Interview dates: 17 and 18 November 2026.
South Downs Health and Care (SDHC) isseeking to appoint two experienced and motivated Frailty Practitioners to joinour developing frailty service, working within the new Integrated NeighbourhoodTeam (INT) model.
These are exciting opportunities forskilled healthcare professionals who are passionate about deliveringhigh-quality, person-centred care and improving outcomes for people living withfrailty and complex health needs.
Working alongside GPs with a specialistinterest in frailty, Community Geriatricians and a wider multidisciplinaryteam, you will play an important role in developing a proactive, coordinatedapproach to care that supports patients to remain safe, well and independentwithin their own homes.
As part of an evolving integrated caremodel, you will have the opportunity to contribute to service development,strengthen collaborative working across organisational boundaries and helpshape the delivery of frailty services within the local community.
Main duties of the job
As a Frailty Practitioner, you will useadvanced clinical assessment and decision-making skills to assess, manage andcoordinate care for patients living with frailty and complex long-termconditions.
Key responsibilities will include
- Undertaking comprehensiveclinical and holistic assessments, including Comprehensive GeriatricAssessments (CGAs).
- Developing and implementingpersonalised care and treatment plans in partnership with patients, carers andmultidisciplinary colleagues.
- Proactively managing patientswith complex needs, supporting early intervention and preventing unnecessaryhospital admissions.
- Working closely with GPs,Community Geriatricians, community nursing teams, social care professionals andother healthcare providers.
- Supporting safe and timelyhospital discharge and reducing the risk of readmission.
- Providing specialist clinicaladvice and guidance to patients, carers and professional colleagues.
- Undertaking medication reviewsand prescribing independently within professional competencies.
- Supporting the delivery ofintegrated frailty pathways, including collaboration with Frailty Virtual Wardand urgent community services.
- Contributing to clinicalgovernance, quality improvement and ongoing service development.
About us
South Downs Health and Care GP Federation is a social enterprise. It was established in 2016 in service to shareholding/member GP practices in the areas of Eastbourne, Hailsham and Seaford. It now has extended membership within East Sussex. Our main purpose is to support GP practices in their task of providing patient care by enabling them to provide and invest in sustainable services by reducing the burden of their workload, maximising income opportunities and minimising their risks and liabilities.
We encourage our staff to take ownership and responsibility, to highlight concerns and feedback and to make an active contribution to their individual success as well as that of their team and the wider organisation. We operate a no-blame culture; by this we mean that everyone is held accountable but in an environment where the focus is on the learning that can be adopted and shared from instances where things havent gone so well.
Benefits of Working with SDHC
- NHS Pension Scheme with generous employer contributions
- 25 days holiday plus bank holidays, increasing in stages to 30 days holiday plus bank holidays after 5 years service (pro rata for part time hours)
- Employee Assistance Programme including access to counselling and support with legal and financial matters
- CycleScheme
- Christmas and summer events
- Discounted rate for membership of Hillbrow Health and Wellbeing Centre facilities
Job responsibilities
As a Frailty Practitioner, you will use advancedclinical assessment and decision-making skills to assess, manage and coordinatecare for patients living with frailty and complex long-term conditions.
Main Duties
Clinical
Within the coreFrailty Practitioner community team:
To use advanced clinical skills and expertknowledge to assess the physical and psychosocial needs of those living withfrailty, instigating treatment based on best available evidence in order tostabilise the individuals condition, prevent admission and maintainindependence appropriate to that person.
To work flexibly across community localitiescovered by Eastbourne ICT. You will need to have your own car transport.
To agree a personal management plan with thepatient, ideally with inclusion of carers, relatives and other appropriatehealth care professionals. This will be based on a full assessment of medical,nursing and basic social care needs.
To use advanced clinical skills and expertknowledge to identify changes in the patients condition, analysing andinterpreting complex health problems and associated scenarios.
To work with patients to identify problemsfrom their perspective and develop holistic management plans.
To negotiate and agree with clients, carers,community nurse teams and other care professionals, individual roles andresponsibilities with actions to be taken and outcomes to be achieved,referring on to other services or professionals as appropriate.
