Risk Stratification


Risk stratification is a process that we will use in the Practice to assist in identifying and caring for patients with long term health conditions and patients who are at high risk of emergency hospital admission. NHS England encourages us as GPs to use risk stratification tools as part of our involvement in local strategies for supporting patients with long-term conditions, such as chronic obstructive pulmonary disease (COPD) and diabetes, to help prevent hospital admissions that could have been avoided. As well as helping us in the Practice in providing direct care support for our patients, risk stratification is used by the CCG to support planning and commissioning, for example, understanding the numbers of patients in the region who require services to support COPD will enable us to manage periods of ill health and to improve the quality of the services we are able to offer you. The CCG will not have access to any information that identifies any individuals.

How we use your information in relation to risk stratification

Risk stratification tools use a mix of historic information about our patients such as age, gender, diagnoses and patterns of hospital attendance and admission as well as data other data collected in within the Practice. We will send details from your records to the Risk Stratification Supplier who will be working on our behalf. They will immediately convert the information into a format that does not identify you but it will have a key to enable it to be linked to other data and also to enable the Practice to re-identify the information when we need to do so in order to provide care for you.

NHS Digital also provides information to the Risk Stratification Supplier about hospital attendances. This will in a format which does not directly identify you but which can be linked to the data about you from our Practice.  Both sets of information are then liked in the risk stratification system.

The risk stratification system uses a formula to analyse the data to produce a risk score. These risk scores are available to us as a Practice where our authorised staff who are responsible for providing direct care for you are able to see these scores in a format that identifies you. This will help our clinical team make better decisions about your future care, for example we may invite you in for a review or if we think you may benefit from a referral to a new service we will discuss this with you. The CCG is provided with reports containing information which does not identify you, to ensure they are commissioning and planning for the right services as required by the population we serve.

Our risk stratification supplier

On behalf of our Practice, the CCG has entered into a contract with NHS Arden and Greater East Midlands Commissioning Support Unit (AGEM CSU) as our Risk Stratification Supplier. They are accredited by NHS England to conduct this service and provide the analysis for us.

AGEM CSU will be acting on behalf our Practice, as a data processor. We have entered into an Agreement with them to ensure that the risk stratification process will be conducted in accordance with Data Protection Regulations and in accordance with NHS England’s rules for risk stratification.  This has been done to keep your data secure at all times and to protect confidentiality.

What should I do if I have further questions about risk stratification?

Please ask the Practice staff if you can speak to someone in more detail.

What if I do not information about me to be included (opt out)

If you do not wish your data to be included in the risk stratification service (even though it is in a format which does not directly identify you) you can choose to opt-out. In this case, please inform the Receptionist who will apply an opt-out code to your record to ensure that your information is not included.

Additional information

Additional information about risk stratification is also available from the NHS England website: www.england.nhs.uk