This document discusses emerging learning from national improvement projects focused on improving home oxygen services in England. It describes phases of work including data review and management, establishing formal assessment services, and integrating and sustaining services. Case studies from 11 project sites highlight innovative approaches to assessing and reviewing patients' oxygen needs. Key challenges addressed optimization of assessments, inter-organizational collaboration, and ensuring appropriate long-term oxygen therapy. The document aims to share learning to help local teams improve care and outcomes for COPD patients requiring oxygen therapy.

1. NHS
CANCER
NHS Improvement
Lung
DIAGNOSTICS
HEART
LUNG
STROKE
NHS Improvement - Lung
Improving Home
Oxygen Services:
Emerging Learning from the
National Improvement Projects

2. Patients and their carers are the reason the health service exists
and therefore they should be at the heart of our services. Service
redesign and improvement generates opportunities to involve
service users who will provide a different perspective on the
service, so that we can better understand whether our service
or improvements make any difference to the patient.
Only when we understand patient’s needs – by asking them, not
second guessing – can we work in a way that meets those needs
and ensures they get maximum benefit from our service.

3. 3
Improving Home Oxygen Services - Emerging
Learning from the National Improvement Projects
Contents
Foreword 4
Executive summary 5
Emerging learning 9
Phases of work 9
Data review and management 9
Establishment of a formal assessment service 11
Service integration and sustainability 13
Testing hypothesis 14
Emerging learning 14
Issues and challenges 15
Improvement stories 16
NHS Newham and Newham University Hospital NHS Trust 16
Royal Free/Waltham Forest PCT/NECLES HIEC 19
West Hertfordshire COPD Service 23
NHS Sheffield 26
NHS Hull and the City Health Care Partnership 28
NHS Gloucestershire 31
Milton Keynes PCT Community Services and Milton Keynes Hospital 33
NHS Blackpool 37
Wirral Integrated Oxygen Service 39
Sherwood Forest Hospitals and NHS Nottinghamshire County Community COPD Team 43
NHS South Staffordshire 46
NHS Birmingham East and North and Heart of England NHS Foundation Trust 49
Appendices 53
Data for improvement projects 53
Newham LTOT pathway 57
Royal Free/Waltham Forest PCT/NECLES HIEC Flow chart 58
Royal Free/Waltham Forest PCT/NECLES HIEC invitation letter to patients 59
Royal Free/Waltham Forest PCT/NECLES HIEC patient proforma 60
Royal Free/Waltham Forest PCT/NECLES HIEC follow-up proforma 61
Wirral COPD and Oxygen Service Process Map 62
NHS Birmingham East and North Process Map (CURRENT STATE) 63
NHS Birmingham East and North Process Map (FUTURE STATE) 62
Acknowledgements 65
References 66

4. 4 Foreword
Foreword
Since July 2010, NHS Improvement – The publication also contains information
Lung has worked with a number of for healthcare professionals and those
clinical teams across England as part of working in commissioning or interfacing
the Department of Health Respiratory with COPD services. This includes those
Programme. Its aim has been to support who are:
the development of patient centred, • Involved in the care of patients who
evidenced based and clinically led services require COPD services
by identifying and sharing innovative • Responsible for commissioning COPD
ways to reduce variations in care and services
improve the quality and experience of • Managing COPD services Professor Sue Hill
patients with chronic obstructive • Local or regional leads
pulmonary disease (COPD).
The project sites were encouraged to
The national improvement projects have employ a range of service improvement
tested approaches at key stages of the tools and techniques. These included
clinical 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 Winter
improvement programme, this There are lots of practical examples within
publication signals the mid-way point in this report to support clinical teams in
the project cycle and has been written to delivering quality and productivity
share the learning from the testing phase benefits to patients and a wider range of
of 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 to
areas of innovative and emerging good test the key principles for change and
practice that can be used locally to deliver implementation. As this learning
improvements for COPD patients and emerges, it will be shared with COPD
their carers. services and the wider NHS
In order to address the paucity of current We would like to take this opportunity to
evidence, particularly around the models thank the project sites for their hard
and principles of implementation, the work, dedication and commitment and
programme will continue to adapt and look forward to the full extent of the
refine the learning. However, these improvement work as it comes to fruition.
lessons will be of value now to any team
working to improve the care it delivers
and commissions for people with COPD. Professor Sue Hill
Dr Robert Winter
This publication contains a number of Joint National Clinical Directors
examples that demonstrate value for for the Respiratory Programme
money, increased productivity and
approaches that can sustain improvements
over the long term.

