Improving the quality and safety of home oxygen services: The case for spread

NHS
CANCER
NHS Improvement
Lung

DIAGNOSTICS

HEART

LUNG

STROKE

NHS Improvement - Lung
Improving the quality and
safety of home oxygen services:
The case for spread

Improving the quality and safety of home oxygen services: The case for spread

Contents

Improving the quality and safety of home
oxygen services: The case for spread

1: Introduction 4

1.1 Context 4
1.2 Summary of workstream learning 4
1.3 The case for spread 8
1.4 Use of data 9

2: Learning from the prototype projects 12

2.1 Components of a quality HOS-AR model 12
2.2 Practical service models 15
2.3 Issues and challenges 17
2.4 Overall project cost savings 17

3: Case studies 19

3.1 Oxford 19
3.2 Hampshire 21
3.3 Derby 23
3.4 Salford 25
3.5 Stockport 27

4: Additional information and resources 29

Appendix 1: North East procurement of HOS-AR provider – 29
a case study

Appendix 2: Project team process maps and other lung 32
improvement resources

5: Acknowledgements and references 34

3


1: Introduction

1.1 Context Home oxygen services have been a The prototype work placed a great
particular priority within the emphasis on the safe and appropriate
This prototype project final report respiratory programme as earlier use of home oxygen and as such was
builds upon the learning from the work had revealed significant waste well aligned with NHS Outcomes
initial testing phase projects. The in the use of resources with many Strategy Domain 5 - Treating and
lessons learned from the earlier work patients either not using, or receiving caring for people in a safe
are documented within two no clinical benefit from, supplied environment; and protecting them
improving home oxygen services therapy. This problem was from avoidable harm6.
workstream publications entitled compounded as an estimated 20% of
Emerging Learning from the National patients requiring therapy were not The prototype project teams were
Improvement Projects1 and Testing receiving it5. widely dispersed across England and
the Case for Change2. this report features case studies from
The testing phase work sought to five sites: Hampshire, Oxford, Derby,
The earlier publications highlighted establish the case for change i.e. that Salford and Stockport.
the work of 12 multidisciplinary quality assured prescribing of home
project teams based in various sites oxygen therapy through structured
across England. As part of the assessment and ongoing clinical 1.2 Summary of workstream
national chronic obstructive review not only improves safety and learning
pulmonary disease (COPD) project quality but also increases cost
cohort these sites were supported in efficiency. A key objective of the prototype
the practical use of service project work was the refinement of
improvement methodology in order The results from the testing projects the testing phase approach in order
to implement home oxygen service - successfully proved this concept and to identify the first steps clinical
assessment and review (HOS-AR) as so the goal of the prototype phase networks should undertake when
specified within the national good was to establish the case for the trying to improve the home oxygen
practice guide3. spread of good practice and so pathway and also to define the key
establish HOS-AR across the country. success principles of practical service
Both the national COPD project work implementation.
and the development of the good The work presented within this
practice guide were constituents of a publication was undertaken by the These ‘first steps’ and ‘success
wider respiratory programme of work six project teams comprising the principles’ have been published
supporting the introduction of the prototype phase of the national separately but are included within
Outcomes Strategy for COPD and COPD projects improving home this document for completeness.
Asthma4. oxygen workstream.

4


First steps to improving chronic obstructive pulmonary disease (COPD) care

LIVIN First steps to improving chronic obstructive pulmonary disease (COPD) care
G
WIT
H

What you can do Why it matters How to do it

7. Do not Home oxygen is a treatment for Promote the message to staff
prescribe chronic hypoxaemia and NOT a and patients that ‘oxygen is not
oxygen for treatment for breathlessness. It a treatment for breathlessness’
‘breathlessness’ is a drug and should only be and that there are often more
prescribed where clinically appropriate ways to manage
and ensure
indicated otherwise it is of NO breathless patients.
prescribing benefit and potentially harmful
remains to some patients. Ensure only patients who have
clinically been assessed by a specialist
appropriate In PCTs that have introduced a service are prescribed oxygen and
and cost review of their oxygen registers that they receive ongoing review.
effective coupled with the introduction of This involves measuring both
through a formal assessment service up oxygen saturations and blood
formal to £400,000 has been saved in gases and reviewing other clinical
one year. If the scale of savings data together with supplier data
assessment
were replicated across England, on usage, flow rate, duration
and ongoing it is estimated that they could and equipment.
review amount to between £10-20m.
Rationalise therapy in line with
clinical need and undertake
supported withdrawal of oxygen
providing no clinical benefit.

8. Oxygen Some patients with COPD or Oxygen alert cards and 24%
alert cards other long term chest conditions masks (recommended in the
should be can become sensitive to medium BTS 2008 guideline) can avoid
provided for or high doses of oxygen. This hypercapnic respiratory failure
does not happen to everyone by alerting healthcare
at risk
with these conditions, only a professionals that patients are
patients small number, therefore, if sensitive to oxygen. Oxygen
oxygen is needed by these alert cards should be issued
patients, it should be given in a to all at risk patients on
controlled way and monitored discharge as part of the
carefully. discharge planning process.

5


Success principle 10: Home oxygen

NHS
10 NHS Improvement
Success principles Lung
Making a real difference

TEN:
FIND
I
Home oxygen
NG
O UT

Home oxygen therapy is provided to about 85,000 people in England, costing approximately £110
million a year. Home oxygen service assessment and review (HOS-AR) is variable as patients in many
LIVIN Primary Care Trusts (PCTs) do not receive a quality assured clinical assessment and a review of their
ongoing need for long term home oxygen.
G
WIT

The variation in provision of HOS-AR increases the potential for poor quality care and waste and it has
H

been estimated that 24% to 43% of home oxygen prescribed in England is not used or provides no
clinical benefit.
N THING
HE
Gross savings of up to 40% - equivalent nationally to £45 million a year or £300,000 per PCT can
S
W

!
GO

potentially be achieved through the establishment of home oxygen services, oxygen register review and
WRO

formal clinical assessment.
N
G

TO W Reducing variation in service provision can help tackle health inequalities and ensure consistency in the
A safety and efficacy of services.
RD
S THE E

1. Implement Home Oxygen Service – Assessment and Review (HOS-AR) in line with nationally
ND identified good practice
Why - In order to ensure quality of care, safe use of oxygen and the avoidance of waste.
How - Review the learning from the national COPD projects improving home oxygen service workstream
available at www.improvement.nhs.uk/lung
Liaise with your respiratory clinicians and make use of national good practice guide and the Department of
Health commissioning specification for HOS-AR in order to construct a business case and devise a service
specification.
Example: NHS Nottinghamshire County Community COPD Team, Sherwood Forest Hospitals NHS
Foundation Trust and County Health Partnership: ‘Patient review provides the ideal opportunity to re-
categorise the oxygen supply according to changing clinical and social needs.’

