Social Prescribing Link Worker

Job summary

Thereis wide recognition that peoples healthis determined primarily by a range of social, economic and environmentalfactors. The NHS has published a boldnew vision for Social Prescribing, a relatively new function within PrimaryCare that seeks to address peoples needs in a non-medicalised way,focusing on What Matters to Me to agree personalised care plans, and thensupport individuals to take greater control of their health, by connecting themtodiverse community groups and statutory services for both practical andemotional support.

Anexisting team of social prescribers have already been working with Primary Careto provide social prescribing. Thisscheme is highly valued and we are looking to expand the existing capacity andenhance the role to encompass more complex case load, and integrate withexisting clinical teams to work on preventative health projects

PrimaryCare Networks were established in 2019 as part of NHS Englands longterm plan to enable services to work collaboratively to meet the needs ofpatients. As Primary Care Networks are becoming the vehicle of change for mostprimary care services, the NHS recognised the need to evolve other services andintegrate Primary Care Networks into a newly formed Integrated Care System.Integrated care systems are geographically based partnerships that bringtogether providers and commissioners of NHS services with local authorities andother local partners to plan, co-ordinate and commission health and care.

Main duties of the job

Working within practices to assess and allocatereferrals from a wide range of agencies, including GP practices andmulti-disciplinary teams

Working with practices and patients to be a representativewithin the newly forming Integrated Care System.

Handle your own caseload of more complex cases

Support practices undertaking and deliveringelements of health and social care population health projects

Supporting the service specifications detailed inthe PCN DES contract.

Promote the service and educate relevant parties

Oversee the data, reporting and evaluation of theservice to strive for continuous improvement and community development

About us

Southend East PCN is located at Norton Place in Shoebury, along Ness Road. We have our own PCN building which is extremely active and is in use by our 5 member practices in the local area. We cover approx 37,000 patients and offer a range of appointments from our wide range of staff, fully utilising the ARRS budget. Our team consists of pharmacists, pharmacy technicians, social prescribers, health trainers, paramedics, physiotherapists and assistant practitioners. We have 2 clinical directors who are partners in two local surgeries, and an operations manager to provide support wherever needed. We have a strong digital presence and have employed a Digital Transformational Lead, to help our PCN network with other businesses and mature over time.

Job description

Job responsibilities

Purpose of Role

Thereis wide recognition that peoples healthis determined primarily by a range of social, economic and environmentalfactors. The NHS has published a boldnew vision for Social Prescribing, a relatively new function within PrimaryCare that seeks to address peoples needs in a non-medicalised way,focusing on What Matters to Me to agree personalised care plans, and thensupport individuals to take greater control of their health, by connecting themtodiverse community groups and statutory services for both practical andemotional support.

Anexisting team of social prescribers have already been working with Primary Careto provide social prescribing. Thisscheme is highly valued and we are looking to expand the existing capacity andenhance the role to encompass more complex case load, and integrate withexisting clinical teams to work on preventative health projects

PrimaryCare Networks (PCNs) were established in 2019 as part of NHS Englands longterm plan to enable services to work collaboratively to meet the needs ofpatients. As Primary Care Networks are becoming the vehicle of change for mostprimary care services, the NHS recognised the need to evolve other services andintegrate Primary Care Networks into a newly formed Integrated Care System.Integrated care systems are geographically based partnerships that bringtogether providers and commissioners of NHS services with local authorities andother local partners to plan, co-ordinate and commission health and care.

Main Responsibilities.

Working within practices to assess and allocatereferrals from a wide range of agencies, including GP practices andmulti-disciplinary teams

Working with practices and patients to be a representativewithin the newly forming Integrated Care System.

Handle your own caseload of more complex cases

Support practices undertaking and deliveringelements of health and social care population health projects

Supporting the service specifications detailed inthe PCN DES contract.

Promote the service and educate relevant parties

Oversee the data, reporting and evaluation of theservice to strive for continuous improvement and community development

KeyTasks

Assessand Allocate Referrals:

The PCN Social prescriber will reviewall referrals and allocate appropriate referrals to:

A programme ofself care

Hold own case loadof complex cases

Introduce orcoordinate an appropriate group support session

Make referrals directlyto external providers DWP, VSC, Help Hub

Managededicated caseload of complex cases:

Develop trustingrelationships, giving individuals time and focus on what matters to them.

