NHS Improvement - Lung: NationalImprovement Projects

Improving Home Oxygen:Testing the Case for Change

NHSNHS Improvement

Lung

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Introduction

Case studies

• Wirral University Hospital NHS Foundation Trust and NHS WirralWirral Integrated Community Oxygen Service

• NHS Hull and the City Health Care PartnershipHome Oxygen Service Improvement Project

• Royal Free Hospital NHS Trust, NHS Waltham Forest & North EastLondon, North Central London and Essex Health InnovationEducation Cluster (NECLES HIEC)The feasibility and impact of withdrawal of Short Burst OxygenTherapy (SBOT)

• NHS Nottinghamshire County Community COPD Team,Sherwood Forest Hospitals NHS Foundation Trust andCounty Health PartnershipHome oxygen – improving quality of care

• NHS Sheffield and Sheffield Teaching HospitalsNHS Foundation TrustHome oxygen service improvement project

• NHS Blackpool and Blackpool Teaching HospitalsNHS Foundation TrustImproving oxygen services and the prescribing of oxygenacross NHS Blackpool

• NHS South StaffordshireImproving home oxygen services through pathway redesign

• Milton Keynes PCT Community Services and Milton KeynesHospital NHS Foundation TrustSustaining the efficiency and effectiveness of the Milton Keynes HomeOxygen Service – Assessment and Review (HOS-AR)

Acknowledgements

Contents

NHS Improvement - Lung National Improvement ProjectsImproving Home Oxygen: Testing the Case for Change

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3CONTENTS

INTRODUCTION4

Introduction

Case for change: the currentposition for home oxygenservices in England

Home oxygen therapy is providedto about 85,000 people inEngland, costing approximately£110 million a year1. Homeoxygen service – assessment andreview (HOS-AR) is variable aspatients in many Primary CareTrusts (PCTs) do not receive aquality assured clinical assessmentand a review of their ongoing needfor long term home oxygen.

The variation in provision of HOS-AR increases the potential for poorquality care and waste and it hasbeen estimated that 24% to 43%of home oxygen prescribed inEngland is not used or provides noclinical benefit1.

Gross savings of up to 40% -equivalent nationally to £45 milliona year or £300,000 per PCT canpotentially be achieved throughthe establishment of home oxygenservices, oxygen register reviewand formal clinical assessment1.

Reducing variation in serviceprovision can help tackle healthinequalities and ensure consistencyin the safety and efficacy ofservices. These are among thegoals of The Outcomes Strategyfor COPD and Asthma in Englandas outlined in objective 2 andobjective 5 of the six sharedobjectives set out in the strategy2.

The aim of the ImprovingHome Oxygenworkstream is to ensurethat patients with aclinical need for homeoxygen receiveappropriate, safe andcost effective therapy ona sustainable basis as aresult of an efficient carepathway providingspecialist assessment andongoing clinical review.

NHS Improvement - Lung workedwith clinical teams across Englandsupporting them in identifying,testing and implementing thechanges needed to achieve goodpractice in HOS-AR and seeking tounderstand the key componentsthat have the greatest impact onthe patient pathway.

The first year of project workfocussed on continuous patient listreview and the systematicutilisation of oxygen usage supplierdata to support clinical decisionmaking around therapy alteration(or withdrawal) and to drive morecoordinated prescribing andimproved multi-disciplinary care.

The project work was undertakenagainst the backdrop of thenational re-procurement of oxygensupply contracts, which wasjust gathering pace. There-procurement together with theNHS Quality, Innovation,Productivity and Prevention agendagave additional context to thework and provided an opportunityfor clinical teams to engage localcommissioners, finance andmedicines management in newand different thinking about Homeoxygen service –assessment andreview.

This publication is aimed athealthcare professionals,commissioners and other keystakeholders involved in respiratoryhealth services. It draws togetherthe evidence and learning from thework undertaken by the nationalCOPD projects constituting theinitial 12 months of the ImprovingHome Oxygen Servicesworkstream.

1Home Oxygen Service – Assessment and Review – Good Practice Guide, NHS Primary Care Commissioning (2011)2An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, Department of Health, July 2011

5INTRODUCTION

Improvement approach

NHS Improvement – Lung invitedNHS organisations to work inpartnership on projects dedicated toimproving the COPD patientpathway and to help address thegeographical variation in care thatpatients receive. Projects plans weresubmitted from a number of sitesincluding acute trusts, primary caretrusts (PCTs) and communityorganisations.

The primary aims of the projectwork were to

• Locally define and implement thepatient’s home oxygen carepathway in alignment with thestandards enshrined within theGood Practice Guide nationalpublication

• Identify and reduce variation in thedelivery of care

• Test the components of care thatled to an effective HOS-AR model

• Identify the success principles thatother organisations and teamscould learn from and adopt

• Inform future ‘prototyping’ work.

However, focus was also given toimproving the patients experienceand outcomes, and to the removalof duplication and waste from thepathway and from specific processesthrough different ways of workingand service redesign.

Through patient list cleansing,rationalising individual patient’soxygen usage (in terms of flow rate,supply duration and supply devices)in line with their clinical need,supported withdrawal ofinappropriate therapy and healthcareprovider education to avoidinappropriate prescribing, 9 out ofthe 12 oxygen workstream projectteams delivered collective prescribingcost efficiencies totallingapproximately £640,000.