2. Use both clinical and oxygen supplier data systematically to support the assessment and
review process
Why - Data review enables the identification of patients who may potentially require therapy rationalisation
or the supported withdrawal of oxygen. It also helps identify sources of inappropriate prescribing and
maintain tight cost control.

6


How - Provide HOS-AR teams with access to oxygen usage data from suppliers and ensure they work collaboratively
with managers and information specialists to routinely review the usage, flow rate, duration and equipment of home
oxygen patients.
Example: NHS Hull and the City Health Care Partnership: ‘Using cost and usage data from the oxygen supplier is
the smartest way to determine a starting point for assessing and reviewing patients.’

3. Integrate HOS-AR within the wider respiratory care pathway and coordinate activities with non-
respiratory specialties
Why - Oxygen therapy assessment and ongoing review provides the opportunity to optimise all other aspects of
patients COPD management (or their other long term conditions).
How - Undertake process mapping and also demand and capacity analysis to understand the whole pathway and
identify opportunities for new ways of working. Ensure that HOS-AR is explicitly detailed within the respiratory service
specification and that the HOS-AR team activities are aligned with other respiratory services such as pulmonary
rehabilitation. Ensure coordination exists with non-respiratory services such as cardiology, neurology and palliative
care.
Example: Wirral University Hospital NHS Foundation Trust and NHS Wirral: ‘Using a model that integrates
oxygen assessment and review with COPD and Pulmonary Rehabilitation services and is supported by secondary care
has contributed to the success of this community based service.’

4 Promote the message that ‘Home oxygen is a treatment for chronic hypoxaemia and NOT a
treatment for breathlessness’
Why - Oxygen is a drug and should only be prescribed where clinically indicated otherwise it is of NO benefit and
potentially harmful to some patients.
How - Establish ongoing and effective communication between the HOS-AR team, primary and secondary care and
also patients groups through education sessions and Forum meetings. A continuing dialogue should occur in respect
of best practice, treatment goals and HOS-AR referral criteria.
Example: NHS Birmingham East & North and Heart of England NHS Foundation Trust: ‘Engage GP consortia to
ensure the project has support and buy-in, engagement with the clinical lead may assist in terms of reinforcing the
message to patients and clarifying the indications for oxygen therapy’

5. Work collaboratively to formalise policies and procedures around the safe use of home oxygen

Why - Oxygen therapy is highly flammable and can result in serious injury or even death if not used safely.
How - Ensure patients and carers receive instruction in the safe use of home oxygen during the assessment and review
process and provide support to stop smoking. Work in partnership with oxygen suppliers and local Fire Rescue Services
to promote consistent messages around the safe use of oxygen and to establish risk identification, risk management
and clinical governance policies and procedures.
Example: NHS Hull and the City Health Care Partnership: ‘Working with the Fire Brigade has helped tackle the
challenges experienced by the team in educating patients and carers of the risks around health and safety and on
dangers of smoking to themselves and others, making such discussions more impactful’

7


1.3 The case for spread Improving the landscape in respect In devising a spread strategy it was
of assessment and review was important to align the approach with
Sharing the learning: The home acknowledged as important in both the DH service specification for
oxygen workstream national supporting the efforts of the HOS-AR5 (part of the COPD
improvement lead sought widespread Department of Health and the regions commissioning toolkit7) and the
collaboration with stakeholders. These as they sought to re-procure and national COPD project learning.
stakeholders included the Department successfully transition the oxygen
of Health home oxygen team, the supply contracts. This ensured a premium was placed
regional respiratory programme teams on quality by emphasising:
and also the regional home oxygen In many localities the strengthened • structured assessment for accurate
service (HOS) leads. This collaboration clinical input, better data management diagnosis and appropriate
was important in the promotion of and overall service coordination prescribing;
nationally endorsed good practice and provided by HOS-AR also assisted the • information management; and
the spread of the emerging learning oxygen supply companies with the • patient and professional education
from the national COPD projects. transition process. around the goals of treatment.

As such, the national improvement In addition, the important service Safety was prioritised by
lead (NIL) participated in numerous coordinating role undertaken by HOS- emphasising:
home oxygen best practice workshops AR teams together with their role in • ongoing review of clinical need;
hosted by respiratory clinical networks educating both patients and • instruction in the safe and
and regional respiratory programme healthcare professionals and also their appropriate use of oxygen; and
teams. role in supporting risk management • risk assessment and clinical
contributed in small part to the success governance.
The workstream publications were also of many regional transition
widely disseminated in both print and programmes. It also strengthened the Productivity was addressed by:
electronic form. The project teams case for HOS-AR to be available more • rationalising therapy to reduce
also played a major role forming an widely. waste; and
informal virtual network for spread • matching prescribing to clinical
and sharing their experiences with The goals of HOS-AR spread: Using need.
colleagues across the country in local intelligence gained from initial surveys
education sessions and communities of of HOS-AR coverage, undertaken by
practice the Department of Health (DH), an In order to ensure the spread
estimated 60% of Primary Care Trusts strategy met these aims four
Collectively this meant that even (PCT) had established some form of principle objectives for the
before a formal spread programme HOS-AR by the time a formal spread spread of HOS-AR were
was established many localities and programme was launched in established:
regions were enabled to adopt much September 2012. These estimates are
of the learning and implement being revised as a more robust survey 1. Adopt formal assessment
improvements in their home oxygen is currently underway. and review;
prescribing procedures, data 2. Reduce variation;
management and cost control. It is difficult to establish exactly what 3. Commission services for
the coverage was prior to the start of sustainability; and
the testing phase project work but is 4. Improve safety and
generally accepted that HOS-AR patient care.
covering the whole population served
by each local PCT was not widespread.

8


1.4 Use of data
Examples of home oxygen project service improvement measures
Home oxygen is an area of the NHS
that has a wealth of data available for 1. What proportion of HOOFs were completed by the HOS-AR team?
it to use, with invoice data, supplier 2. How many patients have potentially clinically inappropriate supply,
concordance reports, and local patient for example:
caseload information. Oxygen usage • Over four hours of SBOT
data from supplier companies is made • Under eight hours of LTOT
available on a regular basis to • Over or Underuse of prescribed oxygen
commissioners in the form of large 3. How much is spent on home oxygen supply per month?
spread sheets. 4. How many patients receive home oxygen each month?
5. What is the service activity – e.g. How many therapy commencements
These large spread sheets can be and removals?
difficult for a non-expert to use and
interpret and often there is so much
data that it is difficult to identify an
area to focus. As a result, HOS-AR The project metrics used were
services often lack key metrics that dependant on the information
might more usefully inform service received from the suppliers, and some
delivery and drive improvement work. required further local data collection.

