NHS Improvement
Improving oxygen services
Dudley PCT introduced a new service
pathway in 2008 to regulate a previously
disjointed oxygen service managed
through a single point of contact,
resulting in improved identification and
treatment of oxygen patients as well as
significant cost savings.
The process of oxygen assessment and
prescribing within the Dudley PCT was
conducted using 'Home Oxygen Order
Forms' (HOOFs). Patients with COPD
would be assessed by their GP who
would then decide whether they required
home oxygen, how much and for how
long. This information would be recorded
on the HOOF and Airproducts would
then supply the oxygen to the patient.
The whole service was very ad-hoc, there
was no use of pulse oximeters and
oxygen prescribing was either seen as
being a last resort treatment option or
utilised too quickly. The quality of the
information on the HOOFs was also
In 2008 the Respiratory local
Implementation Team (LIT) commenced a
review of the Home Oxygen Assessment
Service as it was felt that the use of
HOOFs were adversely affecting the
quality, consistency and appropriateness
of oxygen prescribing.
At the time the review was being
• 700 patients were on home oxygen
(the majority of these were on
• 222 patients were being prescribed
Short Burst Oxygen Therapy (SBOT)
• 170 Long Term Oxygen Therapy (LTOT)
• 115 were on a combination of LTOT
and ambulatory oxygen
• 115 of these patients were 'high
An audit of the home oxygen service was
conducted by the Lead Nurse for COPD
in January 2008. The audit highlighted a
service that was disjointed in places with
several areas which offered room for
• HOOFs were being completed with
minimal information
• Patient usage did not correlate with
what was prescribed on the HOOF
• The service was not cost effective due
to expensive prescribing
• There was a lack of ownership with no
real coordination of the service
• Questions were raised relating to
patient safety through inappropriate
prescribing and potentially
inappropriate management of a
patients’ condition
• There was no (or lack of) patient
education especially in areas where
there was no clinical assessment and
follow up service
• HOOFs were being used to prescribe
oxygen with there being any agreed
oxygen guidelines in place
No monitoring was in place and
therefore compliance and technique
were not being assessed
• There was non-compliance with
directives and guidelines
• Oxygen was being provided 'ad-hoc'
and often wasn't required
• HOOFs were not easy to complete
• The service was not cost effective.
Changes implemented
Once the audit was presented to the
Respiratory LIT, it was agreed that Dudley
patients and clinicians would benefit
from an oxygen service redesign and that
the new service would need to be
managed by a provider with specialist
knowledge of oxygen assessment. The
Dudley Respiratory Assessment Service
(DRAS) based at the acute general
hospital was identified as being best
placed to provide the service.
Dudley PCT
Lung Improvement
JULY 2012
NHS Improvement
The service redesign considered the
findings of the audit alongside the
requirements of the local population. The
‘Oxygen Assessment Service’ (OAS) was
launched in October 2008.
As part of this, new guidelines were
introduced to regulate monitoring and
referring patients for home oxygen.
A total of 60 GP practices were supplied
with pulse oximeters (at a cost of £155
each) so that patients can be screened in
Primary Care and those with oxygen
saturation of less than 92% can be
identified. These are then referred to a
formal assessment (British Thoracic
Society guidelines) for LTOT using a
simple ‘Open Access’ referral form.
During the assessment patient’s Arterial
Blood Gases (ABGs) are measured, and
only those who have PaO2 less than
7.3kPa proceed to the LTOT pathway,
those with a PaO2 between 7.3 and 8.0
will have further assessment (e.g., night
Patients who commence LTOT are then
reviewed at four weeks after
commencement of treatment via a
community/Primary care assessment,
three months at the OAS (ABGs
measured), six months and then annually.
All patients who are on home oxygen
therapy are added to a register and will
be reviewed at the OAS. Those with
SaO2 greater than 92% on air are
reviewed as to whether they need to be
on oxygen.
All results are reviewed by Lead
Respiratory Consultant, who reports
upon and responds to the GP involved,
with recommendations.
Overall impact and benefits
(including measurement and
By formal assessment and review the
team can ensure that the correct
modality and/or flow rate is achieved.
As a result of the new pathway, a single
point of contact dealing with everything
to do with oxygen now exists which is
accessible to all who need, or may need,
access to the OAS.
A greater clarity now exists with HOOF
forms (excluding palliative and
paediatrics) only being completed by the
‘Oxygen Team’.
In the first year, 238 people were sent to
the assessment service and only 68
needed oxygen. Previously all would have
been prescribed oxygen by primary care.
One hundred and seventy people
therefore have avoided being placed on
oxygen with consequential cost savings
to the Dudley PCT.
The oxygen service ensures patient
safety by:
• Avoiding inappropriate prescribing
• Avoiding inappropriate management
of condition
• Ensuring adequate patient education.
By monitoring patients the team can
identify issues with poor compliance and
Current position of good
practice/future plans
There was very much a team approach to
the redesign of the service and the
service continues to be monitored via the
Respiratory LIT. There is to be a further
review of the whole of the Respiratory
assessment service to ascertain any
further opportunities for improving the
oxygen pathway.
QIPP return – productivity and
The service ensures cost efficiency by
ensuring oxygen is only prescribed in
appropriate cases. As demonstrated
spend savings have been made with 170
patients avoiding being placed on oxygen
at an average cost of £770.00 each
totalling £130,900 per annum saved net,
minus the cost of the assessments
This gives a total saving of £116,382
for the PCT.
An integrated service tailored to meet
the individual patient needs has resulted
in an improved, easy to access service
with clear guidelines for referral through
both primary and secondary care. Where
the majority will be seen and assessed
within two weeks.
Patient satisfaction
Patients receive more regular reviews and
are counselled appropriately in the event
of oxygen therapy being removed.
Communication regarding patient
oxygen prescribing has improved
materially between primary and
secondary care.
Patients/carers have a single point of
contact with their oxygen concerns.
The local voluntary sector group
Breatheasy were also consulted on
changes to the clinical pathway and their
comments have been positive as they feel
their needs are being prioritised within
the commissioning process.
NHS Improvement added value
The OAS has demonstrated how the
health economy can work collaboratively
to deliver an improved quality service for
patients. The savings generated were
achieved well above the anticipated
business case developed prior to
Mark Hopkin,
Email: mark.hopkin@dudley.nhs.uk
Tel: 01384 873 311
Lung Improvement
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