improving the quality and safety of home oxygen services: the case for spread

NHS Improvement - Lung

NHSNHS Improvement

Lung

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Improving the quality andsafety of home oxygen services:The case for spread

Contents

1: Introduction

1.1 Context 1.2 Summary of workstream learning 1.3 The case for spread 1.4 Use of data

2: Learning from the prototype projects

2.1 Components of a quality HOS-AR model 2.2 Practical service models 2.3 Issues and challenges 2.4 Overall project cost savings

3: Case studies

3.1 Oxford3.2 Hampshire3.3 Derby3.4 Salford3.5 Stockport

4: Additional information and resources

Appendix 1: North East procurement of HOS-AR provider –a case study

Appendix 2: Project team process maps and other lungimprovement resources

5: Acknowledgements and references

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Improving the quality and safety of homeoxygen services: The case for spread

Improving the quality and safety of home oxygen services: The case for spread

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1.1 Context

This prototype project final reportbuilds upon the learning from theinitial testing phase projects. Thelessons learned from the earlier workare documented within twoimproving home oxygen servicesworkstream publications entitledEmerging Learning from the NationalImprovement Projects1 and Testingthe Case for Change2.

The earlier publications highlightedthe work of 12 multidisciplinaryproject teams based in various sitesacross England. As part of thenational chronic obstructivepulmonary disease (COPD) projectcohort these sites were supported inthe practical use of serviceimprovement methodology in orderto implement home oxygen service -assessment and review (HOS-AR) asspecified within the national goodpractice guide3.

Both the national COPD project workand the development of the goodpractice guide were constituents of awider respiratory programme of worksupporting the introduction of theOutcomes Strategy for COPD andAsthma4.

Home oxygen services have been aparticular priority within therespiratory programme as earlierwork had revealed significant wastein the use of resources with manypatients either not using, or receivingno clinical benefit from, suppliedtherapy. This problem wascompounded as an estimated 20% ofpatients requiring therapy were notreceiving it5.

The testing phase work sought toestablish the case for change i.e. thatquality assured prescribing of homeoxygen therapy through structuredassessment and ongoing clinicalreview not only improves safety andquality but also increases costefficiency.

The results from the testing projectssuccessfully proved this concept andso the goal of the prototype phasewas to establish the case for thespread of good practice and soestablish HOS-AR across the country.

The work presented within thispublication was undertaken by the six project teams comprising theprototype phase of the nationalCOPD projects improving homeoxygen workstream.

The prototype work placed a greatemphasis on the safe and appropriateuse of home oxygen and as such waswell aligned with NHS OutcomesStrategy Domain 5 - Treating andcaring for people in a safeenvironment; and protecting themfrom avoidable harm6.

The prototype project teams werewidely dispersed across England andthis report features case studies fromfive sites: Hampshire, Oxford, Derby,Salford and Stockport.

1.2 Summary of workstreamlearning

A key objective of the prototypeproject work was the refinement ofthe testing phase approach in orderto identify the first steps clinicalnetworks should undertake whentrying to improve the home oxygenpathway and also to define the keysuccess principles of practical serviceimplementation.

These ‘first steps’ and ‘successprinciples’ have been publishedseparately but are included withinthis document for completeness.

1: Introduction

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5

What you can do Why it matters How to do it

Home oxygen is a treatment forchronic hypoxaemia and NOT atreatment for breathlessness. Itis a drug and should only beprescribed where clinicallyindicated otherwise it is of NObenefit and potentially harmfulto some patients.

In PCTs that have introduced areview of their oxygen registerscoupled with the introduction ofa formal assessment service upto £400,000 has been saved inone year. If the scale of savingswere replicated across England,it is estimated that they couldamount to between £10-20m.

Promote the message to staff and patients that ‘oxygen is not a treatment for breathlessness’ and that there are often moreappropriate ways to managebreathless patients.

Ensure only patients who havebeen assessed by a specialistservice are prescribed oxygen andthat they receive ongoing review.This involves measuring bothoxygen saturations and bloodgases and reviewing other clinicaldata together with supplier dataon usage, flow rate, duration and equipment.

Rationalise therapy in line withclinical need and undertakesupported withdrawal of oxygenproviding no clinical benefit.

7. Do notprescribeoxygen for‘breathlessness’and ensureprescribingremainsclinicallyappropriateand costeffectivethroughformalassessmentand ongoingreview

First steps to improving chronic obstructive pulmonary disease (COPD) care

Some patients with COPD orother long term chest conditionscan become sensitive to mediumor high doses of oxygen. Thisdoes not happen to everyonewith these conditions, only asmall number, therefore, ifoxygen is needed by thesepatients, it should be given in acontrolled way and monitoredcarefully.

Oxygen alert cards and 24%masks (recommended in theBTS 2008 guideline) can avoidhypercapnic respiratory failureby alerting healthcareprofessionals that patients aresensitive to oxygen. Oxygenalert cards should be issued to all at risk patients ondischarge as part of thedischarge planning process.

8. Oxygenalert cardsshould beprovided forat riskpatients

LIVING WITH

First steps to improving chronic obstructive pulmonary disease (COPD) care


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FINDING O

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LIVING WITH

W

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WRO

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TOWARDS TH

E END

Home oxygen

Success principlesMaking a real difference

TEN:

NHSNHS Improvement

Lung

1. Implement Home Oxygen Service – Assessment and Review (HOS-AR) in line with nationallyidentified good practice

Why - In order to ensure quality of care, safe use of oxygen and the avoidance of waste.

How - Review the learning from the national COPD projects improving home oxygen service workstreamavailable at www.improvement.nhs.uk/lung

Liaise with your respiratory clinicians and make use of national good practice guide and the Department ofHealth commissioning specification for HOS-AR in order to construct a business case and devise a servicespecification.

Example: NHS Nottinghamshire County Community COPD Team, Sherwood Forest Hospitals NHSFoundation Trust and County Health Partnership: ‘Patient review provides the ideal opportunity to re-categorise the oxygen supply according to changing clinical and social needs.’

2. Use both clinical and oxygen supplier data systematically to support the assessment andreview process

Why - Data review enables the identification of patients who may potentially require therapy rationalisationor the supported withdrawal of oxygen. It also helps identify sources of inappropriate prescribing andmaintain tight cost control.

Home oxygen therapy is provided to about 85,000 people in England, costing approximately £110million a year. Home oxygen service assessment and review (HOS-AR) is variable as patients in manyPrimary Care Trusts (PCTs) do not receive a quality assured clinical assessment and a review of theirongoing need for long term home oxygen.

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

Gross savings of up to 40% - equivalent nationally to £45 million a year or £300,000 per PCT canpotentially be achieved through the establishment of home oxygen services, oxygen register review andformal clinical assessment.

Reducing variation in service provision can help tackle health inequalities and ensure consistency in thesafety and efficacy of services.

Success principle 10: Home oxygen


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How - Provide HOS-AR teams with access to oxygen usage data from suppliers and ensure they work collaborativelywith managers and information specialists to routinely review the usage, flow rate, duration and equipment of homeoxygen patients.

Example: NHS Hull and the City Health Care Partnership: ‘Using cost and usage data from the oxygen supplier isthe smartest way to determine a starting point for assessing and reviewing patients.’

3. Integrate HOS-AR within the wider respiratory care pathway and coordinate activities with non-respiratory specialties

Why - Oxygen therapy assessment and ongoing review provides the opportunity to optimise all other aspects ofpatients COPD management (or their other long term conditions).