Metrics and measures The data requirements for
During the improvement projects, commissioning HOS-AR may differ
teams were encouraged to focus on from those used in a service
driving the quality and appropriateness improvement project. The service
of the supply of oxygen, and improve specification in the Department of
the efficiency of services. Health Home Oxygen Assessment
and Review Commissioning Toolkit
Project measures were chosen that suggests a number of commissioning
were appropriate to the goals, these key performance indicators and a few
included: of these are listed below:

• rules to check for patients potentially
on inappropriate supply and outside
• The percentage of eligible people booked for their HOS
of national clinical guidance;
assessment who attend their appointment.
• process measures to count the
• The percentage of people prescribed oxygen therapy who have
number of patients reviewed;
a follow up home visit within four weeks.
• a measure on the referral source of
• The percentage of people on long-term oxygen therapy who
the new HOOF; and
have had a review in the last nine months.
• outcome measures including total
• The number of inappropriate oxygen prescriptions identified
spend and change to size of
on assessment.
caseload.

9


The benefits of using data to Sample Dashboard
drive improvements in HOS-AR
As has been established during the
testing phase national project work,
the establishment of HOS-AR has a
potential to save money alongside
improving quality of care.
Effective use of data is a critical
success factor in realising these dual
benefits. Systematic use of supplier
and clinical data coupled with the
development of locally appropriate
service metrics are the foundations of
this approach. Below are listed a few
practical tips on data management
arising from the national project
work:

1. Use concordance data, but not in
isolation. Project teams found that
looking at the waste through using
the concordance data was an
excellent start, but combining this 4. Review how HOS-AR teams use data issues surrounding both the
alongside looking at quality of their time – often surprising results improvement project work and the
prescribing enabled them to were discovered in inefficient transition in oxygen supply.
identify many areas for administrative processes, and time
improvement managing oxygen supplier These dashboards together with
2. Who commences oxygen is a good relations. other locally devised data
process measure. In some areas management initiatives supported the
with low spend and well managed Making the data useable – home oxygen teams in making
oxygen use, teams found that over systems and approaches. clearer patient care decisions and
90% of commencements had The data environment described motivated service change.
been initiated by a specialist from above meant that national COPD
their HOS-AR team. project teams needed support from Visual management is an important
3. Review how many patients are the NHS Improvement - Lung team in tool in using data to drive
supplied oxygen outside of order to harness oxygen usage data improvement. While project sites
guidance, where it may not be in a meaningful way to facilitate often thought that they understood
clinically appropriate. For example, appropriate prescribing, cost control their services well, improvements in
consider those on over four hours and clinical governance. the analysis and representation of
of short burst oxygen a day, or these large amounts of data often
under eight hours of long term To this end the work stream was ably identified hidden issues.
oxygen therapy. supported by the NHS Improvement - These improvements also enabled the
Lung senior analyst who worked sites to provide evidence of
with the project teams in the improvement to themselves and their
development of a monitoring commissioners.
dashboard and helped them
understand and overcome the

10


visits’ (Which include refills, By using a simple desktop database
Here are a few points to installation, risk assessment and such as Microsoft Access, the NHS
bear in mind when removal of equipment) and Improvement - Lung senior analyst
developing a local data equipment rental charges (itemised was able to increase the efficiency
dashboard by type of supply). and quality of the data provided to
the HOS-AR teams. The resulting
• Choose a few, focused Knowing where to start, and working Access database tool enabled:
metrics to drive with the comprehensive data now
improvement. supplied by the oxygen suppliers is a • Automation of simple data
• Be pragmatic – it’s not daunting and intimidating task for processing tasks.
easy to get perfect data, many. • Reduction of the repetition of data
and often simple data is processing in Excel.
more useful. Many teams start with the • Introduction of ‘reports’ to highlight
• Present the data in a spreadsheet, adding filters, patients to review, and combining
simple way that makes the highlighting rows of interest, and also key data onto a single patient page.
progress and goals clear. adding columns to total costs. This • Production of more complex reports
We found a dashboard would often be a complex procedure, – summarising transactions,
was a helpful tool. and is usually reliant upon one identifying outliers and risky data.
• Remember data is an individual to process the data. • A single page helpfully summarising
essential part of HOS-AR – the oxygen usage data for a patient
without it, we often do The data often resides in separate which was well received by
not know who our tables for transactions, patient clinicians.
patients are or whether invoices and concordance reporting,
our patients are receiving and so linking data items together Use of the Access database tool at
benefit from this life requires the home oxygen service times required the support of data
prolonging therapy. lead to swap between different files, experts to set up – but it was
writing down patient ID’s to anticipated that any future
compare. It became evident that maintenance would be minimal as
support to process and analyse the the data supplied from the oxygen
Future work – tools to interrogate data was required. providers has an established format.
oxygen supplier data under the
new contract
The new contracts for home oxygen
supply commenced at the end of the Key learning arising from using this database approach
home oxygen improvement projects,
which made it difficult for some 1. There are sometimes discrepancies between the number of cylinders
project sites to provide consistent charged for by providers and the number of cylinders ordered for
data during the transition. patients.
2. The types of cylinders provided may not those specified on the
The new data provided by oxygen order form.
suppliers is very comprehensive and 3. Large numbers of cylinders are still being held in patient homes,
includes information on the ordered highlighting potential danger.
supply, the reported use of the supply 4. Patients are often receiving visits for refill of cylinders multiple times
and a waste estimate. In addition, it per month, sometimes multiple refills per week.
now itemises the number of ‘service 5. There is frequent use of urgent supply services.
6. Clinically inappropriate supply is still occurring in some instances.

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2: Learning from the prototype projects

2.1 Components of a quality
HOS-AR model 1. Commissioned Service (including service specification and
referral criteria)
The Department of Health good
practice guide3 published in 2011 All the project teams felt the need to reinforce the importance of
identified a number of components having the work undertaken by HOS-AR teams explicitly outlined within
of a Home Oxygen Service the specification of a commissioned service.
Assessment and Review and listed
them within appendix 6 of that same This would ensure the sustainability of the service and ensure quality is
document. defined in terms of key performance indicators and articulated
standards.
The national COPD project work
looked at these components from a Historically, much of the oxygen assessment work undertaken across
service improvement perspective and the country has not been detailed within existing respiratory service
re-articulated them as seven critical specifications and in some respects it can be thought of as being
success factors necessary for practical undertaken ‘at risk’ in terms of sustainability and quality assurance.
implementation of an operational
service model. These are: It is also very important to specify the local referral criteria and define
the patients whose care will be managed by the HOS-AR team and
those oxygen patients whose care is perhaps managed elsewhere e.g.
cardiology dept.

The Department of Health recently published a commissioning
specification5 for home oxygen assessment and review which is also
supported by a patient guide jointly developed by NHS Improvement
and the British Lung Foundation and available at
www.improvement.nhs.uk

In addition to the commissioning specification the Department have
also produced a costing tool which can be used to evaluate the
potential benefits of introducing a commissioned service. Both of these
resources are available at www.dh.gov.uk/health/2012/08/copd-toolkit

2. Initial formal assessment (in accordance with good practice)

It is critical that patients are formally assessed in respect of their clinical
need for oxygen before any oxygen supply is issued to patients. As well
as determining whether the patient is hypoxic or not, the patient will
be assessed to ensure they are receiving optimal care in respect of their
condition and potentially referred to other specialist services if
appropriate.

