Project to support people living with frailty in Cheshire East

An initiative to provide tailored support for people living with frailty in Cheshire East has led to significant reductions in A&E visits and emergency hospital admissions, according to initial assessment of its impact.

The targeted, personalised approach taken by the High Intensity Users (HIU) scheme has helped improve the health of those receiving support – reducing their reliance on urgent care services and delivering financial savings.

Developed by NHS Cheshire East Care Community Partnerships, the HIU scheme was set up in response to the high level of A&E attendances among people living with frailty, most of whom are elderly and at increased risk from falls.

Working collaboratively, staff from local NHS trusts, GP-led care community groups and Cheshire East Council used population health data to identify those who could benefit most from targeted support, and complex care practitioners then visited people in their own homes to better understand their health needs and challenges.

Tailored care packages were then designed around people's individual needs – improving their health and wellbeing and removing the triggers that lead them to need sudden or frequent medical emergency contact.

Early assessment of the scheme's impact, carried out by NHS Cheshire and Merseyside, shows it has delivered major benefits for patients and local services. 

Over a 12-month period, between November 2024 and October last year, it led to:
•    A 14.6% reduction in A&E visits by people receiving support
•    A 26% reduction in emergency hospital admissions among people receiving support
•    A £2.8m saving as a result of costs avoided by local NHS and care services

To access the linked population health data it required to begin its work, the HIU scheme was supported by analysts at the Cheshire and Merseyside Data into Action programme which uses patient information to improve care.

Once people had been identified and their health needs assessed, a package of care was drawn up to support them. The help provided across Cheshire East ranged from medicine optimisation reviews to home safety inspections to prevent falls. In some cases, it included specialist care for housebound or end-of-life patients.

With further evaluation of the project planned, the same targeted approach could be used more widely across Cheshire in Merseyside and extended to support people with other health needs.

The success of the project has led to it being shortlisted for the Data Driven Transformation Award at the 2026 Health Service Journal (HSJ) Awards: Read the news story.