Dr Anushta Sivananthan, consultant psychiatrist and integrated neighbourhood teams senior responsible officer for Cheshire East Place (Credit: Cheshire and Wirral Partnership NHS Foundation Trust)
A data-driven neighbourhood care programme spanning eight care communities in Cheshire East has reduced A&E attendances by up to 48% in targeted areas.
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 teams.
Rather than relying on 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.
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.”
Across the identified cohort, A&E attendances fell by 14.6% and emergency admissions reduced by 26%. In some care communities, A&E attendances decreased by up to 48%.
Case studies show 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.
While the population of Cheshire East has risen by 5%, urgent and emergency care demand has not increased at the same rate.
The initiative has also 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.
Using structured population segmentation and predictive risk modelling via the Combined Intelligence for Population Health Action (CIPHA) 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.
CIPHA is a secure, integrated data and intelligence platform used across Cheshire and Merseyside. It 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.
Elsewhere in the Cheshire region, East Cheshire NHS Trust and Mid Cheshire Hospitals NHS Foundation Trust shared last month that they are continuing to optimise their shared electronic patient record (EPR) system months after launch.
Speaking at Digital Health Rewired 2026 on 25 March, Danny Roberts, chief information officer at East Cheshire NHS Trust, said that the trusts entered an optimisation phase in September 2025 which will continue until June 2026, following the go-live of the MEDITECH Expanse system in June 2025.
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