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.
3Improving Home Oxygen Services - EmergingLearning from the National Improvement ProjectsContentsForeword 4Executive summary 5Emerging learning 9Phases of work 9Data review and management 9Establishment of a formal assessment service 11Service integration and sustainability 13Testing hypothesis 14Emerging learning 14Issues and challenges 15Improvement stories 16NHS Newham and Newham University Hospital NHS Trust 16Royal Free/Waltham Forest PCT/NECLES HIEC 19West Hertfordshire COPD Service 23NHS Sheffield 26NHS Hull and the City Health Care Partnership 28NHS Gloucestershire 31Milton Keynes PCT Community Services and Milton Keynes Hospital 33NHS Blackpool 37Wirral Integrated Oxygen Service 39Sherwood Forest Hospitals and NHS Nottinghamshire County Community COPD Team 43NHS South Staffordshire 46NHS Birmingham East and North and Heart of England NHS Foundation Trust 49Appendices 53Data for improvement projects 53Newham LTOT pathway 57Royal Free/Waltham Forest PCT/NECLES HIEC Flow chart 58Royal Free/Waltham Forest PCT/NECLES HIEC invitation letter to patients 59Royal Free/Waltham Forest PCT/NECLES HIEC patient proforma 60Royal Free/Waltham Forest PCT/NECLES HIEC follow-up proforma 61Wirral COPD and Oxygen Service Process Map 62NHS Birmingham East and North Process Map (CURRENT STATE) 63NHS Birmingham East and North Process Map (FUTURE STATE) 62Acknowledgements 65References 66
4 ForewordForewordSince July 2010, NHS Improvement – The publication also contains informationLung has worked with a number of for healthcare professionals and thoseclinical teams across England as part of working in commissioning or interfacingthe Department of Health Respiratory with COPD services. This includes thoseProgramme. Its aim has been to support who are:the development of patient centred, • Involved in the care of patients whoevidenced based and clinically led services require COPD servicesby identifying and sharing innovative • Responsible for commissioning COPDways to reduce variations in care and servicesimprove the quality and experience of • Managing COPD services Professor Sue Hillpatients with chronic obstructive • Local or regional leadspulmonary disease (COPD). The project sites were encouraged toThe national improvement projects have employ a range of service improvementtested approaches at key stages of the tools and techniques. These includedclinical pathways which have included: process mapping, demand and capacity• Improving home oxygen services and data analysis, the application of Lean• Early accurate diagnosis principles, process redesign and the• Transforming acute care human dimensions of change. NHS• Managing COPD as a long term Improvement - Lung also supported the condition testing of new ideas and pathways• Improving end of life care through site visits and project team peer support.Following the first six months of the Dr Robert Winterimprovement programme, this There are lots of practical examples withinpublication signals the mid-way point in this report to support clinical teams inthe project cycle and has been written to delivering quality and productivityshare the learning from the testing phase benefits to patients and a wider range ofof the work. Through a series of case stakeholders. Over the next six months,studies and examples, it aims to highlight NHS Improvement – Lung will continue toareas of innovative and emerging good test the key principles for change andpractice that can be used locally to deliver implementation. As this learningimprovements for COPD patients and emerges, it will be shared with COPDtheir carers. services and the wider NHSIn order to address the paucity of current We would like to take this opportunity toevidence, particularly around the models thank the project sites for their hardand principles of implementation, the work, dedication and commitment andprogramme will continue to adapt and look forward to the full extent of therefine the learning. However, these improvement work as it comes to fruition.lessons will be of value now to any teamworking to improve the care it deliversand commissions for people with COPD. Professor Sue Hill Dr Robert WinterThis publication contains a number of Joint National Clinical Directorsexamples that demonstrate value for for the Respiratory Programmemoney, increased productivity andapproaches that can sustain improvementsover the long term.
Executive summary 5Executive summaryNational position and Thus the overarching aim of this This has led to a workstream 1/3 Ruleworkstream context workstream is that patients receive Savings, testing a hypothesis which accurate quality assured oxygen therapy states:Home oxygen therapy is provided to through optimised assessment and reviewabout 85,000 people in England at a cost models which ensure the right people are ‘One third of the total costof approximately £110 million a year1. in receipt of the right dose of oxygen efficiencies (savings and avoidance) therapy. can be realised through the firstMany Primary Care Trusts (PCTs) do notundertake quality assured clinical In developing the project outline the phase of a three phase process withassessment and review of their patients scope of the project work was framed efficiency gains reaching a plateauneed for long term home oxygen such that teams would consider: and prescribing costs capped byincreasing the potential for poor quality implementation of all three phases.‘care and waste. • The most appropriate (competent) staff to undertake assessment and reviews Placing an emphasis on the assessment ofThe Department of Health estimates that • Assessment and review location clinical need, and ongoing clinical review,around 30% of people prescribed oxygen settings provides an opportunity for healthcareeither derive no clinical benefit from it or • Guidance on correctly documenting professionals to more comprehensivelydo not use their oxygen2. Quality and and interpreting diagnostic results inform and educate patients about theirproductivity in the home oxygen service • Guidance on accurately prescribing condition. In addition if home oxygencan be improved significantly. Gross oxygen therapy is deemed appropriate then thissavings of up to 40% - equivalent • Providing the patient with written interaction also facilitates patientnationally to £45 million a year, or information regarding their oxygen education about equipment use, risk and£300,000 per PCT can potentially be therapy their own responsibilities as regards theachieved according to recent analysis safe use of oxygen at home.carried out by the Department of Health The project teams made extensive use ofthrough the established of home oxygen British Thoracic Society Home Oxygen Project teams will use or develop easy-to-services and oxygen register review and Services Standards3 and early drafts of the read, quality literature to educate patientsformal clinical assessment4. Department of Health Good Practice about the appropriate use and potential Guide4. In addition to the above the (fire) safety risks associated with usingThe rationale for the work of the project project teams have also utilised the work oxygen at home.teams is provided by recommendation 14 of NICE5 and IMPRESS6 to inform theirof the Chronic Obstructive Pulmonary thinking. This educational process is in alignmentDisease (COPD) Strategy Consultation with recommendation 11 of the Chronicdocument1, which states: Summary of emerging learning Obstructive Pulmonary Disease (COPD) Strategy Consultation document1, which‘All people with COPD and Early indications are that the project work states:hypoxaemia should be clinically spans three phases:assessed for long-term oxygen ‘Good-quality information should 1. Data review and data management be provided at diagnosis andtherapy and reviewed at regular 2. Establishment of a formalintervals, and existing home oxygen assessment service delivered in a format that anyregisters should be reviewed’. 3. Service integration and person can understand’ sustainability
