Wantage Primary Care Network rQ4xNPqu
Key responsibilities include taking referrals from various agencies, providing one-on-one support to individuals and their families, helping them identify and address social determinants that affect their health, and fostering relationships with local organisations to enhance community offerings. The Social Prescriber will also engage in community development efforts and data collection to measure the impact of services, while adhering to data protection regulations. This role is crucial for empowering patients to take control of their health through holistic, community-focused interventions.
Wantage Primary Care Network is establishing a new Integrated Neighbourhood Team (INT). Integrated neighbourhood teams play a part in bringing statutory services together to work more effectively with voluntary and community organisation to support our local population.
The aim and purpose of this new INT is to provide a one-stop service to support cohorts of patients with specific health needs to help them stay well for longer.
We are looking to recruit a Social Prescriber to work as part of our INT and practice teams.
Social prescribing empowers people to take control of their health and wellbeing through referral to non-clinical social prescribing link workers. They give people time to focus on what matters to me and take a holistic approach to an individuals health and wellbeing. Social Prescribers play a pivotal role by developing trusting relationships and providing personalised care and support plans.
You will be used to working in a multidisciplinary environment, with changing priorities and challenges. The role will require you to manage and prioritise your own caseload, in accordance with the needs, priorities, including and any urgent support required, by patients as well as assisting them to access other services.
Social prescribing empowers people to take control of their health and wellbeing through referral to non-clinical social prescribing link workers.
Social prescribers give people time to focus on what matters to me and take a holistic approach to an individuals health and wellbeing.
Referrals to the Social Prescriber will be via the INT clinics but also from the practice teams, including GPs, nurses, frailty practitioners, care co-ordinators. You will manage your own caseload and follow up with patients as appropriate. This could be by phone, face to face at the health centre, home visits or in the community including outlying villages, therefore access to your own transport is important as we have a large population of over 34k patients.
About us
Social prescribing link workers take a whole population approach, working with a range of people who may benefit from social prescribing, including people who are lonely, have complex social needs, low level mental health needs and long-term conditions. Help people to identify issues that affect their health & wellbeing, and co-produce a simple personalised care and support plan. Support people by connecting them to non-medical, community-based activities, groups and services that meet their practical, social and emotional needs, including specialist advice services and arts and culture, physical activity, and nature and green based activities. Use coaching and motivational interviewing techniques to support people to take control of their own health and wellbeing. Support development of accessible and sustainable community offers by working in partnership with VCSE organisations, local authorities and others to identify gaps in provision, and take a community development approach to enabling growth in community activities and groups.
Key Responsibilities -Take referrals from the PCNs Core Network Practices and from a wide range of agencies, including pharmacies, health and care multi-disciplinary teams (MDTs), the emergency services, legal and welfare advice services, VCSE organisations, and through self-referrals (list not exhaustive).Provide personalised support to individuals, their families and carers to access community-based activities and support that can help them to take control of their health and wellbeing through co-producing a simple personalised care and support plan and introducing people to appropriate activities, groups and services as described above. Work with appropriate supervision as part of the PCN to manage and prioritise your own caseload, in accordance with needs, priorities and support required by individuals. Refer people back to other health professionals/agencies, as appropriate or necessary. Build ongoing relationships with local infrastructure organisations, community activities and support services to increase knowledge of the community support offer, and work collaboratively to develop effective partnership working to support the community offer to be sustainable, identifying gaps in provision, nurturing community assets and sharing intelligence on gaps or problems with commissioners and local authorities. Increase the strength and capacity of the community, enabling local VCSE organisations and community groups to both receive social prescribing referrals and to make referrals to social prescribing link workers. Educate non-clinical and clinical staff within PCN MDTs on the community support offer, how and when patients can access it, and the value of non-medical community-based interventions. This may include verbal or written advice and guidance. Promote social prescribing as an approach across the PCN and wider agencies, including its role in supported self-management, in addressing health inequalities and the wider determinants of health, reducing pressure on statutory services, improving access to healthcare and improving health outcomes, and in taking a holistic approach to care.
Key Tasks Referrals -Promote social prescribing as an approach across the PCN by attending relevant MDT meetings to build relationships and developing links with local agencies. Proactively develop strong links with local agencies to encourage appropriate referrals. 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. Proactively encourage equitable participation in social prescribing through taking self-referrals and connecting with diverse local communities through a range of methods, particularly communities that statutory agencies may find hard to reach and where health inequalities are most prevalent.
Provide personalised support -Meet people on a one-to-one basis, making home visits and visits to community organisation where appropriate and within organisations policies and procedures. Use appropriate judgement to ascertain the number and length of sessions required, responding to the needs of the individual and their circumstances, for approximately 6-12 contacts over 3 months. Give people time to tell their stories and focus on the question, what matters to me? Build trust and respect with the person, providing non-judgemental and non-discriminatory support, taking a strength-based approach that focuses on a persons assets. Work with the person, their families and carers and consider how they can all be supported through social prescribing. 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 individuals to co-produce a simple personalised support plan to address the persons health and wellbeing needs based on the persons priorities, interests, values, cultural and religious/faith needs and motivations. Provide information on what people can from the groups, activities and services they are being connected to. Provide information on what the person can do for themselves to improve their health and wellbeing. Physically introduce people to appropriate community groups and activities, peer support groups, or statutory services, ensuring they are comfortable, feel valued and respected. Provide follow up support to the person to ensure they are happy, able to engage, feel included and that they are receiving good support. Help people maintain or regain independence through living skills, adaptations, enablement approaches and simple safeguards. 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 safeguarding concerns and follow PCN safeguarding policies around reporting and/or escalating concerns. Seek advice and support from the GP supervisor and/or identified individual(s) to discuss concerns outside the scope of the social prescribing link workers practice and make appropriate onward referrals.
Supporting the community offer -Develop supportive relationships with local VCSE organisations, community groups and statutory services, to understand their offer and make timely, appropriate and supported referrals. Create strong links with local agencies to utilise existing networks and build on existing provision. Work collectively with all local partners to ensure community groups are accessible and sustainable. Work with commissioners and local partners to identify and share information on unmet diverse needs within the community and gaps in community provision. Support development of community groups and assets who promote diversity and inclusion. Encourage people who have been connected to community support through social prescribing to volunteer or to start their own activities and group. 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 -Support referral agencies to provide appropriate information about the person 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 people they referred. Work sensitively with people, their families and carers to capture key information to measure impact of social prescribing on their health and wellbeing, using validated tools determined locally such as the ONS4 wellbeing scale to assess need and measure outcomes. Encourage people, their 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 coded appropriately into clinical systems (as outlined in the Network Contract DES). Adhere to PCN policies around data protection legislation and data sharing agreements, ensuring people give appropriate consent.
Miscellaneous -Work as part of the MDT to seek feedback, continually improve the service, and contribute to service planning. Contribute to the development of policies and plans relating to equality, diversity and inclusion, accessibility, 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.
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