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Segmentation – Johns Hopkins adjusted clinical groups

You may notice a test result appear in your NHS app referring to Johns Hopkins adjusted clinical groups. In order to help us tailor care according to individual patient need, we now have access to a tool that segments or categorises our patient population into Patient Need Groups (PNGs). This system of segmentation, called the ACG^® System, was developed by Johns Hopkins University¹, which is renowned for its contributions to advancing medical practices and healthcare systems globally. Segmentation helps us as a practice understand the individual needs of our patients based on their health and wellbeing to support personalised care and ensures you get the right support in a timely way.

What are PNGs and how are they used in healthcare?

Patient Need Groups categorise patients into different groups based on the complexity and intensity of their healthcare needs rather than just their medical conditions.

Instead of focusing solely on a diagnosis (like diabetes or heart disease) it takes in to account a broader range of health characteristics about a patient.

How do PNGs work?

These groups consider factors like the number of chronic conditions (eg diabetes, heart disease, asthma, cancer, dementia, …) the severity of illness and the level of support a patient might need.

The patients in a particular group have similar patterns of need.

For example:

Red PNG 10,11 = Complex Care Needs: Patients with multiple chronic conditions, requiring regular monitoring and a coordinated care approach.

Amber PNG 5-9 = Stable Chronic Conditions: Patients with chronic conditions that are well-managed and require occasional support to maintain their stability.

Green PNG 1-4 = Healthy: Patients without significant health issues who could benefit from preventive care.

As patient needs change over time, their categorisation changes with them.

PNG offers an at-a-glance indication of a patient’s broader needs, at a point in time.

What are the benefits of having this information available on patient records?

1. Personalised Care: Healthcare providers can use PNGs to tailor their care plans. This means patients receive the specific type of care they need, whether it’s more frequent monitoring, specialised treatment, or preventive care.
2. Improved Coordination: PNGs help healthcare teams coordinate more effectively. If a patient has complex needs, the care team can work together to ensure all aspects of their health are addressed, from medication management to lifestyle support.
3. Better Resource Allocation: Hospitals and GP Surgeries can allocate resources more efficiently based on the needs of different patient groups. This ensures that patients with the most urgent needs receive timely care, while those with less critical conditions are managed appropriately.
4. Proactive Health Management: For patients in lower-need groups, PNGs encourage preventive care and early intervention. This can help them maintain their health status and avoid complications in the future.
5. Enhanced Communication: PNGs facilitate better communication between patients and healthcare providers. By understanding which group a patient falls into, together they can have clearer discussions about what to expect from the care they receive and what actions they can take to manage their health.

Why don’t I have a Johns Hopkins adjusted clinical groups score in my test results?

If you have previously opted out of sharing your health record with local health services and/or used the national data opt-out, you will not have a score.

What if I am unhappy about my data being used for population health management?

The ACG^® system helps us to help you get the right support at the right time based on your specific health needs. However, if you wish to opt out, you can do so by choosing ‘national data opt-out’: Make you choice about sharing data from your health records-NHS 

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News Section

We're in the process of updating our news section more regularly. Be sure to check back for our latest updates!

New Staff

We are delighted to announce we will have a full nursing team from 1st Febuary 2024, 

Jacqueline Fletcher - Practice Nurse

Caroline Hill - Practice Nurse

Karen Ballett - Healthcare Assistant

Ruth Miller - Healthcare Assistant

We look forward to them joining our team! 

Link for Appointment/Admin Requests

https://florey.accurx.com/p/K82028

Spring update 2023

We continue to face severe challenges in the practice, in General Practice,
and in the NHS as a whole.  Demand continues to be very high as we continue
to recover from COVID, deal with backlogs and have added pressures due to
long waiting lists in the hospitals.  We are still working very hard to deal
with as many patients as possible and, when we can, are trying to use the
additional staff the NHS has provided such as Pharmacists, Physiotherapists,
Social Prescribers, and Health and Wellbeing Coaches.



New nurses

We were very sad that our three long-established Practice Nurses retired
over the last five months.  Jenny, Bev and Chris were dedicated and caring
nurses who had a huge range of experience and expertise between them.  We
wish them all a long and healthy retirement.  With the current state of
recruitment in the NHS, we have struggled to replace them but are delighted
to be now joined by Aleksandra and Rebekha.  Please welcome them and be
patient as they train and get used to the ways we work.  Teresa will also be
joining the team as a health care assistant as John has moved to a new role
in the NHS.



New GP contract

Like the rest of the NHS, General Practice is really struggling.  Rather
than working with GPs to improve the situation for patients and practice
teams, the Government has decided to impose a new contract on GPs in
England.  This forces us to make changes to how we use our time and our
staff.  Sadly, despite media reports, there are no new resources with this
contract so staff will be under additional pressure, not less.  The main
focus of these changes has been on "access" - making it easier for patients
to contact the practice.  This is welcome but does not ultimately help
patients if we do not have more doctors or nurses to meet people's needs.



New system for contacting the practice

If you need an appointment with one of our nursing team, such as for an NHS
vaccination, cervical smear, dressing of a wound, chronic disease management
clinic or a blood test requested by your GP, please contact the practice by
phone in the usual way.



If you have a problem and you think you need to consult with a GP, a
pharmacist, a physiotherapist or another of our attached staff, we are
introducing a new online form from Tuesday 16th May 2023 which you can
complete from a computer or a mobile phone.  We will be using the AccuRx
system which we have used successfully for some time to send text messages
to patients.  We chose this system as it is very simple to use with just a
few questions for you to explain your problem without the need to go through
a long list of online questions.  We will ask all patients to complete this
form themselves if they can.  By completing the form yourself, you will free
up time in our receptionist team so that they can help people who cannot do
the form and they can also support other patients quicker.  All the requests
for appointments will then be assessed in the practice to determine the best
member of the team to help and how quickly an appointment might be needed.
This form can also be used for administrative queries such as requests for
sick notes, letters, questions about referrals, or requesting copies of test
results.  There will be links to the online form on the practice website,
our Facebook page, shared with our Patient Participation Group and will be
sent directly to patients where we have a mobile phone number.



We will continue to try to deal with all urgent requests on the day but once
we are fully booked, you may be directed to another service.



We will offer booked telephone appointments for routine issues in the future
up to six weeks.  If you need to be seen, have further tests or treatment,
these will be arranged during the phone call.  If these appointments are
fully booked and we are unable to offer an appointment, we will start a
waiting list for appointments and let you know when we can offer one.



New phone system

We will also be getting a new telephone system on Monday 22nd May.  This was
ordered before the recent Government announcements.  This will allow more
flexibility with new features including the ability for patients to opt for
a "call back" when they reach the top of a queue, rather than having to stay
on hold.  There will also be no limit on the call queue so you should never
hear an engaged tone when calling in.  We have been told there will not be
any disruption on the day but please bear with us if there are problems.
Our phone number is not changing.



There is a lot of change happening and a good deal of it beyond our control.
Please bear with us as we try to manage this. We will continue to do our
best for our patients with the resources we have.  Sadly, we recognise we
will not be able to provide all our patients with everything they want and
need.



We will monitor closely these changes and work with our Patient
Participation Group (PPG) to make changes as we can.  Please feedback to the
PPG who will help collate responses for us.

Spring 2022 Update for patients

Click here for the Spring 2022 update for patients.pdf