Job summary
Calder & Ryburn Primary Care Network (PCN) consist of four GP practices and have a combined patient list of over 43000 patients. We have grown as a collaborative PCN over the past five years and now have over 30 members of staff working across the PCN.
Calder & Ryburn PCN are looking for a self-motivated individual to join our growing
personalised care team. The team currently consists of care coordinators and social prescribing link workers who all work in GP practices across the PCN supporting patients from within the PCN footprint.
Main duties of the job
- Undertake work in line with PCN directed priorities.
- Facilitating transport options to enable attendance at surgery (efficient use of primary care services), support groups and social schemes.
- Interrogate Practice records to identify patients where the biggest impact could be made, in line with PCN priorities.
- Be practice based and work proactively to empower people to take control of their health and wellbeing, enhancing self-management, active care navigation by receptionists and a greater understanding within practice and by patients of alternative options and support outside of practice available to them.
- Establish a clear referral pathway from practices within the PCN and for self-referral from patients registered with practices in the PCN.
- Build and maintain and understanding of existing social prescribing and navigational services available, together with their remit and referral criteria to support collaborative working.
- Work collaboratively with all relevant local organisations, in line with direction from the PCN.
- Provide personalised support to individuals, their families, and carers to take control of their wellbeing, live independently and improve their health outcomes.
- 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.
About us
Pennine GP Alliance is a member-led organisation made up of 19 GP
practices in Calderdale who form 5 Primary Care Networks (PCNs), collectively
serving over 223,000 registered patients.
We work extremely closely with general practice but also in
partnership with other local healthcare providers with a purpose to ensure
viable GP services remain at the heart of local communities, providing
sustainable and high-quality patient-focused healthcare.
Join our team and experience a workplace that truly values growth,
collaboration, and impact. We take pride in fostering a supportive and
inclusive environment where every team member is encouraged to listen, learn,
and lead. Together were dedicated to delivering better outcomes for GP
practices, and ultimately for the people of Calderdale.
At our organisation, your professional growth matters we are
committed to providing the resources and opportunities you need for continuous
development, ensuring you thrive both in your role and your career.
We look forward to receiving your application to join our team of
over 100 employees.
Job description
Job responsibilities
- Develop, manage, and update care plans within the GP clinical system used in the general practice (EMIS or SystmOne)
- 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 need is beyond the scope of the social prescribing link worker role e.g., when there is a physical or mental health need requiring a qualified practitioner.
- Maintain a record of action and outcome that can be used for case studies and to keep practices and the PCN informed.
- Promoting social prescribing, its role in self-management and active care navigation, and the wider determinants of health with practices in the PCN and wider.
- Build relationships with key staff in GP practices within the local PCN, attending relevant meetings, becoming part of the wider network team, giving information and feedback on social prescribing, how to access the service and make appropriate referrals.
- Be proactive in developing strong links with all local statutory and third sector organisations as appropriate, working in partnership with local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health outcomes and enable a holistic approach to care.
- Be proactive in encouraging self-referrals and connecting with all local communities, particularly those communities that statutory agencies may find hard to reach.
- Meet people on a one-to-one basis. Give people time to tell their stories and focus on what matters to me. Build trust with the person, providing non- judgemental support, respecting diversity and lifestyle choices. Work from a strength-based approach focusing on a persons assets.
- Be a friendly source of information about self-management, 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 based on the persons priorities, interests, values 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 community groups, activities and statutory services, ensuring they are comfortable. 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.
- Work closely with GP practices within the PCN to ensure that social prescribing referral codes are inputted to EMIS and SystmOne and that the persons use of the NHS can be tracked, adhering to data protection legislation and data sharing agreements.
- Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities.
- Adhere to Pennine GP Alliance policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
- Adhere to practice (when practice based) policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
- Work with your line manager to access regular supervision.
- Undertake all necessary training recommended for the role. Adhere to the mandatory training programme ensuring training is completed on time and be proactive about seeking additional training that is required for the role.
