Grampian Home Oxygen Service

Summary

A new service was established in 2011 to manage Home Oxygen across Grampian. The multi-professional team provides all home oxygen (except for paediatric and cluster headache) based on a clinical need and risk management approach, and liaises with secondary and primary care. The revised service has demonstrated monthly cost improvements of £15 – 20k per month.

£15-20K
per month gained in cost improvements
Service improvement
based on guidelines, delivering benefits to costs and patient care

Description

The aim of this project has been to provide appropriate oxygen to the approximately 500 users of oxygen (O2) across townships and rural areas of Grampian to enable them to remain active and participating in life as much as possible.  Since the introduction of the service in 2011 we now provide all Adult home oxygen (except cluster headache) thus enabling patients to be discharged home or to remain at home.

I am a respiratory physiotherapist who has worked in Cystic Fibrosis (CF) since 2000.  By 2006, I had been working with a number of the CF patients in assessing ambulatory O2 in order to improve Quality of Life (QOL), enable them to continue to work and to allow activity and exercise to continue especially if awaiting a lung transplant.  One of the consultants then approached me to start an oxygen clinic (physio led) to do some of the same work with Interstitial lung disease (ILD) patients which started in March 2006.  We subsequently presented a poster at the British Thoracic Society (BTS) conference.

In 2009 I was part of the Domiciliary Oxygen Therapy Service (DOTS) review group working on ‘Research to Support the Evaluation of Scotland's Domiciliary Oxygen Therapy Service’.1

In 2010, a generous endowment donation allowed us to enhance the oxygen service to patients by offering funding for 3 years.  This was the first time we were able to have staff working in a dedicated oxygen service as part of their role.

In August 2011, NHS Chief Executives approved a plan to integrate Community Pharmacy cylinder oxygen services with the oxygen concentrator service provided centrally by NHS National Services Scotland (NSS). As I had involvement in oxygen services in Grampian, I was asked to be involved and so worked with the consultants, pharmacists, GP's and nursing team in setting up the new service and transferring all existing patients on to the new service.  This was an immense amount of work, firstly in identifying patients in Grampian who had a cylinder oxygen prescription as records for these patients were often inaccurate or absent.  It was often difficult or impossible to determine who had initially prescribed the cylinder oxygen and why.  It was therefore necessary to try and reassess all patients that we identified with any form of oxygen based on the guidance available at the time.

Clinical guidance was initially based on the British Thoracic Society (BTS) guidance documents.2

The service comprises B7, and B6 physiotherapists and B3 Healthcare support worker (HCSW), B6 nurse, B2 admin assistant and B4 secretary, fully supported by all of the chest consultants in providing the service.  As lead practitioner for the service I liaise with GPs, nurses and other professionals working in Primary Care and other hospitals throughout Grampian.  As operational lead for the team I also liaise with National Service Scotland (NSS), the contractor (Dolby Vivisol) regarding service issues as well as dealing with referrals as they come to the service through a variety of routes. I work very closely with the chest consultants and hold clinics in Aberdeen and Elgin. 

Initiation and implementation

In August 2011, NHS Chief Executives approved a plan to integrate Community Pharmacy cylinder oxygen services with the oxygen concentrator service provided centrally by NHS National Services Scotland (NSS). This new service would be based in Secondary Care and was designed and set up with all existing patients being transferred into the new Grampian Home Oxygen Service.

The project has gradually evolved over time and with different funding arrangements as the project progressed. More of a multi-professional team approach was adopted when 3 years endowment funding became available in 2010, long-term funding was secured when the Scottish Government made changes to how home oxygen was provided in 2012. However, since then, increased pressure on inpatient beds, along with increasing expectations that the oxygen team will assist with pre discharge assessments are placing significant strain on the service.

Involvement in the DOTS group was very helpful as it allowed me to input at a strategic level to ensure that services meet the needs of patients for example in provision of trolleys to carry portable cylinders (patients previously needed to purchase these).  I also attended several oxygen related study days, and ongoing involvement with Cystic Fibrosis (CF) at a national level meant that I was aware of the problems encountered in England and Wales when they moved to a similar system. This was helpful in that we could plan services to avoid similar issues in Scotland.

At the time of transition to the new Scottish service in 2011/12 there were significant challenges as a result of the changes planned.  GPs would no longer be able to prescribe cylinders and Pharmacists would not be involved in their supply.  We worked very closely with these groups at that time in identifying ongoing patients and the most appropriate prescription.  In particular, I worked with a Principal Pharmacist and the respiratory early supported discharge (ESD) nurses who identified patients in Grampian with cylinders and helped assess for ongoing requirements.

