PCN Frailty Practitioner

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.

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

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.

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…