- 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.
- To work flexibly in line with the needs of service, including some occasional early morning, evening, or weekend work.
- You will work as part of a team but will also frequently work unsupervised and using your own autonomy.
- To maintain up to date knowledge of legislation, national and local policies and issues in relation to the specific client group, mental health and community care delivery.
- To comply with the Professional Codes of Conduct and to be aware of changes in these.
- To maintain up to date knowledge of all relevant legislation and local policies and procedures implementing this.
- To ensure that all duties are carried out to the highest standard and in accordance with currently quality initiatives within the work area.
- To comply with all relevant organisations policies, procedures, and guidelines, including those relating to Equal Opportunities, Health and Safety and Confidentiality of Information and to be aware of any changes in these.
- To comply at all times with the PGPAs Information Governance related policies.
- Staff are required to respect the confidentiality of information about staff, patients and PGPA business and in particular the confidentiality and security of personal identifiable information in line with the Data Protection Act.
- All staff is responsible for ensuring that any data created by them is timely, comprehensive, accurate, and fit for the purposes for which it is intended.
Job description
Job responsibilities
- Develop, manage, and update care plans within the GP clinical system used in the general practice (EMIS or SystmOne)
- 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 need is beyond the scope of the social prescribing link worker role e.g., when there is a physical or mental health need requiring a qualified practitioner.
- Maintain a record of action and outcome that can be used for case studies and to keep practices and the PCN informed.
- Promoting social prescribing, its role in self-management and active care navigation, and the wider determinants of health with practices in the PCN and wider.
- Build relationships with key staff in GP practices within the local PCN, attending relevant meetings, becoming part of the wider network team, giving information and feedback on social prescribing, how to access the service and make appropriate referrals.
- Be proactive in developing strong links with all local statutory and third sector organisations as appropriate, working in partnership with local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health outcomes and enable a holistic approach to care.
- Be proactive in encouraging self-referrals and connecting with all local communities, particularly those communities that statutory agencies may find hard to reach.
- Meet people on a one-to-one basis. Give people time to tell their stories and focus on what matters to me. Build trust with the person, providing non- judgemental support, respecting diversity and lifestyle choices. Work from a strength-based approach focusing on a persons assets.
- Be a friendly source of information about self-management, 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 based on the persons priorities, interests, values 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 community groups, activities and statutory services, ensuring they are comfortable. 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.
- Work closely with GP practices within the PCN to ensure that social prescribing referral codes are inputted to EMIS and SystmOne and that the persons use of the NHS can be tracked, adhering to data protection legislation and data sharing agreements.
- Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities.
- Adhere to Pennine GP Alliance policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
- Adhere to practice (when practice based) policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
- Work with your line manager to access regular supervision.
- Undertake all necessary training recommended for the role. Adhere to the mandatory training programme ensuring training is completed on time and be proactive about seeking additional training that is required for the role.
- 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.
- To work flexibly in line with the needs of service, including some occasional early morning, evening, or weekend work.
- You will work as part of a team but will also frequently work unsupervised and using your own autonomy.
- To maintain up to date knowledge of legislation, national and local policies and issues in relation to the specific client group, mental health and community care delivery.
- To comply with the Professional Codes of Conduct and to be aware of changes in these.
- To maintain up to date knowledge of all relevant legislation and local policies and procedures implementing this.
- To ensure that all duties are carried out to the highest standard and in accordance with currently quality initiatives within the work area.
- To comply with all relevant organisations policies, procedures, and guidelines, including those relating to Equal Opportunities, Health and Safety and Confidentiality of Information and to be aware of any changes in these.
- To comply at all times with the PGPAs Information Governance related policies.
- Staff are required to respect the confidentiality of information about staff, patients and PGPA business and in particular the confidentiality and security of personal identifiable information in line with the Data Protection Act.
- All staff is responsible for ensuring that any data created by them is timely, comprehensive, accurate, and fit for the purposes for which it is intended.
