improving home oxygen services: emerging learning from the national improvement projects

NHSNHS Improvement

Lung

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Improving HomeOxygen Services:Emerging Learning from theNational Improvement Projects

NHS Improvement - Lung

Patients and their carers are the reason the health service existsand therefore they should be at the heart of our services. Serviceredesign and improvement generates opportunities to involveservice users who will provide a different perspective on theservice, so that we can better understand whether our serviceor improvements make any difference to the patient.

Only when we understand patient’s needs – by asking them, notsecond guessing – can we work in a way that meets those needsand ensures they get maximum benefit from our service.

Foreword

Executive summary

Emerging learningPhases of workData review and managementEstablishment of a formal assessment serviceService integration and sustainabilityTesting hypothesisEmerging learningIssues and challenges

Improvement storiesNHS Newham and Newham University Hospital NHS TrustRoyal Free/Waltham Forest PCT/NECLES HIECWest Hertfordshire COPD ServiceNHS SheffieldNHS Hull and the City Health Care PartnershipNHS GloucestershireMilton Keynes PCT Community Services and Milton Keynes HospitalNHS BlackpoolWirral Integrated Oxygen ServiceSherwood Forest Hospitals and NHS Nottinghamshire County Community COPD TeamNHS South StaffordshireNHS Birmingham East and North and Heart of England NHS Foundation Trust

AppendicesData for improvement projectsNewham LTOT pathwayRoyal Free/Waltham Forest PCT/NECLES HIEC Flow chartRoyal Free/Waltham Forest PCT/NECLES HIEC invitation letter to patientsRoyal Free/Waltham Forest PCT/NECLES HIEC patient proformaRoyal Free/Waltham Forest PCT/NECLES HIEC follow-up proformaWirral COPD and Oxygen Service Process MapNHS Birmingham East and North Process Map (CURRENT STATE)NHS Birmingham East and North Process Map (FUTURE STATE)

Acknowledgements

References

Contents

Improving Home Oxygen Services - EmergingLearning from the National Improvement Projects

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Foreword4

Since July 2010, NHS Improvement –Lung has worked with a number ofclinical teams across England as part ofthe Department of Health RespiratoryProgramme. Its aim has been to supportthe development of patient centred,evidenced based and clinically led servicesby identifying and sharing innovativeways to reduce variations in care andimprove the quality and experience ofpatients with chronic obstructivepulmonary disease (COPD).

The national improvement projects havetested approaches at key stages of theclinical pathways which have included:• Improving home oxygen services• Early accurate diagnosis• Transforming acute care• Managing COPD as a long term

condition• Improving end of life care

Following the first six months of theimprovement programme, thispublication signals the mid-way point inthe project cycle and has been written toshare the learning from the testing phaseof the work. Through a series of casestudies and examples, it aims to highlightareas of innovative and emerging goodpractice that can be used locally to deliverimprovements for COPD patients andtheir carers.

In order to address the paucity of currentevidence, particularly around the modelsand principles of implementation, theprogramme will continue to adapt andrefine the learning. However, theselessons will be of value now to any teamworking to improve the care it deliversand commissions for people with COPD.

This publication contains a number ofexamples that demonstrate value formoney, increased productivity andapproaches that can sustain improvementsover the long term.

Foreword

Professor Sue Hill

Dr Robert Winter

The publication also contains informationfor healthcare professionals and thoseworking in commissioning or interfacingwith COPD services. This includes thosewho are:• Involved in the care of patients who

require COPD services• Responsible for commissioning COPD

services• Managing COPD services• Local or regional leads

The project sites were encouraged toemploy a range of service improvementtools and techniques. These includedprocess mapping, demand and capacityand data analysis, the application of Leanprinciples, process redesign and thehuman dimensions of change. NHSImprovement - Lung also supported thetesting of new ideas and pathwaysthrough site visits and project team peersupport.

There are lots of practical examples withinthis report to support clinical teams indelivering quality and productivitybenefits to patients and a wider range ofstakeholders. Over the next six months,NHS Improvement – Lung will continue totest the key principles for change andimplementation. As this learningemerges, it will be shared with COPDservices and the wider NHS

We would like to take this opportunity tothank the project sites for their hardwork, dedication and commitment andlook forward to the full extent of theimprovement work as it comes to fruition.

Professor Sue HillDr Robert WinterJoint National Clinical Directorsfor the Respiratory Programme

5Executive summary

National position andworkstream context

Home oxygen therapy is provided toabout 85,000 people in England at a costof approximately £110 million a year1.

Many Primary Care Trusts (PCTs) do notundertake quality assured clinicalassessment and review of their patientsneed for long term home oxygenincreasing the potential for poor qualitycare and waste.

The Department of Health estimates thataround 30% of people prescribed oxygeneither derive no clinical benefit from it ordo not use their oxygen2. Quality andproductivity in the home oxygen servicecan be improved significantly. Grosssavings of up to 40% - equivalentnationally to £45 million a year, or£300,000 per PCT can potentially beachieved according to recent analysiscarried out by the Department of Healththrough the established of home oxygenservices and oxygen register review andformal clinical assessment4.

The rationale for the work of the projectteams is provided by recommendation 14of the Chronic Obstructive PulmonaryDisease (COPD) Strategy Consultationdocument1, which states:

‘All people with COPD andhypoxaemia should be clinicallyassessed for long-term oxygentherapy and reviewed at regularintervals, and existing home oxygenregisters should be reviewed’.

Executive summary

Thus the overarching aim of thisworkstream is that patients receiveaccurate quality assured oxygen therapythrough optimised assessment and reviewmodels which ensure the right people arein receipt of the right dose of oxygentherapy.

In developing the project outline thescope of the project work was framedsuch that teams would consider:

• The most appropriate (competent) staffto undertake assessment and reviews

• Assessment and review locationsettings

• Guidance on correctly documentingand interpreting diagnostic results

• Guidance on accurately prescribingoxygen

• Providing the patient with writteninformation regarding their oxygentherapy

The project teams made extensive use ofBritish Thoracic Society Home OxygenServices Standards3 and early drafts of theDepartment of Health Good PracticeGuide4. In addition to the above theproject teams have also utilised the workof NICE5 and IMPRESS6 to inform theirthinking.

Summary of emerging learning

Early indications are that the project workspans three phases:

1. Data review and data management2. Establishment of a formalassessment service

3. Service integration andsustainability

This has led to a workstream 1/3 RuleSavings, testing a hypothesis whichstates:

‘One third of the total costefficiencies (savings and avoidance)can be realised through the firstphase of a three phase process withefficiency gains reaching a plateauand prescribing costs capped byimplementation of all three phases.‘

Placing an emphasis on the assessment ofclinical need, and ongoing clinical review,provides an opportunity for healthcareprofessionals to more comprehensivelyinform and educate patients about theircondition. In addition if home oxygentherapy is deemed appropriate then thisinteraction also facilitates patienteducation about equipment use, risk andtheir own responsibilities as regards thesafe use of oxygen at home.

Project teams will use or develop easy-to-read, quality literature to educate patientsabout the appropriate use and potential(fire) safety risks associated with usingoxygen at home.

This educational process is in alignmentwith recommendation 11 of the ChronicObstructive Pulmonary Disease (COPD)Strategy Consultation document1, whichstates:

‘Good-quality information shouldbe provided at diagnosis anddelivered in a format that anyperson can understand’

Executive summary6

Some emerging themes arising from thework to date include:

• Data coordination - Clinical teamaccess to data and collaborationbetween clinical and managerial/administrative staff to review/challengeoxygen patient data

• Consistent messages to patients - Inrationalising local oxygen servicesproject teams have been engaging GPsand other healthcare professionals(HCPs) to develop a consensus inrespect of the appropriate initiation ofhome oxygen therapy for COPDpatients. This is often summarised bythe simple message that ‘oxygen is nota treatment for breathlessness’

• Service integration - This is achievedby developing a pathway andprescribing consensus between thehome oxygen service assessment andreview (HOS-AR) team, GPs,commissioners and non respiratoryspecialists. This leads to the alignmentof the HOS-AR service specificationwithin a wider respiratory care pathwayand improved patient safety riskassessment which is enshrined within awider (PCT) governance framework

Summary of site projects

NHS Newham and NewhamUniversity Hospital NHS TrustEstablished a system of oxygen usagedata coordination and review in order tocontrol prescribing costs and performancemanage suppliers. In addition, theyintroduced systematic review of existingacute hospital oxygen clinic patients anddeveloped plans and protocols for futureintegrated home oxygen service -assessment and review (HOS-AR)spanning primary and secondary care.

Royal Free/Waltham ForestPCT/NECLES HIECIntroduced a review of all COPD shortburst oxygen therapy (SBOT) prescriptionsin the Waltham Forest PCT area offeringpatients full assessment of theirrequirement for long term oxygen andcounselling or advice on alternativeinterventions for the management ofbreathlessness and the supportedwithdrawal of the oxygen supply.

West Hertfordshire COPD ServiceIntroduced a system of identifyinghealthcare professionals inappropriatelyprescribing home oxygen to patients withnormal oxygen levels and undertakingtargeted group education around goodpractice in prescribing.

NHS SheffieldDeveloped a detailed business caseand service specification for integratedHOS-AR in line with best practice. Inaddition, they introduced a system ofoxygen usage data coordination andreview in order to control prescribingcosts.

NHS Hull/City Health Care PartnershipIntroduced a new commissioned HOS-ARservice and so the project work providedan opportunity to monitor improvementsto the delivery of appropriate and cost-effective oxygen therapy to COPDpatients and develop safety protocols andprocedures through a multi-stakeholderproject group.

NHS GloucestershireThis team has focussed on developing adetailed business case and servicespecification which incorporates bestpractice and learning from more establishedteams on issues such as workforce andcompetences, set-up and ongoing costs,data management and governance.

Milton Keynes PCT CommunityServices and Milton Keynes HospitalIntroduced pre and post of clinic set upevaluation for the ambulatory oxygenassessment clinic and also a qualitypatient questionnaire pre and post use ofpatient information leaflet to see ifpatient experience improves.

NHS BlackpoolDeveloped a an accurate oxygen usageregister and systematic use of data tomanage performance and extendedformal assessment and review by theintroduction of HOS-AR based within acommunity setting.

Wirral Integrated Oxygen ServiceDeveloped oxygen care pathways for nonCOPD patients in collaboration with nonrespiratory specialist colleagues. Inaddition, they developed systematic riskescalation procedures and protocols.

Sherwood Forest Hospitals and NHSNottinghamshire County CommunityCOPD TeamEstablished multidisciplinary HOS-ARwithin a community setting andcollaborated with GPs and PCT managersto review oxygen usage.

7Executive summary

NHS South StaffordshireDemonstrated the quick win potential ofsystematic review of oxygen usage datain order to re-categorise costing and altertherapy to achieve prescribing efficiencieswithin one locality. This approach willnow be extended across the PCT.

NHS Birmingham East & North andHeart of England NHS FoundationTrustIntroduced transparent systems forsharing information relating to homeoxygen users across the local healtheconomy and a pathway with guidelinessupporting the process of initiatingoxygen therapy for new patients andwithdrawal/cessation where appropriate.

Quality, Innovation, Productivity andPrevention (QIPP) and expectedoutcomesThe demand for services is increasing andthere are areas where we could increasethe quality, efficiency and value formoney of services as well as improvingoutcomes for people with chronicobstructive pulmonary disease (COPD).Focus needs to be centred on these threefactors to make this a reality. First,improving quality whilst improvingproductivity by enforcing the principles ofthe Quality, Innovation, Productivity andPrevention (QIPP) agenda by usinginnovation and prevention to drive thisforward and interlink these values.Secondly, having local clinicians andmanagers working together in amultidisciplinary approach and acrossboundaries in order to spot theopportunities and manage the change.And thirdly, to act now, for the long term.

The goal is to achieve efficiency savingsof up to £20 billion for reinvestment overthe next four years. This represents a verysignificant challenge to be deliveredthrough the detailed work the NHS has

already undertaken on Quality InnovationProductivity and Prevention (QIPP)programme and the additionalopportunities presented in the Equity andExcellence: Liberating the NHS.

In relation to the QIPP challenge, the NHShas been developing proposals toimprove the quality and productivity of itsservices since the challenge was firstarticulated in May 2009. The proposal isto ensure that the NHS continues tomake quality improvements a realityduring a period in which growth inexpenditure within the NHS will berestricted despite increasing demand.

Many of the measures outlined in thisdocument are designed specifically tosupport the NHS to meet the QIPPchallenge, either by identifying whereresources might be released or byimproving understanding of the keyinterventions that have greatest effect.

The work has demonstrated that theannual total spend across nine projectsites can be reduced by a minimum of£600k. This applies for both new andestablished home oxygen services whoimplement oxygen usage reviews andtherapy optimisation. On a national scale,the work compliments the Department ofHealth estimated gross savings of up to40% for each PCT.

The expected outcomes in these projectsites will be:• Minimum of £600k prescribingsavings - achieved through therapyrationalisation, list cleansing, avoidanceof inappropriate prescribing andwithdrawal of clinically unnecessarytherapy

• Introduction of HOS-AR - establishinga cycle of assessment and review,improvement of an existing service tothe standard articulated within theGood Practice Guide, introduction of anew service to a locality in whichHOS-AR currently absent

• Patient education packages - safetyand risk considerations explained topatients and carers, captured withineasy-to-read literature and mutualresponsibilities (both patients andhealthcare professionals) understoodand documented within localagreement documents

• Pathways for the treatment of nonCOPD patients on oxygen -engagement of generalists and nonrespiratory specialists to establishoptimal care pathways for non COPDpatients in need of home oxygentherapy

• Principles of a good service model -development of new ways of workingby examining use of different types ofworkforce along the pathway indifferent settings

• Effective use of data – collaborationbetween clinical and managerialprofessionals to integrate, review andinterpret financial, administrative andclinical data in order to optimise care,rationalise prescribing, overseegovernance and performance managethe oxygen suppliers

Potential for future workThe initial quick win cost efficienciesattributable to the first phase of HOS-ARimprovement work (data review and datamanagement) are becoming self evident.However, more work is needed toconclusively establish that the 1/3 RuleSavings hypothesis has been verified,specifically in relation to the costefficiencies realisable from theestablishment of HOS-AR and by itsintegration within the broader servicecommissioning framework.

Executive summary8

In addition, further narrative is neededaround the demonstrable benefits inquality of care patients may derive fromoptimised home oxygen therapy. Theeffective use of administrative, financialand clinical data relating to oxygen usagefurther promotes the use of diseaseregisters and flags up opportunities formore effective patient record linkage.

An identified gap in the current work isestablishing whether or not improvedcare resultant from formal oxygenassessment and review results in feweradmissions to hospital. Although initialworkstream metrics were devised toexplore this, linking information aboutindividual patients in receipt of homeoxygen with information from hospitalpatient administration systems continuesto present a challenge.

The reasons why a patient with COPD isadmitted to hospital are varied and inaddition COPD patients on long termoxygen tend to have more severe diseaseand thus and increased risk ofhospitalisation. As such it may not bepossible to establish whether optimisedhome oxygen therapy resultant fromsystematic clinical assessment and reviewis an effective admission avoidancestrategy. However, this topic is certainlyworthy of more consideration in future.

Many HOS-AR teams have begun toestablish effective dialogue with non-respiratory specialists in respect of themanagement of non COPD patients inreceipt of home oxygen therapy. As thoserelationships mature, the HOS-AR teamshave been able to explore with their nonrespiratory colleagues the reasons forinitiation of home oxygen therapy in

Ore OkosiNational Improvement Lead,NHS Improvement – Lung

Phil DuncanDirector, NHS Improvement -Lung

non COPD patients, often challengingcolleagues when they appear not to beadhering to their own specialty areaguidelines. Thus there may be scope forfuture projects to more thoroughlyinvestigate the potential cost savingsachievable from rationalisation of homeoxygen therapy in non-COPD patients.

Future work will also thoroughly exploreand test ‘how to’ implement a goldstandard pathway of HOS-AR as definedby the Good Practice Guide in terms ofnew services, but also in relation todriving up quality for existing services.

Finally, further consideration will begiven to the following areas:• Stakeholder engagement• Developing local incentives to

commission HOS-AR• Varying the workforce employed at

different parts of the pathway• Describing optimal models of care in

urban/rural geographies• Developing a consensus around

provision/withdrawal of home oxygento persistent smokers who have aclinical need for oxygen

• Establishing ownership of HOS-ARgovernance and performancemanagement within the emergingcommissioning structures

Phil DuncanDirector, NHS Improvement - Lung

Ore OkosiNational Improvement Lead,NHS Improvement - Lung

9

Phases of workIn attempting to broadly categorise thetype of work being undertaken by the12 ‘improving home oxygen services’national project teams it has been usefulto think in terms of three phases:

1.Data review and data management• Data access• List cleansing• Invoice reconciliation with

concordance reports• Case prioritisation

2.Establishment of a formalassessment service

• Address assessment backlog• Establish assessment and review cycle• therapy modifications• Withdrawals• Education

3.Service integration andsustainability

• Robust referrals• Multidisciplinary team process

mapping resulting in agreed pathway• Demand matches capacity• Service specification aligned with

governance and commissioning• Effective communication with

healthcare professionals, patients andcarers

In reality, many project teams haveundertaken activities in parallel and somay span these phases which are nowoutlined in more detail.