12


3. On-going review (frequency laid down within guidance)

The condition of many Oxygen patients is often subject to change and so it’s important that the therapy they are
receiving is still appropriate to their clinical need. Oxygen is a life prolonging therapy and so it’s vitally important
that the prescription a patient is subject to is ‘fit for purpose’.

The vast majority of oxygen patients are affected by respiratory conditions and as such the DH good practice
guide published in 2011 sets out the gold standard in respect of review frequency.

However a significant number of patients are affected by other conditions such as Heart Failure or Cancer and as
such the healthcare professional (HCP) managing the patient’s condition should do so in line with their own
medical specialty guidelines.

4. Workforce competence in: (i) assessing and reviewing clinical need, (ii) modifying home oxygen
therapy and (iii) identify complications or signs of deterioration needing additional’ management or
onward referral to a specialist.

Complications in respect of an oxygen patient’s condition often arise and so the HCP should be able to spot
significant factors and either appropriately intervene or refer the patient to a colleague skilled in this aspect of
condition management.

Thus it is imperative that the HCP undertaking the assessment is competent to do so and that appropriate liaison
with a consultant is an integral part of the HOS-AR.

5. Integration with respiratory care and coordination with non respiratory specialties

Integration of HOS-AR within the wider respiratory care pathway provides opportunity for improved patient
experience as well as the opportunity to optimise clinical management.
Multi-disciplinary team meetings, shared information systems and well understood patient pathways, treatment
goals and care protocols all support service integration and also improve the responsiveness of services to
changes in a patient’s clinical condition.

There are also natural synergies in terms of the organisation of care and a good example of this is pulmonary
rehabilitation and ambulatory oxygen assessment and provision.

A significant proportion of home oxygen patients have non respiratory conditions such as heart failure or
specialist palliative care requirements. Whilst the HOS-AR may not necessarily manage the care of these patients
(although some teams do operate shared care arrangements) it’s important to have good lines of
communication with these specialties. This ensures care is coordinated enables the HOS-AR team (and
commissioners) to understand the basis upon which these non-respiratory colleagues initiate oxygen and also the
arrangements in place for patient follow-up by these specialties.

13


6. Clinical and supplier data management

Collaboration between clinicians and managers around the effective use of data is vital to achieving safe,
appropriate and cost effective home oxygen prescribing. Clinicians can advise whether patients flagged as
outliers in terms of oxygen consumption are at risk or in receipt of inappropriate therapy. Managers and
clinicians together can use the data to performance manage their local oxygen supplier and familiarity with
equipment and charging mechanisms enables the identification of opportunities to appropriately rationalise
therapy.

7. Education of patients and HCPs (treatment goals/safety/risks)

The HOS-AR team’s role in supporting supplier performance management and their involvement in prescribing
cost control are obvious incentives for commissioning assessment and review teams. Perhaps another equally
value-adding function the HOS-AR team undertake is patient and healthcare professional (HCP) education.

The goals of home oxygen therapy are often equally misunderstood by non (oxygen) specialist healthcare
professionals and the general public alike, and much effort is expended on an ongoing basis to tackle through
education the inappropriate prescribing of oxygen for breathlessness.

In addition there are many risks associated with incorrect use of oxygen therapy especially as regards fire hazards
and tubing-related trips and falls.

The HOS-AR team are more likely to be aware of changes to home oxygen equipment and so they can support
other specialists who perhaps need to prescribe oxygen for their patients.

14


2.2 Practical service models The Oxfordshire project team during a process mapping event

The five project teams undertaking
the prototype project work cover very
different geographical locations and
employ varied staff groups.

Respiratory nurse specialists are by far
the most widely represented clinical
staff group but teams do also
comprise of respiratory
physiotherapists, physiologists/clinical
scientists and pharmacists/pharmacy
technicians.

In addition, the wider project teams
involved (and sometimes were
led by) non clinical managers a) the workforce has the The costing tool uses actual historical
from commissioning, medicines competences to: oxygen consumption in conjunction
management, information • assess, review and modify home with old and new supply contract
management and finance. oxygen therapy prices and applies assumptions in
• optimise or recommend strategies relation to workforce (reflecting the
Some of the teams were based in for optimising a patients overall Oxfordshire model) clinic and home
community based premises whilst management visit frequency and duration in order
others operated out a hospital • recognises when complex or to generate a model of the potential
setting. The majority of teams had unusual presentations require cost impact of introducing HOS-AR.
access to consultant physician advice specialist intervention.
and worked as part of a wider The tool does not try to quantify the
respiratory care pathway. b) the service is accessible and benefits arising from improved
operates on a basis that reflects the patient care and whilst it does allow
Some teams undertook other local populations need and you to tailor assumptions to more
respiratory management duties in to preferences. accurately reflect local priorities it
addition home oxygen assessment should be remembered that it is a
and review and it also varied as to c) the service is viewed as responsive, model all be it a very useful one and
whether or not teams had clinical integrated, cost effective and can not for example convey the
responsibility for non–respiratory sustainable by local commissioners. importance of home oxygen as a
home oxygen patients. constituent part of an admission
The Department of Health have avoidance strategy.
A table summarising the variation in developed a COPD commissioning
workforce model is shown on toolkit which includes a best practice
page 16. service specification and costing tool
to support the commissioning of a
In terms of service models what high quality home oxygen assessment
seems to be important in supporting and review service. These resources
quality assured HOS-AR is that: can be accessed by visiting
www.dh.gov.uk/health/2012/08/
copd-toolkit

15

A table summarising the variation in workforce models across the home oxygen project teams

16
Service as at January 2012 Oxfordshire Derby Salford Stockport Hampshire

Derbyshire PCT Andover Lymington Basingstoke, Fareham Southampton Portsmouth Isle of Wight
(south) & Derby N.E Hampshire
City PCT and Farnham

HOS patients 520 600 480 340 640

Patient management 280 patient 381 patient 259 patient 400 patient 300 patient
case load case load case load case load case load

Respiratory Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Heart failure Yes Yes Yes Yes No Yes Yes No No No

Cluster headache Yes Yes Yes Yes No Yes No No No

Palliative care Yes Yes Yes Yes No Yes No No No No

Paediatrics Do not Rx O2 Not clinically but No No No No No No No No No
for paediatrics manage equipment
but support & data
once on O2 and
monitor usage

Workforce 2.6 WTE band Band 7 full Time Band 7 respiratory Band 7 COPD Nurse 2 x Community 2 WTE Band 7 1.6 WTE band 7 2 X Band ? 1.0 wte 37.5 Band 7 1 WTE 0.6 WTE band
6 nurses Nurse Practitioner nurse specialist (1.28WTE), plus Band Matrons Respiratory Specialist nurses and 1 band Respiratory Band 6 Physio 37.5 hours 6 nurse (at
(1 WTE), Band 6 (1 WTE), Band 6 8a COPD Nurse (0.13 Nurses and 1 x WTE 6 nurse plus Respiratory Nurses Band 6 0.5 WTE recruitment
Nurse Assessor (28hrs Specialist Pharmacy WTE), GPwSI 0.05WTE), Respiratory Specialist Physiotherapist (? WTE) Nurse 18.75 hours phase)
week 0.75 WTE) Technician Band 3 Admin (0.5WTE) Physiotherapist led Amb. O2
assessments