During this ‘testing’ phase of thenational programme the projectteams have explored the reality ofmaking local service improvementsby taking stock of current practiceand understanding theimplementation process necessaryfor the delivery of optimal patientcare in a challenging environment.

The project sites adopted asystematic approach to qualityimprovement to ensure that anychanges implemented werethoroughly tested and measured.Prior to commencing the work theproject sites were required toestablish their service baselinethrough analysis of local data and tounderstand the variation in services.

Upon the establishment of individualproject teams, a period of ‘diagnosis’followed in order to allow teams tounderstand the patient pathway anddispel a number of assumptionsabout the processes, its challengesand the solutions. Potential solutionswere tested using the model forimprovement and Plan-Do-Study-Act(PDSA) cycles with ongoingmeasurement to evaluate the impactof the interventions and refinewhere appropriate.

6 INTRODUCTION

Common challenges andsolutions

Clinical teams at all sites have beenfocussed on specific aims whichhave included:

• Develop accurate registers ofpatients in receipt of home oxygentherapy

• Utilise the home oxygen servicedata around initiating prescriber,oxygen consumption, flow rates,patient concordance and therapymodality more effectively and incombination with clinical dataabout individual patients

• Ensuring all existing and futurepatients in receipt of home oxygenreceive clinical assessment andongoing review in line with bestpractice

• Improve care for non respiratorypatients in receipt of oxygen bybetter collaborative working withnon-respiratory specialists

• Rationalise prescribing of homeoxygen to reflects the clinical needof the local population

• Control home oxygen therapycosts

• Develop and implement effectiverisk assessment and health andsafety procedures

• Achieve greater integration ofassessment and review serviceswithin wider care pathway.

Whilst each project site has worked on a different part of thehome oxygen pathway, a number of key themes have emergedacross all oxygen project sites which have enabled thedevelopment of six top tips for improving home oxygenservices:

1. Provide oxygen assessment and review staff with access tosupplier data and support in its effective use

2. Use clinical and supplier data systematically to supportappropriate prescribing, clinical assessment with ongoingreview and tight cost control

3. Integrate your oxygen service within the wider respiratorypathway and coordinate activities with non-respiratoryspecialties

4. Promote the message that ‘home oxygen is a treatment forchronic hypoxaemia and NOT a treatment forbreathlessness’

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

6. Establish ongoing and effective communication betweenthe oxygen team, primary and secondary care to ensureappropriate prescribing, appropriate referrals andcontinuous education for patients and professionals.

7INTRODUCTION

Project outcomes: Emerging success principles and project learning

NHS Improvement - Lung provides structured support to project teams enabling them to solveproblems by addressing root causes and by undertaking a systematic approach to serviceimprovement. Teams across the different workstreams of the national programme worked througha number of different challenges in order to achieve their project aims. However some commonprinciples have emerged as critical success factors in all national COPD projects:

1. Defining and gaining a good understanding of the whole pathway of care - having a completeunderstanding of the care pathway supported by robust data to demonstrate the effectiveness of currentprocesses, quantifying performance and variation is essential when embarking on improvement work. Thisallowed organisations to identify priorities for change and also to benchmark themselves with others locallyand nationally.

Home oxygen project teams used supplier and clinical data on patients’ condition, therapy consumptionand compliance together with an improved understanding of the sources of prescribing and sources ofreferral to local services in order to rationalise therapy in alignment with clinical need.

2. Taking an integrated approach to service development - issues and challenges viewed in isolationwithout due consideration to the whole patient pathway were less likely to lead to sustainableimprovements in care provision.

Oxygen services need to be viewed within the wider respiratory care pathway to maximise the opportunitiesfor integrating with services such pulmonary rehabilitation and to ensure patients receive optimal andcoordinated management of their overall respiratory condition.

3. Clinical collaboration across the care pathway - effective working relied on the commitment of teamsin primary, secondary and community care to improve communication across the patient pathway.Integrated working helped to build positive relationships with health care professionals, departments andorganisations, and improve the critical interface between these organisations.

Home oxygen teams often had to consider patients with a range of conditions not just COPD and as suchhad to collaborate with non-respiratory specialists in order to ensure coordinated management of patientsrequiring oxygen for neurological and cardiac conditions as well as patients requiring oxygen forpalliative care.

8 INTRODUCTION

Next action steps for NHS teamsseeking to improve home oxygenservices

The learning from this first year ofproject work indicates that otherNHS teams considering improvinghome oxygen services should focusactivity in three areas:

1. Review oxygen usage dataand improve datamanagement – ensure theclinical team has routine access tosupplier data and is collaboratingwith non-clinical colleaguesaround patient list cleansing,identifying candidates for therapyrationalisation. The clinical teamshould provide clinical insight tomanagers and administratorsundertaking monthly invoicereconciliation and collaborate inthe review of patient complianceusing the quarterly concordancereports.

2. Establish clinical assessmentand ongoing review – identifyall patients currently in receipt ofhome oxygen in order to addressany assessment/review backlog,utilise local booking systems tocapture referrals for initialassessment and to establish thereview cycle. Undertakeappropriate therapymodifications, the supportedwithdrawal of inappropriatetherapy, patient safety riskassessment and ongoing patienteducation.

4. Clinicians and managers reviewing data together - access toand effective use of data through collaboration between clinical andmanagerial staff enabled the project teams to better understand thepatient pathway and demonstrate the impact of any change. Theroutine collection and review of data was important in implementingsustainable improvements and understanding outcomes of any serviceimprovements.