Emerging learning

Emerging learning

Data review and datamanagementThe overwhelming message from allnational chronic obstructive pulmonarydisease (COPD) project sites in allworkstreams (not just oxygen) whenstarting improvement work was thatthere was difficulty in getting hold ofdata and information. As the COPDprojects commenced, sites reportedlimited access to data on their day to dayactivity, and very poor access to overallinformation covering the respiratorypathway.

Fortunately, there are many resourcesavailable that can support COPD projectsites understand and compare their localrespiratory services with others, and manyof these are freely and easily accessible.

Local data on oxygen can be combinedwith nationally available data onsecondary care and primary care in orderto build up a picture of local services.

Why is data important?Data and measures are important todemonstrate that change has occurred orneeds to occur. NHS Improvement - Lungfocuses on the delivery of qualitymeasured improvements which arealigned to national priorities andstrategies. In line with the nationalQuality Innovation Productivity andPrevention (QIPP) initiative, it is essentialthat all system changes are measured andrecorded. Whether the change was asuccess or did not demonstrate theanticipated outcomes, you still need todemonstrate its effect and learn from it.

Don’t forget ‘better’ is not measureable.‘More’, ‘faster’, ‘safer’ or ‘cheaper’ can allbe measured but only if you know howmany, how fast, how dangerous or howexpensive things were to begin with. Weneed to establish factual data andmeasures to demonstrate what has beenachieved.

How did oxygen sites workwith data?Project teams grappling with this phasespent much of their time ensuring allappropriate staff had access to the fullrange of information available and thendeveloping effective ways of utilising thisinformation in order to understand andmodify local processes and ensurefinancial control.

This included information provided byoxygen suppliers and or PCT/regionalhome oxygen service (HOS) leads in theform of quarterly concordance reports,monthly invoices, copies of completedhome oxygen order forms (HOOFs) andbespoke performance reports.

In order to provide oversight in respect ofboth clinical appropriateness and financialcontrol it is necessary for clinical membersof the home oxygen service assessmentand review (HOS-AR) team to be ablereview individual patient details containedwithin the completed HOOFs received bythe oxygen supplier.

Emerging learning10

Gaining access to home oxygenorder form dataNHS Connecting for Health providesdesignated users (authorised by individualPCTs) on-line access to individual patientHOOFs held on the National HealthApplications and Infrastructure Services(NHAIS) system database via Open Exetera web-enabled viewer7.

New users have to complete a Data UsersCertification Form (available fromwww.connectingforhealth.nhs.uk/nhais/products_and_services/vaprodopenexe)and get the form authorised by the PCT(or shared services agency) data controllerwho will then process the form on-line orforward it for authentication.

Getting access to oxygen cost dataIn addition to Open Exeter, the majorityof PCT home oxygen service leads andmedicines management teams haveaccess to on-line home oxygen therapyreports from the NHS Business ServicesAuthority Prescription Pricing Division(NHSBSA PPD).

These reports provide information on thepayments made to suppliers for provisionof oxygen and differentiate paymentclaims made for the supplier in respect ofpatients residing within the contractedPCT area and claims for out-of-areapatients8.

Access to these reports is obtained bycompleting a PCT prescribing reports userregistration form and sending it a signedletter from the PCT senior officer toInformation Services Department of NHSPrescription Services in Newcastle.www.nhsbsa.nhs.uk/PrescriptionServices/3091.aspx

Implementing ongoing monitoringfor oxygenThe NHS Home Oxygen Service Manual9

states that in order to effectively monitoractivity within the home oxygen service,PCTs need to have in place a systemcapable of capturing a range ofinformation about each patient on receiptof oxygen, specifically:

• Who oxygen was ordered for• Date of birth• NHS number• Patient’s GP practice• Who placed the order• When was the order placed• What was ordered• Urgent, next day or standard supply• Primary or secondary supply• Flow rate• Hours per day• Status (new or existing patient)• Estimate of cost

The Wirral and Milton Keynes projectteams have each had to independentlydevelop local ‘databases’ which enablethe HOS-AR team to monitor serviceactivity but with limited ability to linkinformation from other clinical recordingsources to specific oxygen data sources.

A key component of their work has beento establish a system of HOOFmanagement which ensures that there iseither a centralised or a coordinatedapproach to HOOF completion and thatcopies of all HOOFs are available for theclinical specialists to review.

Data reconciliationOpen Exeter enables the reconciliation ofmonthly files of invoices from the HomeOxygen suppliers against the patientsrecorded in their NHAIS system7.

The system uses information containedwithin the completed HOOF to calculatethe appropriate cost band from thespecified delivery mechanism, the numberof litres/hour and the duration and thiscan be checked against the cost bandinvoiced by the supplier7.

Open Exeter has a suite of reports whichsupport data reconciliation:

• Deducted patients by• Patients not found on the NHAIS• Inconsistent cost bands• Identical provisions for patient at same

address• Cost band totals by practice• Holiday orders• Emergency• Light weight ambulatory orders• HOOF entered but not matched to a

supplier order record• No HOOF entered for supplier order

record

The improvement stories from the Hull,Sheffield, Sherwood Forest and Blackpoolproject teams are all examples of howclinical team members developed anunderstanding of the prescribing costcategories.

They also illustrate clinical and non-clinical colleague collaboration in order toundertake the almost forensic analysis ofmodalities of oxygen supply associatedwith individual patients.

11Emerging learning

Armed with this information the clinicianswere able to work alongside other nonclinical colleagues in order to:

• Identify patients in receipt of oxygenwho are not known to the specialistteam

• Reconcile invoice information withinformation held on local systems

• Review patients on multiple modalities• Scrutinise the various charge bands• Ensure deceased patients were

removed from lists• Stop charges arising from the supply

of oxygen to patients living outsidethe PCT catchment area

• Set up patient recall and review systems• Identify non-usage, under-usage,

over-usage• Identify sources of inappropriate

prescribing within both primary andsecondary care

Data management and QIPPThe NHS Newham project team cite theiruse of the Open Exeter reporting functionin validating monthly supplier costs andrealised productivity savings of £12,057from April to November 2010 purely fromaccurate data management.

This included removal of deceasedpatients, removal of duplicated patientsand removal of out of area patients.

The improvement stories containedwithin this publication illustrate theeffectiveness of clinicians working incollaboration with managerial andadministrative colleagues (especially thedesignated PCT home oxygen servicelead) in respect of the financialreconciliation process.

The South Staffordshire project teamhave illustrated the quick win productivitygains achievable through primarily thisfirst phase of work.

This team joined the programme fivemonths into the first phase of the projectcycle and over the course of two monthsundertook an inspection of individualpatient oxygen usage data (and otherrecorded clinical information) for 91Cannock Chase locality patients knownto the community COPD team.

The data inspection was coupled withtelephone patient contact and face-to-face review in a limited number ofinstances.

As a result, 10% of patients were movedto a less expensive tariff with forecastindividual savings in excess £1,000 peryear, the total annual forecast costsavings attributable to the review of the91 patients in Cannock Chase localityamounted to £57,573.

Cannock Chase is only one locality withinSouth Staffordshire and so the PCT isexploring whether even greaterproductivity gains can be achieved if thisapproach was spread to other localities.

Establishment of aformal assessmentserviceThis work centres on trying to ensure thatall patients currently in receipt of oxygenare receiving care management inalignment with published standards onassessment and frequency of review.

Following the data exercises undertakenin phase one it is possible to identify inreceipt of oxygen but unknown to thespecialist team.

Using this information together withinformation about the existing specialistteam caseload and the volume of newreferrals for a formal assessment. Someanalysis of demand and capacity can beundertaken in order to inform clinicscheduling/home visits necessary toaddress the backlog of previouslyunassessed patients.

These patients are contacted by theproject team in order to arrange ifnecessary a review and therapy altered orwithdrawn if deemed inappropriate.

This phase involves liaison with thepatient’s GP surgery as many existingoxygen patients received therapy as aresult of a GP completing the originalhome oxygen order form (HOOF).

Emerging learning12

The Department of Health Good PracticeGuide10 sets out very clearly andcomprehensively the gold standardpathway for oxygen assessment andreview. A condensed summary of thepathway is set out below:

1. Referral to formal assessment servicefollowing determination ofhypoxaemia using pulse oximetry(SaO2 level is below 92%)

2. Full assessment for long term oxygentherapy (LTOT) including spirometryand measurement of arterial bloodgases (with LTOT prescribed for 15hours per day in clinically stablepatients where the arterial bloodoxygen measurement is at or below7.3kPa, or under 8kPa if oedemapresent)

3. Determination of safety, flow rate andduration of oxygen for patients inwhom oxygen is indicated

4. Further assessment (if appropriate) todetermine the patient’s capacity forexercise, and whether they shouldbe prescribed additional ambulatoryoxygen

5. Clinician orders appropriate oxygensupply device from oxygen suppliersfollowing discussion with patient

6. Follow-up home visit should beundertaken at four weeks by ahealthcare professional to assess thepatient’s clinical status, compliancewith the oxygen therapy regime andto determine whether further action isnecessary

7. Regular clinical status reviews shouldbe undertakena. Every six weeks after admission

or exacerbationb. Every six months oximetry should

be carried outc. Every twelve months patients

should have their arterial bloodgases measured.

Models of service: The clinical teamswithin this initial cohort of oxygenprojects are varied in terms of theirlocations and workforce composition.

The Hull, Wirral and West Hertfordshireproject teams are all led by respiratorynurse specialists in contrast to theSherwood Forest and Birmingham Eastand North teams which are led by aclinical scientist and a consultantrespiratory physician respectively.

However, all the teams do operate withina multidisciplinary framework withdifferent workforce competencesavailable at various points in the carepathway.

The Sherwood Forest team operate amodel which involves specialistassessment available from communityclinic locations.

The Wirral project team operate fromspecialist clinics and more recently havebegun undertaking clinical reviews fromwithin GP surgeries in order to evaluatethis approach in terms of reducing thenumber of patients who fail to attendtheir scheduled consultation.

The Newham project team are developinga mixed model which utilises bothsecondary care specialists and communitymatrons at different point within the carepathway and facilitated by the use ofpoint-of care arterial blood gas testingequipment.

Part of the Oxygen Care Pathway from the Home Oxygen Service –Assessment and Review: Good Practice Guide. Department of Health,Final version 24th November 2010

Full assessment• Hypoxic• Borderline• Complex

HCP ledoxygen

assessment

LTOTassessment

Consider assessmentfor additional

ambulatory oxygen

Discussequipment

options withpatient

Educationalsession withpatient/carer

Completed HOOFsent to HOS

provider

Discuss follow-uparrangementsand book firstappointment

Inform/GPconsultant and

referring HCP ofmanagement plan

G

No hypoxaemiatransfer back

to referrer

Checkoximetry if not

yet done

B

Borderline casesSaO 92-93%

C

2

F

• Confirm hypoxaemia• Spirometry• ABG• CO retention -

consider need forNIV

• Arrange trainingfor carer if not inattendance

• Provide writtenpatient information

• Patient to confirmunderstandingof training

2

• Access exercise capacity• Access adequate correction

of exercise de-saturation• Determine flow rate• Discuss with patient if immediate

ambulatory supply or derfer until later• Assessment of social situation and

referral to social services if required• Assessment of compliance

13

The choice of model being tested anddeveloped often reflects the geographicalconsiderations of the area with AcuteHospital clinics being the locations ofchoice within the more compact andhighly urbanised Birmingham setting incontrast to community clinic settingsbeing considered by more dispersedpopulations such as NHS Gloucester.

At a recent peer support meeting the12 national project teams reached aconsensus as regards models of servicedelivery which is encapsulated within thephrase ‘Varied models but standardisedprocesses’. This means strict adherence tobest practice as articulated within theDepartment of Health Good PracticeGuide but flexibility in respect of locationand staffing.

Service integration andsustainabilityA number of the project teams areattempting to leverage the oxygen costsavings achieved through rationalisationof processes to raise the profile of oxygenservices among local commissioners.

In areas such Sheffield and Gloucester thetype and scope of oxygen service was notpreviously well defined within localrespiratory service specifications. Theproject team were subsequently given anopportunity for the local health economystakeholders to collectively address this byutilising the emerging learning from theproject work and the Department ofHealth Good Practice Guide to informnew business cases or revise servicespecifications.

The quick win cost savings achievable byundertaking phase one work is obviouslyattractive to commissioners but the moreestablished teams such as the West

Emerging learning

Hertfordshire COPD service are alsoattempting to ensure sustainable financialmanagement by educating GPs about thebenefits of formal assessment.

Teams such as the Wirral COPD andHome Oxygen Service are engaging non-respiratory specialists in discussionsaround the care pathway for patientsreceiving oxygen for non COPD relatedconditions and jointly developing carepathways.

Having achieved significant therapychanges and therapy withdrawals amongexisting oxygen patients, through thework of phases one and two, teams suchas Hull and Wirral have begun to tacklethe challenge of addressing therapymodification in patients who resisted allinitial invitations for clinical review andensure patient safety risks uncovered bythe earlier work is documented andintegrated within the widerorganisational risk managementframework.

The NHS Birmingham East and Northteam are ensuring that safety riskrecording and follow-up procedures arefirmly established within the existing PCTgovernance framework in order to ensuretransition to the newly emerging GPcommissioning consortia.

However, the risks are not just thoseassociated with patient safety, there arealso financial risks posed by poor datamanagement and coordination.

Project teams such as Sherwood Forestare devolving oxygen prescribingbudgetary management to GP localities inorder to preserve the discipline offinancial management during the localNHS transition and further engage GPs indiscussions around the care pathway.

In attempting to establish a moreintegrated model of care, teams have hadto overcome perverse incentives within‘payment by results’ which mightpotentially encourage duplication,redundant processes or unnecessary stepsin pathway.

NHS Birmingham East and North aredeveloping a local payment tariff whichwill encourage multidisciplinary workingby both being fair compensation to theservice provider and financiallysustainable by the commissioner.

In developing a new service or model ofcare it is important to ensure clarity at theoutset in relation to costs. Involvementwith this programme of work enabledNHS Gloucestershire to significantlyre-evaluate their business case.

The NHS Improvement - Lung senioranalyst was able to guide them on howto use their own quarterly concordancereport data to understand potentialpatterns of service demand.

In addition, the Gloucester project leadwas able to review the servicespecifications of more established teamsand through interaction with colleaguesduring regular peer support meetingsgain greater insight in to workforceconsiderations.

This dialogue also enabled previouslyunconsidered ‘hidden costs’ (such asequipment upkeep) to be identified.

Emerging learning14

Testing hypothesisCost savings have been achieved by anumber of project teams. Teams such asSheffield, South Staffordshire (CannockChase locality) and Newham have realisedsignificant quick win cost savingsattributable to the first phase of workwith forecast annual savings of £120K,£57.5K and £12K respectively.

Whilst project teams with moreestablished HOS-AR teams such as Hull,Wirral and West Hertfordshire eithercontinue to achieve a reduction inspending (as compared with the periodprior to the service being established) orexperience very modest fluctuations inmonth-on-month costs.

The following hypothesis is now beingtested by the workstream:

1/3 Rule Savings: one third of total costefficiencies (savings and avoidance)realised through first stage of three stageprocess with efficiency gains reaching aplateau and prescribing costs capped byimplementation of all three stages.

Data collected during the final phase ofthe project cycle will establish whatproportion of overall cost efficiencies isachievable during the three phases.

The results from Sheffield, Staffordshireand Newham lend support to the 1/3Rule Savings workstream testinghypothesis. However, quantification ofthe productivity gains achievable fromeach phase of work will be more evidentwhen a sufficient body of data is availablefrom the total project cohort uponcompletion of the 12 month project cycle.

Emerging themesData coordination – In order to ensuretight financial control and appropriateoxygen prescribing the home oxygenservice - assessment and review (HOS-AR)team need to liaise effectively withmanagerial and administrative staff tojointly review information containedwithin oxygen supplier concordancereports and monthly invoices.

Collaboration between designated PCThome oxygen service (HOS) leads andHOS-AR teams has enabled supplierreports to be used effectively, picking upanomalies within prescribed oxygen andchallenging unnecessary multiplemodalities.

Some HOS-AR teams have establishedagreements with local primary andsecondary care stakeholders that they actas ‘gatekeeper’ for the completion andamendment of the home oxygen orderform (HOOF).

This has reduced inappropriate oxygenprescribing by healthcare professionalswho are not able to accurately determinea patient’s need for oxygen nor thetherapy which most appropriately meetsthat need.

In addition to granting HOS-AR teamsaccess to the national invoiceinterrogation system ‘Open Exeter’, manyproject teams are attempting to create adatabase which is jointly accessible (andjointed populated) by clinical andadministrative staff, thus enabling links tobe made between a patient’s clinicalinformation and other administrativeinformation.

Consistent messages to patients – Inrationalising local oxygen services projectteams have been engaging non-respiratory specialists, GPs and otherhealthcare professionals in order todevelop a local consensus in respect ofoxygen therapy initiation.

