Bevan Commission 

Planned Care Improvement Project

Dr Sian Moynihan, Consultant Community Paediatrician

2018/19 Child Measurement Programme Wales:

• 12.6% of children in reception (age 5) were obese.

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2020/21 Child Measurement Programme England:

• 25.6% of children in year 6 (age 11) were obese.
• 1 in 3 children in the most deprived areas are obese.

NHS Business Problem

Prevalence of Childhood Obesity

%

Background�Cardiff and Vale Weight Management Services Pathway

3

Updated 20/06/2022

Level 1

Level 2

NYLO early years health weight programme. group education & 1:1 interventions www.nylo.co.uk

Early years programme for Black and Asian minority ethnic communities (starting Jan 22)

Foodwise in Pregnancy

Self-management support via www.keepingmewell.co.uk

Living Well including Foodwise for Life

Cluster level diabetes prevention through brief intervention (1 cluster, 2 start March 2022)

AFAL MDT 1:1 interventions including medical; nursing; dietetic; psychology; OT; physiotherapy, support workers

Foodwise in pregnancy

Midwife led healthy pregnancy clinic

SWMS MDT 1:1 interventions including medical; nursing; dietetic; psychology; OT; physiotherapy

Piloting group based intervention as part of research programme.

VLCD intervention (counterweight)

• Renal- Balance group education
• 1:1 dietetic and MDT support

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• Bariatric surgery via Swansea

Level 3

AFAL – Active Families Active Lives MDT 1:1 support

AFAL group education programmes (linked to key stage curriculum

Community signposting.

Settings approach including Food and Fun (previously SHEP and schools programmes; youth services/ settings

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Consultant led antenatal care (BMI>40)

1:1 dietetic support (commenced Nov 21)

Dietetic led 1:1 and group interventions.

Developing groups to support emotional regulation in partnership with psychology

NS4L programmes including Get Cooking. Flying start

Services are supported by a partnership with leisure service providers

Single Point of Access

New services established

Existing

services enhanced

Why wait for ill health to start an intervention for children and young people? 

Level 2

Level 3

Level 1

Level 4

Dietician Advice only

Regional Partnership work

Avoid children needing tier 4 service

Self-management of Wellness

Current Children’s Tier 3 �Face to Face Assessment and Follow up service

MDT in Clinic

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Assessment:

Resources provided and goal setting.

Barriers identified and group education  delivered by MDT over required period.

In clinic follow up at 6 months

In clinic follow up at 12 months

Subjective Progress discussed, outcomes measured limited

Outcomes:

1. Discharge by 12 months

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Follow up pathway 

1. Minimum follow up capacity

already not sustainable.

•  Follow up demand means New assessments not  scalable.
• Patients will disengage due to limits in follow up capacity.
•  Limitation of  outcomes available that can be tracked on face to face.
• Behaviourally informed and measured data impossible to record and track without interfaced tech.

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Assessment Phase

Follow up phase

Discharge

Technology Solution Developed

Engages  the Individual with  their own data via Fit bit watch and app

Engages the young person with a professional…… virtually via AFAL app

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Bespoke designed 

by team

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Cool and acceptable

to young person

Virtual Ward Platform

Aims of Project:

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1. Interfaced wearable that  meets data security and information governance standards and takes a collaborative multidisciplinary approach.
2. Is an interfaced wearable via virtual ward acceptable and useful for a child / young person and professionals?
3. Does an interfaced wearable support clinical outcome to sustain lifestyle changes and weight management outcomes in our population?
4.  Does this way of working provide value base healthcare better than what we are currently doing providing scalability and sustainability?

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Method:

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1. With thanks- Successfully Navigated

Data Protection Impact Assessment & Agreement, signed by Cardiff and Vale  

Data security and Information Governance team.

• Pilot service improvement project submitted via CAV Research and Development. 
• Developed digital on boarding process
• On boarded 10 children
• Engaged  and enabled the full multidisciplinary team of professionals in  the process:
• School Nurse
• Dietician
• Physio
• Occupational Therapist
• Consultant Paediatrician
• Junior Doctor
• HealthCare support worker

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Results: Clinical Outcomes

Lifestyle improvements

Step count: 100% of young people increased this

Sedentary time: 100% of 10 children improved

Sleep data capture 90% wore their fit bit at night

Plants eaten a week towards goal set: 54% recorded 

Average z score for group reduced

Results: Professional Testimonials 

1. Patient doesn't have to work hard to collect  data  with pencil and paper.
2. Patient doesn't have to remember to communicate that data or  bring it with them to the outpatient appointment it's there for the professional to see. 

1. Patient doesn't even have to remember to turn up for an outpatient appointment.
2. Patient doesn't have to miss school, or the parent lose  a day of work.

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Data buddies - parents can support their child if they are not Gillick competent or have mental capacity, which means equity of access for all children at all levels of development. 

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• The care is patient centric.
• Allows earlier discharge.
• Allows development of an education push vehicle to patients, accessible when they need it and as they are ready for it.

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• Reduced outpatient organisation time resource.
• Reduced paper communication demand.
•  Reduces professional documentation demand.
• Frees up planned care time.

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Easy Data Viewing

Patient Centric

More Connection,

Less Time Demand

Access Equity

 Results: Young People & Family Feedback

100%  reported wearable kept interest in goal setting more than without a watch.

‘’Encourages you to monitor as a  daily routine by raising your awareness’’.

