Job responsibilities
Aim of the role
The successful candidate's will be responsible for the delivery of social prescribing in a designated geographical/ service area with a focus on providing person- centred care to the most vulnerable patients within the London Borough of Tower Hamlets. This will include undertaking holistic assessments, personalised care and support planning and case management of individuals with the ultimate aim of empowering them to take control of their own health and wellbeing, thereby reducing demand on GP and hospital services. The Social Prescribing role requires knowledge and understanding of local services and the ability to promote these to both patients and health professionals.
The Social Prescribing role will require you to work across GP practices and / or other locations to enable equal access to a range of individuals. As the service evolves, the role may be based within 0-19-year services, Urgent Care, Community Health Services etc.
Key working relationships
- Internal: THGPCG Social Prescribing Manager, THGPCG Strategic Lead for Social Prescribing, THGPCG Social Prescribing Co-ordinator, Primary Care Network Managers, other Social Prescribers
- External: GP Practice Managers, GPs, Practice Nurses, administrative teams at GP Practices
- Other contacts:
- Service Leads for 0-19, CHS, Secondary Care (Cancer services), Urgent Care, community and voluntary sector service providers etc.
Key result areas
- The successful candidate will enable:
- Holistic and person-centred care planning for patients.
- More effective management of long-term conditions amongst patients engaging with the social prescriber.
- Empowered patients to make better health & wellbeing choices and access local resources.
- Increased engagement with and uptake of wider services.
- Reduced GP attendance and reduced admissions to A &E and secondary care.
- Health professionals having increased awareness of community and voluntary sector services.
- Good networks and relationships amongst local community organisations.
Main duties and responsibilities
- Work with patients on a one to one basis to identify holistic support needs and offer information and signposting to relevant local services.
- To undertake holistic assessments and co-design care plans with patients, focusing on what matters to me principles, identifying support needs to ensure maximum engagement in improving health and well-being.
- Work with individuals to co-produce a personalised support plan to address the persons health and wellbeing needs 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.
- To provide patients with continuity and a co-ordinated experience of care, remaining a point of contact throughout the individuals social prescription. This will include regular follow ups to ensure outcomes are being achieved and patients are supported with their action plans.
- Work with referral agencies to increase appropriate referrals into the service with a particularly focus to include patients with mild to moderate mental health-anxiety, depression or low mood and people who have long term conditions, frequent attenders and people who have wider or non- clinical support needs linked to wider determinants of health.
- Be proactive in encouraging self-referrals and connecting with all local communities, removing barriers particularly for those communities who may be under-represented in this service.
- 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.
- Provide regular feedback to referral agencies on the patients journey and outcomes.
- Continue to develop and maintain a relational network of local services: voluntary, statutory and faith. This can include regularly visiting them to facilitate appropriate referrals and details of service provision.
- To maintain information on local, regional and national services that local people can be referred to and to store this information on the internal shared resource so that the information is available service wide.
- Tap into existing local information sources and portals including the Information and Advice portal being developed by the Council and others within Tower Hamlets Together etc.
- Facilitate networking between primary and secondary care, community health services, 0-19 services and other statutory and voluntary provision to raise awareness of local offers and enable mutually beneficial working without duplication. This will include hosting and promoting regular breakfast networking meetings.
- Encourage patients 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.
- Active promotion of volunteering amongst patients as one of the routes to health and wellbeing.
- Where required you will support patients who need accompanying to services. This will include you accompanying patients to services where required.
- Participate in clinical multi-disciplinary team meetings to offer social prescribing solutions for complex patients.
- Attendance at relevant meetings within referring services to provide feedback on progress and to promote the Social Prescribing service.
- Seek regular feedback about the quality of service and impact of social prescribing on referral agencies.
- Take part in stalls/stands and exhibitions promoting Social Prescribing in the borough and wider.
- Provide quarterly monitoring information and case studies as required by the Social Prescribing Manager and Social Prescribing Co-ordinator within the service.
- Maintaining comprehensive data and evaluation systems, including outcome tools (ONS4).
- Working with the Social Prescribing Manager and Social Prescribing Co-ordinator to ensure that social prescribing codes are inputted into clinical systems as per NHSE guidance.
- Support the Social Prescribing Manager in collaborating with other community connector services in the Borough such as Care Navigators and Community Navigators in Idea Stores etc.
- To regularly take part in team meetings and supervision (including clinical supervision).
- Actively participate in service development initiatives.
- To complete statutory and mandatory training and other training identified by the service and actively participate in personal and professional development.
- To work flexibly as may be required by the needs of the service and carry out any other reasonable duties as required.
General for all employees
- These elements are standard for all employees of the Care Group.
Tower Hamlets GP Care Group values
All employees of the Care Group are expected to work in ways that demonstrate an understanding and commitment to our values, as follows:
- Working together for patients
Patients come first in everything we do
We value every person with respect: patients, families & carers and colleagues
We take responsibility and use our initiative to get the basics right every time such as safety, effectiveness and experience
We are kind and compassion to ourselves and others
We improve peoples health and wellbeing, giving them great experiences of our services
We are inclusive and we appreciate the rich diversity of our colleagues and our communities
- Performance management and appraisal
You are expected to participate in individual performance management process and reviews.
- Personal development and training.
We actively encourage development and are committed to offering learning and development opportunities for all full-time and part-time employees. To support this you must attend all statutory and mandatory training as required.
- Health and safety at work
You have a responsibility to work within Care Group health and safety policies and procedures to ensure that a safe working environment for patients, visitors and employees is maintained.
It is your responsibility to adhere to infection control polices and guidelines in order to promote cleanliness and reduce infections.
- Confidentiality and data protection
You are expected to comply with all Care Group policies and procedures related to confidentiality and data protection and to work in accordance with relevant data protection legislation.
You are expected to be familiar with the Care Group risk assessment and risk control processes and procedures and to report accidents or incidents promptly.
You are required to declare any interest, direct or indirect with contracts involving the Care Group and should not further your private interests in the course of your work with the Care Group.
We value equality and diversity in employment and in the services we provide. We will work hard to ensure that all job applicants, employees and service users are treated fairly and valued equally regardless of sex, marital status, domestic circumstances, age, race, colour, disablement, ethnic or national origin, social background or employment status, sexual orientation, religion, beliefs, HIV status, gender reassignment, political affiliation or trade union membership. You are responsible for understanding and adhering to Care Group policies and procedures regarding the promotion of equality for staff and service users.
You are expected to follow the Care Group code of conduct for employees and managers.
