Integrated care systems (ICSs) now have access to more powerful intelligence than ever before. The reason? CIPHA: the near real-time data platform that originated in Cheshire and Merseyside, and has now scaled to support a population of around 17 million. 

CIPHA is now used across 11 ICSs, providing a single, joined-up intelligence layer for population health, prevention, shared-care data, operational planning and early intervention. Its impact is visible not just in insight generation, but in everyday practice.

Across CIPHA-enabled systems, Shared Care Record usage has increased by around 60% year-on-year, showing that data is being actively used in clinical and operational workflows rather than simply stored.

The challenge now facing ICSs is a practical one: how do we move from “we can see the issue” to “we’ve changed the pathway and patients are already feeling the impact”.

What CIPHA unlocks for ICSs 

At its core, CIPHA brings together health and care data from across providers and sectors, supported by robust governance frameworks and tiered data-sharing agreements, including the Cheshire and Merseyside Health and Care Partnership.  This creates a single, trusted view of the population that ICSs can use confidently and safely.

Building on this foundation, CIPHA delivers population-health analytics across four key areas: 

1. Epidemiology and inequalities: Understanding who is most affected and where gaps in outcomes exist.
2. Predictive modelling and risk stratification: Identifying people at rising risk sooner.
3. Planning and forecasting: Helping systems anticipate demand and design services around it.
4. Evaluation and causality: Assessing which interventions work and why.
   These insights are available through real-time dashboards and reports, with both aggregate and patient-level views. Role-based access ensures that frontline teams can use re-identifiable data for direct care, while system leaders access the broader patterns needed for planning. 

These insights are available through real-time dashboards and reports, with both aggregate and patient-level views. Role-based access ensures that frontline teams can use re-identifiable data for direct care, while system leaders access the broader patterns needed for planning. 

The ‘Insight to Action’ cycle: a practical framework 

To help ICSs move from intelligence to implementation, the following five-step cycle offers a simple, repeatable model that can be applied to any population health priority – from frailty and long-term conditions to elective recovery, mental health or fuel poverty. 

1. Frame the question in terms of action
Start by defining the problem as an action-oriented question. This keeps analysis purposeful and avoids “data fishing”.
For example: “Which frail older adults in our most deprived neighbourhoods are at high risk of admission this winter, and what can we do differently for them?”
A principle drawn from the System P programme is useful here: every request for data should link directly to a clear intended change. When teams know what decision they need to make, they can shape the analysis accordingly.

2. Build and stratify the cohort in CIPHA
Use CIPHA’s segmentation and risk stratification tools to define the cohort you want to support. This might include:

• Frailty index scores
• Number and type of long-term conditions
• Levels of deprivation
• Patterns of service use
• Recent hospital, community or social care activity

The approach used in System P provides a strong blueprint. They created defined population groups such as “frailty/dementia” and “complex lives”, then built detailed insight packs for each place to support local planning.

3. Co-design the intervention with system partners
Many ICSs have found value in bringing together clinicians, analysts, public health teams, local authorities and voluntary sector partners to explore what could realistically be done for the identified cohort.

Examples include:

• Hackathon-style workshops to brainstorm practical responses.
• Agreeing whether the appropriate solution is proactive outreach, a virtual ward, a medication review, changes to clinic design, or another coordinated intervention.
  This step ensures the action is feasible, shared and aligned across the system.

4. Embed insights into frontline workflows

This is where CIPHA and Graphnet’s tools move beyond dashboards and into daily practice. Once a cohort and intervention are agreed, ICSs can embed the intelligence into workflows such as:

• Pushing patient lists into MDTs and care planning meetings via the shared care record.
• Creating or updating digital care plans for specific cohorts (frailty, heart failure, complex lives), ensuring plans are accessible across settings.
• Enrolling suitable patients into remote monitoring or virtual wards, enabling proactive care at home.

By integrating insight directly into the tools teams already use, changes become consistent rather than ad hoc.

5. Measure impact and iterate

Finally, use CIPHA’s analytical capabilities to assess whether the intervention is working - both at population and patient level. This might include:

• Admissions
• A&E attendances
• GP contacts
• Cost
• Clinical outcomes
• Experience measures

Other ICS examples illustrate the value of this loop. For instance, Frimley ICS used population health analytics combined with remote monitoring and saw reductions in hospital admissions by up to 40%. 

Read more about how they achieved it

From population insight to targeted community outreach 

CIPHA enables ICSs to move beyond broad campaigns and deliver highly targeted outreach to the people and neighbourhoods who need support most. 

Cheshire & Merseyside’s work on fuel poverty shows how powerful this can be. By linking health, care, socio-economic and environmental data, the system identified households where cold homes were driving respiratory illness and other health risks. 

This led to programmes such as Warm Homes for Young Lungs, where families were proactively offered respiratory reviews, home-energy support and links to local authority or VCS services — a cross-sector intervention made possible by precise population insight.