Oxygen teams worked with non-clinical colleagues to understandsources of inappropriate prescribing and inappropriate referrals forclinical assessment. This enabled targeted education to beundertaken within both the community and within hospital settingsaccompanied by ongoing data review to assess changes in healthcareprofessional behaviour.

5. Identifying the key levers and drivers in the system - byintegrating local and national priorities into the work such as Quality,Innovation, Productivity and Prevention (QIPP) project teams raised theprofile and priority of the project work with decision makers andhelped to achieve improved engagement from senior managementteams.

Both the QIPP agenda and the national re-procurement of oxygensupply contracts provided an opportunity for clinical teams to engageother clinical and non-clinical stakeholders in a new dialogue aboutissues such as home oxygen therapy usage, reporting arrangements,HOS-AR service specification and its integration within the wider carepathways, treatment goals, fire safety, risk assessment and thecoordination of community and hospital care.

6. Value for money - there was a need to identify and understandthe gaps, duplication and waste in the patient pathway in order tomake best use of available resources. It was essential to work andcommunicate with colleagues, commissioners and other stakeholdersin service provision in order to maximise these resources and to ensurea consistent and co-ordinated approach to care.

Commissioning, finance and medicines management colleaguesworked closely with home oxygen clinical specialists to identifyprescribing anomalies, to address waste, to improve the clinicalgovernance in respect of the safe use of home oxygen and to managethe performance of the oxygen suppliers.

3. Service integration andsustainability – undertakeprocess mapping with themultidisciplinary team tounderstand the current homeoxygen patient pathway for themedical conditions beingmanaged. This should be usedtogether with detailed localcontextual data about prescribing,usage, costs, home oxygen serviceactivity, demand and capacity inorder to ensure the servicespecification supports thedevelopment of a cost-effectivepathway and aligns with localcommissioning considerations.

Future ‘prototyping’ work

In the forthcoming year of projectwork sites will be building on thelearning from the ‘testing’ phase ofwork. Sites will be refining thecomponents attributed to theemerging care models and successprinciples that demonstrated thegreatest impact on the patientpathway during the past year.

The prototyping work will define theefficient and high quality care modelthat reflects best practice, but alsodemonstrates examples of practicalapproaches towards sustainableimplementation. This will includework that focuses on the delivery ofa number of products:

• Home oxygen services-assessment and reviewresource hub - an online toolkitwhich will identify key datameasures and clearly articulate thesuccess principles for sustainableimplementation of HOS-AR. Thisresource will provide case studies,examples of protocols, proceduresand pathways together with Top-tips and ‘next steps’ action sheets.

• Safe use of oxygen supportpackage - highlighting issues ofpatient safety and riskmanagement for the localdevelopment of patient educationprogrammes and also thestrengthening of local clinicalgovernance arrangements througha partnership between patients,local NHS organisations, oxygensuppliers and fire services.

• Spread Framework for HomeOxygen Service - assessmentand review – guidance to assistclinical leads, home oxygen serviceleads, clinical commissioninggroups and clinical networks intheir collaborative effort to drivethe regional implementation ofHOS-AR and the widespreadadoption of good practice inhome oxygen services.

The testing phase workdemonstrated that the potential costefficiencies identified by theDepartment of Health andattributable to therapyrationalisation through home oxygenservice –assessment and review canbe realised in practice. It isanticipated that the prototype phaseof work will further demonstrate theimportance of assessment andreview in the maintenance of safe,high quality, equitable and costefficient home oxygen services.

Ore OkosiNational Improvement Lead,NHS Improvement – Lung

Phil DuncanDirector, NHS Improvement -Lung

9INTRODUCTION

10 CASE STUDIES

What was the problem?The challenge for this community based(but integrated with secondary care)team of nurses, physiotherapists andadministrative staff providing COPD,Pulmonary Rehabilitation and Oxygenservices was to work more effectivelywith the wider multidisciplinary team tomanage patients on oxygen therapy whohave a wide range of health problems(not just COPD). In addition, the teamsought to maintain or even increase thecost efficiencies and improvements inpatient care it had achieved throughpatient review and the use of oxygenbudget and concordance data when theservice was first established.

What was the aim?By the end of July 2011, all existing adultpatients registered with a Wirral GP andprescribed oxygen will have had astructured assessment. New patients willbe formally assessed before oxygen isprescribed and all patients will have ascheduled review programme. Patientswho are prescribed oxygen will have themost clinically and cost effectivetreatment.

• All adult patients on Wirral shouldhave a structured assessment prior tocommencing home oxygen in line withnational guidance. This excludespatients for whom oxygen is palliativefor terminal illness

• Oxygen will only be prescribed ifclinically indicated

• All adult patients on oxygen should bereviewed at least every six months toensure their prescription remainsappropriate for their needs

• Unnecessary oxygen prescribing shouldbe eliminated

• An on-going education programme forhealth professionals about theindications, prescribing and use ofoxygen will be established.

Wirral University Hospital NHS Foundation Trust and NHS Wirral

Wirral Integrated Community Oxygen Service

What has been achieved?• All existing patients on home oxygen

therapy have been reviewed• Maintenance of tight cost control with

continued reduction in non specialistoxygen prescribing

• Acceptance of the service by othercommunity based teams and othernon-respiratory specialist teams

• Development of a pathway forsupported withdrawal of short burstoxygen therapy (SBOT)

• Formalisation of (safety) riskassessment with adoption ofdocumented procedures andescalation process

• Positive feedback from patients via anexternal patient evaluation of theservice

• Development of a shared caretreatment pathway with heartspecialist nurses has reduced theirreferrals for SBOT.

