Seven Quick Wins – 3

In conjunction with our long term collaborators Johns Hopkins Healthcare, we have devised seven ‘quick wins’ for the delivery of population health analytics that supports Population Health Management strategies.

The third of these seven ‘quick wins’ is….

#3 Focus on the very small number of patients with the highest number of GP visits



  • About 1% of patients account for about 9% of GP appointments
  • Need to separate out the ‘needy’ from the ‘noisy’
  • The noisy patients may not need support from a clinician – they might benefit from intervention from a social prescriber for example


  • Undertake segmentation analysis using GP visit count as one dimension and RUB as the second dimension
  • GP visit count can aggregate into 5 or 6 groups based on number of visits – 0, 1-2, 3-9, 10-19, 20-29, >30 for example
  • Review the 1-2% of patients who are in the highest visit groups but who are in RUB 0 or RUB 1



  • Potential reduction in multiple visits from small number of patients
  • Release of ~5% of GP capacity
  • Increase patients and staff satisfaction
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