5. Executive summary 5
Executive summary
National position and Thus the overarching aim of this This has led to a workstream 1/3 Rule
workstream 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 review
about 85,000 people in England at a cost models which ensure the right people are ‘One third of the total cost
of approximately £110 million a year1. in receipt of the right dose of oxygen efficiencies (savings and avoidance)
therapy. can be realised through the first
Many Primary Care Trusts (PCTs) do not
undertake quality assured clinical In developing the project outline the
phase of a three phase process with
assessment and review of their patients scope of the project work was framed efficiency gains reaching a plateau
need for long term home oxygen such that teams would consider: and prescribing costs capped by
increasing 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 of
The 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 healthcare
either derive no clinical benefit from it or • Guidance on correctly documenting professionals to more comprehensively
do not use their oxygen2. Quality and and interpreting diagnostic results inform and educate patients about their
productivity in the home oxygen service • Guidance on accurately prescribing condition. In addition if home oxygen
can be improved significantly. Gross oxygen therapy is deemed appropriate then this
savings of up to 40% - equivalent • Providing the patient with written interaction also facilitates patient
nationally 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 the
achieved according to recent analysis safe use of oxygen at home.
carried out by the Department of Health The project teams made extensive use of
through 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 patients
formal 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 using
The 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 their
of the Chronic Obstructive Pulmonary thinking. This educational process is in alignment
Disease (COPD) Strategy Consultation with recommendation 11 of the Chronic
document1, 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 and
therapy and reviewed at regular 2. Establishment of a formal
intervals, and existing home oxygen assessment service
delivered in a format that any
registers should be reviewed’. 3. Service integration and person can understand’
sustainability

6. 6 Executive summary
Some emerging themes arising from the Royal Free/Waltham Forest
work 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 the
Summary 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 Service
Established a system of oxygen usage patients and develop safety protocols and Developed oxygen care pathways for non
data coordination and review in order to procedures through a multi-stakeholder COPD patients in collaboration with non
control prescribing costs and performance project group. respiratory specialist colleagues. In
manage suppliers. In addition, they addition, they developed systematic risk
introduced systematic review of existing NHS Gloucestershire escalation procedures and protocols.
acute hospital oxygen clinic patients and This team has focussed on developing a
developed plans and protocols for future detailed business case and service Sherwood Forest Hospitals and NHS
integrated home oxygen service - specification which incorporates best Nottinghamshire County Community
assessment and review (HOS-AR) practice and learning from more established COPD Team
spanning 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.