100% goal setting discussion via app and wearing a watch helped  set goals that was felt achievable.

80% reported goal setting and using a watch, supported family discussions to help you achieve goals.

70% reported communicating virtually with professional was helpful.

‘’Being able to communicate virtually with a professional helped as I could get feedback and support without the inconvenience of having to set up a meeting and going to the hospital in person. The professional could analyse my statistics and provide tailored support and feedback to me instantly over message and that most definitely helped.’’

• ‘’Easier than travelling to appointments’’
• ‘’ Helped me keep stick to my goals’’
• ‘’Doesn’t replace face to face when that is needed but on the whole works’’

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86% reported virtual communication more convenient than having an appointment.

Results: Value Based Healthcare: Time/ Waste Impact

Results Value Based Healthcare: Performance Impact

Value Based Health: Economic Impact

Value Based Health Care - Avoidable Tier 4 costs for children and young people

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Tier 4

Tier 3

�Future avoidable costs for adult services if no child enters adulthood suffering from the consequences of living with obesity

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CAVUHB Children’s Tier 3 CURRENT FACE to FACE Weight Management Service

MDT in Clinic

Assessment

Period.

In clinic follow up at 6 months

In clinic follow up at 12 months

Outcomes:

1. Discharge by 12 months

2. Patient may disengage due to delay in follow up capacity

3. Limitation of outcomes available that can be tracked

As data difficult to record ,and track without interfaced tech. 

MDT in Clinic

Initial Assessment Period.

CAVUHB Children’s Tier 3 NEW VIRTUAL WARD Weight Management Service

Up to 18 behaviourally informed contacts with member of the MDT via remote wearable interfaced app, barriers addressed as they arise.

Subjective progress discussed, outcomes measured limited.

Assessment:

Resources provided and goal setting

Barriers identified and group education.

Assessment:

Resources provided and goal setting, barriers identified and  group education.

Data monitored and captured continuously via wearable. Data and outcome rich at every stage till discharge.

Outcomes:

Discharge from as early as 3 months with evidenced outcomes and data capture.

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Benefits of virtual ward:

Cheaper, more flexible, more efficient, frees up clinic space, reduced travel, lower carbon footprint, reduced time off school and work for appointments, no DNA rate for virtual contacts, measurable, behaviourally informed, responsive to  patient’s needs. Evidenced within 3 weeks with data driven management and discharge.

Follow up pathway

• Not Scalable
• Already not sustainable

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Follow up

Follow up

This service improvement evaluation is consistent with WAG strategy:

1. A Healthier Wales: Our Plan for Health and Social Care 

 Calls for Value Based Health care. 

2. Welsh Government Health Strategy 

• ‘Together for Health. ‘Working differently- working together’, National Service Framework (NSF) for Children & Young People
• Have all stressed that a focus on children’s health is essential in order to provide the best start in life for our children.

3. Healthy Weight, Healthy Wales 2021

Recommends that children’s services are prioritised as illness will represent a higher proportion of a child’s whole life and potentially have permanent long -term impact on growth and development. 

4. The Kings Fund (kingsfund.org)

Self-care/ self- management and primary prevention are the top 2 commissioning priorities recommended by the King’s Fund for commissioners.

5. Cardiff and Vale UHB - Shaping Our Future Wellbeing Strategy

This service improvement evaluation addresses all the service principles:

Empower the person, home first, outcomes that matter to people, avoid harm  and waste variation.

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�Our Programme for Transforming and �Modernising Planned Care in Wales and Reducing�Waiting Lists  - Welsh Government April 2022�

1. ‘Increased support for clinicians so they have more time to care, using new technology, which reduces administration and improves communication’. 
2. The AFAL  project provides ‘health care closer to home’ and ‘builds sustainable planned care capacity’ by:
1. Harnessing new technology.
2. Improving self-care/ self-management through responsive virtual management.
3. By following up prudently.
3. The WAG programme recommends that ‘children’s services are prioritised as illness will represent a higher proportion of a child’s whole life and potentially have permanent long-term impact on growth and development.
4. Eliminating long waiters and clinical variation are also prioritised.

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Key Conclusion and Learning

Virtual ward with wearable device enables VALUE in planned care weight management services for children.

1. Provides a behaviourally informed and measured communication with outcomes evidenced from the outset for both professionals and young people.
2. Is supported by Cardiff and Vale DPIA –via an All Wales document and is multidisciplinary in its usability.
3. This method is a positive change and acceptable for the service and children and their families. 
4. Provides value based, CENTERED health care, early intervention, prevention and is a scalable solution. 

Vision for Immediate  Virtual Ward Projects: From prototype to PILOT and spread and scale across Wales�

AFAL 10 patient prototype complete.

To scale prototype to a pilot cohort 200 patients Tier 3 children.

To add spread to a prototype cohort of 10 patients in Adult Weight Management Service to support transition of young people and 10 patients in Paediatric Type 2 Diabetes service  for Cardiff and Vale UHB.

To Spread to three other health boards -Children's Weight Management Service:

Prototype cohort of 10 patients each. 

STEP 1 

completed

STEP 2 

Scale to 200 patients in AFAL and spread into 2 other C+V services. R+D permission signed off  for Cardiff and Vale.

Engaging with CEDAR and Welsh Value in Health care Centre.

STEP 3

What Next: 

We invite interested commissioners

to support the spread and scale of our project

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Thank you