Social Prescribing Link Worker @ Ely PCNs

Job summary

The post is a full-time post (37.5 hours) and the successful candidate will be deployed across any of the practices within Ely PCNs, depending on service need. It may also be necessary to provide cross-cover for annual leave, sickness and similar situations.

This job is about helping people work out what they need to improve their health and wellbeing; and then supporting them to make practical and realistic plans to change things for the better.

The role very much involves helping the person connect into their own local community networks of family, friends, and organisations, and helping the person navigate existing health and social care services when needed.

Over the last seven years, our Social Prescribing Link Workers have become key members of our GP Practice teams - highly valued and appreciated by the GPs and Practice team colleagues, and also by the frontline staff from other organisations working across the East Cambridgeshire Neighbourhood.

We have seven Social Prescribers in our team, one for each of our seven Network practices.

All Social Prescribers have regular support and supervision from our Lead Social Prescriber and Neighbourhood Practice Lead and are encouraged to develop their skills within the role.

Interviews will be held week commencing 7th December 2026.

Main duties of the job

The post-holder will work directly one-to-one with patients who need help with non-medical aspects of their lives. This will include supporting people with emotional, social and practical support, including:

• getting help with housing
• getting help with transport, mobility, and accessibility
• accessing advice around money, debt, and benefits
• managing forms and correspondence
• making meaningful social connections
• connecting with mental health services and social services
• maintaining healthy lifestyles, activities, and exercise
• finding and maintaining employment and meaningful activities
• getting help with activities of daily living and assistive technology
• Getting help with any family or caring responsibilities they may have.

The Social Prescriber is not expected to be expert in each and every area above, but is expected to be a skilled generalist: able to rapidly get a good understanding of the patients own views, needs, and wishes, know what help is available, and how to access it.

Furthermore, over time, Social Prescribers develop a detailed picture and understanding of their local community - what's available, what isn't, what works, and what doesn't and this intelligence helps identify areas of greatest need and the priorities for community development. Many of our Social Prescribers have had great success working with others to set up groups and activities in their local GP patches.

The above is not an exhaustive list.

About us

Primary Care Networks formed in 2019, grouping General Practices into local clusters, with the aim of supporting Practices and driving improvements in population health and wellbeing at a community level.

Ely PCNs are a network of seven of the eight GP Practices in East Cambridgeshire and, in total, look after over 90,000 patients registered at one of our seven GP Practices:

Ely North PCN

• Cathedral Medical Centre, Ely
• St Marys Surgery, Ely
• Priors Field Surgery, Sutton
• St Georges Medical Centre, Littleport

Ely South PCN

• Burwell Surgery, Burwell
• Haddenham Surgery, Haddenham
• Staploe Medical Centre, Soham

Working alongside the GP Practice teams, Ely PCNs support 50 staff, including Social Prescribers, First Contact Physios, Care Coordinators, Health and Wellbeing Coaches, a Recovery Coach, Pharmacy Technicians, and Clinical Pharmacists. Ely PCNs has a full-time manager, a Lead Nurse, and GP Leads for Diabetes, Frailty, Heart failure, and Mental Health.

We have two forward-thinking Clinical Directors and excellent relationships with our local partner organisations. We have a reputation as an innovative PCN that can successfully deliver.

Job description

Job responsibilities

The principle of Social Prescribing is to empower people to take control of their health and wellbeing.

Social Prescribing Link Workers are able to offer individuals time and information. They take a holistic approach to the persons health and wellbeing and help the person focus on what matters to them, and in the context of their local communities.

Link Workers will help connect people to community groups and statutory services for practical, social and emotional support, and work collaboratively with community partners to support existing and new groups to be accessible and sustainable.

Social prescribing can help PCNs to strengthen personal, and community, resilience. Increasing peoples active involvement with their local communities can reduce health and wellbeing inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity. This approach particularly works for people with long term conditions including support for mental health, for people who are lonely or isolated, or have complex social needs that affect their wellbeing.

Social Prescribers already working with the Ely PCNs have had a positive impact on Practices and patients and communities.