How - Undertake process mapping and also demand and capacity analysis to understand the whole pathway andidentify opportunities for new ways of working. Ensure that HOS-AR is explicitly detailed within the respiratory servicespecification and that the HOS-AR team activities are aligned with other respiratory services such as pulmonaryrehabilitation. Ensure coordination exists with non-respiratory services such as cardiology, neurology and palliativecare.

Example: Wirral University Hospital NHS Foundation Trust and NHS Wirral: ‘Using a model that integratesoxygen assessment and review with COPD and Pulmonary Rehabilitation services and is supported by secondary carehas contributed to the success of this community based service.’

4 Promote the message that ‘Home oxygen is a treatment for chronic hypoxaemia and NOT a treatment for breathlessness’

Why - Oxygen is a drug and should only be prescribed where clinically indicated otherwise it is of NO benefit andpotentially harmful to some patients.

How - Establish ongoing and effective communication between the HOS-AR team, primary and secondary care andalso patients groups through education sessions and Forum meetings. A continuing dialogue should occur in respectof best practice, treatment goals and HOS-AR referral criteria.

Example: NHS Birmingham East & North and Heart of England NHS Foundation Trust: ‘Engage GP consortia toensure the project has support and buy-in, engagement with the clinical lead may assist in terms of reinforcing themessage to patients and clarifying the indications for oxygen therapy’

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

Why - Oxygen therapy is highly flammable and can result in serious injury or even death if not used safely.

How - Ensure patients and carers receive instruction in the safe use of home oxygen during the assessment and reviewprocess and provide support to stop smoking. Work in partnership with oxygen suppliers and local Fire Rescue Servicesto promote consistent messages around the safe use of oxygen and to establish risk identification, risk managementand clinical governance policies and procedures.

Example: NHS Hull and the City Health Care Partnership: ‘Working with the Fire Brigade has helped tackle thechallenges experienced by the team in educating patients and carers of the risks around health and safety and ondangers of smoking to themselves and others, making such discussions more impactful’


1.3 The case for spread

Sharing the learning: The homeoxygen workstream nationalimprovement lead sought widespreadcollaboration with stakeholders. Thesestakeholders included the Departmentof Health home oxygen team, theregional respiratory programme teamsand also the regional home oxygenservice (HOS) leads. This collaborationwas important in the promotion ofnationally endorsed good practice andthe spread of the emerging learningfrom the national COPD projects.

As such, the national improvementlead (NIL) participated in numeroushome oxygen best practice workshopshosted by respiratory clinical networksand regional respiratory programmeteams.

The workstream publications were alsowidely disseminated in both print andelectronic form. The project teamsalso played a major role forming aninformal virtual network for spreadand sharing their experiences withcolleagues across the country in localeducation sessions and communities ofpractice

Collectively this meant that evenbefore a formal spread programmewas established many localities andregions were enabled to adopt muchof the learning and implementimprovements in their home oxygenprescribing procedures, datamanagement and cost control.

Improving the landscape in respect of assessment and review wasacknowledged as important insupporting the efforts of theDepartment of Health and the regionsas they sought to re-procure andsuccessfully transition the oxygensupply contracts.

In many localities the strengthenedclinical input, better data managementand overall service coordinationprovided by HOS-AR also assisted theoxygen supply companies with thetransition process.

In addition, the important servicecoordinating role undertaken by HOS-AR teams together with their role ineducating both patients andhealthcare professionals and also theirrole in supporting risk managementcontributed in small part to the successof many regional transitionprogrammes. It also strengthened thecase for HOS-AR to be available morewidely.

The goals of HOS-AR spread: Usingintelligence gained from initial surveysof HOS-AR coverage, undertaken bythe Department of Health (DH), anestimated 60% of Primary Care Trusts(PCT) had established some form ofHOS-AR by the time a formal spreadprogramme was launched inSeptember 2012. These estimates arebeing revised as a more robust surveyis currently underway.

It is difficult to establish exactly whatthe coverage was prior to the start ofthe testing phase project work but isgenerally accepted that HOS-ARcovering the whole population servedby each local PCT was not widespread.

In devising a spread strategy it wasimportant to align the approach withboth the DH service specification forHOS-AR5 (part of the COPDcommissioning toolkit7) and thenational COPD project learning.

This ensured a premium was placedon quality by emphasising:• structured assessment for accurate diagnosis and appropriate prescribing;• information management; and• patient and professional education around the goals of treatment.

Safety was prioritised byemphasising:• ongoing review of clinical need;• instruction in the safe and appropriate use of oxygen; and• risk assessment and clinical governance.

Productivity was addressed by:• rationalising therapy to reduce waste; and • matching prescribing to clinical need.

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In order to ensure the spreadstrategy met these aims fourprinciple objectives for thespread of HOS-AR wereestablished:

1. Adopt formal assessment and review;

2. Reduce variation;3. Commission services for sustainability; and

4. Improve safety and patient care.

1.4 Use of data

Home oxygen is an area of the NHSthat has a wealth of data available forit to use, with invoice data, supplierconcordance reports, and local patientcaseload information. Oxygen usagedata from supplier companies is madeavailable on a regular basis tocommissioners in the form of largespread sheets.

These large spread sheets can bedifficult for a non-expert to use andinterpret and often there is so muchdata that it is difficult to identify anarea to focus. As a result, HOS-ARservices often lack key metrics thatmight more usefully inform servicedelivery and drive improvement work.

Metrics and measuresDuring the improvement projects,teams were encouraged to focus ondriving the quality and appropriatenessof the supply of oxygen, and improvethe efficiency of services.

Project measures were chosen thatwere appropriate to the goals, theseincluded:

• rules to check for patients potentiallyon inappropriate supply and outside of national clinical guidance;• process measures to count the number of patients reviewed;• a measure on the referral source of the new HOOF; and • outcome measures including total spend and change to size of caseload.


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The project metrics used weredependant on the informationreceived from the suppliers, and somerequired further local data collection.

The data requirements forcommissioning HOS-AR may differfrom those used in a serviceimprovement project. The servicespecification in the Department ofHealth Home Oxygen Assessment and Review Commissioning Toolkitsuggests a number of commissioningkey performance indicators and a fewof these are listed below:

Examples of home oxygen project service improvement measures

1. What proportion of HOOFs were completed by the HOS-AR team?2. How many patients have potentially clinically inappropriate supply, for example:

• Over four hours of SBOT• Under eight hours of LTOT• Over or Underuse of prescribed oxygen3. How much is spent on home oxygen supply per month?4. How many patients receive home oxygen each month?5. What is the service activity – e.g. How many therapy commencementsand removals?

• The percentage of eligible people booked for their HOS assessment who attend their appointment.

• The percentage of people prescribed oxygen therapy who havea follow up home visit within four weeks.

• The percentage of people on long-term oxygen therapy who have had a review in the last nine months.

• The number of inappropriate oxygen prescriptions identified on assessment.

Sample Dashboard


The benefits of using data todrive improvements in HOS-AR As has been established during thetesting phase national project work,the establishment of HOS-AR has apotential to save money alongsideimproving quality of care.Effective use of data is a criticalsuccess factor in realising these dualbenefits. Systematic use of supplierand clinical data coupled with thedevelopment of locally appropriateservice metrics are the foundations ofthis approach. Below are listed a fewpractical tips on data managementarising from the national projectwork:

1. Use concordance data, but not in isolation. Project teams found that looking at the waste through usingthe concordance data was an excellent start, but combining this alongside looking at quality of prescribing enabled them to identify many areas for improvement

2. Who commences oxygen is a goodprocess measure. In some areas with low spend and well managed oxygen use, teams found that over90% of commencements had been initiated by a specialist from their HOS-AR team.