6 Executive summarySome emerging themes arising from the Royal Free/Waltham Forestwork to date include: PCT/NECLES HIEC Introduced a review of all COPD short• Data coordination - Clinical team burst oxygen therapy (SBOT) prescriptions access to data and collaboration in the Waltham Forest PCT area offering between clinical and managerial/ patients full assessment of their administrative staff to review/challenge requirement for long term oxygen and oxygen patient data counselling or advice on alternative• Consistent messages to patients - In interventions for the management of rationalising local oxygen services breathlessness and the supported project teams have been engaging GPs withdrawal of the oxygen supply. and other healthcare professionals (HCPs) to develop a consensus in West Hertfordshire COPD Service respect of the appropriate initiation of Introduced a system of identifying home oxygen therapy for COPD healthcare professionals inappropriately patients. This is often summarised by prescribing home oxygen to patients with the simple message that ‘oxygen is not normal oxygen levels and undertaking a treatment for breathlessness’ targeted group education around good Milton Keynes PCT Community• Service integration - This is achieved practice in prescribing. Services and Milton Keynes Hospital by developing a pathway and Introduced pre and post of clinic set up prescribing consensus between the NHS Sheffield evaluation for the ambulatory oxygen home oxygen service assessment and Developed a detailed business case assessment clinic and also a quality review (HOS-AR) team, GPs, and service specification for integrated patient questionnaire pre and post use of commissioners and non respiratory HOS-AR in line with best practice. In patient information leaflet to see if specialists. This leads to the alignment addition, they introduced a system of patient experience improves. of the HOS-AR service specification oxygen usage data coordination and within a wider respiratory care pathway review in order to control prescribing NHS Blackpool and improved patient safety risk costs. Developed a an accurate oxygen usage assessment which is enshrined within a register and systematic use of data to wider (PCT) governance framework NHS Hull/City Health Care Partnership manage performance and extended Introduced a new commissioned HOS-AR formal assessment and review by theSummary of site projects service and so the project work provided introduction of HOS-AR based within a an opportunity to monitor improvements community setting.NHS Newham and Newham to the delivery of appropriate and cost-University Hospital NHS Trust effective oxygen therapy to COPD Wirral Integrated Oxygen ServiceEstablished a system of oxygen usage patients and develop safety protocols and Developed oxygen care pathways for nondata coordination and review in order to procedures through a multi-stakeholder COPD patients in collaboration with noncontrol prescribing costs and performance project group. respiratory specialist colleagues. Inmanage suppliers. In addition, they addition, they developed systematic riskintroduced systematic review of existing NHS Gloucestershire escalation procedures and protocols.acute hospital oxygen clinic patients and This team has focussed on developing adeveloped plans and protocols for future detailed business case and service Sherwood Forest Hospitals and NHSintegrated home oxygen service - specification which incorporates best Nottinghamshire County Communityassessment and review (HOS-AR) practice and learning from more established COPD Teamspanning primary and secondary care. teams on issues such as workforce and Established multidisciplinary HOS-AR competences, set-up and ongoing costs, within a community setting and data management and governance. collaborated with GPs and PCT managers to review oxygen usage.
Executive summary 7NHS South Staffordshire already undertaken on Quality Innovation • Introduction of HOS-AR - establishingDemonstrated the quick win potential of Productivity and Prevention (QIPP) a cycle of assessment and review,systematic review of oxygen usage data programme and the additional improvement of an existing service toin order to re-categorise costing and alter opportunities presented in the Equity and the standard articulated within thetherapy to achieve prescribing efficiencies Excellence: Liberating the NHS. Good Practice Guide, introduction of awithin one locality. This approach will new service to a locality in whichnow be extended across the PCT. In relation to the QIPP challenge, the NHS HOS-AR currently absent has been developing proposals to • Patient education packages - safetyNHS Birmingham East & North and improve the quality and productivity of its and risk considerations explained toHeart of England NHS Foundation services since the challenge was first patients and carers, captured withinTrust articulated in May 2009. The proposal is easy-to-read literature and mutualIntroduced transparent systems for to ensure that the NHS continues to responsibilities (both patients andsharing information relating to home make quality improvements a reality healthcare professionals) understoodoxygen users across the local health during a period in which growth in and documented within localeconomy and a pathway with guidelines expenditure within the NHS will be agreement documentssupporting the process of initiating restricted despite increasing demand. • Pathways for the treatment of nonoxygen therapy for new patients and COPD patients on oxygen -withdrawal/cessation where appropriate. Many of the measures outlined in this engagement of generalists and non document are designed specifically to respiratory specialists to establishQuality, Innovation, Productivity and support the NHS to meet the QIPP optimal care pathways for non COPDPrevention (QIPP) and expected challenge, either by identifying where patients in need of home oxygenoutcomes resources might be released or by therapyThe demand for services is increasing and improving understanding of the key • Principles of a good service model -there are areas where we could increase interventions that have greatest effect. development of new ways of workingthe quality, efficiency and value for by examining use of different types ofmoney of services as well as improving The work has demonstrated that the workforce along the pathway inoutcomes for people with chronic annual total spend across nine project different settingsobstructive pulmonary disease (COPD). sites can be reduced by a minimum of • Effective use of data – collaborationFocus needs to be centred on these three £600k. This applies for both new and between clinical and managerialfactors to make this a reality. First, established home oxygen services who professionals to integrate, review andimproving quality whilst improving implement oxygen usage reviews and interpret financial, administrative andproductivity by enforcing the principles of therapy optimisation. On a national scale, clinical data in order to optimise care,the Quality, Innovation, Productivity and the work compliments the Department of rationalise prescribing, overseePrevention (QIPP) agenda by using Health estimated gross savings of up to governance and performance manageinnovation and prevention to drive this 40% for each PCT. the oxygen suppliersforward and interlink these values.Secondly, having local clinicians and The expected outcomes in these project Potential for future workmanagers working together in a sites will be: The initial quick win cost efficienciesmultidisciplinary approach and across • Minimum of £600k prescribing attributable to the first phase of HOS-ARboundaries in order to spot the savings - achieved through therapy improvement work (data review and dataopportunities and manage the change. rationalisation, list cleansing, avoidance management) are becoming self evident.And thirdly, to act now, for the long term. of inappropriate prescribing and However, more work is needed to withdrawal of clinically unnecessary conclusively establish that the 1/3 RuleThe goal is to achieve efficiency savings therapy Savings hypothesis has been verified,of up to £20 billion for reinvestment over specifically in relation to the costthe next four years. This represents a very efficiencies realisable from thesignificant challenge to be delivered establishment of HOS-AR and by itsthrough the detailed work the NHS has integration within the broader service commissioning framework.
