Demand for home oxygen therapy is growing. Carrying out an assessment and review of this service can result in financial savings and improve patient care
In this article…
- Establishing a home oxygen service assessment and review
- Benefits of conducting an assessment and review
- Improving home oxygen prescribing
Phil Duncan is lung director; Ore Okosi is national improvement lead (home oxygen lead), both at NHS Improvement.
Abstract Duncan P, Okosi O (2011) Reviewing home oxygen services. Nursing Times; 107: 42, early online publication.
Home oxygen therapy costs millions of pounds every year and demand for the service is growing. As part of the Department of Health’s respiratory programme, NHS Improvement – Lung works with several clinical teams in England to address variations in patient care. This article discusses how oxygen service assessment and review can save money and raise the quality of care.
Keywords: Oxygen therapy/Chronic obstructive pulmonary disease/Home oxygen service
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article
5 key points
- Around 85,000 people receive home oxygen therapy in England
- 30% of people in England who are prescribed oxygen either do not use it or derive no clinical benefit from it
- By focusing on improving quality and productivity in home oxygen services, annual savings of £45m could be made
- NHS Improvement – Lung (NHSI-L)aims to support the development of patient-centred, evidence-based and clinically led services
- Since July 2010, NHSI-L has worked with clinical teams to address variations in care
Around 85,000 people receive home oxygen therapy in England at a cost of about £110m a year (Department of Health, 2010a). Demand for the service is increasing and there are areas where the quality, efficiency and value for money of services can be improved, as well as the outcomes and experiences of people with COPD.
The DH has estimated that 30% of people in England who are prescribed oxygen as a form of therapy, either do not use it or derive no clinical benefit from it. The government anticipates that potential savings of £45m a year could be achieved nationally by focusing on improving quality and productivity within the home oxygen service. This would be achieved by establishing a home oxygen service assessment and review (HOS-AR) conducted by appropriately qualified and trained health professionals, with an ongoing oxygen register review. The associated cost savings would be equivalent to £300,000 per primary care trust, or a potential gross national saving of up to 40% (DH, 2010b).
Establishing a HOS-AR ensures new patients who may benefit from the therapy first receive clinical assessment and then an ongoing review. It also ensures that existing patients receiving oxygen have their clinical need for therapy monitored on an ongoing basis.
Patient pathway redesign
Since July 2010, NHS Improvement – Lung (NHSI-L) has worked with a number of clinical teams across England, as part of the DH’s respiratory programme, to address variations in care. Its aim is to support the development of patient-centred, evidence-based and clinically led services by identifying and sharing innovative ways to reduce variations and improve patients’ experiences and outcomes.
The home oxygen service work stream was led by the NHSI-L team, which worked with clinical teams from 12 NHS project sites across England. The NHSI-L team used recommendation 14 of the COPD strategy consultation document (DH, 2010) to drive the improvement work, investigating whether adequate monitoring measures were in place to record and review each patient’s need for home oxygen therapy. The data showed there was variation between PCTs, and they were failing to regularly undertake quality clinical assessments and review patients’ clinical needs for long-term home oxygen use.
The project teams carrying out the improvement work used the British Thoracic Society’s (2006) home oxygen services standards and early drafts of the DH’s HOS-AR good practice guide (NHS Primary Care Commissioning, 2011). They also used work by the National Institute for Health and Clinical Excellence and IMPRESS (a joint initiative between the BTS and the Primary Care Respiratory Society established to improve respiratory services) to inform the initiative and steer the improvement testing.
The NHS Improvement work
Focusing on the assessment of clinical need and ongoing clinical review offers a chance to inform and educate patients about their condition and, if necessary, using home oxygen therapy equipment safely, its risks and their own responsibilities.
Respiratory teams who took on improving their services had to consider additional factors, such as staff competency levels, assessment and review location settings. They also needed to consider guidance on correctly documenting and interpreting diagnostic results, accurately prescribing oxygen and the need for patients to be given written information about their oxygen therapy.