7. Executive summary 7
NHS South Staffordshire already undertaken on Quality Innovation • Introduction of HOS-AR - establishing
Demonstrated 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 to
in order to re-categorise costing and alter opportunities presented in the Equity and the standard articulated within the
therapy to achieve prescribing efficiencies Excellence: Liberating the NHS. Good Practice Guide, introduction of a
within one locality. This approach will new service to a locality in which
now 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 - safety
NHS Birmingham East & North and improve the quality and productivity of its and risk considerations explained to
Heart of England NHS Foundation services since the challenge was first patients and carers, captured within
Trust articulated in May 2009. The proposal is easy-to-read literature and mutual
Introduced transparent systems for to ensure that the NHS continues to responsibilities (both patients and
sharing information relating to home make quality improvements a reality healthcare professionals) understood
oxygen users across the local health during a period in which growth in and documented within local
economy and a pathway with guidelines expenditure within the NHS will be agreement documents
supporting the process of initiating restricted despite increasing demand. • Pathways for the treatment of non
oxygen 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 establish
Quality, Innovation, Productivity and support the NHS to meet the QIPP optimal care pathways for non COPD
Prevention (QIPP) and expected challenge, either by identifying where patients in need of home oxygen
outcomes resources might be released or by therapy
The 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 working
the quality, efficiency and value for by examining use of different types of
money of services as well as improving The work has demonstrated that the workforce along the pathway in
outcomes for people with chronic annual total spend across nine project different settings
obstructive pulmonary disease (COPD). sites can be reduced by a minimum of • Effective use of data – collaboration
Focus needs to be centred on these three £600k. This applies for both new and between clinical and managerial
factors to make this a reality. First, established home oxygen services who professionals to integrate, review and
improving quality whilst improving implement oxygen usage reviews and interpret financial, administrative and
productivity 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, oversee
Prevention (QIPP) agenda by using Health estimated gross savings of up to governance and performance manage
innovation and prevention to drive this 40% for each PCT. the oxygen suppliers
forward and interlink these values.
Secondly, having local clinicians and The expected outcomes in these project Potential for future work
managers working together in a sites will be: The initial quick win cost efficiencies
multidisciplinary approach and across • Minimum of £600k prescribing attributable to the first phase of HOS-AR
boundaries in order to spot the savings - achieved through therapy improvement work (data review and data
opportunities 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 Rule
The 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 cost
the next four years. This represents a very efficiencies realisable from the
significant challenge to be delivered establishment of HOS-AR and by its
through the detailed work the NHS has integration within the broader service
commissioning framework.

8. 8 Executive summary
In addition, further narrative is needed non COPD patients, often challenging
around the demonstrable benefits in colleagues when they appear not to be
quality of care patients may derive from adhering to their own specialty area
optimised home oxygen therapy. The guidelines. Thus there may be scope for
effective use of administrative, financial future projects to more thoroughly
and clinical data relating to oxygen usage investigate the potential cost savings
further promotes the use of disease achievable from rationalisation of home
registers and flags up opportunities for oxygen therapy in non-COPD patients.
more effective patient record linkage.
Future work will also thoroughly explore Phil Duncan
An 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 Lung
care resultant from formal oxygen by the Good Practice Guide in terms of
assessment and review results in fewer new services, but also in relation to
admissions to hospital. Although initial driving up quality for existing services.
workstream metrics were devised to
explore this, linking information about Finally, further consideration will be
individual patients in receipt of home given to the following areas:
oxygen with information from hospital • Stakeholder engagement
patient administration systems continues • Developing local incentives to
to present a challenge. commission HOS-AR
• Varying the workforce employed at
The reasons why a patient with COPD is different parts of the pathway
admitted to hospital are varied and in • Describing optimal models of care in Ore Okosi
addition COPD patients on long term urban/rural geographies National Improvement Lead,
NHS Improvement – Lung
oxygen tend to have more severe disease • Developing a consensus around
and thus and increased risk of provision/withdrawal of home oxygen
hospitalisation. As such it may not be to persistent smokers who have a
possible to establish whether optimised clinical need for oxygen
home oxygen therapy resultant from • Establishing ownership of HOS-AR
systematic clinical assessment and review governance and performance
is an effective admission avoidance management within the emerging
strategy. However, this topic is certainly commissioning structures
worthy of more consideration in future.
Many HOS-AR teams have begun to
establish effective dialogue with non- Phil Duncan
respiratory specialists in respect of the Director, NHS Improvement - Lung
management of non COPD patients in
receipt of home oxygen therapy. As those Ore Okosi
relationships mature, the HOS-AR teams National Improvement Lead,
have been able to explore with their non NHS Improvement - Lung
respiratory colleagues the reasons for
initiation of home oxygen therapy in

