Job Description

Are you passionate about helping people improve their health and wellbeing by addressing the wider social challenges in their lives?

We are a large GP practice in Oxford, with 26,000 patients, looking for a caring and motivated Social Prescriber / Link Worker to join our Proactive Care Team, working across both Manor Surgery and Kennington Health Centre in Oxford.

This is a varied and rewarding role, supporting patients with a wide range of needs - from housing and benefits advice to tackling loneliness, low-level mental health concerns, and connecting people to local community groups and services. You'll spend much of your time visiting patients in their homes and communities, so confidence with independent working and travel is essential.

You will work closely with GPs, nurses, practice staff, and other agencies to ensure that patients receive the right support, at the right time, to improve their wellbeing. If you are empathetic, well-organised, and enjoy making meaningful connections with people, we'd love to hear from you.

Key Relationships:

Proactive Care team

Nursing and allied professionals' team

General Practitioners

Practice based and City-wide Social Prescribers and Practice Link Workers

Practice Managers

Job Summary:

As a Social Prescriber / Link Worker, you will be part of the Proactive Care Team at The Manor Group, working across both Manor Surgery and Kennington Health Centre. You will play a vital role in supporting patients whose health and wellbeing are affected by non-medical issues, such as housing concerns, financial difficulties, loneliness, or low-level mental health challenges. Most of your work will involve visiting patients in their homes or meeting them in community settings, so you will need to feel confident working independently and travelling between locations.

You will spend time getting to know patients, listening carefully to their stories, and understanding what really matters to them. You will then work alongside them to co-produce personalised plans, connecting them to the right services, groups, and support networks. You will be the link between patients, the practice team, and the wider community, helping people overcome barriers to accessing support and empowering them to take control of their health and wellbeing.

Key Responsibilities:

The responsibilities will include the following:

Manage a caseload of patients referred by GPs, clinicians, and the wider practice team. Meet patients in their homes, in the practice, or in community settings to explore what matters most to them and identify appropriate support. Provide regular follow-up and ongoing support to ensure patients can access and engage with services. Develop and maintain strong knowledge of local voluntary, community, and statutory sector services. Signpost and connect patients to appropriate services (e.g. housing advice, welfare/benefits, peer support groups, social clubs, mental wellbeing activities). Support patients to overcome barriers such as transport, confidence, or accessibility. Work closely with GPs, nurses, and the wider Proactive Care Team to ensure joined-up, holistic care. Act as a bridge between patients, carers, health professionals, and external agencies. Contribute to proactive identification of patients who would benefit from social prescribing support. Participate in multi-disciplinary team meetings at both sites. Keep accurate and up-to-date records of referrals, interventions, and outcomes using GP systems. Contribute to evaluation and reporting of the service, feeding back on gaps and opportunities for improvement. Follow safeguarding processes and escalate concerns where required.

Examples of key activities:

Enable access to local services and personalised support:

You will help people access the right non-clinical support for their needs by identifying practical solutions and removing barriers to engagement. Examples include:

Taking referrals and carrying out person-centred assessments (usually in the home or community) to understand needs, strengths and what matters most to the patient.

Co-producing short-to-medium term personalised support plans with clear, realistic goals agreed with the patient.

Signposting and linking people to community groups, welfare and benefits advice, housing support, carers' services and mental-wellbeing activities.

Providing practical help to access services (for example, supporting form completion, arranging transport, making introductions or accompanying patients to appointments where needed).

Helping people build confidence and self-management skills through coaching, motivational conversations and onward referral to appropriate programmes or groups.

Identifying and referring onward to specialist advice where affordability or complexity exceeds the link worker role (e.g. Citizens Advice, housing advocacy, specialist mental health services).

Co-ordinate and integrate care:

You will act as a connector across primary care, social care and the voluntary sector to ensure patients receive joined-up support. Examples include:

Working with GPs, nurses, community teams and social care to identify patients who would benefit from social prescribing input.

Attending and contributing to multi-disciplinary team (MDT) meetings to represent patients' social needs and progress.

Acting as the main practice contact for external agencies involved in a patient's care, ensuring clear and timely information-sharing and handovers.

Supporting the organisation and coordination of short-term support packages and following up to ensure actions are completed.

Identifying when a patient's needs require a step-up to statutory or specialist services and facilitating timely referrals.

Recognising and escalating safeguarding or urgent concerns in line with practice procedures, and supporting the team to implement safety plans.

Keep records and contribute to service monitoring and improvement

You will maintain high-quality records and help the practice understand the impact of social prescribing, supporting ongoing service improvement. Examples include:

Recording all contacts, interventions, outcomes and follow-ups accurately and promptly on the practice clinical system and other agreed records.

