This document discusses several NHS projects aimed at improving home oxygen services. It describes how the projects focused on reviewing patient lists, rationalizing unnecessary oxygen usage, and improving coordination of care. Through these efforts, the projects generated an estimated total of £640,000 in prescribing cost efficiencies. The document provides details of the various projects' approaches, which involved defining patient care pathways, identifying variations in care, and testing solutions through a quality improvement framework.

1. NHS
CANCER
NHS Improvement
Lung
DIAGNOSTICS
HEART
LUNG
STROKE
NHS Improvement - Lung: National
Improvement Projects
Improving Home Oxygen:
Testing the Case for Change

3. CONTENTS 3
NHS Improvement - Lung National Improvement Projects
Improving Home Oxygen: Testing the Case for Change
Contents
Introduction 4
Case studies
• Wirral University Hospital NHS Foundation Trust and NHS Wirral 10
Wirral Integrated Community Oxygen Service
• NHS Hull and the City Health Care Partnership 12
Home Oxygen Service Improvement Project
• Royal Free Hospital NHS Trust, NHS Waltham Forest & North East 14
London, North Central London and Essex Health Innovation
Education Cluster (NECLES HIEC)
The feasibility and impact of withdrawal of Short Burst Oxygen
Therapy (SBOT)
• NHS Nottinghamshire County Community COPD Team, 16
Sherwood Forest Hospitals NHS Foundation Trust and
County Health Partnership
Home oxygen – improving quality of care
• NHS Sheffield and Sheffield Teaching Hospitals 17
NHS Foundation Trust
Home oxygen service improvement project
• NHS Blackpool and Blackpool Teaching Hospitals 18
NHS Foundation Trust
Improving oxygen services and the prescribing of oxygen
across NHS Blackpool
• NHS South Staffordshire 20
Improving home oxygen services through pathway redesign
• Milton Keynes PCT Community Services and Milton Keynes 21
Hospital NHS Foundation Trust
Sustaining the efficiency and effectiveness of the Milton Keynes Home
Oxygen Service – Assessment and Review (HOS-AR)
Acknowledgements 22

4. 4 INTRODUCTION
Introduction
Case for change: the current Reducing variation in service The first year of project work
position for home oxygen provision can help tackle health focussed on continuous patient list
services in England inequalities and ensure consistency review and the systematic
in the safety and efficacy of utilisation of oxygen usage supplier
Home oxygen therapy is provided services. These are among the data to support clinical decision
to about 85,000 people in goals of The Outcomes Strategy making around therapy alteration
England, costing approximately for COPD and Asthma in England (or withdrawal) and to drive more
£110 million a year1. Home as outlined in objective 2 and coordinated prescribing and
oxygen service – assessment and objective 5 of the six shared improved multi-disciplinary care.
review (HOS-AR) is variable as objectives set out in the strategy2.
patients in many Primary Care The project work was undertaken
Trusts (PCTs) do not receive a against the backdrop of the
quality assured clinical assessment national re-procurement of oxygen
and a review of their ongoing need The aim of the Improving supply contracts, which was
for long term home oxygen. Home Oxygen just gathering pace. The
workstream is to ensure re-procurement together with the
The variation in provision of HOS- that patients with a NHS Quality, Innovation,
AR increases the potential for poor clinical need for home Productivity and Prevention agenda
quality care and waste and it has oxygen receive gave additional context to the
been estimated that 24% to 43% appropriate, safe and work and provided an opportunity
of home oxygen prescribed in cost effective therapy on for clinical teams to engage local
England is not used or provides no a sustainable basis as a commissioners, finance and
clinical benefit1. result of an efficient care medicines management in new
pathway providing and different thinking about Home
Gross savings of up to 40% - specialist assessment and oxygen service –assessment and
equivalent nationally to £45 million ongoing clinical review. review.
a year or £300,000 per PCT can
potentially be achieved through This publication is aimed at
the establishment of home oxygen healthcare professionals,
services, oxygen register review NHS Improvement - Lung worked commissioners and other key
and formal clinical assessment1. with clinical teams across England stakeholders involved in respiratory
supporting them in identifying, health services. It draws together
testing and implementing the the evidence and learning from the
changes needed to achieve good work undertaken by the national
practice in HOS-AR and seeking to COPD projects constituting the
understand the key components initial 12 months of the Improving
that have the greatest impact on Home Oxygen Services
the patient pathway. workstream.
Home Oxygen Service – Assessment and Review – Good Practice Guide, NHS Primary Care Commissioning (2011)
1
An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England, Department of Health, July 2011
2