9. Emerging learning 9
Emerging learning
Phases of work Data review and data Don’t forget ‘better’ is not measureable.
‘More’, ‘faster’, ‘safer’ or ‘cheaper’ can all
In attempting to broadly categorise the
type 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 how
12 ‘improving home oxygen services’ expensive things were to begin with. We
national project teams it has been useful national chronic obstructive pulmonary
disease (COPD) project sites in all need to establish factual data and
to 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 then
2.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 the
3.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 by
In reality, many project teams have the oxygen supplier.
undertaken activities in parallel and so Quality Innovation Productivity and
may span these phases which are now Prevention (QIPP) initiative, it is essential
outlined 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. 10 Emerging learning
Gaining access to home oxygen Implementing ongoing monitoring Data reconciliation
order form data for oxygen Open Exeter enables the reconciliation of
NHS Connecting for Health provides The NHS Home Oxygen Service Manual9 monthly files of invoices from the Home
designated users (authorised by individual states that in order to effectively monitor Oxygen suppliers against the patients
PCTs) 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 system
Applications 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 calculate
a web-enabled viewer7. of oxygen, specifically: the appropriate cost band from the
specified delivery mechanism, the number
New users have to complete a Data Users • Who oxygen was ordered for of litres/hour and the duration and this
Certification Form (available from • Date of birth can be checked against the cost band
www.connectingforhealth.nhs.uk/nhais/ • NHS number invoiced by the supplier7.
products_and_services/vaprodopenexe) • Patient’s GP practice
and 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 ordered
forward it for authentication. • Urgent, next day or standard supply • Deducted patients by
• Primary or secondary supply • Patients not found on the NHAIS
Getting access to oxygen cost data • Flow rate • Inconsistent cost bands
In addition to Open Exeter, the majority • Hours per day • Identical provisions for patient at same
of PCT home oxygen service leads and • Status (new or existing patient) address
medicines management teams have • Estimate of cost • Cost band totals by practice
access to on-line home oxygen therapy • Holiday orders
reports from the NHS Business Services The Wirral and Milton Keynes project • Emergency
Authority 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 record
These reports provide information on the activity but with limited ability to link • No HOOF entered for supplier order
payments made to suppliers for provision information from other clinical recording record
of 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 Blackpool
PCT area and claims for out-of-area to establish a system of HOOF project teams are all examples of how
patients8. management which ensures that there is clinical team members developed an
either a centralised or a coordinated understanding of the prescribing cost
Access 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 the
registration 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 to
Information Services Department of NHS undertake the almost forensic analysis of
Prescription Services in Newcastle. modalities of oxygen supply associated
www.nhsbsa.nhs.uk/PrescriptionServices/ with individual patients.
3091.aspx

11. Emerging learning 11
Armed with this information the clinicians The South Staffordshire project team
were able to work alongside other non have illustrated the quick win productivity
Establishment of a
clinical 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 to
Data management and QIPP savings attributable to the review of the address the backlog of previously
The 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 the
realised productivity savings of £12,057 Cannock Chase is only one locality within project team in order to arrange if
from April to November 2010 purely from South Staffordshire and so the PCT is necessary a review and therapy altered or
accurate data management. exploring whether even greater withdrawn if deemed inappropriate.
productivity gains can be achieved if this
This included removal of deceased approach was spread to other localities. This phase involves liaison with the
patients, removal of duplicated patients patient’s GP surgery as many existing
and removal of out of area patients. oxygen patients received therapy as a
result of a GP completing the original
The improvement stories contained home oxygen order form (HOOF).
within this publication illustrate the
effectiveness of clinicians working in
collaboration with managerial and
administrative colleagues (especially the
designated PCT home oxygen service
lead) in respect of the financial
reconciliation process.

