Patient Needs Groups

Understanding Risk Stratification at Our Practice: The Johns Hopkins ACG System

As part of how we look after our patients, our practice uses a tool called the Johns Hopkins. You may also hear it referred to as "risk stratification" or "Patient Needs Groups (PNG)."

What is it?

Rather than looking at one illness or one appointment at a time, this system looks at a patient's overall health picture, taking into account things like existing conditions, medications, and how often someone has needed care. It is a nationally recognised, well-established approach used by GP practices and NHS organisations across the country, not something unique to us.

Why do we use it?

It helps our clinical teams get a fuller understanding of each patient's needs, so we can:

  • Spot patients who might benefit from additional support or a proactive check-in, before problems become more serious
  • Plan and target services more effectively, for example, care for patients with several long-term conditions, or those at higher risk of needing hospital care
  • Make sure the right patients are offered the right care at the right time, rather than only responding once someone becomes unwell

How does it work?

The system looks at anonymised or pseudonymised information already held in your GP record, such as diagnoses and prescriptions, and processes it to produce a summary score. This is used by our clinical team as one part of the bigger picture when planning care; it does not replace clinical judgement or a GP's assessment of you as an individual.

Watch a video about Patient Need Groups and neighbourhood teams

Your data and your choices

Your information is handled in line with strict NHS data protection and confidentiality standards. If you would prefer your data not to be used for this kind of planning and analysis, you have the right to opt out, you can ask a member of our team about the National Data Opt-out, or speak to our Practice Manager for more information.

If you have any questions about this or how your information is used, please don't hesitate to contact the practice.

Patient Need Groups (PNGs)

The Patient Need Groups (PNGs) help us understand how much care and support each patient is likely to need, based on their health conditions, how often they use healthcare, and how complex their needs are.

There are 11 groups in total, ranging from healthy people to those with very complex or serious health needs:

  1. Non-Users
  2. Low-Need Child
  3. Low-Need Adult
  4. Low Complexity Morbidity
  5. Medium Complexity Morbidity
  6. Pregnancy Low Complexity
  7. Pregnancy High Complexity
  8. Dominant Psychiatric Condition
  9. Dominant Major Chronic Condition
  10. Multi-Morbidity High Complexity
  11. Frailty

Knowing these groups helps explain why different patients might need different types or levels of care.

In order to help us tailor care according to individual patient need, we now have access to a tool that categorises our population into these 11 groups.

Find out more on the Johns Hopkins website

Low need

  1. 1Non-user
  2. 2Low need Child
  3. 3Low need Adult
  4. 4Low Complexity Morbidity

Medium need

  1. 5Medium Complexity Morbidity
  2. 6Pregnancy Low Complexity
  3. 7Pregnancy High Complexity
  4. 8Dominant Psychiatric Condition
  5. 9Dominant Major Chronic Condition

High need

  1. 10Multi-Morbidity High Complexity
  2. 11Frailty