Project name

Description

Date of approval

Data used

Where data is used

System P

A group of  projects to that use data analysis to address local priorities and areas of complex need, using the data to support local decision making and identify opportunities to improve patient outcomes.

07/10/2021

Cheshire and Merseyside GP, secondary care, social care, community, mental health and ambulance data, as well as national secondary care, community, GP and mental health data

ICB-wide

RESTORE - Research for Equitable SySTem RespOnse and Recovery

RESTORE is a project that aims to find the best ways to identify people who may be at risk of developing multiple health conditions. It looks at how data can help local health and care services identify these individuals earlier and more accurately, so they can get the right support sooner.

07/10/2021

Cheshire and Merseyside GP data, secondary care data, community data, social care data, mental health data, Covid-19 testing data, Covid-19 vaccination data, Johns Hopkins risk stratification data, and national secondary care, maternity, community, mortality and Covid-shielding patient data

ICB-wide

Responding to National Patient Safety alerts for valproate and topiramate drugs

Two National Patient Safety alerts mandated new measures for the use of valproate (a series of drugs used to manage epilepsy and bipolar disorder) and topiramate (a drug used to treat migraine symptoms). A dashboard has been developed for clinical specialists to identify patients who need medication reviews as a result of these changes.

More information:

• National Patient Safety Alert: Valproate (GOV.UK)
• Topiramate (Topamax): introduction of new safety measures

 5/3/2024

Cheshire and Merseyside GP and secondary care data 

ICB-wide

Understanding the causes of diabetic lower limb amputations

This study aims to prevent unnecessary lower limb amputations linked to diabetes. This is done by reviewing areas of best practice and where improvements can be made to provide consistently better outcomes.

It started in response to an NHS Resolution study in June 2022 which reviewed clinical negligence claims for diabetes and lower limb complications, focusing on understanding the causes of above-the-ankle lower limb amputations. These amputations often start with ulceration and so are potentially preventable.

More information: NHS Resolution.

 26/03/2024

Cheshire and Merseyside GP and Secondary care data

 St Helens

Preventing violent crime

Cheshire Police and NHS Cheshire and Merseyside are working together to reduce crime by analysing hospital attendances related to violence. Alerts are created that can then be followed up by the youth navigator team.

More information: 
The Navigator Programme

 05/03/2024

Cheshire and Merseyside GP, secondary care, community, social care and mental health data 

ICB wide 

Home monitoring to avoid hospital admissions

Some patients with heart conditions and COPD can be monitored at home using specialist equipment. If their condition deteriorates, healthcare professionals are alerted to provide appropriate care.

Population health management data is being used to target this remote monitoring for patients where it will have the greatest impact.

 16/04/2024

Cheshire and Merseyside GP data

 ICB wide

Liverpool Care Coordinators

Care Coordinators support people with complex health conditions to stay out of hospital. Population health management data is used to proactively identify suitable patients in Liverpool for this service, rather than this having to be processed by GPs.

16/04/2024

Liverpool GP, secondary care, community, social care and mental health data

Liverpool

Sefton Care Coordinators

Care Coordinators support people with complex health conditions to stay out of hospital. Population health management data is used to proactively identify suitable patients in Sefton for this service, rather than this having to be processed by GPs.

16/04/2024

Sefton GP, secondary care, community, social care and mental health data

Sefton

PID Access for Sefton Care Coordinators

Care Coordinators support people with complex health conditions to stay out of hospital. Population health management data is used to proactively identify suitable patients in Sefton for this service, rather than this having to be processed by GPs.

16/04/2024

Sefton GP, secondary care, community, social care and mental health data

Sefton

Impact of COVD-19 on Breast Cancer

A study analysing the impact of COVID-19 on patient outcomes of women diagnosed with breast cancer before, during and after the height of the pandemic across Cheshire and Merseyside.

