PCN Social Prescribing Link Worker

Working with direct supervision by a GP, take referrals from the PCNs Core Network Practices and from a wide range of agencies, including pharmacies, wider multi-disciplinary teams, hospital discharge teams, allied health professionals (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 the persons needs are beyond the scope of the link worker role e.g. when there is a mental health needs require a qualified practitioner.

health inequalities and the wider determinants of health.

staff in GP practices within the local PCN, attending relevant MDT meetings,

giving information and feedback on social prescribing.

developing strong links with all local agencies to encourage referrals,

recognising what they need to be confident in the service to make appropriate

referrals.

inclusively with the Primary Care Networks member practices, The Confederation,

H4All and other members of the multi-disciplinary team.

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.

agencies with regular updates about social prescribing, including training for

their staff and how to access information to encourage appropriate referrals.

feedback about the quality of service and impact of social prescribing on

referral agencies.

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.Provide

personalised support

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 person’s

assets.

holistic client needs assessments in the surgery, using the Patient Activation

Measure (PAM) assessment and the ONS4 Wellbeing questionnaire full training on

their use will be provided.

engaging source of information about health, wellbeing and prevention

approaches.

identify the wider issues that impact on their health and wellbeing, such as

debt, poor housing, being unemployed, loneliness and caring responsibilities.

person, their families and carers and consider how they can all be supported

through social prescribing.

maintain or regain independence through living skills, adaptations, enablement approaches

and simple safeguards.

individuals to co-produce a simple personalised support plan to address the

person’s health and wellbeing needs – based on the person’s 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.

between health and care workers and local communities in order to make more effective

use of social capital. Where appropriate, physically introduce people to

culturally 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.

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.

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. Support community groups and VCSE organisations to

receive referrals

links with a wide range of local VCSE organisations, community and

neighbourhood level groups, utilising their networks and building on what’s

already available to create a menu of diverse community groups and assets, who

promote diversity and inclusion.

supportive relationships with local diverse VCSE organisations, culturally

appropriate community groups and statutory services, to make timely,

appropriate and supported referrals for the person being introduced. Work

collectively with all local partners to ensure community groups are strong and

sustainable

commissioners and local partners to identify unmet diverse needs within the

community and gaps in community provision. Map community resources and build

and build community capacity to meet identified gaps in provision.

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.

their families and carers to provide peer support and to do things together,

such as setting up new community groups or volunteering.

Worker programme is integrated into Hillingdon’s well-established social

prescribing programme, delivered by H4All.

with people, their families and carers to capture key information, enabling

tracking of the impact of social prescribing on their health and wellbeing.

their families and carers to provide feedback and to share their stories about

the impact of social prescribing on their lives.

agencies to provide appropriate information about the person they are

referring. Provide appropriate feedback to referral agencies about the people

they referred.

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.

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.

organisational policies and procedures, including confidentiality, safeguarding,

lone working, information governance, equality, diversity and inclusion

training and health and safety.

supervising GP to access regular ‘clinical supervision’, to enable you to deal

effectively with the difficult issues that people present.

Involved in one to one meetings with line

manager monthly to discuss targets and outcomes achieved.

Review yearly progress and develop clear plans

to achieve results within priorities set by others.

the healthcare team to seek feedback, continually improve the service and

contribute to business planning.

development of policies and plans relating to equality, diversity and health

inequalities.

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.

changing the general character of the post or the level of responsibility.

CIC works with General Practice and other healthcare providers to deliver its

vision for Hillingdon to deliver the best primary care outcomes for patients

in the whole of London. We are a not for profit community interest

company. The Confederation works to develop and support individual GP

practices, PCNs and Neighbourhoods and their changing needs. We deliver

excellent clinical services ourselves both at scale and complementary to General

Practice. We are the provider representative voice for local General

Practice into the wider NHS and other Partners. We are of the NHS but

independent, innovative and transformational.

The Confederation determines

to develop as an attractive place to work, providing rewarding roles and

opportunities to grow in order to attract and retain great staff that in turn

delivers our vision.

Our Values

Experience

Desirable: - Hybrid working style.

Knowledge and Skills

Essential: - Educated to NVQ Level 3, Advanced level or equivalent qualifications or equivalent work experience