8 Executive summaryIn addition, further narrative is needed non COPD patients, often challengingaround the demonstrable benefits in colleagues when they appear not to bequality of care patients may derive from adhering to their own specialty areaoptimised home oxygen therapy. The guidelines. Thus there may be scope foreffective use of administrative, financial future projects to more thoroughlyand clinical data relating to oxygen usage investigate the potential cost savingsfurther promotes the use of disease achievable from rationalisation of homeregisters and flags up opportunities for oxygen therapy in non-COPD patients.more effective patient record linkage. Future work will also thoroughly explore Phil DuncanAn identified gap in the current work is and test ‘how to’ implement a gold Director, NHS Improvement -establishing whether or not improved standard pathway of HOS-AR as defined Lungcare resultant from formal oxygen by the Good Practice Guide in terms ofassessment and review results in fewer new services, but also in relation toadmissions to hospital. Although initial driving up quality for existing services.workstream metrics were devised toexplore this, linking information about Finally, further consideration will beindividual patients in receipt of home given to the following areas:oxygen with information from hospital • Stakeholder engagementpatient administration systems continues • Developing local incentives toto present a challenge. commission HOS-AR • Varying the workforce employed atThe reasons why a patient with COPD is different parts of the pathwayadmitted to hospital are varied and in • Describing optimal models of care in Ore Okosiaddition COPD patients on long term urban/rural geographies National Improvement Lead, NHS Improvement – Lungoxygen tend to have more severe disease • Developing a consensus aroundand thus and increased risk of provision/withdrawal of home oxygenhospitalisation. As such it may not be to persistent smokers who have apossible to establish whether optimised clinical need for oxygenhome oxygen therapy resultant from • Establishing ownership of HOS-ARsystematic clinical assessment and review governance and performanceis an effective admission avoidance management within the emergingstrategy. However, this topic is certainly commissioning structuresworthy of more consideration in future.Many HOS-AR teams have begun toestablish effective dialogue with non- Phil Duncanrespiratory specialists in respect of the Director, NHS Improvement - Lungmanagement of non COPD patients inreceipt of home oxygen therapy. As those Ore Okosirelationships mature, the HOS-AR teams National Improvement Lead,have been able to explore with their non NHS Improvement - Lungrespiratory colleagues the reasons forinitiation of home oxygen therapy in
Emerging learning 9Emerging learningPhases of work Data review and data Don’t forget ‘better’ is not measureable. ‘More’, ‘faster’, ‘safer’ or ‘cheaper’ can allIn attempting to broadly categorise thetype of work being undertaken by the management be measured but only if you know how The overwhelming message from all many, how fast, how dangerous or how12 ‘improving home oxygen services’ expensive things were to begin with. Wenational project teams it has been useful national chronic obstructive pulmonary disease (COPD) project sites in all need to establish factual data andto think in terms of three phases: measures to demonstrate what has been workstreams (not just oxygen) when starting improvement work was that achieved.1.Data review and data management• Data access there was difficulty in getting hold of data and information. As the COPD How did oxygen sites work• List cleansing with data?• Invoice reconciliation with projects commenced, sites reported limited access to data on their day to day Project teams grappling with this phase concordance reports spent much of their time ensuring all• Case prioritisation activity, and very poor access to overall information covering the respiratory appropriate staff had access to the full pathway. range of information available and then2.Establishment of a formal developing effective ways of utilising this assessment service information in order to understand and• Address assessment backlog Fortunately, there are many resources available that can support COPD project modify local processes and ensure• Establish assessment and review cycle financial control.• therapy modifications sites understand and compare their local• Withdrawals respiratory services with others, and many of these are freely and easily accessible. This included information provided by• Education oxygen suppliers and or PCT/regional Local data on oxygen can be combined home oxygen service (HOS) leads in the3.Service integration and form of quarterly concordance reports, sustainability with nationally available data on secondary care and primary care in order monthly invoices, copies of completed• Robust referrals home oxygen order forms (HOOFs) and• Multidisciplinary team process to build up a picture of local services. bespoke performance reports. mapping resulting in agreed pathway• Demand matches capacity Why is data important? Data and measures are important to In order to provide oversight in respect of• Service specification aligned with both clinical appropriateness and financial governance and commissioning demonstrate that change has occurred or needs to occur. NHS Improvement - Lung control it is necessary for clinical members• Effective communication with of the home oxygen service assessment healthcare professionals, patients and focuses on the delivery of quality measured improvements which are and review (HOS-AR) team to be able carers review individual patient details contained aligned to national priorities and strategies. In line with the national within the completed HOOFs received byIn reality, many project teams have the oxygen supplier.undertaken activities in parallel and so Quality Innovation Productivity andmay span these phases which are now Prevention (QIPP) initiative, it is essentialoutlined in more detail. that all system changes are measured and recorded. Whether the change was a success or did not demonstrate the anticipated outcomes, you still need to demonstrate its effect and learn from it.