12. 12 Emerging learning
The Department of Health Good Practice
Guide10 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 2010
review. A condensed summary of the • Access exercise capacity
pathway is set out below: • Access adequate correction
of exercise de-saturation
• Determine flow rate
• Discuss with patient if immediate
ambulatory supply or derfer until later
1. 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 provider
2. 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 indicated
4. 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 specialist
5. 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 patient
6. 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.

13. Emerging learning 13
The choice of model being tested and Hertfordshire COPD service are also In attempting to establish a more
developed often reflects the geographical attempting to ensure sustainable financial integrated model of care, teams have had
considerations of the area with Acute management by educating GPs about the to overcome perverse incentives within
Hospital clinics being the locations of benefits of formal assessment. ‘payment by results’ which might
choice within the more compact and potentially encourage duplication,
highly urbanised Birmingham setting in Teams such as the Wirral COPD and redundant processes or unnecessary steps
contrast to community clinic settings Home Oxygen Service are engaging non- in pathway.
being considered by more dispersed respiratory specialists in discussions
populations 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 which
At a recent peer support meeting the conditions and jointly developing care will encourage multidisciplinary working
12 national project teams reached a pathways. by both being fair compensation to the
consensus as regards models of service service provider and financially
delivery which is encapsulated within the Having achieved significant therapy sustainable by the commissioner.
phrase ‘Varied models but standardised changes and therapy withdrawals among
processes’. This means strict adherence to existing oxygen patients, through the In developing a new service or model of
best practice as articulated within the work of phases one and two, teams such care it is important to ensure clarity at the
Department of Health Good Practice as Hull and Wirral have begun to tackle outset in relation to costs. Involvement
Guide but flexibility in respect of location the challenge of addressing therapy with this programme of work enabled
and 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 senior
sustainability integrated within the wider analyst was able to guide them on how
A number of the project teams are organisational risk management to use their own quarterly concordance
attempting to leverage the oxygen cost framework. report data to understand potential
savings achieved through rationalisation patterns of service demand.
of processes to raise the profile of oxygen The NHS Birmingham East and North
services 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 service
In areas such Sheffield and Gloucester the firmly established within the existing PCT specifications of more established teams
type and scope of oxygen service was not governance framework in order to ensure and through interaction with colleagues
previously well defined within local transition to the newly emerging GP during regular peer support meetings
respiratory service specifications. The commissioning consortia. gain greater insight in to workforce
project team were subsequently given an considerations.
opportunity for the local health economy However, the risks are not just those
stakeholders to collectively address this by associated with patient safety, there are This dialogue also enabled previously
utilising the emerging learning from the also financial risks posed by poor data unconsidered ‘hidden costs’ (such as
project work and the Department of management and coordination. equipment upkeep) to be identified.
Health Good Practice Guide to inform
new business cases or revise service Project teams such as Sherwood Forest
specifications. are devolving oxygen prescribing
budgetary management to GP localities in
The quick win cost savings achievable by order to preserve the discipline of
undertaking phase one work is obviously financial management during the local
attractive to commissioners but the more NHS transition and further engage GPs in
established teams such as the West discussions around the care pathway.