To work across professional andorganisational boundaries, identifying areas for skill and knowledgedevelopment applying these to individual practice with the aim of providingcontinuity and high-quality patient centred care.
To enable clients and carers to manage theirmedications in conjunction with GPs, pharmacists and other relevant clinicalstaff, including medication reviews as part of initial assessments and ongoingpatient reviews.
To provide expert clinical care and healthpromotion.
To support the governance team/ChiefCorporate Officer in the management of serious incidents and root causeanalysis, sharing learnt outcomes and best practice with clinical staff.
Use expert knowledge and skill as anon-medical prescriber to independently prescribe within the individualpractitioners areas of prescribing competency.
Develop prescribing clinical management plansas appropriate in partnership with GP colleagues.
Work to the NMC and HCPC codes of practiceand maintain professional registration.
To anticipate medical, care and socialsupport needs of those living with frailty, developing appropriate managementplans and referring to other services or professionals when required.
To regularly review patient care pathwayswith community nurse colleagues and the wider Integrated Locality Adult Teams,preventing duplication of work and promoting service efficiency.
Make direct referrals and orderinvestigations as necessary ensuring medical records are written in accordancewith SDHC and regulatory body policy.
To be responsible and accountable for thecaseload and liaising with other professionals in all settings to optimisecontinuity of care as appropriate.
To establish contact when patients areadmitted to in-patient facilities in order to provide relevant health andsocial care data, faciliti ng consistency of care and discharge planning.
To be a key part of the multidisciplinary andagency team, acting as care co-ordinator for individual patients and workingclosely with the MDT Co-ordinator.
To work collaboratively and in partnershipwith other clinicians to offer appropriate advice to all professions on carepractices, delivery and service development to ensure efficient and effectiveteam approach.
To maintain a high profile within thelocality and ensure the service is easily accessible to patients, families,carers and health professionals in relation to those living with frailty.
Work with colleagues to lead on development,implementation and evaluation of protocols, policies and integrated carepathways consistent with local and national policies, standards and currentresearch, facilitating changes in practice which improve clinical outcomes andmeet the needs of patients and carers.
In conjunction with other health careprofessionals develops and regularly reviews patient information using avariety of mediums that consider cultural diversity and communicationdifficulties in line with SDHC policy and guidance.
To work with patients living with frailty andtheir carers to identify changes in their condition and abilities that mayprecipitate an acute exacerbation or deterioration in condition and advise onrelevant actions.
To critically evaluate and interpretevidence-based research findings from diverse sources making informedjudgements on implications for changing and developing services and clinicalpractice.
To continually evaluate and audit the qualityand effectiveness of the service and make alterations in conjunction with themanager as appropriate.
To identify gaps in services to supportpatient care and participate in resolution with the wider Eastbourne HealthcareSystem.
To contribute to the wider development offrailty practice through publishing, presenting and networking locally andnationally.
To contribute to business planning,development and clinical governance processes, ensuring sustained effective andefficient service delivery.
To participate in locality health educationinitiatives to ensure both staff and the wider public have a greaterunderstanding of the health promotion and self care agenda.
To effectively communicate within the SDHCand ICT team; to a variety of health professionals, users and carers, toprovide the best outcomes for clients.
To provide the interface for individualpatients between hospital, primary, community and social care settings.
To maintain a high level of performance andbe goal and outcome focussed when faced with opposition or when working underconditions of pressure.
To keep accurate contemporaneousdocumentation and management plans using the single assessment process andparticipate in integrated documentation.
Comprehensive and effective use ofcommunication skills, oral and written, to communicate with patients, theirsupporters and other professionals, including the communication of highlysensitive and complex information about their condition.
To prepare patients and their families forchanges in condition, and support choice about end-of-life care.
To use IM&T support systems to obtaineffective feedback on progress of clients and service performance.
In collaboration with Integrated LocalityAdult Team colleagues, regularly attend locality MDT meetings to provideFrailty Practitioner representation. To attend VMT meetings when requested.
