To bring the services up to date and to make sure that every patient has access to modern equipment that is suitable for them and their medical condition. Arrangements have been simplified to make sure this happens across England and Wales from 1 February 2006.

The present arrangement whereby oxygen is prescribed largely by GPs using an FP10 has remained largely unaltered for 50 years. Following an RCCP review in the late 90s, a Department of Health working party reviewed the service in conjunction with the NHS and produced proposals for this revised service in 2003. These proposals resulted in a detailed service specification being prepared in 2004 and tenders being invited for the provision of the new service, which integrates provision of all modalities of supply into one contract.

• Introduction of new technologies in oxygen supply that will bring benefits to patients

• Increased involvement of specialist clinicians in assessing patients

• Provision of ambulatory oxygen to patients following assessment

• Provision of oxygen under the NHS for patients holidaying in the UK
  
• Improved efficiency in the supply chain leading to economies that can help investment assessment

The changes mean that all the patient’s home oxygen needs will be met by a single supplier, who has the expertise to help make decisions on the best service to meet his or her individual needs. Patients should experience improvement in assessment procedures – usually in a secondary care setting – and will have 24/7 access to one central freephone for all oxygen matters.

GPs have largely been prescribing both short burst oxygen therapy (SBOT) and long term oxygen therapy (LTOT) therapy with limited knowledge and expertise. The average GP will only have four to six patients receiving oxygen therapy meaning a GP’s ability to develop the required expertise in assessing patients has of necessity been limited. In some places there is little opportunity for specialist assessment depending on where such services are available. GP involvement will now be more limited to SBOT pending specialist assessment and, in due course, all new and existing patients will be subject to regular clinical review and reassessment by specialist teams. The new contract will significantly enhance the availability of information for clinicians on oxygen use by their patients.

CPs have been the backbone of the service in the past, managing the ordering, storage and delivery of cylinders to patients under the provisions of the Drug Tariff. Once all patients have transferred to the new service the role of community pharmacists will not normally have a responsibility for the supply of oxygen itself after this time.

Once the new service has bedded in, all oxygen orders will be sent from the clinician directly to the supplier, who will then deliver the oxygen cylinders and/or concentrators directly to patients. Community pharmacists will be able to offer advice to patients as they do on many pharmacy related issues.

The new service has been designed by a group led by the DH Medicines, Pharmacy and Industry Group with valuable support from many stakeholders including NHS managers and clinicians, NHS PASA, the British Thoracic Society (BTS), the Pharmaceutical Services Negotiating Committee (PSNC), the British Lung Foundation (BLF), the Prescription Pricing Authority (PPA) and Medicines Healthcare Regulatory Agency (MHRA).

Clinicians were significantly involved in designing the new service. The BTS has now published new clinical guidelines for the provision of therapy, which have been embodied fully in the new specification. http://www.brit-thoracic.org.uk

In the past oxygen therapy has been prescribed by GPs by means of an FP10, which the patient has taken to his or her pharmacist in the usual way.

From 1 February 2006 a clinician in primary or secondary care will complete a Home Oxygen Order Form and submit this directly to their oxygen service supplier. The ordering clinician will also obtain the patient’s consent for the release of their data to the supplier and to the Fire Brigade (who require it for safety reasons). The FP10 will no longer be used for prescribing oxygen, as it is not a prescribable medicine.

The HOOF and the consent form will then be sent to the local supplier who will contact the patient to determine the most appropriate means of delivering the oxygen to the patient (cylinder, concentrator, liquid oxygen), undertake any necessary installation and provide all the necessary equipment. The supplier will also ensure that the patient is trained in its use before informing the specialist team that the order has been completed. The supplier will maintain regular contact with the patient to ensure that they have the necessary supplies and that their equipment is regularly maintained.

It will be available from the same source as FP10s by the end of December for delivery to specialist teams and GPs during January 2006.

To start the service the four new suppliers need accurate information about existing patients immediately prior to the start-up date.

1. 1 .- Concentrator patients

Existing concentrator service contractors hold patient data on those receiving a concentrator service. As a holder of personal data, the contractor also has responsibilities under the Data Protection Act 1998 and NHS guidance on obtaining patient consent.

Therefore, outgoing contractors should be requested to transfer patient data to PCTs rather than directly to the incoming supplier – i.e. to the PCT in which the patient‘s GP practice is located. The PCT will then obtain the approval of each patient before passing this data to the incoming supplier.

The minimum data set required for concentrator patients will be agreed between the incoming and outgoing supplier but will certainly include personal patient information such as name, address and date of birth as well as GP identification and contact data.

