NHS England data shows that just 5% of patients account for nearly 50% of hospital bed days. Most of these vulnerable groups in society have complex needs, such as long-term health conditions or a lack of social support.

Even with advances in data-driven care, too many people are only seen when a crisis occurs, leading to potentially avoidable hospital admissions, longer stays, and repeated interactions with overstretched services.

Integrated Care Systems (ICSs) are well-positioned to change this. By connecting data, services, and frontline teams, ICSs can identify risk earlier, personalise support, and provide proactive care at scale.

Top 5 Vulnerable Groups in Society ICSs Can Help

There are a number of groups that, for whatever reason, are in a vulnerable position when it comes to their health and wellbeing. These groups can often be missed by traditional healthcare approaches. But it doesn’t need to be this way. ICSs need to be adopting a whole suite of digital tools to identify hidden needs and act earlier.

By connecting data from across health and care services and applying powerful analytics, ICSs could shift from reactive to proactive care.

1. Frequent Visitors to Emergency Departments

People who attend A&E multiple times a year often live with underlying issues such as chronic pain, mental‑health problems, housing instability, or substance misuse. In some areas, frequent attenders make up over 16% of all A&E visits.

Barrier: The urgent‑care team rarely sees a full, cross‑sector history in the minutes before treatment, so they address the immediate issue rather than the root cause.

ICS Opportunity: Shared care information and rapid alerts allow ED, mental‑health, community and housing teams to create a single plan and divert people to more suitable services.

How Graphnet Supports

·           Graphnet Shared Care Record surfaces GP, community, mental‑health, social‑care and housing notes at the point of triage, giving staff the full picture in seconds.

·           Real‑time attendance alerts notify the community or mental‑health outreach teams the moment a known frequent attender books in.

·           Multi‑agency care plans embedded in the record spell out de‑escalation steps, preferred contacts, and next‑day follow‑up, reducing repeat attendances.

2. People with Multiple Long‑Term Conditions (MLTC)

One in four UK adults lives with one or more LTCs such as diabetes, COPD, or hypertension. Overlapping treatments and endless clinic appointments can be confusing, making it hard for people to spot early warning signs.

Barrier: Siloed records and limited use of remote data mean worsening symptoms go unnoticed until a hospital episode.

ICS Opportunity: Continuous monitoring and shared dashboards enable teams to intervene before deterioration.

How Graphnet Supports

·           Population Health Risk Stratification flags individuals whose combined clinical readings and social factors place them at imminent risk.

·           Remote Patient Monitoring (RPM) streams blood‑pressure, oxygen‑saturation, and weight data straight into the shared record, triggering automated alerts when thresholds are crossed.

·           Personal Health Record (PHR) app lets patients track readings, medication adherence, and symptoms, fostering self‑management and two‑way messaging with the care team.

3. Older Adults Who Are Frail or Isolated

Living alone - especially in rural settings - increases the risk of falls, malnutrition and loneliness. Social isolation raises dementia risk by 50% [1] and heart‑disease risk by nearly 30% [2].

Barrier: Minimal engagement with health or care professionals means needs remain hidden until a crisis.

ICS Opportunity: Cross‑sector datasets (primary care, community nursing, social care, voluntary services, fire and rescue) can reveal who is frail, housebound or fuel‑poor, so support reaches them proactively.

How Graphnet Supports

·           Frailty Index dashboards blending clinical, functional and socio‑economic data to pinpoint those most likely to fall or be admitted.

·           Community‑triggered alerts — e.g. when a tele‑care device or voluntary‑sector home‑visit logs a concern, a flag pops up in the shared record.

·           Virtual Wards module tracks daily observations for people discharged early, allowing hospital-at-home teams to step in and prevent readmission.

 

4. Children and Young People with Complex Needs

One in six children [3] in England has a probable mental‑health condition. Many more have neurodevelopmental disorders, safeguarding risks or unstable housing.

Barrier: Education, health and social services often hold separate files, making it hard to build a complete, timely picture.

ICS Opportunity: Shared, secure role‑based information and smart alerts drive earlier assessment and wrap‑around support.

How Graphnet Supports

·           Child Health Profiles combine vaccination status, EHCP data, mental‑health notes and safeguarding flags in one longitudinal record.

