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Setting Up a Clinical Safety Officer Role Without Extra Headcount

Define responsibilities and rhythms for a clinical safety officer role using existing team capacity.

Published · 28 October 2025Topics: roles, operations, clinical-safety

Executive Overview

Every organisation using health IT must appoint a Clinical Safety Officer (CSO) to meet DCB0160 requirements. Smaller GP practices can create a sustainable CSO role by allocating time, clarifying responsibilities, and leveraging existing team structures—without hiring new staff. This guide shows how to make the role work in practice.

Understand the CSO’s Core Responsibilities

  • Clinical risk management: oversee hazard identification, risk assessments, and the Clinical Safety Case for all digital systems.
  • Change governance: review and sign off on system changes, upgrades, and new deployments.
  • Incident oversight: monitor safety logs, lead investigations, and ensure mitigations are implemented.
  • Supplier assurance: verify DCB0129 documentation, raise safety concerns with vendors, and track actions.
  • Reporting and escalation: provide updates to practice leadership, PCNs, and commissioners, escalating risks when needed.

Document these responsibilities in the safety file and share them with the wider team.

Select the Right Person

  • Choose a senior clinician (partner, salaried GP, advanced nurse practitioner) with authority to make decisions.
  • Look for strong communication skills, attention to detail, and confidence with digital systems.
  • Confirm support from the partnership so the CSO can challenge decisions when patient safety is at stake.

If no single clinician has capacity, consider a shared role across the PCN with named deputies at each site.

Allocate Time and Resources

  • Plan for 0.1 Whole Time Equivalent (half a day per week) during active change periods, reducing to 1–2 hours weekly during steady state.
  • Build CSO duties into job plans and rota templates so the time is protected.
  • Provide administrative support (practice manager or digital lead) to manage documentation and meeting logistics.
  • Use shared templates (hazard logs, safety cases, change records) to reduce admin burden.

Set Up Supporting Processes

  1. Safety governance: add clinical safety as a standing item in practice meetings and safety huddles.
  2. Change control: require CSO review before any system change or new tool goes live.
  3. Safety log: maintain a central log for staff to report issues; route red flags directly to the CSO.
  4. Training: arrange CSO training through NHS England or recognised providers; schedule annual refreshers.
  5. Peer support: connect with other CSOs in the PCN or ICB to share learning and cover leave.

Integrate with Existing Roles

  • Partner or practice manager: support resource planning, governance, and escalation.
  • Digital champion or IT lead: manage technical tasks, documentation, and supplier liaison alongside the CSO.
  • Reception and admin teams: report incidents and follow agreed escalation routes.
  • PCN leads: coordinate shared risks, templates, and training opportunities.

Use a simple RACI (Responsible, Accountable, Consulted, Informed) matrix to clarify interactions between roles.

Scenario: Broadwater Medical Centre

Broadwater appointed a GP partner as CSO with a half-day protected session each week. The practice manager maintains the safety file and schedules a monthly safety huddle where the CSO reviews incidents, change requests, and supplier updates. A shared PCN template library cuts paperwork, and neighbouring CSOs hold quarterly peer sessions. The model keeps safety oversight strong without adding headcount.

Pitfalls to Avoid

  • Unprotected time: without diary protection, CSO duties slip behind clinical pressures.
  • Vague responsibilities: unclear expectations lead to missed reviews and weak assurance.
  • Lack of admin support: clinicians become overwhelmed by documentation; share the load with management teams.
  • No succession plan: identify deputies to cover leave and ensure knowledge transfer.

Action Checklist

  • Identify a senior clinician with authority to act as CSO and secure partnership support.
  • Allocate protected time and record it in job plans or rotas.
  • Update the safety file with CSO responsibilities, contact details, and supporting processes.
  • Arrange CSO training and set up peer support within the PCN or ICB.
  • Integrate CSO reviews into change control, incident management, and governance meetings.

Resources to Bookmark

Key Takeaways

A well-supported CSO can be established without new headcount by protecting time, clarifying responsibilities, and embedding clinical safety into existing governance. With the right structure, practices stay compliant and keep digital services safe for patients.