The improvement work within the use of home oxygen services has shown that the annual total spend across nine NHS project sites can be reduced by a potential minimum of £600,000. Both new and established home oxygen services implemented oxygen usage reviews. Teams optimised therapy by list cleansing, avoiding inappropriate prescribing and withdrawing clinically unnecessary therapy.
Patients with COPD are admitted to hospital for various reasons. Those on long-term oxygen tend to have more severe disease with increased risk of hospitalisation. It may not be possible to establish from systematic clinical assessment and review whether optimised home oxygen therapy is an effective admission avoidance strategy; however, this is worth investigating in the future.
Many HOS-AR teams are communicating with non-respiratory specialists about managing non-COPD patients with home oxygen therapy. Together they have been looking at the reasons for initiating home oxygen therapy, often challenging when they appear not to adhere to their own specialty area guidelines. There may be scope to investigate the potential cost savings by rationalising home oxygen therapy in non-COPD patients, and to explore and test how to implement a gold standard pathway of HOS-AR.
To find out more about learning and improvement work at NHS Improvement – Lung, which includes accurate diagnosis, transforming acute care, managing COPD, end-of-life care and asthma, visit: www.improvement.nhs.uk/lung
Case study. Sustaining efficiency and effectiveness
In 2009, Milton Keynes Primary Care Trust Community Services and Milton Keynes Hospital recognised there were health inequalities and clinical variations in the use of oxygen for patients on home oxygen. Analysis undertaken to reduce this variation revealed that patients’ experiences varied depending on who prescribed their oxygen and that a two-tier oxygen service existed, with little integration of primary and acute care across the oxygen pathway. These clinical issues, combined with serious financial control issues meant the PCT had the highest prescribed oxygen cost per patient within the strategic health authority. Using a “spend-to-save” approach, the redesign of the home oxygen therapy pathway was reviewed through service mapping and process audit.
Protocols were jointly developed with clinical teams and the implementation monitored by the COPD administrator. The resulting service transformed the care of patients on home oxygen. All new patients were given a formal assessment and monitored for financial control.
To continue to improve this service the team applied to take part in the NHS Improvement – Lung programme and were accepted in 2010.
The project aimed to enhance the existing care pathway by development of a personalised patient leaflet which was assessed by a questionnaire, pre and post use of the leaflet. The ambulatory oxygen assessment clinic was improved by a pre and post clinic set up evaluation.
A good example of financial controls was the 2011 review of short-burst oxygen patients through the concordance reports, which reflects real patient usage amounting to annual cost savings of 13,000K. This has been achieved by reducing non/low users to less 90 minutes a day before they are reviewed by the assessment service.
Case study. Home oxygen – improving quality of care
Sherwood Forest Hospitals NHS Foundation Trust and NHS Nottinghamshire County Community COPD Team jointly enrolled with the NHS Improvement – Lung programme to carry out a project to improve home oxygen prescribing and the prescribing of oxygen upon hospital discharge. An analysis of home oxygen patient data revealed variations within the system: at least 50% of patients had therapy prescribed without referral to the oxygen assessment service, while the other 50% received an evidence-based, gold-standard service.
The project team also aimed to increase the overall GP uptake of direct access to the oxygen assessment service and to establish a standardised pathway for patients discharged with oxygen. Since the interventions have been in place, the cost savings to date have resulted in a projected annual saving of £24,209. Savings associated with the re-categorisation of oxygen therapy were achieved by reducing hours of usage, altering oxygen flow rates or removing supply, with no loss to the quality of care delivered to patients.
The direct cost savings achievable through more appropriate usage and control of home oxygen is attractive for commissioners. The more-established teams undertaking improvement work are also attempting to ensure sustainable financial management by educating GPs about the need for formal assessment and ongoing review.
British Thoracic Society Working Group on Home Oxygen Services (2006) Clinical Component for The Home Oxygen Service In England and Wales. London: BTS.
Department of Health (2010) Consultation on a Strategy for Services for Chronic Obstructive Pulmonary Disease (COPD) in England. London: DH.
NHS Primary Care Commissioning (2011) Home Oxygen Service – Assessment and Review – Good Practice Guide.