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Long Term Conditions Project

The NHS in Heywood, Middleton and Rochdale is testing a new project to improve care for people who have, or may develop, long term health conditions. Through analysis of patient data, we aim to identify more quickly those people most at risk from chronic ill health, such as diabetes and heart and lung diseases. As well as offering more timely and personalised care to people with existing conditions, we hope to identify those who have not yet even been diagnosed. That means we can treat them earlier and keep them healthier longer.

General Practitioner’s will be able to identify patients who are at greatest risk of developing long term illnesses and to intervene earlier, preventing ill health or delaying its onset. For those patients who have already been diagnosed with a long term condition, GP’s will be alerted to those at greatest risk of a further deterioration in their health and help them avoid the need for emergency care.

The project is a partnership between:

  • NHS Heywood, Middleton and Rochdale Clinical Commissioning Group
  • HMR GP’s
  • MSD Informatics
  • Verily Life Sciences

The project is part of a national programme to pilot the impact of new technologies in the NHS to develop better care for patients as well as better value for taxpayers. It aims to find innovative new ways to improve health. The national programme is overseen by NHS England.

The role of each testbed partner is:



HMR GP Member Practices

Provide a pseudonymised GP dataset to use during risk stratification


Provide a pseudonymised SUS dataset to use during risk stratification

MSD Healthcare

Develop risk stratification software that can be used in GP Practices to identify patients with or at risk of developing Long Term Conditions.

MSD will develop a combined pseudonymised dataset that can enhance the risk stratification process

Verily Life Sciences (formerly Google Life Sciences)

Develop risk stratification algorithms in partnership with MSD Healthcare using population and environmental data, localised to HMR, to enhance the MSD software product above.

Verily will build the algorithms using the combined pseudonymised dataset created by MSD Healthcare

University of Manchester

Evaluate the healthcare outcomes of the Long Term Condition project following the application of the tools and interventions developed. The evaluation will use anonymised data provided by MSD Healthcare

You can find out more about this project online at:

If you have a particular question, you can email us at:

Patients have a right to opt out of their information being used during this programme. GP practices must make patients aware that their information is being used during this purpose and that they have a right to opt-out. This information is required for compliance with Principle 1 of the Data Protection Act. NHS England guidance is that GP practices should provide information to patients explaining how their data will be used and what to do if they have any concerns or objections.

If you wish to opt out of this project please contact your GP Practice or the Test Bed Team as above for more information on how to do this.

Your information will not be sent outside of the EU where the laws do not protect your privacy to the same extent as the law in the UK. We will never sell information about you.

Risk Stratification (Pro-Active Care Management)

Risk stratification is a process GP’s use to help them to identify and support patients with long-term conditions and to help prevent un-planned hospital admissions or reduce the risk of certain diseases developing such as type 2 diabetes. This is called risk stratification for case-finding.

The Practice gives the CCG Permission to use risk stratified data to understand the health needs of the local population in order to plan and commission the right services. This is called risk stratification for commissioning. The CCG does not have access to your personal data. The information is de-identified / pseudonymised.

NHS England encourages CCG’s and GPs to use risk stratification tools as part of their local strategies for supporting patients with long-term conditions and to help and prevent avoidable admissions. Knowledge of the risk profile of our population will help the CCG to commission appropriate preventative services and to promote quality improvement in collaboration with our GP practices.

Risk stratification tools use various combinations of historic information about patients, for example, age, gender, diagnoses and patterns of hospital attendance and Admission (secondary care data). The CCG will use anonymised information to understand the local population needs, whereas GP’s will be able to identify which of their patients are at risk in order to offer a preventative service to them.

The CCG with the Practices permission also uses MSD Healthcare to assist with risk stratification specifically related to the Long Term Conditions Project detailed below. MSD Healthcare will work with pseudonymised data to combine data analytics with the goal of helping reduce the risks of Long Term Conditions for HMR residents. The project seeks to develop a tool combining data analytics with a telehealth service for managing patients at risk of developing Long Term Conditions and is designed to help medical professionals better predict who may be at risk and therefore monitor and/or take preventative action where appropriate.

MSD are an NHS England approved risk stratification supplier on behalf of HMR PRACTICE. For the full list of registered risk stratification suppliers, please visit: 

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