14. 14 Emerging learning
Testing hypothesis Emerging themes Consistent messages to patients – In
rationalising local oxygen services project
Cost 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 other
Sheffield, South Staffordshire (Cannock oxygen prescribing the home oxygen healthcare professionals in order to
Chase locality) and Newham have realised service - assessment and review (HOS-AR) develop a local consensus in respect of
significant quick win cost savings team need to liaise effectively with oxygen therapy initiation.
attributable to the first phase of work managerial and administrative staff to
with 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 health
Whilst project teams with more and safety considerations and waste
established HOS-AR teams such as Hull, Collaboration between designated PCT incurred by inappropriate prescribing.
Wirral and West Hertfordshire either home oxygen service (HOS) leads and
continue to achieve a reduction in HOS-AR teams has enabled supplier Project teams have identified that
spending (as compared with the period reports to be used effectively, picking up inappropriate prescribing occurs in both
prior to the service being established) or anomalies within prescribed oxygen and primary and secondary care and so teams
experience very modest fluctuations in challenging unnecessary multiple such as the West Herts COPD service
month-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 established
tested by the workstream: agreements with local primary and During the periodic peer support
secondary care stakeholders that they act meetings facilitated by NHS Improvement
1/3 Rule Savings: one third of total cost as ‘gatekeeper’ for the completion and - Lung the 12 project teams jointly
efficiencies (savings and avoidance) amendment of the home oxygen order identified two simple messages that all
realised through first stage of three stage form (HOOF). project teams need to reinforce within
process with efficiency gains reaching a their local health economy, these were:
plateau and prescribing costs capped by This has reduced inappropriate oxygen
implementation of all three stages. prescribing by healthcare professionals i) Oxygen is not a treatment for
who are not able to accurately determine breathlessness
Data collected during the final phase of a patient’s need for oxygen nor the ii) Think oxygen/think of us - your
the 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 project
The results from Sheffield, Staffordshire access to the national invoice teams are confirming that sustainable
and Newham lend support to the 1/3 interrogation system ‘Open Exeter’, many models of care require an integrated
Rule Savings workstream testing project teams are attempting to create a approach across primary and secondary
hypothesis. 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 and
each phase of work will be more evident administrative staff, thus enabling links to
when a sufficient body of data is available be made between a patient’s clinical
from the total project cohort upon information and other administrative
completion of the 12 month project cycle. information.

15. Emerging learning 15
Having undertaken a comprehensive
process mapping of the existing patient
Issues and challenges Project teams have utilised clinical
guidance from a number of sources and
journey, project teams such as Newham Data access/use/coordination they have engaged local governance
are exploring new ways of working for A number of project teams had to stakeholders in order to frame a
their 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 escalation
review processes undertaken by different Suppliers often expressed great procedures.
staff groups, matching competencies reluctance to share information with
identified within the Department of personnel other than the designated PCT Despite this many project team members
Health Good Practice Guide10 to specific HOS lead and many protracted expressed a sense of ‘exposure’ especially
parts of the care pathway in different discussions and emails had to be engaged in the face of challenges from either a
settings. 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 which
East & North, Blackpool, Sheffield) are contains both clinical and administrative A particular area of concern is the
looking at different ways of using hospital information and which could be jointly withdrawal of therapy in hypoxic patients
tariff costs in order to support accessed and populated by both clinical who smoke. The project teams welcome
multidisciplinary working and sustain and administrative staff is a bug bear for the references made to this topic in the
service 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 the
For many teams the project work has locally. topic is worthy of further discussion
provided an opportunity to strengthen nationally.
links with oxygen suppliers, local fire This lack of record-linkage functionality
services, PCT executive committees, social impairs a joined up study of a patient’s During recent peer support meetings the
services 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 oxygen
governance 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 HOOF
Hull have developed local therapy completion across a local health economy • Offer patient intensive step-up smoking
withdrawal protocols and risk escalation is something that requires specialist teams cessation support
procedures in collaboration with other to invest time in engaging with local GPs • Utilise a multidisciplinary approach
local stakeholders and sought the and non-respiratory specialists on an on- including social services
approval of local governance committees. going basis to ensure harmonised • Consider possible child protection
prescribing. issues where patient is also a carer
Teams such as NHS Gloucester, aspiring to (e.g. smoking grandparent who
establish 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 and
cases and service specifications with real with many teams experiencing challenges a (mental) capacity assessment if
world intelligence from the established around data collection and analysis. appropriate
HOS-AR teams within the project cohort, • Instigate a case conference around
strengthening these documents in respect Governance unmanageable risks
of the data support required and Many of the project teams expressed a • Document all the facts
building-in ongoing ‘hidden costs’ in strong desire for central guidance in • Consider the use/development of a
respect of equipment. respect of healthcare professional liability red card warning system prior to
and the legality of therapy withdrawal. withdrawal