5. INTRODUCTION 5
Improvement approach However, focus was also given to The project sites adopted a
improving the patients experience systematic approach to quality
NHS Improvement – Lung invited and outcomes, and to the removal improvement to ensure that any
NHS organisations to work in of duplication and waste from the changes implemented were
partnership on projects dedicated to pathway and from specific processes thoroughly tested and measured.
improving the COPD patient through different ways of working Prior to commencing the work the
pathway and to help address the and service redesign. project sites were required to
geographical variation in care that establish their service baseline
patients receive. Projects plans were Through patient list cleansing, through analysis of local data and to
submitted from a number of sites rationalising individual patient’s understand the variation in services.
including acute trusts, primary care oxygen usage (in terms of flow rate,
trusts (PCTs) and community supply duration and supply devices) Upon the establishment of individual
organisations. in line with their clinical need, project teams, a period of ‘diagnosis’
supported withdrawal of followed in order to allow teams to
The primary aims of the project inappropriate therapy and healthcare understand the patient pathway and
work were to provider education to avoid dispel a number of assumptions
inappropriate prescribing, 9 out of about the processes, its challenges
• Locally define and implement the the 12 oxygen workstream project and the solutions. Potential solutions
patient’s home oxygen care teams delivered collective prescribing were tested using the model for
pathway in alignment with the cost efficiencies totalling improvement and Plan-Do-Study-Act
standards enshrined within the approximately £640,000. (PDSA) cycles with ongoing
Good Practice Guide national measurement to evaluate the impact
publication During this ‘testing’ phase of the of the interventions and refine
• Identify and reduce variation in the national programme the project where appropriate.
delivery of care teams have explored the reality of
• Test the components of care that making local service improvements
led to an effective HOS-AR model by taking stock of current practice
• Identify the success principles that and understanding the
other organisations and teams implementation process necessary
could learn from and adopt for the delivery of optimal patient
• Inform future ‘prototyping’ work. care in a challenging environment.

6. 6 INTRODUCTION
Common challenges and
solutions
Whilst each project site has worked on a different part of the
home oxygen pathway, a number of key themes have emerged
Clinical teams at all sites have been
across all oxygen project sites which have enabled the
focussed on specific aims which
development of six top tips for improving home oxygen
have included:
services:
• Develop accurate registers of
1. Provide oxygen assessment and review staff with access to
patients in receipt of home oxygen
supplier data and support in its effective use
therapy
2. Use clinical and supplier data systematically to support
• Utilise the home oxygen service appropriate prescribing, clinical assessment with ongoing
data around initiating prescriber, review and tight cost control
oxygen consumption, flow rates, 3. Integrate your oxygen service within the wider respiratory
patient concordance and therapy pathway and coordinate activities with non-respiratory
modality more effectively and in specialties
combination with clinical data 4. Promote the message that ‘home oxygen is a treatment for
about individual patients chronic hypoxaemia and NOT a treatment for
• Ensuring all existing and future breathlessness’
patients in receipt of home oxygen 5. Work collaboratively to formalise policies and procedures
receive clinical assessment and around the safe use of home oxygen
ongoing review in line with best 6. Establish ongoing and effective communication between
practice the oxygen team, primary and secondary care to ensure
• Improve care for non respiratory appropriate prescribing, appropriate referrals and
patients in receipt of oxygen by continuous education for patients and professionals.
better collaborative working with
non-respiratory specialists
• Rationalise prescribing of home
oxygen to reflects the clinical need
of the local population
• Control home oxygen therapy
costs
• Develop and implement effective
risk assessment and health and
safety procedures
• Achieve greater integration of
assessment and review services
within wider care pathway.

7. INTRODUCTION 7
Project outcomes: Emerging success principles and project learning
NHS Improvement - Lung provides structured support to project teams enabling them to solve
problems by addressing root causes and by undertaking a systematic approach to service
improvement. Teams across the different workstreams of the national programme worked through
a number of different challenges in order to achieve their project aims. However some common
principles have emerged as critical success factors in all national COPD projects:
1. Defining and gaining a good understanding of the whole pathway of care - having a complete
understanding of the care pathway supported by robust data to demonstrate the effectiveness of current
processes, quantifying performance and variation is essential when embarking on improvement work. This
allowed organisations to identify priorities for change and also to benchmark themselves with others locally
and nationally.
Home oxygen project teams used supplier and clinical data on patients’ condition, therapy consumption
and compliance together with an improved understanding of the sources of prescribing and sources of
referral to local services in order to rationalise therapy in alignment with clinical need.
2. Taking an integrated approach to service development - issues and challenges viewed in isolation
without due consideration to the whole patient pathway were less likely to lead to sustainable
improvements in care provision.
Oxygen services need to be viewed within the wider respiratory care pathway to maximise the opportunities
for integrating with services such pulmonary rehabilitation and to ensure patients receive optimal and
coordinated management of their overall respiratory condition.
3. Clinical collaboration across the care pathway - effective working relied on the commitment of teams
in primary, secondary and community care to improve communication across the patient pathway.
Integrated working helped to build positive relationships with health care professionals, departments and
organisations, and improve the critical interface between these organisations.
Home oxygen teams often had to consider patients with a range of conditions not just COPD and as such
had to collaborate with non-respiratory specialists in order to ensure coordinated management of patients
requiring oxygen for neurological and cardiac conditions as well as patients requiring oxygen for
palliative care.

