Job summary This role will support Huntingdon PCN which covers 4 GP Practices and have a patient population of just under 47,000 patients. Social prescribing empowers people to take control of their health and wellbeing through referral or direct access to non-medical link workers who give time, focus on what matters to me and take a holistic approach, connecting people to community groups and statutory services for practical and emotional support. Link workers support existing groups to be accessible and sustainable and help people to start new community groups, working collaboratively with all local partners. Social prescribing can help to strengthen community resilience, personal resilience, and reduces health inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity, by increasing peoples 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. Main duties of the job 1. Take referrals, provide consultations with people (and possibly carers or appointed chaperone) within GP Practices, private addresses, public places & community settings 2. Assessing patient needs, evaluating risk & providing welfare checks. Providing personalised support to individuals, their families & carers to take control of their wellbeing & improve their health outcomes. 3. Develop trusting relationships by giving people time & focus on what matters to me. 4. Co-produce a personalised support plan to improve health and wellbeing. 5. Integrate into & form part of General Practice/Primary Care Network teams 6. Liaise & communicate with Patients, Carers, Advocates, Health and Social Care professionals, voluntary sector & stake-holders involved the wellbeing of your caseload and communities. 7. Be proactive in developing strong links with all local organisations. 8. Build relationships with key staff, attending relevant meetings, becoming part of the wider network team, providing caseload reports, case studies and feedback on social prescribing. 9. Managing & prioritising your own caseload, in accordance with the needs, priorities & any urgent support required by individuals on the caseload. 10. Accurately recording patient details & your contact with patients on clinical systems. Discussing complex cases & raising safeguarding issues as required. 11. Attending clinical supervision & peer support networks. Regularly reviewing patient case load & individual patient care plans. About us Huntingdon PCNs vision is to bring GP practices together with other local services to provide the best care in the right place. This role will support Huntingdon PCN which covers 4 GP Practices and have a patient population of just under 47,000 patients. Our values are: Integrity - We promise to conduct ourselves with the upmost integrity, staying open and honest with colleagues and patients. Empathy - We strive to take perspective of and feel emotions of another person, taking action to alleviate stress and pain of others showing kindness and care in our approach. Putting ourselves in other peoples shoes, both patients and colleagues, establishing anempathetic connection. Empowerment - We seek to champion positive relationships and build trust whilst empowering others Date posted 02 April 2025 Pay scheme Other Salary Depending on experience Approximately £25 - £30k dependent on Experience Contract Permanent Working pattern Full-time, Flexible working, Home or remote working Reference number W0017-25-0000 Job locations Huntingdonshire District Council St. Marys Street Huntingdon Cambridgeshire PE29 3TN Acorn Surgery 1 Oak Dr Huntingdon PE29 7HN The Surgery Chequers Lane Cambridge CB23 3QQ Roman Gate Surgery 1 Pinfold Lane Godmanchester Huntingdon Cambridgeshire PE29 2JH Charles Hicks Centre 75 Ermine Street Huntingdon Cambridgeshire PE29 3EZ Priory Fields Doctors Surgery Nursery Road Huntingdon Cambridgeshire PE29 3RL Job description Job responsibilities KEY TASKS REFERRALS Promoting social prescribing, its role in self-management, and the wider determinants of health. Build relationships with key staff in GP practices within the local Primary Care Network (PCN), attending relevant meetings, becoming part of the wider network team, 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 teams within the PCN 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 PROVIDE PERSONALISED SUPPORT 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 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 (if relevant) 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. SUPPORTING COMMUNITY GROUPS Forge strong links with local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a map or menu of community groups and assets. Use these opportunities to promote micro-commissioning or small grants if available. Develop supportive relationships with local VCSE organisations, community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced. Ensure that local community groups and VCSE organisations being referred to have basic procedures in place for ensuring that vulnerable individuals are safe and, where there are safeguarding concerns, work with all partners to deal appropriately with issues. Where such policies and procedures are not in place, support groups to work towards this standard before referrals are made to them. Check that community groups and VCSE organisations meet in insured premises and that health and safety requirements are in place. Where such policies and procedures are not in place, support groups to work towards this standard before referrals are made to them. Support local groups to act in accordance with information governance policies and procedures, ensuring compliance with the Data Protection Act. WORKING COLLABORATIVELY Support local partners and commissioners to develop new groups and services where needed, through small grants for community groups, micro-commissioning and development support. Encourage people who have been connected to community support through social prescribing to volunteer and give their time freely to others, in order to build their skills and confidence, and strengthen community resilience. 