Finance and business management
Ensure an appropriate understanding of theservices financial structure and accounts and provide an informed analyticalperspective of the budgets for which the post holder supports.
Support the Chief Operating Officer to meetagreed targets within the locality and when required represent the team in SDHC/ICTbusiness.
Support the Chief Operating Officer inpreparation of business cases for both internal and external agencies andfunding.
Health, safety and security
Support the Frailty GP to implement approvedchanges in response to legislation and the changing needs of the population.
Support clinical leads, service leads andsenior staff to respond and implement action that provides health, safety andsecurity for workforce and users.
Represent the team as required includingattendance at meetings and committees when required.
Responsible for undertaking personal riskassessments on any work area that directly affects the way in which they work,for example office space, patient homes or any other building. To complete deskand ergonomic and associated risk assessments prior to working from their ownhome.
Ensure that the risks identified areescalated as per SDHC policy.
To ensure that any assessments undertaken aredocumented and reported in line with SDHC policy.
Quality, clinical governance and clinical audit
Identify appropriate audits and assist indelivering these.
To be an active part of the team developingquality outcomes and providing support in delivering these.
To develop with the Frailty Practitioners& GPs a robust process for ensuring clinical governance is integrated inday-to-day work.
To support the development of qualityindicators and acknowledge the quality monitoring of clinical record keepingwithin the team.
Participate in the collection of data toachieve the targets.
Equality, diversity and rights
Ensure that the team provides an appropriatestaffing to reflect the diversity of the population and ensure equalopportunities.
The post holder will ensure that equalopportunities policies are upheld.
Ensure that monitoring of service deliveryincludes access by minority groups.
Patient and public involvement
SDHC has a statutory duty to ensure thatpatients, clients and members of the public are consulted and involved indecisions about local health service developments. The post holder will workwith relevant staff to ensure this happens.
Person Specification
Experience
- Experience of working as an autonomous practitioner
- Working with older people living with frailty and/or complex conditions
- Working with adults with long term conditions, in particular COPD, heart failure, type 2 diabetes
- Good understanding of working in partnership with statutory and non statutory agencies to support patient centred care
- Multi-disciplinary and multi-agency working
- Proven extensive experience of working with older people
- Experience in a Community setting
- Experience of working between other health and social care organisations and settings
- Experience of interpreting microbiology and pathology results
- Experience of managing acute patients
- Use of IT systems, including MS Teams, SystmOne, NerveCentre
Qualifications
- RN first level nurse (Adults) or Allied Health Professional eligible to become an Independent Prescriber
- Teaching and Assessing qualification
- Non-medical independent prescriber or supplementary prescribing, or willingness to commence training within 12 months of coming into post
- Advanced physical assessment module, or willingness to commence training within 12 months of coming into post
- Evidence of continuing professional development in a relevant area of specialist practice to masters equivalent level
- Registered with NMC and/or HCPC
Skills, Knowledge and Abilities
- Able to demonstrate effective leadership and organisational skills
- Advanced clinical decision-making skills to support patient centred care
- Advanced physical assessment skills
- Good knowledge of anatomy and physiology
- Up to date working knowledge of both local and national policy issues pertinent to frail older people, i.e. legislation and disease management
- Extensive experience in working with adults and older people, including frail older people
- Evidence of ability to maintain and monitor high standards of care
- Ability to communicate complex clinical patient presentations to medical colleagues, in particular GPs in Primary Care
- Evidence of ability to direct and co-ordinate complex programmes of care working autonomously and collaboratively across organisational boundaries
- Ability to communicate effectively in a variety of settings across organisational boundaries and with the general public
- Evidence of the ability to work in a changing, stressful situation
- Ability to adapt to working in challenging environments to manage complex patient centred care
- Experience of contributing to the development of new services
- Experience of working through cycles of change, including at times of pressure, embracing and implementing change to provide high quality health outcomes
- Ability to influence and manage a variety of change management programmes
Other
- Must be mobile for regular travel and able to travel between base and client homes within a reasonable timeframe and cost
- Enhanced DBS Disclosure
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.
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