The Liverpool Place Population Management (Proactive Care) initiative has changed how care is delivered to high-risk patients in the city.

The patients most at risk of deterioration or unplanned hospital admission – including those with chronic obstructive pulmonary disease (COPD), chronic kidney disease and frailty – are identified and offered support before they reach crisis point.

Neighbourhood-level teams wrap care around the patients, using telehealth, community respiratory and integrated care teams to reach those most a risk and give them the support they need.

Regular monthly meetings keep all partners in touch and pulling in the same direction.

Among the patients identified and supported proactively, there has been a 28% drop in A&E visits, 36% fewer emergency admissions and 34% fewer GP contacts.

The telehealth caseload grew from 250 patients in January 2024 to 2,000 by the end of 2024, with 70% coming through case finding rather than referrals. That reduced GP workloads. COPD reviews had an 87% uptake rate.

What began as a single service has grown into a joined-up model spanning community, acute, mental health and primary care. A pioneering partnership with Prima Housing is now linking health and housing data to support respiratory patients living in fuel poverty — the first structured approach of its kind nationally.

Lessons from the initiative are being shared across Cheshire and Merseyside.

Winner of the NHS Excellence award for neighbourhood health.