8. 8 INTRODUCTION
Next action steps for NHS teams
seeking to improve home oxygen
4. Clinicians and managers reviewing data together - access to
services
and effective use of data through collaboration between clinical and
managerial staff enabled the project teams to better understand the
The learning from this first year of
patient pathway and demonstrate the impact of any change. The
project work indicates that other
routine collection and review of data was important in implementing
NHS teams considering improving
sustainable improvements and understanding outcomes of any service
home oxygen services should focus
improvements.
activity in three areas:
Oxygen teams worked with non-clinical colleagues to understand
sources of inappropriate prescribing and inappropriate referrals for 1. Review oxygen usage data
clinical assessment. This enabled targeted education to be and improve data
undertaken within both the community and within hospital settings management – ensure the
accompanied by ongoing data review to assess changes in healthcare clinical team has routine access to
professional behaviour. supplier data and is collaborating
with non-clinical colleagues
5. Identifying the key levers and drivers in the system - by around patient list cleansing,
integrating local and national priorities into the work such as Quality, identifying candidates for therapy
Innovation, Productivity and Prevention (QIPP) project teams raised the rationalisation. The clinical team
profile and priority of the project work with decision makers and should provide clinical insight to
helped to achieve improved engagement from senior management managers and administrators
teams. undertaking monthly invoice
reconciliation and collaborate in
Both the QIPP agenda and the national re-procurement of oxygen the review of patient compliance
supply contracts provided an opportunity for clinical teams to engage using the quarterly concordance
other clinical and non-clinical stakeholders in a new dialogue about reports.
issues such as home oxygen therapy usage, reporting arrangements, 2. Establish clinical assessment
HOS-AR service specification and its integration within the wider care and ongoing review – identify
pathways, treatment goals, fire safety, risk assessment and the all patients currently in receipt of
coordination of community and hospital care. home oxygen in order to address
any assessment/review backlog,
6. Value for money - there was a need to identify and understand utilise local booking systems to
the gaps, duplication and waste in the patient pathway in order to capture referrals for initial
make best use of available resources. It was essential to work and assessment and to establish the
communicate with colleagues, commissioners and other stakeholders review cycle. Undertake
in service provision in order to maximise these resources and to ensure appropriate therapy
a consistent and co-ordinated approach to care. modifications, the supported
withdrawal of inappropriate
Commissioning, finance and medicines management colleagues therapy, patient safety risk
worked closely with home oxygen clinical specialists to identify assessment and ongoing patient
prescribing anomalies, to address waste, to improve the clinical education.
governance in respect of the safe use of home oxygen and to manage
the performance of the oxygen suppliers.

9. INTRODUCTION 9
3. Service integration and • Home oxygen services- The testing phase work
sustainability – undertake assessment and review demonstrated that the potential cost
process mapping with the resource hub - an online toolkit efficiencies identified by the
multidisciplinary team to which will identify key data Department of Health and
understand the current home measures and clearly articulate the attributable to therapy
oxygen patient pathway for the success principles for sustainable rationalisation through home oxygen
medical conditions being implementation of HOS-AR. This service –assessment and review can
managed. This should be used resource will provide case studies, be realised in practice. It is
together with detailed local examples of protocols, procedures anticipated that the prototype phase
contextual data about prescribing, and pathways together with Top- of work will further demonstrate the
usage, costs, home oxygen service tips and ‘next steps’ action sheets. importance of assessment and
activity, demand and capacity in • Safe use of oxygen support review in the maintenance of safe,
order to ensure the service package - highlighting issues of high quality, equitable and cost
specification supports the patient safety and risk efficient home oxygen services.
development of a cost-effective management for the local
pathway and aligns with local development of patient education
commissioning considerations. programmes and also the
strengthening of local clinical
Future ‘prototyping’ work governance arrangements through
a partnership between patients,
In the forthcoming year of project local NHS organisations, oxygen
work sites will be building on the suppliers and fire services.
learning from the ‘testing’ phase of • Spread Framework for Home
work. Sites will be refining the Oxygen Service - assessment
components attributed to the and review – guidance to assist
emerging care models and success clinical leads, home oxygen service Phil Duncan
principles that demonstrated the leads, clinical commissioning Director, NHS Improvement -
greatest impact on the patient Lung
groups and clinical networks in
pathway during the past year. their collaborative effort to drive
the regional implementation of
The prototyping work will define the HOS-AR and the widespread
efficient and high quality care model adoption of good practice in
that reflects best practice, but also home oxygen services.
demonstrates examples of practical
approaches towards sustainable
implementation. This will include
work that focuses on the delivery of
a number of products:
Ore Okosi
National Improvement Lead,
NHS Improvement – Lung

10. 10 CASE STUDIES
Wirral University Hospital NHS Foundation Trust and NHS Wirral
Wirral Integrated Community Oxygen Service
What was the problem?
The challenge for this community based Graph title required??
(but integrated with secondary care)
45 New
team of nurses, physiotherapists and
40 New patients prescribed
administrative staff providing COPD, by specialists
Pulmonary Rehabilitation and Oxygen 35
Number of Patients
New patients prescribed
services was to work more effectively 30 by non specialists
with the wider multidisciplinary team to 25 New patients prescribed
by us - palliative
manage patients on oxygen therapy who 20 Linear (new patients prescribed
have a wide range of health problems 15 by non specialists)
(not just COPD). In addition, the team Linear (new patients prescribed
10 by us - palliative)
sought to maintain or even increase the
5 Linear (new patients prescribed
cost efficiencies and improvements in by specialists)
patient care it had achieved through 0
Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Linear (new)
patient review and the use of oxygen Month
budget and concordance data when the
service was first established.
What was the aim?
By the end of July 2011, all existing adult What has been achieved? What are the key learning points?
patients registered with a Wirral GP and • All existing patients on home oxygen • It is important to establish
prescribed oxygen will have had a therapy have been reviewed communication networks with local
structured assessment. New patients will • Maintenance of tight cost control with primary and secondary care
be formally assessed before oxygen is continued reduction in non specialist stakeholders. By attending (or
prescribed and all patients will have a oxygen prescribing presenting at) local professional
scheduled review programme. Patients • Acceptance of the service by other forums opportunities to build trust and
who are prescribed oxygen will have the community based teams and other educate other healthcare professionals
most clinically and cost effective non-respiratory specialist teams can be realised. The education process
treatment. • Development of a pathway for is reinforced through individual
supported withdrawal of short burst discussion of non-specialist
• All adult patients on Wirral should oxygen therapy (SBOT) prescriptions and by giving feed back
have a structured assessment prior to • Formalisation of (safety) risk to referrers post patient assessment
commencing home oxygen in line with assessment with adoption of • Using a model that integrates oxygen
national guidance. This excludes documented procedures and assessment and review with COPD and
patients for whom oxygen is palliative escalation process PR services and is supported by
for terminal illness • Positive feedback from patients via an secondary care has contributed to the
• Oxygen will only be prescribed if external patient evaluation of the success of this community based
clinically indicated service service. Control of the prescribing of
• All adult patients on oxygen should be • Development of a shared care oxygen taking place within the acute
reviewed at least every six months to treatment pathway with heart trust via hospital based respiratory
ensure their prescription remains specialist nurses has reduced their nurses reduces inappropriately
appropriate for their needs referrals for SBOT. prescribed oxygen and improves
• Unnecessary oxygen prescribing should communication about patients who
be eliminated need further assessment and review
• An on-going education programme for
health professionals about the
indications, prescribing and use of
oxygen will be established.