Using agreed outcome measures and collecting patient feedback to monitor progress and capture the benefits of interventions.

Preparing case summaries and activity information for your line manager and the practice team as required.

Contributing insight into demand, common issues and gaps in local provision to help shape how the service operates and develops.

Supporting audits and quality improvement activities that refine referral pathways, documentation and day-to-day processes.

General responsibilities:

You will support the safety, professionalism and development of the service and work effectively across practice sites. Examples include:

Working flexibly across Manor Surgery and Kennington Health Centre, including travel to patients' homes and community venues.

Adhering to all practice policies on confidentiality, information governance, safeguarding, lone-working and health & safety when working in community or home settings.

Participating in supervision, reflective practice and continuing professional development; keeping mandatory training up to date.

Building and maintaining positive working relationships with colleagues, voluntary sector partners and statutory agencies.

Maintaining professional boundaries while delivering compassionate, person-centred support.

Being willing to adapt the role as local needs and service arrangements evolve, and to contribute to wider practice objectives when needed.

Confidentiality

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data

Health & Safety:

The post-holder will assist in promoting and maintaining their own and others' health, safety and security as defined in the practice Health & Safety Policy, the practice Health & Safety Manual, and the practice Infection Control policy and published procedures. This will include:

Using personal security systems within the workplace according to practice guidelines Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks Making effective use of training to update knowledge and skills Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards Actively reporting of health and safety hazards and infection hazards immediately when recognised Keeping own work areas and general / patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the job holder's role Undertaking periodic infection control training (minimum annually) Reporting potential risks identified

Equality and Diversity:

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

Acting in a way that recognizes the importance of people's rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.

Personal/Professional Development

The post-holder will participate in any training programme implemented by the practice as part of this employment, such training to include:

Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work

Quality

The post-holder will strive to maintain quality within the practice, and will:

Alert other team members to issues of quality and risk

Assess own performance and take accountability for own actions, either directly or under supervision Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team's performance Work effectively with individuals in other agencies to meet patients needs Effectively manage own time, workload and resources

Communication

The post-holder should recognize the importance of effective communication within the team and will strive to:

Communicate effectively with other team members Communicate effectively with patients and carers Recognize people's needs for alternative methods of communication and respond accordingly

Contribution to the Implementation of Services

The post-holder will:

Apply practice policies, standards and guidance Discuss with other members of the team how the policies, standards and guidelines will affect own work Participate in audit where appropriate
This job description is not exhaustive and is intended to be an outline only. Changes may be made by agreement at any time.

Person Specification:

Essential

Education/Training

Good standard of general education.

GCSE English and Maths at grade C (or equivalent).

Strong IT skills, including use of email, Word and Excel.

Full UK driving licence and access to a car insured for business use.

Willingness to undertake ongoing training relevant to the role (e.g. safeguarding, lone-working, mental health awareness).

Desirable

Additional training in health, social care, or community support.

Training in motivational interviewing, mental health first aid, or person-centred approaches.

Experience

:

Essential

Ability to collect and record accurate information for record-keeping, monitoring and evaluation, including documenting patient consultations.

Desirable

Experience of working in a healthcare setting.

Experience of working directly with people to identify needs and provide tailored, person-centred support (this may be in a community, social care, voluntary, or other support setting).

Experience of supporting people with complex or vulnerable needs in line with best practice and relevant legislation.

Experience or training in person-centred care planning.

Experience of liaising with and coordinating between multiple agencies or services.

Experience of using clinical IT systems (e.g. EMIS).

Special Skills/Aptitudes:

Essential

Strong organisational skills, with ability to plan, prioritise, and manage workload effectively.

Good verbal and written communication skills, able to adapt style for different audiences.

Ability to build and maintain positive working relationships with colleagues, patients, carers, and external agencies.

Compassionate and professional approach to patient care, with clear boundaries.

Ability to remain calm, diplomatic, and effective when dealing with sensitive or challenging situations.

Skilled in motivating and empowering people to take an active role in their own health and wellbeing.

Ability to recognise gaps in services and escalate safety or safeguarding concerns appropriately.

Confident in identifying when issues fall outside your remit and referring appropriately.

Able to work independently in patients' homes and community settings, following lone-working protocols.

Resilient, flexible, and proactive attitude with willingness to adapt as the role evolves.

Desirable

Knowledge of local voluntary and statutory services available to support patients and carers.

Familiarity with outcome measurement tools used in social prescribing.

Understanding of the wider determinants of health and health inequalities.

Knowledge of behaviour change approaches.

Job Type: Part-time

Pay: From 13.16 per hour

Expected hours: No more than 25 per week

Work Location: In person

Reference ID: SP-01