The plan is to analyse data to determine the impact of COVID-19 on patient delays to diagnosis and treatment, stage at diagnosis, treatment type and 1 year mortality from date of diagnosis for each of the three referral pathways (primary, secondary, NHS Breast Cancer Screening Programme) considering age, ethnicity and social economic status. 

The aim is to review how NHS Cheshire & Merseyside reacted to COVID-19, with results to be presented to local cancer services.

14/02/2024

Cheshire and Merseyside GP, secondary care and north west cancer waiting list data as well as national secondary care and mortalities data

ICB wide

Safe and Well hot spots analysis

Cheshire and Mersey Fire and Rescue Services are working with NHS Cheshire and Merseyside to proactively visit homes most at risk of having an accidental fire. 

The data required for this is already in place, but GP practices are being asked to sign a data sharing agreement to support this work. Once that is complete a dashboard will be created, giving properties risk scores based on health and wellbeing factors in the NHS data. This score is calculated internally in the NHS. Nobody from the fire services will be given access to identifiable personal information.

14/02/2024

Cheshire and Merseyside GP data

ICB wide

Healthy Air for Healthy Lungs - Indoor Air Quality Improvement Project

St Helens Borough Council and Warrington Borough Council are working to improve indoor air quality.

Around 250 households in areas of deprivation will be given an indoor air quality monitor, have an indoor air quality assessment and receive health education and advice. This will be specifically targeted to households with children aged two to 10 years old that have an underlying respiratory illness, such as asthma.

This research is funded by a grant from the Department for Environment, Food and Rural Affairs and will work across six Air Quality Management Areas - four in St Helens and two in Warrington.

25/06/2024

St Helens and Warrington GP Data and National secondary care data

St Helens and Warrington

Cheshire West Care Coordinators 

Care coordinators, complex case managers and team managers will be given access to patient identifiable data for the practices they are embedded in. This enables proactive care for vulnerable patients and will be used in regular multi-disciplinary team meetings with practice staff. 

20/04/2024 

Cheshire West GP, secondary care, community, social care and mental health data 

 Cheshire West

Diabetic Eye Screening -  Wirral

The Access to Enhanced Case Finding Dashboard is being used to support individuals with a learning disability to access diabetic eye screening.

The screening team are able to access patient identifiable data to contact patients in a direct care setting, offering reasonable adjustments and easy read information as required. The team currently has access to similar data for hospitals.

20/04/2024

Wirral GP data

Wirral

Beyond CYP Transformation Programme Population Health Planning

Child social care data has been requested to make it easier to support young people with complex needs in health and social care settings.

The Beyond programme, which is leading the Appropriate Places of Care work across Cheshire and Merseyside, has identified pressures on systems as a result of young people being placed in settings not suited to meeting their needs.

Programmes of system-wide change are working on addressing this, with access to this data being part of that to alleviate previous challenges of getting it from individual providers.

20/04/2024

Cheshire and Merseyside GP, mental health data and national secondary care data for children and young people only

ICB wide

Networked Data Lab (NDL) – Elective Waiting List management and Housing and Health study

The Data into Action Programme and the Civic Health Innovation Lab at Liverpool University are working with the Health Foundation to evaluate the impact of elective surgery waiting lists and housing on health.

This is part of a national study collaborating with four other university data labs.

The insights will be used to identify local Cheshire and Merseyside interventions to support waiting list management and improve the health of patients waiting for surgery.

23/07/2024

Cheshire and Merseyside GP, secondary care, social care data, and national secondary care, community, mental health, waiting list and mortality data

ICB wide

East Cheshire Care Community Coaches and Care Community Support Managers

This project gives Care Community Coaches and Support Managers in Cheshire East access to a special dashboard that shows key patient information. This helps them support clinicians who work with High Intensity Users – people aged 18 or over who go to A&E very frequently (more than 5 times a month or more than 20 times a year). Having access to this information means the Coaches and Support Managers can provide helpful clinical insights and keep things running smoothly when clinical leads are unavailable.

