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:
o Acute admission rates
o Length of stay and NCTR reduction
o Community service utilisation
o Polypharmacy reduction
o 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
Essential
• Registered clinician (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 / Measures of Success
• 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