The Pharmaceutical Journal
Vol 276 No 7385 p101-102
28 January 2006

This article
Reprint   Photocopy

PDF 50K, Acrobat Reader

Handover of the home oxygen service: ensuring patients are not put at risk

In England and Wales, the transfer of home oxygen cylinder provision to four regional companies on 1 February is raising concerns that some patients may not receive the oxygen they need. Tom Moberly (on the staff of The Journal) looks at what is being done to ensure patient safety is not compromised during the handover

From 1 February four regional suppliers — Air Products, Allied Respiratory, Linde Gas and BOC Vitalair — will begin to supply cylinders and concentrators as part of an integrated home oxygen service in England and Wales. Rather than GPs prescribing oxygen, patients will be assessed by a respiratory team and a home oxygen order form (HOOF) will be sent to the patient’s supplier company, which will then be responsible for all the patient’s home oxygen needs.

If all goes to plan, the supply of home oxygen to patients will transfer smoothly over to the new companies and away from community pharmacists — some of whom are pleased to see the back of it, given the supply problems encountered recently — and patients will simply begin to see their oxygen supplied by a large company responsible for the whole region rather than their local community pharmacist.

However, the six-month validity of FP10s will mean that pharmacists will still be expected to supply cylinders between February and the start of August and community pharmacists, the Royal Pharmaceutical Society and the Pharmaceutical Services Negotiating Committee are all concerned that supplies to patients could be disrupted during this time.

Supplies to patients could be affected either if pharmacists have difficulty obtaining cylinders between February and August or if patients have not been transferred over to the new system, in spite of the efforts of Primary Care Contracting, the PSNC and the National Pharmacy Association to inform patients about the changes.

Leaflet

In fact, considerable work has been put into communicating the details of the change to patients and pharmacists ahead of the handover. A patient information leaflet has been produced by Primary Care Contracting in association with the British Lung Foundation and 500,000 were distributed throughout October to pharmacies and GPs together with a letter of explanation.In addition, the PSNC and the NPA have produced an A4 window poster and template patient letter, to enable community pharmacists to communicate the process to patients and carers.

Nigel Barnes, assistant director of clinical effectiveness at Birmingham and the Black Country Strategic Health Authority and lead for the West Midlands on the home oxygen transfer, believes that primary care organisations have probably done as much as they can to inform patients and pharmacists about the changes.

“Patients have been sent materials from their PCT, GP and community pharmacist. They will also be receiving further information shortly from our local provider, Air Products. In addition, many GPs and pharmacists have been advising patients of the changes as they come in for oxygen prescriptions,” he explains. “I am confident that the vast majority of patients have been informed.”

However, it is the infrequent users of home oxygen whom community pharmacists think are most likely to be unaware of the changes and Mr Barnes acknowledges that there is no guarantee that every patient has been contacted. “A few patients who have occasional use of oxygen may still emerge, but these patients will be informed of the change and given a HOOF as they present to their GP for oxygen and are transferred to the new service,” he says.

Tony Schofield, a community pharmacist in Tyne and Wear, commented: “A lot of patients are certainly not aware of the changes. Many of them are elderly and have heard something or have been sent a letter from their GP, haven’t fully understood it and have been frightened. … The problem is that it has been almost impossible to keep tabs on patients if they move away from the area. Often we just give patients their oxygen and that is the last we see of them.” Community pharmacist Steven Curtis adds: “Those patients I have had reason to contact recently are aware that our service will conclude soon, but those I do not see regularly may have slipped through the net.”

The supplier companies are aware that PCT and local health board lists of patients requiring oxygen may be incomplete. Declan Weldon, general manager for home care at Air Products Medicals, says: “There may be some infrequent cylinder oxygen users who may not be known to the PCT or LHB; these patients will be informed when they next visit their GP or indeed their local pharmacy for a repeat prescription. We appreciate the support provided to patients by their local pharmacies in this regard.

Consent form

Even patients who know that they need to be transferred to the new service may not be in a position to receive oxygen from their new supplier on 1 February —their details will have to be passed on by their PCT. For that to happen, patients will have had to sign a consent form, so that the PCT does not breach patient confidentiality. But ensuring that every single patient has returned their consent form by 1 February is proving problematic.

All consent forms were supposed to be returned by 6 January, explains Beryl Bevan, chief pharmacist and co-ordinator of the home oxygen handover at Ealing PCT. But even a week afterwards Ealing PCT still only had two thirds of the forms back, so her team is now writing to GPs to follow up patients as they see them, she says. Part of the problem, she explains, is that many patients do not understand the changes because they do not read or speak English well and so GPs are having to explain the changes to them and explain what they need to do. Another problem is that new patients will have started on oxygen after PCTs conducted their audits in October and November and information about these patients may not have been passed on by GPs to the PCTs, Ms Bevan adds.

