System Response to Reducing Admissions in the Last 90 Days of Life

As part of an ongoing commissioning arrangement with Cheshire East Place and Cheshire and Merseyside Integrated Care Board, EOLP was approached to facilitate a system response to reducing admissions to hospital among people who are in their last 90 days of life. Delivery of the project calls upon EOLP’s leadership and data analysis expertise and close collaboration with local NHS providers ensures that partners are fully engaged and available to provide an operational perspective into the project findings.

In December 2024, elements of the project originally initiated in Cheshire East in July 2024 were further advanced and piloted throughout the North West Region. To facilitate delivery of this regional initiative, EOLP collaborated with partners from NHS England, North West Ambulance Service (NWAS), as well as Clinical Network Teams representing Cheshire & Merseyside, Lancashire & South Cumbria, and Greater Manchester.

Progress to Date

• Developed and validated a proof-of-concept system analysis data dashboard that consolidates ‘system level’ data from Primary Care, Community Services, Hospices, Care Homes, and Out of Hours Services. This dashboard assists both commissioners and providers in identifying areas within the system requiring investment or improvement.
• Convened a specialist group of Business Intelligence Leads across the region to promote and support best practices in end-of-life data collection, analysis, and presentation.
• Reviewed two risk stratification tools used in Cheshire & Merseyside—the Combined Intelligence Population Health Analysis (CIPHA) and the EARLY identification toolkit—to provide recommendations for their clinical application, with the aim of supporting proactive care planning for individuals at risk of repeated and avoidable hospital admissions.
• Conducted an in-depth audit of 80 deaths involving admissions during the last 90 days of life in Cheshire East, and commissioned NWAS to undertake a comprehensive review of 300 palliative/end-of-life ambulance call outs throughout the North West Region.
• Tracked patient journeys for eight complex cases involving multiple admissions in the final 90 days of life, with work underway on the development of educational resources to inform practice changes.
• Surveyed a representative sample of the workforce to gather insights into barriers experienced when preventing hospital admissions and facilitating earlier identification and proactive care planning.
• Interviewed three families (to date) to understand their perspectives regarding emergency admissions at the end of life.

Next Steps

• In December 2025, a “lunch and learn” webinar was held to present progress updates; the presentation slides can be downloaded below and the recording is available at the link below.
• Preparation of final project reports for both the Cheshire East and North West Region projects is underway. Moving forward, we will engage with partner organisations, commissioners, and providers across the region to design and implement a series of service improvements informed by the project outcomes.