Much of this engagement has taken theform of education in respect of thebenefits of formal assessment, the healthand safety considerations and wasteincurred by inappropriate prescribing.

Project teams have identified thatinappropriate prescribing occurs in bothprimary and secondary care and so teamssuch as the West Herts COPD serviceundertook targeted educational visits aspart of their cost avoidance strategy.

During the periodic peer supportmeetings facilitated by NHS Improvement- Lung the 12 project teams jointlyidentified two simple messages that allproject teams need to reinforce withintheir local health economy, these were:

i) Oxygen is not a treatment forbreathlessness

ii) Think oxygen/think of us - yourhome oxygen service!

Service integration - As with manyother areas of healthcare the projectteams are confirming that sustainablemodels of care require an integratedapproach across primary and secondarycare as well as across medical specialties.

15Emerging learning

Having undertaken a comprehensiveprocess mapping of the existing patientjourney, project teams such as Newhamare exploring new ways of working fortheir community and acute based staff onthe basis of standardised assessment andreview processes undertaken by differentstaff groups, matching competenciesidentified within the Department ofHealth Good Practice Guide10 to specificparts of the care pathway in differentsettings.

A number of project teams (BirminghamEast & North, Blackpool, Sheffield) arelooking at different ways of using hospitaltariff costs in order to supportmultidisciplinary working and sustainservice enhancements.

For many teams the project work hasprovided an opportunity to strengthenlinks with oxygen suppliers, local fireservices, PCT executive committees, socialservices and emerging GP consortiaespecially with regards to patient safetygovernance issues.

Both the Wirral team and the team fromHull have developed local therapywithdrawal protocols and risk escalationprocedures in collaboration with otherlocal stakeholders and sought theapproval of local governance committees.

Teams such as NHS Gloucester, aspiring toestablish a new HOS-AR service havebeen able to better inform their businesscases and service specifications with realworld intelligence from the establishedHOS-AR teams within the project cohort,strengthening these documents in respectof the data support required andbuilding-in ongoing ‘hidden costs’ inrespect of equipment.

Project teams have utilised clinicalguidance from a number of sources andthey have engaged local governancestakeholders in order to frame aconsensus around withdrawal protocols,risk assessment and escalationprocedures.

Despite this many project team membersexpressed a sense of ‘exposure’ especiallyin the face of challenges from either apatient, relative, carer or even anotherhealthcare professional.

A particular area of concern is thewithdrawal of therapy in hypoxic patientswho smoke. The project teams welcomethe references made to this topic in themost recent draft of the Department ofHealth Good Practice Guide10 but feel thetopic is worthy of further discussionnationally.

During recent peer support meetings the12 project teams jointly agreed some top-tips in respect of facilitating oxygentherapy withdrawal in patients deemed afire safety risk:

• Offer patient intensive step-up smokingcessation support

• Utilise a multidisciplinary approachincluding social services

• Consider possible child protectionissues where patient is also a carer(e.g. smoking grandparent whoregularly looks after grandchildren)

• Undertake both a risk assessment anda (mental) capacity assessment ifappropriate

• Instigate a case conference aroundunmanageable risks

• Document all the facts• Consider the use/development of a

red card warning system prior towithdrawal

Issues and challengesData access/use/coordinationA number of project teams had toovercome barriers in order to accessdirectly patient data held by the supplier.Suppliers often expressed greatreluctance to share information withpersonnel other than the designated PCTHOS lead and many protracteddiscussions and emails had to be engagedinto in order to unearth information.

The lack of a national database whichcontains both clinical and administrativeinformation and which could be jointlyaccessed and populated by both clinicaland administrative staff is a bug bear formany teams resulting in some teamsattempting to devise their own systemslocally.

This lack of record-linkage functionalityimpairs a joined up study of a patient’swhole system care.

Gaining agreement around the HOS-ARteam acting as HOOF gatekeeper ORensuring coordination of HOOFcompletion across a local health economyis something that requires specialist teamsto invest time in engaging with local GPsand non-respiratory specialists on an on-going basis to ensure harmonisedprescribing.

Access to specialist information support(Trust or PCT based) appears very variablewith many teams experiencing challengesaround data collection and analysis.

GovernanceMany of the project teams expressed astrong desire for central guidance inrespect of healthcare professional liabilityand the legality of therapy withdrawal.

Improvement stories16

The NHS Newham and Astra Zeneca jointproject on improving chronic obstructivepulmonary disease (COPD) services withinthe local healthcare community (LHC)comprised Primary Care, Secondary Care,Community Health Care (provider arm ofthe PCT), Public Health andCommissioning.

The background to their serviceOxygen is prescribed by primary andsecondary care clinicians. Prescribing ofoxygen by secondary care (the chestclinic) is based on structured assessmentand a database is kept of the patientsthat are under their care.

Primary care prescribing may also bebased on an effective assessment butthere is no evidence to verify this.

There were no formal managementarrangements of the oxygen service inNHS Newham. Ongoing review of oxygenpatients were not being preformed forany patients. There was no standarddatabase kept of patients on oxygen andthe information was not being sharedbetween the patients being managed inprimary care and by the chest clinic.

Oxygen invoices were managed by themedicine management team and therewas no reconciliation between thedatabase and monthly invoices providedby the service provider. Also, there waslack of evidence whether any actionswere taken to act on the reportsproduced or provided by the oxygensupplier e.g. compliance reports, out ofarea reports etc.

Improving the prescribing and ongoingmanagement of patients on home oxygen therapyNHS Newham and Newham University Hospital NHS Trust

The pathway of careNewham had localised the COPDpathway using the ‘Map of Medicine’ butit did not incorporate any detailsregarding the prescribing or the ongoingmanagement. There were gaps in theservice being provided and these wouldbe identified during the development ofthe oxygen pathway.

The first page of the draft home oxygentherapy pathway is shown below.

The project aims and objectivesThe aim of the work was to improve theprescribing and ongoing management ofpatient on home oxygen therapy.

Home oxygen therapy - requirement suspectedNewham Development Zone > Thoracic medicine > Home oxygen therapy (HOT)

17Improvement stories

Specific objectives:• To produce/manage the oxygen data

base and check on a monthly basis foraccuracy by April 2010

• To develop and implement anassessment and review process forpatients on oxygen therapy byDecember 2010

• To reassess and review 25% ofpatients on oxygen and record anychanges to their oxygen therapy byApril 2011

• To reduce wastage in oxygenprescribing and secure a 20%reduction in cost September 2010compared to the 2009/10 cost

• To update and expand the localisedpathway (to include development of anew Home Oxygen Service pathway)and promote its implementationacross the local healthcare communityby April 2011

• To incorporate the COPD strategyobjectives into the redesign asappropriate

The process of improvement theyundertook and overall approach toaddress the issues.

A steering group was setup includingprimary and secondary care clinical leadsto address the issues and take forwardthe outcomes of the stakeholder eventwhich incorporated patientrepresentatives.

Issues and challenges they facedwith potential solutionsThe main challenge to potential solutionshas been negotiating change in thecurrent way of working with thesecondary care managers. The clinicianshave been willing to redesign the service.

The other challenge has been the currentreorganisation of the PCTs. As aconsequence there is a risk that noproject support will be available fromApril 2011. This has been reported to thechief executive.

Implementation of the reviews haspresented capacity issues but these havebeen resolved by temporally increasingthe capacity to clear the back log.

The testing they did and key learningto date, including the overall benefitsThe plan to review of patients on oxygenhas commenced and it is anticipated thatat least half of the patients (approx 80)managed by the chest clinic will bereviewed by the end of March 2011. Thedata will be collected and analysed on amonthly basis and the work will beamended accordingly.

Similar process will be followed formonitoring of blood gases for patientswho attend as day cases. Outcomes ofthis initial phase will be used to plan thework for patients not being managed bythe chest clinic. It is anticipated that alloxygen prescribing will be under thespecialist respiratory service but this isdependent upon pathway changes beingagreed.

Commissioning considerationsExtensive discussions have occurred inorder to try to achieve change. If thesechanges are not achieved or result inprotracted meetings and discussions thennotice to terminate the contract will begiven. This has already been consideredand the final decision will rest with theGP Commissioning Board.

Workforce considerationsThe review of the chest clinic oxygenpatients is being supported by twosuitably trained and clinically supervisedsecond year medical students whichposes risk to the ongoing sustainability ofthe work. Agreement has been reachedto add capacity in the form ofCommunity Matrons to review primarycare oxygen patients. Once all thepatients have been reviewed it should bepossible to maintain the ongoing reviewswithin the current workforce.

Potential/actual QIPP and costsavings /avoidance – defined asquality, innovation, productivityand preventionThe oxygen database has been producedand is updated on a monthly basis. Inaddition, the information is shared withthe acute so that the information isconsistent.

Productivity savings of £12,057 havebeen secured from April to November2010 purely from accurate datamanagement. This included removal ofdeceased patients, removal of duplicatedpatients and removal of out of areapatients.

An assessment and reviews form hasbeen developed to use across the localhealthcare community. In addition, localoxygen protocols have been agreed andincorporated into the review form. Thisshould result in improved quality ofmanagement of patients on oxygen andis projected to provide productivitysavings of approximately of £80k.


Review of the patients being managed bythe chest clinic has commenced andoutcome data is being collected. It isanticipated that the target of reviewing25% of patients by April 2011 will beachieved.

The purchase of three Point of CareArterial Blood Gas (ABG) meters willfacilitate with the oxygen reviews and willeliminate day case attendances for ABGmonitoring. This innovative approachshould result in net productivity savings ofapproximately £250k for a full year whilstimproving the quality of the service forpatients.

Discussions are also being held tomanage the oxygen on a sector widebasis to further secure productivity gains.

Data collection, a summary of what itshowed and overall evidenceincluding any chartsBaseline data has been collected and asthe oxygen review data becomesavailable it will be analysed to establishquality and productivity improvements.Initial data indicates that the cost ofhome oxygen service is not increasing.

Emerging workstream principles,including ‘top tips’Top tips for the management of theoxygen service are:

• Engage with IT to produce a databasewhich allows a quick method ofupdating with the oxygen providerinvoice

• Share a common database with otherservices (chest clinic, communitymatrons) to allow immediate databasemanagement

• Incorporate compliance reports into thedatabase and organise reviews asappropriate

• Production and use of standard reports:- Confirm out of PCT catchment area

patients are registered within the PCT- Open Exeter reports – deducted

patients, duplicated patients,identical provision at the sameaddress

• Consider purchase and use of ABGPoint of Care meters to facilitateoxygen prescribing, reviews andoptimising therapy includingdiscontinuation as appropriate

Any generic learning (LTC) that weextrapolate from the work e.g. how thiscould be applied to other areas:

• Ensure engagement of the clinical leadsat the outset and get them to lead theprocess

• Agree metrics and ensure ease ofavailability at the outset

• Ensure robust data collection plan andimplement as soon as possible -sufficient time needs to be allowed forthe data team to incorporate this intotheir workload

• Engage commissioning to ensure thatyou are aware of the current contractand who is monitoring it

Project lead contact details forfurther informationBob AroraMap of Medicine Programme ManagerTelephone: 0207 059 6524,Email: [email protected]


Background to the serviceThere is considerable data available andpublished, that the use of short burstoxygen therapy (SBOT) or intermittentoxygen at home for the relief ofbreathlessness, in patients withoutchronic hypoxemia is not effective andcostly to the NHS.

This pilot was undertaken to address theissue of the prescription of SBOT forpatients with chronic obstructivepulmonary disease (COPD). Althoughcurrent guidance relating to long termoxygen prescription does not supportprovision of SBOT, there is considerableevidence from the home oxygen servicedata and surveys that that SBOT is stillprovided in this way and wastesresources.

Furthermore, there are other moreeffective ways that can be utilised to treatbreathlessness and thus use of SBOTleads to sup-optimal care. It is estimatedthat up to 25% of the home oxygenprovided in England and Wales is in theform of SBOT. However, there is no dataavailable on withdrawal of SBOT inpatients without hypoxaemia and also noinformation regarding how successfulwithdrawal is, in this patient group, bothin the short term and longer term e.g. sixmonths. Patients may become dependenton SBOT and thus considerable educationwill be required, both for the patient andthe healthcare professional, about otherinterventions for breathlessness. Suchdata on withdrawal will also informhealth economic evaluations and aidfuture guidance on home oxygen services.

The original intention was that the projectwould take place in two sites - one site inNorth London: Royal Free Hospital NHSTrust (Christine Mikelsons (CM) &Professor Wisia Wedzicha (JAW)) and NHSCamden, and the other site in North EastLondon: Whipps Cross University HospitalNHS Trust (Professor Mike Roberts - HIEC

facilitator for the theme) and NHSWaltham Forest (Anne Crawford (AC)).Other members of the team includedRobyn Hudson (RH), Charles Bruce (CB),Gavin Donaldson (GD).

The gold standard pathway vs. localpathwayThe gold standard pathway is that longterm oxygen therapy is assessed byarterial blood gases, resulting in aprescription of oxygen for 15 hours over a24 hour period. However, for short burstoxygen therapy (intermittent oxygen) nosuch assessment has been formalised andshort burst oxygen is usually prescribedfor breathless patients without oximetry.Appendix 1 illustrates the pathway forthe NHS Waltham Forest oxygenassessment service.

The project aims and objectivesThe aim of this project was to review allCOPD SBOT prescriptions, of more thanthree months, in the Camden andWaltham Forest PCT areas, in order toreduce SBOT prescription by 75% overthe course of one year (July 2010 to July2011). This figure was aimed high as weare aware that most SBOT patients (oncepalliative prescriptions have beenexcluded) have no clincial indication forSBOT.

Patients in the palliative care categorywere excluded for the purpose of thisanalysis. The intention was to obtain datafrom the PCTs and contractor, regardingcurrent prescription of SBOT in each ofthe study areas.

Patients with a prescription of SBOT wereoffered an appointment with a respiratoryspecialist to discuss their use of oxygenand where indicated, full assessment oftheir requirement for long term oxygenwas performed. In cases where no clinicalneed was identified, patients werecounselled and advised that they did notneed to continue with oxygen at home.

Discussion then took place with thepatient about alternative interventions forthe management of breathlessness.Patients were offered supportedwithdrawal of the oxygen supply andfollowed up with an appointment at aninterval of one month. Arrangementswere made to withdraw the oxygensupply with the contractor.

If SBOT patients were unwilling to havethe oxygen withdrawn, then they wereoffered an appointment with therespiratory consultant for furtherdiscussions and assessment. Furtherassessment of patients unwilling to bewithdrawn from SBOT were offered.All patients will be followed at six monthsto assess outcomes such as quality of life,arterial blood gases, primary care visitsand any hospital admissions.

The process of improvementundertaken and overall approachto address the issuesMeetings and telephone review tosupport this work:

• In the early stages of the project, twomeetings took place (14 June and 30July 2010) with NHS Improvement Lead,Ore Okosi and various members of theteam (JAW, CB, CM, GD, AC, RH) todiscuss and plan the project

• AC, CM, RH attended the NHSImprovement - Lung launch on 16 July2010 and AC & CM attended the NHSImprovement System training day on 28July and 19 August respectively

• AC attended the oxygen peer supportmeeting at Edgware Community Hospitalon 23 September. CM attended theoxygen peer support meeting at MiltonKeynes in November

• AC, CM had a telephone review 13August and two half day meetings on 28October 2010 and 27 January 2011

• In addition, there have been regulartelephone updates between AC and CM(13/8/2010, 27/8/10; 3/9/10; 15/10/10)

The feasibility and impact of withdrawal of ShortBurst Oxygen Therapy (SBOT)Royal Free Hospital NHS Trust, NHS Waltham Forest & North East London, NorthCentral London and Essex Health Innovation Education Cluster (NECLES HIEC)


Data collection was started at WalthamForest on 15 October 2010, following thedevelopment of:• A flyer inviting participation

(see appendices)• A letter of agreement of patients to

take part (see appendices)• An updated patient assessment

proforma (see appendices)• A patient follow-up proforma

(see appendices)• An agreement with local GPs to support

actions within the project• Written details informing GPs of

patient’s involvement in this NHSImprovement - Lung project

Issues and challenges faced withpotential solutions• Issues of maintaining up to date HOOF

data and an oxygen database inWaltham Forest PCT as administrationsupport ceased at the end of August2010. Discussions with the medicinesmanagement lead was required inorder to determine continuation andagreement of support to the oxygenservice

• Access to data proved to be a challengewhich resulted in the following emailtrail:• Commissioners at Camden PCT three

times (CM)• Home oxygen service at Department

of Health (CM)• Clinical lead for respiratory medicine

NHS London (CM)• Oxygen lead for NHS London (CM)• Strategy team NHS London• Commissioners at Camden PCT

(JAW)

The testing was performed and thekey learning to date, including theoverall benefitsPatients in NHS Waltham Forest on shortburst oxygen (CC2a and CC2b) havebeen reviewed and assessed. The datahas been collected and analysed.Metrics and measures included numbersreceiving SBOT, three monthsretrospective data to understand demandand capacity, actual hours SBOT use,FEV1,SaO2 and ABGs, SGRQ, HAD andBORG scores, number of reviews, numberof admissions related to respiratorycondition, number of patients withmaintained withdrawal at six months andimprovement stories to include patient’sexperiences.

