This role will support the growing Proactive Care Team and practice in delivering excellent care by actively supporting patients to take control of their own health and well‑being.
You will take referrals from within the practice and the wider PCN partners for individuals who would benefit from social prescribing support. By providing personalised support to individuals, their families and carers, you will assist people to take control of their health and wellbeing, live independently and improve their health access and outcomes. A key part of the role will be to co‑produce Personalised Care and Support Plans to improve health and wellbeing, introducing or reconnecting people to appropriate community groups and statutory services.
If you share our values of collaboration, integrity, quality, respect and wellbeing and are looking for a new challenge, we would love to hear from you.
The working pattern to be agreed.
Interviews will take place on 19th and 22nd June 2026.
Main duties of the job
Focused on providing personalised support to individuals, families, and carers to support them to be active participants in their own healthcare empowering them to manage their own health and wellbeing.
As well as managing your own caseload of patients, you will work closely with partner agencies and local voluntary and community sectors in Holderness. To be successful, you will need knowledge of the personalised care approach and be able to work from an asset‑based approach, building on existing community and personal assets.
You will have considerable experience of working in community development, adult health and social care, learning support or public health/improvement and an understanding of the wider determinants of health including social, economic and environmental factors and their impact on communities.
You will be committed to fully exploring the benefits that social prescribing can offer our local community.
The role is cross‑site but will be predominantly based in Withernsea.
About us
We are a large rural practice with approximately 34,000 patients. As a single‑practice Primary Care Network, we have a wonderful opportunity to transform care for our patients. We operate from seven locations across Holderness and you must also be willing to travel between sites as necessary. Our hard‑working and dedicated team includes 23 GPs, an extensive multidisciplinary team of healthcare professionals and a great patient services team.
We offer a welcoming practice environment, 25 days annual leave plus bank holidays, access to the NHS pension scheme and the chance to be part of this proactive growing team, which we see as central to the future of care for our most complex and vulnerable patients.
For an informal chat about the role, please contact Tim Monaghan (tim.monaghan@nhs.net).
Job responsibilities
Role Purpose:
To support the practice in delivering excellent care by actively supporting patients to take control of their own health and well‑being.
Take referrals from within the practice and the wider PCN partners for individuals who would benefit from social prescribing support.
Provide personalised support to individuals, their families and carers to take control of their health and wellbeing, live independently and improve their health access and outcomes.
Co‑produce Personalised Care and Support Plans to improve health and wellbeing, introducing or reconnecting people to appropriate community groups and statutory services.
Help people identify the wider issues that impact on their health and wellbeing, such as debt, poor housing, being unemployed, loneliness and caring responsibilities, those who need support with low level mental health needs and long‑term health conditions.
Help people maintain or regain independence through living skills, adaptations, enablement approaches and simple safeguards.
Where appropriate, physically introduce people to culturally appropriate community groups, activities and statutory services, ensuring they are comfortable, feel valued and respected.
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.
Work closely with the practice Care Coordinators, Health & Wellbeing Coaches, GPs and wider clinical team to provide holistic, joined‑up support for patients.
Seek advice and support from your 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.
Development Activity
Promote social prescribing and the practice’s wider proactive care services both internally and externally.
Develop strong links with local health agencies and the voluntary and community sector and work collaboratively for the benefit of our local community.
Support the Social Prescribing Team Leader to develop projects aimed at addressing local health inequalities.
Develop a rolling system of targeted health and wellness campaigns including both national campaigns and locally identified priorities.
Educate non‑clinical and clinical staff within the PCN on what other services are available within the community and how and when patients can access them.
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.
Support the Social Prescribing Team Leader to develop a team of volunteers, start new groups and find creative community solutions to local issues.
Reporting
Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing.
Produce case studies showing the impact of social prescribing.
Work closely with staff across the practice to ensure that the social prescribing referral codes are inputted into clinical systems.
Maintain effective records of activity and produce reports as required.
Provide agreed performance/activity data.
This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post‑holder commensurate with the position. This description will be open to regular review and may be amended to take into account development within the Practice. All members of staff should be prepared to take on additional duties or relinquish existing duties in order to maintain the efficient running of the Practice.
Person Specification
Additional Criteria
* Able to understand and prioritise the needs of patients
* Comfortable working in a team and providing a strong role model
* Able to demonstrate the principles of equality and inclusion in all aspects of this role
* 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
* Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
* Able to gain the confidence of others
* Able and willing to work across all HH sites
* Able and willing to homework as required by the practice
* Punctual and flexible across hours of work when required (including holiday cover)
* Able to demonstrate alignment with the values of the practice
Qualifications
* NVQ Level 3, Advanced level or equivalent qualifications or working towards
* Evidence of continuing professional development
* Educated to degree level
* Training in motivational coaching and interviewing or equivalent experience
Experience
* Experience of working in community development, adult health and social care, learning support or public health/health improvement
* Experience of supporting people, their families and carers in a professional capacity
* Experience of working with voluntary, community or social enterprise sector
* Experience of working with volunteers and community groups
* Experience of data collection and providing monitoring information to assess the impact of services
* Experience of partnership working and of building relationships across a range of organisations
* 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 community development approaches
* Able to prioritise and manage your own workload
* Able to use IT systems including Microsoft Office software and quickly learn to use in‑house IT software
* Able to identify risk and assess/manage risk when working with individuals
* Able to work from an asset‑based approach, building on existing community and personal assets
* Able to communicate effectively with any audience, both verbally and in writing
* Experience of working in a healthcare setting, ideally general practice
* Knowledge of EMIS clinical system
* Knowledge of VCSE and community services within the Holderness locality
* Experience of supporting people with their mental health
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.
£14.09 to £15.07 an hour in line with the practice pay policy.
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