What are the key learning points?• It is important to establish

communication networks with localprimary and secondary carestakeholders. By attending (orpresenting at) local professionalforums opportunities to build trust andeducate other healthcare professionalscan be realised. The education processis reinforced through individualdiscussion of non-specialistprescriptions and by giving feed backto referrers post patient assessment

• Using a model that integrates oxygenassessment and review with COPD andPR services and is supported bysecondary care has contributed to thesuccess of this community basedservice. Control of the prescribing ofoxygen taking place within the acutetrust via hospital based respiratorynurses reduces inappropriatelyprescribed oxygen and improvescommunication about patients whoneed further assessment and review

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11CASE STUDIES

• Autonomy in setting up anddeveloping the service coupled withstrong leadership and clinical andmanagerial support is vital

• The importance of obtaining andmaintaining accurate data aboutpatients, review cycles and costanalysis should not be underestimated,neither should the time and skill takento do this consistently

• Consistent, high quality assessmentand review by expert practitioners isvital in gaining and maintaining thetrust of the patient, carers and clinicalcolleagues. Cost effective prescribingshould follow on from this and not bethe prime motivation

• Developing positive relationships withother specialist teams and clinicalcolleagues is vital to be accepted aspart of the patient’s clinicalmanagement team. This can only beachieved by sustained effort andnetworking.

ContactDenise WilliamsNurse Consultant/ COPD andOxygen Service Manager

Tel: 0151 514 2245 or ext. 3243Email: denise.williams12@nhs.net

12 CASE STUDIES

What was the problem?Final procurement of local Home OxygenService – Assessment and Review (HOS-AR) coincided with the start of the NHSImprovement-Lung project. The projecthad a split focus, one area being thesuccessful commencement of HOS-ARwith the associated challenges ofestablishing a new referral pathway,accessing, interpreting and using dataand also the clinical review of 876existing patients currently receivinghome oxygen. The second area of focuswas to establish robust proceduresaround risk, health and safety andsmoking as this had been identified as alocal priority.

What was the aim?To contribute to a reduction inunscheduled hospital admissions andoptimise chronic obstructive pulmonarydisease (COPD) patient care through thedelivery of appropriate and cost-effectiveoxygen therapy to COPD patientsidentified as being in clinical needdetermined through assessment bytrained healthcare professionals.

• Remove inappropriate oxygenprovision, ensuring correct equipmentand therapy is delivered to new andexisting patients on oxygen

• Reduce unnecessary costs of oxygenand equipment

• Risk assess patients/carers prior to andduring their use of oxygen therapy

• Work with the local fire brigade toproduce and develop a workable localpolicy on smoking and oxygenprovision

• Educate patients on health and safetyissues surrounding smoking andoxygen therapy

• Develop a written (signed) contractbetween patient and health careprofessional (HCP) with clauses toremove provision on grounds of healthand safety or no clinical need/benefit.

NHS Hull and the City Health Care Partnership

Home oxygen service improvement project

What has been achieved?• Patients at risk have been identified by

the HOS-AR team and joint visits havebeen undertaken with the Fire Brigadetogether with the development of ajoint risk assessment pathway andarrangements for future joint trainingbetween both teams

• A policy for the delivery of HOS-AR hasbeen developed and approved by CityHealth Care Partnership with regulareducation for local primary, communityand secondary care (on best practice,referral criteria and optimisingtreatment) built into the team’s servicespecification

• A draft health and safety oxygen usepolicy has been developed and it ishoped that all stakeholders will besigning up to its use shortly

• Prior to the service commencing thenumber of patients in Hull in receipt ofoxygen was 876, the current caseload,as of 3rd October 2011, is 579

• Home oxygen monthly invoices havereduced by £15k since the servicecommenced a reduction in annualforecast spend of £0.204m

• Patient experience as obtained usingthe Long Term Conditions LTC6questionnaire was overwhelmingpositive and scored highly in respect ofpatient involvement in decision-making, information provision, joined-up care and team support.

Picture features Home Oxygen Clinical Team only - the full project group comprisedPCT commissioners, smoking cessation, patients, oxygen supplier and the Fire Brigade

During the period of April 2010 - September 2011:New referrals into the service for patients not in receipt of oxygenAssessments and or follow ups undertakenNumber of those new referrals which were inappropriatePatients were discharged from the service, no longer requiring oxygenRemovals of modalitiesCommencements on oxygen modalitiesIncreases in oxygen flow rates

3411630109168435322234

13CASE STUDIES

What are the key learning points?• Using cost and usage data from the

oxygen supplier is the smartest way todetermine a starting point forassessing and reviewing patients. Atemplate is being developed to supportintegration of clinical system reportingwith oxygen reporting systems. Quickfinancial wins came from theadministration team working throughthe invoices and identifyingdiscrepancies and reporting this backto the oxygen supplier

• A lot of time was spent gaining anunderstanding of the data (with thesuppliers help) and what it meantbefore the team were able to analysethe information and use it proactively

• Working with the Fire Brigade hashelped tackle the challengesexperienced by the team in educatingpatients and carers of the risks aroundhealth and safety and on dangers ofsmoking to themselves and others,making such discussions moreimpactful

• Locally, just as is the case nationally,there is no clinical consensus on theissue of therapy withdrawal in hypoxicpatients who continue to smoke.However, the team work proactively tomanage and minimise the risks topatients and their surroundingsthrough education, working withstakeholders and by involving theCOPD Smoking Cessation Specialistsand the Fire Brigade in care pathwaydevelopment. This has been reallysuccessful and has led to a number ofreported ‘quitters’ among existingoxygen patients identified as continuedsmokers

• Having the commissioners leading thismultidisciplinary project has driven thework, but the project would have hada stronger voice in the wider healthcommunity if the project team had aconsultant or GP among itsmembership.