17/09/2024

East Cheshire GP data, national secondary care data, mental health data, social care data and community data

East Cheshire

Chronic kidney disease prevention in primary care

This project looks at the common characteristics of people who have chronic kidney disease, with the aim of finding ways to identify and  treat the disease earlier.

19/09/2024

Cheshire and Merseyside GP data, national secondary care data and waiting list data

ICB-wide

Prevention of alcohol related harms

This project aims to improve the health of people affected by alcohol by analysing data on patients who are already experiencing alcohol-related harm, such as liver problems. By understanding this data, health services can better identify people who are at risk earlier and identify improved treatment plans to support them.

19/09/2024

Cheshire and Merseyside GP, secondary care, social care data, and national secondary care, community, mental health, waiting list and mortality data

ICB-wide

Identifying patients who may benefit from an integrated care package

This project aims to identify patients with complex needs who may benefit from more joined-up support. It focuses on people aged 18–30 who may be vulnerable, such as those living in deprived areas or already receiving social care. The project brings together information from GP records and other services to see whether these patients would benefit from a multi-agency meeting to plan an integrated package of care. Patients will be asked for their consent before any meeting takes place either via consultation, telephone, or written consent form.

19/09/2024

St Helens and Warrington GP data and national secondary care data, community care and mental health data

St Helens and Warrington

Understanding inequalities in common mental health disorders

This project looks at how factors like age, ethnicity, and socioeconomic status affect people’s mental health. By understanding which groups are more likely to experience common mental health disorders, the project aims to help improve services and make sure support is more targeted, fair, and effective for everyone.

19/09/2024

Cheshire and Merseyside GP, community and mental health data, national secondary care, community, waiting list and mortality data

ICB-wide

North Liverpool Primary Care Network access for COPD searches

This project will help healthcare teams in North Liverpool find patients with chronic obstructure pulmonary disease (COPD) who are current or past smokers and who have a 75% or higher risk of admission to hospital in the last 12 months. By identifying these patients early, they can be seen in order of priority and referred to the Community Respiratory Team before winter, when symptoms may worsen. Social prescribers will also use the Fuel Poverty Dashboard to identify patients who would benefit from social prescribing support.

15/10/2024

North Liverpool GP data

North Liverpool Primary Care Network

Complex Households Liverpool

Staff employed in GP practices will use the Complex Households dashboard to identify families who may need extra support. This will help connect them with early help services, such as education, health services, or school nursing, before problems become more serious.

15/10/2024

Liverpool GP data

Liverpool Place

Understanding access to healthcare for people with essential tremor

This project uses population health data to understand how different groups of people access treatment for essential tremor. The aim is to find out whether some groups face barriers to care, so that steps can be taken to ensure all patients have fair and equal access to treatment.

12/11/2024

Cheshire and Merseyside GP, secondary care and national secondary care data

ICB-wide

St Helens Primary Care Network Advanced Nurse Practitioners

This project supports Advanced Nurse Practitioners in St Helens to use data from the Enhanced Case Finding Dashboard. It helps them identify groups of patients, such as people aged 18–30 who are known to social care and living in the most deprived areas, who may benefit from extra support. The information will be used to support proactive care of patients and to inform discussions at the Care Community Multidisciplinary Team meetings, enabling them to offer joined-up care from different services working together.

12/11/2024

St Helens GP Data, national secondary care data, mental health data, social care data and community data

St Helens

Senior Occupational Therapists 

Senior Occupational Therapists working across Central, South, North, and Newton & Haydock PCNs will use the Enhanced Case Finding Tool to help identify patients who may need extra support, for example, young adults known to social care and living in areas of high deprivation. This information will help multidisciplinary teams to enable proactive care for vulnerable and complex patients by offering them integrated, multi-agency care.