11. CASE STUDIES 11
• Autonomy in setting up and Contact
developing the service coupled with Denise Williams
strong leadership and clinical and Nurse Consultant/ COPD and
managerial support is vital Oxygen Service Manager
• The importance of obtaining and
maintaining accurate data about Tel: 0151 514 2245 or ext. 3243
patients, review cycles and cost Email: denise.williams12@nhs.net
analysis should not be underestimated,
neither should the time and skill taken
to do this consistently
• Consistent, high quality assessment
and review by expert practitioners is
vital in gaining and maintaining the
trust of the patient, carers and clinical
colleagues. Cost effective prescribing
should follow on from this and not be
the prime motivation
• Developing positive relationships with
other specialist teams and clinical
colleagues is vital to be accepted as
part of the patient’s clinical
management team. This can only be
achieved by sustained effort and
networking.

12. 12 CASE STUDIES
NHS Hull and the City Health Care Partnership
Home oxygen service improvement project
What was the problem?
Final procurement of local Home Oxygen
Service – Assessment and Review (HOS-
AR) coincided with the start of the NHS
Improvement-Lung project. The project
had a split focus, one area being the
successful commencement of HOS-AR
with the associated challenges of
establishing a new referral pathway,
accessing, interpreting and using data
and also the clinical review of 876
existing patients currently receiving
home oxygen. The second area of focus
was to establish robust procedures
around risk, health and safety and
smoking as this had been identified as a
local priority.
Picture features Home Oxygen Clinical Team only - the full project group comprised
What was the aim? PCT commissioners, smoking cessation, patients, oxygen supplier and the Fire Brigade
To contribute to a reduction in
unscheduled hospital admissions and
optimise chronic obstructive pulmonary
disease (COPD) patient care through the What has been achieved? • Prior to the service commencing the
delivery of appropriate and cost-effective • Patients at risk have been identified by number of patients in Hull in receipt of
oxygen therapy to COPD patients the HOS-AR team and joint visits have oxygen was 876, the current caseload,
identified as being in clinical need been undertaken with the Fire Brigade as of 3rd October 2011, is 579
determined through assessment by together with the development of a • Home oxygen monthly invoices have
trained healthcare professionals. joint risk assessment pathway and reduced by £15k since the service
arrangements for future joint training commenced a reduction in annual
• Remove inappropriate oxygen between both teams forecast spend of £0.204m
provision, ensuring correct equipment • A policy for the delivery of HOS-AR has • Patient experience as obtained using
and therapy is delivered to new and been developed and approved by City the Long Term Conditions LTC6
existing patients on oxygen Health Care Partnership with regular questionnaire was overwhelming
• Reduce unnecessary costs of oxygen education for local primary, community positive and scored highly in respect of
and equipment and secondary care (on best practice, patient involvement in decision-
• Risk assess patients/carers prior to and referral criteria and optimising making, information provision, joined-
during their use of oxygen therapy treatment) built into the team’s service up care and team support.
• Work with the local fire brigade to specification
produce and develop a workable local • A draft health and safety oxygen use
policy on smoking and oxygen policy has been developed and it is
provision hoped that all stakeholders will be
• Educate patients on health and safety signing up to its use shortly
issues surrounding smoking and
oxygen therapy
• Develop a written (signed) contract During the period of April 2010 - September 2011:
between patient and health care New referrals into the service for patients not in receipt of oxygen 341
professional (HCP) with clauses to Assessments and or follow ups undertaken 1630
remove provision on grounds of health Number of those new referrals which were inappropriate 109
and safety or no clinical need/benefit. Patients were discharged from the service, no longer requiring oxygen 168
Removals of modalities 435
Commencements on oxygen modalities 322
Increases in oxygen flow rates 234

13. CASE STUDIES 13
What are the key learning points? • Locally, just as is the case nationally, Contact
• Using cost and usage data from the there is no clinical consensus on the Toni Yel
oxygen supplier is the smartest way to issue of therapy withdrawal in hypoxic Business Development Manager
determine a starting point for patients who continue to smoke.
assessing and reviewing patients. A However, the team work proactively to Mobile: 07530 719 852
template is being developed to support manage and minimise the risks to Email: toni.yel1@chcphull.nhs.uk
integration of clinical system reporting patients and their surroundings
with oxygen reporting systems. Quick through education, working with
financial wins came from the stakeholders and by involving the
administration team working through COPD Smoking Cessation Specialists
the invoices and identifying and the Fire Brigade in care pathway
discrepancies and reporting this back development. This has been really
to the oxygen supplier successful and has led to a number of
• A lot of time was spent gaining an reported ‘quitters’ among existing
understanding of the data (with the oxygen patients identified as continued
suppliers help) and what it meant smokers
before the team were able to analyse • Having the commissioners leading this
the information and use it proactively multidisciplinary project has driven the
• Working with the Fire Brigade has work, but the project would have had
helped tackle the challenges a stronger voice in the wider health
experienced by the team in educating community if the project team had a
patients and carers of the risks around consultant or GP among its
health and safety and on dangers of membership.
smoking to themselves and others,
making such discussions more
impactful

