Lead Family Link Worker - Neurodivergence and Learning Disabilities

Reports to: PCN Business & Transformation Manager / Clinical Lead GP

Responsible to: PCN Clinical Director / Clinical Lead GP

Proposed salary: Band 6.1 – 6.10 on the ABC pay scale which is equivalent to £34,872.71 - £41,676.11 per annum dependent on experience, pro rata

Hours of work: Up to37.5 hours per week

Base: Horley Health Hub / Townhill Medical Practice (Caterham)

About Alliance for Better Care CIC

Alliance for Better Care (ABC) is a GP Federation uniting 77 NHS GP member practices across 98 sites within 24 Primary Care Networks in Sussex and Surrey. We support our Primary Care colleagues - and their patients - to transform how healthcare is delivered in their communities.

We work closely with GP Practices, PCNs, Hospitals, Community Organisations, and the Third Sector. These vital partnerships enable us to deliver a truly integrated approach that offers the support and expertise needed to effectively serve our populations.

More about our organisation: www.allianceforbettercare.org

Our Values

• We innovate

If we can do something better, we should.

• We are honest

Even when it is difficult.

• We care

And put the patient first.

• We are inclusive

We listen and we act.

• We deliver

And we’re known to like a challenge!

Healthy Horley PCN

Our Primary Care Network (PCN) is an NHS collaboration between 2 GP practices – East Surrey Modality Medical Practice and Wayside Surgery – covering Horley and surrounding areas (Outwood, Salfords and Smallfield) and has one site in Caterham. The practices have a combined population of 45,000, with approximately 30% of patients being aged between 0-25 years. There is a wide socio-economic and demographic served within this area which will provide an interesting and varied case mix. You will be joining an enthusiastic team of clinicians and administrators, including GPs, Social Prescribing Link Workers, Care Coordinators, Physician Associates, Paramedic Practitioners, Pharmacy Technicians and Clinical Pharmacists, Occupational Therapists, First Contact Physiotherapists, Practice Nurses, Healthcare Assistants and more.

Our surgery teams work closely, sharing expertise and resources to develop new services. Our vision is to continue to improve the quality of care that we provide in alignment with the needs of our patient population and find innovative solutions in general practice to deliver the best care we can for our patients.

Our Primary Care Network builds on the existing primary care services and enables a greater provision of proactive, personalised and more integrated health and social care. We are supported by practitioners in additional roles who allow us to create bespoke multi-disciplinary teams based on the needs of our local population. By working together with local community services, this allows us to make support available to people where it is most needed. The PCN delivers a wider range of services including a Children and Young Persons Wellbeing Service, Anticipatory Care / Frailty Hub, GP Integrated Mental Health Services, Employment Specialist Services, and a Community Health Hub (Horley Health Hub). We are proactively engaged with the Neighbourhood Health and Wellbeing Networks and aim to remain at the forefront of community engagement and Integrated Neighbourhood Teams as they develop. More about our proactive approach and community support can be found at https://allianceforbettercare.org/horley-health-hub/

Healthy Horley PCN have an exciting opportunity to expand their Primary Care Workforce by employing a Lead Family and Young Persons Link Worker, specialising in Learning Disability and Neurodiversity, and supporting the delivery of an existing CYP wellbeing service for our patients. Within the PCN, there is an identified need for a Lead Link Worker, to work with Children and Young People and their families, with a particular focus on Learning Disability and Neurodiversity, to support their health and wellbeing, provide social support, and help them navigate through different support networks available to them. This may include linking families and young people in with Sexual Health Services, Drug and Alcohol support and Mental Health support as required.

More about our Primary Care Network and our services: www.horleypcn.org/

Benefits

• Generous annual leave allowance
• Access to NHS pension
• NHS discounts and employee benefits scheme
• 24-hour external employee assistance programme
• Enhanced Maternity Pay
• Leadership Development Programme
• Salary sacrifice schemes – technology and electric vehicle
• Access to supervision by the National Centre for Behavioural Change
• Opportunities to develop special interests

Job summary

This is an exciting expansion to our PCN Children and Young Persons Wellbeing Service, and as such the successful post holder will have the opportunity to be involved in the development of the service, research opportunities, as well as having the responsibility for collecting user feedback and adapting the role to suit the needs of users in line with the ‘THRIVE’ model.

The role is primarily to work with children, young people and parents/carers, specialising in Neurodiversity and Learning Disability. You will work closely with the Mindworks Surrey service to provide a range of services for children, young people and their families and deliver the appropriate level of support at the right time. The role will also provide leadership to the PCN Personalised Care roles, whilst acting as the liaison between social prescribing and PCN practice staff.