Key aspects of the role

• Provide personalised support to individuals, their families and carers to help them take control of their health and wellbeing, live independently and improve their health outcomes.
• Develop trusting relationships by giving people time and focus on what matters to me. Take a holistic approach, based on the persons priorities.
• Work with individuals, to co-produce a simple personalised support plan to address the persons health and wellbeing needs based on the persons priorities, interests, values and motivations.
• To take referrals from a wide range of agencies. These agencies might include for example PCN member-Practices and Practice multi-disciplinary teams; hospital discharge teams, allied health professionals, fire service, police, job centres, social care services, housing associations, and voluntary, community and social enterprise organisations.
• This is a community focused post. The post-holder will be expected to work with clients and colleagues in the community across East Cambridgeshire. As such, the post-holder will be expected to have access to their own vehicle.
• This is a hybrid role and will involve working from home, working from practices, attending meetings and working in the community depending on the needs of the service and the clients.
• All social prescribers are expected to attend every Wellness Hub / Solution Finding Group, in person. These run every other Tuesday afternoon and are held in Ely.
• The role will require managing and prioritising your own caseload, working both independently and as part of a team. 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 persons needs are beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner.
• Draw on and increase the strengths and capacities of local communities, enabling local VCSE organisations and community groups to receive social prescribing referrals.
• Alongside other members of the PCN multi-disciplinary team, work collaboratively with all local partners to contribute towards supporting the local VCSE organisations and community groups to become sustainable and that community assets are nurtured, through sharing intelligence regarding any gaps or problems identified in local provision with commissioners and local authorities.
• Social prescribing link workers will have a role in educating non-clinical and clinical staff within their PCN multi-disciplinary teams on what other services are available within the community and how and when patients can access them. This may include verbal or written advice and guidance.
• As part of the PCN multi-disciplinary team, build relationships with staff in GP practices within the local PCN, attending relevant MDT meetings, giving information and feedback on social prescribing.
• 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.
• 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.
• Be proactive in encouraging self-referrals and connecting with all local communities, particularly those communities that statutory agencies may find hard to reach.
• 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.
• Show an awareness of Mental Capacity Act principles, including the starting presumption of capacity and a persons right to make unwise decisions.
• Help people maintain or regain independence through living skills, adaptations, enablement approaches and simple safeguards.
• Seek advice and support from the GP supervisor and/or identified individual(s) to discuss patient-related concerns (e.g. abuse, domestic violence and support with mental health), referring the patient back to the GP or other suitable health professional if required.
• Forge strong links with local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a menu of community groups and assets.
• Support referral agencies to provide appropriate information about the person they are referring. Provide appropriate feedback to referral agencies about the people they referred.
• Work with commissioners and local partners to identify unmet needs within the community and gaps in community provision.

The above is not an exhaustive list and a job description / Person Specification is also attached in supporting documents.

Person Specification

Qualifications

Essential

• GCSE grade C or equivalent in Maths and English.

Desirable

• Evidence of further general education (eg further GCSE passes, A-Levels etc)
• Further training and qualifications relevant to the role.
• NVQ Level 3 in relevant role.

Additional criteria

Essential

• Satisfactory Enhanced DBS check.
• Satisfactory employment references.
• Access to own vehicle and ability to travel easily in the community.
• Willingness to work with people in the community and in their own homes.

Desirable

• Absence of referee concerns / client complaints.
• Willingness to work flexible hours when required to meet work demands.
• Good fit with the Practice and PCN teams.

Experience

Essential

• Two years experience of working in adult health and social care, or related sectors (e.g. learning support; community development; housing; public health sectors.) This can include voluntary work.

Desirable

• Experience of supporting people, their families and carers.
• Experience of working with the Voluntary, Community and Social Enterprise sector.
• Experience of volunteering or working with volunteers.
• Experience of supporting people with decision making as it relates to the Mental Capacity Act.
• Experience of partnership/collaborative working and of building relationships across a variety of organisations.
• Experience of data collection and using tools to measure the impact of services.

Personal Skills and Attributes

Essential

• Enthusiastic about supporting individuals and communities.
• Ethical, non-judgemental approach to working with people.
• Committed to equality, social inclusion, and strengths-based, person-centred approaches.
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders.
• Competent with commonly used IT systems (e.g. Email, MS office, MS Teams etc)
• Good social skills in formal and informal settings, maintaining ethical and organisational norms.
• Well-organised, diligent, Self-motivated and able to prioritise.
• Works well as part of a team.
• Can demonstrate personal accountability, emotional resilience and ability to work well under pressure.
• Dependable and a good time-keeper.
• Enthusiasm to continue to learn and develop.

Desirable

• Excellent communicator.
• Ability to build strong working relationships and can influence and motivate people.
• Ability to solve-problems and come up with innovative solutions.
• Advanced IT skills.

Knowledge

Essential

• Good understanding of patient confidentiality its importance and expectations.
• Broad knowledge of how the NHS, voluntary and statutory sector works, including primary care.
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities, individuals, their families and carers.
• Basic appreciation of the Mental Capacity Act.
• Understanding of the importance of accessible communication approaches.
• Basic knowledge of the Voluntary and Community Sector and community health and social care services in the locality.

Desirable

• Knowledge of the personalised care approach.
• Knowledge of community development approaches.
• Knowledge of IT systems, including ability to use word processing skills, emails and the internet to communicate with clients and colleague and create simple plans and reports.
• SystmOne or similar client record management software.
• More detailed knowledge of VCSE and community services in the locality.
• More advanced understanding of the Mental Capacity Act.

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

Ely PCNs

Address

Staploe Medical Centre

Brewhouse Lane

Soham

Cambridgeshire

CB7 5JD

United Kingdom

Employer's website

https://www.meresidemedical.nhs.uk/about/primary-care-networks/ (Opens in a new tab)