Continuity of care moved up the agenda for 2026/27. The Network Contract DES specification now includes the use of risk-stratification tools to identify and prioritise cohorts for continuity of care, which turns continuity from a description of how a network works into something it identifies, prioritises and can show.
The good news for anyone running a medicines team is that most of the machinery already exists. The searches that find patients for structured medication reviews, high-risk drug monitoring and discharge follow-up are pointed at very similar populations. What changes is the question you ask of them.
What risk stratification means in this context
Risk stratification is the process of sorting a registered list into groups by likelihood of a defined outcome, so that limited clinical time goes to the people most likely to benefit. It is not a single tool or a single score. In general practice it usually combines some mix of age, long-term condition count, medication count, recent unplanned activity, frailty scoring and deprivation.
For continuity specifically, the useful question is narrower than general risk: which patients get materially worse outcomes when they see a different clinician each time? That is a smaller and more identifiable group than the whole high-risk population.
Why medicines data is a strong signal
Medicines data is unusually good at finding the continuity group, for three reasons.
- It is structured and current. Repeat lists, issue dates and monitoring codes are recorded consistently, unlike much free-text clinical information.
- It moves early. A patient whose repeat list changes several times in a quarter, or whose monitoring lapses, is usually signalling instability before it appears anywhere else.
- It captures complexity directly. Medication count and high-risk drug presence are among the strongest available proxies for the patients who benefit from seeing the same clinician.
Cohorts worth building first
Networks that get somewhere with this tend to start with a small number of well-defined groups rather than a single large one. Four that consistently earn their place:
- High medication count with recent change. Patients on a large number of repeats whose list has changed in the last three months. High volume of clinical decisions, high value in one clinician holding the thread.
- High-risk drug monitoring due or overdue. DMARDs, lithium, amiodarone, anticoagulants. Continuity here has a direct safety argument, and the search already exists in most systems.
- Recent unplanned admission with a medication change. The discharge population, where the medication that came back is different from the one that went in. Small group, disproportionate benefit.
- Care home residents. Already a focus this year through the vaccination expectations, and a group where continuity is straightforward to organise because the population is geographically concentrated.
Each of these is a search, not a project. Most networks can build all four in an afternoon in EMIS or SystmOne.
Turning a cohort into something that actually happens
The step where this usually stalls is not identification. It is what happens after the list is produced. A cohort with nobody assigned to it becomes a report that gets filed.
Three things make the difference:
- A named owner per cohort. Not a team, a person. The cohort belongs to someone who reviews it on a fixed cycle.
- A defined action. “Review” is too vague to schedule. “Medication review with the same pharmacist within six weeks, then six-monthly” is schedulable.
- A recorded outcome. Coding the contact so the next search can tell who has been seen and who has not. Without this the cohort regenerates the same names every month.
Where a pharmacy team fits
Continuity does not have to mean continuity with a GP. For a patient whose complexity is medicines complexity, continuity with the same pharmacist often delivers more of the benefit, and is easier to schedule because the pharmacist is not also holding an urgent list.
In practice this looks like a named pharmacist holding a defined cohort, seeing the same patients across a year, running their reviews and monitoring, and escalating to a GP when the clinical question needs it. The GP keeps oversight and keeps the complex decisions. The patient gets the same person for the medicines conversation, which is the conversation they have most often.
That model also holds up when the pharmacist works remotely, because continuity is about who, not where. A remote pharmacist working in the practice system sees the same patients on the same cycle. We describe how that works day to day in remote clinical pharmacist services.
Measuring it without building a reporting project
A small number of measures is enough to show a cohort is being worked:
- Proportion of the cohort seen by their named clinician in the last review cycle.
- Proportion of high-risk drug monitoring within its interval for that cohort.
- Number of patients in the cohort with a completed structured medication review in the year.
All three come out of the same searches that built the cohort in the first place, which is the point. A continuity programme that needs its own reporting infrastructure tends not to survive a busy winter.
A sensible starting point
Pick one cohort, give it a named owner, define the action and the interval, and run it for a quarter before adding a second. Networks that try to stand up continuity across the whole list at once generally end up with a spreadsheet nobody opens. Networks that run one cohort properly usually have something worth showing by the end of the first cycle, and a method they can repeat.
If you want help building the searches or running a cohort, get in touch.
The continuity of care and risk-stratification expectations described here are taken from NHS England’s published Network Contract DES material for 2026/27, read in August 2026. Clinical cohort choices in this article are illustrative and should be agreed locally.
Frequently asked questions
What does risk stratification mean for continuity of care?
It is sorting a registered list into groups by likelihood of a defined outcome, so limited clinical time goes to the people most likely to benefit. For continuity the useful question is narrower than general risk: which patients get materially worse outcomes when they see a different clinician each time.
Which patient cohorts are worth starting with?
Four that consistently earn their place are patients on a high medication count whose list changed recently, patients on high-risk drug monitoring, patients with a recent unplanned admission where medication changed, and care home residents.
Why is medicines data useful for identifying these patients?
Repeat lists, issue dates and monitoring codes are recorded consistently and update frequently, so they move early when a patient becomes unstable. Medication count and high-risk drug presence are also among the strongest available proxies for complexity.
Can a remote pharmacist provide continuity of care?
Continuity is about who rather than where. A remote pharmacist working in the practice clinical system sees the same patients on the same review cycle, which is the same arrangement as an on-site colleague holding a cohort.
How should a PCN measure continuity without building a reporting project?
Three measures drawn from the same searches that built the cohort are usually enough: the proportion of the cohort seen by their named clinician in the last cycle, the proportion of high-risk drug monitoring within interval, and the number with a completed structured medication review in the year.
