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Thought Leadership

Data will pave the way to earlier, more targeted interventions across Integrated Care Systems

30 July 2021

Long awaited social care reform and funding is very much back on the agenda. Time will tell exactly how Sajid Javid will respond to renewed calls for government action – but social care leaders have been quick to remind him of his remit, and the promises made by his predecessor.

It’s no wonder, as the statistics make for distressing reading. Last month, the End Child Poverty Coalition revealed that even before the pandemic, 4.3 million children were living in poverty, up 200,000 from the previous year – and 500,000 over the past five years. At the other end of the scale, Age UK has estimated there are 1.5 million elderly people in England who need some help with day-to-day life, but do not receive it.

Targeted early support programmes, delivered through collaboration from across care networks, must be a part of the plan if we are to move forwards.


Supporting a system under strain with trackable, targeted support


Breaking the cycle of known paths that lead to entrenched issues, and spiraling costs and impacts, will be key. The challenge is how to create focus when the fundamentals of social care delivery are under strain from increasing demand, and rising funding pressures.

Early support is a familiar concept in social care settings and the arguments are well made. Providing help early, whether that be for adults with complex health issues, or children and younger people in crisis, the same principles apply:

  • Targeting the outcomes or aims of the support should be clear so that it can be tracked and measured
  • Acting in anticipation based on joined up data from different agencies and aspects of the individual's life could provide vital signs before situations escalate
  • The interaction of health (mental and physical), with living conditions, education, family support, employment, and other social factors all combine to create the potential for increased risk and a ‘chain reaction’ of personal or family crisis.

Actionable insights will tell us where and how to target services

A way forward could be for proven local initiatives to be scaled up to regional services, supported by data driven targeting of the support. This would go a long way towards helping Integrated Care Systems meet their responsibilities. Each one has been tasked to develop an ICS Partnership Body, with the NHS and local government as equal partners, and they must develop an integrated care strategy for their whole population. To achieve this, they have been asked to use best available evidence and data, to address the wider determinants of health and wellbeing, and to improve outcomes.

With this new focus, one of the main objectives should be to exploit data to understand where and how to target services and with early support as a key outcome.

The data and insights used in existing health and social care support programmes can be easily transferred to other areas with the combined will to deliver change supported by robust information governance.

Many of the data-driven support initiatives are health focused with pioneering work such as the CIPHA programme, that originated across the Cheshire and Merseyside ICS, using combined health and care data to deal with the immediate Covid pandemic. Use cases from a growing number of contributing CIPHA partner ICSs have been rapidly developed, and virtual hubs and services created to optimise the management of long-term conditions such as blood pressure monitoring in hypertensive patients. Work to support people with cancer, along with suicide prevention, and complex care (multi-morbidity) is all in the pipeline. The data platforms and supporting applications delivered through the CIPHA programme can be rapidly adapted to target social care challenges too.

Huge strides have been made on the social care side, with initiatives like the newly named, Supporting Families (formerly Troubled Families), the children’s social care programme, proving their worth. It too is heavily dependent on data analysis, relying on data from multiple sources where intensive multi-agency support could reduce the incidence of negative consequences for individuals and families. Since 2015, over 400,000 families have achieved positive outcomes – ranging from improved school attendance, to supporting parents to overcome substance misuse – as a result of direct support funded through the programme.

Targeting services at those with health deficits is complex but it is already proven with programmes like CIPHA and on other data platforms – while programmes like Supporting Families are providing a glimpse of what could be possible within social care. Applying this approach more broadly will demand even greater integration of health and lifestyle data, and other agencies, to identify individuals of all ages who may benefit from assistance. The data and insights used in existing health and social care support programmes can be easily transferred to other areas with the combined will to deliver change supported by robust information governance.

Social care and NHS organisations repeatedly demonstrate their excellence when in a crisis and now need to take some of that approach into tackling big underlying issues in the same way. The technology and data is available and needs to be ‘in the room’ as the ICS teams forge their plans. We look forward to a time when the word ‘Information’ is supplanted by ‘Action and Insights’ in all aspects of managing the challenges we face.

Chief Executive, Graphnet Health

Brian Waters

Chief Executive, Graphnet Health