About this role
Job summary
Interview dates: 17 and 18 November 2026.
South Downs Health and Care (SDHC) is seeking to appoint two experienced and motivated Frailty Practitioners to join our developing frailty service, working within the new Integrated Neighbourhood Team (INT) model.
These are exciting opportunities for skilled healthcare professionals who are passionate about delivering high-quality, person-centred care and improving outcomes for people living with frailty and complex health needs.
Working alongside GPs with a specialist interest in frailty, Community Geriatricians and a wider multidisciplinary team, you will play an important role in developing a proactive, coordinated approach to care that supports patients to remain safe, well and independent within their own homes.
As part of an evolving integrated care model, you will have the opportunity to contribute to service development, strengthen collaborative working across organisational boundaries and help shape the delivery of frailty services within the local community.
Main duties of the job
As a Frailty Practitioner, you will use advanced clinical assessment and decision-making skills to assess, manage and coordinate care for patients living with frailty and complex long-term conditions.
Key responsibilities will include
Undertaking comprehensive clinical and holistic assessments, including Comprehensive Geriatric Assessments (CGAs). Developing and implementing personalised care and treatment plans in partnership with patients, carers and multidisciplinary colleagues. Proactively managing patients with complex needs, supporting early intervention and preventing unnecessary hospital admissions. Working closely with GPs, Community Geriatricians, community nursing teams, social care professionals and other healthcare providers. Supporting safe and timely hospital discharge and reducing the risk of readmission. Providing specialist clinical advice and guidance to patients, carers and professional colleagues. Undertaking medication reviews and prescribing independently within professional competencies. Supporting the delivery of integrated frailty pathways, including collaboration with Frailty Virtual Ward and urgent community services. Contributing to clinical governance, 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 description Job responsibilities
As a Frailty Practitioner, you will use advanced clinical assessment and decision-making skills to assess, manage and coordinate care for patients living with frailty and complex long-term conditions.
Main Duties
Clinical
Within the core Frailty Practitioner community team:
To use advanced clinical skills and expert knowledge to assess the physical and psychosocial needs of those living with frailty, instigating treatment based on best available evidence in order to stabilise the individuals condition, prevent admission and maintain independence appropriate to that person.
To work flexibly across community localities covered by Eastbourne ICT. You will need to have your own car transport.
To agree a personal management plan with the patient, ideally with inclusion of carers, relatives and other appropriate health care professionals. This will be based on a full assessment of medical, nursing and basic social care needs.
To use advanced clinical skills and expert knowledge to identify changes in the patients condition, analysing and interpreting complex health problems and associated scenarios.
To work with patients to identify problems from their perspective and develop holistic management plans.
To negotiate and agree with clients, carers, community nurse teams and other care professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate.
To work across professional and organisational boundaries, identifying areas for skill and knowledge development applying these to individual practice with the aim of providing continuity and high-quality patient centred care.
To enable clients and carers to manage their medications in conjunction with GPs, pharmacists and other relevant clinical staff, including medication reviews as part of initial assessments and ongoing patient reviews.
To provide expert clinical care and health promotion.
To support the governance team/Chief Corporate Officer in the management of serious incidents and root cause analysis, sharing learnt outcomes and best practice with clinical staff.
Use expert knowledge and skill as a non-medical prescriber to independently prescribe within the individual practitioners areas of prescribing competency.
Develop prescribing clinical management plans as appropriate in partnership with GP colleagues.
Work to the NMC and HCPC codes of practice and maintain professional registration.
Care co-ordinator
To anticipate medical, care and social support needs of those living with frailty, developing appropriate management plans and referring to other services or professionals when required.
To regularly review patient care pathways with community nurse colleagues and the wider Integrated Locality Adult Teams, preventing duplication of work and promoting service efficiency.
Make direct referrals and order investigations as necessary ensuring medical records are written in accordance with SDHC and regulatory body policy.
To be responsible and accountable for the caseload and liaising with other professionals in all settings to optimise continuity of care as appropriate.
To establish contact when patients are admitted to in-patient facilities in order to provide relevant health and social care data, facilitate consistency of care and discharge planning.
To be a key part of the multidisciplinary and agency team, acting as care co-ordinator for individual patients and working closely with the MDT Co-ordinator.
To work collaboratively and in partnership with other clinicians to offer appropriate advice to all professions on care practices, delivery and service development to ensure efficient and effective team approach.