Person Specification
Qualifications
Essential
- NVQ Level 3, advanced level or equivalent qualifications or experience.
- Training in motivational coaching and interview or equivalent.
Desirable
- Training in Cognitive behavioural therapy (CBT).
Other Requirements
Essential
- Flexibility to work outside core office hours.
- Disclosure Barring Service (DBS) check.
- Maintain confidentiality at all times.
- Full UK driving licence.
Personal Qualities
Essential
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- Able to work from an asset-based approach, building on existing personal assets. Able to provide leadership and to finish work tasks in a timely manner.
- Able to work with others to reduce hierarchies and find creative solutions.
- Demonstrates personal accountability, emotional resilience and works well under pressure.
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
- High level of written and oral communication skills.
- Demonstratable commitment to professional and personal development.
Skills
Essential
- Proven ability to listen, empathise with people and provide person-centred support in a non-judgemental way.
- Commitment to reducing health inequalities and proactively working to reach people from all communities.
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Ability to identify risk and assess/manage risk when working with individuals.
- 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 person needs is beyond the scope of the social prescribing link worker role, e.g., when there is a mental health need requiring a qualified practitioner.
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues in PGPA, PCN and wider system.
- Commitment to collaborative working with all local statutory and third sector statutory and third sector organisations organisation avoiding duplication but adding value.
- Ability to work flexibly and enthusiastically within a team or on own initiative, whilst understanding when its important to refer to line manager.
Experience
Essential
- Experience of getting along with people from all backgrounds and communities, respecting lifestyles and diversity.
- Experience of working directly in a community development context, adult health, and social care, learning support or public health/health improvement (including unpaid work).
- Experience of supporting people, their families, and carers in a related role (including unpaid work).
- Experience of partnership/collaborative working and of building relationships across a variety of organisations.
Desirable
- Experience of working with or in a general practice.
- Experience of supporting people with their mental health, either in a paid, unpaid, or informal capacity.
- Experience of data collection and providing monitoring information to assess the impact of services.
Person Specification
Qualifications
Essential
- NVQ Level 3, advanced level or equivalent qualifications or experience.
- Training in motivational coaching and interview or equivalent.
Desirable
- Training in Cognitive behavioural therapy (CBT).
Other Requirements
Essential
- Flexibility to work outside core office hours.
- Disclosure Barring Service (DBS) check.
- Maintain confidentiality at all times.
- Full UK driving licence.
Personal Qualities
Essential
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential.
- Able to work from an asset-based approach, building on existing personal assets. Able to provide leadership and to finish work tasks in a timely manner.
- Able to work with others to reduce hierarchies and find creative solutions.
- Demonstrates personal accountability, emotional resilience and works well under pressure.
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines.
- High level of written and oral communication skills.
- Demonstratable commitment to professional and personal development.
Skills
Essential
- Proven ability to listen, empathise with people and provide person-centred support in a non-judgemental way.
- Commitment to reducing health inequalities and proactively working to reach people from all communities.
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
- Ability to identify risk and assess/manage risk when working with individuals.
- 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 person needs is beyond the scope of the social prescribing link worker role, e.g., when there is a mental health need requiring a qualified practitioner.
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues in PGPA, PCN and wider system.
- Commitment to collaborative working with all local statutory and third sector statutory and third sector organisations organisation avoiding duplication but adding value.
- Ability to work flexibly and enthusiastically within a team or on own initiative, whilst understanding when its important to refer to line manager.
Experience
Essential
- Experience of getting along with people from all backgrounds and communities, respecting lifestyles and diversity.
- Experience of working directly in a community development context, adult health, and social care, learning support or public health/health improvement (including unpaid work).
- Experience of supporting people, their families, and carers in a related role (including unpaid work).
- Experience of partnership/collaborative working and of building relationships across a variety of organisations.
Desirable
- Experience of working with or in a general practice.
- Experience of supporting people with their mental health, either in a paid, unpaid, or informal capacity.
- Experience of data collection and providing monitoring information to assess the impact of 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.
