Delivering a more holistic and targeted approach to tackling fuel poverty
Tuesday, 12 November 2024
Cheshire and Merseyside fuel poverty project
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), NHS Cheshire and Merseyside 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.
Approach
Working in conjunction with Optum UK 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
- 1.54m people across Cheshire and Merseyside have a medical condition that would seriously increase their risk of harm if their home was poorly heated.
- 490,000 of these are known to live in a fuel poverty ‘hotspot’, defined as being in the top 20% of most fuel poor areas in the country.
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.
What they said
“What we’re seeing in our trailblazer sites is extremely positive. The application of this data and intelligence on the ground is actively transforming how community teams support their patients and service users – helping us to unlock new possibilities, fresh avenues of support, and better partnerships across the community to improve their wider health and wellbeing.”
— Professor Rowan Pritchard Jones, Medical Director, NHS Cheshire and Merseyside
“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.”
— Lucy Malcolm, Programme Manager, NHS Cheshire and Merseyside
“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.”
— Dianne Green, community respiratory nurse at Mersey and West Lancashire Teaching Hospital, and lead COPD nurse for the St Helens Community COPD Rapid Response
“Sharing good practice is vital for developing an effective, system-wide approach to addressing complex issues like fuel poverty. We are pleased to be working with Cheshire and Merseyside to capture the lessons from these projects and support their ongoing efforts to expand this approach.”
— Rhiannon Clarke, Respiratory Programme Manager, Health Innovation North West Coast
Optum has worked with Cheshire and Merseyside ICB on a detailed blueprint describing how this programme was developed. Click here to download your copy now.