1. Ambulatory Oxygen Matters in London Cassie Lee, Lynn McDonnell & Craig Davidson on behalf of the London Clinical Oxygen Network

2. Background The home oxygen service (HOS) contract change in 2012 offered the potential benefit to patients of new technology to assist ambulatory use such as liquid oxygen (LOX) and refillable cylinders (Homefill). Guidance to commissioners also recommended the need for assessment and review services (HOS-ARs). Only 3 such services had been commissioned in London (population approx 10m, HOS users 10,000 and cost £10.5m) and anecdotally the LRT were aware that nurses or therapy staff were in many areas attempting to meet demand with no increase in resources. We therefore audited the provision of ambulatory oxygen assessment across the capital.

3. Aims To determine the service provison, commissioning arrangement and assessment protocols for ambulatory oxygen across London Establish an ambulatory oxygen network across London

4. Methods Telephone audit January - March 2013 All known oxygen assessments centres across London were contacted by email to arrange a telephone interview, Two AO 2 clinicians used an agreed proforma Subsequent questions/queries were followed by email and contributors given the opportunity to correct errors in report in May 2013

5. Interview Proforma Access to service, referral pathway/ number of referral Assessment protocolIntegration Location (i.e hospital/ community site Commissioning/ funding arrangements Disciplines/grades

6. Results 34 interviews Criteria: Formal referral pathway in use Access to and knowledge of, a wide range of equipment for assessment (Cylinders + at least 2 others) BTS criteria for ambulatory oxygen used Formal reproducible walking test used Set minimal time period between tests of at least 15 mins or more Have a protocol for follow-up Tier 2 = Met > 3 criteria Tier 1 = Met 1-3 criteria No Service = 2 boroughs GREEN = ‘Tier 2’ Comprehensive/adequate level of service YELLOW = ‘Tier 1’ Basic/Adequate level of service RED = No service

7. Results 34 interviews completed, 32 boroughs Access: 2 boroughs had no service, some had multiple Who: 20 teams include nursing staff, 15 physiotherapists and 7 include lung function staff. Larger services (>10 or more per month) more likely to include physiotherapists, smaller services were more likely to be nurse led Where: 16 teams are based in the hospital setting, 9 in the community and 7 are located in both settings. How: The majority of services perform the 6MWT, none of the teams that perform home assessments use validated reproducible exercise tests.

8. Results Equipment: The majority had standard cylinders (88%), approx half had lightweight (53%) and conservers (53%), other devices were rarely (3-16%) available Funding: 47% have some funding arrangements in place; 29% = No funding or no service provided 24% = Unclear on funding arrangements. Integration: 67% Part of an integrated service, 18% stand alone, 6% have no service and 12% unclear

9. Assessment equipment

10. Conclusions No established network across London, many clinicians reported they felt isolated. Different levels of service provision across London. Many services saw minimal numbers There is no standardised referral pathways for AO across London, raising concerns over consistent access to service and clinical skills and competencies. Patients not consistently assessed on the prescribed device Approximately half of services are considered to be providing a ‘comprehensive/ adequate’ level of service and half ‘limited’ or basic. Approximately half of the services have no or unclear funding arrangements. The majority of services (67%) are integrated within a wider COPD/IRS, however the commissioning arrangements around this is less clear.

11. Recommendations  AO services should be commissioned within an integrated respiratory service.  Minimum standards are required for referral pathway, assessment and prescription of AO  London based training and support network for AO clinicians including the dissemination of the LCON Guidance on Assessment for AO.  A model of Tier 1 and 2 services be explored across London as potential framework to provide adequate AO to all patient.