Dedicated 1 WTE Fulltime project Yes – post improvement Yes No Yes 19 hours No No 0.2 wte 7.5 Band 3 0.27 WTE 0.6 band
administrative administrative support officer project – now have a per week Admin Admin assistant 2 admin
support hours band 3 (1WTE) 10 hours

Do the HOS-AR Yes No Yes – non O2 patients Yes Yes Yes Yes No No No Yes
clinicians manage under ongoing review,
other (non-oxygen) eg. ILD patients to
respiratory patients? determine O2 need if not
already on therapy

Clinical support 1 hour per week Consultant Respiratory Nurse Respiratory Nurse Consultant 3 X Consultant Consultant Consultant Consultant Consultant Consultant
of respiratory Physicians Consultant Consultant GP with a Physicians Physicians Physicians Physicians Physicians Physicians Physicians
consultant input. Consultant specialist interest in
Physicians respiratory medicine

Integrated working Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes
withwider respiratory
pathway?

Operations Clinic- Mon, Wed Home visits, Home Visits Monday to Daily clinics spread over Monday - Friday clinics Monday to Fri clinics Monday to Wednesday and Monday clinic
and Thursday Community Clinics, Friday. Clinics once a 3 locations Home visits 08.00-16.00 in varying locations Friday incl. Friday clinics, Home Home visits Tuesday
(9 to 5)Home visits – Acute Ward visits month at 3 venues Monday to Wednesday visits Monday to to Friday incl.
Mon-Friday (9 to 5) across the city incl. Thursday clinic Friday incl.

Clinic location Hospital and Hospital and Hospital Community Community Lymington New Hospital and Community Hospital Hospital Hospital and
Community Community locations *3 Forest Hospital Community Community
only at present

Home visits Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes


2.3 Issues and challenges The Derby team had historically had a The administrative and data
challenge with inappropriate management requirements of HOS-
Analysis of oxygen usage data, prescribing arising from General AR are a challenge that all teams held
process mapping exercises Practice. With support from the in common. Incomplete information
undertaken individually with project national programme senior data upon referral often meant that highly
teams and knowledge exchange at analyst and the use of data skilled clinical resource spent a lot of
collective project cohort peer support dashboards they were able to time trying to establish a more
events uncovered both differences establish that GP prescribing of home complete clinical picture of patients in
and similarities as regards the issues oxygen was now significantly reduced advance of their appointment.
and challenges faced by the teams in and that the current sources of
implementing high quality HOS-AR. inappropriate prescribing were based In some instances this was addressed
in the hospital setting. somewhat by more complete and
Historically, the clinic DNA rates in robust referral processes and
both Salford and Stockport had been In Oxford the process mapping documentation and by reinforcing/re-
identified as problematic and so to exercises highlighted that slight launching referral criteria.
this end both teams had searched for variations in practice had arisen
ways increase their capacity to among the team in response to However, the need to monitor
undertake home visits. specific clinical scenarios. The team oxygen usage data and keep track of
had a long-standing practice of guideline mandated review dates
Salford, prior to starting the project holding regular clinical update and does require administrative support.
had already reduced the number of knowledge sessions and so they
clinics they performed in order to provided a forum to ensure 2.4 Overall project cost savings
increase their capacity to undertake consistency across the team was re-
home visits. established. The HOS-AR teams included within
the prototype project cohort had
However, by analysing the processes In Hampshire, both the data analysis already demonstrated to the
associated with an individual and the series of process mapping satisfaction of their local
assessment clinic they spotted events with teams across the county commissioners their ability to
opportunities to change practice and supported a gap analysis in respect of prescribe and rationalise home
reduce the duration of the initial adherence to national standards, oxygen therapy in an appropriate and
oxygen assessment. This enabled resource constraints and potential cost effective manner prior to
them to create additional capacity for variations in prescribing behaviour. embarking upon this phase of work.
a dedicated clinic for palliative oxygen
assessment. This information further informed the Prior to the project work many of the
development of a Pan-Hampshire teams had already comprehensively
Stockport also reorganised their service specification and provided the reviewed supplier concordance and
clinics and increased home visits basis for a service investment invoice data, cleansing the data of
capacity. They overcame the business case. anomalies (such as charges for
challenge of requiring two staff per deceased patients, multiple data
home visit (in order to transport entries for a single patient etc) and
laboratory style blood gas analyser had married this data with clinical
equipment and concentrators) by the information to create home oxygen
adoption of portable blood gas patient registers or actual databases.
equipment

17


3
These teams were already routinely Best estimates seem to indicate that Although the prototype project sites
updating these registers establishing the prototype teams were on target had completed thorough data
cycles of patient therapy assessment to achieve an average of £100,000 validation exercises, there were still
and review and identifying candidate per site in HOS-AR related annual opportunities for further savings from
patients for therapy alteration/ prescribing cost efficiencies (based reviewing data on a regular basis.
removal post clinical review. upon comparison with the annual
spend in 2010/11), resulting in a This finding only serves to reinforce
The prototype works main thrust was collective workstream annual forecast earlier workstream learning about the
to identify key elements in the saving of approximately £570, 000. need for HOS-AR teams to have a
implementation of quality assured, regular plan to review data and not
safe and appropriate home oxygen Despite the intrinsic cost efficiencies see it as a one off exercise.
therapy. deriving from the new national
oxygen supply contract, there is still The absence of regular data review
However, NHS Improvement - Lung the potential for costs to rise if will inevitably lead to a slow increase
was also interested in these teams patients are not initially assessed for in costs. Although the new supply
ability to continue the tight control of their need for home oxygen therapy contract does include large penalties
any increases in expenditure by healthcare practitioners who are for supplier data errors, the new
associated with optimised therapy or both thoroughly familiar with the contractual arrangements are not
uncovering unmet need. various equipment modalities and sufficient to deliver the data quality
also acquainted with current charging improvements alone.
It was therefore of considerable structures.
interest that many teams were still This is particularly the case for those
able to demonstrate cost savings HOS-AR team clinicians across the suppliers who are dealing with a
(prior to oxygen supply contract country attend on an ongoing basis legacy of equipment and inaccurate
transition and its inherent contractual the oxygen device training sessions historic data.
cost efficiencies) through appropriate held by the oxygen suppliers and so
home oxygen prescribing and therapy have a complete understanding of
rationalisation. the range of equipment available and
also each device’s suitability for the
Difficulties in ascertaining consistent different presenting symptoms and
data in the immediate aftermath of changing patient clinical needs.
the supply transition (which for most HOS-AR teams are also best placed to
teams took place during the mid- prescribe a treatment modality which
point of the project) made it difficult is both clinically appropriate but also
to differentiate between savings from cost effective – a generalist or a
HOS-AR related functions and those specialist clinician who has not
benefits deriving from a more undergone this training is unlikely to
efficient contract. be able to do this on a consistent
basis.

