Frailty Neighbourhood Health Project Manager

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Huntingdon PCN Frailty Neighbourhood Health Project Manager

The closing date is 13 November 2026

Apply for this job

Job summary

Huntingdon PCN serves about 47,000 patients through four practices: Acorn Surgery, The Hicks Group Practice, Papworth Surgery and Priory Fields Surgery. It is a limited company registered with the CQC. It runs a single SystmOne hub, a PCN-wide multidisciplinary team (MDT) with Adult Social Care and community nursing, and services including Community Matrons, Social Prescribing and Enhanced Access.

From April 2027, Central East ICB intends to commission Frailty Neighbourhood Health Teams through a local variation agreement (LVA) of the PCN DES.First contract offers are due on 18 November 2026 and contracts are to be signed by 28 February 2027.

The PCN aims to be ready to lead its own neighbourhood as the single (lead) neighbourhood provider. It will do this within the Hunts/Fens GP Practices Collaborative of six PCNs, with North Care Partnership expected to act as integrator. The ICB has given the PCN £25,000 in 2026/27 to prepare, and this post is the largest part of that investment.

Main duties of the job

The postholder will lead and coordinate the programme of work required to prepare Huntingdon PCN to become the lead neighbourhood provider for frailty from April 2027. Working with the Clinical Director, Frailty GP Lead and system partners, they will deliver the priority actions within the PCN's Neighbourhood Development Plan, ensuring the organisation is ready for future neighbourhood commissioning and contracting arrangements.The role will focus on programme delivery and responsibilities will include project management, partner engagement, workforce and financial planning, population health intelligence, governance development and readiness assurance. The postholder will ensure that agreed milestones are delivered on time, risks are identified and managed, and the evidence required to demonstrate progress and support reporting to the ICB is collected and maintained.

The Clinical Director and Frailty GP Lead will provide clinical leadership and strategic direction. The Project Manager will coordinate the work required to establish the foundations for a future Frailty Neighbourhood Health Team, enabling the PCN to take on neighbourhood responsibilities and contracts as they emerge.

About us

OUR VISION AND VALUES

Huntingdon PCNs vision is to bring GP practices together with other local services to provide the best care in the right place. This role will support Huntingdon PCN which covers 4 GP Practices and have a patient population of just under 47,000 patients. Our values are:

Integrity - We promise to conduct ourselves with the utmost integrity, staying open and honest with colleagues and patients.

Empathy - We strive to take perspective of and feel emotions of another person, taking action to alleviate stress and pain of others showing kindness and care in our approach. Putting ourselves in other peoples shoes, both patients and colleagues, establishing an empathetic connection.

Empowerment - We seek to champion positive relationships and build trust whilst empowering others

Details

Date posted

28 October 2026

Pay scheme

Other

Salary

£19,332 a year

Contract

Fixed term

Duration

4 months

Working pattern

Part-time, Flexible working

Reference number

W0017-26-0004

Job locations

Huntingdon PCN

St Marys Street

Huntingdon

PE293TN

United Kingdom

Charles Hicks Centre

75 Ermine Street

HUNTINGDON

Cambridgeshire

PE29 3EZ

United Kingdom

Acorn Surgery

2 Oak Drive

HUNTINGDON

Cambridgeshire

PE29 7HN

United Kingdom

Roman Gate Surgery

Unit A

1 Pinfold Lane, Godmanchester

HUNTINGDON

Cambridgeshire

PE29 2JH

United Kingdom

Priory Fields Doctors Surgery

Nursery Road

HUNTINGDON

Cambridgeshire

PE29 3RL

United Kingdom

Papworth Surgery

Chequers Lane

Papworth Everard

CAMBRIDGE

CB23 3QQ

United Kingdom

Job description

Job responsibilities

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 PCNs: 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.

Job description

Job responsibilities

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 PCNs: 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.

Person Specification

Qualifications

Desirable

• Educated to degree level or equivalent experience
• Project management qualification, such as PRINCE2, MSP or Agile
• Training in quality improvement methods, such as Plan-Do-Study-Act

Knowledge

Essential

• Awareness of frailty and how care for frail people is organised
• Experience of Stakeholder engagement across multiple organisations
• Understanding of how general practice, PCNs and community services work together, and the barriers between services

Desirable

• Knowledge of the PCN DES, NHS contracting and neighbourhood health policy
• Experience of population health data, such as SystmOne or Ardens searches, frailty index and dashboards
• Knowledge of health inequalities approaches, including CORE20PLUS5
• Knowledge of the local health and care system in Huntingdonshire or Cambridgeshire and Peterborough
• Understanding of Neighbourhood Health Models
• Understanding of information governance and data-sharing agreements

