Job summary
A Social Prescribing Care Co-ordinator is an ARRS-funded role working within a Primary Care Network (PCN) - Westminster Living Well. The post holder supports patients to take control of their health and wellbeing by connecting them to non-medical, community-based services. Working within a Primary Care Network (PCN), the post holder helps individuals address social, emotional, or practical issues affecting their health (e.g., loneliness, debt, housing, lifestyle concerns).
The role contributes to the delivery of personalised care under the NHS Long Term Plan and supports the reduction of health inequalities.
This position is funded under the Additional Roles Reimbursement Scheme (ARRS), which enables PCNs to recruit specific workforce roles to expand multidisciplinary teams.
Main duties of the job
1. Patient Support & Engagement
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Receive referrals from GPs, nurses, and other healthcare professionals.
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Provide one-to-one personalised support using a holistic, person-centred approach.
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Co-produce simple personalised care and support plans.
-
Identify patient goals and help them access appropriate community services.
-
Support behaviour change and self-management strategies.
2. Social Prescribing & Community Linking
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Develop strong knowledge of local voluntary, community and social enterprise (VCSE) organisations.
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Connect patients with services such as:
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Mental health and wellbeing groups
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Bereavement support
-
Financial/debt advice
-
Housing support
-
Physical activity programmes
-
Employment and training services
-
Build and maintain relationships with community providers.
3. Care Co-ordination
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Work collaboratively within the multidisciplinary team (MDT).
-
Attend MDT meetings and case discussions.
-
Ensure appropriate follow-up and review of patient progress.
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Maintain accurate records on clinical systems (e.g., EMIS/SystmOne).
4. Safeguarding & Risk Management
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Recognise and escalate safeguarding concerns appropriately.
-
Undertake risk assessments when required.
-
Work within NHS and organisational policies.
5. Data & Reporting
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Record patient contacts and outcomes.
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Contribute to service evaluation and reporting requirements.
-
Support achievement of PCN targets related to personalised care.
About us
Pimlico is an NHS GP Practice. Our doctors have been serving the community of Pimlico and Westminster for many years. We provide a range of dedicated services within our practice including diabetes, paediatric clinic, chronic disease management and homevisiting service. We are part of the newly established Westminster Living Well PCN in which this position will play an integral part.
Job description
Job responsibilities
Key Duties and ResponsibilitiesPersonalised Care & Patient Support1 Personalised Care & Patient Support
-
Receive and triage referrals from GPs, nurses and other PCN staff.
-
Undertake comprehensive person-centred assessments.
-
Identify social, emotional, practical and financial factors affecting health.
-
Co-produce personalised care and support plans.
-
Support individuals to identify goals and develop action plans.
-
Provide motivational support and behaviour change interventions.
-
Offer short- to medium-term support, typically 612 sessions.
-
Promote independence and resilience.
2 Social Prescribing & Community Navigation
-
Develop and maintain up-to-date knowledge of local community assets.
-
Establish strong relationships with voluntary, community and social enterprise (VCSE) organisations.
-
Facilitate referrals into services including (but not limited to):
-
Mental health and wellbeing support
-
Loneliness and social isolation groups
-
Welfare benefits and debt advice
-
Housing support
-
Lifestyle and physical activity programmes
-
Employment and skills services
-
Support patients to attend initial appointments where appropriate.
-
Address barriers to access (digital exclusion, language, confidence).
3 Care Co-ordination within the PCN
-
Work collaboratively within the multidisciplinary team (MDT).
-
Attend MDT meetings and case reviews.
-
Contribute to integrated care planning.
-
Liaise with district nurses, pharmacists, mental health teams and community providers.
-
Support PCN priorities including prevention and health inequalities reduction.
4 ARRS Compliance & Workforce Requirements
As an ARRS-funded role, the post holder must:
-
Work within the national Social Prescribing Link Worker role descriptor.
-
Complete mandatory training aligned with ARRS requirements.
-
Undertake training via the Personalised Care Institute where required.
-
Participate in regular supervision and reflective practice.
-
Contribute to PCN workforce reporting requirements.
The role is reimbursed through ARRS funding and must remain compliant with scheme criteria.
5 Safeguarding & Risk Management
-
Identify safeguarding concerns for adults and children.
-
Escalate concerns in accordance with local safeguarding procedures.
-
Undertake risk assessments where appropriate.
-
Maintain professional boundaries.
-
Follow information governance and confidentiality policies.
6 Data Recording & Outcome Monitoring
-
Accurately record patient contacts using clinical systems (e.g., EMIS/SystmOne).
-
Code activity appropriately.
-
Collect outcome measures where required.
-
Contribute to service evaluation and impact reporting.
-
Support reporting linked to PCN targets and national guidance.
7 Equality, Diversity & Inclusion
-
Work in a culturally sensitive and inclusive manner.
-
Actively address health inequalities.
-
Ensure services are accessible to diverse populations.
-
Promote anti-discriminatory practice.
Person SpecificationEssential Criteria
-
Experience working in health, social care, community or voluntary sector.
-
Experience supporting vulnerable or complex individuals.
-
Strong interpersonal and motivational skills.
-
Ability to manage a caseload independently.