14. 14 CASE STUDIES
Royal Free Hospital NHS Trust, NHS Waltham Forest & North East London,
North Central London and Essex Health Innovation Education Cluster
The feasibility and impact of withdrawal
of Short Burst Oxygen Therapy (SBOT)
What was the problem? The results of 19 patients in terms of What are the key learning points?
There is considerable evidence from HAD, SGRQ, FEV1 (morbidity) and The issues relating to withdrawal of
home oxygen service data and related oxygen SaO2 at assessment on first visit SBOT are highly complex and multi-
surveys that the use of short burst are presented in the oxygen workstream factorial. They relate not to sub-optimal
oxygen (SBOT) or intermittent oxygen at emerging learning publication management, but rather to the fact that
home, for the relief of breathlessness in www.improvement.nhs.uk/lung this subgroup of patients have severe
patients without chronic hypoxemia, is COPD, are unwell, are maintained at
still being provided, despite considerable In the second PCT, the project team home and are too sick to consider
published data that it is not effective and encountered considerable difficulty in removal of oxygen. The majority of
is therefore costly to the NHS. This accessing oxygen usage data. The patients in this study had SBOT
project was undertaken to address the project team developed a questionnaire prescribed for over 12 months (often
issue of the prescription of short burst exploring the issue of oxygen data access following an exacerbation) which had
oxygen (SBOT) for patients with chronic and it’s usefulness in managing care and also led to some psychological
obstructive pulmonary disease (COPD). circulated it to 17 teams within the NHS dependence over time. However, the
Improvement-Lung national programme. project duration spanned an excessively
What was the aim? The 12 completed questionnaires cold period with a high incidence of
To review all COPD SBOT prescriptions, indicated: acute exacerbations where patients
of more than 3 months, in two PCT genuinely needed their SBOT and which
areas, in order to reduce SBOT • Variation in ease of access to data was felt to be justified by their clinician.
prescription by 75% over the course of across the respondents
one year (July 2010 to July 2011). This • Clinicians do not have access to the The following points have become clear
target figure was deliberately aimed high full range of data during the project:
as most SBOT patients (with the • Respondents all doing something
exclusion of palliative prescriptions) have slightly different depending on their • Communication between the
no clinical indication for SBOT. location community and hospital on discharge
• Access via commissioners and PCT but needs improving to ensure seamless
What has been achieved? not available to secondary care care of home oxygen patients
Twenty-five patients on SBOT in the • Accuracy of data a problem • Patients were discharged with no
borough of Waltham Forest with a • Current and accurate tariffs not always information about the use of oxygen
primary diagnosis of COPD were available so hard to control and once at home and no support
identified. Appointments were sent and manage expenditure regarding their oxygen therapy
patients, who agreed to participate in • Issues over data protection resulting in • Patients commenced on SBOT for an
the project, visited in their homes: challenges around wider access to data. exacerbation need reviewing at six
weeks for assessment, education and
support with a view to removal to
avoid psychological dependence
Results of Oct to Jan to • Whilst there is an assumption that
home visits Dec 2010 Jun 2011
patients on SBOT have been given it
erroneously, this study has
SBOT successfully withdrawn 2 demonstrated that in the majority of
Exacerbating at time of assessment 9 these cases, this has not been the case
• There needs to be clarity about the
Withdrawn from study project 2 correct prescription of LTOT, given the
SBOT left in place on compassionate grounds 2 complexity of removal of SBOT
Refused assessment 1
SBOT replaced by LTOT or Ambulatory Oxygen 1
Admitted to hospital 1
Total 18 7

15. CASE STUDIES 15
• Patients who are prescribed SBOT may
not have been seen by a clinical
specialist in oxygen therapy and may
not have been told how long the
prescribed oxygen should be used
• Patients who are prescribed oxygen in
nursing homes need to be reviewed
and require clinical specialist support in
their management, the management
of nursing homes need to be informed
that patients require regular
assessment and that appropriate and
cost effective arrangements can be put
in place for emergency oxygen
supplies.
Contact
Christine Mikelsons
Consultant Respiratory Physiotherapist
(Royal Free)
Tel: 0207 794 0500 ext 34068
or bleep 1041
Email: christine.mikelsons@nhs.net
Anne Crawford
Respiratory Services Team Lead /
Respiratory Nurse Specialist
(Waltham Forest)
Tel: 0208 430 8255
Email: anne.crawford@wf-pct.nhs.uk