Social prescribing empowers people to take control of their health and wellbeing through referral to a non-medical ‘link worker’ who gives time, focuses on ‘what matters to me’ and takes a holistic approach, connecting people to community groups and statutory services for practical and emotional support. Link workers support existing groups to be accessible and sustainable and help people to start new community groups, working collaboratively with all local partners. Social prescribing can help to strengthen personal and community resilience and reduces health inequalities. It addresses the wider determinants of health, such as debt, poor housing, and physical inactivity, by increasing people’s active involvement with their local communities.

The successful postholder will engage with and offer advice and support to children, young people and their families using a combination of 1:1, group, online and telephone interventions. You will work as part of a small team, undertaking initial assessments and delivering a range of evidence-based interventions, which will include holding a caseload.

You will receive ongoing support and supervision of your caseload from the PCN GPs, and have the opportunity to access group supervision with other Social Prescribing colleagues via the National Centre for Behavioural Change (NCBC). You will join the ABC East Surrey CYP wellbeing team peer support network including those from neighbouring PCNs and access monthly reflective practice sessions.

Primary duties and areas of responsibility

Personalised care and support:

• Assess the needs and strengths of individuals referred to the service and help them identify individual goals to achieve desired change.
• Provide specialist support to children, young people and parents with Learning Disabilities and Neurodiversity (diagnosed and suspected).
• Design, deliver and evaluate interventions for young people and families which aim to improve mental health and wellbeing, build on existing strengths and increase levels of resilience.
• Provide personalised support to children, young people and their families, to enable them to take control of their wellbeing, live independently and improve their health outcomes.
• Offer evidence-based interventions to families to increase social support and parenting skills for parents with learning disabilities.
• Manage and prioritise your own caseload, in accordance with the needs, priorities and support required by individuals, some with complex and multiple needs.
• Co-produce a personalised support plan to improve health and wellbeing, introducing, connecting, and supporting young people and parents to community groups and statutory services.
• Have a good understanding of and utilise the ‘THRIVE’ delivery model in sessions, which conceptualises the mental health and wellbeing needs of children, young people and families in terms of five different needs-based groupings: getting advice, getting help, getting more help, getting risk support, and thriving.
• Offer time-limited sessions with children, young people and families for up to an hour, face-to-face or virtual and offer follow up where needed.
• Meet young people on a one-to-one basis and give them 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 person’s assets.
• Provide earlier intervention whilst waiting or avoiding the need to wait for triage through the Mindworks Access and Advice line.

Leadership:

• Act as a PCN lead point of contact for young people with additional needs requiring support.
• Take responsibility for more complex cases/situations presenting within the service, under the supervision of a clinical lead / GP.
• Provide point of contact support to the PCN Personalised Care team to include 1:1’s, appraisals, assessing training needs, and service development.
• Ensure the service operates to national best practice, that processes are safe, effective and working guidelines are kept up to date.
• Play a leadership role in PCN projects providing a social prescribing perspective and interventions, as appropriate – i.e. tackling neighbourhood inequalities specification.
• Promote, monitor and maintain health, safety and security in the working environment.

Integrated partnership working:

• Accept referrals from a wide range of agencies including GP practices within primary care networks.
• Work closely with Mindworks Alliance Partners such as YMCA and the school-based mental health support teams, as well as the Children’s community health provider, in order to ease cross referral processes and provide effective service for children, young people and their families.
• Work closely and communicate with other agency partners such as schools, Community Development Workers, Local Area Coordinators, Targeted Youth Service and Family Support Teams when necessary to ensure the local system is working in a joined-up way to provide the young person(s) with holistic care.
• Build relationships with key staff in GP practices within the local Primary Care Network, becoming part of the wider network team and giving information and feedback on social prescribing, work as part of a team and attend team meetings, practice huddles, training events and participate fully in one to one, peer and group supervision.
• Form effective links with local schools and other community enterprises.
• Refer young people and families back to other health professionals/agencies, when their needs are beyond the scope of the link worker role.

Proactive care and early intervention:

• Support the Primary Care Network in reducing inequalities by proactively seeking engagement from Children and Young People and their families, who may require early intervention and support.
• Use population health management tools to identify patients who may benefit from early intervention.
• Deliver proactive group consultation workshops and peer-support workshops for patients with Learning Disabilities and/or Neurodivergence.

Data capture:

• Keep accurate records of individual engagement, evidence of change and celebrate progress with children, young people and families.
• Provide, record and report the appropriate data to ensure the service and support offers can be accurately monitored and evaluated.
• Work sensitively with young people and families to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing. This will include written case studies as evidence of the effectiveness of individual interventions.
• Encourage young people and families to provide feedback and to share their stories about the impact of social prescribing on their lives.
• Provide quarterly reports to the PCN board and an annual evaluation report for the service.

Clinical supervision:

• Actively participate in regular clinical supervision with a GP.
• Work cooperatively and under the management of the PCN board to ensure the highest quality of delivery and support.
• Apply safeguarding and child protection procedures and work closely with the safeguarding lead to ensure any issues and concerns are escalated and dealt with quickly and effectively.

