Social Prescribing Link Worker

1. Job Purpose The Social Prescribing Link Worker will work as part of the Primary Care Network (PCN) multidisciplinary team to deliver personalised care in line with NHS England ARRS guidance. The post holder will support individuals to improve their health and wellbeing by addressing wider determinants of health, including social, emotional, practical, and financial factors. This includes proactive work with patients identified through: Risk stratification QOF requirements including 3-month cancer reviews GP and MDT referrals The role contributes to: Improved patient outcomes and experience Reduction in health inequalities Proactive and preventative care Reduction in avoidable GP workload 2. Key Responsibilities 2.1 Personalised Care & Social Prescribing Manage referrals from GPs, MDTs, and external agencies. Undertake holistic assessments using a person-centred what matters to you approach. Co-produce personalised care and support plans. Support individuals to access community, voluntary, statutory, and health services. Provide interventions via face-to-face, telephone, digital, and home visits. 2.2 QOF Cancer 3-Month Reviews Support delivery of QOF cancer care indicators, particularly 3-month post-diagnosis reviews. Work alongside clinicians to: o Contact patients following a cancer diagnosis o Offer holistic needs conversations o Identify non-clinical needs (e.g. emotional wellbeing, finances, transport, carers support) Develop personalised support plans following diagnosis. Signpost to: o Cancer support services o Community groups o Welfare and benefits advice Ensure accurate coding and documentation to support QOF achievement. 2.3 Risk Stratification & Proactive Care Work with PCN teams to support patients identified through risk stratification tools e.g. high-intensity users, frailty cohorts, complex needs. Proactively engage patients to: o Prevent deterioration o Improve self-management o Reduce hospital admissions and GP attendances Support delivery of personalised care for: o Frail patients o Patients with multiple long-term conditions o Frequent attenders Contribute to anticipatory care planning where appropriate. 2.4 Behaviour Change & Patient Activation Use recognised techniques: o Motivational interviewing o Health coaching o Goal setting Support individuals to increase confidence, resilience, and independence. Provide follow-up support to sustain engagement. 2.5 Community Development & Partnership Working Maintain an up-to-date directory of local services and assets. Build strong relationships with: o Voluntary and community sector o Social care and statutory services Promote social prescribing pathways across the PCN. 2.6 MDT Working Participate in MDT meetings (e.g. frailty, complex care, cancer reviews). Provide updates on patient progress and outcomes. Support integrated care planning. 2.7 Addressing Health Inequalities Proactively engage underserved populations. Encourage self-referrals and outreach. Ensure culturally appropriate support. 2.8 Data, Outcomes & Quality Maintain accurate records and coding. Capture outcomes using validated tools. Support reporting for: o QOF o DES requirements o PCN performance Collect patient feedback and evidence impact. ________________________________________ 3. Governance & Professional Responsibilities Work within ARRS role specification. Adhere to safeguarding, GDPR, and information governance. Escalate concerns appropriately. Participate in supervision, appraisal, and CPD. Maintain confidentiality, dignity, and professional boundaries. Flexibility Clause The duties of this role may evolve in line with PCN priorities, ARRS guidance, QOF, and DES requirements. Job description Job responsibilities 1. Job Purpose The Social Prescribing Link Worker will work as part of the Primary Care Network (PCN) multidisciplinary team to deliver personalised care in line with NHS England ARRS guidance. The post holder will support individuals to improve their health and wellbeing by addressing wider determinants of health, including social, emotional, practical, and financial factors. This includes proactive work with patients identified through: Risk stratification QOF requirements including 3-month cancer reviews GP and MDT referrals The role contributes to: Improved patient outcomes and experience Reduction in health inequalities Proactive and preventative care Reduction in avoidable GP workload 2. Key Responsibilities 2.1 Personalised Care & Social Prescribing Manage referrals from GPs, MDTs, and external agencies. Undertake holistic assessments using a person-centred what matters to you approach. Co-produce personalised care and support plans. Support individuals to access community, voluntary, statutory, and health services. Provide interventions via face-to-face, telephone, digital, and home visits. 2.2 QOF Cancer 3-Month Reviews Support delivery of QOF cancer care indicators, particularly 3-month post-diagnosis reviews. Work alongside clinicians to: o Contact patients following a cancer diagnosis o Offer holistic needs conversations o Identify non-clinical needs (e.g. emotional wellbeing, finances, transport, carers support) Develop personalised support plans following diagnosis. Signpost to: o Cancer support services o Community groups o Welfare and benefits advice Ensure accurate coding and documentation to support QOF achievement. 2.3 Risk Stratification & Proactive Care Work with PCN teams to support patients identified through risk stratification tools e.g. high-intensity users, frailty cohorts, complex needs. Proactively engage patients to: o Prevent deterioration o Improve self-management o Reduce hospital admissions and GP attendances Support delivery of personalised care for: o Frail patients o Patients with multiple long-term conditions o Frequent attenders Contribute to anticipatory care planning where appropriate. 2.4 Behaviour Change & Patient Activation Use recognised techniques: o Motivational interviewing o Health coaching o Goal setting Support individuals to increase confidence, resilience, and independence. Provide follow-up support to sustain engagement. 2.5 Community Development & Partnership Working Maintain an up-to-date directory of local services and assets. Build strong relationships with: o Voluntary and community sector o Social care and statutory services Promote social prescribing pathways across the PCN. 2.6 MDT Working Participate in MDT meetings (e.g. frailty, complex care, cancer reviews). Provide updates on patient progress and outcomes. Support integrated care planning. 2.7 Addressing Health Inequalities Proactively engage underserved populations. Encourage self-referrals and outreach. Ensure culturally appropriate support. 2.8 Data, Outcomes & Quality Maintain accurate records and coding. Capture outcomes using validated tools. Support reporting for: o QOF o DES requirements o PCN performance Collect patient feedback and evidence impact. ________________________________________ 3. Governance & Professional Responsibilities Work within ARRS role specification. Adhere to safeguarding, GDPR, and information governance. Escalate concerns appropriately. Participate in supervision, appraisal, and CPD. Maintain confidentiality, dignity, and professional boundaries. Flexibility Clause The duties of this role may evolve in line with PCN priorities, ARRS guidance, QOF, and DES requirements.