Job Description

Working with GPs, take referrals from a wide range of agencies, including PCNs GP Practices and multi-disciplinary teams: pharmacies, wider multi-disciplinary teams, hospital discharge teams, allied health professionals, job centres, social care services and housing associations (list not exhaustive). Provide personalised support to individuals, their families and carers to take control of their health and wellbeing, live independently and improve their health access and outcomes, as a key member of the PCN multi-disciplinary team. Develop trusting relationships by giving people time and focus on what matters to me. Take a holistic approach, based on the persons priorities and the wider determinants of health.



Co-produce a simple personalised care and support plan to improve health and wellbeing, introducing or reconnecting people to appropriate community groups and statutory services. The role will require managing and prioritising your own caseload, in accordance with the needs, priorities and any urgent support required by individuals on the caseload. It is vital that you have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the persons needs are beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner.



Work with a diverse range of people and communities, to draw on and increase the strengths and capacities of local communities, enabling local VCSE organisations and community groups to receive social prescribing referrals. Alongside other members of the PCN multi-disciplinary team, work collaboratively with all local diverse partners to contribute towards supporting the local VCSE organisations and community groups to become sustainable, through sharing intelligence regarding any gaps or problems identified in local authorities. Social Prescribing Link Workers will have a role in educating non-clinical and clinical staff within their PCN multi-disciplinary teams on what other services are available within the community and how and when patients can access them. This may include verbal or written advice and guidance.



Promote social prescribing, its role in self-management, addressing health inequalities and the wider determinants of health. As part of the PCN multi-disciplinary team, build relationships with staff in GP practices within the local PCN, attending relevant MDT meetings, giving information and feedback on social prescribing. Be proactive in developing strong links with all local agencies to encourage referrals, recognising what they need to be confident in the service to make appropriate referrals. Work in partnership with all local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health access and outcomes and enable a holistic approach to care.



Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals. Seek regular feedback about the quality of service and impact of social prescribing on referral agencies. Be proactive in encouraging equality and inclusion, through self-referrals and connecting with all diverse local communities, particularly those communities that statutory agencies may find hard to reach. Supporting the safeguarding lead - liaising with professional services and the patient where appropriate.



Attending and supporting patient group meetings and activities. Meet people on a one-to-one basis, making home visits where appropriate within organisations policies and procedures. Give people time to tell their stories and focus on what matters to me. Build trust and respect with the person, providing non-judgemental and non-discriminatory support, respecting diversity and lifestyle choices.



Work from a strength-based approach focusing on a persons assets. Be a friendly and engaging source of information about health, wellbeing and prevention approaches. Help people identify the wider issues that impact on their health and wellbeing, such as debt, poor housing, being unemployed, loneliness and caring responsibilities. Work with the person, their families and carers and consider how they can all be supported through social prescribing.



Help people maintain or regain independence through living skills, adaptations, enablement approaches and simple safeguards. Work with individuals to co-produce a simple personalised support plan to address the persons health and wellbeing needs based on the persons priorities, interests, values, cultural and religious/faith needs and motivations including what they can expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing. Where appropriate, physically introduce people to appropriate community groups, activities and statutory services, ensuring they are comfortable, feel valued and respected. Follow up to ensure they are happy, able to engage, included and receiving good support.



Where people may be eligible for a personal health budget, help them to explore this option as a way of providing funded, personalised support to be independent, including helping people to gain skills for meaningful employment, where appropriate. Seek advice and support from the GP supervisor and/or identified individual(s) to discuss patient-related concerns (e.g. abuse, domestic violence and support with mental health), referring the patient back to the GP or other suitable health professional if required. Forge strong links with a wide range of local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a menu of diverse community groups and assets, who promote diversity and inclusion Develop supportive relationships with local diverse VCSE organisations, appropriate community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced.



Work with commissioners and local partners to identify unmet diverse needs within the community and gaps in community provision. Encourage people who have been connected to community support through social prescribing to volunteer and give their time freely to others, building their skills and confidence and strengthening community resilience. Develop a team of volunteers within your service to provide buddying support for people, starting new groups and finding creative community solutions to local issues Encourage people, their families and carers to provide peer support and to do things together, such as setting up new community groups or volunteering Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing. Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives.



Support referral agencies to provide appropriate information about the person they are referring. Provide appropriate feedback to referral agencies about the people they referred Work closely within the MDT and with GP practices within the PCN to ensure that the social prescribing referral codes are inputted into clinical systems (as outlined in the Network Contract DES), adhering to data protection legislation and data sharing agreements. Work with your supervising GP and/or line manager (if different) to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.



Work with your supervising GP to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present. Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning. Contribute to the development of policies and plans relating to equality, diversity and health inequalities. Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.



Duties may vary from time to time, without changing the general character of the post or the level of responsibility.