Potential/actual QIPP and cost savings/avoidance – defined as quality,innovation, productivity andpreventionThere are potential cost savings fromwithdrawal of SBOT and in additionfurther cost savings could be identified asa result of performing ABG sampling inthe community thus obviating the needfor patients to attend hospital for thisreason.

Data collection summaryOctober to December 2010 results:A total of 25 patients on SBOT in theborough of Waltham Forest with aprimary diagnosis of COPD wereidentified. Appointments were sent andpatients, who agreed to participate in theproject, visited in their homes:

• Two patients have had their SBOTsuccessfully withdrawn

• Nine patients (47.3%) wereexacerbating at the time of assessment

• Two patients were withdrawn from thestudy :one unwilling to comply withinterventions, one recently bereavedand worsening of short term memoryloss

• One patient was dying and refusinghospital admission and one refusedassessment

• One withdrawn from SBOT as requiredlong term oxygen therapy

• One was in hospital having beenadmitted with pneumonia

• The remainder are awaiting assessment

The results of 19 patients are presentedbelow for HAD, SGRQ, FEV1 (morbidity)and oxygen SaO2 at assessment on firstvisit.

35

30

25

20

15

10

5

0

-5

HA

D

NOVPatients

A B C D E F G H I J K L M N O P Q R S

7000000

5 6 79

28

21

26

20

14

31

24

17

Waltham Forest PCT Waltham Forest PCT

1 October 2010 - 31 December 2010 - Waltham Forest PCTHAD


Since December 2010, a further fourpatients have been assessed:

• One patient was depressed anddeclined to participate

• One patient was depressed with shortterm memory loss and withdrew fromthe study

• One patient refused to have SBOT andwas removed from the study

• One patient agreed to removal of SBOTwhich was replaced with ambulatoryoxygen

• One patient assessed earliersubsequently withdrew from study

• One patient has not been seen due tofrequent hospital admissions

SummaryOut of a small sample of 25 patients,three patients have been removed fromSBOT.

There were a variety of reasons for non-removal of SBOT including:

• Current exacerbations (not recovering)• Frequent exacerbations• Dying• Depression and memory loss• Eligible for LTOT but declined this

therefore SBOT left in• Patient intermittently desaturated,

therefore needed SBOT

25

20

15

10

5

0

-5

SCR

Q

NOVPatients


14

000000

9

17

2018

0

12

21 21

1415

21

11


80

60

40

20

0

-20

FEV

1

NOVPatients


40

0000

18

0000

29 30

0

3731

37 37

63

42


100

80

60

40

20

0

-20

Sa0

on

air

NOVPatients

A B C D E F G I J K L M N O P Q R S

93

00

85

66

9590

96 94 96 94


2

88

64

8898969495

1 October 2010 - 31 December 2010 - Waltham Forest PCTSGRQ

1 October 2010 - 31 December 2010 - Waltham Forest PCTMorbidity

1 October 2010 - 31 December 2010 - Waltham Forest PCTOxygen Assessment First Visit


Emerging workstream principles,including ‘top tips’The issues relating to withdrawal of SBOTare complex and multifactorial: thesetend not to relate 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 SBOT prescribedfor over 12 months (often following anexacerbation) which had also led to somepsychological dependence over time.

However, it is worthy of note that thetime frame for this study has spanned anexcessively cold period resulting in highincidents of acute exacerbations wherepatients genuinely needed their SBOTwhich was justified.

The following points have become clearduring the study:

• Communication issues arounddischarge of complex patients whohave oxygen requirements at home:e.g. incorrect oxygen prescription ondischarge which has lead toreadmissions

• Patients discharged with noinformation and no support regardingtheir oxygen therapy

• Patients who are commenced on SBOTfor exacerbation need to be reviewedsix weeks for assessment, educationand support with a view to removal ofoxygen (as it is clear that long termSBOT encourages psychologicaldependence)

• 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

Any generic learning (LTC) that can beextrapolated from this work i.e. howthis could be applied to other areas• The need to ensure that

communication between thecommunity and hospital on discharge isimproved for seamless care

• Patients who are prescribed SBOT maynot have been seen by a clinicianspecialist in oxygen therapy and maynot have been told how long theprescribed oxygen should be used.Often this results in an instruction fromthe engineer in the use of the oxygenaccording to what is recorded on theHOOF (e.g. for two hours, or morningand evening regardless ofbreathlessness). Hence it may not bethe case that the patient has had aninstruction to use it for 5-10 minutebursts to relieve breathlessness (whichis a commonly held assumption byclinicians). Further information in theHOOF comments box needs to explainhow the prescribed oxygen should beadministered

Future workThe plan for the next six months includesthe following:

• Continue to look at new starters onSBOT six weeks post exacerbationwith a view to reassessment

• Document the SBOT patient journey viaa process map to indicate the referralroutes and possible gaps in the carepathway

• Develop a questionnaire relating toaccess to oxygen data and circulate itto other members of the NHSImprovement - Lung - ‘ImprovingOxygen Services’ group so that anunderstanding of the difficultiesregarding access can be gained

Project leads contact details forfurther informationChristine MikelsonsConsultant Respiratory PhysiotherapistTel. 0207 794 0500 ext 34068or bleep 1041Email [email protected]

Anne CrawfordTeam Lead, Respiratory Nurse SpecialistTelephone 0208 430 8255Email [email protected]


The background to their serviceThe West Hertfordshire communitychronic obstructive pulmonary disease(COPD) service is a service commissionedby NHS Hertfordshire and provided byBarnet Community Services. The serviceis integrated across care settings andorganisational boundaries and providespatients with home oxygen assessmentand review, hospital-at-home, respiratoryconsultant clinics and pulmonaryrehabilitation.

Upon the commencement of the servicethe West Hertfordshire team verypromptly began assessing new patientsfor oxygen therapy and reviewingpatients already in receipt of oxygen,documenting changes to the homeoxygen order forms (HOOFs) andmonitoring the associated changes inoxygen prescribing spend.

NHS Hertfordshire supply the service withdetailed reports around activity and costwhich are free of ‘ghost patients’ (e.g.patients listed as in receipt of oxygen butare actually deceased) and clinicians haveaccess to a weekly list of new oxygenorders and the identity of the clinicianinitiating the prescription.

As at July 2010 the new service hadreviewed 40% of the 800 patients inreceipt of oxygen therapy andundertaken therapy modifications andwhere clinically appropriate therapywithdrawal in a number of the reviewedpatients.

Having achieved these quick wins theservice sought acceptance from NHSImprovement - Lung in order to facilitatea shift in focus from cost savings to costavoidance.

Improving home oxygen servicesWest Hertfordshire COPD Service

The project aims and objectivesAims:To reduce the amount of inappropriatehome oxygen prescribing and reduce thecost of home oxygen within WestHertfordshire.

Objectives:• Identify where and who is

inappropriately prescribing homeoxygen to patients with normal oxygenlevels

• Review all patients commenced onhome oxygen within four weeks ofcommencing and alter oxygenprescription to match patient needs inmost cost effective way

• Target education at groups of clinicianswho are prescribing home oxygeninappropriately

• Develop an educational package andcompetency assessment tool

• Produce proposal for the introductionof a register of home oxygenprescribers who have undergonetraining and competency assessmentwith the aim of improving the qualityof prescribing

The process of improvement theyundertook and overall approach toaddress the issuesA project team was established andproject monitoring integrated withinexisting key performance indicatorreporting to the Trust Director ofOperations and PCT Commissioners.

The clinical team continued to review ona weekly basis all sources of new oxygenprescribing and collaborated with the PCThome oxygen services lead in reviewingmonthly prescribing reports and quarterlysupplier concordance data, ensuringclinical oversight around the modalities ofoxygen received by patients.

Inappropriate prescribers were identifiedwithin both primary and secondary careand so the first phase of work centred onproviding education sessions withintarget GP surgeries.

The second phase of work currently indevelopment is educational sessionstargeted within the local Acute Hospitaland the teams have secured a place onthe teaching rota for new doctors andeducational sessions booked with highergrade healthcare professionals - specialistregistrars, foundation year one andfoundation year two.

The feedback and experienced gainedfrom this work will inform thedevelopment of an oxygen prescribingeducational pack and competencyassessment.


Sp02 <92% on airor

breathless on exertion thought to bedue to oxygen desaturation

Refer patient for home oxygenassessment in COPD clinic or at home

• Arterial blood gases• 6 minute walking test

Patient requiresoxygen

Patient does notrequire oxygen

HOOF completedand faxed to BOCand PCT medicines

managementadministrator

Acute Hospital and GPprescribing, weekly

list to community team

If patient breathlessconsider referral

to pulmonary rehabor breathlessness

clinic or communityconsultant clinic

Patient followed upat home withinfour weeks of

commencing homeoxygen by

community COPDteam

Reassess 02 requirementsand alter HOOF if indicated

Patient education and adviceon safety and coping with 02

Monitor patient andfeedback to GP

Provide patient with contactnumber for clinical support

Adult home oxygen service

Patient registeredon clinical homeoxygen database

(HoXAM) and COPDdatabase

Communityrespiratory nurse

follows patient upat 6 and 12 months

in first year then6 monthly

Identify HCP whoare prescribing

inappropriately andtarget education

sessions toimprove prescribing

Monitors patient and providefeedback to GP

Reassess 02 requirements andalter HOOF if indicated

COPD review and developself-management plan

Issues and challenges they faced withpotential solutionsData collection: Current service keyperformance indicators (KPIs) are in adifferent format to the requirements ofNHS Improvement - Lung and therefore ithas been a challenge to find time totransform the data from one format toanother.

Solution: A local measures matrix wasdiscussed and agreed with the oxygenprojects national improvement lead (NHSImprovement - Lung) and so appropriatedata has been collected to demonstrateprogress in respect of the specific projectaims and objectives.

Secretarial support and a budget hasbeen agreed and secured from theproject team’s own organisation so datacan be put into a format suitable forproject reporting.

Potential/actual QIPP and cost savings/avoidance – defined as quality,innovation, productivity andpreventionCost savings have been achieved fromwhen the project commenced, with themonthly spend on oxygen prescribingshowing a consistent decline. TheOctober 2010 spend represented a 12%reduction on the monthly spend in April2010.

The West Hertfordshire Care Pathway


This has been accompanied by a reducing trend in the actual numbers ofpatients on home oxygen.

Key learningModel of care: An integrated model ofcare prevents duplication and is a costeffective solution to managing the homeoxygen service. The assessment andfollow-up of patients on home oxygencan be undertaken by a nurse led serviceprovided there is integration withrespiratory physicians so that promptreview when indicated can take place.

Workforce competences: The analysisof the sources of oxygen prescribing andsubsequent educational sessions haverevealed that home oxygen is oftenprescribed by junior medical staff whohave insufficient knowledge of bestpractice guidelines.

Data coordination: The data providedby the suppliers is not deemed user-friendly and there also appears to be areluctance on the part of the oxygensupplier to directly provide serviceclinicians with the data even when thePCT agree that this is appropriate.

The project team feel that a home oxygendatabase (such as the proprietary HOxAMsystem) is necessary for serviceprofessionals to efficiently monitor thelarge numbers of oxygen patients whorequire follow-up.

Project lead contact details forfurther informationGlenda EsmondRespiratory Nurse ConsultantTelephone 07908 846033Email: [email protected]

West Hertfordshire prescribing spend

Number of patients on home oxygen in West Hertfordshire

2

0

-2

-4

-6

-8

-10

-12

-14

-16

Perc

enta

ge

chan

ge

Month

Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10

900

890

880

870

860

850

840

830

820

810

800

Nu

mb

ero

fp

atie

nts

Month

Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10

The background to their serviceNHS Sheffield as part of their AchievingBalance Health Strategy (2010) identifiedthat they had the highest projectedforecast spend on home oxygen therapywithin the region.

There was no local requirement forpatients to have an oxygen assessment inadvance of therapy being ordered/prescribed and patient’s ongoing needfor oxygen therapy was not alwaysreviewed.

The project aims and objectivesAim: By July 2012, all NHS Sheffieldchronic obstructive pulmonary disease(COPD) patients newly prescribed homeoxygen have had an initial quality assuredassessment and all COPD patients withhome oxygen are systematically reviewedin line with British Thoracic Society/NICEguidelines resulting in the correct therapy(home oxygen order forms (HOOFs) andequipment) leading to improvement inpatient quality of life, increased activitiesof daily living as well as increased lifeexpectancy, reduced unscheduledadmissions and robust oxygen costcontrol.

The process of improvement theyundertook and overall approach toaddress the issuesA project team was established(comprising clinicians, medicinemanagement technician and managersfrom both primary and secondary care)and the NHS Improvement - Lung workintegrated within Sheffield’s AchievingBalanced Health Strategy initiative.

The project manager, medicinemanagement technician, and specialistnurses were assigned to the project andtogether undertook a detailed analysis ofthe home oxygen register and HOOFs.

• Patients not receiving a formalassessment and or not undergoingregular review or risk assessment

• Changes in clinical need not beingcommunicated to the supplier

• Holiday home oxygen order form(HOOF) not being cancelled

• Inefficient time of removal follow death• No locally commissioned services• No designated home oxygen therapy

manager• No robust systems, process or pathway,

including fire risk assessment

Some initial demand modelling has beenundertaken and this has been coupledwith some analysis of the costs ofdifferent parts of the pathway.

This work together with information fromthe Department of Health Good PracticeGuide has been used to inform a businesscase and draft a new service specification.

The team carefully studied theconcordance report data and monthlyinvoices to understand the scope andscale of the issues. They were then ableto break this down to GP in order toanalyse ordering or prescribing at a locallevel.

This enabled oxygen under/over usage tobe identified together with non-usageand anomalies in the oxygen modalitiesassigned to individual patients.

An initial process mapping workshop wasundertaken to understand the sources ofoxygen prescribing, the basic patientjourney and service gaps.

Initial scoping work identified areas ofpotential efficiency improvement withinhome oxygen provision:

• Oxygen being supplied when notrequired

Home oxygen service improvement projectNHS Sheffield



Issues and challenges they faced withpotential solutionsInitially the project experienced somechallenges gaining access to some of thedata needed to record baseline measures.

Protracted telephone and email contactwith the oxygen supplier was required inorder to assure the supplier that projectteam members (who were not theoriginally designated PCT home oxygenservice lead) were legitimately entitledto access.

Persistent and on-going liaison with theoxygen supplier has resulted in betterdata access.

Commissioning considerations (whereappropriate)The multidisciplinary project team haveworked together and along side theDepartment of Health Good PracticeGuide, Home Oxygen Services –Assessment and Review (HOS-AR) havedeveloped a successful business case togo forward to commission a HOS-AR inSheffield

This will be a long term conditionsHOS- AR and will integrate with othercare pathways such as cardiology,palliative care, neurology. It will link withand complement part of a COPD Quality,Innovation, Productivity and Prevention(QIPP) redesign which is currentlytargeted at those patients with mild andmoderate disease.

The oxygen service business caseoutlined the de-commissioning andre-commissioning of a new integratedevidence based quality led HOS-ARservice that promotes efficiencies andeffectiveness and will serve the other endof the continuum for adult patients withsevere and very serve COPD across theprimary secondary care interface.

addition oxygen devices were removedfrom patients’ homes where it wasestablished they were no longer needed.

This has resulted in a saving of £10k permonth, with a forecast saving of £120kper year and subsequent years.

Key learningCross functional working has enabled theproject to move more quickly and takethe pressure off core team membersbecause others are working on behalf ofthe project.

An example of this is the additional helpsought from the internal audit team inorder to undertake an in-depth analysisto help support our initial findings. Thisis supported by our finance andperformance directorate.

Early on in reviewing the data,anomolies were seen which needed tobe understood and assessed in relationtto see if they were system, processerrors or adverse occurrences.

By approaching the fraud team the styleof data required has been specificallyrequested so that it is easy to read andmeaningful to the end user.

This has enabled the team to helpshape change and to very quickly gainorganisational support, setting the barhigh for the vision of improved oxygenservices.

This is motivational to the core projectteam as improvements that have beenset in place have now been realised.

Project lead contact details forfurther informationSue ThackrayRespiratory Project LeadTelephone: 07773790915Email: [email protected]

This approach is known to have a markedimpact on quality adjusted life years andlife expectancy.

The proposal will enable a greaterproportion of assessments to be carriedout in the community. This will avoidpotentially high cost associated withrespiratory outpatient tariffs.

Draft outline of new modelLevel 1 (Community):• Pulse oximetry at a GP practice level for

the timely identification of hypoxia• District nurses – ongoing assessment

for at risk groups

Level 2 (Community):• Short bust oxygen therapy (SBOT) for

the assessment and removal of SBOT• Ambulatory (AB) for assessment,

provision and ongoing monitoring• Assessment for long term oxygen therapy

Level 3 (Secondary care team inputwith community based follow-up):• LTOT assessment of complex patients.

The team are setting in place internalmeasures to help mitigate risk (forexample financial and oxygen patientregister management systems) and havedevolved responsibility, for registermanagement and referral for fire riskassessment to the practice basedconsortium and local GP practices.

Workforce considerationsStaff shortages in the wider team (2WTE)are making resources limited.