16. 16 Improvement stories
Improving the prescribing and ongoing
management of patients on home oxygen therapy
NHS Newham and Newham University Hospital NHS Trust
The NHS Newham and Astra Zeneca joint The pathway of care The first page of the draft home oxygen
project 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’ but
the local healthcare community (LHC) it did not incorporate any details The project aims and objectives
comprised Primary Care, Secondary Care, regarding the prescribing or the ongoing The aim of the work was to improve the
Community Health Care (provider arm of management. There were gaps in the prescribing and ongoing management of
the 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 service
Oxygen is prescribed by primary and
secondary care clinicians. Prescribing of
oxygen by secondary care (the chest Home oxygen therapy - requirement suspected
clinic) is based on structured assessment Newham Development Zone > Thoracic medicine > Home oxygen therapy (HOT)
and a database is kept of the patients
that are under their care.
Primary care prescribing may also be
based on an effective assessment but
there is no evidence to verify this.
There were no formal management
arrangements of the oxygen service in
NHS Newham. Ongoing review of oxygen
patients were not being preformed for
any patients. There was no standard
database kept of patients on oxygen and
the information was not being shared
between the patients being managed in
primary care and by the chest clinic.
Oxygen invoices were managed by the
medicine management team and there
was no reconciliation between the
database and monthly invoices provided
by the service provider. Also, there was
lack of evidence whether any actions
were taken to act on the reports
produced or provided by the oxygen
supplier e.g. compliance reports, out of
area reports etc.

17. Improvement stories 17
Specific 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 November
The process of improvement they this initial phase will be used to plan the 2010 purely from accurate data
undertook and overall approach to work for patients not being managed by management. This included removal of
address 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 area
A steering group was setup including specialist respiratory service but this is patients.
primary and secondary care clinical leads dependent upon pathway changes being
to address the issues and take forward agreed. An assessment and reviews form has
the outcomes of the stakeholder event been developed to use across the local
which incorporated patient Commissioning considerations healthcare community. In addition, local
representatives. Extensive discussions have occurred in oxygen protocols have been agreed and
order to try to achieve change. If these incorporated into the review form. This
Issues and challenges they faced changes are not achieved or result in should result in improved quality of
with potential solutions protracted meetings and discussions then management of patients on oxygen and
The main challenge to potential solutions notice to terminate the contract will be is projected to provide productivity
has 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 the
secondary care managers. The clinicians GP Commissioning Board.
have been willing to redesign the service.

18. 18 Improvement stories
Review of the patients being managed by • Incorporate compliance reports into the
the chest clinic has commenced and database and organise reviews as
outcome data is being collected. It is appropriate
anticipated that the target of reviewing • Production and use of standard reports:
25% of patients by April 2011 will be - Confirm out of PCT catchment area
achieved. patients are registered within the PCT
- Open Exeter reports – deducted
The purchase of three Point of Care patients, duplicated patients,
Arterial Blood Gas (ABG) meters will identical provision at the same
facilitate with the oxygen reviews and will address
eliminate day case attendances for ABG • Consider purchase and use of ABG
monitoring. This innovative approach Point of Care meters to facilitate
should result in net productivity savings of oxygen prescribing, reviews and
approximately £250k for a full year whilst optimising therapy including
improving the quality of the service for discontinuation as appropriate
patients.
Any generic learning (LTC) that we
Discussions are also being held to extrapolate from the work e.g. how this
manage the oxygen on a sector wide could be applied to other areas:
basis to further secure productivity gains.
• Ensure engagement of the clinical leads
Data collection, a summary of what it at the outset and get them to lead the
showed and overall evidence process
including any charts • Agree metrics and ensure ease of
Baseline data has been collected and as availability at the outset
the oxygen review data becomes • Ensure robust data collection plan and
available it will be analysed to establish implement as soon as possible -
quality and productivity improvements. sufficient time needs to be allowed for
Initial data indicates that the cost of the data team to incorporate this into
home oxygen service is not increasing. their workload
• Engage commissioning to ensure that
Emerging workstream principles, you are aware of the current contract
including ‘top tips’ and who is monitoring it
Top tips for the management of the
oxygen 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: bob.arora@newhampct.nhs.uk
• Share a common database with other
services (chest clinic, community
matrons) to allow immediate database
management