12/11/2024

St Helens Primary Care Networks GP, secondary care, community, social care and mental health data

Central, South, North, Newtown & Haydock PCNs

Crewe Care Co-ordinator

This project gives the care co-ordinator for two Crewe Primary Care Networks (Crewe Eagle Bridge PCN and Crewe GHR PCN) access to the Enhanced Case Finding Dashboard. It forms part of the national Better Care Fund and aims to reduce the number of unplanned or crisis contacts by high intensity or frail users of health services over a 12-month period. By using data to identify people most at risk, the Care Co-ordinator can work with others to proactively manage their care, helping to avoid emergency hospital and long-term care admissions where possible.

12/11/2024

Crewe GP, secondary care, community, Social care and mental health data

Crewe Eagle Bridge Primary Care Network  (Earnswood  and Millcroft Medical Centres) and Crewe Grosvenor, Hungerford and Rope Primary Care Network (Grosvenor, Hungerford and Rope Green Medical Centres)

Diabetes and Learning Difficulties Eye Screening Programme

This project aims to improve uptake of the diabetic eye screening programme in Central Merseyside. It focuses on contacting patients who have not regularly attended appointments or who may need extra support because they have a learning disability. 

12/11/2024

Central Merseyside GP data

Central Merseyside, covering Knowsley, Warrington, Halton and St Helens

Primary Care 24 Complex Households 

This project is to use the Complex Households Dashboard to identify patients who may benefit from additional help.

12/11/2024

GP data for Garston, Netherley, Maghull, Litherland Seaforth and Netherton, 15 Sefton Road, Great Crosby and Thornton, North Park and Hightown practices

Garston, Netherley, Maghull, Litherland Seaforth and Netherton, 15 Sefton Road, Great Crosby and Thornton, North Park and Hightown

Warrington and Halton Gold Standard Framework end of life data

This project aims to improve palliative (end of life) care for patients in Warrington and Halton. It identifies patients with palliative care needs who either attend the Emergency Department or Same Day Emergency Care (SDEC), or who are admitted to hospital. Clinicians can then check whether these patients have a Personalised Care Plan (PCP) in place that reflects their care preferences. If a PCP is not already in place, and it’s clinically appropriate, staff can support the patient in creating one.

10/12/2024

Warrington and Halton GP data

Warrington and Halton

East Cheshire GP (Ashfields Primary Care Centre) 

This scheme, part of the national Better Care Fund, aims to reduce the number of unplanned or crisis contacts by high intensity and frail users of health services over a 12-month period. By using data to identify patients most at risk, healthcare teams can proactively manage their care, helping to avoid emergency hospital and long-term care admissions where possible.

10/12/2024

Ashfield Primary Care Centre GP, secondary care, community, social care and mental health data

East Cheshire GP (Ashfield Primary Care Centre) 

Audlem Medical Practice and Nantwich & Rural Primary Care Network

This scheme, part of the national Better Care Fund, aims to reduce the number of unplanned or crisis contacts by high intensity and frail users of health services over a 12-month period. By using data to identify patients most at risk, healthcare teams can proactively manage their care, helping to avoid emergency hospital and long-term care admissions where possible.

21/01/2025

Nantwich and Rural Primary Care Network GP, secondary care, community,  social care and mental health data

Nantwich and Rural Primary Care Network

Liverpool Diabetes Partnership

Liverpool Diabetes Partnership will use the Enhanced Case Finding Dashboard to identify patients with poorly controlled diabetes to offer targeted support.

21/01/2025

Liverpool GP, secondary care, community, social care and mental health data

Liverpool

Liverpool Community Respiratory Team

The Liverpool Community Respiratory Team, along with the Liverpool Acute Respiratory Virtual Ward, will use the Enhanced Case Finding Dashboard to identify adults with a COPD diagnosis who are current or former smokers and have between a 30% and 75% risk of hospital admission to offer them targeted direct care.

21/01/2025

Liverpool GP, secondary care, community, social care and mental health data

Liverpool

Liverpool Telehealth Service

The Liverpool Telehealth Service will use the Waiting List Dashboard to identify who would benefit from the telehealth service. They will search specialities that have patients awaiting planned care procedures, who have COPD, heart failure and/or diabetes who may be at risk of cancellation, complications, or poor outcomes. By offering a telehealth support package before their procedure, the service aims to improve their overall health and wellbeing and reduce these risks.

