PCN Social Prescribing Link Worker

Job description

Job responsibilities

The following are the core responsibilities of the Social Prescribing Link Worker. There may be, on occasion, a requirement to carry out other tasks. This will be dependent upon factors such as workload and staffing levels.

• Manage referrals from member GP practices and the PCN Anticipatory Care Team, applying tailored social prescribing approaches that reflect each patients needs and priorities.
• Proactively identify and work with patients, including those who are frail, elderly, or living with long-term conditions, to coordinate care and navigate support across health and social care services.
• Provide personalised support to patients, families, and carers to promote independence, improve quality of life, and support better health outcomes.
• Build trusting, empathetic relationships by focusing on what matters most to each patient, using a holistic, strengths-based approach that considers the wider determinants of health.
• Co-produce personalised support plans with patients, linking them to appropriate community groups, activities, and services to ensure timely access to the right support.
• Help patients address challenges such as debt, poor housing, unemployment, loneliness, and caring responsibilities that affect their health and wellbeing.
• Collaborate closely with GP practices and the wider PCN multidisciplinary team to ensure patients receive timely, coordinated support to manage their health and access relevant services.
• Facilitate access to community, statutory, and voluntary sector services, promoting care that reflects each patients preferences and supports their overall wellbeing.
• Support and strengthen local VCSE organisations to ensure they can safely and effectively receive social prescribing referrals.
• Educate clinical and non-clinical colleagues within the PCN on the local community support offer, advising on when and how patients can access it, and champion the value of non-medical interventions.
• Promote social prescribing across the PCN and with external agencies, highlighting its role in improving health outcomes, reducing inequalities, easing pressure on healthcare services, and supporting self-management.
• Act as a trusted source of guidance on wellbeing and preventative health, raising awareness of local resources and empowering individuals to take greater control of their health.
• Engage confidently and sensitively with individuals from diverse backgrounds, adapting approaches to reflect varied cultural, social, and environmental contexts.
• Maintain accurate, timely records and produce high-quality documentation in line with organisational and information governance standards.

KEY TASKS

Referrals

• Screen and accept or reject social prescribing referrals from PCN member practices in collaboration with the GP supervisor.
• Promote social prescribing as an approach across the PCN by attending relevant MDT meetings to build relationships and raise awareness.
• Proactively encourage equitable participation in social prescribing across the PCN, ensuring accessibility for diverse and underserved communities.

Provide personalised support

• Meet patients, families, and carers on a one-to-one basis, make home visits, and meet with community organisations where appropriate.
• Use appropriate judgement to ascertain the number and length of sessions required, responding to the needs of the individual and their circumstances.
• Give patients time to tell their stories and focus on the question, "What matters to me?".
• Build trust and respect with patients, providing non-judgemental and non-discriminatory support, taking a strengths-based approach that focuses on a patients assets.
• Work with patients, families, and carers and consider how they can all be supported through social prescribing.
• Help patients identify the wider issues that impact their health and wellbeing, such as debt, poor housing, unemployment, loneliness and caring responsibilities.
• Co-produce simple, personalised support plans based on patients priorities, interests, values, and cultural or religious needs.
• Clearly explain and provide information on the services, groups, and activities the patient is being connected to.
• Provide information on self-care approaches to improve health and wellbeing.
• Physically accompany patients to groups or services where appropriate, ensuring they feel comfortable, valued, and respected.
• Offer follow-up support to encourage ongoing engagement and ensure satisfaction.
• Help patients maintain or regain independence through skills training, adaptations, enablement approaches, and simple safeguards.
• Where patients 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 them to gain skills for meaningful employment, where appropriate.
• Provide support in the patients preferred language, either directly if fluent or through professional translation services such as Language Line or other approved interpreters.
• Seek advice and support from the GP supervisor and/or designated individuals to discuss safeguarding concerns and follow safeguarding policies around reporting and/or escalating concerns.
• Seek advice and support from the GP supervisor and/or designated individuals to discuss concerns outside the scope of practice.
• Make appropriate onward referrals where needed.

Supporting the community offer

• Develop strong, supportive relationships with local VCSE organisations, community groups, and services to understand their offerings and facilitate timely, appropriate, and well-supported referrals.
• Create strong links with local agencies to utilise existing networks and build on existing provision.
• Collaborate with local partners to ensure accessibility and sustainability of community groups.
• Work with commissioners and local partners to identify and share information on unmet diverse needs within the community and gaps in service provision.
• Support the development of community groups that promote diversity and inclusion.
• Encourage patients to volunteer or start their own groups after engaging with community support.
• Support existing local volunteering schemes to strengthen community resilience and explore potential to develop a team of volunteers to provide buddying support, peer support or to start new community-based groups or activities.