10 Emerging learningGaining access to home oxygen Implementing ongoing monitoring Data reconciliationorder form data for oxygen Open Exeter enables the reconciliation ofNHS Connecting for Health provides The NHS Home Oxygen Service Manual9 monthly files of invoices from the Homedesignated users (authorised by individual states that in order to effectively monitor Oxygen suppliers against the patientsPCTs) on-line access to individual patient activity within the home oxygen service, recorded in their NHAIS system7.HOOFs held on the National Health PCTs need to have in place a systemApplications and Infrastructure Services capable of capturing a range of The system uses information contained(NHAIS) system database via Open Exeter information about each patient on receipt within the completed HOOF to calculatea web-enabled viewer7. of oxygen, specifically: the appropriate cost band from the specified delivery mechanism, the numberNew users have to complete a Data Users • Who oxygen was ordered for of litres/hour and the duration and thisCertification Form (available from • Date of birth can be checked against the cost bandwww.connectingforhealth.nhs.uk/nhais/ • NHS number invoiced by the supplier7.products_and_services/vaprodopenexe) • Patient’s GP practiceand get the form authorised by the PCT • Who placed the order Open Exeter has a suite of reports which(or shared services agency) data controller • When was the order placed support data reconciliation:who will then process the form on-line or • What was orderedforward it for authentication. • Urgent, next day or standard supply • Deducted patients by • Primary or secondary supply • Patients not found on the NHAISGetting access to oxygen cost data • Flow rate • Inconsistent cost bandsIn addition to Open Exeter, the majority • Hours per day • Identical provisions for patient at sameof PCT home oxygen service leads and • Status (new or existing patient) addressmedicines management teams have • Estimate of cost • Cost band totals by practiceaccess to on-line home oxygen therapy • Holiday ordersreports from the NHS Business Services The Wirral and Milton Keynes project • EmergencyAuthority Prescription Pricing Division teams have each had to independently • Light weight ambulatory orders(NHSBSA PPD). develop local ‘databases’ which enable • HOOF entered but not matched to a the HOS-AR team to monitor service supplier order recordThese reports provide information on the activity but with limited ability to link • No HOOF entered for supplier orderpayments made to suppliers for provision information from other clinical recording recordof oxygen and differentiate payment sources to specific oxygen data sources.claims made for the supplier in respect of The improvement stories from the Hull,patients residing within the contracted A key component of their work has been Sheffield, Sherwood Forest and BlackpoolPCT area and claims for out-of-area to establish a system of HOOF project teams are all examples of howpatients8. management which ensures that there is clinical team members developed an either a centralised or a coordinated understanding of the prescribing costAccess to these reports is obtained by approach to HOOF completion and that categories.completing a PCT prescribing reports user copies of all HOOFs are available for theregistration form and sending it a signed clinical specialists to review. They also illustrate clinical and non-letter from the PCT senior officer to clinical colleague collaboration in order toInformation Services Department of NHS undertake the almost forensic analysis ofPrescription Services in Newcastle. modalities of oxygen supply associatedwww.nhsbsa.nhs.uk/PrescriptionServices/ with individual patients.3091.aspx
Emerging learning 11Armed with this information the clinicians The South Staffordshire project teamwere able to work alongside other non have illustrated the quick win productivity Establishment of aclinical colleagues in order to: gains achievable through primarily this formal assessment first phase of work.• Identify patients in receipt of oxygen service who are not known to the specialist This team joined the programme five This work centres on trying to ensure that team months into the first phase of the project all patients currently in receipt of oxygen• Reconcile invoice information with cycle and over the course of two months are receiving care management in information held on local systems undertook an inspection of individual alignment with published standards on• Review patients on multiple modalities patient oxygen usage data (and other assessment and frequency of review.• Scrutinise the various charge bands recorded clinical information) for 91• Ensure deceased patients were Cannock Chase locality patients known Following the data exercises undertaken removed from lists to the community COPD team. in phase one it is possible to identify in• Stop charges arising from the supply receipt of oxygen but unknown to the of oxygen to patients living outside The data inspection was coupled with specialist team. the PCT catchment area telephone patient contact and face-to-• Set up patient recall and review systems face review in a limited number of Using this information together with• Identify non-usage, under-usage, instances. information about the existing specialist over-usage team caseload and the volume of new• Identify sources of inappropriate As a result, 10% of patients were moved referrals for a formal assessment. Some prescribing within both primary and to a less expensive tariff with forecast analysis of demand and capacity can be secondary care individual savings in excess £1,000 per undertaken in order to inform clinic year, the total annual forecast cost scheduling/home visits necessary toData management and QIPP savings attributable to the review of the address the backlog of previouslyThe NHS Newham project team cite their 91 patients in Cannock Chase locality unassessed patients.use of the Open Exeter reporting function amounted to £57,573.in validating monthly supplier costs and These patients are contacted by therealised productivity savings of £12,057 Cannock Chase is only one locality within project team in order to arrange iffrom April to November 2010 purely from South Staffordshire and so the PCT is necessary a review and therapy altered oraccurate data management. exploring whether even greater withdrawn if deemed inappropriate. productivity gains can be achieved if thisThis included removal of deceased approach was spread to other localities. This phase involves liaison with thepatients, removal of duplicated patients patient’s GP surgery as many existingand removal of out of area patients. oxygen patients received therapy as a result of a GP completing the originalThe improvement stories contained home oxygen order form (HOOF).within this publication illustrate theeffectiveness of clinicians working incollaboration with managerial andadministrative colleagues (especially thedesignated PCT home oxygen servicelead) in respect of the financialreconciliation process.