Person Specification

Experience

Essential

• Experience of working with a range of professionals including senior clinicians
• Minimum of 2 years experience of working within a primary care setting
• Experience of working with children and young people or directly in a community development context, childrens health and social care, learning support or public health/health improvement (including unpaid work)
• Experience of working with children, young people and families with Learning Disabilities and/or Neurodiversity.
• 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 (Voluntary, Community and Social Enterprise) sector (in a paid or unpaid capacity), including with volunteers and small community groups
• Experience of data collection and providing monitoring information to assess the impact of services
• Experience in using IT based patient documentation systems
• Experience of partnership/collaborative working and of building relationships across a variety of organisations

Qualifications

Essential

• NVQ Level 3 Health and Social Care, or equivalent qualifications, or working towards
• Demonstrable commitment to professional and personal development
• Training in motivational coaching and interviewing, or equivalent experience

Desirable

• Introductory training to CBT, or equivalent experience
• Zones of regulation training, or equivalent experience

Personal Qualities & Attributes

Essential

• Ability to listen, empathise with, and provide person-centred support to children, young people and families
• Ability to form and maintain connections with people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from all communities
• Ability to demonstrate leadership skills, with or without formal designation, including problem-solving, decision-making, and collaboration
• Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to communicate effectively with people, their families, carers, community groups, partner agencies and stakeholders, using various methods (written, verbal, assistive technology etc.)
• Ability to identify risk and assess/manage risk when working with children and young people
• Understanding of and commitment to cultural competency, with the ability to work effectively with patients and colleagues from diverse backgrounds
• 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 person needs is beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner
• Able to work from an asset-based approach, building on existing community and personal assets
• Able to provide leadership and to finish work tasks
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
• Commitment to collaborative working with all local agencies (including VCSE organisations and community groups). Able to work with others to reduce hierarchies and find creative solutions to community issues
• Demonstrated ability to foster an inclusive and supportive environment for colleagues and patients of all backgrounds
• Committed to bringing diverse perspectives to the team and fostering a culture of equity and inclusion
• Ability to motivate other team members
• Ability to promote a learning environment
• Ability to organise, plan and prioritise using your own initiative, including when under pressure and meeting deadlines
• Ability to demonstrate professionalism and commitment to high standards of care, including equity and inclusion
• Ability to work flexibly and enthusiastically within a team or using your own initiative
• Ability to professionally and appropriately challenge differing opinions as a patient advocate
• Understanding of the needs of small volunteer-led community groups and ability to support their development
• Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety

Skills & Knowledge

Essential

• Knowledge of the personalised care approach
• Ability to demonstrate good organisational skills including effective time management
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities
• Knowledge of community development approaches
• Knowledge of safeguarding and child protection issues
• Knowledge of IT systems, including ability to or ability to learn to use word processing skills, emails and the internet to create simple plans and reports, with appropriate adjustments or support as needed
• Knowledge of motivational coaching and interview skills

Desirable

• Knowledge of VCSE and community services in the locality

Experience

Essential

• Experience of working with a range of professionals including senior clinicians
• Minimum of 2 years experience of working within a primary care setting
• Experience of working with children and young people or directly in a community development context, childrens health and social care, learning support or public health/health improvement (including unpaid work)
• Experience of working with children, young people and families with Learning Disabilities and/or Neurodiversity.
• 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 (Voluntary, Community and Social Enterprise) sector (in a paid or unpaid capacity), including with volunteers and small community groups
• Experience of data collection and providing monitoring information to assess the impact of services
• Experience in using IT based patient documentation systems
• Experience of partnership/collaborative working and of building relationships across a variety of organisations

Other Requirements

Essential

• Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions
• Willingness to work flexible hours when required to meet work demands
• Ability to address sensitive issues with cultural awareness and respect for individual beliefs and identities e.g. sudden death/bereavement, child abuse, domestic violence
• Access to own transport and ability to travel across the locality when required
• Champion of equality and valuing diversity
• Operates at all times in line with Confidentiality and Data Protection Act

Job Types: Full-time, Part-time

Pay: £34,872.71-£41,676.11 per year

Expected hours: No more than 37.5 per week

Benefits:

• Company pension
• Cycle to work scheme
• Employee discount
• Enhanced maternity leave
• Health & wellbeing programme
• On-site parking
• Sick pay

Schedule:

• Day shift
• Monday to Friday

Ability to commute/relocate:

• Horley RH6 7BL: reliably commute or plan to relocate before starting work (required)

Education:

• A-Level or equivalent (required)

Experience:

• primary care: 2 years (required)

Work authorisation:

• United Kingdom (required)

Work Location: In person

Application deadline: 24/06/2025