Job responsibilities
Purpose of Role
There
is wide recognition that peoples health
is determined primarily by a range of social, economic and environmental
factors. The NHS has published a bold
new vision for Social Prescribing, a relatively new function within Primary
Care that seeks to address peoples needs in a non-medicalised way,
focusing on What Matters to Me to agree personalised care plans, and then
support individuals to take greater control of their health, by connecting them
to
diverse community groups and statutory services for both practical and
emotional support.
An
existing team of social prescribers have already been working with Primary Care
to provide social prescribing. This
scheme is highly valued and we are looking to expand the existing capacity and
enhance the role to encompass more complex case load, and integrate with
existing clinical teams to work on preventative health projects
Primary
Care Networks (PCNs) were established in 2019 as part of NHS Englands long
term plan to enable services to work collaboratively to meet the needs of
patients. As Primary Care Networks are becoming the vehicle of change for most
primary care services, the NHS recognised the need to evolve other services and
integrate Primary Care Networks into a newly formed Integrated Care System.
Integrated care systems are geographically based partnerships that bring
together providers and commissioners of NHS services with local authorities and
other local partners to plan, co-ordinate and commission health and care.
Main Responsibilities.
Working within practices to assess and allocate
referrals from a wide range of agencies, including GP practices and
multi-disciplinary teams
Working with practices and patients to be a representative
within the newly forming Integrated Care System.
Handle your own caseload of more complex cases
Support practices undertaking and delivering
elements of health and social care population health projects
Supporting the service specifications detailed in
the PCN DES contract.
Promote the service and educate relevant parties
Oversee the data, reporting and evaluation of the
service to strive for continuous improvement and community development
Key
Tasks
Assess
and Allocate Referrals:
The PCN Social prescriber will review
all referrals and allocate appropriate referrals to:
A programme of
self care
Hold own case load
of complex cases
Introduce or
coordinate an appropriate group support session
Make referrals directly
to external providers e.g. DWP, VSC, Help Hub
Manage
dedicated caseload of complex cases:
Develop trusting
relationships, giving individuals time and focus on what matters to them.
Support
individuals to identify the wider issues that impact their health and
Wellbeing, such as debt, poor housing, unemployment, isolation and caring
responsibilities.
Co-produce a
simple personalised care and support plan to improve health and wellbeing.
Where appropriate
introduce individuals to appropriate community groups, activities and statutory
services, ensuring they feel comfortable, valued and respected.
Hold 1-1
appointment with individuals at the most appropriate location to meet
individual needs, making home visits where appropriate within Southend East PCN Limited policies and procedures.
Work with
individuals their families and carers to maintain or regain independence
through living skills, adaptations, enablement and simple safeguards.
Have an awareness
and understanding of when it is appropriate or necessary to refer individuals
back to other health professionals/agencies, when there are additional needs
such as mental health that requires a trained practitioner.
Where people are
eligible for a personal health budget, support them to explore this option as a
way of providing funding to enhance personalised support, to be independent and
gain skills for meaningful employment, where appropriate.
Seek advice and
support from the GP supervisor to discuss patient related concerns (e.g. abuse,
domestic violence and support with mental health) referring back to the GP or
other suitable health professional.
Support
population health management projects:
Work as part of
the PCN project team to pilot new ways of working in response to population
health data, delivering any aspect relating to social prescribing, and advising
on community and voluntary sector services that should be included in the solution
Support
the implementation of the PCN service specifications:
Work with the PCN
to develop the service where individuals require social prescribing activity,
or advice regarding available community and additional activity other than that
already undertaken within the role.
Promote
the service to wider partners:
Be proactive in
developing strong links with the PCN practice teams to encourage referrals and
raise awareness on what other services are available within the community and
how patients can access them
Expanding the
referral criteria to include wider agencies such as; pharmacies, hospital discharge teams, allied health
professionals, fire service, job centers, social care services, housing
associations, VCSE organisations, the list is not exhaustive.
Work in
partnership with all local agencies to educate and raise awareness of social
prescribing and how partnership working can reduce pressure on statutory
services.
Provide referral
agencies with regular updates about social prescribing, including training
their staff and how to access information, and seek their feedback
Be proactive in
encouraging equality and inclusion, through self-referrals and connecting with
all diverse local communities particularly those that statutory agencies may
find hard to reach.
Enable local VCSE
organisations and community groups including faith groups to receive social
prescribing referrals. Working collaboratively to support community and local
VCSE organisations to become sustainable
Work with
commissioners and local partners to identify unmet diverse needs within the
community and gaps in community provision.
Encourage
individuals their families and carers to provide peer support and do things
together such as setting up new community groups or volunteering.
Oversee
the data capture, reporting and evaluation for the service
By working
sensitively with individuals, their families and carers, use a suitable
evaluation tool to capture key information to demonstrate the impact of social
prescribing on their health and wellbeing.
Encourage
individuals, their families and carers to provide feedback and to share their
personal stories about the impact of social prescribing on their lives.
Work closely
within the multi-disciplinary team to ensure relevant data is captured
efficiently throughout the process and relevant reports are completed and
reviewed
Work as part of
the healthcare team to seek feedback and continually improve the service and
contribute to business planning
Professional
Development
Work with GP
supervisor and line manager 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 the GP Supervisor to access regular
clinical supervision to enable them to deal effectively with the difficult
issues that people present.
