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This toolkit brings together assets developed with the teams across Cheshire and Merseyside to identify, engage and support those at greatest risk. 

Useful Resources


Cohort identification

This section contain links and instructions for accessing Cheshire & Merseyside’s Combined Intelligence for Population Health Action (CIPHA) dashboard and how to apply the filters to identify the patient cohorts we used, within your locality.

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

Our fuel poverty project has been covered in Forbes magazine - you can read the article here.

Dashboard access request form
Dashboard instructions including how to use the dashboard and apply filters.  

Dashboard instructions
These instructions explain how to apply filters within the CIPHA dashboard to identify the 2 cohorts we have focussed on to date: 

  • Cohort 1 - COPD patients - the numbers of people which fall within the COPD cohort identified through the project in each place. 
  • Cohort 2 - Pre-School Respiratory Wheeze - the numbers of children which fall within the identified cohort criteria in each place. 

Data collection

This section contains example data collection templates and patient feedback forms that were developed with our early adopter sites.

Data Capture Proforma
This spreadsheet is used by the Knowsley and St Helens Projects to track and collate services accessed by patients.

St Helens Patient Feedback Form
Used to gather qualitative data from patients on the impact of the project.                        
 

Pathways and processes

Here is a blueprint guide to the work that has been done to date. This section also contains the pathways and SOPs that were developed at Place level to implement this approach.

Blueprint 
This document provides specific information about the Population Health Management (PHM) approach informing this work and describes process, interventions, outcomes and lessons learnt. 

St Helens Warm Homes for Lungs Process Map 
Step-by-step process for delivering the St Helens COPD project.

Knowsley COPD Project Process Map
Step-by-step process for delivering the Knowsley COPD project 


Partners

We have produced an asset map of all of the partners we have engaged with, within Cheshire and Merseyside, to create our holistic approach to patient reviews.

Asset Map
This provides an overview of the various assets among the health, care, housing and voluntary sectors across C&M which are being used to support the fuel poverty agenda, directly or indirectly, or which could be used to target priority groups. 

Energy Projects Plus Eco4 Project
In Cheshire and Merseyside, Energy projects Plus are delivering the Government’s grant scheme for improving the energy efficiency of homes.  The aim of the ECO4 project is to assist potentially vulnerable residents to achieve whole-house retrofit.

St Helens Warm Home for Lungs Poster

     

 

Case Studies and evaluation

Fuel Poverty Evaluation Study undertaken by Graphnet

Project case studies
This document provides the use case for the fuel poverty dashboard in Knowsley and St Helens and includes four patient case studies from these projects

St Helens Warm Homes for Lungs Project

News and events
Graphnet Insights into Action webinar
This webinar explores how using data intelligently supports Integrated Care Systems to operate in a more agile manner, adapting and scaling up new services as demands change. We examine the demand and funding challenge in the NHS and how IT innovations can help to meet that challenge. It also features a summary of the Cheshire and Merseyside Fuel Poverty Project. 


Graphnet Fuel Poverty webinar
How can NHS organisations best work to identify specific health inequalities in a local area? How can partnerships supporting such initiatives be reliably forged between constituent members of ICSs? What data is needed, and how can it best be collected, analysed and stored? And once specific issues have been identified, how can they best be addressed?

This HSJ webinar, run in association with Optum, brought together a small panel to consider the answers to these and other questions.  

Optum webinar on Health Inequalities 
How can those in the NHS tackle fuel poverty? By linking data.

This webinar explores the story of how Optum have partnered with the NHS in Cheshire and Merseyside.  By integrating data on respiratory conditions with national fuel poverty data they have been able to proactively reach out and bring tens of thousands of pounds in financial support to people who were eligible, but not accessing it, as well as tackling gaps in care.

Using data to reduce health inequalities in Cheshire and Merseyside podcast
Professor Rowan Pritchard-Jones
Executive Medical Director, NHS Cheshire & Merseyside


Health project tackles fuel poverty
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