View the project poster and slides from the Cohort 9 Bevan Exemplar Showcase

View the project poster and slides from the Cohort 9 Bevan Exemplar Showcase

Double Award Winners:

This project won the Digital and Technology Innovation Award at the Advancing Healthcare Awards Cymru 2025.

This project won the Technology and Digital Impact Award at the MediWales Innovation Awards 2024. A film on the project, produced by MediWales, can be found below:

Background

Following the COVID pandemic, elective surgical waiting lists in Wales have increased dramatically. Managing, supporting and optimising patients whilst they wait has never been more important. This project demonstrates the impact and utility of a new interactive digital platform to monitor patient health and provide customised health support and optimisation.

Aims and Objectives

Working in collaboration with Pro-Mapp Limited, Swansea Bay co-created a customised digital platform allowing patients to self-report their health and well being symptoms whilst they wait for hip and knee replacement surgery.  The interactive platform uses intelligent technology to offer customised lifestyle support. It validates the waiting list and triages and prioritises patients with higher health needs to align with Therapy services. It highlights patients who report underlying health conditions requiring optimisation and signposts to appropriate support services. It can also health profile patients to stratify their risk for surgery.

Approach

Outcomes

The OWLi digital platform was launched in March 2023. Over 5000 patients have been on-boarded and benefitted from universal preoperative advice and support.  Over 300 patients with a significantly raised body mass index (BMI) have been referred to specialist Prehabilitation weight management services. 200 smokers have been signposted to cessation support. Over 500 patients with pre-existing health conditions have been signposted to engage with their primary and secondary care providers to ensure their comorbidities are optimised and any overdue surveillance blood tests or reviews arranged. Without the platform interaction, these patients would not have sought review or optimisation and would have attended their pre-operative assessment without these comorbidities addressed. 65% of patients were identified as Green and the majority of these were successfully streamed to high volume low complexity sites including private providers.

Impact

Conclusions

Using a digital platform to monitor and support the health needs of patients waiting for surgery has huge potential benefits for planned care pathways in Wales. A digital platform with in-built intelligence to customise support according to need is a highly innovative technology asset. The platform has the ability to engage patients at the point of being listed for their procedure, to start preparing and optimising their health in readiness for their surgery.  The pathway team has used health data to streamline pathways and improve the efficient use of resource. OWLi has supported patients to “Wait Well”, actively preparing and becoming engaged in managing and improving their health status in readiness for their procedure.

View the project poster and slides from the Cohort 9 Bevan Exemplar Showcase

When Billy had a fall he experienced a long lie of 20 hours, before being admitted to hospital. The Red Bag (and Future Care Plan) ensured that Billy’s medical information and care preferences were immediately available. Billy experienced a smooth transition to his chosen place of care where his dying wishes were treated with dignity and respect.

Future Care Planning alone has shown:

– Improved patient agency.

– Reduced hospitalisation.

– Better carer confidence and system coordination.

Unfortunately Billy’s experience remains common for many frail older people who are admitted to hospital in Wrexham. Older people continue to experience the long lie, followed by prolonged hospital stays, unnecessary medical interventions and loss of independence

View the project poster and slides from the Cohort 9 Bevan Exemplar Showcase

View the project poster and slides from the Cohort 9 Bevan Exemplar Showcase

A Practical Framework for Application at Local, Regional and National levels

1. Structural Investment and Systems Integration

Firstly, a sustained structural investment is required to move beyond short-term, project based models. Embedding co-production and community participation within commissioning and regulatory frameworks, and allocating core funding to support community infrastructure and leadership development, are all considered essential steps towards embedding and institutionalising these practices.

2. Capacity Building and Workforce Development

Secondly, capacity building must be prioritised across both professional and community domains. The health and care workforce requires capacity and support for training in facultative, relational, and power sharing practices while communities, particularly those which have been historically marginsalised, must be supported to develop leadership, organisational capacity, and participatory confidence.

3. Embedding Equity and Inclusion

Equity must be embedded as a guiding principle across all stages of design, implementation, and evaluation. This includes prioritising engagement in high-need communities, adopting intersectional approaches to understand differential impacts and ensuring that power is re-balances and shared meaningfully with those most affected by health inequalities. This shift represents not only a strategic imperaitive but a moral one: to ensure that health systems are shaped with, not merely for, the populations they serve.

4. Creating a Lasting Legacy

Finally, these approaches must be adopted as a means to create a lasting legacy through evaluation., learning and accountability. In order to re-build and maintain trust, shared ownership and accountability, organisations should come together in partnership alongside empowered communities.

View the project poster and slides from the Cohort 9 Bevan Exemplar Showcase

• 62 % reported improvement in symptoms following tailored support and intervention.
• 70% reported improved quality of life.
• 87.5% found service beneficial.
• Time to access specialist care reduced to ¼ of previous timelines

“Thank you so much for listening to me, for over a year I knew something was wrong, even when doctors told me it was normal after cancer treatment.”

Patient diagnosed with bile acid malabsorption 19 months after radiotherapy completed.

