Risk stratification

Risk stratification is a process of identifying people who may be at higher risk for health issues, allowing healthcare providers to focus on those who need extra support or preventive care.

Preventing people from becoming ill or developing more serious health issues is critical. It saves lives by catching potential health issues early, often before they become serious. Proactive measures are not only more effective but can also reduce the need for costly treatment after a condition has developed.

Analysing data to predict which patients may face health complications or deteriorating health allows healthcare professionals prioritise support for most vulnerable populations. For example, if data shows certain patients are at higher risk for chronic conditions, they can receive more frequent check-ups, lifestyle guidance, and personalised care plans.

This approach helps prevent hospitalisations and emergencies, improving patient outcomes and reducing strain on healthcare services. Risk stratification helps the NHS and care providers prioritise those at highest risk, ensuring resources are used effectively to support a healthier population and a more sustainable healthcare system.

How it works

Risk stratification uses advanced algorithms and data analysis to evaluate patient data and identify those at higher risk for conditions such as diabetes, heart disease, and respiratory issues.

To conduct risk stratification, national datasets are linked with GP data using the NHS Number and an algorithm is applied to produce risk scores. Risk stratification provides focus for future demands by enabling commissioners to prepare plans for both individual and groups of vulnerable patients who may require elevated levels of care.

Risk stratification helps GPs focus interventions on patients who may need extra support. Using a tool called Eclipse, which uses advanced predictive data analysis, GPs and NHS Mid and South Essex can identify groups of patients at higher right and plan targeted interventions in primary care.

Patient data is initially de-identified to protect privacy, but it can be re-identified by the patient’s GP practice if needed for direct care. NHS Mid and South Essex ensures this process complies with all legal and ethical standards, safeguarding patient confidentiality while allowing for informed clinical decision-making.

What we aim to achieve

The primary goal of effective risk stratification is to create a more focused and proactive approach to patient care, particularly for people who are identified as high-risk. These people receive tailored interventions aimed at preventing serious health events and issues, such as hospital admissions or complications arising from chronic conditions.

This proactive approach not only improves individual patient outcomes but also leads to a more efficient allocation of NHS resources. By focusing on prevention rather than reactive treatment, NHS Mid and South Essex can ensure that care is delivered to those who need it most, ultimately contributing to the overall health of the population and the sustainability of NHS services. Additionally, insights from risk stratification enable continuous improvements in care delivery, helping to address and reduce health inequalities across the community.