ContactToni YelBusiness Development Manager

Mobile: 07530 719 852Email: toni.yel1@chcphull.nhs.uk

14 CASE STUDIES

What was the problem?There is considerable evidence fromhome oxygen service data and relatedsurveys that the use of short burstoxygen (SBOT) or intermittent oxygen athome, for the relief of breathlessness inpatients without chronic hypoxemia, isstill being provided, despite considerablepublished data that it is not effective andis therefore costly to the NHS. Thisproject was undertaken to address theissue of the prescription of short burstoxygen (SBOT) for patients with chronicobstructive pulmonary disease (COPD).

What was the aim?To review all COPD SBOT prescriptions,of more than 3 months, in two PCTareas, in order to reduce SBOTprescription by 75% over the course ofone year (July 2010 to July 2011). Thistarget figure was deliberately aimed highas most SBOT patients (with theexclusion of palliative prescriptions) haveno clinical indication for SBOT.

What has been achieved?Twenty-five patients on SBOT in theborough of Waltham Forest with aprimary diagnosis of COPD wereidentified. Appointments were sent andpatients, who agreed to participate inthe project, visited in their homes:

Royal Free Hospital NHS Trust, NHS Waltham Forest & North East London,North Central London and Essex Health Innovation Education Cluster

The feasibility and impact of withdrawalof Short Burst Oxygen Therapy (SBOT)

The results of 19 patients in terms ofHAD, SGRQ, FEV1 (morbidity) andoxygen SaO2 at assessment on first visitare presented in the oxygen workstreamemerging learning publicationwww.improvement.nhs.uk/lung

In the second PCT, the project teamencountered considerable difficulty inaccessing oxygen usage data. Theproject team developed a questionnaireexploring the issue of oxygen data accessand it’s usefulness in managing care andcirculated it to 17 teams within the NHSImprovement-Lung national programme.The 12 completed questionnairesindicated:

• Variation in ease of access to dataacross the respondents

• Clinicians do not have access to thefull range of data

• Respondents all doing somethingslightly different depending on theirlocation

• Access via commissioners and PCT butnot available to secondary care

• Accuracy of data a problem• Current and accurate tariffs not always

available so hard to control andmanage expenditure

• Issues over data protection resulting inchallenges around wider access to data.

What are the key learning points?The issues relating to withdrawal ofSBOT are highly complex and multi-factorial. They relate not to sub-optimalmanagement, but rather to the fact thatthis subgroup of patients have severeCOPD, are unwell, are maintained athome and are too sick to considerremoval of oxygen. The majority ofpatients in this study had SBOTprescribed for over 12 months (oftenfollowing an exacerbation) which hadalso led to some psychologicaldependence over time. However, theproject duration spanned an excessivelycold period with a high incidence ofacute exacerbations where patientsgenuinely needed their SBOT and whichwas felt to be justified by their clinician.

The following points have become clearduring the project:

• Communication between thecommunity and hospital on dischargeneeds improving to ensure seamlesscare of home oxygen patients

• Patients were discharged with noinformation about the use of oxygenonce at home and no supportregarding their oxygen therapy

• Patients commenced on SBOT for anexacerbation need reviewing at sixweeks for assessment, education andsupport with a view to removal toavoid psychological dependence

• Whilst there is an assumption thatpatients on SBOT have been given iterroneously, this study hasdemonstrated that in the majority ofthese cases, this has not been the case

• There needs to be clarity about thecorrect prescription of LTOT, given thecomplexity of removal of SBOT

Results ofhome visits

SBOT successfully withdrawn

Exacerbating at time of assessment

Withdrawn from study project

SBOT left in place on compassionate grounds

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15CASE STUDIES

• Patients who are prescribed SBOT maynot have been seen by a clinicalspecialist in oxygen therapy and maynot have been told how long theprescribed oxygen should be used

• Patients who are prescribed oxygen innursing homes need to be reviewedand require clinical specialist support intheir management, the managementof nursing homes need to be informedthat patients require regularassessment and that appropriate andcost effective arrangements can be putin place for emergency oxygensupplies.

ContactChristine MikelsonsConsultant Respiratory Physiotherapist(Royal Free)

Tel: 0207 794 0500 ext 34068or bleep 1041Email: christine.mikelsons@nhs.net

Anne CrawfordRespiratory Services Team Lead /Respiratory Nurse Specialist(Waltham Forest)

Tel: 0208 430 8255Email: anne.crawford@wf-pct.nhs.uk

What was the problem?The community COPD team, incollaboration with the local respiratoryfunction department established acommunity based oxygen assessmentservice, co-located with an existingconsultant led COPD clinic and apulmonary rehabilitation service, withassessments being provided across twosites.

