Social Prescriber in Oxford

We are seeking a compassionate, motivated Social Prescriber to join our team and support some of our most vulnerable patients within the community, including older adults and those living with long-term health conditions. This is a rewarding, patient-facing role focused on improving wellbeing, promoting independence, and ensuring individuals and their carers receive the right support at the right time.

Main duties

You will manage a caseload of identified patients, working closely with GPs, practice staff, and wider community services to coordinate personalised care plans and respond proactively to changing needs.

About us

The team at Hedena is a friendly, supportive group working closely with GP practices and community partners to improve people's health and wellbeing. We focus on a positive, inclusive atmosphere where collaboration, compassion, and high standards of care are central to everything we do.

Job responsibilities

• You will work closely with GPs and practice teams to manage a caseload of identified patients, ensuring appropriate support is in place and that patients' evolving needs are identified and addressed.
• The role involves meeting patients and carers in a variety of settings, including GP practices, patients' homes, and community venues.
• You will assess needs, support care planning, and help individuals access appropriate health, social care, and voluntary sector services.
• A strong understanding of local services is essential in order to effectively connect patients with the support available and help them overcome any barriers they may face.

Core Responsibilities

• Develop and maintain an in-depth knowledge of local community, statutory and voluntary sector services.
• Work with practice teams to identify patients at risk of loss of independence or hospital admission due to inadequate social support.
• Support GPs in reviewing, updating, and implementing personalised care plans for elderly, frail, or long-term condition patients.
• Provide time-limited, supported signposting to appropriate services (free or paid where relevant).
• Ensure patients receive the right level of support at the right time through effective coordination with service providers.
• Promote joined-up care by acting as a key point of contact between patients, carers, GPs, Integrated Locality Teams (ILT), social services, and other agencies.
• Encourage effective help-seeking behaviours and help reduce avoidable hospital admissions and A&E attendances.
• Respond to communications from out-of-hours and inpatient services regarding changes in patient status.
• Maintain up-to-date records of hospital inpatients and support discharge coordination with ILT.
• Record referrals, interventions, and outcomes to support service monitoring and evaluation.
• Contribute to service development, risk assessments, and impact evaluations.
• Work collaboratively with commissioners, ILTs, and partner organisations to develop the Social Prescribing role.

Examples of Key Activities

1. Enable Access to Local Services and Personalised Support
   • Accept referrals from GPs and multidisciplinary team members.
   • Meet patients in community or home settings to review proactive care plans.
   • Hold empathetic, person-centred conversations leading to holistic care planning.
   • Communicate care plans clearly to GPs and other professionals and update clinical records.
   • Support access to community care and carers assessments where appropriate.
   • Identify unpaid carers and link them to relevant support services.
   • Provide basic benefits guidance and signpost to specialist advice where needed.
   • Support patients with personal budgets, including advising on key choices.
   • Keep GPs and practice teams informed of available community resources.
2. Coordinate and Integrate Care
   • Liaise regularly with multidisciplinary professionals and agencies.
   • Support care delivery that promotes independence and prevents unnecessary admissions.
   • Participate actively in MDT meetings.
   • Identify when urgent action or escalation of care is required and raise concerns promptly.
3. Record-Keeping and Evaluation
   • Maintain accurate, up-to-date records using GP clinical systems and other relevant IT systems.
   • Collate data in line with agreed protocols to support monitoring and quality improvement.
   • Contribute to reports, meetings, and presentations related to service development.
   • Identify gaps in services and feedback improvement opportunities.
4. General Responsibilities
   • Work collaboratively with other Social Prescribers and Link Workers.
   • Participate in training, education, and professional development activities.
   • Build strong working relationships with GPs and practice staff.
   • Work in accordance with practice policies and procedures.
   • Contribute to the wider aims of the Primary Care Network.
   • Maintain a flexible approach and undertake other reasonable duties as required.

Confidentiality

The post-holder will have access to confidential information relating to patients, carers, staff, and the practice. All information must be treated as strictly confidential and handled in line with practice policies, data protection legislation, and professional standards.

Health & Safety

The post-holder will support the promotion and maintenance of health, safety, and infection control standards, including risk identification, safe working practices, training compliance, and reporting hazards promptly.

Equality & Diversity

You will promote equality, diversity, and inclusion by respecting the rights, dignity, beliefs, and needs of patients, carers, and colleagues, and by acting in a non-judgemental and inclusive manner.

Personal & Professional Development

Participate in annual performance reviews. Maintain records of learning and development. Take responsibility for continuous professional development.

Quality & Communication

You will contribute to maintaining and improving quality by managing your workload effectively, reflecting on practice, and communicating clearly and sensitively with patients, carers, and colleagues.

Person Specification

• Good standard of general education GCSE English and Maths Grade C or equivalent.
• Strong IT skills - including email, Word, and Excel.
• Full UK driving licence and access to a vehicle insured for work.
• Minimum 2 years experience in health, social care, or support roles.
• Experience working with elderly or vulnerable people.
• Experience working within multi-disciplinary teams.
• Ability to collect and record data for monitoring and evaluation.
• Experience or training in person-centred care planning.
• Experience using EMIS clinical systems.
• Up-to-date knowledge of local services supporting patients and carers.

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.