Cheshire and Merseyside uses data-led approach for vulnerable people

Cheshire and Merseyside Integrated Health and Care Partnership is using a data-led approach to help support vulnerable people who are facing fuel poverty.

Through the use of population health technology and targeted support, it has so far identified 1,317 people who are at risk of developing serious health issues due to fuel poverty. It has then been able to offer support, including more than £41,000 in household support funding, fuel vouchers, replacement boilers, medication reviews, Winter Warm Packs and referrals to healthcare and wellbeing teams.

Cheshire and Merseyside Integrated Health and Care Partnership is using a population health platform from Graphnet Health. The targeted population health, data-led approach is supporting the partnership to identify people who may otherwise have slipped through the net.

As part of the fuel poverty project, patients with severe COPD residing in deprived areas were focused on first, as living in a cold, damp home puts them at high risk of hospital admission.

Through a WarmHomes for Lungs project in St Helens,106 patients were referred to the St Helens Wellbeing Service, with 18 patients referred to the Pulmonary Rehabilitation Team, 19 onboarded to the COPD Telehealth Service and 82 patients receiving £500 payments from household support funds.

A similar scheme in Knowsley saw patients reviewed in a fuel poverty optimisation clinic resulting in inhaler changes, pulmonary function referrals, social prescribing initiatives and referrals to charity schemes.

The COPD programme is set to be expanded across Cheshire and Merseyside and will be supported by a fuel poverty toolkit which will be available online soon, to help others start similar projects.

Dr Rowan Pritchard, executive medical director, Cheshire and Merseyside Health and Care Partnership said: “The beauty of the CIPHA data is that it allows us to stratify our fuel-poor population using risk of admission, mortality risk and other factors such as living alone. Applying these filters means we can break down a big societal challenge like fuel poverty into more manageable and actionable chunks – allowing precise and targeted support to be delivered where it’s needed most.”

Dr Sarah Sibley, clinical lead for the Cheshire and Merseyside Respiratory Clinical Network and consultant chest physician at Liverpool and Chest NHS Foundation Trust, added: “These trailblazer projects show what can be achieved if you combine smart data with strong and active collaboration between the NHS and local partners. As well as expanding this approach to other parts of the Integrated Care System, there’s no reason why we can’t apply the same principles to other health challenges in future. It’s been invaluable to us.”

The Cheshire and Merseyside ICS has also recently expanded its waiting list initiative, across all nine acute trusts in the area, following a new agreement with tech provider C2-Ai.