·           School nurse and Child and Adolescent Mental Health Services (CAMHS) integration means concerns raised in education settings flow into the shared system instantly.

·           Multi‑agency dashboards highlight children missing appointments or achieving below expected development milestones, prompting outreach.

5. Communities Experiencing Health Inequalities

Life expectancy in the most deprived areas of England is almost 10 years lower [4] than in the least deprived. Barriers include language, digital exclusion, distrust, and limited access to transport or broadband.

Barrier: If people do not register with a GP or use digital services, they stay invisible in traditional datasets.

ICS Opportunity: Linking non‑traditional data (e.g. housing, benefits, community‑pharmacy, voluntary‑sector) helps target outreach and create inclusive services.

How Graphnet Supports
·           Social Determinants of Health (SDOH) integration merges the Index of Multiple Deprivation (IMD), housing quality, employment and safeguarding data alongside clinical factors.

·           Geospatial analytics map prevalence and service use down to Lower Layer Super Output Area (LSOA), helping ICSs direct mobile clinics and community champions.

·           Accessible PHR offers multiple languages, offline caching and text‑message triggers, reducing digital‑exclusion barriers.

Graphnet Health Solutions That Power Proactive, Inclusive Care

Solution Area	What It Delivers	Why It Matters
Shared Care Record	A unified, secure patient record across acute, primary, community, mental‑health and social‑care systems	Gives every professional the same, up‑to‑date information — the foundation for integrated care.
Population Health Analytics	Risk stratification, segmentation and cohort‑building	Surfaces hidden need, tracks inequality gaps and measures programme impact.
Predictive Analytics	Machine‑learning models for unplanned admission risk, preventable ED attendance, and likelihood of non‑attendance (DNA)	Allows earlier, targeted interventions and resource optimisation.
Remote Patient Monitoring	Home and care‑home devices integrated with the shared record and virtual‑ward dashboards	Keeps people safe at home, reduces A&E attendances and shortens length of stay — Frimley ICS cut admissions by 50 % in key pathways.
Command‑Centre Dashboards	Real‑time system‑pressure and flow visualisation	Enables ICS‑wide operational decisions and rapid escalation when thresholds are breached.
Personal Health Record & Citizen Engagement	Web/mobile app for self‑management, appointment booking, messaging and digital care‑plans	Empowers citizens, improves adherence and bridges the digital‑divide with multilingual, low‑data‑use design.
Care Planning & Coordination	Multi‑agency care‑plan templates, task‑assignment and progress tracking	Aligns goals, reduces duplication and supports Safe Discharge and Virtual Ward pathways.
Open APIs & Single Sign‑On	FHIR‑compliant APIs and embedded views in PAS/EPR and EMIS/SystmOne	Fits seamlessly into existing clinical workflows, avoiding password fatigue and context‑switching.
Data Quality & Governance Services	Automated data‑quality scoring, IG toolkit, and advisory services	Builds trust, ensures regulatory compliance and underpins safe analytics and AI.
Implementation & Change‑Management Support	Dedicated customer‑success and clinical‑engagement teams	Accelerates adoption, trains staff and co‑designs dashboards around local priorities.

Building a More Inclusive, Sustainable Health‑and‑Care System

Removing barriers to healthcare access for vulnerable and hidden populations is not optional - it is the path to a financially and clinically sustainable NHS.

Graphnet Health equips ICSs with the technology and expertise to shift from reactive to proactive care into a neighbourhood health service, reduce pressure on frontline services and close health‑inequality gaps.

Ready to start? Graphnet’s team will work with you to configure shared‑care views, analytics dashboards and remote‑monitoring pathways around your local priorities — and show measurable results rapidly.

Contact Graphnet Health today to explore pilot projects, business‑case modelling and funded implementation options.

 

Sources
[1] - https://pmc.ncbi.nlm.nih.gov/articles/PMC10357115/

[2] - https://newsroom.heart.org/news/social-isolation-and-loneliness-increase-the-risk-of-death-from-heart-attack-stroke

[3] - https://www.england.nhs.uk/2023/11/one-in-five-children-and-young-people-had-a-probable-mental-disorder-in-2023/

[4] - https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities/bulletins/healthstatelifeexpectanciesbyindexofmultipledeprivationimd/2018to2020