The 2025/26 GP contract introduced risk stratification as part of the Capacity and Access Improvement Payment. The 2026/27 contract embeds it as a core PCN requirement — no longer optional, no longer just for payment purposes. PCNs must use digital risk stratification tools to identify and prioritise cohorts for continuity of care.
What Risk Stratification Is
Risk stratification uses patient data — diagnoses, medications, age, hospitalisation history, A&E attendance, and utilisation patterns — to assign a risk score to each patient on the practice register. The score predicts which patients are most likely to deteriorate, be hospitalised, or benefit from proactive intervention.
The purpose is not to label patients but to prioritise resources. In a system where every GP has far more patients than they can proactively manage, risk stratification identifies the patients who will benefit most from continuity of care (seeing the same GP), proactive review (rather than waiting until they present in crisis), and complex care planning (rather than reactive, problem-by-problem consultations).
What the Contract Requires
PCNs must certify that they are using digital risk stratification tools, have risk-stratified their patients in accordance with need, have identified patients who would benefit most from continuity of care with a named GP where appropriate, and are taking action on the intelligence the tools provide. This is not a tick-box exercise — the expectation is that risk stratification actively informs how PCNs allocate clinical time and continuity.
Which Tools Qualify
The contract does not mandate a specific tool. Several options integrate with EMIS and SystmOne: NHS England's Core20PLUS5 approach for population health management, Eclipse for predictive risk modelling, RAIDR and other population health tools available through ICBs, QAdmissions for predicting hospital admission risk, and built-in risk stratification features within GP clinical systems. Most GP clinical systems now have some level of embedded capability. The key is ensuring it is switched on, regularly run, and acted upon.
What to Do With the Output
This is where the clinical challenge begins. A risk stratification tool flags a patient as high-risk. The patient needs a structured review — one that addresses their specific risk factors, reconciles their medications, reviews their chronic conditions against current guidelines, and establishes a continuity plan.
These are exactly the consultations where clinical reference tools matter most. When you are seeing a complex, multimorbid patient identified through risk stratification, Ask iatroX provides instant, NICE-grounded answers to the clinical questions that arise: medication interactions, treatment thresholds, referral criteria, and care process requirements. Brainstorm supports structured clinical reasoning for patients whose complexity defies simple guideline application.
The risk stratification tool identifies the patient. The clinical knowledge tool helps you manage them effectively. Both are necessary. Start with your clinical system's built-in risk stratification, ensure it is running, review the output monthly, and use iatroX to support the clinical decisions that follow.