PCN Social Prescribing Link Worker - Over 65s

Morecambe Bay Primary Care Collaborative


This job is now closed

Job summary

Kendal Primary Care Network consists of 3 practices serving a population of nearly 38,000 patients. We are looking for someone to support the work of the 3 GP practices in Kendal.

We already employ 2 experienced Social Prescribers and we are looking to expand this team by employing a Social Prescriber to work with our older patients in particular.

The successful candidate will be involved in the identification, assessment, and support of older patients with complex health or social needs. You will help them to identify and engage with their GP practice and local services to improve their long term health and wellbeing, be involved in them creating a Personalised Care Plan that will best meet their needs, and you will assess the impact of the support that has been given.

Main duties of the job

The successful candidate will have experience of working with older patients and a background in social or health care. You will be enthused by the prospect of working in a new role and have the skills to develop care pathways and drive change. You will enjoy working with people with complex needs on a one to one basis, be experienced at assessing risk and capacity, and be clear what can and cant be done within the boundaries of this developing role.

You will identify and work with charitable and volunteer organisations, promoting their services to your patients as well as advising practice staff on the support available.

About us

Kendal PCN is a forward thinking and dynamic Primary Care Network, who seeks to deliver clinical excellence and patient care to our patient population, and we seek like-minded individuals to join our excellent clinical team.

For further information please contact matt.loveland@nhs.net.

Job description

Job responsibilities

Key responsibilities

1. Take referrals from any of the practices within Kendal Primary Care Network.

2. Provide personalised support to individuals, their families and carers to take control of their wellbeing, live independently and improve their health outcomes. Develop trusting relationships by giving people time and focus on what matters to me.

3. Take a holistic approach, based on the persons priorities and the wider determinants of health. Co-produce a personalised support plan to improve health and wellbeing, introducing or reconnecting people to community groups and statutory services.

4. 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 needs is beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner.

5. Draw on and increase the strengths and capacities of local communities, enabling local Voluntary, Community, and Social Enterprise (VCSE) organisations and community groups to receive social prescribing referrals. Ensure they are supported, have safeguarding processes for vulnerable individuals and can provide opportunities for the person to develop friendships, a sense of belonging, and build knowledge, skills and confidence.

6. Work together with all local partners to collectively ensure that local VCSE organisations and community groups are sustainable and that community assets are nurtured, by making them aware of small grants or micro-commissioning if available, including providing support to set up new community groups and services, where gaps are identified in local provision.

Key Tasks


1. Promoting social prescribing, its role in self-management, and the wider determinants of health.

2. 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.

3. 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.

4. 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.

5. Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals.

6. Seek regular feedback about the quality of service and impact of social prescribing on referral agencies.

7. Be proactive in encouraging referrals and connecting with all local communities, particularly those communities that statutory agencies may find hard to reach.

Provide Personalised Support

1. Meet people on a one-to-one basis, making 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 persons assets

2. Be a friendly source of information about wellbeing and prevention approaches.

3. Help people identify the wider issues that impact on their health and wellbeing, such as debt, poor housing, being unemployed, loneliness and caring responsibilities.

4. Work with the person, their families and carers and consider how they can all be supported through social prescribing.

5. Help people maintain or regain independence through living skills, adaptations, enablement approaches and simple safeguards.

6. 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.

7. 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.

Support community groups and VCSE organisations to receive referrals

1. 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.

2. Develop supportive relationships with local VCSE organisations, community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced.

3. 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.

4. 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.

5. Support local groups to act in accordance with information governance policies and procedures, ensuring compliance with the Data Protection Act.

Work collectively with all local partners to ensure community groups are strong and sustainable

1. Work with commissioners and local partners to identify unmet needs within the community and gaps in community provision.

2. Support local partners and commissioners to develop new groups and services where needed, through small grants for community groups, micro-commissioning and development support.

3. 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

4. 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.

5. Encourage people, their families and carers to provide peer support and to do things together, such as setting up new community groups or volunteering.

6. 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.

General tasks

Data capture

1. 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.

2. Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives.

3. 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.

4. Work closely with GP practices within the PCN to ensure that social prescribing referral codes are inputted to EMIS and 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

1. Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities.

2. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.

3. Work with your line manager to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present.


1. Work as part of the team to seek feedback, continually improve the service and contribute to business planning.

2. 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.

3. Duties may vary from time to time, without changing the general character of the post or the level of responsibility.

Person Specification

Skills & knowledge


  • Knowledge of the personalised care approach
  • Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities
  • Knowledge of IT systems, including ability to use word processing skills, emails and the internet to create simple plans and reports


  • Knowledge of community development approaches
  • Knowledge of motivational coaching and interview skills
  • Knowledge of VCSE and community services in the locality



  • Experience of working directly in a community development context, adult health and social care, learning support or public health/health improvement (including unpaid work)
  • Experience of supporting people, their families and carers in a related role (including unpaid work)


  • Experience of supporting people with their mental health, either in a paid, unpaid or informal capacity
  • Experience of using tools and resources that support effective family relationships
  • Experience of working with the VCSE sector (in a paid or unpaid capacity), including with volunteers and small community groups
  • Experience of data collection and providing monitoring information to assess the impact of services
  • Experience of partnership/collaborative working and of building relationships across a variety of organisations



  • Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions
  • Willingness to work flexible hours when required to meet work demands
  • Access to own transport and ability to travel across the locality on a regular basis, including to visit people in their own homes



  • NVQ Level 3, Advanced level or equivalent qualifications or working towards
  • Demonstrable commitment to professional and personal development


  • Training in motivational coaching and interviewing or equivalent experience

Personal Qualities & Attributes


  • Ability to listen, empathise with people and provide person-centred support in a non-judgemental way
  • Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
  • Commitment to reducing health inequalities and proactively working to reach people from all communities
  • Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
  • Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
  • 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 back to other health professionals/agencies, when what the person needs is beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner
  • Able to work from an asset based approach, building on existing community and personal assets
  • Able to provide leadership and to finish work tasks
  • Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
  • Commitment to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues
  • Demonstrates personal accountability, emotional resilience and works well under pressure
  • Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
  • High level of written and oral communication skills
  • Ability to work flexibly and enthusiastically within a team or on own initiative
  • Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety


  • Understanding of the needs of small volunteer-led community groups and ability to support their development

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

Morecambe Bay Primary Care Collaborative


Moor Lane Mills

Moor Lane




Employer's website

https://mbpcc.co.uk/ (Opens in a new tab)

For questions about the job, contact:

Hazel Donegan



Date posted

13 July 2021

Pay scheme



£21,892 to £27,416 a year



Working pattern

Full-time, Flexible working

Reference number


Job locations

Moor Lane Mills

Moor Lane








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