21/01/2025

Liverpool GP, secondary care, community, social care and mental health data

Liverpool

Liverpool High Intensity Users

Mersey Care Liverpool Place Integrated Care Teams (ICTs) will use the Enhanced Case Finding Dashboard to identify patients who frequently attend the Emergency Department, so that proactive help can be offered.

21/01/2025

Liverpool GP, secondary care, community, social care and mental health data

Liverpool

Developing strategies to manage high-risk patients with antipsychotic medications and cardiovascular conditions 

This project will analyse data to determine if patients on multiple psychotic medications face heightened cardiovascular risks. The findings will be used to develop proactive strategies to help reduce these risks.

18/02/2025

Cheshire and Merseyside ICB GP and mental health data, national secondary care, community services and mental health data.

ICB-wide

AI for Chest X-Ray studies

This project uses lung cancer diagnosis data to help improve how chest X-rays are interpreted using artificial intelligence (AI). The aim is to reduce the time it takes for patients to receive a diagnosis and start treatment.

18/02/2025

Cheshire and Merseyside secondary care data

ICB-wide

Lung cancer SABR (Stereotactic Ablative Body Radiotherapy) treatment study

This project is seeking to improve the outcomes of lung cancer patients who also have other underlying health conditions and have been treated for lung cancer with a specific treatment called Stereotactic Ablative Body Radiotherapy (SABR). It will analyse survival rates over a three-year period (2016–2019) to help improve treatment decisions and ultimately boost survival rates for people with lung cancer.

18/02/2025

Cheshire and Merseyside GP and secondary care data

ICB-wide

Wirral Community Health and Care Foundation Trust - HIgh Intensity Users Project

This project will review patients who regularly attend the Emergency Department to provide poractive support with the aim of preventing further Emergency Department attendances.

18/02/2025

Wirral GP, secondary care and community data

Wirral

Reducing the over use of SABA (short-acting beta-2 agonists)

This project will provide access to the Enhanced Case Finding Dashboard for a Consultant Physiotherapist who also serves as the Asthma and Lung UK Respiratory Champion for Cheshire and Merseyside. The Consultant Physiotherapist seeks to identify patients who may be overusing SABA inhalers. This includes patients with asthma or COPD who are using SABA frequently, and people without a respiratory diagnosis who are using them. The goal is to reduce overuse.

18/02/2025

Knowsley GP data

Knowsley

Crewe Care Community Support Manager

This scheme, part of the national Better Care Fund, aims to reduce the number of unplanned or crisis contacts by high intensity and frail users of health services over a 12-month period. By using data to identify patients most at risk, healthcare teams can proactively manage their care, helping to avoid emergency hospital and long-term care admissions where possible.

21/02/2025

Crewe GP, secondary care, community, social care and mental health data

Crewe Eagle Bridge Primary Care Network  (Earnswood  and Millcroft Medical Centres) and Crewe Grosvenor, Hungerford and Rope Primary Care Network (Grosvenor, Hungerford and Rope Green Medical Centres)

One Wirral Community Interest Company

Data will be used to identify, contact and promote/support access to the National Cancer Screening Programmes to increase uptake for those with a Learning Disability and/or Autism to reduce health inequalities.

18/03/2025

Wirral GP data

Wirral

Fuel Poverty for Sefton Place

The Sefton Community Respiratory Team will use the Fuel Poverty Dashboard to identify patients who would benefit from a clinical review and other support.

22/04/2025

Sefton GP, secondary care and community data

Sefton Place (Sefton, Southport and Formby)

Halton Public Health Fuel Poverty

This project, led by Halton Borough Council's Public Health Team, aims to implement preventative care measures to alleviate fuel poverty in the borough.

22/04/2025

Halton GP data

Halton