Frailty Neighbourhood Health Project Manager

Key responsibilities The work is set by the eight high-priority actions in the PCN's self-assessment and Development Plan. Clinical decisions stay with the Clinical Director and the Frailty GP lead. The postholder will; Run the process for the four practices to agree how and when they decide on the April 2027 DES variation, including each practice's sign-off. Draft the Frailty Neighbourhood Health Team (NHT) terms of reference and accountability matrix with partners. Prepare Board papers Brief and coordinate the PCN's legal advisers and the LMC. Track advice on liability, hosting, employment and data-controller arrangements. Keep the risk register up to date. Support the Clinical Director to check the model against the PCN's CQC registration and statement of purpose Cost delivery of the Frailty NHT specification against the funding offered through the DES variation, to inform the practices' decision Support practices with the DELPPHI data agreements. Agree a 2025/26 baseline and a small set of NHT measures. If DELPPHI is not ready, build an interim dashboard from SystmOne and Ardens searches, QOF and IIF, activity data and MYCaW Support the Frailty GP lead and Community Matron lead to agree how the cohort is identified (electronic frailty index with clinical validation, Community Matron caseload, high-intensity users). Test it on a sample to estimate cohort size Map PCN and partner workforce for the frailty cohort (skills, capacity, gaps). Help develop the PCN-wide MDT into the

Frailty NHT MDT

membership, frequency, shared caseload, named care coordinator, action log Produce a single pathway map with partners covering JET, Urgent Community Response, virtual wards, Home First, acute frailty at Hinchingbrooke, Adult Social Care and end of life care. Produce a CORE20PLUS5 profile for the PCN. Add equality monitoring to the NHT dashboard. Complete an equality impact assessment for the pathway, including digital exclusion Partnership working and engagement About half the role is spent with people: building relationships, running meetings and working through barriers between services. Frailty GP lead and

Community Matron lead

work with them day to day on the cohort, MDT and pathway.

Member practices

keep the four practices and their Practice Managers involved. Bring a neighbourhood and frailty item to each PCN Board and gather practice insight on the frailty cohort.

Neighbourhood partners

build working links with community nursing, Adult Social Care, mental health, JET, Urgent Community Response, Hinchingbrooke Hospital, the voluntary sector and community pharmacy. Work with the Integrated Neighbourhood Managers at Huntingdonshire Locality meetings to agree a shared partner charter. Neighbouring PC

Ns

work with the other five PCNs in the Hunts/Fens GP Practices Collaborative, and with North Care Partnership, sharing work where it avoids duplication.

Central East ICB

keep in step with the contract timetable, the DELPPHI roll-out and the scheme's reporting requirements.

Patients

keep the four practice Patient Participation Groups informed and give them a chance to review the proposed pathway.

Barriers

spot where services do not join up, propose practical fixes, and escalate to the Clinical Director when needed. Population data, finance and workforce planning These three pieces of work belong to this post, with the PCN Manager overseeing.

Population

Work with practice data leads to run and interpret searches using SystmOne, Ardens, the electronic Frailty Index and other relevant datasets. Produce and maintain a PCN footprint map showing practice boundaries, neighbouring PCN interfaces and alignment with local partner organisations. Develop population health intelligence and frailty cohorts using PCN, ICB and neighbourhood data to identify patients who would benefit from proactive intervention and support planning for future neighbourhood services.

Finance

keep spend against the £25,000 on its separate cost centre, with a quarterly report showing it does not duplicate work the PCN DES already funds. Prepare the groundwork for a two-year financial plan (2027/28 to 2028/29), to be completed once the contract award is known.

Workforce

prepare the groundwork for a linked two-year workforce plan, using the MDT workforce mapping. Support a shared training plan for the Frailty NHT with partners and the Training Hub. Support multidisciplinary team development, workforce planning, training and organisational development activities across the Neighbourhood Health Team. Governance, reporting and information governance Keep a project plan and action log against the Development Plan milestones, and report progress monthly to the PCN Manager and Clinical Director. Write short papers and updates for each PCN Board. Gather the evidence and draft the PCN's year-end report to the ICB, due by 31 March 2027, including an updated view of the maturity self-assessment. Work only on what the scheme funds. The post must not take on routine work already funded through the PCN DES. Handle patient-identifiable data only within agreed data sharing agreements and data protection impact assessments, under the Clinical Director as Caldicott Guardian. Record risks on the PCN risk register and report incidents through PCN procedures, in line with the PCN's governance for its CQC registration. Complete the PCN's mandatory training, including information governance and safeguarding at the level set for the role. Support development and maintenance of Neighbourhood Health Team governance arrangements including risk management, reporting, policies, operational procedures and board assurance.