The same model can be applied to any outreach priority. ICSs can follow a simple process:

1. Define the goal – e.g. improve screening uptake, reduce fuel-poverty-related risks, increase vaccination coverage.
2. Segment and map the population in CIPHA – combine age, conditions, deprivation, service use and geography to identify those most likely to benefit.
3. Identify priority neighbourhoods and partners – PCNs, councils, housing teams and VCS organisations.
4. Generate outreach lists and share via agreed workflows – ensuring safe, governed data sharing.
5. Track uptake and outcomes through CIPHA dashboards – to understand impact and refine outreach criteria.
   By using CIPHA in this way, ICSs can focus resources where they make the biggest difference, reduce inequalities and bring coordinated support directly to the communities that need it most.

Risk stratification for proactive, personalised care

Risk stratification is one of the clearest ways ICSs can turn CIPHA intelligence into earlier, more personalised intervention. Instead of responding when someone reaches crisis point, systems can identify rising risk sooner - especially for frailty and long-term conditions.

Real examples already show the value of this approach, from stratifying treatment lists to prioritise patients with the highest clinical risk.

A streamlined process ICSs can follow:

1. Choose a priority area: For example, unplanned admissions in frail older adults or high A&E use among people with complex needs.
2. Build the risk model in CIPHA: Combine indicators such as comorbidities, previous admissions, frailty scores, deprivation and medications to create a robust segmentation.
3. Produce risk-stratified lists: Generate the same cohort at ICS, place and practice level so each team knows who needs attention.
4. Assign ownership: PCN MDTs, community teams or virtual ward teams take responsibility for acting on the list.
5. Embed into workflows: Push lists into MDT meetings, care planning templates and, where appropriate, virtual wards or remote monitoring.
6. Track outcomes and refine: Use CIPHA to monitor admissions, A&E use, GP contacts and patient-reported outcomes, adjusting criteria as necessary.

In this way, risk stratification becomes the bridge between analytics and personalised care, ensuring the people most likely to benefit from proactive support are consistently identified and reached.

Feeding CIPHA insights into MDTs and care planning 

For CIPHA to change outcomes, its insights need to show up in the rooms where care is coordinated. A “CIPHA-enabled MDT” brings data, shared decision-making and proactive planning together in one workflow.

What a CIPHA-enabled MDT looks like

Start with a CIPHA cohort list: Define who the MDT will focus on, such as people with complex lives or rising clinical risk.

Use the shared care record: Give teams one joined-up view of health, social care and service interactions.

Agree a shared digital care plan: Record actions and follow-ups in one place, with links to remote monitoring or patient-facing tools where relevant.

How this works in different settings

Virtual frailty & LTC wards: CIPHA flags rising-risk patients; MDTs review, update plans and enrol people into virtual monitoring.

“Complex lives” MDTs: NHS, social care, housing and VCS partners coordinate support, using CIPHA cohorts to bring the right people into discussion.

MDT implementation checklist for ICSs

• Make CIPHA data visible and usable in your standard MDT platforms/workspaces.
• Standardise agendas to include a standing item: “CIPHA-identified cohort review.”
• Train MDT leads and clinicians on interpreting the analytics and risk stratification.
• Ensure digital care plans are consistently captured, updated and shared.
• Connect care plans to remote monitoring or personal health record tools where appropriate.
• Embedding CIPHA directly into MDT workflows ensures insight translates into coordinated, person-centred action — every time.

Governance, trust and public engagement 

People naturally want to know how their data is used and how it’s kept safe. CIPHA operates within a clear, well-governed framework designed to protect privacy and maintain public trust.

CIPHA connects data to support population health and proactive care. For secondary uses, data is pseudonymised, and identifiable information is only used for direct care under strict role-based access controls. The platform is used for defined purposes, such as understanding inequalities, predicting risk, planning services and evaluating interventions.

The national data opt-out is fully honoured, and sensitive codes are excluded in line with RCGP guidance. Oversight is provided through strong information governance structures, including a Data Asset and Data Access Group with clinical and citizen representation.
ICSs are not “experimenting” with data. They are working within a mature, transparent and continually reviewed governance model designed to protect people while improving care.

Getting started: practical next steps for ICSs 

1. Run an “Insight to Action” workshop: Bring together transformation leads, analysts, clinicians and partners to apply the 5-step cycle to one priority cohort and shape an initial intervention.
2. Build a first wave of use cases: Start where CIPHA is already proven: elective recovery, frailty, complex lives, fuel poverty and maternity inequalities.
3. Embed CIPHA in governance and MDTs: Make CIPHA-derived cohorts a standard item in keyboards and MDT meetings so insight feeds directly into planning and care.
4. Set clear metrics and feedback loops: Agree success measures early, track progress in CIPHA, and review regularly to refine and scale what works.

If you’re exploring how to turn insight into action at scale, our team can share what’s worked for other ICSs and help shape an approach that fits your context.

Contact us today to find out more