Practice News

Segmentation

You may notice a test result appear in your NHS app referring to Johns Hopkins adjusted clinical groups score. Johns Hopkins segmentation system is a simple way of categorising patients based on their specific health needs. It 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.

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 University, 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?

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.

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.

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.
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.

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 your choice about sharing data from your health records – NHS

Published on 24th Oct 2025

Segmentation – Johns Hopkins adjusted clinical groups score

Published on 23rd Oct 2025

Mounjaro

Published on 18th Jul 2025

Data Opt Out

We have been asked to share the following important information with you. 

This practice is supporting vital health and care planning and research by sharing your data with NHS Digital. For more information about this see the GP Practice Privacy Notice for General Practice Data for Planning and Research." =

https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-collections/general-practice-data-for-planning-and-research

This collection will start on 1 July 2021

If you do not want your data to be shared with NHS Digital please register your Type 1 Opt-out with your GP practice by 23 June 2021.

What data is shared:

Data may be shared from the GP medical records about:

• any living patient registered at a GP practice in England when the collection started - this includes children and adults
• any patient who died after 1 July 2021, and was previously registered at a GP practice in England when the data collection started

NHS Digital will not collect patients’ names or addresses. Any other data that could directly identify patients (such as NHS Number, date of birth, full postcode) is replaced with unique codes which are produced by de-identification software before the data is shared with NHS Digital.

This process is called pseudonymisation and means that patients will not be identified directly in the data. NHS Digital will be able to use the software to convert the unique codes back to data that could directly identify patients in certain circumstances, and where there is a valid legal reason.

If you would prefer that your identifiable patient data is only shared for your own health care purposes, you can opt-out by registering a Type 1 Opt-out or a National Data Opt-out, or both.

 These opt-outs are different and they are explained in more detail below. Your individual care will not be affected if you opt-out using either option (or both).

A Type 1 opt out has to be registered by your Practice; please let us know if you want to register a type 1 opt out.  

A National Opt out can be done without contacting your practice, at https://www.nhs.uk/your-nhs-data-matters/

Type 1 Opt-out (opting out of NHS Digital collecting your data)

NHSD will not collect data from GP practices about patients who have registered a Type 1 Opt-out with their practice. More information about Type 1 Opt-outs is in the GP Data for Planning and Research Transparency Notice, including a form that you can complete and send to your GP practice.

This collection will start on 1 July 2021 so if you do not want your data to be shared with NHS Digital, please register your Type 1 Opt-out with your GP practice by 23 June 2021.

If you register a Type 1 Opt-out after this collection has started, no more of your data will be shared with NHSD. They will however still hold the patient data which was shared before you registered the Type 1 Opt-out.

If you do not want NHS Digital to share your identifiable patient data with anyone else for purposes beyond your own care, then you can also register a National Data Opt-out.

National Data Opt-out (opting out of NHS Digital sharing your data with other organizations)

NHSD will collect data from GP medical records about patients who have registered a National Data Opt-out. The National Data Opt-out applies to identifiable patient data about your health, which is called confidential patient information.

NHS Digital won’t share any confidential patient information about you - this includes GP data, or other information, such as hospital data - with other organisations, unless there is an exemption to this.

To find out more information and how to register a National Data Opt-Out, please read NHSD GP Data for Planning and Research Transparency Notice.

= https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-collections/general-practice-data-for-planning-and-research/transparency-notice

ALL MEMBERS OF THE HOUSEHOLD

The data held in your GP medical records is shared with other healthcare professionals for the purposes of your individual care. It can also be shared with other organisations to support health and care planning and research.

If you do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice. This is known as a Type 1 Opt-out.

a National Data Opt-out which is not done at GP practice level; for this, you must contact NHS Digital - more information about the National Data Opt-out is here: https://www.nhs.uk/your-nhs-data-matters/

 

You can use this form to:

• register a Type 1 Opt-out, for yourself or for a dependent (if you are the parent or legal guardian of the patient) (to Opt-out)
• withdraw an existing Type 1 Opt-out, for yourself or a dependent (if you are the parent or legal guardian of the patient) if you have changed your preference (Opt-in)

This decision will not affect individual care and you can change your choice at any time, using this form. This form, once completed, should be sent to your GP practice by email or post.

Yours faithfully

Long Furlong Medical Centre

 

Details of the patient

Title
Forename(s)
Surname
Address
Phone number
Date of birth
NHS Number (if known)

 

 

 

 

 

 

 

 

 

 

Details of parent or legal guardian

If you are filling in this form on behalf of a dependent e.g. a child, the GP practice will first check that you have the authority to do so.  Please complete the details below:

Name
Address
Relationship to patient

Your decision

Opt-out  

I do not allow my identifiable patient data to be shared outside of the GP practice for purposes except my own care.

Withdraw Opt-out (Opt back in))

I do allow my identifiable patient data to be shared outside of the GP practice for purposes beyond my own care.

Your declaration

I confirm that:

• the information I have given in this form is correct
• I am the parent or legal guardian of the dependent person I am making a choice for set out above (if applicable)

Signature

 

Date signed

 

When complete, please post or send by email to receptionists.longfurlong@nhs.net

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For GP Practice Use Only

Date received
Date applied
Tick to select the codes applied	Opt – Out - Dissent code: 9Nu0 (827241000000103 |Dissent from secondary use of general practitioner patient identifiable data (finding)|)
	Opt – In - Dissent withdrawal code: 9Nu1 (827261000000102 |Dissent withdrawn for secondary use of general practitioner patient identifiable data (finding)|)]

 

Published on 3rd Jun 2021