18

3: Case studies

3.1 Oxford Health NHS Foundation Trust

Improving and fine tuning Oxfordshire’s
Home Oxygen Service

What was the problem?
Oxfordshire’s home oxygen service
has been operational for
approximately three years and is
recognised nationally for having
successfully improved patients
experience as a result of appropriate
and cost effective oxygen therapy
prescribing undertaken by trained
professionals.

Staffing changes had created an
identified skills gap and the service
was subject to an ongoing
commissioning requirement to remain
both high quality and cost effective.
The team also identified areas for
improvement such as smoking related
incidents, out-of-hours coverage and • Develop a risk assessment tool in Through contact with clinical teams
100% underuse of prescribed oxygen order to formally risk assess patients across the country at NHS
therapy in a large number of patients. who smoke Improvement-Lung peer support
In addition, the team wanted to • Manage the transition to the new events the team were able to reflect
make a smooth transition to the new oxygen supplier. upon their clinical practice and
oxygen supply contract. capture ideas for potential new
What did they do? ways of working.
What was the aim? The team allotted project
The project team sought to improve responsibilities and met regularly with What has been achieved?
the quality and standards of the support from NHS Improvement-Lung Process mapping enabled the team to
service in three areas: in order to refine their aims and examine differences in the service
1. To reduce the number of patients objectives, plan project activities, across the county and confirm the
with significant (100%) underuse identify stakeholders, review the skills required at different parts of the
of prescribed oxygen therapy by patient journey and undertake pathway. It was also instructive in
25% process mapping (with the ensuring that all members of the
2. To reduce smoking related commissioner in attendance). team were applying a consistent
incidents clinical approach.
3. To reduce the cost of prescribed The team also undertook a demand
oxygen by 10% over one year. and capacity exercise in order to
better understand the impact of
They planned to achieve this by travelling and administration on
meeting the following objectives: face-to-face time with patients.
• Review and update patient
pathways
• Develop a new competency
framework
• Train staff and ensure competency
in key areas

19


In terms of the stated objectives What are the key learning points?
the team: • The importance of risk
• Reduced under users from 115 to identification (in general) and
54 (53% reduction) shared awareness among the team
• Began development of a smoking in respect of patients who pose a
risk assessment too higher risk due to smoking
• Increased teams awareness of • Service improvement methodology
smoker safety and general oxygen provides effective tools for
safety identifying ‘risk’ areas and areas for
• Developed greater awareness of quality improvement
service demands • Knowledge exchange with other
• Reduced oxygen costs by 12% teams (and opening pathways of
from September 2011 to April local and national communication)
2012 promotes the development of new
• Gained insight into team member ways of working
knowledge levels and began • The importance of regularly
implementing a competency evaluating clinical knowledge
framework among the team in respect of more
• Started weekly training sessions to complex patients (CO2 retention,
improve the knowledge and skill hypercapnoea, use of oxygen in
mix (e.g. maintain competences in exacerbations etc) and the value in
arterial blood gas measurements) implementing ongoing training.
• Successfully managed supply
contract transition which was Contact
initially characterised by significant Jo Riley
increase in calls from patients Respiratory Service County Lead
• Implemented an out of hours Tel: 01865 225472
oxygen ordering pathway Email:
• Exploring the use of portable joanne.riley2@oxfordhealth.nhs.uk
(capillary) blood gas analysers on
home visits and acquiring Sophie Beveridge
equipment through cost savings. Respiratory and Home Oxygen
Service Nurse
Tel: 01865 787185
Email:
sophie.beveridge@oxfordhealth.nhs.uk

20


3.2 NHS Southampton, Hampshire IoW Portsmouth; SHIP PCT Cluster

The Hampshire Model for the Home Oxygen
Service - Assessment and Review

What was the problem? Specific project objectives included:
Considerable differences in the type • Gap analysis - to understand
of service experienced by home levels of compliance with national
oxygen patients across Hampshire standards in respect of HOS-AR
were known to exist as a result of the • Staffing review - to understand
way the teams undertaking home the workforce variations across the
oxygen service – assessment and county
review (HOS-AR) had evolved in the • Care pathway review - to
different geographical localities. understand differences in the
patient journey experienced across
In many instances these different the county.
service models reflected differences in
local need but they were also a What did they do?
reflection of differences in local Pathway analysis: A series of
funding arrangements and process mapping events were
differences in the interpretation of initiated across the county involving
(and compliance with) national the home oxygen teams situated in
guidance. Lymington, Fareham and Basingstoke
respectively. This was supported by use of the
In addition, the impending change in data dashboard devised by the NHS
oxygen supply provider and This enabled differences in clinical Improvement-Lung senior analyst and
contractual changes necessitated practice to be identified and the liaison with both the outgoing and
further strengthening in the specific local challenges and resource incoming oxygen supply providers.
arrangements for monitoring oxygen constraints documented and
usage in preparation for the understood. Service planning: The team also
transition by building upon recent reviewed NHS Improvement national
analyses of patient concordance. In addition, the teams in Isle of publications, the Department of
Wight, Southampton and Portsmouth Health (DH) Good Practice Guide,
What was the aim? provided information about local early versions of the DH
The aims of the project were to resources and the patient journey by Commissioning toolkit for COPD &
1. Develop robust Pan-Hampshire completion of a mapping table Asthma and the DH Specification for
service plans, specifications and a questionnaire. HOS-AR in order to develop a Pan-
business (investment) case which Hampshire service specification and
reflected national guidance Data management: Work on the business case framework which can
2. Further improve data management analysis of patient concordance was support the development of local
to achieve ongoing active intensified to gain an accurate picture investment cases by constituent
monitoring of oxygen usage and of usage activity in each location and clinical commissioning groups (CCGs)
ensure the successful transition of an understanding of the variations in across the county
supply in March 2012. prescribing costs across the county.

