Do you care passionately about the health and
wellbeing of the people of Downham, Grove Park and Catford? We are seeking an innovative motivator so
that Sevenfields Primary Care Network (PCN) can develop and deliver new approaches
to tackling the social causes of ill health that are patient focused and enable
patients to resolve the challenges they face.
The post holder will have a key role in supporting our work through supporting patients to tackle the issues underlying their ill health, money issues, health issues, social issues and much more.
The post holder will also work closely with allied community health and social care workers and will support service integration work around mental health, social care, community nursing and the voluntary sector.
This role may involve working with specific grounds (i.e. children and young people) depending on the applicants experience. 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.
The post holder will be employed by Sevenfields PCN and the role is offered with working hours of 37.5 hours per week (part time work or job sharing will be considered).
Sevenfields PCN is one of the largest PCNs (of six) in Lewisham and is seeking to be a key driving force for improving community health and wellbeing in the neighbourhood. Our PCN is made up of 6 GP Practices serving a population of around 70,000 patients. We are led by a local GP who performs the role of Clinical Director - Dr Helen Tattersfield (Oakview Family Practice).
Our local population is somewhat older than other parts of Lewisham and contains several large care homes. It includes areas of extreme socioeconomic deprivation and the PCN is keen to find innovative ways of addressing the health challenges that accompany this.
Job description
Job responsibilities
Duties and
Responsibilities
Working with direct supervision by the
lead social prescriber, take referrals from PCNs GP practices and
multi-disciplinary teams, and working closely with PCNs for the benefit of the
local population.
Discuss the persons needs with them,
based on guidance from the referrer, and identify a range of options that could
assist the person to improve their independence and health and wellbeing.
Strengthen Community and personal
resilience, focusing on what matters to me and taking a holistic approach
with each individual case
Co-produce a simple personalized care and
support plan to improve health & wellbeing introducing or reconnecting people
to community groups and statutory services.
Manage and prioritise own caseload, in
accordance with the needs
Have a strong awareness and understanding
of when it is appropriate or necessary to refer people back to other health
professionals/agencies, when 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.
Identify new, and work in partnership
with voluntary and statutory organisations.
Understand the barriers and opportunities
for people to self-manage their conditions in the community.
Have a role in educating clinical and
non-clinical staff within their PCN multi-disciplinary teams on what other
services are available within the community and how and when people can access
them.
Key Tasks
Promote social
prescribing, its role in self-management and the wider determinants of health.
As part of the PCN
multi-disciplinary team, attend relevant MDT Network meetings, providing
information and feedback on social prescribing on request.
Be proactive in
encouraging self-referrals and connecting with all local communities,
particularly those communities that statutory agencies may find hard to reach
Be a friendly source of
information about well being 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.
Help people maintain or
regain independence through living skills, adaptations, enablement approaches
and simple safeguards.
Seek advice and support
from relevant GPs to discuss people-related concerns (e.g. abuse, domestic violence
and support with mental health), referring the person back to the GP or other
suitable health professional if required.
Work with the PCNs
Clinical Directors, commissioners and local partners to identify unmet needs
within the community and gaps in community provision.
Where possible,
encourage people, their families and carers to provide peer support and to do
things together, such as setting up new community groups or volunteering.
The Link Worker will be
expected to keep accurate and up-to-date records on relevant health and social
care systems.
The Link Worker will
gather record and collate data, including case studies, in a prescribed format
in order to demonstrate the impact of the service.
Undertake and 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.
Provide
personalised support
Meet people on a one-to-one basis, making
home visits or telephone assessments where appropriate within organisations
policies and procedures. Give people time to tell their stories and focus on
what matters to me. Build trust and respect with the person, providing
non-judgemental and non-discriminatory support, respecting diversity and lifestyle
choices. Work from a strength-based approach focusing on a persons
assets.
Be a friendly and engaging 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.
Help people maintain or regain independence
through living skills, adaptations, enablement approaches and simple
safeguards.
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, cultural and
religious/faith needs 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.
Where appropriate, physically introduce people
to culturally appropriate community groups, activities and statutory services,
ensuring they are comfortable, feel valued and respected. Follow up to ensure
they are happy, able to engage, included and receiving good support.
Where people may be eligible for a personal
health budget, help them to explore this option as a way of providing funded,
personalised support to be independent, including helping people to gain skills
for meaningful employment, where appropriate.
Seek advice and support from the lead social
prescriber 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.
Support community
groups and VCSE organisations to receive referrals
Working closely with other link workers in
Lewisham and the Neighbourhood Community and voluntary networks to forge strong
links with a wide range of local VCSE organisations, community and
neighbourhood level groups. Utilising their networks and building on whats
already available to create a menu of diverse community groups and assets, who
promote diversity and inclusion.
Develop supportive relationships with local
diverse VCSE organisations, culturally appropriate community groups and
statutory services, to make timely, appropriate and supported referrals for the
person being introduced.
Work collectively
with all local partners to ensure community groups are strong and
sustainable
Work with the GP Federation, PCNs and other
local partners to identify unmet diverse needs within the community and gaps in
community provision.
Encourage people 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.
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.
Encourage people, their families and carers to
provide peer support and to do things together, such as setting up new
community groups or volunteering.
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.
Key Relationships
PCN clinical directors, OHL Community
development lead GP and Medical Director, PCN forum, OHL board, Age UK Lewisham
and Southwark, Lewisham Health and Social Care, Lewisham voluntary and
community networks