19. Improvement stories 19
The feasibility and impact of withdrawal of Short
Burst Oxygen Therapy (SBOT)
Royal Free Hospital NHS Trust, NHS Waltham Forest & North East London, North
Central London and Essex Health Innovation Education Cluster (NECLES HIEC)
Background to the service facilitator for the theme) and NHS Discussion then took place with the
There is considerable data available and Waltham Forest (Anne Crawford (AC)). patient about alternative interventions for
published, 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 supported
oxygen at home for the relief of Gavin Donaldson (GD). withdrawal of the oxygen supply and
breathlessness, in patients without followed up with an appointment at an
chronic hypoxemia is not effective and The gold standard pathway vs. local interval of one month. Arrangements
costly 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 by
issue of the prescription of SBOT for arterial blood gases, resulting in a If SBOT patients were unwilling to have
patients with chronic obstructive prescription of oxygen for 15 hours over a the oxygen withdrawn, then they were
pulmonary disease (COPD). Although 24 hour period. However, for short burst offered an appointment with the
current guidance relating to long term oxygen therapy (intermittent oxygen) no respiratory consultant for further
oxygen prescription does not support such assessment has been formalised and discussions and assessment. Further
provision of SBOT, there is considerable short burst oxygen is usually prescribed assessment of patients unwilling to be
evidence 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 months
provided 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 objectives
effective ways that can be utilised to treat The aim of this project was to review all The process of improvement
breathlessness and thus use of SBOT COPD SBOT prescriptions, of more than undertaken and overall approach
leads to sup-optimal care. It is estimated three months, in the Camden and to address the issues
that up to 25% of the home oxygen Waltham Forest PCT areas, in order to Meetings and telephone review to
provided 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 July
available on withdrawal of SBOT in 2011). This figure was aimed high as we • In the early stages of the project, two
patients without hypoxaemia and also no are aware that most SBOT patients (once meetings took place (14 June and 30
information 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 the
in the short term and longer term e.g. six SBOT. team (JAW, CB, CM, GD, AC, RH) to
months. Patients may become dependent discuss and plan the project
on SBOT and thus considerable education Patients in the palliative care category • AC, CM, RH attended the NHS
will be required, both for the patient and were excluded for the purpose of this Improvement - Lung launch on 16 July
the healthcare professional, about other analysis. The intention was to obtain data 2010 and AC & CM attended the NHS
interventions for breathlessness. Such from the PCTs and contractor, regarding Improvement System training day on 28
data on withdrawal will also inform current prescription of SBOT in each of July and 19 August respectively
health economic evaluations and aid the study areas. • AC attended the oxygen peer support
future guidance on home oxygen services. meeting at Edgware Community Hospital
Patients with a prescription of SBOT were on 23 September. CM attended the
The original intention was that the project offered an appointment with a respiratory oxygen peer support meeting at Milton
would take place in two sites - one site in specialist to discuss their use of oxygen Keynes in November
North London: Royal Free Hospital NHS and where indicated, full assessment of • AC, CM had a telephone review 13
Trust (Christine Mikelsons (CM) & their requirement for long term oxygen August and two half day meetings on 28
Professor Wisia Wedzicha (JAW)) and NHS was performed. In cases where no clinical October 2010 and 27 January 2011
Camden, and the other site in North East need was identified, patients were • In addition, there have been regular
London: Whipps Cross University Hospital counselled and advised that they did not telephone updates between AC and CM
NHS 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. 20 Improvement stories
Data collection was started at Waltham The testing was performed and the Data collection summary
Forest 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 memory
Issues and challenges faced with experiences. loss
potential 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