Customer stories
Delivering a more holistic and targeted approach to tackling fuel poverty
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Fuel poverty is on the rise in the UK and represents a major public health threat, contributing to thousands of preventable deaths a year. In Cheshire and Merseyside, local integrated neighbourhood teams have successfully applied population health management principles to deliver effective and targeted support for those at greatest risk.
Overview
Supported by NHS England’s Innovation for Healthcare Inequalities Programme (InHIP), Cheshire and Merseyside ICB and Health Innovation North West Coast has brought together NHS, voluntary and community sector and local authority partners to explore new ways of helping people with respiratory illness who are living in fuel poverty.
Drawing on analysis of its linked dataset – which combines GP data with secondary care, mental health, social care and other socio-economic datasets – the programme identified population groups at greatest risk of harm and then established several ‘trailblazer’ projects across the area to support them. These involved multidisciplinary teams working together to reach out to high-risk groups with targeted and holistic support.
Being able to show people that you can quickly and easily identify a small cohort of high-risk patients to zero in on, instantly made this feel more manageable and realistic for local teams. It’s helped people see ‘the art of the possible’ and has really given the trailblazer projects a momentum of their own.”
Approach
Working in conjunction with Optum and Graphnet, the Cheshire and Merseyside project team combined analysis of fuel poverty hotspots with health data assessing the vulnerability of its fuel-poor population to potential health harms. This helped to identify two target cohorts: an adult group with a COPD diagnosis who lived in neighbourhoods with the highest rates of fuel poverty and carried a 50% or higher risk of an emergency admission; and a children’s group, aged 0-4 years, prescribed a salbutamol inhaler in the past 12 months, and with a 5% or higher chance of emergency admission.
Optum then facilitated workshop sessions involving clinicians and other professionals across NHS, local authority and voluntary sector organisations to interrogate the data and work together to develop targeted actions to support people at risk. This resulted in the development of local trailblazer projects, with integrated teams working together to offer a more holistic package of care to these groups.
Key numbers
1.5m people risk harm from poor home heating.
490K of these are known to live in a fuel poverty ‘hotspot’.
Impact generated
Delivering a more proactive, integrated and person-centred model of care
The trailblazer sites helped people connect to a wider range of NHS, council and community-based services through a single point of contact. The support available included: arranging medicines reviews and other health assessments, making referrals to respiratory clinics, connecting people to financial aid, organising housing repairs and other social services, and signposting mental health services or wider sources of community support as required.
Ensuring vulnerable people get the financial assistance to which they are entitled
A major focus has been on ensuring clinically vulnerable people living in fuel poverty could access the Affordable Warmth funding on offer from the local council. In one trailblazer site, payments totalling over £100,000 have been made to patients, who have also been reviewed by the specialist nursing team and offered a pulse oximeter and a warm home pack. As one beneficiary described, this has helped free them from what had previously been “a choice between heating my home or using my oxygen”.
Laying the foundations for delivering similar models at scale
Drawing on the success of the trailblazer sites, the ICB programme team is now working with its place directors, Health Innovation North West Coast, and other local stakeholders to fully evaluate the benefits generated, share key lessons, and identify other opportunities to expand this approach. This includes building an implementation toolkit, which is being used to help deliver similar integrated models at scale across the ICS.
Through the fuel poverty dashboard, we’ve been able to identify patients in need and target them in a completely different way. As nurses, at the click of a button, we now have all the information that we need for those patients to truly help them. It is hard not to cry when speaking about the importance of this work, and how it has helped the patients that I support. It is truly proactive.”
Blueprint guide
Learn more about how Cheshire and Merseyside use data-driven PHM strategies for addressing health inequalities in our blueprint guide.
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