Potential/actual QIPP and cost savings/avoidance – defined as quality,innovation, productivity andpreventionThrough improved data management anddata cleansing a number of patients wereidentified who upon consultation wereable to have therapy modified and in


The background to their serviceHistorically, NHS Hull did not have astructured or funded oxygen assessmentand follow up service, with patients’predominantly prescribed long-term,ambulatory and short burst oxygen ondischarge from hospital without formalassessments and structured follow upreview.

In addition, GPs issued oxygen therapy topatients on a ‘want’ rather than needbasis usually for breathlessness withoutany form of assessment.

From April 2010, following a tenderingprocurement process, NHS Hullcommissioned a new home oxygenassessment and follow up service. This isa new service for the city; the providersuccessful in the procurement processwas City Health Care Partnership.

Hull had approximately 800 patients inreceipt of oxygen therapy at thebeginning of April 2010. The new servicehad a total of 260 patients referred intothe service within the first three monthsof being operational.

The project aims and objectivesTo 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.

Specific objectives:• Remove inappropriate oxygen

provision, ensuring correct equipmentand therapy is delivered to new andexisting patients on oxygen

• Reduce unnecessary costs of oxygenand equipment

The project team work was integratedwithin wider COPD pathway servicedevelopment work being undertaken bythe PCT.

Data metrics were agreed by the projectteam and data collection processesestablished and information provisionresponsibilities assigned.

Invoices from the oxygen supplier (AirProducts) are received by NHS Hull homeoxygen services lead within thecommissioning department and the homeoxygen service (HOS) also has access tothese and the concordance reports. TheService checks against the Open Exeterhome oxygen order form (HOOF)database and reviewed by the specialistnurses who also review flow andprovisions rates).

The administration team within theservice also data cleanse the invoices andreport back to the oxygen provider witherrors and updates as necessary.

• 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 and oxygentherapy

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

The process of improvement theyundertook and overall approach toaddress the issuesFollowing acceptance from NHSImprovement - Lung in June 2010, amultidisciplinary project team was formedwith experienced respiratory nurses,smoking cessation specialists,commissioners, oxygen providers, apatient, and the fire brigade

Home oxygen service improvement projectNHS Hull and the City Health Care Partnership

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


Patients on ambulatory oxygen arerecalled for an ambulatory assessmentand the project has made cost savingsthrough this recall mechanism.The team analysed the long term oxygentherapy (LTOT) patient data provided bythe supplier giving particular regard to:

• Multiple therapy combinations• Duplicate charging• Deceased patients• Out-of-area patient charges• Under/over usage

Since July 2010, a total of 428 patientshave been assessed or reviewed by theservice with new therapy being initiatedand appropriate changes to existingtherapy made in terms of duration and/orflow rate alterations, device changes andin some instances therapy withdrawal(when deemed of no clinical benefit).

The team takes a proactive approach tomanaging the ongoing safety risks topatients in receipt of oxygen (or whopose a risk to others) due to potential firehazards.

A local risk assessment pro-forma iscompleted by the clinical team at everyreview and which has strong links withboth the local oxygen provider and theFire Brigade, enabling issues and concernsto be highlighted and addressed.Mechanisms for involving patients (andcarers) in their risk assessment have beendeveloped and the dangers of smokingwith oxygen are discussed.

The team aim to undertake 40 riskassessments per month and the multi-stakeholder team have drafted a localpolicy on smoking and removal of oxygenprovision.

Hull GP/Consultant or any healthcare professional referral

All patients initiated on LTOT whoare discharged from hospital (apart

from palliative care patients)

Review of currentSBOT/ambulatoryoxygen patients

Community, respiratory,physiotherapist and

pulmonary rehabilitation

Review of disease management/need for oxygen

Oxygen assessment indicated

Patient known tooxygen team

Oxygen assessmentnot indicated

Patient educationprovided

Patient not knownto oxygen team

Clinicappointment

Communication with referrer• Assessment results

• Advice on follow up arrangements

Appointment for homeoxygen assessment

Assessment undertaken

Oxygen required

Patient education provided

HOOF/HOCF docs completed

No oxygen required

Communication with referrer• Assessment/review results

• Advice on folllow up arrangements

Follow up appointments made:

CBG clinic/home at month1, 3, 6, then annually

(Spirometry, CBGs, clinicalassessment, risk assessment,

education)

NB Patients will beseen 5 weeks post

discharge whenclinically stable ifrecovering from

an infection/exacerbation

The service pathway

The performance and delivery of theservice is monitored via these indicatorson a monthly basis. The commissionerand provider meet regularly to gothrough this data and discuss servicedelivery. The service was initiallycommissioned for two years, based onthe data and patient outcomes reportedthe commissioning organisation will lookto extend this contract. Due to thechanges in the way services will becommissioned in the future, the GPConsortia will need to be involved in thisprocess and future developments.

Workforce considerationsDiscussions have taken place with theprovider in terms of how they expandtheir respiratory workforce. Theycurrently employ two specialist respiratorynurses and two oxygen nurses, as theservice expands they will be consideringthe options of having respiratory expertiseacross their long term conditions serviceand training other staff in terms ofrespiratory.

Potential/actual QIPP and cost savings/avoidance – defined as quality,innovation, productivity andpreventionSince July 2010, 428 patients have beenassessed or reviewed, prior to assessmentthese patients had a combination of 601oxygen therapies in place.

After the assessments the combination oftherapies was reduced to 433 and therewere 145 removals and 44 decreases inoxygen flow rate. This has reduced themonthly invoice by £11,378.

In addition, 24 patients on oxygen havestopped smoking, due to COPD smokingcessation specialists, and the homeoxygen service now have 404 patients ontheir caseload and in the cycle of review.

Issues and challenges they faced withpotential solutionsStakeholder agreement: bringing widerstakeholders on board in respect of the‘Smoking and Removal Policy’ has provedchallenging and resulted in delayed policydevelopment and continued risk ofpossible incidents with patients.

The team is attempting to address this bybringing all stakeholders together andproviding evidence around health andsafety, information on incidents occurredand monitoring the clinical impact oftherapy removal.

Healthcare professional compliance:Not all local healthcare professionals arecurrently delivering care in line withfuture local policy, resulting ininconsistent messages to patients, safetyrisks and incidents.

The team are addressing througheducation sessions developed (for allhealthcare professions groups) aroundthe new policy and how it should beimplemented into their working practice.

Patient refusal/anxiety regardingremoval of therapy: Strategies beingadopted to address this include educatingpatients via information leaflets, DVD,verbally about the dangers and referringsmokers to smoking cessation services.

Project team capacity: Pressures fromexisting work are being offset throughongoing development of a ProjectDelivery Plan with specified activities,timescales and team memberresponsibilities.

Commissioning considerationsThe service forms part of a communitycontract with a service specification andperformance indicators in place.


The total number of oxygen users in Hullis 763, at this current time, whichincludes palliation patients who are not inthe current service caseload, over halfcoming in to the service already.

Key learningData can be utilised effectively to providerequired analysis; at first it seemsimpossible but with specialisedperformance analysts on board this canbe done.

Launching a new service in parallel withundertaking a process improvementproject is very challenging - in hindsight itmay have been better to allow the serviceto develop then seek improvements.However, the opportunity to take part ina national programme was a bigincentive.

Collaboration with NHS Improvement -Lung has provided:• Greater clarity, structure and focus via

project planning• Motivational interaction with peers• Support for reviewing areas of

weakness and development of• The expansion of the future work plan

to include demand and capacityanalysis and the development of aprescribing costs ‘dashboard’

N.B. Please note that in respect ofdata and finance this report is as at15 December 2010.

Project lead contact details forfurther informationToni YelCommissioning Development ManagerTel: 01482 344772Email: [email protected],[email protected]


NHS Gloucestershire home oxygen assessmentservice implementationNHS Gloucestershire

The background to their serviceThe existing respiratory service providerfunction is spread over a very largegeography with a varying and diversesocio-demographic. There is no formallycommissioned community-based oxygenassessment service; the only assessmentsavailable being for a limited number ofspecialist conditions and children allwithin the acute hospital setting.

Prior to the commencement of theproject there were approximately 1,000patients on oxygen therapy who requiredreview and 150 new patients per yearbeing referred for initial hospital (clinic-based) oxygen assessment.

There are currently around 860 patientsreceiving home oxygen inGloucestershire, however the oxygensupplier data indicates that there aremore than a quarter of these patientswho are using none or very little of theirprescribed oxygen.

The project aims and objectivesTo commission a high quality homeoxygen assessment service for patients inGloucestershire

Specific objectives• Produce a service specification which

details the expectations of thecommissioners with robust qualityoutcome and activity performanceindicators

• Implement a service which enables allnew and existing patients on HomeOxygen Therapy to be appropriatelyassessed, reviewed and monitored

• Undertake a rationalisation of currentprescriptions for oxygen in order toreduce unnecessary spend on oxygenwithin the county

The process of improvement theyundertook and overall approach toaddress the issuesThe project lead undertook a review ofservice specifications for establishedHome Oxygen Assessment and Reviewteams by visiting a number of projectteam sites. In addition, intelligencegathering on service costs, workforcearrangements and infra-structure wasundertaken from a number of sourcesincluding the Department of Health GoodPractice Guide10.

Work was undertaken to betterunderstand the current patient profileand prescribing costs; this was achievedby a detailed analysis of the concordancereports and monthly invoice data.

A process of obtaining ‘sign-off’ of aprevious (2009) business case wasundertaken with new (additional) costsidentified through the project workintegrated within the proposal.

A service specification was drafted andthen reviewed by the respiratory steeringgroup. This was presented then to theQuality, Innovation, Productivity andPrevention (QIPP) management board, aforum set up to assess, evaluate andscrutinise all service developmentproposals that required pump-primingand/or recurrent funding.

In parallel to this work the PCTprocurement team began the initial workon proceeding with a tender process as itwas envisaged that the new servicewould be open to any willing provider.

Issues and challenges they facedwith potential solutionsParticipation with NHS Improvement -Lung has provided the opportunity todiscuss our locally proposed service planswith more established teams. Throughthe course of these discussions, it hasbecome evident that the original sumidentified and budgeted to fund the costof the development does not in fact coverthe true costs of the service as specifiedand therefore does not support thebusiness case and progression to opentender.

The findings have been presented tomembers of the NHS GloucestershireExecutive and it has been decided thatsmall short-life working group will beestablished to focus on the top 10% ofpatients identified on the concordancereport as not using their prescribedoxygen.

The work of this group will utilise a plan-do-study-act cycle in order to monitor thereduction in oxygen usage with thissample of patients.

The evidence collected will then be usedto amend the original business case toreflect the success of the pilot project.The ongoing challenges to this projectcontinue to be financial and the presentchanging organisational situation.


Commissioning considerations• The application of service improvement

tools such as multi-stakeholder processmapping must proceed carefully in ahealth economy which may beconsidering putting out future servicesto tender

• It is important that in seeking tounderstand the existing oxygen patientjourney (and uncover existing ‘hidden’oxygen services) the process ofidentifying areas of improvement doesnot in any way compromise a futuretender process

• It is evident that having workedthrough the development a fullbusiness case, the full finance tosupport the project service specificationis identified and earmarked early on,otherwise a protracted tender processmight result no suitable bidders for theservice

• The tendering process also takes aconsiderable amount of time e.g. aminimum of five months and thereforeit is unlikely that potential benefitsfrom the service are not realised beforethe end of the project term

Potential/actual QIPP and cost savings/ avoidance – defined as quality,innovation, productivity andpreventionFollowing data analysis from both thePCT information team and the senioranalyst from NHS Improvement - Lung,we were able to demonstrate thepotential savings to the PCT would be inthe region of £250K. However, we doneed to confirm that these savings arematerial and could be achieved anddelivered.

Although we have fairly robust numericaldata from the concordance reports it willbe a challenge to identify the patientsfrom this data and there will be a relianceon paper records and GP surgeryinformation to identify individuals.

However, once identified it is anticipatedthat this cohort will be already be knownto the respiratory team both in primaryand secondary care.

Key learningAlthough it may appear that NHSGloucestershire has not made rapidprogress during the first six months ofthis project, we do however have a muchclearer understanding of the data that wehave and also the financial implications ofoxygen usage within the community. Wealso have a clear understanding of thepotential impact to patients and servicesif we continue to do nothing to improvethe service.

Project lead contact details forfurther informationSandra MajorClinical Development ManagerTel. 08454 221434Email: [email protected]


The background to their serviceA PCT sponsored pilot project conductedin 2008, highlighted health inequalitiesand variation in usage of oxygen forpatients on home oxygen.

Patient experience varied depending onwho prescribed their oxygen, with a two-tier oxygen service in existence and littleintegration of primary and secondary careacross the oxygen pathway.

These clinical issues combined withserious financial control issues whichmeant that the PCT had highest cost perpatient within the SHA.

In January 2009, a chronic obstructivepulmonary disease (COPD) co-ordinatorand an administrator were appointed(through using a ‘spend-to-save’ initiative)to support the redesign of the homeoxygen therapy pathway through servicemapping and process audit.

Protocols were jointly developed withclinical teams and the implementationmonitored by the COPD administrator.

The resulting service significantlytransformed the care of patients on homeoxygen within Milton Keynes, with newlyinitiated respiratory oxygen patients firstsubject to a formal assessment and withindramatically improved financial control.Palliative care, cluster headache andpaediatric patients were not included inthis protocol but were supported andmonitored by the home oxygen serviceteam.

In order to sustain and enhance thebenefits of this improved service, and toaddress outstanding areas forimprovement (most notably patient recallmechanisms for long term oxygentherapy (LTOT) review and ambulatoryoxygen assessment), the multidisciplinaryteam applied to take part with NHSImprovement - Lung and were acceptedon to the programme in the summer of2010.

The project aims and objectives• Enhancement of existing care pathway

by the production of a (service)adoption ladder

• Improve ambulatory oxygenassessment by carrying out a pre andpost of clinic set up evaluation for theambulatory oxygen assessment clinic

• Development of quality patientquestionnaire pre and post use ofpatient information leaflet to see ifpatient experience improves

The process of improvement theyundertook and overall approach toaddress the issues

Objective 1:Enhancement of existing care pathwayfor the HOS-AR service.

An initial process mapping exercise wascarried out by the project lead by talkingto key personnel in the service(consultant, admin, respiratory team) inorder to understand the following.

• New appointments lead time(approximately three weeks atJanuary 2011)

• The reasons why patients were notbeing recalled for review (initial findingsindicate a demand and capacitymismatch combined with a problem onhospital discharge a patientappointment requested but no followup appointment made)

Sustaining the efficiency and effectiveness of theMilton Keynes Home Oxygen Service - Assessmentand Review (HOS-AR)Milton Keynes PCT Community Services and Milton Keynes Hospital


PCT protocol for primary and secondary care patients

• The clinical profile of patients whoappear on monthly invoices but are notcurrently part of the specialist teamcaseload (ensuring assessment ifappropriate)

From the findings, a business case isbeing prepared to improve patient followup in the community by funding acommunity matron for one day a week toperform follow up home visits in line withBritish Thoracic Society guidance. Thematron will also carry out a follow upassessment by Sp02 or CBG (CapillaryBlood Gas) depending on the initial Sp02outcome.

In addition, close working with therespiratory team, community matrons,NHS Improvement - Lung and regionalleads is being maintained and work onthe final adoption ladder (a model whichwill allow any similar health economy torapidly implement specific changes toimprove their local oxygen services) isplanned to commence in April 2011.

Objective 2:Improve ambulatory oxygen assessments(AOA) by carrying out a pre and postreview evaluation of clinic set up andpatients.

A clinic was started in October 2010 torun alongside the home oxygen service -assessment and review (HOS-AR) clinic.Evaluation of patients on AOA isundertaken by physiologist initial baselineanalysis has been carried out with thefollowing results.

The questionnaire was reviewed by (andgained approval from) the hospital clinicalgovernance team. Use of thequestionnaire started in January-March2011, followed by (parallel) use of thepatient information leaflet in order tocompare outcomes and undertake a plan-do-study-act cycle of processimprovement.

Issues and challenges they faced withpotential solutions

• Staffing issues – see workforceconsiderations

• Lack of funding – project leadership hasbeen resourced from a previous (nonrecurrent) PCT initiative and souncertainty has arisen in respect ofproject completion. The team aretrying to leverage the work to date inorder to influence local decision-makersabout the added value of the workcontinuing

• Rapidly changing NHS landscape – it iscurrently unclear whether existing PCTproject support structures will bepreserved within the new systemarchitecture

From these results further work will becarried out to review the 145 patientsidentified as not having a walktest/ambulatory oxygen assessment(AOA). This will be carried out by theHOS-AR lead as some patients may havehad tests at other hospitals and this willbe documented in the original auditfrom 2009.

Objective 3:Development of quality patientinformation questionnaire.

This is for use pre and post introductionof a patient leaflet to assess if the patientexperience improves with the use of theleaflet and if there is any other way ofimproving patient experience.

A meeting with the project team and theNHS Improvement - Lung oxygen projectsnational improvement lead to discuss apossible questionnaire and its contentoccurred in September 2010.

