NHS data is driving positive change in healthcare. From early diagnosis tools to remote care solutions, these real-life examples of data in action demonstrate how we can improve health outcomes and transform patient care in Cheshire and Merseyside.

The Enhanced Case Finding Tool uses a wide range of data to quickly identify individuals and groups who could benefit from early support and care.

This tool helps Integrated Care Neighbourhood Teams provide proactive, well-coordinated care on both local and regional levels.

Enhanced Case Finding Tool

The Enhanced Case Finding Tool draws data from general practice, hospitals, community services, mental health, and social care. This provides a broad understanding of the kind of health issues a person is living with, and the services that they are using (or not using). 

The Tool not only helps describe the population level challenges and opportunities across Cheshire & Merseyside, but it also has the functionality to drill down into local areas, GP practices, and wards, so that at-risk patients can be easily identified.  

A well-established risk stratification model – the Johns Hopkins model – is included in the tool. This model looks at factors around health and service utilisation and assigns a level of risk to an individual based on their history.  They may be at risk of being admitted to hospital or having an extended period in hospital – both of which can have a negative impact upon their overall health and wellbeing. 

We want to avoid people becoming unwell and needing a hospital stay. We also want to avoid people staying in hospital longer than they need to, as patients can deteriorate, lose their independence, acquire other infections, or experience some level of anxiety or distress from being away from home.

The Enhanced Case Finding Tool is designed to help find vulnerable groups of people, so that teams with the right skills, can find and care for them when they need it. These teams will work closely with GPs to ensure that any new developments are complementary to existing services. 

"This intelligence-led approach empowers community services, alongside GPs, to find and keep vulnerable patients safe and well at home. Population health management is everyone’s responsibility, and this Enhanced Case Finding Tool really helps that become a reality."

- Dr Janet Bliss, Clinical Director - Liverpool Place.

Telehealth 

The Telehealth Team delivers remote monitoring services across Cheshire and Merseyside, and West Lancashire, supporting around 2,000 patients a day with long-term conditions like COPD, diabetes, and heart failure.

Telehealth started using the Enhanced Case Finding Tool in January 2024 to proactively identify and onboard eligible patients for long term condition monitoring.  This has helped the team to increase its caseload from 300 to 1,500, which means they are able to help more than fives times as many patients to optimise their health.

To date, the following patient outcomes have been identified:

• 33% of patients made a lifestyle change.
• There was a 40% reduction in the need for patients to visit a hospital or GP.
• 74% of patients were more confident in managing their condition.
• Health has improved for 41% of patients.
• 56% of patients found that family and carers benefited.
• There was a 25.3% reduction in the number of emergency admissions for Telehealth patients*. 

*Retrospective observational study of the impact on emergency admission of telehealth at scale delivered in community care in Liverpool, UK - BMJ.

Healthcare professionals can refer patients to the service if they believe it would be beneficial, even if the patients don’t fully meet the specified criteria. The criteria are intended as a guide, not a strict requirement, ensuring flexibility to support those who may benefit.

The service has been positively received in the area, with local GPs reporting that they have been able to identify patients they might not have otherwise considered for referral.

We are working closely with key stakeholders, including the Local Medical Committees, to continually monitor and adapt the service as we gain new insights and understanding.

Fuel poverty refers to a situation where a household is unable to afford to heat their home adequately. This might be due to a combination of low income, high energy costs, and poor energy efficiency in the home.

When someone experiences fuel poverty, they might struggle to keep their home warm enough during colder months, which can lead to various health and wellbeing issues. Those with circulatory and respiratory problems are especially vulnerable to poor health due to fuel poverty. Depression and anxiety are also more prevalent in cold homes.

In October 2022, estimates showed that 42% of households in Cheshire and Merseyside were likely to be impacted by fuel poverty in 2023, meaning thousands were at risk of worsened health.

In response, a fuel poverty dashboard was created via funding from the Innovation for Health Inequalities programme (InHip).

Organisations in Cheshire and Merseyside can access the fuel poverty dashboard, which enables identification of high priority cohorts of people based on a range of data, including demographic, diagnosis, deprivation and prescription data. The level of data available is subject to individual roles and a non-patient identifiable version is available.

St Helens Warm Homes for Lungs

The St Helens Warm Homes for Lungs programme was first rolled out in February 2023, and uses the fuel poverty dashboard to identify chronic obstructive pulmonary disease (COPD) patients that might benefit from more support.

Health staff then work with the local council to help address poor living conditions, alongside regular clinical care, and remote monitoring.

In 2023, 418 patients were identified by the St Helens Community COPD Team. Of these patients:

• 77% were referred to the St Helens affordable warmth team.
• 76% received a Warm Homes booklet and a vitamin D voucher.
• 58% had their medication optimised and developed a self-management plan.
• 56% were provided with volumatic spacers.
• 56% received a pulse oximeter.
• 54% received a £500 payment from local authority household support funds.
• 43 patients also received a second payment of £500. 
• 40% were referred to wellbeing social prescribers, smoking cessation, health trainers, and/or weight management services.
• 10% were new patients referred to COPD team.
• 9% were referred to pulmonary rehabilitation.
• 5% were onboarded to COPD Telehealth.

In total, £135,500 of payments were facilitated.

Nurse and service manager Dianne Green from the Mersey and West Lancashire Teaching Hospital said that she’d “never transformed lives like this” since she first worked as a nurse in 1986.

“As a community nurse, we regularly go into patients houses but they never tell us that they can’t afford a light bulb upstairs, they never tell us that they’re really struggling to pay the bills,” she said. “The difference that we’ve made by looking at them and their lives through different eyes, using this population health technology, is unbelievable.”

St Helens preschool wheeze

Preschool wheeze is when children under the age of five wheeze. It can be heard from the chest and is caused by the airways narrowing. It is very common, with 1 in 3 children having an episode of wheezing by the time they are three years old. 

The dashboard was used to identify children aged 2-7 who:

• live in areas with the highest levels of fuel poverty and deprivation,
• have used a Salbutamol inhaler in the past year,
• had one hospital admission within the same period, and
• live in households with five or more occupants.

These patients were then directed to a range of services that offered comprehensive care to significantly improve health outcomes.

Clinical interventions: Patients had access to inhaler reviews, diagnostics asthma therapy, and inhaler training. GPs were notified of all interventions via letters.

Family hubs: The social prescribing services provided families with access to warm hubs, food banks, PATCH funding, and smoking cessation services.

Breathe Buddies: Families were offered holistic, non-clinical support that includes self-care training, 1:1 peer support, play groups and workshops suitable for children and parents.

Home improvement team: Families were provided with financial and housing support, including home visits, referrals to the housing department, home safety checks, and energy efficiency measures by Energy Plus.

Air quality improvement: 500 homes were targeted and provided with air quality advice and guidance. Households are provided with air quality monitors.