Primary Care – About our CAG

About the Primary Care CAG

The goal of the Primary Care CAG is to improve patient care through better education underpinned by relevant research.

Our Aims

As well as promoting health through better research and education our other primary aim is to understand how best to coordinate and focus the effort and resources of the primary care services and to meet the challenges of the health and social care landscape across Surrey, North Hampshire and parts of Berkshire so that they have the greatest impact for our clients through improved patient care.

Key research areas will be:

Integrated care – This theme will focus on service delivery and include improved self-management support, and patient access to their records and services using IT.

Better use of community resources e.g exercise to improve health and reduce requirements for medication.

Improved anticipatory care: (1) Risk scores e.g. risk of falling. (2) Better antimicrobial stewardship and uptake of vaccination.

Understanding the impact of psychological ill health on: (1) Quality of life, (2) Health, and (3) Health service utilisation.

Co-morbidities – Many people have a complex group of conditions and therapies. These often interact. Diseases can’t be treated in silos. E.g. Anaemia in people with chronic kidney disease.

Health Infomatics – using data, information, and knowledge to improve health, health care and its delivery across the NHS and other health and social care providers.

Ambulatory Care Specialties – Care delivered in an out-patient setting as well as preventive measures such as screening, and helping patients to manage factors which could put them at risk of ill health.

Our Work


CAG Research bids:

 “Falls Model” pilot

The aim of this research is to validate the falls model- a regression model of predicting falls developed by the University of Surrey. We will use the model to select patients and understand what interventions are used to reduce falls in conjunction with Guildford and Waverley CCG and the Primary Care CAG.

We will run the study through the Surrey Cohort- a repository holding computerised health data from practices in Surrey, funded by Surrey Health Partners (SHP).

In collaboration with the CCGs we aim to find a scientific basis for falling- what interventions are done/needed to be done to reduce the chance of falling, what the consequences are and what should have been avoided.

“Psoriasis and detecting associated arthritis”

Early signs of psoriasis are associated with arthritis, cardio vascular disease and depression).  The aim of the project would be to pinpoint a number of patients with psoriasis (up to 500) and hopefully bring in those with early onset arthritis, and validate a screening tool – Psoriasis Epidemiology Screening Tool (PEST).


The Primary Care CAG supports the Surrey Winter Statistic School (SWISS) and Surrey Informatics Summer School (SISS) held at the University of Surrey:


Service Improvement

We are delighted that the Primary Care Clinical Academic Group in conjunction with the Diabetes Clinical Academic Group, Cancer Clinical Academic Group, Royal Surrey County Hospital, Guildford and Waverley Clinical Commissioners Group and the University of Surrey was successful in winning the Surrey Health Partners Development and Innovation Fund with its Surrey Health Partners Cohort bid.

We are aiming to recruit 11 practices into the Surrey cohort and if all of the below are recruited, the cohort will cover around 140,000 of the Surrey population.


  • 4 fully signed up practices: 3 in NHS Guildford and Waverley CCG and 1 in NHS Surrey Downs CCG with population around 41,000 people (please note that my numbers may be out of date and the list size could actually be bigger)
  • 3 confirmed practices with outstanding agreements only:  2 in NHS Surrey Downs CCG and 1 in NHS East Surrey CCG, with total population of around 28,000
  • 4 practices that are currently considering joining: 2 in NHS Guildford and Waverley CCG, 1 in NHS North West Surrey CCG and 1 in NHS North West Surrey CCG with total population of around 59,000


Also to note that the following recruitment strategies were implemented:

  • Surrey is liaising with the local CRN, who are very supportive of the Cohort and have liaised with their research active practices to invite them into the cohort
  • The study was also advertised in the RCGP Faculties February e-Bulletin
  • Invite letters were sent by post to 107 practices in Surrey. The latest batch of 69 letters were sent out on Friday last week and we are waiting to have some response from practices any time now
  • Guildford and Waverley CCG are also aware and very supportive of the Cohort.

Our People

©2018 Surrey Health Partners

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