A neighbourhood care model in Cheshire East has reduced A&E attendances and emergency admissions through earlier, coordinated community-based interventions.
The neighbourhood care model is delivered through Cheshire East’s place-based Integrated Care Partnership (ICP).
Delivered across eight care communities between November 2024 and November 2025, the programme supported 3,587 high-risk residents identified through population health data.
Across the cohort, A&E attendances fell by 14.6% and emergency admissions by 26%.
In some areas, A&E attendances fell by up to 48%.
How the neighbourhood care model works
The initiative has identified up to £2.8m in indicative cost avoidance, including £1.1m linked to reduced A&E and emergency admissions.
The model uses the CIPHA (Combined Intelligence for Population Health Action) platform to identify and stratify at-risk residents using linked health and care data.
More than 2,150 people were identified for intervention, with 450 receiving intensive multidisciplinary support.
Teams including GPs, nurses, pharmacists, physiotherapists, social prescribers and local authority staff delivered coordinated care in the community.
Interventions included proactive reviews, medication optimisation, falls prevention and social prescribing.
Despite population growth of 5%, urgent and emergency demand has not risen in line with need.
The programme is being recognised across Cheshire and Merseyside as a leading example of neighbourhood-based population health management.
“This programme demonstrates what can be achieved when neighbourhood teams are empowered to work proactively around residents most at risk,” said Dr Anushta Sivananthan, Integrated Neighbourhood Teams SRO for Cheshire East Place.