Neighbourhood care model in Cheshire East reduces A&E attendances by up to 48 per cent and improves outcomes for frail residents

A data-driven neighbourhood care programme across eight Care Communities in Cheshire East has reduced A&E attendances by up to 48 per cent in targeted areas, while improving outcomes for residents living with complex frailty and high service use.

Between November 2024 and November 2025, 3,587 residents identified as being at high risk of hospital attendance or clinical deterioration were proactively supported through coordinated, multidisciplinary neighbourhood teams.

Rather than relying on reactive, hospital-based care, the programme focused on earlier, coordinated community support - using data to identify patients most at risk and enabling neighbourhood teams to intervene through proactive reviews, rapid multidisciplinary input, medication optimisation, falls prevention, social prescribing and practical support before crises occurred.

Across the identified cohort:

• A&E attendances reduced by 14.6 per cent
• Emergency admissions reduced by 26 per cent
• In some Care Communities, A&E attendances fell by up to 48 per cent
• 74 per cent of patients maintained or improved their Resource Utilisation Band (RUB) or Patient Need Group (PNG) score

The initiative has identified indicative secondary care cost avoidance opportunities of up to £2.8m, including £1.2m linked directly to reductions in A&E attendances and emergency admissions.

The programme was endorsed by the Cheshire East Better Care Fund Committee in April 2024 and delivered through eight Care Communities operating within a shared framework. Its core ambition was to move from reactive, crisis-based care to proactive, anticipatory neighbourhood support.

Using structured population segmentation and predictive risk modelling via the CIPHA (Combined Intelligence for Population Health Action) platform, neighbourhood teams were able to identify residents at greatest risk of deterioration and coordinate earlier, community-based interventions.

More than 2,150 residents were identified through enhanced case finding processes, with 450 receiving comprehensive integrated care interventions.

Multidisciplinary teams - including GPs, community nurses, pharmacists, physiotherapists, social prescribers, local authority colleagues and voluntary sector partners - worked around defined population cohorts, enabling more coordinated and personalised support.

Case studies demonstrate the clinical impact of the approach:

An 83-year-old man with complex physical health needs, recent falls and low mood received rapid physiotherapy input, coordinated urology and district nursing review, and referral to befriending support. His mobility improved, pain reduced and his mood stabilised following intervention.

An 81-year-old woman living with diabetes, stroke complications and heart failure received coordinated referrals across audiology, continence and memory services, improving independence and day-to-day functioning.

A 61-year-old woman struggling with obesity, pre-diabetes and financial stress was supported through physiotherapy, social prescribing and household support funding, resulting in improved wellbeing and engagement.

Importantly, while the population of Cheshire East has risen by 5 per cent, urgent and emergency care demand has not increased at the same rate, suggesting the impact of proactive neighbourhood management.

The approach is underpinned by CIPHA - a secure, integrated data and intelligence platform used across Cheshire and Merseyside. CIPHA brings together information from primary, secondary, community and social care datasets to support population health management.

Within the platform, the Johns Hopkins ACG® population segmentation model is used to stratify residents by complexity, risk and predictive likelihood of hospital admission. The platform is delivered locally in partnership with Graphnet Health, working alongside system partners to enable secure data sharing and neighbourhood-level intelligence.

Dr Anushta Sivananthan, Consultant Psychiatrist and Integrated Neighbourhood Teams Senior Responsible Officer for Cheshire East Place, said:

This programme demonstrates what can be achieved when neighbourhood teams are empowered to work proactively around residents most at risk.

By combining strong clinical leadership, multidisciplinary collaboration and shared intelligence, we have improved continuity of care and reduced avoidable hospital use. Most importantly, we are helping people live well for longer in their usual place of residence while building a more sustainable model for the future.

Cheshire East is now regarded as a forerunner within Cheshire and Merseyside for its population segmentation approach and neighbourhood working model.

The programme aligns with national ambitions for anticipatory, neighbourhood-based care and demonstrates how structured population intelligence can support measurable improvements in outcomes and system sustainability.