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Addressing fuel poverty through a population health management approach:
The Cheshire and Merseyside experience

By Lucy Malcolm, November 2023

Can smarter use of linked data improve the way we tackle the health harms associated with fuel poverty? In this blog Lucy Malcolm, Senior Digital Transformation and Clinical Improvement Manager at Cheshire and Merseyside Integrated Care Board, explains how population health management techniques are supporting a series of “trailblazer” projects enabling local teams to identify, engage and support the most susceptible patients.

As temperatures fall and the nights draw in, many of us will be reaching for the thermostat to warm up our homes during the cold winter months ahead. Yet for a significant proportion of our population – two in every five households across Cheshire and Merseyside – this is a far from straightforward choice.

Just under half a million households in our region were living in a fuel poverty ‘hotspot’ last year

According to government figures, just under half a million households in our region were living in a fuel poverty ‘hotspot’ last year. Being unable to heat your home properly causes hardship and misery for everyone affected, yet for those with respiratory and other underlying conditions it can be particularly harmful, significantly increasing their chances of complications and serious ill health.

In fact, it’s likely that many thousands of unplanned hospitalisations every year are directly associated with cold homes across the country, and the National Institute for Clinical Excellence (NICE) has said that simple preventative action to combat these health harms could prevent as many as 28,000 deaths each year.

As an integrated care system, working with Health Innovation North West Coast and supported by the Innovation for Health Inequalities Programme (InHIP), we wanted to find a better way of supporting those at greatest risk. Over the last eighteen months, we’ve therefore been working with local partners to develop a number of “trailblazer” projects using population health management (PHM) techniques to identify, engage and support specific cohorts of patients within their communities.

We’ve learnt a lot through this process and have brought our collective experiences together in a new blueprint document we’ve just published with Optum UK. This describes in detail:

  • how we engaged and supported teams to establish the trailblazer project sites;
  • how we used linked data to identify our target cohorts based on risk;
  • how the projects themselves were embedded and run on the ground; and
  • what difference this is making for patients in these communities.

In one area alone (St Helens), the interventions have already resulted in 93% of targeted patients being referred to local wellbeing and affordable warmth teams and 72% receiving payments from household support funds to support their heating needs – a total of £41,000 has been paid to these households that would otherwise have gone unclaimed.

While the blueprint provides a full account of what we did and how we did it, I wanted to share a few things stand out as being particularly important.

The first is the value of starting small and adopting a “test and learn” approach.

To date, we’ve worked with a handful of teams across our geography, developing target cohorts of between 50 to 100 patients in each locality. Being able to filter local data using tailored dashboard to identify and engage a small, manageable group of particularly high-risk patients has been crucial for demonstrating “the art of the possible”. This has given the programme a momentum of its own, enabling local teams to adapt and develop their approach based on what works best for their communities.

The second is around understanding the human realities of fuel poverty and the potential touchpoints.

We engaged widely across the trailblazer areas, bringing relevant people together from NHS, local authority and voluntary sector organisations in a set of facilitated workshops run by Optum UK. These gave professionals the opportunity to think deeply about how fuel poverty affects people on a human level, how it influences the way they experience local health and care services and what could make a difference at every touchpoint. Having these collective discussions helped to get everyone pulling in the same direction and building solutions that are truly anchored around the needs of the patient.

The third is the need to democratise access to relevant data.  

We’re extremely fortunate in Cheshire and Merseyside to have our Combined Intelligence for Population Health Action (CIPHA) platform, which brings together health and social care data in a single place. Graphnet, who run the platform for us, designed fuel poverty dashboards which allowed local teams to apply relevant filters and define target cohorts at a neighbourhood level. Giving access to the data has given health professionals the ability to identify high-risk patients and track their outcomes over an extended period – it’s been essential for enabling trailblazer projects like this to operate effectively on the ground.

The fourth and final lesson is the importance of scaling up and creating a greater momentum for change.

With three projects supporting adults with COPD already established, and a further two projects starting shortly focused on pre-school aged children with a respiratory wheeze, we’re only at the early stages of what is possible in Cheshire and Merseyside. Yet what we’re already seeing in the stories coming back from these trailblazer sites demonstrates the impact this is having: how it’s allowing community teams to work more effectively together in helping people access the right blend of social and medical care, housing improvements and financial support they need. And the testimonies of the patients themselves, as captured in our blueprint document, speak volumes.

As we get a clearer picture of how these interventions support longer term outcomes (including A&E attendances and unplanned hospital admissions), it’s important we start to build these solutions at scale across the region. So, if you’re a PCN or community respiratory team who wants to get involved as a future trailblazer site, please do get in touch – we can help you access the right data to define your target cohorts, map out and engage the relevant local organisations that can play a role, and support you in developing the right delivery model to suit your needs.

Cheshire and Merseyside ICS and Optum UK have produced a blueprint guide that provides a step-by-step guide detailing how population health management solutions helped to tackle the issue of fuel poverty for citizens in Cheshire and Merseyside.

To download the 24-page blueprint document, complete the form at the top of this page.
Lucy Malcolm, Senior Digital Transformation and Clinical Improvement Manager, Cheshire and Merseyside ICS
Blueprint guide: Tackling Fuel Poverty in Cheshire and Merseyside: A population health management approach
Cheshire and Merseyside ICS and Optum UK have produced a downloadable blueprint providing a step-by-step guide detailing how population health management solutions helped to tackle the issue of fuel poverty for citizens in Cheshire and Merseyside.

Complete the form below to download the blueprint.

By filling out this form, you agree to be contacted by Optum UK by telephone or email about relevant events, solutions and content pertinent to your role.
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