12 Emerging learningThe Department of Health Good PracticeGuide10 sets out very clearly and Part of the Oxygen Care Pathway from the Home Oxygen Service –comprehensively the gold standard Assessment and Review: Good Practice Guide. Department of Health,pathway for oxygen assessment and Final version 24th November 2010review. A condensed summary of the • Access exercise capacitypathway is set out below: • Access adequate correction of exercise de-saturation • Determine flow rate • Discuss with patient if immediate ambulatory supply or derfer until later1. Referral to formal assessment service • Assessment of social situation and referral to social services if required following determination of • Assessment of compliance hypoxaemia using pulse oximetry Full assessment Discuss HCP led (SaO2 level is below 92%) • Hypoxic • Borderline oxygen LTOT assessment Consider assessment for additional equipment options with Educational session with Completed HOOF sent to HOS assessment ambulatory oxygen patient/carer provider2. Full assessment for long term oxygen • Complex patient therapy (LTOT) including spirometry • Confirm hypoxaemia • Spirometry • Arrange training for carer if not in and measurement of arterial blood • ABG • CO2 retention - attendance • Provide written Discuss follow-up gases (with LTOT prescribed for 15 consider need for NIV patient information • Patient to confirm arrangements and book first understanding appointment hours per day in clinically stable of training patients where the arterial blood Check oximetry if not No hypoxaemia B F transfer back oxygen measurement is at or below yet done to referrer Inform/GP consultant and 7.3kPa, or under 8kPa if oedema referring HCP of management plan present)3. Determination of safety, flow rate and Borderline cases C SaO2 92-93% duration of oxygen for patients in G whom oxygen is indicated4. Further assessment (if appropriate) to determine the patient’s capacity for exercise, and whether they should be prescribed additional ambulatory Models of service: The clinical teams The Sherwood Forest team operate a oxygen within this initial cohort of oxygen model which involves specialist5. Clinician orders appropriate oxygen projects are varied in terms of their assessment available from community supply device from oxygen suppliers locations and workforce composition. clinic locations. following discussion with patient6. Follow-up home visit should be The Hull, Wirral and West Hertfordshire The Wirral project team operate from undertaken at four weeks by a project teams are all led by respiratory specialist clinics and more recently have healthcare professional to assess the nurse specialists in contrast to the begun undertaking clinical reviews from patient’s clinical status, compliance Sherwood Forest and Birmingham East within GP surgeries in order to evaluate with the oxygen therapy regime and and North teams which are led by a this approach in terms of reducing the to determine whether further action is clinical scientist and a consultant number of patients who fail to attend necessary respiratory physician respectively. their scheduled consultation.7. Regular clinical status reviews should be undertaken However, all the teams do operate within The Newham project team are developing a. Every six weeks after admission a multidisciplinary framework with a mixed model which utilises both or exacerbation different workforce competences secondary care specialists and community b. Every six months oximetry should available at various points in the care matrons at different point within the care be carried out pathway. pathway and facilitated by the use of c. Every twelve months patients point-of care arterial blood gas testing should have their arterial blood equipment. gases measured.
Emerging learning 13The choice of model being tested and Hertfordshire COPD service are also In attempting to establish a moredeveloped often reflects the geographical attempting to ensure sustainable financial integrated model of care, teams have hadconsiderations of the area with Acute management by educating GPs about the to overcome perverse incentives withinHospital clinics being the locations of benefits of formal assessment. ‘payment by results’ which mightchoice within the more compact and potentially encourage duplication,highly urbanised Birmingham setting in Teams such as the Wirral COPD and redundant processes or unnecessary stepscontrast to community clinic settings Home Oxygen Service are engaging non- in pathway.being considered by more dispersed respiratory specialists in discussionspopulations such as NHS Gloucester. around the care pathway for patients NHS Birmingham East and North are receiving oxygen for non COPD related developing a local payment tariff whichAt a recent peer support meeting the conditions and jointly developing care will encourage multidisciplinary working12 national project teams reached a pathways. by both being fair compensation to theconsensus as regards models of service service provider and financiallydelivery which is encapsulated within the Having achieved significant therapy sustainable by the commissioner.phrase ‘Varied models but standardised changes and therapy withdrawals amongprocesses’. This means strict adherence to existing oxygen patients, through the In developing a new service or model ofbest practice as articulated within the work of phases one and two, teams such care it is important to ensure clarity at theDepartment of Health Good Practice as Hull and Wirral have begun to tackle outset in relation to costs. InvolvementGuide but flexibility in respect of location the challenge of addressing therapy with this programme of work enabledand staffing. modification in patients who resisted all NHS Gloucestershire to significantly initial invitations for clinical review and re-evaluate their business case.Service integration and ensure patient safety risks uncovered by the earlier work is documented and The NHS Improvement - Lung seniorsustainability integrated within the wider analyst was able to guide them on howA number of the project teams are organisational risk management to use their own quarterly concordanceattempting to leverage the oxygen cost framework. report data to understand potentialsavings achieved through rationalisation patterns of service demand.of processes to raise the profile of oxygen The NHS Birmingham East and Northservices among local commissioners. team are ensuring that safety risk In addition, the Gloucester project lead recording and follow-up procedures are was able to review the serviceIn areas such Sheffield and Gloucester the firmly established within the existing PCT specifications of more established teamstype and scope of oxygen service was not governance framework in order to ensure and through interaction with colleaguespreviously well defined within local transition to the newly emerging GP during regular peer support meetingsrespiratory service specifications. The commissioning consortia. gain greater insight in to workforceproject team were subsequently given an considerations.opportunity for the local health economy However, the risks are not just thosestakeholders to collectively address this by associated with patient safety, there are This dialogue also enabled previouslyutilising the emerging learning from the also financial risks posed by poor data unconsidered ‘hidden costs’ (such asproject work and the Department of management and coordination. equipment upkeep) to be identified.Health Good Practice Guide to informnew business cases or revise service Project teams such as Sherwood Forestspecifications. are devolving oxygen prescribing budgetary management to GP localities inThe quick win cost savings achievable by order to preserve the discipline ofundertaking phase one work is obviously financial management during the localattractive to commissioners but the more NHS transition and further engage GPs inestablished teams such as the West discussions around the care pathway.
