Dr Sarah Phillips, chief medical officer at Kent Community Health NHS Foundation Trust (Credit: Kent Community Health NHS FT)
Graphnet Health has announced that its population health analytics have been embedded across almost nine million patients, supporting earlier intervention and reduced emergency care.
The firm says that almost one in six patients in England are being identified and stratified using the Johns Hopkins ACG System methodology through platforms delivered by Graphnet Health, moving population health analytics into routine operational use.
Patient identification and segmentation is used to inform decision-making across integrated care systems (ICSs), NHS trusts and primary care organisations.
Dr Priya Kumar, a primary care lead in this work, said: “Urgent care is a complex system to navigate. By embedding the ACG System segmentation tool into our systems, we are further supporting our clinicians with a greater understanding of the patient in front of them.
“Combining this with their clinical decision-making skills means our patients are being seen by the right healthcare professional first time, which creates time and space to care and improves the overall outcomes and experiences for our patients.”
NHS teams are able to identify rising risk earlier, enabling them to prioritise workforce capacity and redesign pathways around neighbourhood-based care.
In East Kent, a 12-month proactive care programme focused on people living with frailty and complex needs saw emergency department attendances fall by around 69% and emergency hospital admissions reduce by approximately 70% for the cohort involved.
Graphnet says that patients reported greater confidence in managing their health at home and feeling better supported by local services.
Dr Sarah Phillips, chief medical officer at Kent Community Health NHS Foundation Trust, senior lead for the programme and chair of the programme board, said: “We are delighted with these powerful results.
“The solution is not only making patients feel more in control of their wellbeing, but also proactively keeping people out of hospital and in the community – actively supporting the left shift in healthcare.”
At the system level, Frimley ICS has applied the Johns Hopkins Patient Need Groups segmentation model to urgent and emergency care data to better understand patterns of demand.
Analysis found that approximately 15% of total emergency department attendances – around 102 attendances per day – were driven by minor illness cases within defined cohorts, highlighting opportunities for earlier intervention and reduced reliance on acute care.
Population health analytics is also supporting operational change in primary care, where GP practices have used ACG-based segmentation to enhance triage processes, prioritise urgent cases more safely and route patients to the most appropriate clinician first time.
In October 2025, Graphnet and Luscii announced a partnership to launch Graphnet Remote Monitoring, an integrated platform which combines remote monitoring with population health and shared care records.
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