3. Review how many patients are supplied oxygen outside of guidance, where it may not be clinically appropriate. For example, consider those on over four hours of short burst oxygen a day, or under eight hours of long term oxygen therapy.

4. Review how HOS-AR teams use their time – often surprising resultswere discovered in inefficient administrative processes, and time managing oxygen supplier relations.

Making the data useable –systems and approaches.The data environment describedabove meant that national COPDproject teams needed support fromthe NHS Improvement - Lung team inorder to harness oxygen usage datain a meaningful way to facilitateappropriate prescribing, cost controland clinical governance.

To this end the work stream was ablysupported by the NHS Improvement -Lung senior analyst who workedwith the project teams in thedevelopment of a monitoringdashboard and helped themunderstand and overcome the

data issues surrounding both theimprovement project work and thetransition in oxygen supply.

These dashboards together withother locally devised datamanagement initiatives supported thehome oxygen teams in makingclearer patient care decisions andmotivated service change.

Visual management is an importanttool in using data to driveimprovement. While project sitesoften thought that they understoodtheir services well, improvements inthe analysis and representation ofthese large amounts of data oftenidentified hidden issues.These improvements also enabled thesites to provide evidence ofimprovement to themselves and theircommissioners.

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Here are a few points tobear in mind whendeveloping a local datadashboard

• Choose a few, focused metrics to drive improvement.

• Be pragmatic – it’s not easy to get perfect data, and often simple data is more useful.

• Present the data in a simple way that makes theprogress and goals clear. We found a dashboard was a helpful tool.

• Remember data is an essential part of HOS-AR – without it, we often do not know who our patients are or whether our patients are receiving benefit from this life prolonging therapy.

Future work – tools to interrogateoxygen supplier data under thenew contractThe new contracts for home oxygensupply commenced at the end of thehome oxygen improvement projects,which made it difficult for someproject sites to provide consistentdata during the transition.

The new data provided by oxygensuppliers is very comprehensive andincludes information on the orderedsupply, the reported use of the supplyand a waste estimate. In addition, itnow itemises the number of ‘service


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visits’ (Which include refills,installation, risk assessment andremoval of equipment) andequipment rental charges (itemisedby type of supply).

Knowing where to start, and workingwith the comprehensive data nowsupplied by the oxygen suppliers is adaunting and intimidating task formany.

Many teams start with thespreadsheet, adding filters,highlighting rows of interest, and alsoadding columns to total costs. Thiswould often be a complex procedure,and is usually reliant upon oneindividual to process the data.

The data often resides in separatetables for transactions, patientinvoices and concordance reporting,and so linking data items togetherrequires the home oxygen servicelead to swap between different files,writing down patient ID’s tocompare. It became evident thatsupport to process and analyse thedata was required.

By using a simple desktop databasesuch as Microsoft Access, the NHSImprovement - Lung senior analystwas able to increase the efficiencyand quality of the data provided tothe HOS-AR teams. The resultingAccess database tool enabled:

• Automation of simple data processing tasks.• Reduction of the repetition of data processing in Excel.• Introduction of ‘reports’ to highlightpatients to review, and combining key data onto a single patient page.• Production of more complex reports– summarising transactions, identifying outliers and risky data.• A single page helpfully summarisingthe oxygen usage data for a patientwhich was well received by clinicians.

Use of the Access database tool attimes required the support of dataexperts to set up – but it wasanticipated that any futuremaintenance would be minimal asthe data supplied from the oxygenproviders has an established format.

Key learning arising from using this database approach

1. There are sometimes discrepancies between the number of cylinders charged for by providers and the number of cylinders ordered for patients.

2. The types of cylinders provided may not those specified on the order form.

3. Large numbers of cylinders are still being held in patient homes, highlighting potential danger.

4. Patients are often receiving visits for refill of cylinders multiple times per month, sometimes multiple refills per week.

5. There is frequent use of urgent supply services.6. Clinically inappropriate supply is still occurring in some instances.


2.1 Components of a quality HOS-AR model

The Department of Health goodpractice guide3 published in 2011identified a number of componentsof a Home Oxygen ServiceAssessment and Review and listedthem within appendix 6 of that samedocument.

The national COPD project worklooked at these components from aservice improvement perspective andre-articulated them as seven criticalsuccess factors necessary for practicalimplementation of an operationalservice model. These are:

2: Learning from the prototype projects

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1. Commissioned Service (including service specification andreferral criteria)

All the project teams felt the need to reinforce the importance ofhaving the work undertaken by HOS-AR teams explicitly outlined withinthe specification of a commissioned service.

This would ensure the sustainability of the service and ensure quality isdefined in terms of key performance indicators and articulatedstandards.

Historically, much of the oxygen assessment work undertaken acrossthe country has not been detailed within existing respiratory servicespecifications and in some respects it can be thought of as beingundertaken ‘at risk’ in terms of sustainability and quality assurance.

It is also very important to specify the local referral criteria and definethe patients whose care will be managed by the HOS-AR team andthose oxygen patients whose care is perhaps managed elsewhere e.g.cardiology dept.

The Department of Health recently published a commissioningspecification5 for home oxygen assessment and review which is alsosupported by a patient guide jointly developed by NHS Improvementand the British Lung Foundation and available atwww.improvement.nhs.uk

In addition to the commissioning specification the Department havealso produced a costing tool which can be used to evaluate thepotential benefits of introducing a commissioned service. Both of theseresources are available at www.dh.gov.uk/health/2012/08/copd-toolkit

2. Initial formal assessment (in accordance with good practice)

It is critical that patients are formally assessed in respect of their clinicalneed for oxygen before any oxygen supply is issued to patients. As wellas determining whether the patient is hypoxic or not, the patient willbe assessed to ensure they are receiving optimal care in respect of theircondition and potentially referred to other specialist services ifappropriate.


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3. On-going review (frequency laid down within guidance)

The condition of many Oxygen patients is often subject to change and so it’s important that the therapy they arereceiving is still appropriate to their clinical need. Oxygen is a life prolonging therapy and so it’s vitally importantthat the prescription a patient is subject to is ‘fit for purpose’.

The vast majority of oxygen patients are affected by respiratory conditions and as such the DH good practiceguide published in 2011 sets out the gold standard in respect of review frequency.

However a significant number of patients are affected by other conditions such as Heart Failure or Cancer and assuch the healthcare professional (HCP) managing the patient’s condition should do so in line with their ownmedical specialty guidelines.

4. Workforce competence in: (i) assessing and reviewing clinical need, (ii) modifying home oxygentherapy and (iii) identify complications or signs of deterioration needing additional’ management oronward referral to a specialist.

Complications in respect of an oxygen patient’s condition often arise and so the HCP should be able to spotsignificant factors and either appropriately intervene or refer the patient to a colleague skilled in this aspect ofcondition management.

Thus it is imperative that the HCP undertaking the assessment is competent to do so and that appropriate liaisonwith a consultant is an integral part of the HOS-AR.

5. Integration with respiratory care and coordination with non respiratory specialties

Integration of HOS-AR within the wider respiratory care pathway provides opportunity for improved patientexperience as well as the opportunity to optimise clinical management.Multi-disciplinary team meetings, shared information systems and well understood patient pathways, treatmentgoals and care protocols all support service integration and also improve the responsiveness of services tochanges in a patient’s clinical condition.

There are also natural synergies in terms of the organisation of care and a good example of this is pulmonaryrehabilitation and ambulatory oxygen assessment and provision.

