1. Introduction

During 2013-14 Eastern Cheshire Clinical Commissioning Group (EC CCG), in partnership with Integral Health Solutions (IHS) – partners with Johns Hopkins University - has been piloting the Adjusted Clinical Groups (ACGs) tool within 8 large general practices with a total population of 80,000 (40%) of the CCG’s resident population.

The project has been managed by an inter-disciplinary and inter-agency Project Group including lead GPs with a special interest in business intelligence, commissioning and practice innovation. The practices have provided challenge to the process throughout the pilot with regards to patient benefit, the evidence-base and value for money, in relation to practice time.   Practices have also provided continual feedback on the design and content of the reporting functions, in terms of ease of use, clinical-relevance and reliability of the predictive model in identifying patients at risk.  

Some practices initially approached the pilot with a perception that risk stratification needs to demonstrate its value.  However, ACGs is now deemed by our practices as fundamental to delivering proactive care for the people of Eastern Cheshire.   At a practical level, the pilot has enabled multidisciplinary teams (MDT) to provide targeted interventions to patients identified as high risk and in some cases not known as such by their GP.  Without these interventions it is the clinician’s view these patients would, more than likely, have suffered a crisis, which would likely have resulted in a hospital admission. 

“Not only are we systematically using the tool to support the multi-disciplinary team work at practice and locality level, we are actively using the ACG Tool to support other practice activity such as medicines management”. (Priorsleigh Surgery).

In terms of business intelligence, ACGs is now central to our large-scale change programme - Caring Together - to inform our new model of health and social care.   By successfully risk stratifying the population of Eastern Cheshire, care professionals are able to target care to those people who most need it.  Indeed due to the CCG’s relatively high older population, we have identified a higher than average number of high-risk patients (7% compared to 5% nationally).   This is despite a relatively low deprivation factor and this illustrates how age and deprivation alone can underestimate need at local level.   That said we can now quantify the opportunity for more effective care coordination given that aggregate analysis of the ACG data shows that this 7% group accounts for 40% of total hospital and primary care expenditure.  By improving patient experience and clinical outcomes, we can realise the significant scope to mitigate primary care utilisation and pharmacy costs.  This point was reinforced during a 50-strong CCG-wide stakeholder workshop in January 2014, led by an Integral Health Solutions Case Manager.  Feedback from this workshop advocated care coordination, supported by risk stratification, as a crucial mechanism to address GP workload pressures and the consequent risk of burnout.


2. Learning Points

A key learning point is the need for experienced clinicians to work with GPs to embed the risk stratification tool into general practice.  Part of our success has rested with our determination to work intensively at the clinical interface, supported by Case Managers from Integral Health Solutions.  We have also learned that one-size fits all approach would not have worked well in Eastern Cheshire.  Integral Health Solutions responded flexibly to the feedback from practices by tailoring their ACG solution to meet our specific needs.  Indeed as we encountered inevitable technical issues during the pilot, it became clear that we would risk losing the engagement of practices without this flexibility in the system design.


3. Going forward

Following the evaluation of the pilot the CCG’s Risk Stratification Steering Group agreed that they would support the roll out of the ACG tool to all 23 GP practices within Eastern Cheshire.   However, one of the key requirements that arose from the Caring Together care model design work is that a risk stratification tool will either need to have social care input or be a joint risk stratification tool across health and social care.   Therefore the CCG and Integral Health Solutions, together with their links to the Personal Social Services Research Unit  at Manchester University  have devised a pioneering approach to  the inputting  of social care risk factors into the ACG model, and has launched its new risk stratification tool – iRIS-ACGs (Integrated Risk Intelligence Solution) that will not only better inform holistic, individualised  care planning and delivery, but also  predict high health and social care costs such as the risk of nursing home placement.    We look forward to collaborating with this important innovation that will inform the improvement of services for the residents of Eastern Cheshire.


Cheshire and Wirral CCGs - Continuing Health Care Five CCGs across Cheshire and Wirral were looking to develop a new service delivery model for the management of Continuing Healthcare, Complex Care, Funded Nursing Care and Quality and Safeguarding. The outputs of this work included a detailed Due Diligence Review. This included a review of the performance of the service (identifying areas of clinical and financial risks), a workforce review and productivity assessment, together with a set of detailed recommendations for the re-design of the CHC, complex care and FNC service. This subsequently led on to Stage 2 – developing the CCG transition model and plan as well as supporting the CCGs with the safe transition of CHC services by 1st February 2015. Following the successful, safe transfer of the service on 1st February 2015, we have been asked to support the CCGs with Stage 3 - the development of the Future Service Model and supporting business case to be delivered by July 2015.

Go back to Case Studies