In our recent Graphnet Health webinar, Population Health from Data to Impact: Proactive Care for Complex Patients, we were joined by two trailblazers in population health transformation: Andrea Astbury, Programme Director for Data Into Action at NHS Cheshire and Merseyside, and Chris Buckels, Deputy Head of Business Intelligence (Population Health Into Action) at the Cheshire and Merseyside Integrated Care Board.

Hosted by Graphnet’s Director of Health Analytics, Sarah Adams, the session showcased how the region is moving beyond traditional reporting to deliver proactive, insight-driven care for patients with complex needs.

“It’s been a journey of learning as we go,” said Andrea. “We’ve often felt like we’re building the aeroplane while flying it - but it’s working, and it’s changing how care is delivered.”

From Reports to Real-World Impact

Cheshire and Merseyside’s Data Into Action programme is a system-wide effort to translate population health data into decisions that directly improve care. Rather than working in silos or reacting to crises, the ICS is proactively identifying patients who may be at risk and intervening earlier.

Chris Buckels explained how the programme is structured to support clinical and operational teams on the ground:

“We’re trying to bridge the gap between analytics and action. That means embedding insights into everyday pathways and making them accessible to people who can do something with them.”

This involves everything from interactive dashboards and virtual clinics to advanced risk stratification models - underpinned by the shared data infrastructure provided by Graphnet.

Expanding the Data Horizon: Housing, Environment and the Wider Determinants of Health

One of the most forward-thinking aspects of the session was the ICS’s focus on broadening the scope of its data to include non-healthcare determinants - especially housing.

Andrea shared how the team is working with PRIMA Group, a local housing association, to integrate data about housing conditions. The aim is to better understand how issues like overcrowding, damp, or poor ventilation contribute to ill health and hospital use.

“We’re bringing in housing data not just to look at individuals, but at household-level patterns,” said Andrea. “So we can start to understand how multi-generational households or co-existing conditions within families impact care needs. The more we link broader datasets, the greater the shared ownership of outcomes across the system.”

Chris added that this also includes privately rented housing - often an invisible risk factor. 

“We’re working with local authorities who hold landlord licensing data. That helps us identify private properties that may not meet basic standards, which can have a real impact on things like respiratory conditions or childhood illness. It’s about filling in the blind spots.”

Overcoming Challenges: Data Governance, Trust and Culture Change

Integrating wider datasets is not without its challenges. Andrea and Chris were candid about the barriers - from information governance to technical complexity and culture change.

“Sometimes it’s a chicken-and-egg situation,” said Andrea. “Local authorities want to know how sharing their data will help them - and we need their data to show that impact. So we’re trying to demonstrate the value, one use case at a time.”

She also emphasised the importance of ongoing engagement, mutual trust, and patience.

“There’s so much rich local data out there - environmental, housing, social care - but it takes time to bring it in. That cultural shift is happening, slowly but surely.”

Building Capability: Population Health Academy and Light-Touch Training

For Andrea and Chris, it’s not just about the tech - it’s about people. They’ve invested heavily in capability-building across the system, recognising that for population health tools to be effective, people need to understand and use them with confidence.

They’ve created the Population Health Academy, a mix of formal and informal learning opportunities. This includes accredited three- to four-month programmes for in-depth learning, and more informal “drop-in” sessions for busy clinicians and operational teams.

“Not everyone can commit to a formal course,” said Andrea. “That’s why we offer lunchtime sessions and bite-sized learning - we’ve opened these up to all GP practices. If you don’t use these tools regularly, it’s easy to lose confidence, so we’ve created flexible ways for people to stay connected and keep their skills fresh.”

The team also listens to feedback from each cohort to refine and improve the offer, ensuring it continues to meet the evolving needs of users across the ICS.

A Living, Learning System

What came through strongly in the session was the team’s commitment to continuous learning. Rather than waiting for perfect conditions, Cheshire and Merseyside have embraced a live, adaptive approach - trying, learning, refining, and scaling.

“We’re still learning,” said Chris. “But the more we do, the more people can see the value. We’re getting stronger all the time - not just in terms of the data, but in how we work together as a system.”

Andrea summed it up well:

“This is about improving lives. We’ve got complex patients in complex systems. If we can link the right data, at the right time, and make it easy for people to act - that’s when the magic happens.”

Part of a National Movement

Cheshire and Merseyside is also a founding member of the CIPHA consortium - a collaborative of 11 integrated care systems covering more than 17 million people. Together, these systems have built one of the UK’s most advanced shared population health infrastructures. By combining local insight with national collaboration, the region is helping to set the standard for what’s possible when data is truly put into action.

Want to Learn More?

If you’d like to explore how Graphnet supports population health management across the NHS, click here