A significant proportion of home oxygen patients have non respiratory conditions such as heart failure orspecialist palliative care requirements. Whilst the HOS-AR may not necessarily manage the care of these patients(although some teams do operate shared care arrangements) it’s important to have good lines ofcommunication with these specialties. This ensures care is coordinated enables the HOS-AR team (andcommissioners) to understand the basis upon which these non-respiratory colleagues initiate oxygen and also thearrangements in place for patient follow-up by these specialties.


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6. Clinical and supplier data management

Collaboration between clinicians and managers around the effective use of data is vital to achieving safe,appropriate and cost effective home oxygen prescribing. Clinicians can advise whether patients flagged asoutliers in terms of oxygen consumption are at risk or in receipt of inappropriate therapy. Managers andclinicians together can use the data to performance manage their local oxygen supplier and familiarity withequipment and charging mechanisms enables the identification of opportunities to appropriately rationalisetherapy.

7. Education of patients and HCPs (treatment goals/safety/risks)

The HOS-AR team’s role in supporting supplier performance management and their involvement in prescribingcost control are obvious incentives for commissioning assessment and review teams. Perhaps another equallyvalue-adding function the HOS-AR team undertake is patient and healthcare professional (HCP) education.

The goals of home oxygen therapy are often equally misunderstood by non (oxygen) specialist healthcareprofessionals and the general public alike, and much effort is expended on an ongoing basis to tackle througheducation the inappropriate prescribing of oxygen for breathlessness.

In addition there are many risks associated with incorrect use of oxygen therapy especially as regards fire hazardsand tubing-related trips and falls.

The HOS-AR team are more likely to be aware of changes to home oxygen equipment and so they can supportother specialists who perhaps need to prescribe oxygen for their patients.


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2.2 Practical service models

The five project teams undertakingthe prototype project work cover verydifferent geographical locations andemploy varied staff groups.

Respiratory nurse specialists are by farthe most widely represented clinicalstaff group but teams do alsocomprise of respiratoryphysiotherapists, physiologists/clinicalscientists and pharmacists/pharmacytechnicians.

In addition, the wider project teamsinvolved (and sometimes were led by) non clinical managers from commissioning, medicinesmanagement, informationmanagement and finance.

Some of the teams were based incommunity based premises whilstothers operated out a hospitalsetting. The majority of teams hadaccess to consultant physician adviceand worked as part of a widerrespiratory care pathway.

Some teams undertook otherrespiratory management duties in toaddition home oxygen assessmentand review and it also varied as towhether or not teams had clinicalresponsibility for non–respiratoryhome oxygen patients.

A table summarising the variation inworkforce model is shown on page 16.

In terms of service models whatseems to be important in supportingquality assured HOS-AR is that:

a) the workforce has the competences to: • assess, review and modify home oxygen therapy • optimise or recommend strategies for optimising a patients overall management• recognises when complex or unusual presentations require specialist intervention.

b) the service is accessible and operates on a basis that reflects the local populations need and preferences.

c) the service is viewed as responsive, integrated, cost effective and sustainable by local commissioners.

The Department of Health havedeveloped a COPD commissioningtoolkit which includes a best practiceservice specification and costing toolto support the commissioning of ahigh quality home oxygen assessmentand review service. These resourcescan be accessed by visitingwww.dh.gov.uk/health/2012/08/copd-toolkit

The costing tool uses actual historicaloxygen consumption in conjunctionwith old and new supply contractprices and applies assumptions inrelation to workforce (reflecting theOxfordshire model) clinic and homevisit frequency and duration in orderto generate a model of the potentialcost impact of introducing HOS-AR.

The tool does not try to quantify thebenefits arising from improvedpatient care and whilst it does allowyou to tailor assumptions to moreaccurately reflect local priorities itshould be remembered that it is amodel all be it a very useful one andcan not for example convey theimportance of home oxygen as aconstituent part of an admissionavoidance strategy.

The Oxfordshire project team during a process mapping event


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A table summarising the variation in workforce models across the home oxygen project teams

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17

2.3 Issues and challenges

Analysis of oxygen usage data,process mapping exercisesundertaken individually with projectteams and knowledge exchange atcollective project cohort peer supportevents uncovered both differencesand similarities as regards the issuesand challenges faced by the teams inimplementing high quality HOS-AR.

Historically, the clinic DNA rates inboth Salford and Stockport had beenidentified as problematic and so tothis end both teams had searched forways increase their capacity toundertake home visits.

Salford, prior to starting the projecthad already reduced the number ofclinics they performed in order toincrease their capacity to undertakehome visits.

However, by analysing the processesassociated with an individualassessment clinic they spottedopportunities to change practice andreduce the duration of the initialoxygen assessment. This enabledthem to create additional capacity fora dedicated clinic for palliative oxygenassessment.

Stockport also reorganised theirclinics and increased home visitscapacity. They overcame thechallenge of requiring two staff perhome visit (in order to transportlaboratory style blood gas analyserequipment and concentrators) by theadoption of portable blood gasequipment

The Derby team had historically had achallenge with inappropriateprescribing arising from GeneralPractice. With support from thenational programme senior dataanalyst and the use of datadashboards they were able toestablish that GP prescribing of homeoxygen was now significantly reducedand that the current sources ofinappropriate prescribing were basedin the hospital setting.

In Oxford the process mappingexercises highlighted that slightvariations in practice had arisenamong the team in response tospecific clinical scenarios. The teamhad a long-standing practice ofholding regular clinical update andknowledge sessions and so theyprovided a forum to ensureconsistency across the team was re-established.

In Hampshire, both the data analysisand the series of process mappingevents with teams across the countysupported a gap analysis in respect ofadherence to national standards,resource constraints and potentialvariations in prescribing behaviour.

This information further informed thedevelopment of a Pan-Hampshireservice specification and provided thebasis for a service investmentbusiness case.

The administrative and datamanagement requirements of HOS-AR are a challenge that all teams heldin common. Incomplete informationupon referral often meant that highlyskilled clinical resource spent a lot oftime trying to establish a morecomplete clinical picture of patients inadvance of their appointment.

In some instances this was addressedsomewhat by more complete androbust referral processes anddocumentation and by reinforcing/re-launching referral criteria.

However, the need to monitoroxygen usage data and keep track ofguideline mandated review datesdoes require administrative support.

2.4 Overall project cost savings

The HOS-AR teams included withinthe prototype project cohort hadalready demonstrated to thesatisfaction of their localcommissioners their ability toprescribe and rationalise homeoxygen therapy in an appropriate andcost effective manner prior toembarking upon this phase of work.

Prior to the project work many of theteams had already comprehensivelyreviewed supplier concordance andinvoice data, cleansing the data ofanomalies (such as charges fordeceased patients, multiple dataentries for a single patient etc) andhad married this data with clinicalinformation to create home oxygenpatient registers or actual databases.

3 Improving the quality and safety of home oxygen services: The case for spread

18

These teams were already routinelyupdating these registers establishingcycles of patient therapy assessmentand review and identifying candidatepatients for therapy alteration/removal post clinical review.

The prototype works main thrust wasto identify key elements in theimplementation of quality assured,safe and appropriate home oxygentherapy.

However, NHS Improvement - Lungwas also interested in these teamsability to continue the tight control ofany increases in expenditureassociated with optimised therapy oruncovering unmet need.

It was therefore of considerableinterest that many teams were stillable to demonstrate cost savings(prior to oxygen supply contracttransition and its inherent contractualcost efficiencies) through appropriatehome oxygen prescribing and therapyrationalisation.