16. 16 CASE STUDIES
NHS Nottinghamshire County Community COPD Team, Sherwood Forest
Hospitals NHS Foundation Trust and County Health Partnership
Home oxygen – improving quality of care
• Develop the systems and protocols to
introduce GP direct access and to
target hospital discharge oxygen
• Re-categorise therapy modality or
remove oxygen therapy for a large
number of patients and consequently
recover a projected £98,000 in annual
costs attributable to inappropriate
prescribing.
What are the key learning points?
• Integration of home oxygen services
with pulmonary rehabilitation provides
a seamless service for patients. It
increases key worker understanding of
both therapies and it also improves
service efficiency. In addition, both
What was the problem? Objectives: patient knowledge and experience is
The community COPD team, in • Introduce GP direct access to the improved which leads to informed
collaboration with the local respiratory oxygen assessment service patient choices and more appropriate
function department established a • Quantify the work that would be prescribing
community based oxygen assessment associated with retrospective • Pulmonary rehabilitation is the ideal
service, co-located with an existing assessment (for patients with oxygen platform to trial ambulatory oxygen
consultant led COPD clinic and a and no history of assessment) therapy
pulmonary rehabilitation service, with • Develop a strategy for the • Patient review provides the ideal
assessments being provided across two identification and assessment of opportunity to re-categorise the
sites. patients discharged with oxygen oxygen supply according to changing
following a hospital admission clinical and social needs
The service proved successful and highly • Improve oxygen prescribing ensuring • Liaison with data analysts is important
regarded by patients but was not utilised therapy matched clinical need and in order to make effective use of
by all prescribers of oxygen, resulting in a actual usage, and also to reduce available oxygen usage data
significant proportion of patients supply costs. • Access to monthly oxygen supply
receiving home oxygen without clinical invoices is important to track what is
assessment. The service recommended What has been achieved? happening to the oxygen supply
to the PCT and to PBCs that prescribing Although audit and review of oxygen • Encouraging dialogue between the
without assessment should be barred but patient registers and oxygen usage data home oxygen service and primary care
the advice was rejected thus alternative suggested the need for a significant together with improved accessibility to
options to address the shortfall of increase in staff and staff availability (in specialist HOS-AR team advice was
assessments needed to be developed. order to undertake retrospective important in ensuring improved
assessments), through service re-design oxygen prescribing.
What was the aim? the project team were able to:
The project aimed to increase the Contact
proportion of patients undergoing • Increase the number of assessment Dr Sue Revill
oxygen assessment and regular review in sessions Clinical Scientist COPD Services
order to improve both patient • Identify areas where they could
management and cost containment by integrate with other community teams Tel: 01623 785407
introducing a ‘direct access’ pathway for in order to streamline and increase Email: sue.revill@sfh-tr.nhs.uk
general practice, community nursing and service capacity
other medical prescribers, thereby • Improve integration within the COPD
supporting areas with high rates of community team i.e. integrating the
oxygen prescription (i.e. hospital services of oxygen assessment and
discharge and general practice). pulmonary rehabilitation

17. CASE STUDIES 17
NHS Sheffield and Sheffield Teaching Hospitals NHS Foundation Trust
Home oxygen service improvement project
What was the problem?
NHS Sheffield as part of their Achieving
Balanced Health Strategy (2010)
identified that they had the highest
projected forecast spend on home
oxygen therapy. There was no local
requirement for patients to have an
oxygen assessment in advance of therapy
being ordered /prescribed and patient’s
ongoing need for oxygen therapy was
not always reviewed.
What was the aim?
By July 2012, all NHS Sheffield chronic
obstructive pulmonary disease (COPD)
patients newly prescribed home oxygen
have had an initial quality assured
assessment and all COPD patients with
home oxygen are systematically reviewed
in line with British Thoracic Society/NICE
guidelines resulting in the correct
therapy (detailed on home oxygen order • Improved communication and • Garner wider organisation support –
forms and equipment) and leading to understanding between PCT the engagement of Clinical
improvements in patient quality of life, commissioners and service providers. Commission Group (CCG) enabled the
increased life expectancy, reduced • Raised the profile and importance of profile of home oxygen therapy
(unscheduled) admissions and robust pulse oximetry among local GP's patients and service issues to be raised
oxygen cost control. • Improved use of data from oxygen within the CCG
supplier • Undertake analysis of service demand
What has been achieved? • Reduction of between £120K to and capacity with service provider staff
The cost saving potential and £150K in estimated annual oxygen to inform the service specification
improvements in care demonstrated by prescribing costs • Set standards high and be prepared to
the project work have enabled a new • Established ongoing systematic negotiate around new ways of
service specification to be written and monitoring of HOOFs. working
agreed with the provider of the new • Take time to understand and assess
service, which includes the assessment What are the key learning points? prescribing anomalies.
and review of both respiratory and non Use of internal audit to develop systems,
respiratory patients. The start date for audit oxygen cost monitoring processes, Contact
the new service is planned for Jan 2012 clarify invoices and avoid errors ensured Joanne Watson
pending agreement of funding support from the finance and Lead Public Health Development Nurse
arrangements and mobilisation of the performance directorate and enabled
service. detailed analysis of oxygen usage to be Tel: 07816 271547
undertaken. Email: j.watson11@nhs.net
Notable project achievements include:
• Validation of oxygen usage completed • Remain motivated in order to deliver
in 2010/11 and a further one is eventual improvements
planned for November 2011. • Encourage cross functional working –
• Register compilation with a system PCT commissioner, medicines
now in place to check Home Oxygen management, clinicians and provider
Order Forms (HOOFs) are completed
properly