Supportindividuals to identify the wider issues that impact their health andWellbeing, such as debt, poor housing, unemployment, isolation and caringresponsibilities.

Co-produce asimple personalised care and support plan to improve health and wellbeing.

Where appropriateintroduce individuals to appropriate community groups, activities and statutoryservices, ensuring they feel comfortable, valued and respected.

Hold 1-1appointment with individuals at the most appropriate location to meetindividual needs, making home visits where appropriate within Southend East PCN Limited policies and procedures.

Work withindividuals their families and carers to maintain or regain independencethrough living skills, adaptations, enablement and simple safeguards.

Have an awarenessand understanding of when it is appropriate or necessary to refer individualsback to other health professionals/agencies, when there are additional needssuch as mental health that requires a trained practitioner.

Where people areeligible for a personal health budget, support them to explore this option as away of providing funding to enhance personalised support, to be independent andgain skills for meaningful employment, where appropriate.

Seek advice andsupport from the GP supervisor to discuss patient related concerns ( abuse,domestic violence and support with mental health) referring back to the GP orother suitable health professional.

Supportpopulation health management projects:

Work as part ofthe PCN project team to pilot new ways of working in response to populationhealth data, delivering any aspect relating to social prescribing, and advisingon community and voluntary sector services that should be included in the solution

Supportthe implementation of the PCN service specifications:

Work with the PCNto develop the service where individuals require social prescribing activity,or advice regarding available community and additional activity other than thatalready undertaken within the role.

Promotethe service to wider partners:

Be proactive indeveloping strong links with the PCN practice teams to encourage referrals andraise awareness on what other services are available within the community andhow patients can access them

Expanding thereferral criteria to include wider agencies such as; pharmacies, hospital discharge teams, allied healthprofessionals, fire service, job centers, social care services, housingassociations, VCSE organisations, the list is not exhaustive.

Work inpartnership with all local agencies to educate and raise awareness of socialprescribing and how partnership working can reduce pressure on statutoryservices.

Provide referralagencies with regular updates about social prescribing, including trainingtheir staff and how to access information, and seek their feedback

Be proactive inencouraging equality and inclusion, through self-referrals and connecting withall diverse local communities particularly those that statutory agencies mayfind hard to reach.

Enable local VCSEorganisations and community groups including faith groups to receive socialprescribing referrals. Working collaboratively to support community and localVCSE organisations to become sustainable

Work withcommissioners and local partners to identify unmet diverse needs within thecommunity and gaps in community provision.

Encourageindividuals their families and carers to provide peer support and do thingstogether such as setting up new community groups or volunteering.

Overseethe data capture, reporting and evaluation for the service

By workingsensitively with individuals, their families and carers, use a suitableevaluation tool to capture key information to demonstrate the impact of socialprescribing on their health and wellbeing.

Encourageindividuals, their families and carers to provide feedback and to share theirpersonal stories about the impact of social prescribing on their lives.

Work closelywithin the multi-disciplinary team to ensure relevant data is capturedefficiently throughout the process and relevant reports are completed andreviewed

Work as part ofthe healthcare team to seek feedback and continually improve the service andcontribute to business planning

ProfessionalDevelopment

Work with GPsupervisor and line manager to undertake continual personal and professional development,taking an active part in reviewing and developing the roles andresponsibilities

Adhere to organisationalpolicies and procedures, including; confidentiality, safeguarding, loneworking, information governance, equality, diversity and inclusion training andhealth and safety.

Work with the GP Supervisor to access regularclinical supervision to enable them to deal effectively with the difficultissues that people present.

Person Specification

ARRS Requirements

Essential

has completed the NHS England and online learning programme accessed via the Personalised Care Institute website is enrolled in, undertaking or qualified from appropriate training as outlined by the Personalised Care Institute Core Curriculum and social prescribing link worker competency framework attends the peer support networks delivered at place or system by the ICS in the region

Experience

Essential

Experience of dealing with vulnerable patients Good knowledge of the local area and the range of voluntary and community services that are available

Desirable

Experience with Systmone Experience in Primary Care

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