Difficulties in ascertaining consistentdata in the immediate aftermath ofthe supply transition (which for mostteams took place during the mid-point of the project) made it difficultto differentiate between savings fromHOS-AR related functions and thosebenefits deriving from a moreefficient contract.

Best estimates seem to indicate thatthe prototype teams were on targetto achieve an average of £100,000per site in HOS-AR related annualprescribing cost efficiencies (basedupon comparison with the annualspend in 2010/11), resulting in acollective workstream annual forecastsaving of approximately £570, 000.

Despite the intrinsic cost efficienciesderiving from the new nationaloxygen supply contract, there is stillthe potential for costs to rise ifpatients are not initially assessed fortheir need for home oxygen therapyby healthcare practitioners who areboth thoroughly familiar with thevarious equipment modalities andalso acquainted with current chargingstructures.

HOS-AR team clinicians across thecountry attend on an ongoing basisthe oxygen device training sessionsheld by the oxygen suppliers and sohave a complete understanding ofthe range of equipment available andalso each device’s suitability for thedifferent presenting symptoms andchanging patient clinical needs. HOS-AR teams are also best placed toprescribe a treatment modality whichis both clinically appropriate but alsocost effective – a generalist or aspecialist clinician who has notundergone this training is unlikely tobe able to do this on a consistentbasis.

Although the prototype project siteshad completed thorough datavalidation exercises, there were stillopportunities for further savings fromreviewing data on a regular basis.

This finding only serves to reinforceearlier workstream learning about theneed for HOS-AR teams to have aregular plan to review data and notsee it as a one off exercise.

The absence of regular data reviewwill inevitably lead to a slow increasein costs. Although the new supplycontract does include large penaltiesfor supplier data errors, the newcontractual arrangements are notsufficient to deliver the data qualityimprovements alone.

This is particularly the case for thosesuppliers who are dealing with alegacy of equipment and inaccuratehistoric data.

3: Case studiesImproving the quality and safety of home oxygen services: The case for spread

19

What was the problem?Oxfordshire’s home oxygen servicehas been operational forapproximately three years and isrecognised nationally for havingsuccessfully improved patientsexperience as a result of appropriateand cost effective oxygen therapyprescribing undertaken by trainedprofessionals.

Staffing changes had created anidentified skills gap and the servicewas subject to an ongoingcommissioning requirement to remainboth high quality and cost effective.The team also identified areas forimprovement such as smoking relatedincidents, out-of-hours coverage and100% underuse of prescribed oxygentherapy in a large number of patients.In addition, the team wanted tomake a smooth transition to the newoxygen supply contract.

What was the aim?The project team sought to improvethe quality and standards of theservice in three areas:1. To reduce the number of patients with significant (100%) underuse of prescribed oxygen therapy by 25%

2. To reduce smoking related incidents

3. To reduce the cost of prescribed oxygen by 10% over one year.

They planned to achieve this bymeeting the following objectives:• Review and update patient pathways• Develop a new competency framework• Train staff and ensure competency in key areas

• Develop a risk assessment tool in order to formally risk assess patientswho smoke• Manage the transition to the new oxygen supplier.

What did they do?The team allotted projectresponsibilities and met regularly withsupport from NHS Improvement-Lungin order to refine their aims andobjectives, plan project activities,identify stakeholders, review thepatient journey and undertakeprocess mapping (with thecommissioner in attendance).

The team also undertook a demandand capacity exercise in order tobetter understand the impact oftravelling and administration on face-to-face time with patients.

Through contact with clinical teamsacross the country at NHSImprovement-Lung peer supportevents the team were able to reflectupon their clinical practice andcapture ideas for potential new ways of working.

What has been achieved?Process mapping enabled the team toexamine differences in the serviceacross the county and confirm theskills required at different parts of thepathway. It was also instructive inensuring that all members of theteam were applying a consistentclinical approach.

Improving and fine tuning Oxfordshire’s Home Oxygen Service

3.1 Oxford Health NHS Foundation Trust


20

In terms of the stated objectives the team:• Reduced under users from 115 to 54 (53% reduction)

• Began development of a smoking risk assessment too

• Increased teams awareness of smoker safety and general oxygen safety

• Developed greater awareness of service demands

• Reduced oxygen costs by 12% from September 2011 to April 2012

• Gained insight into team member knowledge levels and began implementing a competency framework

• Started weekly training sessions to improve the knowledge and skill mix (e.g. maintain competences in arterial blood gas measurements)

• Successfully managed supply contract transition which was initially characterised by significant increase in calls from patients

• Implemented an out of hours oxygen ordering pathway

• Exploring the use of portable (capillary) blood gas analysers on home visits and acquiring equipment through cost savings.

What are the key learning points?• The importance of risk identification (in general) and shared awareness among the team in respect of patients who pose a higher risk due to smoking

• Service improvement methodology provides effective tools for identifying ‘risk’ areas and areas forquality improvement

• Knowledge exchange with other teams (and opening pathways of local and national communication) promotes the development of new ways of working

• The importance of regularly evaluating clinical knowledge among the team in respect of morecomplex patients (CO2 retention, hypercapnoea, use of oxygen in exacerbations etc) and the value in implementing ongoing training.

ContactJo RileyRespiratory Service County LeadTel: 01865 225472Email:[email protected]

Sophie BeveridgeRespiratory and Home Oxygen Service NurseTel: 01865 787185Email:[email protected]


21

What was the problem?Considerable differences in the typeof service experienced by homeoxygen patients across Hampshirewere known to exist as a result of theway the teams undertaking homeoxygen service – assessment andreview (HOS-AR) had evolved in thedifferent geographical localities.

In many instances these differentservice models reflected differences inlocal need but they were also areflection of differences in localfunding arrangements anddifferences in the interpretation of(and compliance with) nationalguidance.

In addition, the impending change inoxygen supply provider andcontractual changes necessitatedfurther strengthening in thearrangements for monitoring oxygenusage in preparation for thetransition by building upon recentanalyses of patient concordance.

What was the aim?The aims of the project were to 1. Develop robust Pan-Hampshire service plans, specifications and a business (investment) case which reflected national guidance

2. Further improve data managementto achieve ongoing active monitoring of oxygen usage and ensure the successful transition of supply in March 2012.

Specific project objectives included: • Gap analysis - to understand levels of compliance with national standards in respect of HOS-AR

• Staffing review - to understand the workforce variations across the county

• Care pathway review - to understand differences in the patient journey experienced across the county.

What did they do?Pathway analysis: A series ofprocess mapping events wereinitiated across the county involvingthe home oxygen teams situated inLymington, Fareham and Basingstokerespectively.

This enabled differences in clinicalpractice to be identified and thespecific local challenges and resourceconstraints documented andunderstood.

In addition, the teams in Isle ofWight, Southampton and Portsmouthprovided information about localresources and the patient journey bycompletion of a mapping tablequestionnaire.

Data management:Work on theanalysis of patient concordance wasintensified to gain an accurate pictureof usage activity in each location andan understanding of the variations inprescribing costs across the county.

This was supported by use of thedata dashboard devised by the NHSImprovement-Lung senior analyst andliaison with both the outgoing andincoming oxygen supply providers.

Service planning: The team alsoreviewed NHS Improvement nationalpublications, the Department ofHealth (DH) Good Practice Guide,early versions of the DHCommissioning toolkit for COPD &Asthma and the DH Specification forHOS-AR in order to develop a Pan-Hampshire service specification andbusiness case framework which cansupport the development of localinvestment cases by constituentclinical commissioning groups (CCGs)across the county

The Hampshire Model for the Home OxygenService - Assessment and Review

3.2 NHS Southampton, Hampshire IoW Portsmouth; SHIP PCT Cluster


22

What has been achieved?A better understanding of thedifferences in service models anddelivery across the county hasenhanced the ongoing discussionstaking place between the serviceprovider organisations and thecommissioners of the services.