21


What has been achieved? What are the key learning points?
A better understanding of the 1. Differences in service models
differences in service models and across the county did not
delivery across the county has necessary imply differences in
enhanced the ongoing discussions service quality. However,
taking place between the service differences in adherence to
provider organisations and the national guidance could be a
commissioners of the services. source of service inequality
especially in respect of ongoing
The Pan-Hampshire service clinical review.
specification has been accepted by all 2. Differences existed across the
constituent CCGs across the county county in terms of the prescribing
and its recommendations in respect cost per patient and this might
of service levels will be reflected in also be attributable to differences
local service performance indicators. in each teams capacity to review
patients changing clinical need
The various options outlined in the (and modify therapy) or differences
Pan-Hampshire business case have in the use of oxygen device
prompted a number of CCGs to modalities especially in relation to
consider investment in their local palliative care.
HOS-AR to ensure compliance with 3. Significant clinical time is taken up
good practice and to also examine by routine administration as a
the extent of wider respiratory service result of lack of admin. support.
integration. 4. Clinical teams lacked consistent
and concise information and
Good lines of communication were central management support
established with the incoming oxygen concerning home oxygen patients.
supply provider and home oxygen
patients who were concordance Contact
outliers were identified and flagged Chris Slade
up with clinical staff for review and Clinical Networks Manager
Tel. 02380 627672 / 07833293074
Email: chris.slade@hampshire.nhs.uk
or chris.slade@nhs.net

22


3.3 Derby Hospitals NHS Foundation Trust,
Derbyshire County PCT, Derby City PCT

Service improvement review to ensure
sustainability and consistency of the Derbyshire
Home Oxygen Service
What was the problem? What was the aim?
The introduction of home oxygen The project aimed to address these
service-assessment and review (HOS- problems by developing and
AR), with blood gas monitoring implementing plans to:
available both within clinic and home 1. Improve data coordination, analysis
settings, and the establishment of and reporting by reducing
clinical and oxygen supply usage data administrative duplication,
review and management had enabled inconsistent recording and getting
great strides to taken in addressing greater clarity around lines of
historic problems of inappropriate reporting.
oxygen prescribing and sub-optimal 2. Achieve greater consistency of
management together with message among healthcare
inequalities of care associated with professionals in terms of the
patients varying ability to travel to message to patients and in terms
hospital for assessment or review. of the goals of therapy.
3. Identify clearly who, where and
This had enabled the newly why home oxygen was prescribed
established service to meet all its through improved.
initial quality and financial measures 4. Improve ambulatory oxygen • The team worked with the NHS
during its first two years of existence. assessment and monitoring Improvement - Lung senior analyst
procedures. to develop data dashboards which
However, problems still remained 5. Improve the removal pathway for would more easily enable the
with many local healthcare patients without a clinical tracking and monitoring of oxygen
professionals still not familiar with the requirement for home oxygen. usage and prescribing.
principal goals of oxygen therapy • An initial demand and capacity
(addressing hypoxia) resulting in What did they do? exercise was undertaken to identify
inappropriate therapy initiation. • The team undertook a process ways of increasing service capacity.
mapping event and involved • Patient information literature was
Many patients understanding about patients, community and hospital- revised in order to strengthen
both their condition and their therapy based respiratory staff together messages about the goals of
was still variable and the with colleagues from palliative care, oxygen therapy and also the safe
administrative and governance IT and the Trust transformation and effective use of equipment.
processes for the local HOS-AR department.
needed to both keep pace with the • Patient referral forms and data
changing primary care landscape and entry processes were reviewed to
enable greater analysis and reporting. capture redundancy and identify
areas for improvement.
• Ongoing dialogue and training was
undertaken with the (new) in-
coming oxygen supplier in order to
manage the transition to a new
supply contract.

23


What has been achieved? What are the key learning points? Contact
• Inappropriate prescribing has been • Changes in respect of the new Sue Smith
reduced by establishing a local HOOF were initially a source of Specialist Practitioner for
consensus among healthcare frustration for GPs and Consultants Home Oxygen
professionals about the use of the but these changes have now been Tel. 01332 787825
new part a/b Home Oxygen Order agreed. Email. sue.smith31@nhs.net
Form (HOOF). • Access to data, and critical review,
• Prescribing guidance for all has been particularly valuable in
modalities of oxygen is now more identifying the priorities and
closely aligned to national objectives for the service.
standards and best practice and as Previously, the team believed that
such is both tighter and clearer. It they had issues with GP
has also been made widely commenced HOOFs, however the
available and is being incorporated data suggested that this was no
into the Trust website. longer the case. This indicates that
• Data harmonisation work has made both the original work has been a
progress and all (clinical and supply success, but also that resources
usage) data will be entered onto could now be focused elsewhere in
System1 to enable it to be accessed order to achieve improvements in
across the multi-disciplinary team. areas of a greater need – the team
• The new patient information leaflet are considering supporting in-
has been well received and the hospital prescribing.
quality of prescribing has improved • Service Improvement has become a
with a shift from 60% of patients key part of the team’s thinking,
having an optimal oxygen and ensuring that they have
prescription to 90%. evidence has been helpful for the
• A thorough review of the team, but also in supporting
governance arrangements in discussions with commissioners.
respect of oxygen therapy and • The team could have continued
persistent smokers has been being ‘good enough’ – the service
undertaken inclusive of liaison with improvement work has encouraged
expert legal counsel. them to think critically and aim for
better.

24


3.4 Salford Royal NHS Foundation Trust

Maintaining a safe, cost effective and accessible
Home Oxygen Therapy Service (HOTS)

Home oxygen service – assessment
and review (HOS-AR) had been
successfully introduced in Salford in
2008 with the establishment of the
Home Oxygen Therapy Service
(HOTS). Robust referral processes
had been implemented and the HOTS
team were part of an integrated
respiratory service. They also had
very strong links with other non-
respiratory disciplines.

The team had access to supplier
invoices and reports which they used
to monitor oxygen usage, the sources
of prescribing and also the range of
clinical conditions existing among
patients in receipt of home oxygen What was the aim? What did they do?
therapy. A safe, cost effective and accessible The team undertook a number of
home oxygen service was a local project activities in support of the
The use of an electronic referral priority and so the primary aim was above objectives:
proforma (incorporated within local that 95% of all HOOFs originate from
GP computer systems) together with the HOTS team (5% allowance for Multidisciplinary engagement: A
systematic changes to clinic venue paediatric and end-of-life patients). process mapping event involving
locations and the establishment of Continuous service improvement numerous staff types, assorted
home visit clinics improved access to would be achieved by: medical specialties and stakeholders.
HOTS significantly. This highlighted areas for
• Reviewing HOTS referral processes improvement both in respect of
However, each month there remained and documentation clinical and administrative processes.
a small number of new Home Oxygen • Continued integration of HOTS It also illustrated the evolving role of
Order Forms (HOOFs) originating with wider respiratory team to the HOTS team and raised awareness
from outside of the HOTS team and support delivery of a high quality of issues across the wider respiratory
initiating home oxygen in un-assessed COPD care bundle care pathway.
patients. This was of great concern • Greater links with end-of–life carers
as the HOTS team were uncovering and staff to ensure appropriate, Change in clinical practice: Further
(un-assessed) home oxygen therapy beneficial and cost-effective home low-level mapping of the actual
patients with chronic type 2 oxygen prescribing, therapy oxygen assessment process prompted
respiratory failure for which oxygen alteration and follow-up the team to continue taking blood
therapy could be potentially harmful. • Continued monitoring of home gas measurements on air in both the
oxygen usage data to support first and subsequent (three week)
transition to a new oxygen supply clinic visit but to undertake titration
provider, maintain clinical on oxygen (to target oxygen
governance and ensure cost- saturations) in the three week clinic
effectiveness assessment visit only.