Other regions have had slightly more success in retrieving forms, but still do not have forms back for all patients. Cannock Chase PCT, for instance, had consent from 92 per cent of their list of oxygen patients and are now up to 97 per cent of patients. “We are fairly confident that we have identified as many patients as we can,” Adele Edmondson, communications manager at Cannock Chase Primary Care Trust, says.

For patients who do slip through the net — because they are either not aware of the new arrangements or have not yet been transferred to the new service — and approach community pharmacists for oxygen after 1 February, the PSNC has produced a handover plan for pharmacists, which is available via its website (see Panel).

Patients who do not have valid FP10s should be referred to their GP for a HOOF, unless they require an emergency supply of oxygen, in which case the pharmacist should refer them directly to the new supplier company. If the patient presents with a valid FP10, community pharmacists should supply oxygen according to the FP10 and advise the patient to contact his or her GP for future supplies via a HOOF.

Reimbursement

Advice on the reimbursement of pharmacy contractors who continue to provide an oxygen service to patients after 1 February 2006 will be set out in amendments to Part X of the Drug Tariff to be issued on 1 February, Sarah Wrixton of Primary Care Contracting’s communications team says.

However, if a pharmacy cannot obtain any oxygen — and accessing supplies during the transition period may be difficult, the PSNC believes — the pharmacists should refer the patient to another local contractor with stock or to the new supplier via the company’s free-of-charge telephone number (see Panel), the PSNC says.

These concerns over the ability of pharmacists to obtain cylinders — and worries that some patients may be left without oxygen when the service goes live in February — have led the Society to ask PCTs and pharmacists to pull together to ensure that the new service is implemented as smoothly as possible and with minimal risk to patients. “We would encourage pharmacists to ask patients to ensure they have oxygen supplies leading up to the transition period to minimise the need for the new supplier to make emergency supplies during the handover,” the Society advised.

Despite such concerns, Primary Care Contracting is confident that, after 1 February, there will be few supply incidents affecting patients. “The shortages reported over Christmas and the New Year — when demand for cylinder oxygen is usually at its peak — amounted to three reports nationwide,” Ms Wrixton says. “We have no reason to believe that there will be a disruption to the supply of home oxygen after 1 February.”

“This is a reflection of the plans made by the Department of Health and NHS back in August 2005, the good communications that have been established between community pharmacists and the NHS and in, particular, the excellent work undertaken by community pharmacists to ensure that services to patients were maintained during this peak period,” she added.

In any case, she explained to The Journal, the terms and conditions of service of the new contract set out clear and detailed service requirements. “All new suppliers have assured us that they are ready to meet these,” she said. “Where there is a failure to supply, the contract also sets out steps that can be taken by suppliers and the NHS to address this.”

For two of the companies the new service will entail either no expansion of service, but rather a shift, or a simple expansion of services already offered.

BOC Vitalair will not see an increase in the number of patients served, but rather a change in geographical coverage, the company says. “We have planned the transition over a period of two years and are well prepared for February with new sites, staff and equipment in place,” Greg McNeil of BOC says.

Air Products is also currently supplying liquid oxygen, providing a holiday service and supplying cylinders direct to patients, on behalf of pharmacies in the south west, and providing a four-hour emergency call-out service, Mr Weldon says.

New challenges

“Our experience in England and Wales encompasses the complete range of requirements for the new service. … Our background experience has prepared us for most eventualities, although we appreciate that a major change such as this often presents new and unexpected challenges,” he adds.

The number of regions covered by each provider differs widely, however. For instance, whereas Air Products will cover north west England, Yorkshire and Humberside, the east and west Midlands, north London, south west England and Wales, Linde Gas will only be supplying north east England. Being reliant on a single supplier could lead to difficulties, Mr Schofield, believes.

“I think it is a big risk to only have one supplier for each region,” he says. “In the past, if BOC could not supply a cylinder, it might be that another supplier had one. That won’t be the case now. And whereas the other firms cover several areas each and might be able to make up for a supply difficulty in one area through excess in another, Linde [which will be serving our area] only has one contract. … I just have to assume that the DoH has satisfied itself that Linde has done everything necessary to assuage my fears about the company’s ability to supply a satisfactory service.”

However, Ian Spencer, director of clinical governance at Northumberland, Tyne and Wear SHA and home oxygen lead for the north east region, says: “Having worked closely with Linde Gas, I am confident of its ability to deliver a safe and secure service and of its responsiveness to our local needs.”

Even if the four supplier companies are well prepared for the handover, one final bottleneck in the system may lead to difficulties in supplying patients with the oxygen they need — the requirement that all patients are assessed by a respiratory specialist. “The difficulty [for the new service] will be in PCTs identifying resources to commission an improved assessment and follow-up service, the costs of which have to be met from existing resources,” Ms Edmondson says.

This part of the new service will, however, be out of community pharmacists’ hands. Their role will simply be to facilitate the smooth transition of a service they have run successfully for many years over to the new service providers and to make sure that patients are not left wanting — asking them to ensure they have sufficient oxygen supplies leading up to the transition period, in order to minimise the need for the new supplier to make emergency supplies during the handover period.