There were difficulties associated with this as many patients had been given oxygen under different criteria than we were using and with no measurement of saturations or ABG.  This meant that the expectations of both users and referrers needed to change in line with the updated clinical guidance.

Quality

Provision of home oxygen is now more standardised across Grampian and should only be given where there is a clinical indication (not just to ease symptoms of breathlessness)3.  In addition, patients who are referred to the service will be given advice on the management of breathlessness whether or not they receive home oxygen.  Avoiding inappropriate use of oxygen and issue of oxygen alert cards in certain patients should reduce the need for hospital admission and non-invasive ventilation. 

Safety is clearly a factor in this service and there is always a risk of fire and trip hazards which can be significant in certain patients.  We would avoid giving oxygen to patients who smoke and where patients are found to be smoking we would take action as appropriate to minimise the risk. 

Informal patient and carer feedback has largely been positive, however where there have been issues it is around inappropriate expectations.  Patients or carers can have an expectation that oxygen will ease their symptoms but in fact if they are not hypoxic or if there are other risk factors, then oxygen may not be suitable.  In this situation we would provide education in order to explain why oxygen may not be appropriate or helpful alongside advice regarding alternative options for management of breathlessness.

Cost and savings

The initial Physiotherapist led clinic was set up with no additional resource by working with the CF and ward based physiotherapists. 

Funding of approximately 23K, was made available via a generous endowment grant in 2010 and allocated as follows in the first year, recurring funding over the next 2 years met ongoing costs:

  • 1 day per week of ESD staffing                  £7,000 (5,299 – 7,066 band 5 0r 6)
  • 1 day per week of physiotherapy assistant  £4,084 (2.5% pay increase for 2010)
  • 3 hours per week of senior physiotherapist  £3,414  (2.5% pay increase for 2010)
  • Purchase of portable gas analyzer              £6,495 (awaiting updated quote)
  • Consumables for gas analyzer                   £1,100 (based on 50 patients per year)
  • Travel cost associated with ESD travel        £1,000 (approx)

In 2012 funding for the new service was made available and the multi-professional service is funded by NHS Grampian. This was made possible by cost-savings from improved efficiency of the new service. The 2016 costings were a total of £118,493 as follows:

WTE

Banding

Post

 

0.2

7

Physiotherapist

 

 

1

6

Physiotherapist

 

 

1

6

Nurse

 

 

0.16

4

Secretary

 

 

0.53

3

Physio HCSW

 

 

0.53

2

Admin assistant

 

 

Total staffing costs

£112,493

 
leased car, travel and stationary £    6,000      
Total £118,493

 

 

 

 

This service was not set up with the intention of saving money, however it made savings of approximately £15-20K per month in the first year (2012/13)and further savings of approximately £135K are anticipated over the next (2016/17) with changes in the new contact awarded last year.  These savings result as a combination of efficiencies within the Grampian Oxygen team and reduced costs from the contractor.

What did you learn?

Learning has been significant throughout the process and includes the following

  • How government policy is developed and implemented
  • How projects are funded and decisions made regarding this, including costings and budgets.
  • I have learned about many aspects of HR relating to setting up and appointing to posts but also incidentally as staff have had problems or issues that I have had to deal with.
  • Submitting a poster to a national conference and presenting that poster
  • I have read through numerous clinical guidelines and recommendations relating to the topic.
  • I am much more aware of the role of the MDT involved with the care of respiratory patients and how challenging this can be for Primary Care colleagues (I am based in secondary care)

Relevant contacts and resources

1. Domiciliary Oxygen Therapy Service (2009) Research to Support the Evaluation of Scotland's Domiciliary Oxygen Therapy Service. published by the Scottish Government, http://www.gov.scot/Publications/2009/12/01113351/0  2. The British Thoracic Society (2006). Clinical Component for the Home Oxygen Service in England and Wales. https://www.brit-thoracic.org.uk/document-library/clinical-information/oxygen/home-oxygen-guideline-(adults)/bts-home-oxygen-in-adults-clinical-component.(Withdrawn) 3. Hardinge M, Annandale J, Bourne S, et al. (2015). Guidelines for Home oxygen use in Adults. The British Thoracic Society; Thorax 2015;70: i1–i43.1https://www.brit-thoracic.org.uk/document-library/clinical-information/…