The North Southall Primary Care Network (PCN) is looking to recruit a social prescriber to support the residents of North Southall to take control of their health and wellbeing, gives time, focuses on ‘what matters to me’ and takes a holistic approach to an individual’s health and wellbeing.
This role will be employed by Ealing GP Federation on behalf of the North Southall PCN.
Social prescribing link workers will also work as a key part of the primary care network (PCN) multi-disciplinary team. Social prescribing can help PCNs to strengthen community and personal resilience and reduces health and wellbeing inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity, by increasing people’s active involvement with their local communities. It particularly works for people with long term conditions (including support for mental health), for people who are lonely or isolated, or have complex social needs which affect their wellbeing.
The successful candidate will work to develop and engage a Network-wide patient participation group, aiming to deliver lifestyle promotion talks and activities such as walking groups, gardening clubs, etc, as identified by the Network members, with a view to enriching the lives of patients and improving their health and wellbeing. In recognition of the size of the network, we accept that a hub-based model for the delivery of these services may be necessary.
- Working under supervision of the core network member practices i.e. the GPs, practice managers and the network manager, take referrals from the network practices.
- Provide support to individuals, their families and carers to take control of their health and wellbeing, live independently and improve their health 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 person’s priorities and the wider determinants of health.
- Work with patients to produce a simple personalised care and support plan to improve health and wellbeing, introducing or reconnecting people to community groups and statutory services.
- Proactively identify and arrange locality-based wellbeing events to improve the general health of patients in the North Southall Network. Have the ability to think laterally, to offer suggestions in discussion with the core group, as to lead at such events.
- Refer people and/or introduce them to appropriate organisations in Ealing and nationally (where appropriate) e.g. voluntary, statutory (local authority) and local NHS organisations.
- 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 person’s needs are beyond the scope of the link worker role – e.g. when there is a mental health need requiring a qualified practitioner.
- Social prescribing link workers will have a role in educating non-clinical and clinical staff within The Network’s multi-disciplinary teams on what services are available in the local area and how and when people can access them. This may include verbal or written advice and guidance.
- Provide progress and performance reports to the North Southall Network Core Group e.g. caseload monitoring reports, outcomes seen within people and families any cross-organisational barriers experiences and other reports as determined by The Network.
- Promote social prescribing, its role in self-management, 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.
- 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 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 self-referrals and connecting with all local communities, particularly those communities that statutory agencies may find hard to reach.
Provide personalised support
- Where the Network anticipates that much of the work will be group based, to physically introduce people to community groups, activities and statutory services. The social prescriber may be required to arrange such well-being events, where they do not already exist, in conjunction with local services and VCSEs.
- Follow up to ensure they are happy, able to engage, included and receiving good support.
- Be a friendly 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 where necessary 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 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.
- 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.
- If necessary assist/facilitate a GP appointment for the delivery of healthcare and attend with the person/family if appropriate.
- Make 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 with the person, providing non-judgemental support, respecting diversity and lifestyle choices. Work from a strength-based approach focusing on a person’s assets.
Support community groups and VCSE organisations to receive referrals
- Develop supportive relationships with local VCSE organisations, 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 needs within the community and gaps in community 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.
- In the long term develop a team of volunteers within your service to provide ‘buddying support’ for people, starting new groups and finding creative community solutions to local issues.
- Encourage people, their families and carers to provide peer support and to do things together, such as setting up new community groups or volunteering.
- 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, and health and safety.
- Work with your supervising GPs, practice managers and network managers to access regular ‘supervision’, to enable you to deal effectively with the difficult issues that people present.
- Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning.
- 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.
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