This project was funded between January 2019 and March 2020.

  • Project led by Dickens Place Group, a general practice in Chelmsford, Essex, in partnership with Co-formation Ltd, a health consultancy that supports transformation of primary care.
  • Will identify patients from the GP practice who need greater continuity and coordination of care.
  • Using a clinically designed stratification tool, the practice’s population will be segmented into three tiers, based on medical complexity and social care needs.

The ageing population and increase in the number of people living with long-term conditions has meant a significant rise in demand for GP appointments. The average person sees a GP six times a year; double the rate a decade ago.

Primary care is struggling to deliver the traditional model of general practice, where the same type of care is offered to all patients, regardless of their medical and social needs.  This project will investigate whether there is a better way to ensure GPs are seeing the most appropriate patients, and where they can have the greatest impact.

A stratification tool will be developed and implemented at Dickens Place Group, a practice of 14,000 patients currently based across three sites. It will identify those patients with the greatest need for continuity and coordination of care. It will look at the presence of long-term conditions and social care need, defined by age, frailty, vulnerability and safeguarding issues.

The stratification will involve a search of coded patient data held in the GP practice’s IT system, and a secondary stratification by clinicians identifying a smaller cohort of patients with the most complex needs. 

Patients will be segmented into three tiers, and the tool will update regularly, to reflect changes in patients’ circumstances.

Pre-emptively knowing the potential workload of each tier will allow staffing to be adjusted across the tiers. GPs will then be concentrated around care for the most complex patients, using new roles such as care navigators to support them; allowing nurse practitioners to focus on less complex patients. 

Contact information

For more information about this project, please contact Sharon Kendall, Managing Partner, Dickens Place Group.

About this programme


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