The Pan-Hampshire servicespecification has been accepted by allconstituent CCGs across the countyand its recommendations in respectof service levels will be reflected inlocal service performance indicators.

The various options outlined in thePan-Hampshire business case haveprompted a number of CCGs toconsider investment in their localHOS-AR to ensure compliance withgood practice and to also examinethe extent of wider respiratory serviceintegration.

Good lines of communication wereestablished with the incoming oxygensupply provider and home oxygenpatients who were concordanceoutliers were identified and flaggedup with clinical staff for review and

What are the key learning points?1. Differences in service models across the county did not necessary imply differences in service quality. However, differences in adherence to national guidance could be a source of service inequality especially in respect of ongoing clinical review.

2. Differences existed across the county in terms of the prescribing cost per patient and this might also be attributable to differences in each teams capacity to review patients changing clinical need (and modify therapy) or differencesin the use of oxygen device modalities especially in relation to palliative care.

3. Significant clinical time is taken up by routine administration as a result of lack of admin. support.

4. Clinical teams lacked consistent and concise information and central management support concerning home oxygen patients.

ContactChris SladeClinical Networks ManagerTel. 02380 627672 / 07833293074Email: [email protected] [email protected]


23

What was the problem?The introduction of home oxygenservice-assessment and review (HOS-AR), with blood gas monitoringavailable both within clinic and homesettings, and the establishment ofclinical and oxygen supply usage datareview and management had enabledgreat strides to taken in addressinghistoric problems of inappropriateoxygen prescribing and sub-optimalmanagement together withinequalities of care associated withpatients varying ability to travel tohospital for assessment or review.

This had enabled the newlyestablished service to meet all itsinitial quality and financial measuresduring its first two years of existence.

However, problems still remainedwith many local healthcareprofessionals still not familiar with theprincipal goals of oxygen therapy(addressing hypoxia) resulting ininappropriate therapy initiation.

Many patients understanding aboutboth their condition and their therapywas still variable and theadministrative and governanceprocesses for the local HOS-ARneeded to both keep pace with thechanging primary care landscape andenable greater analysis and reporting.

What was the aim?The project aimed to address theseproblems by developing andimplementing plans to: 1. Improve data coordination, analysisand reporting by reducing administrative duplication, inconsistent recording and getting greater clarity around lines of reporting.

2. Achieve greater consistency of message among healthcare professionals in terms of the message to patients and in terms of the goals of therapy.

3. Identify clearly who, where and why home oxygen was prescribed through improved.

4. Improve ambulatory oxygen assessment and monitoring procedures.

5. Improve the removal pathway for patients without a clinical requirement for home oxygen.

What did they do?• The team undertook a process mapping event and involved patients, community and hospital-based respiratory staff togetherwith colleagues from palliative care,IT and the Trust transformation department.

• Patient referral forms and data entry processes were reviewed to capture redundancy and identify areas for improvement.

• Ongoing dialogue and training wasundertaken with the (new) in-coming oxygen supplier in order to manage the transition to a new supply contract.

• The team worked with the NHS Improvement - Lung senior analyst to develop data dashboards which would more easily enable the tracking and monitoring of oxygen usage and prescribing.

• An initial demand and capacity exercise was undertaken to identify ways of increasing service capacity.

• Patient information literature was revised in order to strengthen messages about the goals of oxygen therapy and also the safe and effective use of equipment.

Service improvement review to ensuresustainability and consistency of the DerbyshireHome Oxygen Service

3.3 Derby Hospitals NHS Foundation Trust, Derbyshire County PCT, Derby City PCT


24

What has been achieved?• Inappropriate prescribing has been reduced by establishing a local consensus among healthcare professionals about the use of the new part a/b Home Oxygen Order Form (HOOF).

• Prescribing guidance for all modalities of oxygen is now more closely aligned to national standards and best practice and as such is both tighter and clearer. It has also been made widely available and is being incorporated into the Trust website.

• Data harmonisation work has madeprogress and all (clinical and supply usage) data will be entered onto System1 to enable it to be accessedacross the multi-disciplinary team.

• The new patient information leaflethas been well received and the quality of prescribing has improved with a shift from 60% of patients having an optimal oxygen prescription to 90%.

• A thorough review of the governance arrangements in respect of oxygen therapy and persistent smokers has been undertaken inclusive of liaison with expert legal counsel.

What are the key learning points?• Changes in respect of the new HOOF were initially a source of frustration for GPs and Consultantsbut these changes have now been agreed.

• Access to data, and critical review, has been particularly valuable in identifying the priorities and objectives for the service. Previously, the team believed that they had issues with GP commenced HOOFs, however the data suggested that this was no longer the case. This indicates that both the original work has been a success, but also that resources could now be focused elsewhere in order to achieve improvements in areas of a greater need – the team are considering supporting in-hospital prescribing.

• Service Improvement has become a key part of the team’s thinking, and ensuring that they have evidence has been helpful for the team, but also in supporting discussions with commissioners.

• The team could have continued being ‘good enough’ – the service improvement work has encouraged them to think critically and aim for better.

ContactSue SmithSpecialist Practitioner for Home OxygenTel. 01332 787825Email. [email protected]


25

What was the problem?Home oxygen service – assessmentand review (HOS-AR) had beensuccessfully introduced in Salford in2008 with the establishment of theHome Oxygen Therapy Service(HOTS). Robust referral processeshad been implemented and the HOTSteam were part of an integratedrespiratory service. They also hadvery strong links with other non-respiratory disciplines.

The team had access to supplierinvoices and reports which they usedto monitor oxygen usage, the sourcesof prescribing and also the range ofclinical conditions existing amongpatients in receipt of home oxygentherapy.

The use of an electronic referralproforma (incorporated within localGP computer systems) together withsystematic changes to clinic venuelocations and the establishment ofhome visit clinics improved access toHOTS significantly.

However, each month there remaineda small number of new Home OxygenOrder Forms (HOOFs) originatingfrom outside of the HOTS team andinitiating home oxygen in un-assessedpatients. This was of great concernas the HOTS team were uncovering(un-assessed) home oxygen therapypatients with chronic type 2respiratory failure for which oxygentherapy could be potentially harmful.

What was the aim?A safe, cost effective and accessiblehome oxygen service was a localpriority and so the primary aim wasthat 95% of all HOOFs originate fromthe HOTS team (5% allowance forpaediatric and end-of-life patients).Continuous service improvementwould be achieved by:

• Reviewing HOTS referral processes and documentation

• Continued integration of HOTS with wider respiratory team to support delivery of a high quality COPD care bundle

• Greater links with end-of–life carersand staff to ensure appropriate, beneficial and cost-effective home oxygen prescribing, therapy alteration and follow-up

• Continued monitoring of home oxygen usage data to support transition to a new oxygen supply provider, maintain clinical governance and ensure cost-effectiveness

What did they do?The team undertook a number ofproject activities in support of theabove objectives:

Multidisciplinary engagement: Aprocess mapping event involvingnumerous staff types, assortedmedical specialties and stakeholders.This highlighted areas forimprovement both in respect ofclinical and administrative processes.It also illustrated the evolving role ofthe HOTS team and raised awarenessof issues across the wider respiratorycare pathway.