The service proved successful and highlyregarded by patients but was not utilisedby all prescribers of oxygen, resulting in asignificant proportion of patientsreceiving home oxygen without clinicalassessment. The service recommendedto the PCT and to PBCs that prescribingwithout assessment should be barred butthe advice was rejected thus alternativeoptions to address the shortfall ofassessments needed to be developed.

What was the aim?The project aimed to increase theproportion of patients undergoingoxygen assessment and regular review inorder to improve both patientmanagement and cost containment byintroducing a ‘direct access’ pathway forgeneral practice, community nursing andother medical prescribers, therebysupporting areas with high rates ofoxygen prescription (i.e. hospitaldischarge and general practice).

NHS Nottinghamshire County Community COPD Team, Sherwood ForestHospitals NHS Foundation Trust and County Health Partnership

Home oxygen – improving quality of care

Objectives:• Introduce GP direct access to the

oxygen assessment service• Quantify the work that would be

associated with retrospectiveassessment (for patients with oxygenand no history of assessment)

• Develop a strategy for theidentification and assessment ofpatients discharged with oxygenfollowing a hospital admission

• Improve oxygen prescribing ensuringtherapy matched clinical need andactual usage, and also to reducesupply costs.

What has been achieved?Although audit and review of oxygenpatient registers and oxygen usage datasuggested the need for a significantincrease in staff and staff availability (inorder to undertake retrospectiveassessments), through service re-designthe project team were able to:

• Increase the number of assessmentsessions

• Identify areas where they couldintegrate with other community teamsin order to streamline and increaseservice capacity

• Improve integration within the COPDcommunity team i.e. integrating theservices of oxygen assessment andpulmonary rehabilitation

• Develop the systems and protocols tointroduce GP direct access and totarget hospital discharge oxygen

• Re-categorise therapy modality orremove oxygen therapy for a largenumber of patients and consequentlyrecover a projected £98,000 in annualcosts attributable to inappropriateprescribing.

What are the key learning points?• Integration of home oxygen services

with pulmonary rehabilitation providesa seamless service for patients. Itincreases key worker understanding ofboth therapies and it also improvesservice efficiency. In addition, bothpatient knowledge and experience isimproved which leads to informedpatient choices and more appropriateprescribing

• Pulmonary rehabilitation is the idealplatform to trial ambulatory oxygentherapy

• Patient review provides the idealopportunity to re-categorise theoxygen supply according to changingclinical and social needs

• Liaison with data analysts is importantin order to make effective use ofavailable oxygen usage data

• Access to monthly oxygen supplyinvoices is important to track what ishappening to the oxygen supply

• Encouraging dialogue between thehome oxygen service and primary caretogether with improved accessibility tospecialist HOS-AR team advice wasimportant in ensuring improvedoxygen prescribing.

ContactDr Sue RevillClinical Scientist COPD Services

Tel: 01623 785407Email: sue.revill@sfh-tr.nhs.uk

16 CASE STUDIES

17CASE STUDIES

What was the problem?NHS Sheffield as part of their AchievingBalanced Health Strategy (2010)identified that they had the highestprojected forecast spend on homeoxygen therapy. There was no localrequirement for patients to have anoxygen assessment in advance of therapybeing ordered /prescribed and patient’songoing need for oxygen therapy wasnot always reviewed.

What was the aim?By July 2012, all NHS Sheffield chronicobstructive pulmonary disease (COPD)patients newly prescribed home oxygenhave had an initial quality assuredassessment and all COPD patients withhome oxygen are systematically reviewedin line with British Thoracic Society/NICEguidelines resulting in the correcttherapy (detailed on home oxygen orderforms and equipment) and leading toimprovements in patient quality of life,increased life expectancy, reduced(unscheduled) admissions and robustoxygen cost control.

What has been achieved?The cost saving potential andimprovements in care demonstrated bythe project work have enabled a newservice specification to be written andagreed with the provider of the newservice, which includes the assessmentand review of both respiratory and nonrespiratory patients. The start date forthe new service is planned for Jan 2012pending agreement of fundingarrangements and mobilisation of theservice.

Notable project achievements include:• Validation of oxygen usage completed

in 2010/11 and a further one isplanned for November 2011.

• Register compilation with a systemnow in place to check Home OxygenOrder Forms (HOOFs) are completedproperly

NHS Sheffield and Sheffield Teaching Hospitals NHS Foundation Trust

Home oxygen service improvement project

• Improved communication andunderstanding between PCTcommissioners and service providers.

• Raised the profile and importance ofpulse oximetry among local GP's

• Improved use of data from oxygensupplier

• Reduction of between £120K to£150K in estimated annual oxygenprescribing costs

• Established ongoing systematicmonitoring of HOOFs.

What are the key learning points?Use of internal audit to develop systems,audit oxygen cost monitoring processes,clarify invoices and avoid errors ensuredsupport from the finance andperformance directorate and enableddetailed analysis of oxygen usage to beundertaken.

• Remain motivated in order to delivereventual improvements

• Encourage cross functional working –PCT commissioner, medicinesmanagement, clinicians and provider

• Garner wider organisation support –the engagement of ClinicalCommission Group (CCG) enabled theprofile of home oxygen therapypatients and service issues to be raisedwithin the CCG

• Undertake analysis of service demandand capacity with service provider staffto inform the service specification

• Set standards high and be prepared tonegotiate around new ways ofworking

• Take time to understand and assessprescribing anomalies.

