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Header image for the current page Data-driven transformation of care for people with frailty and dementia wins HSJ Award 2023

Data-driven transformation of care for people with frailty and dementia wins HSJ Award 2023

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Arden & GEM’s Business Intelligence team is delighted to be part of an HSJ Award-winning project, with Mid and South Essex Integrated Care System (ICS) and Essex Partnership University NHS Foundation Trust (EPUT), in the Data-Driven Transformation category.



The project, which was led by clinical and care leaders from across Mid and South Essex ICSs ‘Ageing Well’ stewardship group, has seen over 9,000 local people living with or at risk of frailty or dementia benefitting from more preventative, personalised care.

Dr Matt Sweeting, Interim Medical Director and Ageing Well steward at the Mid and South Essex Integrated Care Board said:
“This is absolutely terrific news. This work is a real example of what can be achieved through working together and agreeing best-practice through evidence-based, personalised, and proactive input from different staff working across different health organisations across our system. We are now able to better identify and support people earlier to achieve safer, smarter care earlier in peoples care journey.”

Thanks to successful collaboration, innovative use of data and dashboards has enabled health and care staff, no matter which local organisation they work for, to have live access to the information they need to provide the best care possible. This has meant improved outcomes and experiences of some of the most vulnerable members of the local community including less emergency admissions and reduced 30-day hospital readmission rates for older people throughout the region.

Hayley Black, Principal BI Analyst at NHS Arden & GEM said:
“We are absolutely delighted to see the work of our partnership recognised in this way. This initiative has shown what can be achieved when we bring together the wealth of data that exists across our health and care systems in unique and innovative ways to answer key questions about patients, their experience of care and their health outcomes. By using data to tell stories we can support staff to make the best decisions for local people and local services.”

Within stewardship groups, small teams of frontline health and care staff and managers collaborate as ‘stewards’ using their different perspectives, skills and knowledge - alongside population-level data - to take a fresh look at the value delivered from our shared resources. 

Ageing Well stewards involved in this work developed a model to help tackle challenges including:

Arden & GEM’s BI team worked with the stewardship group to design FrEDA (the frailty end of life dementia assessment tool) and eFraCCS (the electronic frailty care co-ordination system) to meet their specific needs. The bespoke dashboards bring in data flows from across the ICS and are presented in a way that is accessible and meaningful to users. The tools are hosted on the system-wide strategic data and analytics platform, Athena, so they can be accessed by those working in a range of organisations including trusts, hospices and PCNs.

Spencer Dinnage, Operational Service Manager for Older People’s Community Mental Health, Dementia and Frailty at EPUT, said:
“It was an amazing experience to see the work which started in a very small project nearly eight years ago now recognised at a national level with such a prestigious award. This data driven work to reduce inequalities in an often hidden population, to improving outcomes, experience and reduce system pressures is a fantastic achievement of integration and collaboration between so many system partners.

“I am so proud to have been part of this work from the very beginning and of the whole team who have been on the journey with FrEDA and eFraCCS, this recognition could not have been achieved without this fantastic group.”

The HSJ Awards took place on Thursday 16 November 2023 in London and were hosted by comedian, Matt Lucas, who led the way in celebrating the commitment of hard-working teams and individuals across the UK and their ongoing efforts to deliver improved patient outcomes.

Winning an HSJ Award is the most esteemed accolade of healthcare excellence in the UK and this year saw a record-breaking 1,456 entries received with 223 making it to the final shortlist, following two rounds of rigorous judging. The full list of winners can be found here.