Core20Plus5 Dashboard

The Core20Plus5 dashboards provide detailed insight into the most vulnerable and high-risk patient groups in your PCN, helping you prioritise interventions where they can have the greatest impact. Data is presented across four tabs, each offering a different view.

1. Plus 5 Totals

• Shows the number of patients in each practice who have Core 20 +1, +2, +3, +4 or +5 other high-risk factors.

• Provides a quick way to identify where the most complex and vulnerable patients are concentrated.

• Hover over any number to view a trend chart for that practice over time.

Use it for:

• Targeting resources at practices with the highest multi-risk patients.

• Tracking whether high-risk patient numbers are increasing or decreasing.

2. Area Totals

• Displays the number of patients for each individual element of Core20Plus5 in every practice.
  

• Core20 (deprivation measure): Townsend Score > 2.5.

• Plus 5 elements:

  • Cancer diagnosis in the last year

  • COPD

  • Currently pregnant + BAME or most deprived

  • Hypertension case finding

  • Severe Mental Illness (SMI)

• Hover over any value to see the trend for that element in the selected practice.

Use it for:

• Understanding the prevalence of each risk factor within each practice.

• Pinpointing specific high-need groups for targeted interventions.

3. Plus 5 Totals Trend

• Shows the PCN-wide trend over time for Core20 +1 through to Core20 +5.
  

• Allows you to see whether multi-risk patient numbers are growing, stable, or declining.

• All practices are included in the totals.

Use it for:

• Monitoring the overall PCN trend for complex patient groups.

• Measuring the impact of population health programmes or targeted outreach.

4. Area Totals Trend

• Displays the PCN-wide trend for each individual Core20Plus5 element.
  

• Tracks changes in:

  • Townsend Score > 2.5

  • Cancer diagnosis in the last year

  • COPD

  • Pregnancy + BAME or most deprived

  • Hypertension case finding

  • Severe Mental Illness

• Lines on the chart represent each element, with exact patient numbers available when hovering over any data point.

Use it for:

• Identifying emerging trends in specific high-risk groups.

• Tracking the success of condition-specific interventions.

✅ Tip: The ability to hover over any number in the Plus 5 Totals or Area Totals views to see historical data makes it easy to combine snapshot information with trend analysis, giving you both the "what now" and "how it’s changing" in one place.