ContactJoanne WatsonLead Public Health Development Nurse

Tel: 07816 271547Email: j.watson11@nhs.net

18 CASE STUDIES

What was the problem?The PCT had a high proportion ofpatients using oxygen compared to otherareas within the region and this wasassociated with higher than (regional)average prescribing costs. A preliminaryaudit undertaken in collaboration withsecondary care in 2009 revealed thatonly 30% of patients on home oxygenhad been assessed or reviewed by aclinical specialist.

This audit identified the risk that patientsmay be receiving oxygen inappropriatelyresulting in adverse clinical outcomes ifprescribed not matching the patient’sclinical needs or patient in receipt ofunnecessary oxygen.

What was the aim?The objectives of the project were to:

• Develop an accurate home oxygentherapy register

• Identify number of patients receivinghome oxygen who do not meet theguideline criteria

• Identify patients who could have theirtherapy changed or discontinued

• Conduct urgent review of individualsreceiving high/low dose oxygen toensure clinical risks are managed

• Develop a structuredassessment/follow up service whichmeets NICE guidance

• Increase the proportion of patientsreceiving a structured assessment fromthe current level (30%) to (80%)within time frame of the project.

NHS Blackpool and Blackpool Teaching Hospitals NHS Foundation Trust

Improving oxygen services and theprescribing of oxygen across Blackpool

What has been achieved?• £141k pa cost reduction to date• Patients referred seen within a week• 94% of patients have now been seen

– in excess of target of 80% ofpatients outstanding at the start(approximately 270)

• Now that the team know the patients,and have established rapport withthem, the consultation time issometimes shorter, further increasingefficiency

• Access to information is now sharedwith the HOS-AR team informing theirclinical decisions and improving quality

• Blackpool GPs are no longer routinelystarting patients on oxygenthemselves, but are using the service

• Pulmonary rehabilitation is nowreferring into the HOS-AR and viceversa

• Community matrons and the earlysupported discharge service linkingwith HOS-AR service and expertiseshared.

What are the key learning points?• Identify the PCT oxygen lead in order

to progress work utilising concordancereports and supplier invoices andengage the finance dept. in finalanalysis work

• Establish strong links and goodpersonal working relationshipsbetween primary and secondary carefor a consistent approach to servicedelivery

• Identify all stakeholders, and developengagement and inclusion from thestart, keeping everyone up-dated andacknowledge individual and teameffort to drive project

• Consider what information you needlocally, and why, when developing yourown data resource to capture andcollect clinic activity, cost savings andfollow-ups

19CASE STUDIES

• Effective data collection systems wereessential in order to calculate numbersfor future capacity and demand and torecord the cost savings being realisedfor future sustainability of the HomeOxygen Service through improvedquality and productivity

• Ensure clinicians have access to all up-to-date relevant patient information ina timely fashion in order to make moreinformed clinical decisions at the timeof contact

• Establishing a robust baseline supportsrealistic and effective planning withinthe resources available, it also helpsfocus and supports identification ofquick win reductions in prescribingwhich help team motivation andprovide momentum

• Process map early to identify gaps inservice provision

• Make use of ‘protected time out’ toensure full engagement from allmembers of the team with problemsolving and action planning

• Highlight work that could be morecost effectively performed byadministration staff and release clinicalcapacity

• Changing behaviour is bothchallenging and evolves gradually overtime, pathways revisited regularlythrough stakeholder meetings, trainingand support

• Working with patients to reduce theirprescription where appropriate isdifficult and not always pleasant

• It is important to consistently promotethe message to patients andprofessionals that oxygen isappropriate only when patients arehypoxic

• Maintaining service efficiency providescapacity to ensure DNAs are followedup by home visits if necessary

• Phone call reminders helps to reduceDNA rate and follow-up phone callsfollowing a DNA can also help infuture attendance rates

• Home oxygen service – Assessmentand review within the communitysetting has had both advantages (staffcan focus exclusively on assessmentand review without interruptionsarising from other issues within theacute setting) and disadvantages(community clinic computers notcurrently linked to the appointmentsystem)

• Access to expertise with ability to costvarious service delivery optionsenabled a range of evidence-basedscenarios to be presented to ClinicalCommissioning Groups.

ContactRos InceLead Nurse Diabetes and Respiratory

Tel: 01253 651316Email: rosalyn.ince@blackpool.nhs.uk

20 CASE STUDIES

What was the problem?A gap in service provision had beenidentified within the Cannock Chaselocality of South Staffordshire PCT due tothe absence of Home Oxygen Service –Assessment and Review (HOS-AR)despite the fact that 537 patients wereknown to be in receiptof home oxygen within Cannock Chaselocality, of which only 149 were knownto the local community respiratory team.

In addition, the majority of costsassociated with oxygen prescribing wereattributed to the use of intermittentoxygen or short burst oxygen a therapymodality for which there is currently nosupporting evidence

What was the aim?Cannock Chase respiratory servicereviewed local oxygen treatment in orderto:• Rationalise and evaluate home oxygen

prescribing• Establish treatment appropriate to

clinical need• Rectify invoice anomalies and• Liberate efficiency gains for investment

in permanent HOS-AR provision.

