The Confederation, Hillingdon CIC

PCN Social Prescribing Link Worker

The closing date is 09 July 2025

Job summary

Social prescribing empowers people to take control of their health & wellbeing through referral to link workers who give time, focus on what matters to me & take a holistic approach to an individuals health & wellbeing, connecting people to diverse community groups & statutory services for practical & emotional support. Link workers support existing groups to be accessible, sustainable & help people to start new community groups, working collaboratively with all local diverse partners.

Social prescribing link workers will work as a key part of the primary care network (PCN) multi-disciplinary team. Social prescribing can help PCNs to strengthen community & personal resilience, reduce health inequalities (in relation to timely access and outcomes) & wellbeing inequalities by addressing wider determinants of health, such as debt, poor housing & physical inactivity, by increasing peoples active involvement with their local diverse communities. In particularly for people with long term conditions (including support for mental health), people who are lonely/isolated, or have complex social needs which affect their wellbeing.

The successful candidate will manage a caseload of clients through assessment to onward-referral, working with clients in the practice that have been referred by the GP. Providing ongoing support over an allocated timeframe.

Main duties of the job

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.

About us

The Confederation, Hillingdon 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:

We work together to make a difference for patients
We care enough to go the extra mile
We support, trust, and empower
We sincerely value each other
We support Primary Care to own its destiny

Date posted

25 June 2025

Pay scheme

Other

Salary

£30,000 to £38,000 a year Dependent on Experience

Contract

Permanent

Working pattern

Full-time

Reference number

E0004-25-0040

Job locations

1A, Civic Centre, High Street

Uxbridge

Middlesex

UB8 1UW

Job description

Job responsibilities

Key Tasks:

Referrals:

• Promote social prescribing, its role in self-management, addressing health inequalities and the wider determinants of health.

• As part of the PCN multi-disciplinary team, build relationships with staff in GP practices within the local PCN, attending relevant MDT meetings, giving information and feedback on social prescribing.

• Be proactive in developing strong links with all local agencies to encourage referrals, recognising what they need to be confident in the service to make appropriate referrals.

• To work inclusively with the Primary Care Networks member practices, The Confederation, H4All and other members of the multi-disciplinary team.

• Work in 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.

• Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals.

• Seek regular feedback about the quality of service and impact of social prescribing on referral agencies.

• Be proactive in 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

• Meet people on a 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.

• To undertake 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.

• Be a friendly and engaging source of information about health, 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 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.

• Act as the bridge 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.

• 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.

• Seek advice and 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

Community Development:

• Forge strong 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.

• Develop 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

• Work with 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.

• Encourage people 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.

• Encourage people, their families and carers to provide peer support and to do things together, such as setting up new community groups or volunteering.

• To ensure that the Link Worker programme is integrated into Hillingdon’s well-established social prescribing programme, delivered by H4All.

Measuring Effectiveness:

• Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing.

• Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives.

• Support referral agencies to provide appropriate information about the person they are referring. Provide appropriate feedback to referral agencies about the people they referred.

• Work closely 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.

Professional development:

• Work with your 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.

• Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.

• Work with your 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.

Miscellaneous:

• Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning.

• Contribute to the development of policies and plans relating to equality, diversity and health inequalities.

• 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.