14 Emerging learningTesting hypothesis Emerging themes Consistent messages to patients – In rationalising local oxygen services projectCost savings have been achieved by a Data coordination – In order to ensure teams have been engaging non-number of project teams. Teams such as tight financial control and appropriate respiratory specialists, GPs and otherSheffield, South Staffordshire (Cannock oxygen prescribing the home oxygen healthcare professionals in order toChase locality) and Newham have realised service - assessment and review (HOS-AR) develop a local consensus in respect ofsignificant quick win cost savings team need to liaise effectively with oxygen therapy initiation.attributable to the first phase of work managerial and administrative staff towith forecast annual savings of £120K, jointly review information contained Much of this engagement has taken the£57.5K and £12K respectively. within oxygen supplier concordance form of education in respect of the reports and monthly invoices. benefits of formal assessment, the healthWhilst project teams with more and safety considerations and wasteestablished HOS-AR teams such as Hull, Collaboration between designated PCT incurred by inappropriate prescribing.Wirral and West Hertfordshire either home oxygen service (HOS) leads andcontinue to achieve a reduction in HOS-AR teams has enabled supplier Project teams have identified thatspending (as compared with the period reports to be used effectively, picking up inappropriate prescribing occurs in bothprior to the service being established) or anomalies within prescribed oxygen and primary and secondary care and so teamsexperience very modest fluctuations in challenging unnecessary multiple such as the West Herts COPD servicemonth-on-month costs. modalities. undertook targeted educational visits as part of their cost avoidance strategy.The following hypothesis is now being Some HOS-AR teams have establishedtested by the workstream: agreements with local primary and During the periodic peer support secondary care stakeholders that they act meetings facilitated by NHS Improvement1/3 Rule Savings: one third of total cost as ‘gatekeeper’ for the completion and - Lung the 12 project teams jointlyefficiencies (savings and avoidance) amendment of the home oxygen order identified two simple messages that allrealised through first stage of three stage form (HOOF). project teams need to reinforce withinprocess with efficiency gains reaching a their local health economy, these were:plateau and prescribing costs capped by This has reduced inappropriate oxygenimplementation of all three stages. prescribing by healthcare professionals i) Oxygen is not a treatment for who are not able to accurately determine breathlessnessData collected during the final phase of a patient’s need for oxygen nor the ii) Think oxygen/think of us - yourthe project cycle will establish what therapy which most appropriately meets home oxygen service!proportion of overall cost efficiencies is that need.achievable during the three phases. Service integration - As with many In addition to granting HOS-AR teams other areas of healthcare the projectThe results from Sheffield, Staffordshire access to the national invoice teams are confirming that sustainableand Newham lend support to the 1/3 interrogation system ‘Open Exeter’, many models of care require an integratedRule Savings workstream testing project teams are attempting to create a approach across primary and secondaryhypothesis. However, quantification of database which is jointly accessible (and care as well as across medical specialties.the productivity gains achievable from jointed populated) by clinical andeach phase of work will be more evident administrative staff, thus enabling links towhen a sufficient body of data is available be made between a patient’s clinicalfrom the total project cohort upon information and other administrativecompletion of the 12 month project cycle. information.
Emerging learning 15Having undertaken a comprehensiveprocess mapping of the existing patient Issues and challenges Project teams have utilised clinical guidance from a number of sources andjourney, project teams such as Newham Data access/use/coordination they have engaged local governanceare exploring new ways of working for A number of project teams had to stakeholders in order to frame atheir community and acute based staff on overcome barriers in order to access consensus around withdrawal protocols,the basis of standardised assessment and directly patient data held by the supplier. risk assessment and escalationreview processes undertaken by different Suppliers often expressed great procedures.staff groups, matching competencies reluctance to share information withidentified within the Department of personnel other than the designated PCT Despite this many project team membersHealth Good Practice Guide10 to specific HOS lead and many protracted expressed a sense of ‘exposure’ especiallyparts of the care pathway in different discussions and emails had to be engaged in the face of challenges from either asettings. into in order to unearth information. patient, relative, carer or even another healthcare professional.A number of project teams (Birmingham The lack of a national database whichEast & North, Blackpool, Sheffield) are contains both clinical and administrative A particular area of concern is thelooking at different ways of using hospital information and which could be jointly withdrawal of therapy in hypoxic patientstariff costs in order to support accessed and populated by both clinical who smoke. The project teams welcomemultidisciplinary working and sustain and administrative staff is a bug bear for the references made to this topic in theservice enhancements. many teams resulting in some teams most recent draft of the Department of attempting to devise their own systems Health Good Practice Guide10 but feel theFor many teams the project work has locally. topic is worthy of further discussionprovided an opportunity to strengthen nationally.links with oxygen suppliers, local fire This lack of record-linkage functionalityservices, PCT executive committees, social impairs a joined up study of a patient’s During recent peer support meetings theservices and emerging GP consortia whole system care. 12 project teams jointly agreed some top-especially with regards to patient safety tips in respect of facilitating oxygengovernance issues. Gaining agreement around the HOS-AR therapy withdrawal in patients deemed a team acting as HOOF gatekeeper OR fire safety risk:Both the Wirral team and the team from ensuring coordination of HOOFHull have developed local therapy completion across a local health economy • Offer patient intensive step-up smokingwithdrawal protocols and risk escalation is something that requires specialist teams cessation supportprocedures in collaboration with other to invest time in engaging with local GPs • Utilise a multidisciplinary approachlocal stakeholders and sought the and non-respiratory specialists on an on- including social servicesapproval of local governance committees. going basis to ensure harmonised • Consider possible child protection prescribing. issues where patient is also a carerTeams such as NHS Gloucester, aspiring to (e.g. smoking grandparent whoestablish a new HOS-AR service have Access to specialist information support regularly looks after grandchildren)been able to better inform their business (Trust or PCT based) appears very variable • Undertake both a risk assessment andcases and service specifications with real with many teams experiencing challenges a (mental) capacity assessment ifworld intelligence from the established around data collection and analysis. appropriateHOS-AR teams within the project cohort, • Instigate a case conference aroundstrengthening these documents in respect Governance unmanageable risksof the data support required and Many of the project teams expressed a • Document all the factsbuilding-in ongoing ‘hidden costs’ in strong desire for central guidance in • Consider the use/development of arespect of equipment. respect of healthcare professional liability red card warning system prior to and the legality of therapy withdrawal. withdrawal
16 Improvement storiesImproving the prescribing and ongoingmanagement of patients on home oxygen therapyNHS Newham and Newham University Hospital NHS TrustThe NHS Newham and Astra Zeneca joint The pathway of care The first page of the draft home oxygenproject on improving chronic obstructive Newham had localised the COPD therapy pathway is shown below.pulmonary disease (COPD) services within pathway using the ‘Map of Medicine’ butthe local healthcare community (LHC) it did not incorporate any details The project aims and objectivescomprised Primary Care, Secondary Care, regarding the prescribing or the ongoing The aim of the work was to improve theCommunity Health Care (provider arm of management. There were gaps in the prescribing and ongoing management ofthe PCT), Public Health and service being provided and these would patient on home oxygen therapy.Commissioning. be identified during the development of the oxygen pathway.The background to their serviceOxygen is prescribed by primary andsecondary care clinicians. Prescribing ofoxygen by secondary care (the chest Home oxygen therapy - requirement suspectedclinic) is based on structured assessment Newham Development Zone > Thoracic medicine > Home oxygen therapy (HOT)and 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.
