Transformation Directorate

Hywel Dda University Health Board virtual orthopaedic prehabilitation

The pandemic had a significant and long-lasting effect on the delivery of planned care across Hywel Dda University Health Board. More than 4000 orthopaedic patients had their treatment delayed and this had a significant impact both on their physical and psychological wellbeing.


No prehabilitation service available to support optimisation for patients across a large geographical rural area.


To offer a tiered virtual prehabilitation service to all patients awaiting elective hip and knee arthroplasties across Hywel Dda University Health Board, providing advice on the:

  • self-management of symptoms
  • physical exercise sessions
  • healthy lifestyle
  • nutrition
  • home safety
  • psychological wellbeing


Hywel Dda University Health Board developed and implemented a virtual, tiered, multi-disciplinary orthopaedic prehabilitation service with partners in industry.

Patients are assessed and stratified onto one of three different virtual patient centred tiers of prehabilitation based on their clinical, physical and psychological needs utilising digital platforms.

Tier 1: 8-week online prehabilitation programme using a digital personal held health record (Patients Know Best).

Tier 2: Tier 1 plus “live” virtual group home based prehabilitation (12 sessions over 12 weeks) utilising Attend Anywhere group functionality using a virtual group consultation concept and remote monitoring through technology enabled care (blood pressure/ weight/ heart rate/ oxygen saturation) supported by Delta Wellbeing and Tunstall’s “MyMobile” app.

Tier 3: Tier 1 plus supported one to one virtual prehabilitation sessions for patients with more complex needs or digital accessibility challenges (hearing, eyesight etc) utilising Attend Anywhere video consultations and remote monitoring (default virtual, flexibility for face-to-face if required).

Patient Reported Outcome Measures (PROMs)  and Patient Reported Experience Measures  (PREMs) data capture through the DrDoctor platform.


  • Improved patient clinical outcomes (weight management, improved mood and wellbeing).
  • 60% of patients reporting PROM via DrDoctor.
  • 100% of consultations have been virtual.
  • Improved patient experience.
  • Increased uptake of virtual group consultations (100% of tier 2 consultations are delivered through virtual group consultations).
  • Increased virtual appointments (100% of tier 2 and 3 consultations virtual, over 600 consultations).
  • Increased digital inclusion and access.
  • 100% of patients have been offered prehabilitation as part of their pathway using a tiered virtual approach.
  • Increased use of personal held health records – over 400 patients signed up to the online 8-week programme.


Tier 1 prehabilitation  - Patients Know Best (PKB):

  • Cloud-based web app accessed on any internet enabled device by users. PKB is integrated into the NHS App in many regions of England, and will be integrated into the forthcoming NHS Wales App.
  • Resources identified by the Ortho Prehab were added to the PKB “Library” so patients could access this information anytime. This included web links to charity groups, surgery information booklets and condition-specific leaflets in both Welsh and English.
  • The team requested patients respond to questionnaires throughout their programme at set points, for the patient to complete online and return securely through PKB.
  • The team created an EQ-5D (validated quality of live questionnaire) and a healthy lifestyle questionnaire.
  • 8 week online prehabillitation programme  with access to exercises videos, healthy eating advice and mindfulness exercises.

Tier 2/3  prehabilitation - Tunstall MyMobile app:

  • Use on any smart device.
  • Remote monitoring via bluetooth (blood pressure/ weight/ heart rate/ oxygen saturation) and symptom monitoring via a clinical decision tree developed by the clinical team.
  • Clinical team could view remote observations and symptom reporting.
  • System highlighted when symptoms or observations needed clinical attention or escalation.
  • Provided access to exercise videos.
  • Clinical team could communicate and send messages to the patient via the app.

Delta Wellbeing:

  • Provide digital devices (digital inclusion) as part of local partnership.
  • Supported and educate patients to use digital devices.
  • Delivered, collect, store and maintained remote monitoring devices in partnership with Tunstall.
  • Contact patients if remote monitoring readings are not being submitted.


  • Enabled digital PROMs and PREMs data collection.


  • Safe and effective delivery of virtual prehabilitation across a large rural geographical area.
  • Virtual group consultations via Attend Anywhere.
  • Remote optimisation of health and wellbeing whilst patients are on elective surgery waiting lists.
  • Enabled a tiered approached to prehabilitation service delivery based on individual patients needs and choices.


This service can be used in the patient’s own home to optimise their health and wellbeing prior to surgery.

Key learning points

  • Age was not a barrier to virtual service delivery models.
  • Virtual prehabilitation was safe and effective and can provide equity of service provision over large geographical areas.
  • Partnership with industry was a key enabler for digital transformation.
  • Virtual first approach helped staff to adapt to new ways of working.
  • Staff buy-in led to patient buy-in for virtual approaches to care.

Digital equalities

  • Tier 2/3 patients who do not have access to digital devices, are provided with devices and are supported on how to use them.
  • Phone service and paper-based advice and guidance are available for patients who choose not to engage in digital options.
  • PKB supports those less digitally enabled, including a carer functionality for supported access.
  • PKB is available in 22 different language options.
  • PKB users can navigate most of the website using speech recognition software, using just a keyboard or using a screen reader. Users can zoom in up to 300%, as well as accessing the platform on the device of their choice e.g. handheld mobile phone, tablet or large desktop computer.

Key quotes

“I was worried when I first got told about using the equipment as I’m not confident with technology, but I’ve found it very easy to use and it’s been great.”

Brian, 75 year old patient

“Prior to beginning this role I believed the uptake of the virtual part of the service would be limited in this patient group. However, I have been pleasantly surprised that a lot of patients already have the skills and equipment for virtual consultations and for the ones that did not, they were eager to learn new skills to be a part of the service.”

“It has proved difficult at times as you are dealing with complex and frustrated patients that are in urgent need of their surgery. However, I feel that our service has offered the patients support, advice and motivated them to improve their health and well-being prior to their operation and in turn will improve their health beyond that.”

Ben Matthews, Clinical Lead Physiotherapist, Orthopaedic Prehabilitation Service, Hywel Dda University Health Board

Key contact

Marilize du Preez, Improvement and Transformation lead, Hywel Dda University Health Board

Olivia Kennedy, Patients Know Best

Tracey Hipkiss, Clinical Applications Specialist, Tunstall

Paul Faulkner, DeltaWellbeing