Change in clinical practice: Furtherlow-level mapping of the actualoxygen assessment process promptedthe team to continue taking bloodgas measurements on air in both thefirst and subsequent (three week)clinic visit but to undertake titrationon oxygen (to target oxygensaturations) in the three week clinicassessment visit only.

Maintaining a safe, cost effective and accessibleHome Oxygen Therapy Service (HOTS)

3.4 Salford Royal NHS Foundation Trust


26

Many patients present with markedlyimproved blood gas levels at thethree week assessment and so theoriginal titration exercise wasunnecessary. In addition, patients(with no known heart failurediagnosis) who have a PaO2 > 8.3kPaat the first initial assessment arereferred back to their GP with advicefor subsequent re-referral to HOTS ifthe patient deteriorates. Previouslypatients were kept under review iftheir PaO2 < 9kPa

Administrative and datamanagement changes: The referralform was altered to includeadditional information to establishthat patients are medically stableprior to assessment. The involvementof the commissioner in the mappingevents supported the team’s effortsin acquiring administrative support tohelp improve data management inadvance of oxygen supply transitionand oversee the introduction ofadditional data recording and audittools.

The team have also established ageneric email address which allowsfor prompt processing of referrals anda shortened appointment bookingprocess.

What has been achieved?Home oxygen prescribing – The aimof ensuring safe quality assuredprescribing of home oxygen thoughthe 95% HOOF target has been met.This was accompanied by continuedmonth-on-month reductions inprescribing costs in the monthspreceding the transition of oxygensupply (which is likely to introducefurther cost efficiencies).

Increased assessment clinic capacity –Initial assessment clinic duration timeshave been reduced through thechange in practice, reducing waitingtimes for new referrals and enablingan additional clinic slot for urgentassessment for palliative oxygen.

Further safeguards against acuteoxygen toxicity - the multi-disciplinarywhole pathway discussions promptedthe routine issuing of oxygen alertcards to all patients in need of noninvasive ventilation (NIV).

What are the key learning points?• Process mapping supports the identification of opportunities to quickly change both clinical practice and also the organisation of care processes.

• Multidisciplinary involvement in service re-design enables consideration of the whole pathway of care and identification of areas for improvement outside the immediate project scope.

• Quality assured prescribing and costefficiency will only be maintained by continual monitoring of oxygen usage by the HOTS team and tight control of HOOF prescribing.

ContactMelissa CollingeRespiratory Nurse SpecialistTel. 0161 206 0865Email. [email protected]


27

What was the problem?The Oxygen Assessment Service inStockport (Oasis) and localcommissioners jointly identified theneed to expand the community-based service to enable GPs to referpatients for specialist home oxygenservice - assessment and review(HOS-AR) and also to appropriatelyrepatriate home oxygen patients(whose condition did not requireacute hospital / tertiary centre care)back to the community.

The service also needed to preparefor the transition to a new oxygensupply contract, which washappening in parallel with the teamtransferring from the Primary CareTrust (PCT) to the local FoundationTrust, by identifying andimplementing improvements inservice efficiency, data managementand prescribing

What was the aim?The project was established toachieve the following objectives: • Review the current service in order to identify both good practice and areas for improvement

• Identify gaps in consistency of care to patients prescribed home oxygen

• develop clinical and prescribing data management systems in order to meet the requirements and timescale for implementation of a new national Home Oxygen supply contract (2 July 2012)

• Expand the service to ensure that all patients who would benefit fromoxygen therapy are offered timely high quality assessment and care appropriate to their needs

• Maximise the cost effectiveness of the HOS-AR service whilst minimising the cost of prescribed oxygen

• Ensure that oxygen is prescribed safely, (without causing increased carbon dioxide retention), and onlywhen clinically beneficial (hypoxic)

• Build close working relationships with other local clinical teams managing patients prescribed oxygen and ensure care is consistent across the health economy.

What did they do?The project team undertook anumber of specific project activitiesnamely:• Care pathway mapping: The team process mapped the journey for patients currently cared for by Oasis in order to identify inefficiencies, highlight patients who fell outside of the pathways ofcare and reveal inequalities in service provision. This was used to generate improvement ideas

• Patient reconciliation: Patients prescribed oxygen but not known to the service were identified by reconciling to the oxygen provider (Air Products) concordance report to their patient care records

• Audit of GP oxygen prescribing: This enabled the team to estimate the numbers of expected GP referrals upon commencement of GP direct access to Oasis

• Patient categorisation: Patients were stratified according to disease complexity, age and prescribing modality short burst/long-term oxygen therapy in order to support discussions between clinicians about which patients should be provided full HOS-AR by Oasis those patients who should be known to the service but managed by other specialist services

Fit for purpose – clinical quality, cost effectiveness and patient satisfaction

3.5 Stockport NHS Foundation Trust


28

• Workforce modeling: The team worked with their commissioner in the development of a tool to estimate staff numbers required forthe new expanded service and to develop the business plan. The toolused information from:• GP prescribing audit and the patient categorisation exercise

• the revised care pathway from the mapping exercise

• projected volume of patients receiving full HOS-AR care from the patient reconciliation exercise

• Department of Health good practice guide requirements in respect of clinical competence

• demand and capacity informationin respect of assessments, reviews, administration and data management.

This model also took account ofappointments being a mix of homevisits and clinic based appointmentswith an increased emphasis on homevisits in order to address the relativelyhigh historic DNA rates for clinicappointments.

• Review of Home assessment equipment: As part of the nationalCOPD project cohort the Stockport team were able to discuss alternative blood gas analyser equipment with other HOS-AR services and select clinically effective portable equipment that could be managed by one person as two staff are currently required to deploy the current analyser and other equipment.

• Development of a referral pathway for GPs for acute assessment: Working with the primary care respiratory lead / GP with a specialist interest and the local commissioners the team developed a referral pathway whichincorporated use of the Choose and Book service.

What has been achieved?The project met all the statedobjectives and delivered a number ofnotable achievements namely:• Development a GP referral pathwayand proforma ensuring that GP’s no longer issue Home Oxygen Order Forms.

• Increased clinic / visit capacity enabling the creation 1x urgent slotavailable daily Mon-Friday

• Development of an Out of hours pathways with the Mastercall service

• Reduced the costs associated with home visits through use of a portable blood gas analyser by a single nurse

• Improved patient data management enabling historic oxygen usage and patient clinic contact records to be viewed together

What are the key learning points?• Collaboration between the clinical team and the local commissioner inthe use of patient clinical data and the oxygen supplier data enabled a model of service workforce requirements to be developed which met the needs of the local population

• Working with the PCT quality team enabled the development of an improved reporting tool which could merge monthly supplier invoice data with the active patient clinical list.

• Networking with other national COPD project teams assisted the process of clinical practice review and generated ideas for improvements to service delivery such as:• use of portable equipment to facilitate blood gas analysis of housebound patients

• shift to a locality based work planto reduce travel time and mileageand

• development of new template forpatient contacts to reduce time spent dictating letters

• The new service arrangements haveuncovered challenges associated with the initiation of oxygen therapy for palliative /End-of-life patients

• The ability to safely and appropriately initiate oxygen therapy immediately following a senior specialist nurse home visit should increase patient satisfaction and service effectiveness – this assertion will be tested through patient satisfaction surveys and continued monitoring of clinical and usage data.

ContactKaren FernCOPD Team LeaderTel. 0161 426 9613Email: [email protected]


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The North East (NE) RespiratoryProgramme team undertook abaseline assessment of Home OxygenService-Assessment and Review (HOS-AR) within existing clinical providerorganisations and uncovered widevariation in the provision of HOS-AR.