25


Many patients present with markedly What has been achieved? What are the key learning points?
improved blood gas levels at the Home oxygen prescribing – The aim • Process mapping supports the
three week assessment and so the of ensuring safe quality assured identification of opportunities to
original titration exercise was prescribing of home oxygen though quickly change both clinical
unnecessary. In addition, patients the 95% HOOF target has been met. practice and also the organisation
(with no known heart failure This was accompanied by continued of care processes.
diagnosis) who have a PaO2 > 8.3kPa month-on-month reductions in • Multidisciplinary involvement in
at the first initial assessment are prescribing costs in the months service re-design enables
referred back to their GP with advice preceding the transition of oxygen consideration of the whole
for subsequent re-referral to HOTS if supply (which is likely to introduce pathway of care and identification
the patient deteriorates. Previously further cost efficiencies). of areas for improvement outside
patients were kept under review if the immediate project scope.
their PaO2 < 9kPa Increased assessment clinic capacity – • Quality assured prescribing and cost
Initial assessment clinic duration times efficiency will only be maintained
Administrative and data have been reduced through the by continual monitoring of oxygen
management changes: The referral change in practice, reducing waiting usage by the HOTS team and tight
form was altered to include times for new referrals and enabling control of HOOF prescribing.
additional information to establish an additional clinic slot for urgent
that patients are medically stable assessment for palliative oxygen. Contact
prior to assessment. The involvement Melissa Collinge
of the commissioner in the mapping Further safeguards against acute Respiratory Nurse Specialist
events supported the team’s efforts oxygen toxicity - the multi-disciplinary Tel. 0161 206 0865
in acquiring administrative support to whole pathway discussions prompted Email. melissa.collinge@srft.nhs.uk
help improve data management in the routine issuing of oxygen alert
advance of oxygen supply transition cards to all patients in need of non
and oversee the introduction of invasive ventilation (NIV).
additional data recording and audit
tools.

The team have also established a
generic email address which allows
for prompt processing of referrals and
a shortened appointment booking
process.

26


3.5 Stockport NHS Foundation Trust

Fit for purpose – clinical quality, cost
effectiveness and patient satisfaction

The Oxygen Assessment Service in
Stockport (Oasis) and local
commissioners jointly identified the
need to expand the community-
based service to enable GPs to refer
patients for specialist home oxygen
service - assessment and review
(HOS-AR) and also to appropriately
repatriate home oxygen patients
(whose condition did not require
acute hospital / tertiary centre care)
back to the community.

The service also needed to prepare
for the transition to a new oxygen
supply contract, which was
happening in parallel with the team
transferring from the Primary Care • Maximise the cost effectiveness of • Patient reconciliation: Patients
Trust (PCT) to the local Foundation the HOS-AR service whilst prescribed oxygen but not known
Trust, by identifying and minimising the cost of prescribed to the service were identified by
implementing improvements in oxygen reconciling to the oxygen provider
service efficiency, data management • Ensure that oxygen is prescribed (Air Products) concordance report
and prescribing safely, (without causing increased to their patient care records
carbon dioxide retention), and only • Audit of GP oxygen prescribing:
What was the aim? when clinically beneficial (hypoxic) This enabled the team to estimate
The project was established to • Build close working relationships the numbers of expected GP
achieve the following objectives: with other local clinical teams referrals upon commencement of
• Review the current service in order managing patients prescribed GP direct access to Oasis
to identify both good practice and oxygen and ensure care is • Patient categorisation: Patients
areas for improvement consistent across the health were stratified according to disease
• Identify gaps in consistency of care economy. complexity, age and prescribing
to patients prescribed home oxygen modality short burst/long-term
• develop clinical and prescribing What did they do? oxygen therapy in order to support
data management systems in order The project team undertook a discussions between clinicians
to meet the requirements and number of specific project activities about which patients should be
timescale for implementation of a namely: provided full HOS-AR by Oasis
new national Home Oxygen supply • Care pathway mapping: The those patients who should be
contract (2 July 2012) team process mapped the journey known to the service but managed
• Expand the service to ensure that for patients currently cared for by by other specialist services
all patients who would benefit from Oasis in order to identify
oxygen therapy are offered timely inefficiencies, highlight patients
high quality assessment and care who fell outside of the pathways of
appropriate to their needs care and reveal inequalities in
service provision. This was used to
generate improvement ideas

27


• Workforce modeling: The team • Development of a referral • Working with the PCT quality team
worked with their commissioner in pathway for GPs for acute enabled the development of an
the development of a tool to assessment: Working with the improved reporting tool which
estimate staff numbers required for primary care respiratory lead / GP could merge monthly supplier
the new expanded service and to with a specialist interest and the invoice data with the active patient
develop the business plan. The tool local commissioners the team clinical list.
used information from: developed a referral pathway which • Networking with other national
• GP prescribing audit and the incorporated use of the Choose COPD project teams assisted the
patient categorisation exercise and Book service. process of clinical practice review
• the revised care pathway from and generated ideas for
the mapping exercise What has been achieved? improvements to service delivery
• projected volume of patients The project met all the stated such as:
receiving full HOS-AR care from objectives and delivered a number of • use of portable equipment to
the patient reconciliation exercise notable achievements namely: facilitate blood gas analysis of
• Department of Health good • Development a GP referral pathway housebound patients
practice guide requirements in and proforma ensuring that GP’s • shift to a locality based work plan
respect of clinical competence no longer issue Home Oxygen to reduce travel time and mileage
• demand and capacity information Order Forms. and
in respect of assessments, • Increased clinic / visit capacity • development of new template for
reviews, administration and data enabling the creation 1x urgent slot patient contacts to reduce time
management. available daily Mon-Friday spent dictating letters
• Development of an Out of hours • The new service arrangements have
This model also took account of pathways with the Mastercall uncovered challenges associated
appointments being a mix of home service with the initiation of oxygen
visits and clinic based appointments • Reduced the costs associated with therapy for palliative /End-of-life
with an increased emphasis on home home visits through use of a patients
visits in order to address the relatively portable blood gas analyser by a • The ability to safely and
high historic DNA rates for clinic single nurse appropriately initiate oxygen
appointments. • Improved patient data therapy immediately following a
management enabling historic senior specialist nurse home visit
• Review of Home assessment oxygen usage and patient clinic should increase patient satisfaction
equipment: As part of the national contact records to be viewed and service effectiveness – this
COPD project cohort the Stockport together assertion will be tested through
team were able to discuss patient satisfaction surveys and
alternative blood gas analyser What are the key learning points? continued monitoring of clinical
equipment with other HOS-AR • Collaboration between the clinical and usage data.
services and select clinically team and the local commissioner in
effective portable equipment that the use of patient clinical data and Contact
could be managed by one person the oxygen supplier data enabled a Karen Fern
as two staff are currently required model of service workforce COPD Team Leader
to deploy the current analyser and requirements to be developed Tel. 0161 426 9613
other equipment. which met the needs of the local Email: Karen.Fern@nhs.net
population

28

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