Fig. 1 Ave. Improvement in quality of life score since being seen by the late radiotherapy effects – demonstrating a highly significant increase

Impact on Service

Reducing appointments with GPs and secondary care specialists. Removed the need for initial GP appointment and follow up via self-referral pathway, cost avoidance of £90 per patient.

Streamlined referral pathways, consistent follow-up and earlier intervention for all patients. Reduced the number of unnecessary tests and secondary care specialist appointments.

Cost Avoidance

Examples given below represent the management pathways taken of 2 patients who both developed long term rectal bleeding as a result of radiotherapy. Patient A had multiple appointments and tests, it took >1.5 years for correct treatment; under the pilot, similar cases were referred and treated within 2 months. Estimated cost avoidance of up to £900 per patient compared to traditional management pathways

Conclusions

• A radiographer-led late effects service is both feasible and effective, filling a critical gap in survivorship care.
• It reduces time to specialist intervention, improves symptom control, and enhances patient quality of life.
• The model offers cost savings and eases pressure on oncology, primary care and secondary care teams.
• Patient testimonials highlight the emotional and practical value of timely, tailored support.
• The service shows strong potential for scaling and integration into routine follow-up pathways.

View the Slides and Poster from the Cohort 9 Bevan Exemplar Showcase

Finalist  – Primary Care Team of the Year, Welsh Pharmacy Awards

Finalist – PCPA Primary Care Pharmacy Team Award, PCPA Excellence in General Practice Pharmacy Awards 2025

Background

ABUHB supports 1,800 beds across 43 care homes, where residents are typically older, frailer, and living with multiple comorbidities. Over 80% of people aged 75+ take at least one medicine, and more than a third take four or more—figures even higher in care homes—raising risks of falls, cognitive decline, and hospital admissions.

Polypharmacy contributes to harm, with 6.5% of UK acute hospital admissions linked to medicines. NICE recommends regular medication reviews, but many residents miss timely reviews due to service pressures.

This project aimed to evaluate the impact of a clinical review of care home patients by a dedicated care home pharmacist.

Aim

Improve medication safety, patient outcomes, and reduce medicines waste in care homes through structured, pharmacist-led medication reviews.

Objectives

• Deliver detailed medication reviews for care home residents, focusing on high-risk medicines, dose optimisation, and deprescribing.
• Measure impact on patient safety (e.g., reduced adverse effects, improved ACB scores, fewer hospital admissions).
• Optimise prescribing and reduce waste through in-depth polypharmacy reviews with appropriate and improved compliance.
• Assess impact on GP workload by reducing appointments and care home visits.
• Engage stakeholders to co-produce and evaluate the project for continuous improvement.
• Develop a standardised toolkit to support consistency and scalability across ABUHB and beyond.

Approach

Outcomes

New Clinical Service

Pharmacist-led medication reviews introduced for care home residents and Complex Care Team patients, delivering personalised pharmaceutical care closer to home.

Structured Toolkit
A comprehensive implementation resource with guidance, templates, and training materials to support service spread and scale.

Protocols & Policies

Developed PRN and OTC medication guidance, with educational materials to promote safe, autonomous medicine use.

Impact

(PDSA cycle 1,2 and 3)

Residents reviewed 341

Potential ACB score reduction: 55 across residents contributing falls reduction risk

(PDSA cycle 2 and 3)

• 40 Medicines stopped
• 64 less administrations per day across 89 residents freeing up nursing time
• 34% of residents aligned to 28-day cycle to reduce waste
• 7 high risk drug interventions
• 12% formulation changes to aid compliance
• 51 PPIs reviewed
• ACB score reduction of 10 across residents reviewed
• Stopping 40 medicines (≈ 0.5 kg CO₂ per box) saved 20 kg of CO₂ — roughly the same as driving an average petrol car 100 km
• 267 GP appointments saved
• Rectified doses, ordering of up-to-date monitoring and specialist advice for high-risk medicines
• Resident previously chewing all tablets – now compliant with medication in a suitable form

Conclusions

• Safer, personalised medication for residents
• GP time saved via pharmacist-led reviews
• Empowered care home staff through education
• Reduced medication waste and environmental impact
• Enhanced patient safety
• Care brought closer to home
• Developed a replicable toolkit for medication reviews

View the project poster and slides from the Cohort 9 Bevan Exemplar Showcase

Background

Rare diseases affect 1 in 17 people globally, including around 180,000 in Wales, many facing life-limiting and complex conditions with limited treatment options or care pathways.

Individuals and families often experience isolation, delayed diagnoses, and fragmented support. The “diagnostic odyssey” can take years, with patients repeatedly explaining their history to different professionals.

Even after diagnosis, they face ongoing challenges coordinating health, education, and welfare needs with little support.

This lack of integration fuels health inequalities, limits access to research and NHS services, and contributes to declining mental, physical, and social wellbeing, increasing reliance on care resources

Aims

1. Develop a Wales digital rare care centre (WDRCC)

• In three SE Wales health boards, complete IG guidance to enable access for all.
• Complete a 5-year contract between health board and industry partners for continued development.
• Engage four rare disease clinical teams to support the pilot; developing resources and onboarding families onto the platform for evaluation and co-creation.