Improvement stories 17Specific objectives: The other challenge has been the current Workforce considerations• To produce/manage the oxygen data reorganisation of the PCTs. As a The review of the chest clinic oxygen base and check on a monthly basis for consequence there is a risk that no patients is being supported by two accuracy by April 2010 project support will be available from suitably trained and clinically supervised• To develop and implement an April 2011. This has been reported to the second year medical students which assessment and review process for chief executive. poses risk to the ongoing sustainability of patients on oxygen therapy by the work. Agreement has been reached December 2010 Implementation of the reviews has to add capacity in the form of• To reassess and review 25% of presented capacity issues but these have Community Matrons to review primary patients on oxygen and record any been resolved by temporally increasing care oxygen patients. Once all the changes to their oxygen therapy by the capacity to clear the back log. patients have been reviewed it should be April 2011 possible to maintain the ongoing reviews• To reduce wastage in oxygen The testing they did and key learning within the current workforce. prescribing and secure a 20% to date, including the overall benefits reduction in cost September 2010 The plan to review of patients on oxygen Potential/actual QIPP and cost compared to the 2009/10 cost has commenced and it is anticipated that savings /avoidance – defined as• To update and expand the localised at least half of the patients (approx 80) quality, innovation, productivity pathway (to include development of a managed by the chest clinic will be and prevention new Home Oxygen Service pathway) reviewed by the end of March 2011. The The oxygen database has been produced and promote its implementation data will be collected and analysed on a and is updated on a monthly basis. In across the local healthcare community monthly basis and the work will be addition, the information is shared with by April 2011 amended accordingly. the acute so that the information is• To incorporate the COPD strategy consistent. objectives into the redesign as Similar process will be followed for appropriate monitoring of blood gases for patients Productivity savings of £12,057 have who attend as day cases. Outcomes of been secured from April to NovemberThe process of improvement they this initial phase will be used to plan the 2010 purely from accurate dataundertook and overall approach to work for patients not being managed by management. This included removal ofaddress the issues. the chest clinic. It is anticipated that all deceased patients, removal of duplicated oxygen prescribing will be under the patients and removal of out of areaA steering group was setup including specialist respiratory service but this is patients.primary and secondary care clinical leads dependent upon pathway changes beingto address the issues and take forward agreed. An assessment and reviews form hasthe outcomes of the stakeholder event been developed to use across the localwhich incorporated patient Commissioning considerations healthcare community. In addition, localrepresentatives. Extensive discussions have occurred in oxygen protocols have been agreed and order to try to achieve change. If these incorporated into the review form. ThisIssues and challenges they faced changes are not achieved or result in should result in improved quality ofwith potential solutions protracted meetings and discussions then management of patients on oxygen andThe main challenge to potential solutions notice to terminate the contract will be is projected to provide productivityhas been negotiating change in the given. This has already been considered savings of approximately of £80k.current way of working with the and the final decision will rest with thesecondary care managers. The clinicians GP Commissioning Board.have been willing to redesign the service.
18 Improvement storiesReview of the patients being managed by • Incorporate compliance reports into thethe chest clinic has commenced and database and organise reviews asoutcome data is being collected. It is appropriateanticipated that the target of reviewing • Production and use of standard reports:25% of patients by April 2011 will be - Confirm out of PCT catchment areaachieved. patients are registered within the PCT - Open Exeter reports – deductedThe purchase of three Point of Care patients, duplicated patients,Arterial Blood Gas (ABG) meters will identical provision at the samefacilitate with the oxygen reviews and will addresseliminate day case attendances for ABG • Consider purchase and use of ABGmonitoring. This innovative approach Point of Care meters to facilitateshould result in net productivity savings of oxygen prescribing, reviews andapproximately £250k for a full year whilst optimising therapy includingimproving the quality of the service for discontinuation as appropriatepatients. Any generic learning (LTC) that weDiscussions are also being held to extrapolate from the work e.g. how thismanage the oxygen on a sector wide could be applied to other areas:basis to further secure productivity gains. • Ensure engagement of the clinical leadsData collection, a summary of what it at the outset and get them to lead theshowed and overall evidence processincluding any charts • Agree metrics and ensure ease ofBaseline data has been collected and as availability at the outsetthe oxygen review data becomes • Ensure robust data collection plan andavailable it will be analysed to establish implement as soon as possible -quality and productivity improvements. sufficient time needs to be allowed forInitial data indicates that the cost of the data team to incorporate this intohome oxygen service is not increasing. their workload • Engage commissioning to ensure thatEmerging workstream principles, you are aware of the current contractincluding ‘top tips’ and who is monitoring itTop tips for the management of theoxygen service are: Project lead contact details for further information• Engage with IT to produce a database Bob Arora which allows a quick method of Map of Medicine Programme Manager updating with the oxygen provider Telephone: 0207 059 6524, invoice Email: firstname.lastname@example.org• Share a common database with other services (chest clinic, community matrons) to allow immediate database management