Data capture and feedback

• Support referral agencies to provide appropriate information about the patient they are referring, including demographic data and data on wider determinants, for example, caring status.
• Provide appropriate and timely feedback to referral agencies about the patients they referred.
• Work sensitively with patients, their families and carers to capture key information to measure the impact of social prescribing on their health and wellbeing, using validated tools determined locally such as the ONS4 wellbeing scale or MYCAW to assess needs and measure outcomes.
• Encourage patients, families, and carers to provide feedback on their experience, for example, through patient satisfaction surveys, and to share their stories about the impact of social prescribing on their lives.
• Ensure that social prescribing referral SNOMED codes are recorded appropriately into clinical systems (as outlined in the Network Contract DES).
• Adhere to organisational policies around data protection legislation and data sharing agreements, ensuring patients give appropriate consent.
• Collaborate as part of the MDT to gather feedback, drive continuous service improvement, and contribute to service planning.
• Assess patient and staff feedback to evaluate the quality of service and the impact of social prescribing.

Continuing professional development

• Undertake continual personal and professional development in line with the Social Prescribing Workforce Development Framework Competency Framework.
• Participate in regular supervision.
• Take an active role in reflecting, reviewing, and developing professional knowledge, skills and behaviours.
• Attend appropriate mandatory training before working with patients and be aware of own competence, maintaining boundaries around scope of practice and referring onwards for patients whose needs fall outside of these boundaries.
• Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training, and health and safety.

Person Specification

Experience

Essential

• Experience supporting individuals one-to-one and/or working with families and carers (paid or voluntary)
• Experience of working in community development, adult health and social care, learning support, or public health (paid or voluntary)
• Experience of working in a person-centred, empowering role (e.g. support work, advocacy, care coordination)
• Experience of partnership working and building relationships across organisations

Desirable

• Experience supporting individuals with complex social needs, long-term conditions, or mental health challenges
• Previous experience working as a PCN-based Social Prescribing Link Worker
• Experience of data collection and outcome measurement tools
• Experience of using EMIS Web, Docman, Accurx

Knowledge

Essential

• Understanding of the wider determinants of health (social, economic and environmental) and their effect on individuals, families, carers, and communities
• Knowledge of, and ability to work to, policies and procedures
• Knowledge of the personalised care approach

Desirable

• Local knowledge of VCSE organisations and services
• Understanding of community development approaches

Aptitudes

Essential

• Able to support patients in a way that builds trust and motivates them to reach their goals
• Polite, punctual, and cooperative
• Culturally sensitive and respectful of diverse backgrounds and lifestyles
• Compassionate in interactions with patients, carers, and colleagues
• Values aligned with person- and family-centred care
• Professional, tactful, and effective communicator
• Commitment to tackling health inequalities and engaging with underserved communities
• Demonstrates personal resilience and adaptability

Qualifications

Essential

• NVQ Level 3, Advanced Level, or equivalent qualifications, or working towards
• Demonstrable commitment to ongoing professional and personal development

Desirable

• PCI Social Prescribing Learning for Link Workers
• Training in motivational coaching and interviewing, or equivalent experience

Skills / Abilities

Essential

• Excellent communication, interpersonal and influencing skills
• Ability to actively listen and provide empathetic, person-centred, non-judgemental support
• Ability to manage sensitive and confidential information appropriately
• High attention to detail and ability to produce high-quality documentation
• Strong IT skills, including Microsoft Office (Word, Excel, PowerPoint)
• Effective time management with the ability to prioritise and manage multiple tasks
• Ability to work independently and use initiative
• Ability to maintain effective working relationships and promote collaborative practice with colleagues
• Commitment to collaborative working with all local agencies, including VCSE organisations, and community groups
• Awareness of when and how to refer individuals to other professionals or agencies when needs exceed the roles scope

Desirable

• Motivational coaching and interview skills
• Ability to define, collect, analyse, and interpret data
• Understanding of NHS Long Term Plan and priorities relevant to primary care
• Awareness of current issues facing primary care

Other Requirements

Essential

• Meets Disclosure and Barring Service (DBS) reference standards
• Ability to work and travel flexibly, including to visit patients in their own homes and support individuals to attend activities as appropriate
• Attendance at annual updates and mandatory training as required

Desirable

• Ability to speak an additional language/s relevant to the local population (e.g. Bengali)

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.

Employer details

Employer name

Camden Health Evolution Ltd

Address

Ampthill Practice

Crowndale Road

London

NW1 1TN

Employer's website

https://www.camdenhealthevolution.nhs.uk/ (Opens in a new tab)