Workload demands meant thatsubstantive work on the questionnairecommenced in November, with the teamincorporating the long term conditions(LTC) six questionnaire alongside 11locally devised questions specificallyaround patient experience in the HOS-ARclinic.


Ambulatory Oxygen Audit(Data from Oxygen Concordance Report Jul-Oct 2010)

Total patient accounts analysed = 354Total patients on AOX = 243Total patients had AOA/walk tests = 50Total RIP (on AOX) = 33Total paediatric (on AOX) = 9Total patients cancelled = 6Patients not had walk test = 145


In addition, the impact on the respiratoryteam and the HOS-AR service of apotential merger of local hospital andcommunity services is unknown at thispoint.

The project team is proactively seeking toboth highlight the importance of thiswork (and thus raise the project’s profile)among the emerging GP commissioningconsortia in order to ensure sustainability.

Commissioning considerationsCommissioning will be approached toapprove the extended HOS-AR servicebusiness case, which will be focusedaround QIPP rather than primarily costsavings which the previous spend to saveproject was based on.

Workforce considerationsCurrent project leadership (obtainedthrough fixed term contract workingassociated with previous PCT strategicinitiatives) has reduced to 0.6 WTE andthis may be further impacted by theadditional workload required to projectmanage the oxygen contractre-procurement process.

Confirmation of continued funding hasbeen agreed for the coordinator for thisPCT (0.2WTE and the administrator0.4WTE) the coordinator is also due toofficially start as regional home oxygenproject lead for the re-procurement ofhome oxygen for the South East regionfrom April 2011.

Potential/actual QIPP and cost savings/avoidance – defined as quality,innovation, productivity andpreventionThe tight cost regimen established in2009 is still adhered to. However, theproductivity gains seen from the initialquick wins achieved have reduced as the2010 monthly expenditure has stabilised.

the proprietary HoXAM database may beanother for services setting up a newHOS-AR service. Further evaluation ofthe utility of local, national andproprietary oxygen data collectionsystems would be of value.

Contract control: This is central to thecontrol of prescribing spend used togenerate cost savings that can gotowards funding a HOS-AR service. Areview of short burst oxygen therapypatients in January has predicted a £6kcost saving and a further saving of £13kin AMB oxygen prescribing by reducingnon users down to <1 hour a day beforethey are reviewed by the ambulatoryassessment service.

Project lead contact details forfurther informationSue ChannonCOPD Co-ordinatorTelephone 01908 650402,Email: [email protected]

Further savings through inappropriatetherapy withdrawal are less frequent aspatient numbers have stabilised and theservice undertakes the slow ongoingwork of assessing the last few patientswho have repeatedly missed their homeoxygen appointments.

Key learningProject planning: This has been a newexperience for all members of this multi-disciplinary team as none of the projectgroup had been involved in this type ofsystematic process improvement projectbefore.

Having a clear project plan is the key tosuccess and this could have been morerobustly developed at the outset.

Data coordination: Use of a HOS-ARdatabase is important to control what ishappening with patients. The teamcurrently use a locally developedMicrosoft Access database but use of

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Variance in 2010/11 prescribing spend


The background to the serviceThe PCT had a high proportion ofpatients using oxygen, 0.22% ofweighted population on oxygencompared with 0.18% regionally, withassociated higher (than the regionalaverage) prescribing costs.

A preliminary audit undertaken incollaboration with secondary care in 2009revealed that only 30% of patients onhome oxygen had been assessed orreviewed by a clinical specialist.

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

Undertaking a review of the servicethrough the work of NHS Improvement -Lung, provided the opportunity toimprove patient outcomes and increaseefficiency.

The project aims and objectives• Develop an accurate oxygen register• Identify number of patients receiving

oxygen who do not meet the guidelinecriteria

• Identify the number of patients whohave their oxygen therapy changed ordiscontinued

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

• Develop a structured assessment/followup service which meets NationalInstitute for Health and ClinicalExcellence (NICE) guidance

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

The process of improvement theyundertook and overall approach toaddress the issuesA project team was established,comprising of staff from the NHSBlackpool and Blackpool Wyre & FyldeHospital, and with facilitation from NHSImprovement - Lung. The current oxygenpatient journey was process mapped inorder to identify gaps in the service andpotential risks.

Clinical engagement and commitment tothe project was achieved through amultidisciplinary team of stakeholders.Respiratory specialists from the acuteservice, practice based commissioning,primary care and community cliniciansand also included patient representationand feedback.

A paper data collection system wasdeveloped in advance of the homeoxygen service (HOS) being establishedwithin a community setting.

Project members visited the regionaloxygen data clearing house (LaSCA) inorder to understand the process and toensure data cleansing of the Blackpooloxygen register and on-going monitoringarrangements.

A referral pathway into the oxygenassessment clinics was developed andwork has begun on developing a datacollection system to capture patientnumbe /type/oxygen and cost in termsof increase/decrease.

This information will be completed by theacute hospital HOS team and will bestored on the PCT system for evaluationand reporting analysis.

Improving the prescribing of oxygenacross NHS BlackpoolNHS Blackpool


Self-care plans and patient informationleaflets for long term oxygen therapy andambulatory oxygen have also beendeveloped.

The clinicians within the oxygenassessment service are now more clinicallyinformed as they have access to OpenExeter which allows up-to date history ofindividual home oxygen order forms(HOOFs).

Issues and challenges they faced withpotential solutionsIn the current climate attractingadditional resources to pump-primeservice developments is difficult so morework on demand and capacity is required.The project will need to provide evidenceof improved cost effectiveness which canbe demonstrated through the bespokeoxygen prescribing (and service) datacollection system.

It has proved difficult changing cultureand behaviour patterns within primarycare healthcare professionals and alsowith patients. However ongoingeducational opportunities to publicise theevidence around the need for formalassessment and review should addressthis and the project team are alsodeveloping primary care clinicalchampions and using them to guide andsupport others.

The testing they did and keylearning to dateTesting: In order to address capacityissues an additional oxygen assessmentclinic was piloted within a communitysetting. This increased the current servicecapacity by an additional 17 patients perweek and over 60 previously un-assessedpatients were invited to attend.

Initial invitations to attend this clinicresulted in a large number of patientswho did not attend so the teamundertook phoning individual patients inorder to give more information about theservice and benefits of attending (75patients have gone through assessmentbut as at time of writing we still havethree weeks of data to calculate in orderto confirm final numbers).

Key learning• The importance of developing an

integrated bespoke data collectionsystem that links to supplier data baseand will calculate ongoing cost changes

• Developing a shared oxygen registerbetween the oxygen assessment clinic,suppliers and LaSCA on a monthlybasis, that is up dated and linked withprimary care on a quarterly basis inorder to ratify and data cleanse

• The importance of engagement with allstakeholders including practice basedcommissioning (PBC) as a potentialforerunner of the GP Consortia.Meetings that have focused on holisticpatient care to reduce NELs for COPDhave facilitated this process

Commissioning considerations(where appropriate)• Developing a business case• Developing a service specification• Inclusion in commissioning intensions

for the acute contract

Workforce considerations(where appropriate)The potential loss of key members of staffthat are highly trained in their area ofexpertise poses a risk and so there is aneed to ensure other team memberswork alongside them in order to up-skillthrough clinical supervision.

Potential/actual QIPP and cost savings/avoidance – defined as quality,innovation, productivity andpreventionInitial analysis have led to monthly costsaving estimates of between £3,000 to£4,000 compared with previous monthlyspending patterns before the projectwork started.

Project lead contact details forfurther informationRos InceLead Nurse Diabetes and RespiratoryTelephone: 01253 651316Email: [email protected]


• Unnecessary oxygen prescribing shouldbe eliminated

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

Issue, challenges and solutionsAs an established service much of thegroundwork had already been done interms of setting up the service,developing referral and review processesand documentation.

Oxygen patient data had been ‘cleaned’and the obvious ‘quick wins’ in terms ofdiscontinuing inappropriately prescribedor no longer needed oxygen had beenachieved.

Since joining the NHS Improvement -Lung project we have undertaken areview of our operational processes andaltered documentation.

Background to the serviceThe Wirral integrated service whichincorporates a non-acute chronicobstructive pulmonary disease (COPD)and pulmonary rehabilitation service, wasestablished in October 2009 following along consultation and negotiation processbetween primary and secondary care.

The acute trust was commissioned byNHS Wirral to provide a comprehensiveassessment and review service forpotential and existing oxygen patients.

Prior to the service, outpatient oxygenassessments were undertaken on anadhoc basis by the nurse consultant inthe secondary care chest clinic and followup was lacking in structure. There was nodatabase of patient assessment.

Oxygen invoices were managed initiallyby the Wirral medicines managementteam (MMT) and later by the CheshireHealth Agency. Concordance lists werereviewed by the MMT but there were noresources to reconcile or manage oxygenlists.

Since becoming andr NHS Improvement -Lung pilot site, the Wirral Oxygen Serviceestablished referral processes,documentation, oxygen patient lists anda database for recall and review.

The oxygen lists were reconciled andobvious ‘quick wins’ were made byimproving data management. Clinics foroxygen assessments were established andthe process of contacting existingpatients began.

Project aims and objectivesMission statement: By the end of July2011, all existing adult patients on Wirralprescribed 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.

Specific objectives:• All adult patients in Wirral should have

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 prescriptions remainsappropriate for their needs

Wirral integrated oxygen serviceWirral University Hospital NHS Foundation Trust and NHS Wirral


Potential and actual QIPP and costsavings/avoidanceThe data collected shows a reduction inoverall oxygen use and a cost reductionof £5k-£7k per month since the servicebegan in October 2009. In addition,following formal assessment, 80 patientshave not proceeded to oxygen treatmentleading to further significant cost savings.

The number of non-specialist, non-palliative oxygen prescriptions eachmonth is reducing significantly. This islargely as a result of promoting theservice at every opportunity througheducational events and one to onemeetings at GP practices.

The team have now completed anassessment and review of 80% of allexisting patients on oxygen. Remainingpatient assessment will be completed byApril 2011.

The team are now collecting data onpotential cost savings made fromchanging charge bands.

It is likely that costs will either level out oreven rise in the next few years. Howeverprovided there is continuing support forthe oxygen service and datamanagement, costs will be as a result ofbetter management and assessment.

The main aim of this was to record andreduce variance in assessment.

Data collection and metrics have beenvery challenging and obstacles still remainin providing the required data needed forNHS Improvement - Lung. Further waysare being developed for recording andretrieving relevant data in a way that iseffective and efficient.

The team have employed a dedicated nonclinical oxygen coordinator withresponsibility for data collection andmanaging the ‘oxygen list’.

The team have negotiated a pathway forreferral for heart failure patients with thecardiac network group.

This aims to ensure that prior to referralfor oxygen assessment, treatment will beoptimised according to guidelines andexisting heart failure patients on oxygenand labelled as palliative for more thanone year will be reviewed by a heartfailure nurse.

A review of the pathway for oxygen withpatients who suffer from clusterheadaches is being developed with theregional tertiary care centre. This aims toensure that patients with clusterheadaches who require a trial of oxygentherapy have the most clinically and costeffective option and receive regularreview to ensure it meets their need.Ineffective treatment will be subsequentlystopped.

A comprehensive risk assessment andescalation process for each patient onoxygen has been developed and isawaiting approval by the PCT.

Next phase challengesAs the team have now achieved most ofthe quick wins, there is a need tocontinue to find ways of achieving furthercost reduction or at least maintainingwhat has been achieved. This will bedone by continuing to educate andpromote the benefits of accurateassessment and working closely withprimary care.

Concordance data is being used tochallenge under or non-users ofprescribed oxygen and we are starting areview clinic in two key GP practiceswhere this is a particular issue. It is hopedthat this approach will lead to joined upworking with GPs, help them tounderstand the issues better and providea template for how best to tackle patientswho are not using oxygen but refuse tohave it discontinued.

The service is now facing challenges frompatients who are on oxygen without anyclinical indication. The aim is to withdrawoxygen without losing the trust ofpatients and GPs and inadvertentlyincreasing admissions or use of otherhealth services. We are starting to collectdata on patients who have had oxygenwithdrawn to measure the effect.


45000

40000

35000

30000

25000

20000

15000

10000

5000

0Baseline(Sept 09)

June 10 July 10 Aug 10 ``Sept 10 Oct 10 Nov 10 Dec 10

Cumulative savings

Data collection

Dec 10

Nov 10

Oct 10

Sep 10

Aug 10

Jul 10

Jun 10

Baseline Sep 09

0 5 10 15 20 25 30

Patients discontinued after review

Number of patients

Adult patients on oxygen

1000

900

800

700

600

500

400

300

200

100

0Baseline(Sept 09)

June 10 July 10 Aug 10 ``Sept 10 Oct 10 Nov 10 Dec 10

Total patients on 02 SBOT LTOT

Cumulative savings

Patients discontinued after review

72

643

Patients not yet reviewed

Patients reviewed

LTOT

SBOT

PalliativeSpecialist

AOT


Emerging workstream principles• Get the database right to avoid

duplication of data collection• Decide and agree metrics at the start so

data collection is relevant• Identify a dedicated data and/or oxygen

coordinator to support clinical work• The process of review cannot be

undertaken as a paper exercise• Patients sometimes suspect an ulterior

motive to the reassessment process andbelieve it is more about saving moneythat providing a quality service

• Engage with GPs about their patientsfrom the start to get support withdecision making

Process mappingFollowing a comprehensive serviceprocess mapping exercise in September2010, objectives for each part of theservice were drawn up and agreed. Thiswill be repeated annually (see Page 62).

Service evaluationUsers of our total service (which includesCOPD and pulmonary rehabilitation aswell as oxygen assessment and review),have had their experiences evaluated byManchester Metropolitan University.

A further series of patient focus groupsspecifically for patients on oxygen tookplace in March 2011 and a brief summaryof the results showed that 163 patientsseen by the team replied to the survey.

Project lead contact details forfurther informationDenise WilliamsNurse Consultant and Service ManagerTelephone 0151 514 2244Email: [email protected]

Questions

COPD/02 staff checkedeverything about my respiratoryproblems at the start

I feel better in myself and Imanage my condition sincestarting with oxygen service

The respiratory team providedme with all the information Iwanted to know about mycondition

I felt I was treated with dignityand respect

I had confidence and trust in thestaff examining and treating me

Unsatisfied/very

11 (5.8%)

11 (6%)

13 (8%)

9 (4.8%)

9 (4.8%)

Neutral

12 (6.4%)

27 (14.4%)

12 (6.4%)

9 (4.8%)

13 (6.9%)

Satisfied/very

145 (77%)

130 (69.2%)

147 (78%)

148 (78.7%)

146 (77.6%)


The project aims and objectivesThe project aims to assess:

• The uptake of GP direct access to theoxygen assessment services

• The workload implications ofperforming retrospective oxygenassessment for patients never assessed

• The introduction of a standard pathwayfor patients discharged with oxygenfollowing admission

The process of improvement theyundertook and overall approach toaddress the issues.

Direct access: A direct access pathway(see below) was devised for introductionto GP practices on a rolling locality–by-locality basis.

The background to their serviceThree specialist oxygen assessment(community-based) clinics wereestablished in 2006 for patients referredfor assessment by secondary care.

These clinics form part of a high qualitycommunity chronic obstructive pulmonarydisease (COPD) service which is led by aconsultant respiratory physician andforms a constituent part of a managedclinical (COPD) network aligned topractice based commissioning consortia.

A number of problem areas have beenidentified within the current oxygenpathway:

• Oxygen prescribing is undertaken byany local healthcare practitioner (HCP)often without prior formal clinicalassessment

• Misconceptions among HCPs andpatients around the role and purposeof oxygen

• Poor knowledge of the assessmentprocess

• Variable patient education on thepurpose, safe and optimum use of thetherapy

• Poor understanding of the orderingprocess and the cost implications

• Life-long therapy costing the local NHS£millions in inappropriate prescribing

• Only 52% of patients have evidencebased reviews

• Inconsistent messages and variable levelof patient information

These issues generate a number ofconcerns in respect of patient care:

• Sub-standard clinical service for non-assessed patients – leading tounnecessary life-long therapy for somepatients

• Inequity of provision across the PBCareas – only 52% of patients haveevidence based clinical assessment

• Patients missing out on therapies suchas pulmonary rehabilitation, anxietymanagement and relaxation techniques

• Inappropriate prescription of intrusive,activity limiting therapy for somepatients

• Premature deterioration in health dueto decreased activity and sedentarylifestyle imposed by the oxygen supplyequipment

• Toxic effects of high levels of oxygenfor some patients

• Increased risk of fire and death due tocigarettes and oxygen

Sherwood Forest Hospitals NHS Trust andNottinghamshire County CommunityCOPD Team jointly enrolled with NHSImprovement - Lung.

Together they are undertaking a 12 monthimprovement project to test a GP directaccess oxygen assessment and reviewservice model and to improve oxygenprescribing upon hospital discharge.