18. 18 CASE STUDIES
NHS Blackpool and Blackpool Teaching Hospitals NHS Foundation Trust
Improving oxygen services and the
prescribing of oxygen across Blackpool
What was the problem?
The PCT had a high proportion of
patients using oxygen compared to other
areas within the region and this was
associated with higher than (regional)
average prescribing costs. A preliminary
audit undertaken in collaboration with
secondary care in 2009 revealed that
only 30% of patients on home oxygen
had been assessed or reviewed by a
clinical specialist.
This audit identified the risk that patients
may be receiving oxygen inappropriately
resulting in adverse clinical outcomes if
prescribed not matching the patient’s
clinical needs or patient in receipt of
unnecessary oxygen.
What was the aim?
The objectives of the project were to:
• Develop an accurate home oxygen
therapy register What has been achieved? What are the key learning points?
• Identify number of patients receiving • £141k pa cost reduction to date • Identify the PCT oxygen lead in order
home oxygen who do not meet the • Patients referred seen within a week to progress work utilising concordance
guideline criteria • 94% of patients have now been seen reports and supplier invoices and
• Identify patients who could have their – in excess of target of 80% of engage the finance dept. in final
therapy changed or discontinued patients outstanding at the start analysis work
• Conduct urgent review of individuals (approximately 270) • Establish strong links and good
receiving high/low dose oxygen to • Now that the team know the patients, personal working relationships
ensure clinical risks are managed and have established rapport with between primary and secondary care
• Develop a structured them, the consultation time is for a consistent approach to service
assessment/follow up service which sometimes shorter, further increasing delivery
meets NICE guidance efficiency • Identify all stakeholders, and develop
• Increase the proportion of patients • Access to information is now shared engagement and inclusion from the
receiving a structured assessment from with the HOS-AR team informing their start, keeping everyone up-dated and
the current level (30%) to (80%) clinical decisions and improving quality acknowledge individual and team
within time frame of the project. • Blackpool GPs are no longer routinely effort to drive project
starting patients on oxygen • Consider what information you need
themselves, but are using the service locally, and why, when developing your
• Pulmonary rehabilitation is now own data resource to capture and
referring into the HOS-AR and vice collect clinic activity, cost savings and
versa follow-ups
• Community matrons and the early
supported discharge service linking
with HOS-AR service and expertise
shared.

19. CASE STUDIES 19
• Effective data collection systems were • Maintaining service efficiency provides
essential in order to calculate numbers capacity to ensure DNAs are followed
for future capacity and demand and to up by home visits if necessary
record the cost savings being realised • Phone call reminders helps to reduce
for future sustainability of the Home DNA rate and follow-up phone calls
Oxygen Service through improved following a DNA can also help in
quality and productivity future attendance rates
• Ensure clinicians have access to all up- • Home oxygen service – Assessment
to-date relevant patient information in and review within the community
a timely fashion in order to make more setting has had both advantages (staff
informed clinical decisions at the time can focus exclusively on assessment
of contact and review without interruptions
• Establishing a robust baseline supports arising from other issues within the
realistic and effective planning within acute setting) and disadvantages
the resources available, it also helps (community clinic computers not
focus and supports identification of currently linked to the appointment
quick win reductions in prescribing system)
which help team motivation and • Access to expertise with ability to cost
provide momentum various service delivery options
• Process map early to identify gaps in enabled a range of evidence-based
service provision scenarios to be presented to Clinical
• Make use of ‘protected time out’ to Commissioning Groups.
ensure full engagement from all
members of the team with problem Contact
solving and action planning Ros Ince
• Highlight work that could be more Lead Nurse Diabetes and Respiratory
cost effectively performed by
administration staff and release clinical Tel: 01253 651316
capacity Email: rosalyn.ince@blackpool.nhs.uk
• Changing behaviour is both
challenging and evolves gradually over
time, pathways revisited regularly
through stakeholder meetings, training
and support
• Working with patients to reduce their
prescription where appropriate is
difficult and not always pleasant
• It is important to consistently promote
the message to patients and
professionals that oxygen is
appropriate only when patients are
hypoxic

20. 20 CASE STUDIES
NHS South Staffordshire
Improving home oxygen services through
pathway redesign
What was the problem?
A gap in service provision had been
identified within the Cannock Chase
locality of South Staffordshire PCT due to
the absence of Home Oxygen Service –
Assessment and Review (HOS-AR)
despite the fact that 537 patients were
known to be in receipt
of home oxygen within Cannock Chase
locality, of which only 149 were known
to the local community respiratory team.
In addition, the majority of costs
associated with oxygen prescribing were
attributed to the use of intermittent
oxygen or short burst oxygen a therapy
modality for which there is currently no
supporting evidence
What was the aim?
Cannock Chase respiratory service
reviewed local oxygen treatment in order
to:
• Rationalise and evaluate home oxygen • Duplicate orders to multiple addresses • Clinicians in GP surgeries have limited
prescribing were eliminated as were erroneous knowledge of the type oxygen to order
• Establish treatment appropriate to multiple charges levied against and in some cases prescribe
clinical need individual patient therapy orders inappropriately
• Rectify invoice anomalies and • Established that 64% of the patient • Oxygen assessment and review can
• Liberate efficiency gains for investment register had never been previously improve care by ensuring appropriate
in permanent HOS-AR provision. assessed and had normal oxygen levels therapy and ensure costs are reflective
measured by pulse oximetry of the true clinical need of the
What has been achieved? • Supply orders relating to patients who population.
• 257 oxygen therapy reviews took place have moved were cancelled
and all 257 patients also received a fire • Payment for equipment never received Contact
service safety check was stopped. Joan Manzie
• 194 patients had their therapy Consultant Respiratory Nurse
rationalised as a result of specialist In total, the improvements undertaken
review over a six month period achieved cost Tel: 01543 509756
• 30 patients with no clinical indication savings of £130,512 Email: joan.manzie@ssotp.nhs.uk
for oxygen had their therapy
withdrawn resulting in a saving of What are the key learning points? Sally Young
£24,352 • Existing home oxygen data collection Staffordshire Cluster Patch Manager
• Cessation of payments made in and administration systems are
respect of deceased patients and complex Tel: 03007900233 ext 3538
discontinuation of their continued • Invoicing processes are remote from Email: sally.young@northstaffs.nhs.uk
oxygen supply led to a saving of clinicians ordering home oxygen and
£23,442 require administrative support to work
effectively

