As a Social Prescriber within Sunderland East Primary Care Network, PCN, you will work closely with our seven GP practices, clinical teams, and community partners to support patients with the nonmedical factors affecting their health. You'll offer personalised, one-to-one appointments to explore what matters most to each individual and connect them with local services such as wellbeing groups, housing support, financial advice, mental health resources, or social activities. Your role is central to delivering truly holistic, integrated care across the PCN and improving health outcomes for our local population.
Main duties of the job
KeyResponsibilities
PersonalisedCare & Social Prescribing - Receive and manage referrals from GP practices, PCN MDTs, and other primary care professionals. - Undertake personalised conversations using a what matters to me approach. - Co-produce personalised wellbeing plans with individuals. - Support individuals to access appropriate voluntary, community, faith and statutory services. - Empower people to build resilience, confidence, and self-management skills. - Provide time limited support, reviewing progress and adjusting plans as needed.
ReducingHealth Inequalities - Proactively support individuals experiencing health inequalities, social isolation, loneliness, or wider determinants of poor health. - Work with underserved groups, including those with long-term conditions, mental health needs, carers, and people experiencing deprivation. - Ensure equitable access to social prescribing across Sunderland East PCN practices.
PCN &MTD Working - Work closely with GPs, nurses, care coordinators, mental health practitioners, and other ARRS roles. - Participate in PCN MDT meetings, neighbourhood working, and integrated care approaches. - Support practices to embed social prescribing into routine workflows and referral pathways. - Contribute to PCN service development and continuous improvement.
About us
Joining our PCN means becoming part of a collaborative, supportive, and forward-thinking team with a strong commitment to community wellbeing. We will give you the time and autonomy to provide genuine person-centred care while working closely with GPs, care coordinators, mental health practitioners, and voluntary sector partners. You'll be valued for your ideas, encouraged to shape new initiatives, and supported in your professional development. Most importantly, you will make a visible, meaningful impact on the lives of patients across all our practices helping people feel more confident, connected, and in control of their health.
Job responsibilities
Job Description Social Prescriber Link Worker
Primary Care Network: East PCN
Salary: Competitive salary depending on experience
Hours: 37.5
Reporting to: PCN Clinical Director, PCN Manager
Accountable to: Tracy Hutchinson, Sunderland East PCN Manager
Location: GP practices across East PCN
Job Purpose
The Social Prescriber, Link Worker will work as part of the East PCN multidisciplinary team to support people with non medical needs that affect their health and wellbeing. The role focuses on personalised care, addressing health inequalities, and supporting individuals to improve their quality of life by connecting them to community based services, activities, and support.
The postholder will contribute directly to the PCN DES personalised care requirements, supporting demand management in general practice and helping people to take greater control of their own health and wellbeing.
East PCN consists of 7 GP partnership practices: Ashburn, Deerness Park, New City, Park Lane, River View, Southlands, Villette.
You will become part of our well-established social prescribing team in supporting our patients to ensure they receive the best possible care.
Key Responsibilities
Personalised Care and Social Prescribing
Receive and manage referrals from GP practices, PCN MDTs, and other primary care professionals.
Undertake personalised conversations using a what matters to me approach.
Co produce personalised wellbeing plans with individuals.
Support individuals to access appropriate voluntary, community, faith and statutory services.
Empower people to build resilience, confidence, and self management skills.
Provide time limited support, reviewing progress and adjusting plans as needed.
Reducing Health Inequalities
Proactively support individuals experiencing health inequalities, social isolation, loneliness, or wider determinants of poor health.
Work with underserved groups, including those with long term conditions, mental health needs, carers, and people experiencing deprivation.
Ensure equitable access to social prescribing across East PCN practices.
PCN and MDT Working
Work closely with GPs, nurses, care coordinators, mental health practitioners, and other ARRS roles.
Participate in PCN MDT meetings, neighbourhood working, and integrated care approaches.
Support practices to embed social prescribing into routine workflows and referral pathways.
Contribute to PCN service development and continuous improvement.
Community Asset Mapping
Develop and maintain up to date knowledge of local community assets and services.
Build strong relationships with voluntary and community sector partners.
Support sustainable links between primary care and community services.
Identify gaps in provision and feedback intelligence to the PCN.
Support referral agencies to provide appropriate information about the person they are referring, including demographic data and data on wider determinants, for example, caring status.
Provide appropriate and timely feedback to referral agencies about the people they referred.
Work sensitively with people, their families and carers to capture key information to measure impact of social prescribing on their health and wellbeing, using validated tools
Monitoring, Reporting and Governance
Maintain accurate records in line with PCN and host organisation policies.
Collect activity data and outcomes to support PCN DES assurance and reporting.
Contribute to evaluation of social prescribing impact at PCN level.
Work within safeguarding, information governance, and confidentiality frameworks.
Professional Development and Supervision
Engage in regular supervision and reflective practice.
Participate in relevant training, including personalised care and safeguarding.
Work within the scope of the role and elevate concerns appropriately.
Contribute to peer support and learning across the PCN social prescribing team.
Leadership
Be a system leader in the development, delivery and education of social prescribing, ensuring involvement where value can be added.
Provide role coaching and mentoring for all staff where appropriate.
Key Relationships
GP Practices within East PCN
PCN Clinical Director and PCN Management Team
Community and Voluntary Sector Organisations
Other ARRS roles and neighbourhood teams
Person Specification
Experience
* 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
* Experience of data collection and using tools to measure the impact of services
* Experience of partnership/collaborative working and of building
* relationships across a variety of organisations
* Local knowledge of VCSE and community services
* Knowledge of how the NHS works, including primary care and MDT working
Qualifications
* Meets DBS reference standards and criminal record checks
* Willingness to work flexible hours when required to meet work demands
* Full UK driving licence with use of own car
* Access to transport and ability to travel across the locality on a regular basis, including to visit people in their own homes and support people to attend activities as appropriate.
* NVQ Level 3, Advanced level or equivalent qualifications or working towards
* Demonstrable commitment to professional and personal
* development
* Training in motivational coaching and interviewing or equivalent experience
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.
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