Our digital and technology fellow John McGuinness has brought together a number of resources and recorded webinars to support digital development in primary care.
Patient Segmentation
All PCN and practices should be segmenting their population to meet the requirement set out in the PCN CAIP (Capacity and Access Payment) and support neighbourhood working. Across Devon there are a number of practices and PCN who are using a simple RAG model to achieve this. Through patient segmentation, you can improve continuity for patients and prioritise need and ensure the patient see’s the right clinician at the right time. Feedback from practices implementing this has shown improved efficiency, better patient experience and happier clinicians.
A meeting was held with practice managers from across Devon and Richard Blackwell (Health Innovation South West) on 22nd October 2025 to explore segmentation models that could improve access, continuity of care, and consistency of patient management across the county. The recording and slides are available below.
The RAG Model uses data from three areas to segment the population.
- QOF registers and LTCs
- Number of repeat medications
- Number of appointments last 12m
Further additional data points can be added for further segmentation e.g. Core20Plus data, LSOA for Index of Multiple Deprivation for example.
The population list is then segmented into percentage groups:
- Red: Top 5%
- Amber: Next 10%
- Green: Remaining 85%
SNOMED Coding & Standardisation
There are no SNOMED codes explicitly describing “segmentation”, but Ardens uses national codes that can be adopted consistently, this would be part of the zap/QOF box to alert receptionists and clinicians when triaging and booking appointments.
- Red: Chronic long-term disease management required: complex needs
- Amber: Chronic long-term disease management required
- Green: General good health
Using the same codes across practices would support:
- Standardisation and consistent interpretation
- Reliable comparison and shared reporting
- Better interoperability when patients swap surgeries
RAG rules
The rules applies to how to use the RAG are adaptable locally to each practice depending on their access, staff mix and booking process
One GP surgery have applied the operational model below:
- Red: Seen only by permanent GPs (salaried or partner)
- Amber: Seen by permanent GPs, with ST2/3 involvement if agreed by supervisor
- Green: Seen by ACPs, F2s, locums, or other clinicians
- Locums do not see Red or Amber patients to maintain continuity for the most complex patients
Case studies:
Torridge Health Primary Care Network implemented this RAG system. This has allowed them to setup an acute hub seeing green patients with red and amber patients remain attending the GP surgery.
Chilcote Surgery in Torquay have been using this RAG system for a year and had positive feedback clinicians and evaluating the impact on continuity of care
If you are interested in hearing more about this, please get in touch.
Clinical Safety Officer
A Clinical Safety Officer (CSO) is a senior clinician responsible for overseeing clinical risk management and ensuring digital health systems are safe for use under DCB0129 and DCB0160 standards. To become a CSO, an individual must hold current professional registration (e.g. with the GMC or NMC), have sufficient clinical experience, and complete appropriate training in clinical safety and clinical risk management. Once appointed, the CSO leads on hazard identification, risk assessment, documentation of safety processes, and development or review of key artefacts such as the safety case, hazard log and clinical risk management plan, ensuring digital tools are implemented and used safely in clinical settings.
NHS CSO Practitioner training is available online or in person. CSO training costs currently £475 for NHS organisations. There has been an offer from the Devon ICB to fund one CSO per PCN.
Further information: Digital Clinical Safety training – NHS England Digital
NHS CSO Course Booking website: Accent Course Manager