21. CASE STUDIES 21
Milton Keynes PCT Community Services and Milton Keynes
Hospital NHS Foundation Trust
Sustaining the efficiency and effectiveness of the Milton
Keynes Home Oxygen Service – Assessment and Review
What was the problem?
Milton Keynes undertook a service Invoice variation 2010/11 (excluding VAT and holiday
redesign initiative through a ‘spend-to- HOOF’s and deductions)
save’ programme and successfully
reduced inequalities in oxygen service 4
provision and also reduced the costs of 2
home oxygen prescribing. However, they
0
were aware that further improvements Jun10 Aug10 Oct10 Dec10 Feb11 Apr11 Jun11 Aug11
% Age Variation
Jul10 Sept10 Nov10 Jan11 Mar11 May11 Jul11
could still be made, especially in respect -2
of ambulatory oxygen assessments, and -4
were keen to both sustain and enhance
-6
service quality and efficiency by
participation in the NHS Improvement- -8
Lung national COPD project. -10
-12
What was the aim?
The project team identified three -14
principle objectives: Month
• Enhancement of existing care pathway
by the production of a HOS-AR (best
practice) adoption ladder What are the key learning points?
• Improve ambulatory oxygen provision • Clearing the backlog of un-assessed
and care by carrying out an evaluation patients has enabled the service to
pre and post the setting-up of an reach a steady state in terms of
ambulatory oxygen assessment clinic matching demand and capacity
• Assess the impact of patient literature • Process mapping exercises uncovered a
on patient experience through the gap in service provision in respect of
development and use of a quality guideline required home visits and the
patient questionnaire pre and post the review of house bound patients. The
use of a patient information leaflet. service is confident it can address this
gap before the transition to a new
What has been achieved? supply contract
The service is on target towards ensuring • Sustainable improvements to this
that all existing home oxygen patients service were achieved by building
have been assessed before the transition An ambulatory oxygen clinic has now progressively on service changes and
to a new supply contract. Therapy been established and a patient by ensuring ongoing, coordinated
alterations continue to be undertaken satisfaction audit around the use of use and monitoring of oxygen
after clinical review and the service has liquid oxygen has been undertaken. In supply data.
been able to sustain monthly cost addition, the home oxygen service
savings in the order of £1,000 - £2,000 patient information leaflet has been Contact
per month. However, the cost saving deployed. An evaluation of the leaflet is Sue Channon
trajectory is on the decline as ongoing as the evaluation questionnaire Home Oxygen Commissioning Manager,
improvements in ambulatory oxygen was used to obtain baseline findings pre- Regional HOS Lead Specialist,
assessment are uncovering the clinical leaflet deployment but as this exercise COPD Co-ordinator
need for higher flow rates among many has coincided with another Trust patient
patients and so the cost per patient is experience gathering exercise the post- Tel: 01908 650402
rising. deployment evaluation is currently Email: sue.channon@mkchs.nhs.uk
outstanding.

22. 22 ACKNOWLEDGEMENTS
Acknowledgements
NHS Improvement – Lung would like to thank all national improvement project sites
for their hard work and dedication to improve quality and care for people with COPD,
and for their support and contributions to this document.
In addition, the following people have provided a source of expertise and support and
their help is gratefully acknowledged:
• Sandie Bisset
Home Oxygen Service, Department of Health
• Hamza Jamil
Home Oxygen Service, Department of Health
• Dr Mike Ward
Sherwood Forest Hospitals NHS Foundation Trust
• Dr Maxine Hardinge
Oxford Radcliffe Hospitals NHS Trust
• Bob Arora
NHS East London and the City
• Glenda Esmond
Central London Community Healthcare
• Sandra Major
NHS Gloucestershire
• Yvonne Richards
NHS Birmingham East and North
• NHS Improvement - Lung
References
1. Home Oxygen Service - Assessment and Review - Good Practice Guide,
NHS Primary Care Commissioning (2011)
2. An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD)
and Asthma in England, Department of Health, July 2011

24. NHS
CANCER
NHS Improvement
DIAGNOSTICS
HEART
LUNG
STROKE
NHS Improvement
NHS Improvement’s strength and expertise lies in practical service improvement. It has over a
decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and
stroke and demonstrates some of the most leading edge improvement work in England which
supports improved patient experience and outcomes.
Working closely with the Department of Health, trusts, clinical networks, other health sector
partners, professional bodies and charities, over the past year it has tested, implemented, sustained
and spread quantifiable improvements with over 250 sites across the country as well as providing
an improvement tool to over 2,000 GP practices.
NHS Improvement
3rd Floor | St John’s House | East Street | Leicester | LE1 6NB
Telephone: 0116 222 5184 | Fax: 0116 222 5101
www.improvement.nhs.uk
Delivering tomorrow’s
Publication Ref: NHSImp Lung 0001 - May 2012
©NHS Improvement 2012 | All Rights Reserved
improvement agenda
for the NHS