Experience

Essential

• Experience of working in the NHS, with a practical understanding of how it works
• Has managed projects to deadlines in an NHS or ICB setting
• Has worked across organisations, for example ICB, community, acute, social care or system-level roles

Desirable

• Experience in an ICB or commissioning role
• Experience of NHS financial or workforce planning
• Experience of Service redesign and Pathway development

Skills

Essential

• Highly proficient with Microsoft 365, including Word, Excel and Teams
• Confident user of AI tools such as Copilot or ChatGPT to produce documents and analysis
• Builds and uses spreadsheets for data, costing and tracking
• Excellent interpersonal skills with clinicians, managers and partner organisations
• Writes clear, concise papers for a Board

Personal Qualities & Attributes

Essential

• Highly proactive; gets things moving without waiting to be asked
• Works with the way the NHS operates while pushing for practical change
• Manages own time and priorities well on a part-time contract
• Able to travel across the PCN area and to partner sites

Person Specification

Qualifications

Desirable

• Educated to degree level or equivalent experience
• Project management qualification, such as PRINCE2, MSP or Agile
• Training in quality improvement methods, such as Plan-Do-Study-Act

Knowledge

Essential

• Awareness of frailty and how care for frail people is organised
• Experience of Stakeholder engagement across multiple organisations
• Understanding of how general practice, PCNs and community services work together, and the barriers between services

Desirable

• Knowledge of the PCN DES, NHS contracting and neighbourhood health policy
• Experience of population health data, such as SystmOne or Ardens searches, frailty index and dashboards
• Knowledge of health inequalities approaches, including CORE20PLUS5
• Knowledge of the local health and care system in Huntingdonshire or Cambridgeshire and Peterborough
• Understanding of Neighbourhood Health Models
• Understanding of information governance and data-sharing agreements

Experience

Essential

• Experience of working in the NHS, with a practical understanding of how it works
• Has managed projects to deadlines in an NHS or ICB setting
• Has worked across organisations, for example ICB, community, acute, social care or system-level roles

Desirable

• Experience in an ICB or commissioning role
• Experience of NHS financial or workforce planning
• Experience of Service redesign and Pathway development

Skills

Essential

• Highly proficient with Microsoft 365, including Word, Excel and Teams
• Confident user of AI tools such as Copilot or ChatGPT to produce documents and analysis
• Builds and uses spreadsheets for data, costing and tracking
• Excellent interpersonal skills with clinicians, managers and partner organisations
• Writes clear, concise papers for a Board

Personal Qualities & Attributes

Essential

• Highly proactive; gets things moving without waiting to be asked
• Works with the way the NHS operates while pushing for practical change
• Manages own time and priorities well on a part-time contract
• Able to travel across the PCN area and to partner sites

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.

Employer details

Employer name

Huntingdon PCN

Address

Huntingdon PCN

St Marys Street

Huntingdon

PE293TN

United Kingdom

Employer's website

https://www.huntingdonpcn.nhs.uk/ (Opens in a new tab)

Employer details

Employer name

Huntingdon PCN

Address

Huntingdon PCN

St Marys Street

Huntingdon

PE293TN

United Kingdom

Employer's website

https://www.huntingdonpcn.nhs.uk/ (Opens in a new tab)

Employer contact details

For questions about the job, contact:

Management Assistant

Lindsey Hum

[email protected]

07741374380

Details

Date posted

28 October 2026

Pay scheme

Other

Salary

£19,332 a year

Contract

Fixed term

Duration

4 months

Working pattern

Part-time, Flexible working

Reference number

W0017-26-0004

Job locations

Huntingdon PCN

St Marys Street

Huntingdon

PE293TN

United Kingdom

Charles Hicks Centre

75 Ermine Street

HUNTINGDON

Cambridgeshire

PE29 3EZ

United Kingdom

Acorn Surgery

2 Oak Drive

HUNTINGDON

Cambridgeshire

PE29 7HN

United Kingdom

Roman Gate Surgery

Unit A

1 Pinfold Lane, Godmanchester

HUNTINGDON

Cambridgeshire

PE29 2JH

United Kingdom

Priory Fields Doctors Surgery

Nursery Road

HUNTINGDON

Cambridgeshire

PE29 3RL

United Kingdom

Papworth Surgery

Chequers Lane

Papworth Everard

CAMBRIDGE

CB23 3QQ

United Kingdom

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