What has been achieved?• 257 oxygen therapy reviews took place

and all 257 patients also received a fireservice safety check

• 194 patients had their therapyrationalised as a result of specialistreview

• 30 patients with no clinical indicationfor oxygen had their therapywithdrawn resulting in a saving of£24,352

• Cessation of payments made inrespect of deceased patients anddiscontinuation of their continuedoxygen supply led to a saving of£23,442

NHS South Staffordshire

Improving home oxygen services throughpathway redesign

• Duplicate orders to multiple addresseswere eliminated as were erroneousmultiple charges levied againstindividual patient therapy orders

• Established that 64% of the patientregister had never been previouslyassessed and had normal oxygen levelsmeasured by pulse oximetry

• Supply orders relating to patients whohave moved were cancelled

• Payment for equipment never receivedwas stopped.

In total, the improvements undertakenover a six month period achieved costsavings of £130,512

What are the key learning points?• Existing home oxygen data collection

and administration systems arecomplex

• Invoicing processes are remote fromclinicians ordering home oxygen andrequire administrative support to workeffectively

• Clinicians in GP surgeries have limitedknowledge of the type oxygen to orderand in some cases prescribeinappropriately

• Oxygen assessment and review canimprove care by ensuring appropriatetherapy and ensure costs are reflectiveof the true clinical need of thepopulation.

ContactJoan ManzieConsultant Respiratory Nurse

Tel: 01543 509756Email: joan.manzie@ssotp.nhs.uk

Sally YoungStaffordshire Cluster Patch Manager

Tel: 03007900233 ext 3538Email: sally.young@northstaffs.nhs.uk

21CASE STUDIES

What was the problem?Milton Keynes undertook a serviceredesign initiative through a ‘spend-to-save’ programme and successfullyreduced inequalities in oxygen serviceprovision and also reduced the costs ofhome oxygen prescribing. However, theywere aware that further improvementscould still be made, especially in respectof ambulatory oxygen assessments, andwere keen to both sustain and enhanceservice quality and efficiency byparticipation in the NHS Improvement-Lung national COPD project.

What was the aim?The project team identified threeprinciple objectives:

• Enhancement of existing care pathwayby the production of a HOS-AR (bestpractice) adoption ladder

• Improve ambulatory oxygen provisionand care by carrying out an evaluationpre and post the setting-up of anambulatory oxygen assessment clinic

• Assess the impact of patient literatureon patient experience through thedevelopment and use of a qualitypatient questionnaire pre and post theuse of a patient information leaflet.

What has been achieved?The service is on target towards ensuringthat all existing home oxygen patientshave been assessed before the transitionto a new supply contract. Therapyalterations continue to be undertakenafter clinical review and the service hasbeen able to sustain monthly costsavings in the order of £1,000 - £2,000per month. However, the cost savingtrajectory is on the decline asimprovements in ambulatory oxygenassessment are uncovering the clinicalneed for higher flow rates among manypatients and so the cost per patient isrising.

Milton Keynes PCT Community Services and Milton KeynesHospital NHS Foundation Trust

Sustaining the efficiency and effectiveness of the MiltonKeynes Home Oxygen Service – Assessment and Review

An ambulatory oxygen clinic has nowbeen established and a patientsatisfaction audit around the use ofliquid oxygen has been undertaken. Inaddition, the home oxygen servicepatient information leaflet has beendeployed. An evaluation of the leaflet isongoing as the evaluation questionnairewas used to obtain baseline findings pre-leaflet deployment but as this exercisehas coincided with another Trust patientexperience gathering exercise the post-deployment evaluation is currentlyoutstanding.

What are the key learning points?• Clearing the backlog of un-assessed

patients has enabled the service toreach a steady state in terms ofmatching demand and capacity

• Process mapping exercises uncovered agap in service provision in respect ofguideline required home visits and thereview of house bound patients. Theservice is confident it can address thisgap before the transition to a newsupply contract

• Sustainable improvements to thisservice were achieved by buildingprogressively on service changes andby ensuring ongoing, coordinateduse and monitoring of oxygensupply data.

ContactSue ChannonHome Oxygen Commissioning Manager,Regional HOS Lead Specialist,COPD Co-ordinator

Tel: 01908 650402Email: sue.channon@mkchs.nhs.uk

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22 ACKNOWLEDGEMENTS

NHS Improvement – Lung would like to thank all national improvement project sitesfor their hard work and dedication to improve quality and care for people with COPD,and for their support and contributions to this document.

In addition, the following people have provided a source of expertise and support andtheir help is gratefully acknowledged:

• Sandie BissetHome Oxygen Service, Department of Health

• Hamza JamilHome Oxygen Service, Department of Health

• Dr Mike WardSherwood Forest Hospitals NHS Foundation Trust

• Dr Maxine HardingeOxford Radcliffe Hospitals NHS Trust

• Bob AroraNHS East London and the City

• Glenda EsmondCentral London Community Healthcare

• Sandra MajorNHS Gloucestershire

• Yvonne RichardsNHS Birmingham East and North

• NHS Improvement - Lung

Acknowledgements

References

1. Home Oxygen Service - Assessment and Review - Good Practice Guide,NHS Primary Care Commissioning (2011)

2. An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD)and Asthma in England, Department of Health, July 2011

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NHS Improvement’s strength and expertise lies in practical service improvement. It has over adecade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung andstroke and demonstrates some of the most leading edge improvement work in England whichsupports improved patient experience and outcomes.

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