-
Understanding of safeguarding principles.
-
Knowledge of community services and local resources.
-
IT literacy and ability to use digital systems.
Desirable Criteria
-
Level 3 or above qualification in Health & Social Care or equivalent.
-
Experience within primary care or NHS setting.
-
Training in motivational interviewing or behaviour change.
-
Understanding of personalised care models.
-
Experience in community development.
Core Competencies
-
Person-centred and strengths-based approach
-
Effective communication and active listening
-
Collaborative working
-
Professional accountability
-
Organisation and time management
-
Emotional resilience
-
Problem-solving skills
Job description
Job responsibilities
Key Duties and ResponsibilitiesPersonalised Care & Patient Support1 Personalised Care & Patient Support
-
Receive and triage referrals from GPs, nurses and other PCN staff.
-
Undertake comprehensive person-centred assessments.
-
Identify social, emotional, practical and financial factors affecting health.
-
Co-produce personalised care and support plans.
-
Support individuals to identify goals and develop action plans.
-
Provide motivational support and behaviour change interventions.
-
Offer short- to medium-term support, typically 612 sessions.
-
Promote independence and resilience.
2 Social Prescribing & Community Navigation
-
Develop and maintain up-to-date knowledge of local community assets.
-
Establish strong relationships with voluntary, community and social enterprise (VCSE) organisations.
-
Facilitate referrals into services including (but not limited to):
-
Mental health and wellbeing support
-
Loneliness and social isolation groups
-
Welfare benefits and debt advice
-
Housing support
-
Lifestyle and physical activity programmes
-
Employment and skills services
-
Support patients to attend initial appointments where appropriate.
-
Address barriers to access (digital exclusion, language, confidence).
3 Care Co-ordination within the PCN
-
Work collaboratively within the multidisciplinary team (MDT).
-
Attend MDT meetings and case reviews.
-
Contribute to integrated care planning.
-
Liaise with district nurses, pharmacists, mental health teams and community providers.
-
Support PCN priorities including prevention and health inequalities reduction.
4 ARRS Compliance & Workforce Requirements
As an ARRS-funded role, the post holder must:
-
Work within the national Social Prescribing Link Worker role descriptor.
-
Complete mandatory training aligned with ARRS requirements.
-
Undertake training via the Personalised Care Institute where required.
-
Participate in regular supervision and reflective practice.
-
Contribute to PCN workforce reporting requirements.
The role is reimbursed through ARRS funding and must remain compliant with scheme criteria.
5 Safeguarding & Risk Management
-
Identify safeguarding concerns for adults and children.
-
Escalate concerns in accordance with local safeguarding procedures.
-
Undertake risk assessments where appropriate.
-
Maintain professional boundaries.
-
Follow information governance and confidentiality policies.
6 Data Recording & Outcome Monitoring
-
Accurately record patient contacts using clinical systems (e.g., EMIS/SystmOne).
-
Code activity appropriately.
-
Collect outcome measures where required.
-
Contribute to service evaluation and impact reporting.
-
Support reporting linked to PCN targets and national guidance.
7 Equality, Diversity & Inclusion
-
Work in a culturally sensitive and inclusive manner.
-
Actively address health inequalities.
-
Ensure services are accessible to diverse populations.
-
Promote anti-discriminatory practice.
Person SpecificationEssential Criteria
-
Experience working in health, social care, community or voluntary sector.
-
Experience supporting vulnerable or complex individuals.
-
Strong interpersonal and motivational skills.
-
Ability to manage a caseload independently.
-
Understanding of safeguarding principles.
-
Knowledge of community services and local resources.
-
IT literacy and ability to use digital systems.
Desirable Criteria
-
Level 3 or above qualification in Health & Social Care or equivalent.
-
Experience within primary care or NHS setting.
-
Training in motivational interviewing or behaviour change.
-
Understanding of personalised care models.
-
Experience in community development.
Core Competencies
-
Person-centred and strengths-based approach
-
Effective communication and active listening
-
Collaborative working
-
Professional accountability
-
Organisation and time management
-
Emotional resilience
-
Problem-solving skills
Person Specification
Qualifications
Essential
- At least one of the following:
- Level 3 Diploma in Health & Social Care
- Level 3 NVQ in Health & Social Care
- Level 3 Community Development qualification
Desirable
- Level 4 Certificate in Health & Social Care
- Level 4/5 in Community Development
- Level 4/5 Leadership & Management in Health & Social Care
Experience
Essential
- Experience in health, social care, community work or voluntary sector.
- Good communication and motivational skills.
- Understanding of safeguarding.
- Ability to work independently and manage a caseload.
- Knowledge of local community services.
Person Specification
Qualifications
Essential
- At least one of the following:
- Level 3 Diploma in Health & Social Care
- Level 3 NVQ in Health & Social Care
- Level 3 Community Development qualification
Desirable
- Level 4 Certificate in Health & Social Care
- Level 4/5 in Community Development
- Level 4/5 Leadership & Management in Health & Social Care
Experience
Essential
- Experience in health, social care, community work or voluntary sector.
- Good communication and motivational skills.
- Understanding of safeguarding.
- Ability to work independently and manage a caseload.
- Knowledge of local community services.
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.
