures are driven by long-stay frailty patients and No Criteria to Reside (NCTR) occupancy rather than ED demand, and that integrated, proactive frailty care offers the greatest opportunity for impact.
Key Responsibilities
Clinical Leadership & Oversight
- Act as the clinical lead for frailty within Coastal PCN and the INT
- Provide clinical oversight and supervision to frailty practitioners, care coordinators, and advanced practitioners
- Support proactive and anticipatory clinical decision-making for frail patients
- Ensure high-quality, person-centred, evidence-based frailty care
Frailty Prevention & Proactive Identification
- Lead early identification of frailty and those at risk of deterioration
- Use population health tools (e.g. BRAVE AI) to stratify and prioritise cohorts
- Promote comprehensive geriatric assessment (CGA), anticipatory care planning, and medicines optimisation
- Reduce frailty progression through MDT-led proactive interventions
Admission Avoidance
- Develop and strengthen frailty-at-the-front-door and community alternatives to admission
- Support same-day assessment and decision-making pathways
- Reduce avoidable conveyance and admissions by rapid INT response
- Work with GPs, ambulance services, community teams, and acute services to manage frailty crises in community settings where appropriate
Early and Safe Discharge
- Lead frailty input into discharge planning from the earliest point of admission
- Reduce long length of stay, stranded and super-stranded frail patients
- Actively reduce No Criteria to Reside (NCTR) occupancy
- Work closely with discharge teams, therapy services, social care, and community hospitals to improve patient flow
- Promote seven-day working and therapy input for frail patients where required
Team Development & INT Working
- Build and lead a rapidly responsive frailty team operating at INT level
- Utilise existing INT team members across health, social care, mental health, and VCSE partners
- Develop clear escalation, communication, and response pathways for frailty leads
- Foster a strong MDT culture with shared accountability and rapid decision-making
Service Development & Quality Improvement
- Map current frailty services across Coastal PCN and identify gaps, duplication, and opportunities
- Support development of frailty hubs and neighbourhood-based models of care
- Lead or contribute to pathway redesign across prevention, admission avoidance, discharge, and reablement
- Support audits and evaluation, including:
- Acute admission rates
- Length of stay and NCTR reduction
- Community service utilisation
- Polypharmacy reduction
- Patient outcomes and experience
System Leadership & Collaboration
- Represent frailty services at PCN, neighbourhood, and ICS meetings
- Work closely with acute trusts, community providers, local authorities, and VCSE organisations
- Align local frailty work with GIRFT, SAMIT, and ICS priorities
- Work collaboratively with the INT Lead and PCN Clinical Director to progress integrated neighbourhood working
Person Specification
Qualifications
Essential
- Registered clinician to consider GP, Geriatrician, Advanced Practitioner, Paramedic Practitioner, or equivalent
- Demonstrable interest and experience in frailty care
- Experience of MDT working and integrated care models
- Understanding of admission avoidance and discharge pathways
- Ability to work across organisational and professional boundaries
- Strong leadership, communication, and influencing skills
Desirable
- Experience working within PCNs or Integrated Neighbourhood Teams
- Knowledge of population health tools such as BRAVE AI
- Experience in service redesign or quality improvement
- Understanding of GIRFT, SAMIT, and frailty flow metrics
Key outcomes and Measures of success
Essential
- Reduction in avoidable acute admissions for frail patients
- Reduction in long-stay frailty and NCTR bed occupancy
- Improved early discharge and system flow
- Improved utilisation of community and reablement services
- Positive feedback from patients, carers, and staff
Person Specification
Qualifications
Essential
- Registered clinician to consider GP, Geriatrician, Advanced Practitioner, Paramedic Practitioner, or equivalent
- Demonstrable interest and experience in frailty care
- Experience of MDT working and integrated care models
- Understanding of admission avoidance and discharge pathways
- Ability to work across organisational and professional boundaries
- Strong leadership, communication, and influencing skills
Desirable
- Experience working within PCNs or Integrated Neighbourhood Teams
- Knowledge of population health tools such as BRAVE AI
- Experience in service redesign or quality improvement
- Understanding of GIRFT, SAMIT, and frailty flow metrics
Key outcomes and Measures of success
Essential
- Reduction in avoidable acute admissions for frail patients
- Reduction in long-stay frailty and NCTR bed occupancy
- Improved early discharge and system flow
- Improved utilisation of community and reablement services
- Positive feedback from patients, carers, and staff
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).