About this role
Job summary
Are you looking for a rewarding and impactful role within Primary Care? Do you have a passion for empowering individuals, strengthening community resilience, and tackling health inequalities at a local level?
We are seeking a dedicated and motivated Social Prescribing Link Worker to join our Primary Care Network (PCN) multidisciplinary team, working across our five member practices.
This is an exciting opportunity to play a vital role in delivering personalised, person-centred support that makes a real difference to peoples lives.
As a Social Prescribing Link Worker, you will adopt a holistic approach to care, working closely with individuals to understand their unique needs and priorities. You will support people to improve their health and wellbeing by addressing the wider determinants of health, including social, emotional, practical, and financial challenges.
By building strong relationships and working collaboratively with local community groups, voluntary organisations, and statutory services, you will connect individuals to a range of support that enhances wellbeing, reduces isolation, and promotes independence.
If you are passionate about making a meaningful difference, we would love to hear from you.
This role involves visiting people in their own homes and in the community. A driving licence and own vehicle is essential. You may be required to work from any of PCN practices.
This job may close earlier than the date provided subject to applications.
Main duties of the job
At Hartlepool Network PCN , you manage and prioritise a diverse and, at times, complex caseload, connecting people to community based services and support networks, addressing the wider determinants of health to reduce inequalities. You will work collaboratively with General Practice and PCN colleagues to deliver co-ordinated , person centred support, while contributing to wider service delivery. This includes supporting PCN and practice initiatives such as annual reviews, participating in the development and implementation of projects to improve population health outcomes including working with colleagues within Neighbourhood Teams.
About us
Hartlepool Network PCN is a collaborative partnership of five established practices: West Quay Medical Practice, West View Millennium Surgery, Seaton Surgery, Gladstone House Surgery and Hart Medical Practice. Together, we serve a diverse population of approximately 35,000 patients across the Hartlepool locality.
We are a friendly, supportive and forward-thinking organisation, committed to delivering high-quality, person-centred care.
Our PCN team includes Social Prescribers, Care Coordinators, First Contact Physiotherapists, a Mental Health team, and Pharmacy professionals. We work collaboratively across services, fostering a positive and inclusive environment.
We are committed to continuous development, staff wellbeing and innovation, creating a workplace where you can thrive while making a meaningful difference to the local community.
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.
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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.
Person Specification
Qualifications Essential
GCSEs (or equivalent) in English and Maths Level 3 qualification in health, social care, community development, or a related field (or equivalent work experience) Where no Level 3 qualification is held (e.g., A Level or equivalent post-16 education), must be enrolled in or undertaking appropriate training or an apprenticeship to obtain a Level 3 occupational standard accredited by the Personalised Care Institute for Social Prescribing Link Workers, in line with the Workforce Development Framework for Social Prescribing Link Workers Demonstrable commitment to professional and personal development
Desirable
Training in motivational coaching and interviewing or equivalent experience
Personal Qualities and Attributes Essential
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 wellbeing facilitator role e.g. when there is a mental health need requiring a qualified practitioner 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, mental health organisations, community groups and faith organisations). 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
Desirable
Understanding of the needs of small volunteer-led community groups and ability to support their development
Other Essential
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
Skills & Knowledge Essential
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
Desirable
Knowledge of community development approaches Knowledge of motivational coaching and interview skills Knowledge of VCSE and community services in the locality Knowledge of SystmOne Clinical System
Experience Essential
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 working with the VCSE sector (in a paid or unpaid capacity), including with volunteers and small community groups
Desirable
Experience of partnership/collaborative working and of building relationships across a variety of organisations 2 years experience working as a social prescribing link worker/care co-ordinator in a similar role.
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 Hartlepool Network
Address West View Millenium Surgery
West View Road
Hartlepool
TS24 9LJ
United Kingdom
Employer's website https://www.seatonsurgery.co.uk/ (Opens in a new tab)