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Population health tools helping Cheshire & Merseyside support those most at risk of fuel poverty

25 October 2023

Energy prices and the cost-of-living crisis have barely been out of the headlines, and for good reason. According to government data released in early 2023, 13.4 percent of households in the UK were in fuel poverty in 2022, some 3.26 million in total. It is projected that this year, fuel poverty will increase to 14.4 per cent (3.53 million).

The impact has been felt most keenly by those on low incomes, families with children, ethnic minorities, the elderly, and those living with disabilities. Circulatory, respiratory, and mental health problems are an issue within all age groups.

By October 2022, it was clear that fuel poverty was starting to bite across Cheshire and Merseyside, including in St Helens where estimates were showing that 42 per cent of households were likely to be impacted by fuel poverty in 2023. In response, we secured funding through the Innovation for Health Inequalities Programme and pulled a multi-stakeholder steering group together, with representation from across health, social care, housing, community, and voluntary sectors.

Graphnet Health, a British company providing population health solutions, developed a fuel poverty dashboard in CIPHA (Combined Intelligence for Population Health Action), which draws health and care information on 2.6 million Cheshire and Merseyside residents, from all parts of the care system. Optum advised us on developing interventions using the data from that dashboard.

Finding and helping those most in need

Our steering group identified patients diagnosed with severe COPD as an appropriate group to start with as individuals are particularly vulnerable to cold, damp homes, and their condition is likely to deteriorate without an improvement in the environment.

We then drilled down further, using the dashboard to focus on those who had a 50% or higher risk of emergency admission in the next 12 months, were not in a care home, and were living in the most deprived and fuel poor geographies. That provided us with a list of 1317 individuals across Cheshire and Merseyside, a manageable number that we were confident we would be able to improve outcomes for, and then learn from to develop other pathways.

The first project to go live was St Helens WarmHomes for Lungs in February 2023. Patients were contacted by the Community COPD Rapid Response Team at Mersey and West Lancs Teaching Hospitals NHS Trust to attend either a phone or in-person session to introduce the fuel poverty project, and to obtain their consent to share information with other agencies that could support them. Recommendations were then made depending on the needs of the individual, but could include a referral to their GP, the St Helens Wellbeing Service, or the St Helens Council Affordable Warmth Unit. We also connected people with Energy Plus Projects, a charity that helps citizens in need achieve lower energy tariffs and warmer homes.

Bringing people and services together

The fuel poverty programme has not been about reinventing the wheel but building on what is already being done. All of our places have existing cost of living programmes, with people and organisations doing great things for their residents. The fuel poverty programme, with its population health and data-led approach, simply brings services together in a more holistic way, and enables us to track the results more effectively.

As of August 2023, 85 patients have been contacted through the St Helens WarmHomes for Lungs project, resulting in 85 referrals to the Wellbeing Team, 14 referrals to the Pulmonary Rehabilitation (PR) Team, 18 patients have been onboarded to the COPD Telehealth Service, and 65 patients have received £500 payments from household support funds, with further payments due in October 2023. A total of £32,500 in payments have been made so far, and all patients have received a Winter Warmer Pack.

The impact is brought home when we speak to the residents involved. Take Jo, for example. He has a dual diagnosis of COPD with primary condition pulmonary fibrosis and requires high-flow oxygen 24-hours per day. Living in a cold home, he can’t afford rising energy bills. He was also struggling to leave his home on his mobility scooter.

Jo was referred to the Affordable Warmth Team for a household assessment, referred for an occupational therapist assessment for a stairlift and ramp, and assisted to register on the Priority Services Register with an energy provider. Jo also received a medication review, which resulted in an oxygen saturation probe, oxygen concentrator and provision of a fan for fan therapy.

Jo received a replacement boiler and installation of a bespoke ramp. He is managing his condition better; using his more efficient oxygen equipment for eight hours per day, which is more cost effective; and he has been able to access the £500 household warmth fund towards improvements.

When asked about the programme, Jo said:


"I have to choose between my oxygen or heating the home - but not anymore."


What’s next?

As we head towards the colder months, our objective is to build on the pathway that we have developed in St Helens and embed it across different places.

The next priority is our Preschool Wheeze project, which will support children aged 0-4 with an undiagnosed wheeze. This is the second cohort that we have identified as being at risk of negative health implications (including asthma) due to cold homes. We will also be expanding the COPD pilot and rolling it out further across St Helens, Knowsley, and Warrington.

We have learned a lot during the course of the programme, namely that there is value in testing and learning from small pilot projects to support scaling up of work going forward. It has also emphasised that the people involved are crucial. The technology provides the data that we need, but it’s the people from health, social care, and other sectors, who have put their hands up to get involved, who are the heart of the programme, harnessing those insights to provide vital, life-improving support to our most vulnerable residents.

To find out more about how Graphnet can support your fuel poverty projects, click here.

Lucy Malcolm Photo

Lucy Malcolm,

Senior Digital Transformation and Clinical Improvement Manager,

Cheshire and Merseyside Health and Care Partnership