Cheshire & Merseyside Discuss Transforming Care with Data Into Action

Ahead of their Digital Health Rewired 2025 presentation, Data Into Action: Implementing a Strategy to Use Population Health Analytics to Be Proactive and Identify the Most Complex Patients, we caught up with Andrea Astbury, DIA Programme Director, Cheshire and Mersey ICB, and Chris Buckels, Deputy Head of Business Intelligence (Population Health Into Action), Cheshire and Mersey ICB. They share insights into their innovative work, including the role of the Data Into Action Academy, proactive case finding, and multidisciplinary teams (MDTs) in driving better health outcomes.

Q: Can you explain what the Data Into Action (DIA) programme is and why it’s important for Cheshire and Merseyside?

Andrea Astbury (AA): The DIA programme is our Integrated Care Partnership's approach to tackling the deep-rooted health inequalities across Cheshire and Merseyside, where we serve a population of 2.7 million. Many of our citizens face higher rates of long-term and mental health conditions, with mortality rates disproportionately affecting the most deprived areas. DIA uses linked population health data to identify these inequalities, flag at-risk patients, and implement interventions to improve outcomes.

Chris Buckels (CB): It’s about moving from reactive care to proactive care. Instead of waiting for people to present with complex needs, we use analytics to anticipate and address those needs earlier. The DIA programme also enables us to evaluate the effectiveness of interventions, ensuring we’re consistently improving how we deliver care.

Q: How does proactive case finding work, and what tools are you using?

CB: Proactive case finding is central to DIA. Our Enhanced Case Finding Tool integrates data from various sources to identify individuals at risk, whether they’re vulnerable to hospitalisation, managing multiple long-term conditions, or falling through gaps in the system.

AA: For example, the tool flags patients who might benefit from being referred to telehealth programmes, Integrated Care Teams, or Specialist Teams (MDTs). These insights allow us to personalise care and intervene early, improving patient outcomes and reducing pressure on acute services.

Q: The Data Into Action Academy sounds like a key part of your strategy. Can you tell us more about it?

CB: The Data Into Action Academy is an accredited, interactive learning programme designed for health and care staff across Cheshire and Merseyside. It’s all about empowering people to make data-informed decisions.

AA: The Academy provides training on tools like the Enhanced Case Finding Tool, the Waiting List/Elective Recovery Dashboard, and the Complex Households Dashboard. We also teach participants how to use the Business Intelligence Portal and apply the Real-World Intervention Causal Evaluation (RICE) methodology to assess the impact of their interventions. There is a video here, which goes into more detail.  

CB: Through virtual workshops and active learning discussions, we’re creating consistency in how data is used across the system. The goal is to equip leaders and teams with the knowledge and skills to address health inequalities, improve outcomes, and drive efficiencies.

Q: Who is the Academy for, and what impact has it had?

AA: It’s for anyone in the public sector within the Integrated Care System (ICS) footprint—whether they’re commissioning services, transforming care pathways, or delivering on-the-ground interventions.

CB: The Academy has been a game changer. By fostering a data-informed culture, we’ve strengthened leadership across the ICS. People now have the confidence and tools to take action based on data, whether that’s designing services, targeting interventions, or evaluating outcomes.

Q: Can you share an example of how DIA has made a difference?

AA: A great example is our work with the Telehealth Team who have been using the Enhanced Case Finding Tool (ECFT) to proactively onboard patients. Telehealth have a strong evidence base that their support and remote monitoring of people with Diabetes, Heart Failure or COPD can help reduce the likelihood of them being admitted to hospital.
Prior to the use of the ECFT, the team were struggling to onboard sufficient numbers on their caseload, as referrals were required from other services and teams, mainly GPs, who have little time to proactively search caseloads to refer onwards. Now the team can use the data to highlight which patients have any of the key health conditions alongside an elevated risk of admission and can subsequently make direct contact. GPs are closely monitoring the processes and have been very supportive to date.  Since this new model has been implemented caseloads have increased six-fold.

CB: Another example is using the Complex Households Dashboard to identify vulnerable families who would benefit from an offer of Early Help.  Developing a targeted approach to embedding preventative interventions for this cohort is a real priority as we know they tend to receive lots of reactive care but far less coordinated and integrated support. 

Q: What’s next for the DIA programme?

AA: We’re focused on scaling our approach and embedding it across all parts of the ICS. This includes expanding the reach of the Data Into Action Academy and refining our tools to ensure they remain effective in addressing emerging challenges.

CB: Listening to our communities is also critical. We’re working to ensure that the voice of local people is at the heart of how we use data. By doing so, we can build trust and deliver care that truly meets their needs.

Q: Why should people attend your session at Digital Health Rewired 2025?

AA: This session is a unique opportunity to see how population health analytics can transform care. We’ll share practical examples of proactive case finding, population segmentation approaches, and how the Academy is driving cultural change.

CB: Whether you’re a data enthusiast or someone looking for actionable insights to improve care delivery, this session will inspire you to take your use of data to the next level.

Session Details

Title: Data Into Action: Implementing a Strategy to Use Population Health Analytics to Be Proactive and Identify the Most Complex Patients

Speakers:

• Andrea Astbury DIA Programme Director, Cheshire and Mersey ICB
• Chris Buckels, Deputy Head of Business Intelligence (Population Health Into Action), Cheshire and Mersey ICB

Don’t miss this inspiring session at Digital Health Rewired 2025!