Home oxygen – improving quality of careSherwood Forest Hospitals NHS Foundation Trust andNHS Nottinghamshire County Community COPD Team

COPD Team, Ashfield Community HospitalLtoR:Ms Vanessa Leat, Physiotherapist, Dr Sue Revill, Clinical Scientist,Mrs Julie Willets,Assistant Technical Officer, Mrs Diane Reynolds, Respiratory Nurse Specialist


Cost control and data management:Responsibility for data management isbeing devolved to the practice basedcommissioning (PBC) groups who are inthe process of organising invoicereconciliation which will ensure deceasedand out of area patients are identifiedand removed from the billing system.

The clinical project team commencedhome oxygen order form (HOOF)amendment/oxygen charge bandre-categorisation of patients known tothe service in August 2010. Patientsattending for review have all oxygensupplies re-categorised according toclinical need.

In October 2010, the clinical project teamwas granted access to the monthlyoxygen supply invoice and commencedwork to resolve supply modalityanomalies.

Issues and challenges they faced withpotential solutionsPrimary care engagement: This hasbeen challenging as follow-up meetingsto the initial round of discussions (aboutthe referral protocols and assessmentprocess) were difficult to arrange andfeedback about the new direct accesspathway has been variable from onelocality to the next.

The project team exploring thedevelopment of oxygen champions fromamong general practice to assist in thedevelopment of good practice amongtheir peers.

Workforce considerationsThe project team is comprised of a clinicalscientist working in partnership with aconsultant respiratory physician and acommunity COPD team.

Hospital discharge prescribing:Secondary care oxygen guidelines werejointly devised between the respiratoryteam and other medical departments andsubmitted to the hospital clinicalgovernance officers.

To improve the support provided atdischarge (for COPD patients followingnon-elected admission), a nurse-ledclinical check list and dischargeinformation pack is being developed. Thepack will include prescribing guidelinesfor discharge oxygen, self managementinformation and action plan, standardpatient information and follow up oxygenassessment appointment.

The project team met with practice nursesand managers to share the communityreferral form, pathway and protocol.

An active review of concordance lists wasundertaken in order to facilitate patientrecall and target practices for individualGP surgery education and engagementvisits.

Guidance notes were drafted for local GPpractices on improving patientconcordance and invoice validatio /patient register data cleansing wasundertaken by PCT finance and primarycare commissioning teams.

OximetryCurrent chest infection?

or antibiotics (for CI) <5 weeks

FEVq <50% predicted

Primary careCOPD review

Review smoking statusSprometryCheck inhaler techsReviw medicationSigns and symptoms*Flu/pneum jabsSelf management plan

MRC score

Record %SP02

Review 5 weeksfrom last antibiotics

NO

YES

1 or 2

3, 4 or 5

Exercise advice/refer to localexercise scheme

Refer to pulmrehab

>92% No action**

>92%

Refer for 02

assessment

(If % SP02less than 88%

seek medical advice)

*Check for current chest infection. Patient should be clear of axacerbation and antibiotics for 5 weeks

**If a patient has secondary polycythaemia or cor pulmonale refer directly to local COPD clinic.

COPD home oxygen pre referral pathway


Future work: The next phase of theproject will examine how to include GPpractices in the retrospective assessmentprocess (e.g.assessing patients withoxygen supplies and no record ofassessment). The partnership withSherwood Forest Hospital will continue todevelop and implement a discharge packand assessment its impact on the oxygenassessment service workload will beexamined.

Project lead contact details forfurther informationDr Sue RevillClinical Scientist - COPD ServicesTelephone 01623 785407Email: [email protected]

Potential/actual QIPP and costsavings/ avoidance – defined asquality, innovation, productivityand preventionTo date, 36 patients have been re-categorised by the clinical project teamresulting in a projected saving £24,209per annum.

Re-categorisation consisted of reducinghours of usage, reducing oxygen flow orremoval of supply.

Key learningHealth inequalities: Analysis of theoxygen patient data has highlighted theinequities of the current system where atleast 50% of patients have the therapyprescribed without referral to the oxygenassessment service whilst the other 50%of patients receive an evidence-based,gold standard service.

Service integration and productivity:The work of the project team to date hasdemonstrated the potential for makingfinancial savings from regular review andre-categorisation of supply. The savingswere achieved amongst those patientsknown to the oxygen assessment serviceand to the community pulmonaryrehabilitation service e.g. integratedcommunity services with shared specialiststaff.

The clinical review and charge bandre-categorisation work will continue andfurther savings will be achieved; howevermaximising the potential savings isundermined by continuing oxygenprescription without referral to theoxygen assessment service.


Objectives:• Improve patient safety• Evidence based treatment• Improve quality of life and reduced

mortality (long term oxygen therapy(LTOT) group)

• Reduced LOS (LTOT group)• Cost savings• Reduce inequalities• Improve patient experience• Adhere to British Thoracic Society (BTS)

and condition specific clinicalguidelines

The process of improvement theyundertook and overall approach toaddress the issuesThe project team sought to demonstratethe cost-saving potential of the approachoutlined below and thus help informwider health economy work on whole(respiratory) service redesign and Quality,Innovation, Productivity and Prevention(QIPP) efficiency.

The project aims and objectivesThis project centres on the CannockChase locality having been approved byNHS Improvement - Lung in October2010 (commencing the following month),after the initial South Staffordshire projectin East Staffordshire locality failed toprogress.

Aim: To address the issues arising fromthe lack of a comprehensive oxygenassessment and review service throughpathway redesign in line with nationalguidance and best practice.

The specific issues of patient safety, usageand compliance will be addressed toensure appropriate prescribing of oxygen,leading to cost effective and appropriatedelivery of treatment and a reduction inhospital length of stay (LOS).

The background to their servicePrescribing costs in South Staffordshirehave increased by 30% since 2006 andrecent analysis has predicted that thistrend would continue through 2010/11.

The following issues with the currentservice were highlighted:• Lack of understanding amongst primary

care clinicians regarding home oxygenorder form (HOOF) completion coupledwith inappropriate prescribing ofoxygen for patients outside theguidelines

• There is a lack of understandingamongst healthcare professionalsregarding the prescription charges peroxygen flow rate

• Poor compliance and extremeover/under use by patients on oxygen

• Lack of specialist assessment forpalliative care patients

• Secondary care oxygen assessmentoccurring but follow-ups not meetingnational guidelines

• Escalating costs due to clinicalprescribing anomalies invoicing errors:invoicing for deceased patients,incorrect oxygen mode charges,patients not registered in the PCT,patients with duplicate accounts,oxygen that has been removed and stillbeing charged

537 patients were known to be in receiptof home oxygen within Cannock Chaselocality, of which 149 are known to thecommunity respiratory team (127/149patients having chronic obstructivepulmonary disease (COPD).

Improving home oxygen servicesthrough pathway redesignNHS South Staffordshire


Review of these patients allowed theproject clinicians to review the clinicalbasis for the oxygen prescription andwhere appropriate match actual oxygenusage to the prescribed oxygen usage. Inall instances where a change inprescription (and therefore tariff code)was made, the resulting code wascheaper.

At least 10% patients were moved to aless expensive tariff with forecast savingsin excess £1k per year.

The total annual forecast cost savingsattributable to the review of the 91patients in Cannock Chase localityamount to £57,573.

Key learningComplexity: This work has uncovered alot of complexity within existing datacollection and administration systems forhome oxygen, which pre-date thecreation of a single PCT from fourseparate organisations. Thus they arecomplex, fragmented and difficult tomonitor.

In addition, there is very limitedadministration support to process ordersand invoices, with little analysis of dataprovided and this function is remote fromclinicians ordering home oxygen.

Competences: Clinicians in GP surgerieshave limited knowledge of the typeoxygen to order and in some casesprescribe inappropriately. In someinstances the order form is completed bynon clinical staff. A GP trainingprogramme would help improveprescribing habits. The Cannockrespiratory team are uncovering a largenumber of inappropriate orders.

Issues and challenges they faced withpotential solutionsThe capacity of the project team todeliver the clinical reviews and to ensurereturns are completed submitted in atimely fashion has been an ongoingchallenge to the delivery of the project.

The project work is aligned to wider PCTlong term conditions (LTC) andDepartment of Health LTC ignitionprojects and additional demands are nowbe made in respect of the cardiac andstroke portfolio.

These issues will be offset slightly throughindustry partnership working with AstraZeneca who offered analyst supportaround data collection.

Workforce considerationsStaff time:91 patients reviewed at 30 minutesper patient)Total time for 91 = 45 staff hoursCost saving per hour of staff time =£1,265

Potential/actual QIPP and cost savings/avoidance – defined as quality,innovation, productivity andpreventionEach patient order generates a cost usinga tariff that reflects prescribed flow rateand hours usage. This tariff has 47 codeswith a range of ‘per day costs’ fixedagainst the prescribed flow rate andhours usage.

These costs are paid regardless of theactual flow rate and hours usage and inmany instances the patients reviewedwere not using their oxygen in keepingwith the prescribed usage.

The team undertook an initial data reviewof all patients in receipt of home oxygenin the Cannock Chase locality with phonecontact reviews and face-to-face patientreviews to all existing Cannock Chasecommunity respiratory team caseload.

Patients not on the Cannock Chasecommunity respiratory team caseloadmay be contacted where oxygenprescribing data suggested:

• Over or under use of oxygen• Multiple orders running concurrently• Anomalies in prescribed flow rate /

hours usage

At the time of writing the project teamhad reviewed 103 patients. For 91 ofthese patients there were under use orclinical reasons to change the prescribedoxygen order to one more appropriate tothe patients clinical condition and existingoxygen usage. In all 91 patients thechanges made to the oxygen orderattracted a less expensive tariff, reflectingmore appropriate oxygen treatments withoptimal cost efficacy.

Commissioning considerationsPCT based project staff are currentlysubject to a high degree of uncertaintyand so in order to ensure sustainability ofservice improvements within theemerging practice based commissioning(PBC) and the GP commissioning anacceleration of the second phase of theproject will be required to create a robustand integrated clinical assessment andreview service.


A centralised and integrated oxygenassessment, review and ordering teamwould prevent this happening and relieveGPs of the burden of completing homeoxygen order forms (HOOFs), a taskwhich is often delegated to non clinicalstaff.

Financial control: The PCT oxygenbudget has remained part of the overallpharmacy budget. However, oxygenspending is not monitored and PBCs haveremained unaware of the amount spentin their consortia. An initial reviewsuggests that one half of the PCT hasmore patients on home oxygen but thatthe other half of the PCT consistentlyspends much more per patient.

By sharing the practice spend with eachPBC this will increase the interest in therobust management of this budget andthat systems are put in place to ensurethe right patients receive the right supplyof home oxygen, with a review system inplace.

A future pathway redesign work priorityis to review the processes associated withthe prescription of the high cost supply ofoxygen on an 'emergency' basis, i.e.delivered to the patient within four hours.

Project lead contact details forfurther informationSally YoungLong Term Conditions LeadTelephone: 01283 507128Email: [email protected]


The project team have process mappedthe patient journey in terms of thecurrent and future state and identifiedwhere gaps exist in current provision, andhow in the longer term we envisage amove towards single point of referral forinitial oxygen assessment and prescribing.

The project aims and objectives• To work in partnership to change the

way in which oxygen services aredelivered to our community.

• To embed an approach that leads to acohesive, effective and cost efficientoxygen management process across theNHS BEN and HoEFT Health economy.

• Develop transparent systems forsharing information relating to homeoxygen users across the local healtheconomy

• Agree a clear and transparent pathwayand guidelines that support the processof initiating oxygen therapy for newpatients and advises on the challengesof withdrawal/cessation

• Scope the requirements for a singledatabase across the sites which willfacilitate review assessmentrequirements

• Involve the support of clinical healthpsychology to establish an approachwhich is consistent with models of bestpractice in reducing psychologicaldependency

Oxygen is predominantly initiated bysecondary care clinicians; however theprocesses vary across the sites (Heartlandsand Good Hope Hospitals). There arerespiratory clinics which review and assesspatients referred however as initial homeoxygen order forms (HOOF) arecompletely by any clinician the systemcan be quite fragmented.

Within NHSBEN the responsibility forcommissioning oxygen services hasmoved from primary care contracting towithin the long term conditions teamresponsible for chronic obstructivepulmonary disease (COPD).

The information systems that support themanagement of oxygen across the healtheconomy reside within stand alonesystems that are inaccessible to the threesites across the local health economy.There was some enthusiasm to create asystematic approach to the review andassessment of patients that had been onoxygen for a number of years and to putin place pathways and processes thatdemonstrate effective review ofconcordance reports.

For those patients commenced on oxygenfrom hospital (under specialties otherthan respiratory) there is a need for apathway that establishes confidence thatfurther review will take place as part ofthe ongoing patient management.

To support and underpin this there will bea review and revision of local guidelinesfor prescribing home oxygen therapy.

NHS Birmingham East & North (NHS BEN)and Heart of England NHS FoundationTrust (HoEFT) are working in partnershipto change the way in which oxygenservices are delivered to our community.

The project team aim to deliver andembed a cohesive approach that leads toclinically effective and cost efficientoxygen management processes across thelocal health economy.

The background to their serviceNHS BEN first embarked on addressingthe way oxygen services were managedin 2007; the approach taken at that timewas to aim to secure a designated postwith funding support from the BritishLung Foundation (BLF).

Differences between the BLF fundingcycle and PCT business case developmentprocess prevented funding being withinspecified timelines and therefore nofurther plans were developed to addressthe review assessment pathway.

The approach from that point forwardwas to robustly manage the internalmechanisms and to ensure thatcontracting information was kept up todate (removing out of area and deceasedpatients) whilst this was an effectiveapproach to data quality, the effectiveassessment of all patients on homeoxygen could not be undertaken.

Improving home oxygen servicesNHS Birmingham East & North and Heart of England NHS Foundation Trust


The team commenced clinics on 5January 2011, assessing approximatelyfour to eight patients per week, it hasbeen recognised that we will need aprocess to request the permission ofother consultants prior to reviewing nonrespiratory patients.

One aspect of key learning to date relatesto home oxygen order forms (HOOF)which have limited information recordedin terms of coding of patient diagnosisalso the transfer of HOOF forms acrossorganisations is fragmented. As such it isa challenge to clearly define and grouppatients in receipt of oxygen by theirdiagnosis.

Commissioning considerationsAs new funding is not anticipated themanagement of oxygen therapy has beenentered into the commissioningintentions of both the acute andcommunity provider contract for 2011-12. This project will enable us to test thisservice and more accurately specify therequirements for the future.

Workforce considerationsThe reviews are carried out by arespiratory physiology techniciansupporting the respiratory consultant.This clinic will (once workforce isconfirmed) include a nurse andphysiotherapist establishing a trulymultidisciplinary approach. In the interimpatients who require nursing input arehighlighted to the respiratory nursespecialists.

Issues and challenges they faced withpotential solutionsOne of the key issues has been the abilityto secure continued commitment fromcommunity teams, particularly as theproject has taken place during the keystages of the Transforming CommunityServices programme. There have alsobeen some issues to overcome in terms ofcommunicating the project in secondarycare, it was important that executive signup translated into commitment andengagement from the managerial andclinical teams to the objectives.

The transfer of information between siteshas required input from informationgovernance leads in order to comply withlegal requirements relating to informationsharing. A protocol for informationsharing is being developed and the teamhave been briefed in relation to theappropriate level of information sharedacross organisations.

Of course the current organisationalturbulence has resulted in some loss ofmomentum due to increasing workloadand conflicting priorities but due to thecommitment and focus witnessed fromthe team this should not be a barrier.

The testing performed and subsequentkey learning witnessed has alreadyresulted in overall benefits encounteringsecondary care establishing a clinic withno waiting list and therefore it seemedappropriate to re-assign it as amultidisciplinary clinic with consultantinput for the purpose of the project. A‘test’ cohort was not chosen based onreviews highlighted in the concordancereport and those who have previously hadan assessment where clinically oxygencould have been withdrawn but patientswere reluctant and fearful ofrelinquishing this.

The project will review the informationcurrently held at NHSBEN as this formsthe basis on which contracting andcharging takes place. With theinformation from secondary care anddata supplied from the oxygen providerwe will prioritise those patients thatrequire a review assessment with theintention of ensuring that only thosepatients that meet the clinical criteriacontinue with this treatment.The process of improvement theyundertook and overall approach toaddress the issues.

Following the development a project plana programme board was established,inviting members from across communityand secondary care under the clinicalleadership of a respiratory physician.

The team have taken the approach ofensuring multidisciplinary representationand this has gained the support ofrespiratory physiotherapists and healthimprovement specialists.

The project has been communicated tolocal GP localities in order to ensure theyare aware of the intended outcomes andthis has also received positive feedback.


Emerging workstream principles,including ‘top tips’

Top tips for the management of theoxygen service are:• The earliest quick win for oxygen

therapy is active and robust data qualitythis requires a committed informationmanager and establishment ofprocesses to reconcile disparities ininformation, remove deceased patientsand alert in terms of movement out ofthe area

• If clinics will take place in secondarycare agree on the tariff that will beapplied

• Input into the oxygen clinic to effectsafe and sustainable service (byidentifying high risk patients) withdevelopment of a system of‘inappropriate oxygen cessation’notices

Potential/actual QIPP and costsavings/ avoidance – defined asquality, innovation, productivityand preventionAs mentioned above the PCT basedoxygen database has been robustlymanaged in terms of data cleansing andquality. As such NHS BEN does notanticipate the significant savings thatother organisations will experience.