Improvement stories 19The 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)Background to the service facilitator for the theme) and NHS Discussion then took place with theThere is considerable data available and Waltham Forest (Anne Crawford (AC)). patient about alternative interventions forpublished, that the use of short burst Other members of the team included the management of breathlessness.oxygen therapy (SBOT) or intermittent Robyn Hudson (RH), Charles Bruce (CB), Patients were offered supportedoxygen at home for the relief of Gavin Donaldson (GD). withdrawal of the oxygen supply andbreathlessness, in patients without followed up with an appointment at anchronic hypoxemia is not effective and The gold standard pathway vs. local interval of one month. Arrangementscostly to the NHS. pathway were made to withdraw the oxygen The gold standard pathway is that long supply with the contractor.This pilot was undertaken to address the term oxygen therapy is assessed byissue of the prescription of SBOT for arterial blood gases, resulting in a If SBOT patients were unwilling to havepatients with chronic obstructive prescription of oxygen for 15 hours over a the oxygen withdrawn, then they werepulmonary disease (COPD). Although 24 hour period. However, for short burst offered an appointment with thecurrent guidance relating to long term oxygen therapy (intermittent oxygen) no respiratory consultant for furtheroxygen prescription does not support such assessment has been formalised and discussions and assessment. Furtherprovision of SBOT, there is considerable short burst oxygen is usually prescribed assessment of patients unwilling to beevidence from the home oxygen service for breathless patients without oximetry. withdrawn from SBOT were offered.data and surveys that that SBOT is still Appendix 1 illustrates the pathway for All patients will be followed at six monthsprovided in this way and wastes the NHS Waltham Forest oxygen to assess outcomes such as quality of life,resources. assessment service. arterial blood gases, primary care visits and any hospital admissions.Furthermore, there are other more The project aims and objectiveseffective ways that can be utilised to treat The aim of this project was to review all The process of improvementbreathlessness and thus use of SBOT COPD SBOT prescriptions, of more than undertaken and overall approachleads to sup-optimal care. It is estimated three months, in the Camden and to address the issuesthat up to 25% of the home oxygen Waltham Forest PCT areas, in order to Meetings and telephone review toprovided in England and Wales is in the reduce SBOT prescription by 75% over support this work:form of SBOT. However, there is no data the course of one year (July 2010 to Julyavailable on withdrawal of SBOT in 2011). This figure was aimed high as we • In the early stages of the project, twopatients without hypoxaemia and also no are aware that most SBOT patients (once meetings took place (14 June and 30information regarding how successful palliative prescriptions have been July 2010) with NHS Improvement Lead,withdrawal is, in this patient group, both excluded) have no clincial indication for Ore Okosi and various members of thein the short term and longer term e.g. six SBOT. team (JAW, CB, CM, GD, AC, RH) tomonths. Patients may become dependent discuss and plan the projecton SBOT and thus considerable education Patients in the palliative care category • AC, CM, RH attended the NHSwill be required, both for the patient and were excluded for the purpose of this Improvement - Lung launch on 16 Julythe healthcare professional, about other analysis. The intention was to obtain data 2010 and AC & CM attended the NHSinterventions for breathlessness. Such from the PCTs and contractor, regarding Improvement System training day on 28data on withdrawal will also inform current prescription of SBOT in each of July and 19 August respectivelyhealth economic evaluations and aid the study areas. • AC attended the oxygen peer supportfuture guidance on home oxygen services. meeting at Edgware Community Hospital Patients with a prescription of SBOT were on 23 September. CM attended theThe original intention was that the project offered an appointment with a respiratory oxygen peer support meeting at Miltonwould take place in two sites - one site in specialist to discuss their use of oxygen Keynes in NovemberNorth London: Royal Free Hospital NHS and where indicated, full assessment of • AC, CM had a telephone review 13Trust (Christine Mikelsons (CM) & their requirement for long term oxygen August and two half day meetings on 28Professor Wisia Wedzicha (JAW)) and NHS was performed. In cases where no clinical October 2010 and 27 January 2011Camden, and the other site in North East need was identified, patients were • In addition, there have been regularLondon: Whipps Cross University Hospital counselled and advised that they did not telephone updates between AC and CMNHS Trust (Professor Mike Roberts - HIEC need to continue with oxygen at home. (13/8/2010, 27/8/10; 3/9/10; 15/10/10)
20 Improvement storiesData collection was started at Waltham The testing was performed and the Data collection summaryForest on 15 October 2010, following the key learning to date, including the October to December 2010 results:development of: overall benefits A total of 25 patients on SBOT in the• A flyer inviting participation Patients in NHS Waltham Forest on short borough of Waltham Forest with a (see appendices) burst oxygen (CC2a and CC2b) have primary diagnosis of COPD were• A letter of agreement of patients to been reviewed and assessed. The data identified. Appointments were sent and take part (see appendices) has been collected and analysed. patients, who agreed to participate in the• An updated patient assessment Metrics and measures included numbers project, visited in their homes: proforma (see appendices) receiving SBOT, three months• A patient follow-up proforma retrospective data to understand demand • Two patients have had their SBOT (see appendices) and capacity, actual hours SBOT use, successfully withdrawn• An agreement with local GPs to support FEV1,SaO2 and ABGs, SGRQ, HAD and • Nine patients (47.3%) were actions within the project BORG scores, number of reviews, number exacerbating at the time of assessment• Written details informing GPs of of admissions related to respiratory • Two patients were withdrawn from the patient’s involvement in this NHS condition, number of patients with study :one unwilling to comply with Improvement - Lung project maintained withdrawal at six months and interventions, one recently bereaved improvement stories to include patient’s and worsening of short term memoryIssues and challenges faced with experiences. losspotential solutions • One patient was dying and refusing• Issues of maintaining up to date HOOF Potential/actual QIPP and cost savings hospital admission and one refused data and an oxygen database in /avoidance – defined as quality, assessment Waltham Forest PCT as administration innovation, productivity and • One withdrawn from SBOT as required support ceased at the end of August prevention long term oxygen therapy 2010. Discussions with the medicines There are potential cost savings from • One was in hospital having been management lead was required in withdrawal of SBOT and in addition admitted with pneumonia order to determine continuation and further cost savings could be identified as • The remainder are awaiting assessment agreement of support to the oxygen a result of performing ABG sampling in service the community thus obviating the need The results of 19 patients are presented• Access to data proved to be a challenge for patients to attend hospital for this below for HAD, SGRQ, FEV1 (morbidity) which resulted in the following email reason. and oxygen SaO2 at assessment on first trail: visit. • Commissioners at Camden PCT three times (CM) • Home oxygen service at Department of Health (CM) 1 October 2010 - 31 December 2010 - Waltham Forest PCT HAD • Clinical lead for respiratory medicine 35 NHS London (CM) • Oxygen lead for NHS London (CM) 30 31 28 • Strategy team NHS London 25 26 24 • Commissioners at Camden PCT 20 21 20 HAD 15 17 (JAW) 14 10 9 5 6 7 7 5 0 0 0 0 0 0 0 -5 A B C D E F G H I J K L M N O P Q R S NOV Patients Waltham Forest PCT Waltham Forest PCT