Risk Stratification


Risk stratification is a process that uses personal data from health care services to determine which people are at high risk of experiencing certain outcomes, such as unplanned hospital admissions.

Risk stratification tools can be useful in analysing the overall health of a population (known as ‘risk stratification for commissioning’) and for identifying which patients should be offered targeted preventative support to reduce those risks (known as ‘risk stratification for case finding.’).

These tools use a mix of limited historical information about patients (such as age, gender, diagnoses, and hospital attendance) as well as data collected in GP practices. The GPs can use their data to identity which of their patients would benefit from a certain preventative service. Risk stratification is a helpful tool to support GPs in identifying patients at risk.

The CCG may use data that cannot be tracked back to individuals, to understand the local population needs and plan for future requirements. This is known as ‘risk stratification for commissioning’.

NHS East Riding of Yorkshire CCG covers a population of circa 300,000. Our population is ageing and the numbers of older people as a proportion of the overall population will continue to grow in the future. It is important to ensure that individuals with long term conditions who are most at risk of hospital admission are identified and supported proactively by Primary Care and Complex Care Teams.

East Riding of Yorkshire CCG currently commission eMBED Health Consortium (Kier Business Services and Dr Foster Limited) to provide practices with a risk stratification solution. The risk stratification tool takes data from multiple sources (including Primary and Secondary care), to perform a risk assessment of East Riding of Yorkshire CCGs entire population. Using proven predictive models, the tool provides timely, comprehensive information to clinicians to support interventions for those patients most in need, ensuring better long term patient outcomes whilst driving down costs.

Bulk Data Extract
Data from the GP Practice system will be obtained by using a “bulk data extract”, uploaded directly by the risk stratification tool supplier from the practice system. Prior to the upload, the supplier will obtain permission from the practice to request the data from the practice system provider and the practice will notify their system providers that this permission has been granted.

The specific arrangements for authorisation and extraction vary by GP system provider, a chart of the process for the two main GP system providers is included here.

The data extract will EXCLUDE patients who have expressed a wish not to share information. Reports produced from the system including identifiable data is only provided back to your GP or member of your care team as data controller in an identifiable form, the CCG does not have access to identifiable information.

Your GP can provide more information about any risk stratification programmes they are using. Should you have any concerns about how your information is managed at the surgery please contact the Practice Manager to discuss how the disclosure of your personal information can be limited.