2. Pilot peer support content and horizon scan for technology

• Develop peer support groups and access to resources developed to facilitate a smooth transition from paediatrics to adult services.
• Work with clinicians to understand the current gaps in support and potential solutions.
• Work with Expert Patient Programmes to improve access to leadership and empowerment skills support.

3. Understand the impact of online service provision to NHS Wales

• Enrol in the climate emergency dragons heart academy.
• Continue stakeholder engagement about the impact of the WDRCC on the Welsh Government digital and data strategy for health and social care in Wales.

4. Peer clinical support and share opportunities across rare disease clinical services

• Bringing Medical and social care professionals working with rare conditions together
• Signposting each other to relevant resources to help increase access to support materials for professionals and families alike.
• Regular peer support sessions and shared learning opportunities.

Approach

1.Industry partner developed the rare disease platform.

2.Clinicians and lived experience groups defined priorities.

3.Governance, cybersecurity, and partnerships with NHS and charities followed.

4.Stakeholder engagement, PPIE groups, and shared learning shaped progress.

5.Combined resources improved access and equality.

6.Ongoing development invites community input into the Wales Digital Rare Care Centre vision.

Results

The Wales Digital Rare Care Centre is already highlighted as an example of good practice. The NICE Rare Disease Quality Standards and other UK rare disease framework guidance documents are currently being developed, focusing on public requirements for a one point of access digital platform to improve awareness of rare diseases and to share resources and peer support.

Impact

The development of a rare disease MDT peer support group will have benefits further than the boundaries of this project and help the clinical team members involved in rare disease care to share learning and gain valuable support from each other.

One access point, currently links to three separate, but interlinked hubs.  48 spaces (rooms) have been requested and developed by stakeholders and accessible in 5 languages (including Welsh). 186 documents have been uploaded, including videos. 64 clinicians and non-clinicians are using the site

The Project Team

The first meeting of the Bevan Commission Exemplar Project team, looking at meaningful outputs and measures of progress in order to start our SMART objectives over the next 11 months.

View the project poster and slides from the Cohort 9 Bevan Exemplar Showcase

As frailty and dementia rise among older adults (See graph), staying safe at home becomes more challenging. Traditional care can’t always provide real-time support—potentially leading to increased risks and reduced quality of life.

Personal alarm watches can offer a smart solution:

• Continuous monitoring
• Instant emergency alerts
• Peace of mind for users and caregivers

Aims and Objectives

Enhance safety, promote independence, and improve quality of life for vulnerable populations—particularly people living with dementia in Wales—through wearable technology.

Objectives

1.Assess Acceptability: Understand how the watches are received by participants, caregivers, and professionals.

2.Evaluate Usability: Assess ease, reliability, and practicality in daily life.

3.Measure Impact: Measure effects on safety, independence, and overall quality of life.

4.Establish Viability: Provide evidence to support integration into health and care systems.

Approach

The project dealt with several challenges:

• Technical issues such as signal loss in rural areas, SIM card problems, and complex setup.
• Battery life and non-standard chargers posed barriers, especially for those with cognitive decline.
• Patients often needed prompting or support to wear and charge the device.
• Volume limitations made it hard for those with hearing impairments.
• Some watches were returned due to anxiety or relocation to assisted living.
• Families sometimes underutilized features due to lack of training or time.
• Cognitive status influenced acceptance and consistent use.

Evaluation Approach

Mixed Methods: Combining data and lived experience to assess impact.

Quantitative: Short questionnaires from participants and caregivers measured safety, independence, and usability. CORE-10 PROM

Qualitative: Interviews and case studies captured real-world feedback.

Impact

• Enhanced Safety & Independence:
  Real-time location tracking allowed patients to continue daily routines safely, reducing the risk of wandering and accidents. The devices helped preserve autonomy and independence while offering reassurance to caregivers.
• Improved Family Experience:
  Relatives, especially those working full-time or living far away, experienced greater peace of mind.
• SOS contact setup was intuitive. Fall detection triggered alerts and calls to emergency contacts. Geo-fencing and Wi-Fi boundaries helped monitor movement. Pedometer and reminders added functional value.

Clinical Outcomes

The CORE-10 assessment for the CTM UHB cohort showed a decrease in clinical score from 8 to 6 over 8 days, indicating a positive shift in mental health status, with reduced anxiety and distress, though sleep difficulties and suicidal ideation remained concerns.

Conclusions

• Involving patients, carers, and community representatives throughout ensured the solution addressed real needs and preferences.
• Technology acceptance varied, influenced by cognitive ability, anxiety, and support systems—highlighting the need for tailored education and setup support.
• Reliable connectivity and simple device setup are essential, especially in rural areas and for users with cognitive challenges.
• Ongoing involvement from carers and clinicians underpins successful adoption and sustained use.

Watch the Project Presentation

View the project poster from the Cohort 9 Bevan Exemplar Showcase