Personalising care for patient sub-groups in general practice: segmenting within general practice to improve health and increase efficiency Valentine Health Partnership

  • Led by Valentine Health Partnership, in partnership with Cognitive Connections Ltd, and implemented at a GP practice in Woolwich, London.
  • An innovation to improve care, outcomes and experience for sub-groups of patients who are frequent users of general practice and who have gaps in the care they receive.
  • Used comprehensive data analysis to identify patient population segments with similar care needs, and design interventions tailored to those needs.
  • Project ran from March 2016 to August 2017.

This project identified high users of general practice services, and co-designed methods to deliver care to these patients tailored to their needs and preferences. The aims were to improve health, address gaps in care and manage the use of practice resources.

The intervention was innovative in blending analysis of practice data with patient and staff views to develop new approaches to working with high use patients. Contrary to initial plans, a generic intervention was developed for all high user patients rather than tailored interventions for different sub-groups.

The project has delivered:

  • methods to identify high user patients through analysis of practice data
  • administrative systems and clinical pathways to improve continuity of care
  • training and resources for varied consultation techniques with high user patients, and
  • a guide on identifying high user patients that can be used in other practices.

Evaluation covered impact in terms of change in use of clinical consultations; change in overall health and wellbeing (EQ-5D); qualitative assessment of staff and patient views; and change in use of wider services. 

All patients had fewer consultations post-intervention than pre-intervention, and the very high user intervention group had the biggest reduction. Patients in the intervention group had a bigger increase in their EQ-5D score (used as a measure of overall wellbeing) than non-intervention patients. Patients had mixed views on the intervention and staff felt continuity and quality of care had improved for some patients some of the time.

The project has changed day to day processes in the practice and the clinical behaviours of some, but not all, GPs and there is ongoing work to embed alternative consultation styles into clinicians’ work. Future initiatives include a new electronic template for high user patients.

Contact information

For more information about this project, please contact Dr Rebecca Rosen, GP Principal, Valentine Health Partnership, London.

About this programme


Innovating for Improvement


This programme supports up to 23 projects with up to £75,000 to test and develop innovative ideas...

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