However, the team recognise theguidance in terms of indications for usingSBOT and will be striving to appropriatelywithdraw this where possible.

Also, as there are a number of patientswho have not been reviewed we expectthe project to deliver a number ofcessations following review, unfortunatelythis is not easily quantified at this stage.

However, based on the current PCT spendon oxygen applying the nationally quotedsaving projections would result in a localreduction of approximately £200k.

Data summaryBaseline activity has been collected fromacross the three sites, there was anexisting list of patients who wereconsidered borderline for withdrawalfrom the first assessment and this groupare now being invited for review, whilstthe team review concordanceinformation.

The information manager has producedsome valuable and insightful reports fromthe contracting data held by NHS BEN.This includes analysis on the number ofadmission for patients on home oxygenand those with a diagnosis of COPD.

• Ensure commitment of secondary andcommunity care teams from the outset,both clinical and managerial

• Explore the requirements forinformation sharing acrossorganisations and any associatedprotocol needed

• Establish how the system of managingHOOF forms works prior toimplementing a project

• Explore the establishment of a singlepoint oxygen assessment initiationprocess with secondary care to streamline

• Consider psychology advice for thosepatients who are particularly dependantor lack coping skills

Quality

Innovation

Productivity

Prevention

This project will bring about whole system improvement in theclinical identification and management of patients on Oxygen.Improving quality of service provision and patient QoL.This also includes the right treatment at the right time withappropriate patient support.

Whilst locally our organisations have attempted to address thisissue it remains largely disjointed, the approach of a structuredOxygen ‘snatching’ clinic creates a consistent approach thataddresses inappropriate interventions and creates a robustframework for the future.

Improving this pathway through this project enables theorganisation to maximise the benefit of every pound spent onmanagement of this disease.

An emphasis on supporting patients to self care, is reflected inour strategic priorities, we will use existing services to supportthis e.g. healthy incentive schemes, health trainers, BOH, ExpertPatient Programme and disease specific education approaches.

Alignment with QIPP framework


Any generic learning (LTC) that weextrapolate from the work e.g. how thiscould be applied to other area’s

• Clinical leadership in the process is key,also the engagement of the widerspecialist team e.g. respiratoryphysiology, nursing and physiotherapy

• Evidence of other similar projects andtheir associated saving to engagefinance leads and demonstrate goodpractice from elsewhere

• Early identification of where thepathway would be placed in anestablished model e.g. community,secondary care or within a privateprovider

• Engage commissioning to ensure thatyou are aware of the current contractand who is monitoring it

• Data to align information with GPpractices which is linked toconcordance reports

• Engage GP consortia to ensurethe project has support and buy in,engagement with clinical lead mayassist in terms of reinforcing themessage to patient and clarifying theindications for oxygen therapy

Project lead contact details forfurther informationYvonne RichardsStrategy and Redesign ManagerTelephone 0121 380 9084,Email: [email protected]

53Data for improvement projects

QOF may be useful for COPD projects, asit provides annual information on thefollowing indicators:

• The percentage of patients with COPDwho have had influenza immunisation

• The percentage of patients with COPDwith a record of FeV1 in the previous

• The percentage of all patients withCOPD diagnosed in whom thediagnosis has been confirmed by postbronchodilator spirometry

• The percentage of patients with COPDwho have had a review, undertaken bya healthcare professional, including anassessment of breathlessness using theMRC dyspnoea score in the preceding15 months

What data is available to supporthome oxygen sites?Primary care data is often seen as adifficult area to extract data, and our sitesfound it difficult to access primary caredata at first. However, a number ofresources are easily available which canprovide a picture of primary care which isvaluable for improvement work (furtherdetails on how to access this information,and how to analyse it, are in the datasection below).

Quality and Outcomes FrameworkThe Quality and Outcomes Framework(QOF) is a voluntary annual reward andincentive programme for all GP surgeriesin England, detailing practiceachievement results. It is not aboutperformance management but resourcingand then rewarding good practice.

QOF data is useful, particularly forbuilding evidence and understandingaround the diagnosis and communityparts of the patient pathway. QOF data isparticularly valuable when compared toother indicators for chronic obstructivepulmonary disease (COPD), such asadmissions, or expected prevalence.Comparing the proportion of patientspredicted to have COPD against actualreported COPD on QOF may highlightareas of unmet need, find missingpopulations, and suggest where to targetsupport and future work.

It also collects figures on the reportedprevalence of COPD.

It is important that sites using QOF reviewany exception reports, as it is possible toexclude patients.

Data for improvement projects

Example of QOF data

Data for improvement projects54

The NHS Information Centre is planningto improve access to GP informationthrough the development of a nationalGP data extraction service. For furtherinformation visit the information centrewebsite. www.ic.nhs.uk

NHS ComparatorsNHS Comparators has been muchdeveloped in the last year, and sites wereimpressed with the information itprovided, which helped provide basicbenchmarking and comparison forprimary care.

For a general view of data, NHSComparators can provide suitableinformation for many areas. The siteprovides total admissions data on aquarterly or annual basis, from SHA toPractice level. The site includesfunctionality to plot data on charts andmaps. Data can also be exported for localuse in Excel.

The NHS Comparators tool is free toaccess, and is not limited to NHS staff.There is a set of COPD measures, whichincludes:

• Total admissions for COPD• Emergency and planned admissions,• Reported prevalence compared to

predicted prevalence

General Practice SystemsLocal investigation of primary care datamay reveal more information. Project siteshave found value in interrogating theinformation held within primary caresystems. The importance of accuratecoding has been emphasised by projectsites, sites have learned more about theexacerbations of their patients byensuring coding is correct.

Primary care data can be explored usingthe reporting functions built into primarycare systems, or using external tools,examples of which include the POINTSaudit tool from GSK, and the OptimalPatient Care Project. Details on how toaccess these resources are in the dataguide.

NHS Comparators mapping example

GSK POINTS audit tool

55

Programme Budget Interactive AtlasA recent development is the ProgrammeBudget Interactive Atlas. This contains avariety of indicators at PCT level, and canbe useful in comparing PCT level data. Toaccess the Programme Budget Atlas, yourequire access to the NHS Network, andaccess the site via nww.nchod.nhs.uk

The Programme Budget Interactive Atlasis a tool available to plot a number ofrespiratory indicators and comparenationally, within an SHA, or with similarPCTs. This interactive tool cap map, andshow correlations between two indicators(for example, cost and outcome).

Accessing HES data locallyMany sites have found access to HES datathrough using local performance reports.These reports typically include averagesfor length of stay, numbers of admissionsand readmissions, and are typically usedfor performance management.

Data for improvement projects

For process improvement, it is oftenvaluable to get this information at anindividual level. This will be best used toshow individual variation in Length ofStay, rather than the average.

If you have access to an informationanalyst who can extract the data from theacute trust or commissioner databases,then you can have a more flexibleapproach to accessing admissions data.

Public Health ObservatoriesEach region has a Public HealthObservatory (PHO), who’s role is tosupport clinicians and commissionersaccess information on the health of thepopulation. In addition, each PHO hasareas of specialist interest. The EasternRegion (ER) PHO has the specialist interestfor respiratory illness – and a number ofdata sources and reports are availablefrom their website at: www.erpho.org.uk

SHA benchmarking andInformation packsThe Department of Health in conjunctionwith the ER PHO and NationalProgramme Budgeting team haveproduced a respiratory health informationpack for each SHA area. These packscover a variety of indicators, thathighlight the difference in expectedprevalence, diagnosis, admissions, spendand outcome across all SHAs nationally.These can be downloaded for your SHAarea from the NHS Networks site at:www.networks.nhs.uk

National Programme Budget Interactive Atlas – http://nww.nchod.nhs.uk (NHS Network connections only)

Data for improvement projects56

Tobacco Control ProfilesThe London Public Health Observatoryhas produced a smoking profile, whichmay be useful for projects planning anddeveloping smoking cessation services.These are available online, at thefollowing addresswww.lho.org.uk/LHO_Topics/Analytic_Tools/TobaccoControlProfiles/

Guide for building support from dataanalysts and expertsMany of our project sites haveemphasised the benefits from gettingearly support from a dedicated dataanalyst. This has helped projects inobtaining baseline information,supporting process mapping, andongoing support to monitorimprovement.

The key tips for getting and keepinganalysts involved in projects are:

Get your analyst involved earlySites that included analyst support fromthe beginning had a head start withdata, and rapidly built the evidencebase and understanding for the servicechange. Those sites without analystsupport struggled to understand theimportance of data, and later expressedregret as data revealed challenges ormisunderstandings which could havebeen challenged sooner. Earlyinvolvement helps ensure that you andthe analyst have a sharedunderstanding of the project.

Involving analysts closely with theproject, rather than an externalfunctionThis close involvement ensured theanalysts had a greater understanding ofthe purpose of the projects, and theanalyst could input into the project goalsto ensure the aims are measurable andachievable. It is also valuable, as it mayreveal other sources of information orapproaches which may be unknown tothe project team.

Seek formal support from theanalyst and managerAnalysts are often seen as a valuableresource, and as such their time may beprotected. Some sites have founddifficulties in maintaining analyst supportin projects due to competing pressureselsewhere in the organisation. Sites haverecommended that you ensuremanagement support is in place for theimprovement work, ensuring that analysttime is made available to support yourwork.

Look widely for your supportPeople with access and expertise to datamay not always be in analyst roles. Siteslooking for information may wish tocontact performance managers, clinical

coders, data managers and contractmanagers, who exist in a variety of roles,supporting the management of PCTs andProvider trusts, with access to data beinga core part of their roles.

Be clear on data requirements toinformation departmentsIt helps to explain what you are trying tomeasure or demonstrate, as they may beable to suggest alternative indicators. Aswell as information analysts, involve allthose involved in delivering care tocontribute to a data collection plan.

Smoking profile tool example

57Newham LTOT pathway

Newham LTOT pathway

Appendices

The following appendices are an initialsample collection of resources (letters topatients, care pathways and algorithms,assessment forms etc.) which may provehelpful to other NHS colleagues about toembark upon similar work. This initial setof resources will be substantially added towhen the final publication marking theend of the project cycle is published.

IMPORTANT NOTE: Locally reviewed refers to the dateof completion of the most recent review process for apathway. All pathways are reviewed every twelve months,and on an ad hoc basis if required. Due for review refersto the date after which the pathway on this page is nolonger valid for use. Pathways should be reviewed beforethe due for review date is attached.

Long term oxygen therapy (LTOT)Newham Development Zone > Thoracic medicine > Home oxygen therapy (HOT)

Royal Free/Waltham Forest PCT/NECLES HIEC - Flow chart58

Royal Free/WalthamForest PCT/NECLES HIECFlow chart

59Royal Free/Waltham Forest PCT/NECLES HIEC - Invitation letter to patients

Royal Free/WalthamForest PCT/NECLES HIECInvitation letter to patients

DearRe: NHS Improvement - LungI am writing to invite you to join this new initiative that is being developed nationally toimprove the care and services we deliver to people with lung disease. In Waltham Forestwe are specifically offering an opportunity to people who have been prescribed oxygen tomanage their breathlessness. Extensive research has shown that whilst oxygen is linkedto breathlessness, there is negligible evidence to show that it is of benefit. Unfortunatelydependence on oxygen frequently occurs which prevents patients developing techniquesand skills that enables them to manage their breathless more efficiently -without the useof oxygen.I would like to offer you the opportunity to work with a Respiratory Specialist to help youto develop breathing techniques which enable you to improve the control yourbreathlessness.This will be managed through a time table of home visits to:• Discuss your use of home oxygen.• Offer full assessment of your requirement for oxygen therapy• Teach you techniques to manage your breathlessness and review your progress atregular intervals.

• Address your concerns and work with you to build your confidence in the selfmanagement of your breathing without the use of oxygen.

You will be supported throughout the process and encouraged to monitor and discussyour development at each stage. When this point has been reached, with your agreementthe oxygen will be withdrawn. You will continue to receive support visits and telephonesupport for six months. If you feel you are unable to allow the withdrawal of the oxygenyou will be offered an appointment with a Respiratory Consultant for further discussionand assessment.I hope you will take up this unique opportunity that has the potential to make a realdifference to the management of your breathlessness. If you do not wish to take partplease call me on 0208 430 8255. This decision will not affect your usual care.I look forward to working with you.

Yours sincerely

Anne CrawfordRespiratory Nurse SpecialistTeam LeaderWaltham Forest Respiratory Services

Waltham Forest Respiratory ServiceTelephone: 020 8430 8255/8266

NHSOuter North East London

Community Services

Royal Free/Waltham Forest PCT/NECLES HIEC - Patient proforma60

Royal Free/WalthamForest PCT/NECLES HIECPatient proforma

61Royal Free/Waltham Forest PCT/NECLES HIEC - Follow-up proforma

Royal Free/WalthamForest PCT/NECLES HIECFollow-up proforma

Wirral COPD and Oxygen Service process map62

Wirral COPD and Oxygen Service Process Summary’

63NHS Birmingham East & North process map - Current state

NHS Birmingham North & East process map - Current state

NHS Birmingham East & North process map - Future state64

NHS Birmingham North & East process map - Future state

65Acknowledgements

NHS Improvement - Lung would like tothank all national improvement projectsites for their hard work and dedicationto improve quality and care for peoplewith COPD, and for their contributions tothis document.

Sincere thanks goes out to the membersof the publication working group namely:

• Bob Arora, NHS Newham• Denise Williams, Wirral COPD and

Oxygen Service• Yvonne Richards, NHS Birmingham

East and North• Rahul Mukherjee, Birmingham

Heartlands Hospital• Heidi Wilkinson, South Staffordshire

PCT• Sally Young, South Staffordshire PCT• Joan Manzie, South Staffordshire PCT• Sue Channon, NHS Milton Keynes• Toni Yel, NHS Hull• Julie Danby, Hull City Health Care

Partnership

Acknowledgements

In addition, the following people haveprovided a source of expertise andsupport and their help is gratefullyacknowledged:

• Phil Duncan, Director, NHSImprovement - Lung

• Alex Porter, Senior Analyst, NHSImprovement - Lung

• Zoe Lord, National ImprovementLead, NHS Improvement - Lung

• Catherine Blackaby, NationalImprovement Lead, NHSImprovement - Lung

• Catherine Thompson, NationalImprovement Lead, NHSImprovement - Lung

• Hannah Wall, National ImprovementLead, NHS Improvement - Lung

• Sandie Bisset, Home Oxygen Service,Department of Health

• Hamza Jamil, Home Oxygen Service,Department of Health

• Viv Smith, NHS Western Cheshire,Home Oxygen Services RegionalOxygen Lead for Cheshire & Merseyside

• Karen Hatch, NHS Central Lancashire,Regional Oxygen Lead - Cumbria &Lancashire and Greater Manchester

• Judith McElroy, NHS Blackburn withDarwen, Oxygen Service Manager andHome Oxygen Service Lead

For more information please contact:Ore Okosi, National Improvement Lead:[email protected]

1. Department of Health. Consultationon a Strategy for Services for ChronicObstructive Pulmonary Disease(COPD) in England. Department ofHealth, 2010.

2. Department of Health. Consultationon a Strategy for Services for ChronicObstructive Pulmonary Disease(COPD) in England: ConsultationImpact Assessment. Department ofHealth, 2010.

3. British Thoracic Society (BTS) WorkingGroup on Home Oxygen Services.Clinical Component For The HomeOxygen Service In England and Wales.British Thoracic Society, January 2006.

4. Department of Health. Home OxygenService – Assessment and Review:Good Practice Guide. Department ofHealth, DRAFT of 14 May 2010.

5. National Clinical Guideline Centre.(2010) Chronic obstructive pulmonarydisease: management of chronicobstructive pulmonary disease inadults in primary and secondary care.London: National Clinical GuidelineCentre.

6 . IMPRESS - Improving and IntegratingRespiratory Services in the NHS.Rationalising oxygen use to improvepatient safety and to reduce waste:The IMPRESS step-by-step guide.IMPRESS, September 2010.

7. NHS Connecting for Health. BrochureLSD08088 Home Oxygen4: OpenExeter and Home Oxygen.

8. NHS Business Services Authoritywebsite. NHS Prescription Services,Home Oxygen Therapy ReportsOverview. Accessed 24th February2011www.nhsbsa.nhs.uk/PrescriptionServices/1990.aspx

9. NHS Home Oxygen Service. HomeOxygen Service Manual, Version 2(July 2007).

10.Department of Health. Home OxygenService – Assessment and Review:Good Practice Guide. Department ofHealth, Final version 24th November2010.

References

References66

NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHS ImprovementNHS Improvement’s strength and expertise lies in practical service improvement. It has overa decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart,lung and stroke and demonstrates some of the most leading edge improvement work inEngland which supports improved patient experience and outcomes.

Working closely with the Department of Health, trusts, clinical networks, other health

sector partners, professional bodies and charities, over the past year it has tested,

implemented, sustained and spread quantifiable improvements with over 250 sites across

the country as well as providing an improvement tool to over 800 GP practices.

Delivering tomorrow’simprovement agendafor the NHS

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improving home oxygen services: emerging learning from the national improvement projects

Health & Medicine