To maintain a high profile within the locality 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 care pathways consistent with local and national policies, standards and current research, facilitating changes in practice which improve clinical outcomes and meet the needs of patients and carers.
In conjunction with other health care professionals develops and regularly reviews patient information using a variety of mediums that consider cultural diversity and communication difficulties in line with SDHC policy and guidance.
Education and research
To work with patients living with frailty and their carers to identify changes in their condition and abilities that may precipitate an acute exacerbation or deterioration in condition and advise on relevant actions.
To critically evaluate and interpret evidence-based research findings from diverse sources making informed judgements on implications for changing and developing services and clinical practice.
To continually evaluate and audit the quality and effectiveness of the service and make alterations in conjunction with the manager as appropriate.
To identify gaps in services to support patient care and participate in resolution with the wider Eastbourne Healthcare System.
To contribute to the wider development of frailty practice through publishing, presenting and networking locally and nationally.
To contribute to business planning, development and clinical governance processes, ensuring sustained effective and efficient service delivery.
To participate in locality health education initiatives to ensure both staff and the wider public have a greater understanding of the health promotion and self care agenda.
Communication skills
To effectively communicate within the SDHC and ICT team; to a variety of health professionals, users and carers, to provide the best outcomes for clients.
To provide the interface for individual patients between hospital, primary, community and social care settings.
To maintain a high level of performance and be goal and outcome focussed when faced with opposition or when working under conditions of pressure.
To keep accurate contemporaneous documentation and management plans using the single assessment process and participate in integrated documentation.
Comprehensive and effective use of communication skills, oral and written, to communicate with patients, their supporters and other professionals, including the communication of highly sensitive and complex information about their condition.
To prepare patients and their families for changes in condition, and support choice about end-of-life care.
To use IM&T support systems to obtain effective feedback on progress of clients and service performance.
In collaboration with Integrated Locality Adult Team colleagues, regularly attend locality MDT meetings to provide Frailty Practitioner representation. To attend VMT meetings when requested.
Finance and business management
Ensure an appropriate understanding of the services financial structure and accounts and provide an informed analytical perspective of the budgets for which the post holder supports.
Support the Chief Operating Officer to meet agreed targets within the locality and when required represent the team in SDHC/ICT business.
Support the Chief Operating Officer in preparation of business cases for both internal and external agencies and funding.
Health, safety and security
Support the Frailty GP to implement approved changes in response to legislation and the changing needs of the population.
Support clinical leads, service leads and senior staff to respond and implement action that provides health, safety and security for workforce and users.
Represent the team as required including attendance at meetings and committees when required.
Responsible for undertaking personal risk assessments 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 desk and ergonomic and associated risk assessments prior to working from their own home.
Ensure that the risks identified are escalated as per SDHC policy.
To ensure that any assessments undertaken are documented and reported in line with SDHC policy.
Quality, clinical governance and clinical audit
Identify appropriate audits and assist in delivering these.
To be an active part of the team developing quality outcomes and providing support in delivering these.
To develop with the Frailty Practitioners & GPs a robust process for ensuring clinical governance is integrated in day-to-day work.
To support the development of quality indicators and acknowledge the quality monitoring of clinical record keeping within the team.
Participate in the collection of data to achieve the targets.
Equality, diversity and rights
Ensure that the team provides an appropriate staffing to reflect the diversity of the population and ensure equal opportunities.
The post holder will ensure that equal opportunities policies are upheld.
Ensure that monitoring of service delivery includes access by minority groups.
Patient and public involvement
SDHC has a statutory duty to ensure that patients, clients and members of the public are consulted and involved in decisions about local health service developments. The post holder will work with relevant staff to ensure this happens.
Person Specification
Experience Essential
Experience of working as an autonomous practitioner Case management experience 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
Desirable
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 Essential
RN first level nurse (Adults) or Allied Health Professional eligible to become an Independent Prescriber Bachelors degree Case management experience 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
Desirable
Relevant post-graduate or masters level degree
Skills, Knowledge and Abilities Essential
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
Desirable
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 Essential
Must be mobile for regular travel and able to travel between base and client homes within a reasonable timeframe and cost Enhanced DBS Disclosure Reliable work record
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).
Employer details Employer name South Downs Health and Care Ltd (SDHC)
Address Hillbrow Health and Wellbeing
1 Denton Road
Eastbourne
East Sussex
BN20 7SS
United Kingdom
Employer's website http://www.sdhc.org.uk/ (Opens in a new tab)