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. Provide a regular confidence survey to community groups receiving referrals, to ensure that they are strong, sustained and have the support they need to be part of social prescribing. DATA CAPTURE 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. Use the case management system to track the persons progress. Provide appropriate feedback to referral agencies about the people they referred. Work closely with GP practices within the PCN to ensure that social prescribing referral codes are inputted to SystmOne (GP Clinical database) so that the persons use of the NHS can be tracked, adhering to data protection legislation and data sharing agreements with the clinical commissioning group (CCG). PROFESSIONAL DEVELOPMENT Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety. Work with your line manager to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present. Work as part of the 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. RECORD KEEPING, INFORMATION COLLECTION AND COMMUNICATION To ensure data recorded (by post holder and by those staff supervised by post holder) on all electronic systems conforms to necessary policies, processes and protocols. To be responsible for the accurate maintenance of clinical record keeping and the required communication of individual patient care packages for which the post holder has responsibility. To be responsible for the accurate recording of information relating to the patients in receipt if care as determined by the PCNs operational policies or when directed by the Clinical Director. DEVELOPMENT AND SUPERVISION Participate in clinical audits and research as necessary to own work. Provide the day to day supervision and direction of junior staff as allocated by the Clinical Director. To measure own personal goals ensuring they align to the wider PCN goals and strategic objectives. To assist service projects as and when required. PROFESSIONAL AND PCN POLICIES The post holder must comply with all national, statutory, legislative, professional and local policy. The post holder should proactively contribute to improve local policy and any changes to improve service or protocols. To be responsible for the application in practice of the PCNs policies and procedures and the limit of the authority and responsibility the post holder has within these. To operate within the PCNs standing financial instructions and their application to financial and physical resources. Job description Job responsibilities KEY TASKS REFERRALS Promoting social prescribing, its role in self-management, and the wider determinants of health. Build relationships with key staff in GP practices within the local Primary Care Network (PCN), attending relevant meetings, becoming part of the wider network team, 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 teams within the PCN 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 PROVIDE PERSONALISED SUPPORT 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 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 (if relevant) 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. SUPPORTING COMMUNITY GROUPS Forge strong links with local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a map or menu of community groups and assets. Use these opportunities to promote micro-commissioning or small grants if available. Develop supportive relationships with local VCSE organisations, community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced. Ensure that local community groups and VCSE organisations being referred to have basic procedures in place for ensuring that vulnerable individuals are safe and, where there are safeguarding concerns, work with all partners to deal appropriately with issues. Where such policies and procedures are not in place, support groups to work towards this standard before referrals are made to them. Check that community groups and VCSE organisations meet in insured premises and that health and safety requirements are in place. Where such policies and procedures are not in place, support groups to work towards this standard before referrals are made to them. Support local groups to act in accordance with information governance policies and procedures, ensuring compliance with the Data Protection Act. WORKING COLLABORATIVELY Support local partners and commissioners to develop new groups and services where needed, through small grants for community groups, micro-commissioning and development support. Encourage people who have been connected to community support through social prescribing to volunteer and give their time freely to others, in order to build their skills and confidence, and strengthen community resilience. 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. Provide a regular confidence survey to community groups receiving referrals, to ensure that they are strong, sustained and have the support they need to be part of social prescribing. DATA CAPTURE 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. Use the case management system to track the persons progress. Provide appropriate feedback to referral agencies about the people they referred. Work closely with GP practices within the PCN to ensure that social prescribing referral codes are inputted to SystmOne (GP Clinical database) so that the persons use of the NHS can be tracked, adhering to data protection legislation and data sharing agreements with the clinical commissioning group (CCG). PROFESSIONAL DEVELOPMENT Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety. Work with your line manager to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present. Work as part of the 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. RECORD KEEPING, INFORMATION COLLECTION AND COMMUNICATION To ensure data recorded (by post holder