At Kumar Medical Centre (KMC) in Slough, innovation is driven by the needs of a diverse and often underserved population. Recognising the limitations of traditional models, particularly for managing long-term conditions, the team adopted Johns Hopkins Patient Need Groups (PNGs) to stratify patients based on clinical and social complexity, rather than birth month.
By embedding PNGs into both QOF reviews and urgent care triage, KMC transformed care delivery. High-risk patients are prioritised, appointments are tailored digitally or face-to-face and low-complexity cases are efficiently redirected to services like Pharmacy First. This data-driven approach led to significant improvements with 90% of QOF reviews completed by September 2023, with 70% of patients achieving clinical stability ahead of winter. It also streamlined workflows, freeing up valuable time and capacity for proactive, targeted outreach.
Crucially, this freed-up capacity enabled the team to continue the multigenerational household visits, addressing immunisations, overdue screenings, preventative care, and wider social needs all in one setting. These visits built trust, removed access barriers, and empowered families to invest in their health.

• Understand limitations of traditional care for long-term conditions.
• Explain Johns Hopkins Patient Need Groups (PNGs) and patient stratification by complexity.
• Describe embedding PNGs into QOF reviews and urgent care triage.
• Recognise benefits of prioritising high-risk patients and redirecting low-complexity cases.
• Appreciate how data-driven workflows free capacity for proactive outreach.
• Explore multigenerational household visits to address clinical and social needs.
• Reflect on building trust and reducing access barriers in underserved populations.