The need to address the identifiedgap in HOS-AR provision andestablish a quality service in line witha recently published national goodpractice guide prompted an allianceof stakeholders in the former NHSNorth East to develop a tender andprocure a local HOS-AR capability.

A sense of urgency was created by anumber of driving factors, mostnotably:

1. The NE was scheduled as the second region to transition to the new nationally developed oxygen supply contract

2. It had been agreed as a strategic priority following a Respiratory programme stock-take meeting between the NE Regional Respiratory Leads, Managers and Directors of the former North East Strategic Health Authority and the National Clinical Directors for Respiratory Medicine

3. Some individual Primary Care Trusts (PCTs) in the NE had attempted to commission HOS-AR in the past but did not follow-through due to other competing local priorities.

Thus followed an approximately 12month procurement process(beginning late March/early April2011) which involved PCTcommissioning managers,procurement managers and stafffrom a centralised contracting(shared) services team and the NERespiratory Programme team.

A total of seven PCTs (Gateshead,South Tyneside, Sunderland, CountyDurham, Darlington, Middlesbroughand Redcar & Cleveland) agreed towork collaboratively with the NERespiratory Programme team withone PCT acting as the lead on behalfof the collective.

This approach built on a stronglegacy of local cluster working. Theseven PCTs agreed that the tenderwould be for one regional servicespecified in accordance with nationalgood practice to provide assessmentand review adult Respiratory,Cardiology and Palliative care patientsrequiring home oxygen therapy.

4: Additional information and resources

Appendix 1: North East procurement of HOS-AR provider – a case study

The procurement process was guidedby local NHS procurement managerswho were able to keep a tight trackof the process using an electronic (e-Tendering) procurement softwaresystem. The (clinical healthcare)nature and value of the tender meantit fell outside of the requirement toadvertise on a Europe-wide basis andalso permitted more flexibility inrelation to the specified timelines.

A ‘Request for information’ (RFI) pre-tender process was established. Thisenabled the proposed servicespecification to be circulated inadvance to interested parties to solicitcomments and feedback in advanceof the final tender process andelicited additional expressions ofinterest.


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No objections were raised to theservice specification which aligned toa payment regimen involving a ‘blockcontract’ in year 1 with a mixture ofcost & volume and payment byresults schedules in subsequent years.The contract also utilises theCommissioning for Quality andInnovation (CQUIN) paymentframework to drive service qualityperformance.

The procurement team were struckby the differences in approachbetween potential NHS andcommercial bidders, the latter beingadept at asking very pertinent andastute questions in order to supportthe process of gathering informationwhich might support their potentialfuture bids.

A total of four bids were receivedthese included two oxygen supplycompanies as well a bid from aconsortium of local NHS FoundationTrusts who decided at a relatively latestage to mount a joint bid.

The HOS-AR provision tender waseventually awarded to Air Liquide(formerly the regional oxygen supplierbut now succeeded by BOC as aresult of the national oxygen supplyre-procurement and regionaltransition process).

Staff recruitment has commenced inline with the service beginning inOctober 2012.

All seven PCTs are signatories to theHOS-AR contract thus its contractualterms and conditions shouldtransition smoothly to the successorClinical Commissioning Groups(CCGs).

Key learning points

1. Ensure the process is allotted sufficient time.

Devising a robust questioning,evaluation and scoring methodologyand sourcing an external evaluator istime consuming, as is the process ofdeveloping a tender and servicespecification. Engagement of localstakeholders such as CCG leadsshould be initiated early in order tobe sure of getting the right decision-makers involved.

In addition, there is a lead time forthe service to be established whichmust take account of staffrecruitment, liaison withneighbouring services, securingservice premises etc.

2. Establish a team comprised of the right skills and disciplines.

The NE team were able to build uponstrong existing shared commissioningand cluster working arrangementssupported by proactive expert clinicalinput from the Regional RespiratoryProgramme and an experienced localprocurement team.

3. Gain a clear understanding of potential service demand, service costs and identify appropriate funding streams.

The NE team had to reference servicecosts from a neighbouring PCT anduse information from the incumbentoxygen supplier to develop a costingmodel and establish potential costefficiencies resulting from the newservice.

This process was conducted inadvance of the recently publishedCOPD Commissioning Toolkit(containing a Commissioningspecification for HOS-AR) whichaddresses this need.

4. Ensure a strong contract management framework and a robust service specification

The NE team built service quality and(caseload responsibility) safeguardsinto the eventual service specificationto ensure the new service isintegrated within the widerrespiratory care pathway and theexisting contract managementprocesses mitigated any risks posedfrom a potential situation in which (asa the result of the tender process) theclinical service provider and theoxygen supplier were the sameorganisation.


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5. Appointment of a non-NHS provider involves a considerable time commitment in respect of change management in order to:

a) ensure whole service integration through collaboration between thenew commercial HOS-AR provider and existing NHS respiratory service providers

b) meet local NHS concerns about the commissioned arrangements to sustain high quality care and workforce competence

c) establish trust and open communication between all stakeholders.

Contact:Vikki BaileyRespiratory Programme Manager -North East (NHS North of England)Mobile: 07824342721Email: [email protected]

Process mapping was used by all ofthe prototype project sites to helpdiagnose problems and identify areasof their respective services in need ofimprovement.

All of these process maps (whichreflect the service before theimprovement project) makeinteresting reading but due topublication printing constraints it isonly possible to reproduce one ofthese maps here.

For more information about processmapping and other serviceimprovement tools and techniquesplease visitthe lung websitewww.improvement.nhs.uk/lung

Appendix 2: Lung improvement resources and sample projectteam process maps

You can also download a copy of the publication entitled ‘First stepstowards quality improvement: A simple guide to improving services’by visiting the publications section of the lung website.

The following resources are also available from the lung website:


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Acknowledgements

NHS Improvement - Lung would liketo thank all the national improvementproject sites for their hard work anddedication to improve the quality andcare for people with COPD, and alsofor their support and contributions tothis document.

In addition, the following people alsocontributed to the overall prototypeproject cohort learning and their helpis gratefully acknowledged:

• Lorraine CurtinBedford Hospital

• Fiona Maryan-InstoneBedford Hospital

Final thanks go to the national clinicaldirectors for respiratory medicine, theregional home oxygen service leads,the regional clinical leads forrespiratory medicine and also theDepartment of Health home oxygenteam for their ongoing support andexpertise.

References

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

2. NHS Improvement - Lung Improving Home Oxygen Services: Emerging Learning from the National Improvement Projects, NHS Improvement 2011 Publication Ref:IMP/comms011 – April 2011.

3. NHS Improvement - Lung: NationalImprovement Projects Improving Home Oxygen: Testing the Case for Change, NHS Improvement 2012 Publication Ref: NHSImp Lung 0001 - May 2012

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

5. COPD Commissioning Toolkit: Home Oxygen Assessment and Review Service Specification, NHS Medical Directorate, August 2012

6.The NHS Outcomes Framework 2013-14, Department of Health, November 2012

7. COPD Commissioning Toolkit, NHSMedical Directorate, August 2012

5: Acknowledgements and references

Further information

For further information about thispublication please contact:

Ore OkosiNational Improvement LeadEmail:[email protected]. 0776 644 1093

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

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHS ImprovementNHS Improvement’s strength and expertise lies in practical service improvement. It has over adecade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lungand stroke and demonstrates some of the most leading edge improvement work in Englandwhich 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 2,400 GP practices.

Delivering tomorrow’simprovement agenda for the NHS

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Publication Ref: NHSIMP/Lung0008 - March 2013

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