Job summary
We are looking for a dedicated and proactive Social Prescriber/Care Coordinator to join our team at Woodseats Medical
Centre and support the delivery of personalised, coordinated, and holistic
care. This role is designed to help patients navigate the health and care
system, improve their wellbeing, and access the right services at the right
time.
The postholder will work closely with clinical
and non-clinical colleagues to ensure that individuals receive timely, targeted
support, reduces health inequalities, and meets the needs of at-risk patient
groups.
Main duties of the job
- Proactively identify and work with individuals, including the elderly, frail, and those living with long-term conditions.
- Provide navigation of care and support across health, social, and community services.
- Focus on delivering personalised care aligned with local objectives and population health priorities.
- Run clinical system searches on SystmOne to meet targeted goals and identify patients for recall or intervention.
- Ensure patients are contacted and directed to appropriate services based on clinical alerts, call/recall policies, or care plans.
About us
We are a six GP Partner Practice with a practice population over 12,700 patients and this is increasing.
We are a high achieving QOF Practice with an emphasis on providing individual personalised tailored care to our patients many of whom we have looked after since childhood. We strive to offer the best care available to our patient population meeting our vision of:
"Always striving to provide the highest quality of health care and support to our local community"
"Each and every patient matters"
Job description
Job responsibilities
Key Responsibilities:
Care Coordination & Social Prescribing:
- Develop person-centred care plans that reflect individual needs, preferences, and aspirations.
- Refer and signpost patients to a range of non-clinical services, such as social support groups, community initiatives, housing advice, and wellbeing programs.
- Support people to become more confident in managing their own health and social needs.
- Liaise with GPs, nurses, allied health professionals, and social care teams to coordinate care delivery.
- Promote patient self-management, choice, and empowerment through motivational conversations and health coaching techniques.
- Follow up with patients and services to monitor progress and address any barriers to engagement.
Clinical System & Performance Support:
- Run clinical system searches to support population health management, including long term condition reviews.
- Contact patients as part of recall systems for QOF, IIF, vaccination, and long-term condition reviews.
- Monitor practice performance against QOF, IIF, enhanced services, and other relevant metrics.
- Extract key clinical information from hospital letters and correspondence, ensuring accurate coding into patient records.
Job description
Job responsibilities
Key Responsibilities:
Care Coordination & Social Prescribing:
- Develop person-centred care plans that reflect individual needs, preferences, and aspirations.
- Refer and signpost patients to a range of non-clinical services, such as social support groups, community initiatives, housing advice, and wellbeing programs.
- Support people to become more confident in managing their own health and social needs.
- Liaise with GPs, nurses, allied health professionals, and social care teams to coordinate care delivery.
- Promote patient self-management, choice, and empowerment through motivational conversations and health coaching techniques.
- Follow up with patients and services to monitor progress and address any barriers to engagement.
Clinical System & Performance Support:
- Run clinical system searches to support population health management, including long term condition reviews.
- Contact patients as part of recall systems for QOF, IIF, vaccination, and long-term condition reviews.
- Monitor practice performance against QOF, IIF, enhanced services, and other relevant metrics.
- Extract key clinical information from hospital letters and correspondence, ensuring accurate coding into patient records.
Person Specification
Qualifications
Essential
- - Experience in a health, social care, or community-based role.
- - GCSE grade C or above or equivalent in English and Maths
- - Strong communication and interpersonal skills with a person-centred approach.
- - Understanding of the wider determinants of health and barriers to accessing care.
- - Confidence using clinical systems (e.g., EMIS or SystmOne), with ability to run searches and manage data.
- - Ability to organise, prioritise, and manage a varied workload.
- - High attention to detail with commitment to confidentiality and data accuracy.
- - Willingness to undertake appropriate clinical and safeguarding training.
Desirable
- - Experience in primary care or working with vulnerable or complex patient populations.
- - Familiarity with QOF, IIF, and population health management tools.
- - Training in motivational interviewing, health coaching, or care navigation.
Person Specification
Qualifications
Essential
- - Experience in a health, social care, or community-based role.
- - GCSE grade C or above or equivalent in English and Maths
- - Strong communication and interpersonal skills with a person-centred approach.
- - Understanding of the wider determinants of health and barriers to accessing care.
- - Confidence using clinical systems (e.g., EMIS or SystmOne), with ability to run searches and manage data.
- - Ability to organise, prioritise, and manage a varied workload.
- - High attention to detail with commitment to confidentiality and data accuracy.
- - Willingness to undertake appropriate clinical and safeguarding training.
Desirable
- - Experience in primary care or working with vulnerable or complex patient populations.
- - Familiarity with QOF, IIF, and population health management tools.
- - Training in motivational interviewing, health coaching, or care navigation.
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.