and by those staff supervised by post holder) on all electronic systems conforms to necessary policies, processes and protocols. To be responsible for the accurate maintenance of clinical record keeping and the required communication of individual patient care packages for which the post holder has responsibility. To be responsible for the accurate recording of information relating to the patients in receipt if care as determined by the PCNs operational policies or when directed by the Clinical Director. DEVELOPMENT AND SUPERVISION Participate in clinical audits and research as necessary to own work. Provide the day to day supervision and direction of junior staff as allocated by the Clinical Director. To measure own personal goals ensuring they align to the wider PCN goals and strategic objectives. To assist service projects as and when required. PROFESSIONAL AND PCN POLICIES The post holder must comply with all national, statutory, legislative, professional and local policy. The post holder should proactively contribute to improve local policy and any changes to improve service or protocols. To be responsible for the application in practice of the PCNs policies and procedures and the limit of the authority and responsibility the post holder has within these. To operate within the PCNs standing financial instructions and their application to financial and physical resources. Person Specification Qualifications Essential Educated to GCSE level or equivalent NVQ Level 2 in Health and Social Care or other relevant professional experience Desirable Health & Well-being qualification Training in motivational coaching and interviewing or equivalent experience. Personal Qualities and Attributes Essential Polite and confident Ability to listen, empathise with people and provide person-centred support in a non-judgemental way Ability to get along with people from all backgrounds and communities, respecting lifestyles and diversity Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential Ability to work flexibly and enthusiastically within a team or on own initiative Motivated Forward thinker 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 to other health professionals/agencies e.g. when there is a mental health need requiring a qualified practitioner High levels of integrity and loyalty, ability to maintain effective working relationships and to promote collaborative practice with all colleagues Knowledge of and ability to work to policies and procedures Aware of NHS policies of confidentiality, safeguarding, lone working, information governance, and health and safety Ability to plan and prioritise on own initiative, including when working under pressure and meeting deadlines Demonstrate commitment to continuous professional development. Experience Essential Experience of working with the general public Experience of working in a healthcare setting or in the leisure industry / public / voluntary sector Desirable Experience of delivering lifestyle changes interventions Experience of working with vulnerable people Experience of working as a health advisor / trainer Experience of partnership/collaborative working and of building relationships across a variety of organisations Skills Essential General understanding of personalised care, well-being, community services and developments. Good understanding of interventions, behavioural and motivational change methodologies Good understanding of social prescribing Knowledge and understanding of environmental factors, and their impact on communities. Person Specification Qualifications Essential Educated to GCSE level or equivalent NVQ Level 2 in Health and Social Care or other relevant professional experience Desirable Health & Well-being qualification Training in motivational coaching and interviewing or equivalent experience. Personal Qualities and Attributes Essential Polite and confident Ability to listen, empathise with people and provide person-centred support in a non-judgemental way Ability to get along with people from all backgrounds and communities, respecting lifestyles and diversity Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential Ability to work flexibly and enthusiastically within a team or on own initiative Motivated Forward thinker 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 to other health professionals/agencies e.g. when there is a mental health need requiring a qualified practitioner High levels of integrity and loyalty, ability to maintain effective working relationships and to promote collaborative practice with all colleagues Knowledge of and ability to work to policies and procedures Aware of NHS policies of confidentiality, safeguarding, lone working, information governance, and health and safety Ability to plan and prioritise on own initiative, including when working under pressure and meeting deadlines Demonstrate commitment to continuous professional development. Experience Essential Experience of working with the general public Experience of working in a healthcare setting or in the leisure industry / public / voluntary sector Desirable Experience of delivering lifestyle changes interventions Experience of working with vulnerable people Experience of working as a health advisor / trainer Experience of partnership/collaborative working and of building relationships across a variety of organisations Skills Essential General understanding of personalised care, well-being, community services and developments. Good understanding of interventions, behavioural and motivational change methodologies Good understanding of social prescribing Knowledge and understanding of environmental factors, and their impact on communities. 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. Employer details Employer name Huntingdon PCN Address Huntingdonshire District Council St. Marys Street Huntingdon Cambridgeshire PE29 3TN Employer's website https://www.huntingdonpcn.nhs.uk/ (Opens in a new tab)