By Markus Bolton, Director, Graphnet Health

The NHS is at a pivotal point in its evolution, with a clear focus on using digital tools to shift towards integrated, community-based care. As part of this transformation, Integrated Care Systems (ICSs) such as Frimley Health and Care, Cheshire and Merseyside, and Surrey Heartlands are leading the charge, harnessing the power of Shared Care Records to drive efficiencies, improve patient outcomes, and reduce pressure on healthcare services.

Across these ICSs, CIPHA’s tools are making a tangible difference. In Frimley Health and Care, the introduction of remote monitoring has led to a 40% reduction in emergency department attendances for monitored patients, a clear sign that proactive care is reducing the need for acute interventions. In Cheshire and Merseyside, over 1,000 vulnerable individuals facing fuel poverty have been supported through the use of population health management tools. Meanwhile, Surrey Heartlands Health and Care Partnership used CIPHA population health solutions to tackle smoking cessation, leading to a 11% decline in smoking prevalence in East Surrey.

The Power of Data: Transforming Healthcare Delivery

ICSs are using CIPHA to transform how they use data. Across 11 ICSs, the programme is already delivering impressive results. In the past year alone, the use of Shared Care Records has increased by 60%, moving beyond simple infrastructure to real-world clinical impact. As Shared Care Record usage grows, so do the benefits: from time savings and better care coordination to more informed decision-making and improved patient outcomes.

For example, in their most recent Innovation Impact Report, Health Innovation Manchester reported that healthcare professionals now access the GM Care Record more than 270,000 times each month - marking a 21% increase year-on-year. The positive impact is undeniable and includes:

• Clinicians saving an average of 33 minutes per day, equating to £10 million in annual savings.
• Critical care plans, such as those for frailty, dementia, and end-of-life care, are now integrated across the region.
• Almost 20,000 patients have been identified as being eligible to receive novel therapies to help reduce their cholesterol. 

Supporting Proactive, Preventative Care with Population Health Tools

One of the most significant shifts in the NHS is towards proactive, preventative care. This transformation is reflected in both the NHS’s 2025/26 priorities and operational planning guidance, as well as the government’s 2025 mandate to NHS England. These documents underscore the importance of data-driven decision-making to identify high-risk patients and intervene before conditions worsen. This is where CIPHA’s population health tools come into play.

CIPHA supports healthcare teams by integrating data from across care settings - GP practices, hospitals, social care, and mental health services - into a single, unified platform. This allows healthcare professionals to act earlier, intervening before conditions escalate and preventing unnecessary hospital admissions.
In Cheshire and Merseyside, for instance, population health dashboards have helped identify vulnerable households, leading to targeted initiatives like the St Helens Warm Homes for Lungs project. This project supported 418 COPD patients and delivered the following within the first six months:

• 100% of patients received home visits from COPD nurses
• 100% of patients were referred to the wellbeing team and to the affordable warmth team for further support
• 100% patients received winter warmth packs
• 76% received £500 payments from the household support funds
• A total of £32,500 of additional support was paid to these struggling households

Dianne Green, Nurse and Service Manager at Mersey and West Lancashire Teaching Hospitals NHS Trust, stated,

We didn’t know how many people were struggling until we looked through this lens.

The data-driven approach not only improves care but ensures that resources are directed to the people who need them most.

Reducing Surgery Postponements with Diabetes Prehabilitation Services

A key application of CIPHA’s tools has been in improving preoperative care, particularly in reducing surgery delays and improving patient outcomes. One Wirral Integrated Care Community (CIC) launched a diabetes prehabilitation service aimed at reducing surgery postponements, tackling lengthy waiting lists, and improving postoperative outcomes.

Using CIPHA’s population health management system on Graphnet Health’s platform, the service analysed hospital waiting lists and identifies diabetic patients who were most at risk of surgery delays due to uncontrolled diabetes. By focusing on patients with a high HbA1c or BMI, the service proactively optimised their diabetes care before surgery.

As part of this service, 58 people were reviewed by a diabetes specialist nurse, 37 had medication added (such as SGLT2i, metformin, or gliclazide), 19 patients received support with their insulin, and 6 patients started using Libre sensors—a sensor-based glucose monitoring system.

Dr Dave Thomas, Wirral Diabetes GP lead, explained,

A service where we’re getting people fit and healthy, and optimising their diabetes care prior to their operation can only benefit the patients. From a Wirral-wide point of view, it’s going to help reduce surgical waiting times, reduce complication rates, and it will allow us to reduce hospital stays.

Remote Monitoring: Expanding Coverage for More of the Population

Remote monitoring tools, which are integrated with Shared Care Records, enable clinicians to track patient data in real-time, allowing for early interventions and better outcomes. These tools have proven to be especially effective in managing chronic conditions and reducing the need for hospital visits.

In Frimley, for example, the use of remote monitoring tools for 3,673 patients from December 2022 to October 2023 resulted in:

• A 53.7% reduction in hospital admissions.
• A 38.6% drop in A&E attendances.
• A 26.7% reduction in outpatient appointments.

These tools also contributed to significant financial savings, with £5-8 million saved annually. Moreover, patients had fewer interactions with emergency services, including a 36.1% reduction in 999 calls and a 36.9% decrease in 111 calls. This further highlights the value of remote monitoring in reducing the strain on acute services while improving patient care. As Frimley’s Clinical Lead for Virtual Wards stated,

We’re seeing patients through data and intervening. It’s life-saving.

Population Health and the Future of Healthcare

The future of healthcare lies in population health management—an approach that empowers healthcare teams to act on data, provide earlier interventions, and focus on prevention. By embedding tools like Shared Care Records and remote monitoring into everyday clinical practice, healthcare systems are not just sharing data—they are using it to drive real change.

From virtual wards to Cheshire’s population health dashboards, the evidence is clear: these tools are making a difference. They help save time, reduce pressure on services, prevent avoidable admissions, and tackle long-term conditions and health inequalities.

CIPHA’s tools have become integral to this shift, supporting the NHS’s move towards a more proactive, data-driven, and integrated healthcare system. As more ICSs adopt these technologies, the benefits will only continue to grow.

Conclusion: A Smarter, More Efficient Healthcare System

CIPHA is at the forefront of a healthcare transformation that is enabling more personalised, efficient, and equitable care. By integrating Shared Care Records and population health tools, healthcare teams can make more informed decisions, act earlier, and reduce reliance on acute services. The evidence from ICSs like Frimley, Cheshire and Merseyside, Surrey, and others shows that this approach is driving real change.

The path forward is clear: by continuing to innovate and expand the use of digital health technologies, we can build a healthcare system that is not only smarter and more efficient but also more responsive to the needs of patients, improving outcomes and creating a more sustainable system for all.