1. 2.- Cylinder patients

PCTs should obtain data for existing cylinder patients from appropriate sources that may include:

• Their payment services provider (e.g. a shared or common services agency)
• The PCT itself – e.g. from community pharmacist claim forms
• General practices

PCTs may wish to consult their Local Medical Committees once they have determined the most appropriate source for such data and any approach in seeking patient consent for the transfer of data.

The minimum data set that will be required by the incoming supplier is:

• Title, name, address and postcode
• Date of birth
• Patient (or carer) telephone number
• GP identifier (name and/or number)
• Average number of cylinders used per month for static services
• Average number of cylinders used per month for ambulatory services

It is then the PCT’s responsibility to obtain each patient’s consent before passing this data to the incoming supplier.

• Together with their SHAs to agree a process to manage the implementation
• Communicate with stakeholders and involve them in the implementation process
• Meet with the incoming contractor to agree implementation plans
• Collect data on current cylinder patients to pass to incoming contractor
• Contact patients to obtain explicit permission for data to be passed to incoming contractor
• Ensure that services for patients can be maintained until 1 February 2006
• Prepare care pathways for oxygen patients
• Consider what respiratory assessment services need to be commissioned
• Review invoicing and payment systems in preparation for the new contract
• Determine arrangements to support performance management of the contract

Peter Williams has been appointed by the DH as national project manager for HOS and will lead on issues that are most effectively handled at national level. Peter can be contacted at prwill@onetel.com

Sarah Wrixon has been appointed by the DH as communications manager for HOS and will lead on all communications issues. Sarah can be contacted at hos.newletter@pcconline.info

Current national tasks include:

• Sharing good practice
• Supporting regions and PCTs as requested
• Acting as a national co-ordinating point for new suppliers
• Establishing a small national steering group
• Developing and disseminating guidance
• Identifying and engaging with stakeholders
• Working closely with the DH policy lead
• Monthly reporting
• Overseeing design of the new oxygen order form and patient consent form
• Advising on a national minimum data set for cylinder patients
• Developing and implementing a national communications strategy
• Developing patient information leaflets
• Identifying key risks and developing mitigation actions

The DH is sending weekly e-bulletins to SHA and PCT oxygen leads and other key stakeholders in newsletter format each Friday. These are succinct and bring you news of all developments and need-to-know information. Anything requiring greater explanation will be hyper-linked through to the HOS section of the PCC website, which will be the primary warehouse of all material relating to HOS.

Nationally the key risks facing the maintenance of services to patients during the implementation period include:

• The ability to collect and maintain accurate data on existing and new cylinder patients until it is handed over to the new suppliers in January.

• Ensuring that consent to hand over data to the new suppliers is obtained from all patients.

• The ability of the NHS across the country to engage with suppliers and respond to their needs at a time of heightened workload pressure and organisational change.

• Patients, existing service providers and clinicians not being aware of the new arrangements causing confusion and concern.

Everything possible is being done to minimise these risks. Specifically:

• 200 bar cylinders

The October Drug Tariff has introduced a payment for 200 bar cylinders, which can be prescribed by GPs and other clinicians immediately. These cylinders will increase the capacity of existing cylinders by 50%, meaning that they will last longer before needing to be refilled.

• Change in concentrator threshold

The threshold at which patients should be considered for concentrators has been changed to anyone who is using oxygen for more than two hours. This change has immediate effect, and GPs and other clinicians should be advised to review their prescribing practice and prescribe concentrators for patients using oxygen for more than two hours per day (providing this modality is clinically acceptable).

• Headset purchase

PCTs have been advised to step in where there are shortages of headsets and purchase supplies of these items and allocate to community pharmacists. However, it should be noted that after 1 February 2006 all cylinders must have integral headsets and therefore separate headsets will be largely redundant.

• A clear communications strategy

No. Existing patients will continue to receive their oxygen. Specialist teams will need to assess these patients, but this may not be completed for some two years due to the intense workload on specialist teams initially.

The DH is of the view that this new service should be cost neutral to the NHS. The savings to be made from establishing more efficient supply chains and from carefully reviewing patients are expected to offset additional costs of the assessment process. However, in view of the scarcity of good data particularly regarding cylinder patients and the take up of the new ambulatory service the DH has agreed to review this position as part of the audit of the new service to be undertaken 18 months after its start.

No. Because determining factors differ so much from region to region it has been decided that it will be better to prepare business cases at a local level.