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Debate to be resumed on Friday 17 March.
CRIME PREVENTION AND THE BUILT ENVIRONMENT BILL
Order for Second Reading read.
To be read a Second time on Friday 17 March.
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Domiciliary Oxygen
Motion made, and Question proposed, That this House do now adjourn.—[Mr. Watson.]
2.31 pm
Sandra Gidley (Romsey) (LD): I welcome an early opportunity to highlight problems with the new contract for delivering oxygen to people's homes, which was the subject of heated debated in Health questions. It is nice to see the Under-Secretary of State for Health, the hon. Member for Birmingham, Hodge Hill (Mr. Byrne), but I regret that he does not have direct knowledge of the subject or responsibility for overseeing the implementation of the new service which the Minister of State, Department of Health, the right hon. Member for Liverpool, Wavertree (Jane Kennedy) described, perhaps inadvertently, as a shambles. I therefore hope that the Under-Secretary is well briefed.
It is worth setting out the background to the problem. For many years, community pharmacists supplied oxygen cylinders, and that service was supplemented by other companies supplying oxygen concentrators. In a response to a parliamentary question that I tabled, the Minister of State said:
"For many years, patient organisations have sought improvements in the domiciliary oxygen service, which has seen little change over the past 50 years."—[Official Report, 27 February 2006; Vol. 443, c. 435W.]
That is not exactly inaccurate, but the bulk of those concerns centred on the old-fashioned nature of the equipment, rather than on the suppliers.
The Department asked the Royal College of Physicians to lead a multi-disciplinary working group in a review of the clinical assessment and prescribing of oxygen in the home. That group reported in 1999. I have been unable to clarify the composition of the group, so I would be grateful if the Under-Secretary would do so, as it has been suggested that there was not a proper consultation, which prevented full consideration of the benefits of retaining a supply from pharmacies. In 2003, the hon. Member for Tottenham (Mr. Lammy), who then had ministerial responsibility for pharmacies, stated in a written answer:
"Although the working party's terms of reference precluded making specific recommendations about alterations in service provision, a number of the guidelines had implications for the content of the existing domiciliary oxygen service and for the way in which the service is delivered."—[Official Report, 12 June 2003; Vol. 406, c. 1075W.]
He then mentioned that as a result of the exercise, a review of the domiciliary oxygen service had taken place and he would announce the results. It may have been at this stage that the Department of Health issued a questionnaire. A joint response by the pharmaceutical services negotiating committee and the National Pharmaceutical Association made a strong case for cylinder oxygen to continue to be supplied by community pharmacies and proposed a beefed-up monitoring role.
The then Minister announced that the new model would transfer responsibility for ordering oxygen for long-term oxygen therapy from GPs to specialist consultants in hospital. The idea was that this was a specialist service and that many patients would benefit from having oxygen available in different forms. GPs
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could continue to prescribe oxygen for patients who required relatively small amounts. So far, so good. However, he went on to say that specialist contractors would provide the service, and that a specification for the provision of the service would be drawn up. He anticipated that the new service would be fully operational early in 2005.
Not everybody was happy. The pharmaceutical services negotiating committee lodged an official protest with the Department of Health that the domiciliary oxygen service was to be swept aside and replaced by a secondary-based system. The main strands of the complaint were that it had been launched without proper consultation and put at risk the provision of oxygen therapy to patients. Those proved to be sound words.
However, when the details of the invitation to tender were announced, it was clear that pharmacy was out of the picture. Despite ministerial protestations to the contrary, because the Government required a one-supplier-fits-all approach, and pharmacy expertise did not extend to fitting the concentrators, pharmacy was effectively excluded.
Initially, the service was supposed to start on 1 October 2005. That deadline was not achieved because of legal action by one of the potential suppliers. Throughout this period, pharmacy contractors remained keen to help, and despite the fact that pharmacies had already begun to run down the stocks and infrastructure, such as the vans and storage equipment, they all did what they could to keep the service going. The PSNC tells me that efforts were made to find ways of transferring pharmacies' valuable knowledge about patients to the new suppliers, but the Department of Health and the primary care trusts believed that they did not need that help.
As February 2006 approached, some patients were transferred to a concentrator service but, as the Minister acknowledged in health questions on Tuesday, that was only about half the patients who were receiving oxygen. What she did not acknowledge was that on 1 February there were effectively 30,000 patients without an oxygen service. Those had been relying on the local pharmacy network to supply their oxygen.
Prior to 1 February it was clearly understood by pharmacy contractors that they would not be able to supply oxygen after 1 February other than on a pre-dated prescription, so I was somewhat surprised to read in The Times a letter from the Minister with responsibility for public health stating:
"The service was always planned to be phased over a six month transition period and not suddenly switched".
Such assertions have been repeated by the Minister with responsibility for pharmacy, and they are misleading. That was not the impression given by the NHS in the run-up to the 1 February deadline. If the Minister disbelieves me, I refer him to the primary care contracting NHS website.
In 2005 some frequently asked questions were produced. One was how suppliers would receive their orders. Under the old system, GPs wrote a prescription, called an FP 10, and pharmacists supplied against that. The answer is interesting. It clearly states that doctors would have to use the home oxygen order form—HOOF—and submit it directly to the oxygen service provider. It continues categorically:
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As there was no clear cut-off point, it would be helpful if the Minister could explain what the Minister meant when she stated in her letter that the service was to be "phased in", and what phasing was planned for after 1 February. Any phasing should have taken place before that date, when a complete switch-over was planned.
What happened? Within a few days of 1 February, I received complaints from a local hospital doctor that he was unable to discharge patients into the community because of difficulties in obtaining oxygen. He also claimed that many doctors had raised concerns about the transfer to the new system. In addition, I received calls from pharmacists highlighting the long delays experienced by patients receiving oxygen from the new suppliers. Many GPs did not transfer patients as anticipated, and it would be helpful if the Minister were to explain how that process was monitored during the lead-up to 1 February.
Much of the information supplied by GPs was inaccurate or incomplete, which compounded the demand on the inadequate resources of the new suppliers. Air Products, which is one of the new suppliers, claims that 80 per cent. of the HOOF forms that it received had been filled in incorrectly. It would be useful to know what guidance was issued to GPs on the changes and the extra information required on the new forms.
The four main suppliers had insufficient telephone line capacity, and it is interesting that they passed the buck to GPs and patients and blamed them for contacting helplines with general queries about future supply orders. In many parts of the country, the February transfer can only be described as "chaotic". One supplier, Allied Respiratory, was moved to issue a press release stating:
"DoH and NHS had discussed the transitional arrangements, and it had always been anticipated that a gradual change would take place, phasing the transfer of existing cylinder patients from their current suppliers"—
namely pharmacies—"to the new suppliers", but that did not happen. Instead supply from the existing network ceased abruptly, leaving patients with no choice other than to pursue the new suppliers for their oxygen from 1 Feb 2006. As I have said, that situation involved some 30,000 people.
It seems clear that the much quoted "phased transfer" was supposed to occur before 1 February and that the scheme was badly managed by the NHS. The original intention was to pass regulations to prevent doctors from using prescription forms after 1 February, which would effectively have curtailed supply from community pharmacies. We have to be hugely thankful for yet another piece of Department of Health mismanagement, which meant that those regulations were never actually passed. That effectively threw the Government a lifeline, because GPs continued to prescribe as they always have done and pharmacists continued to supply and bail out the failing service. Despite the fact that many pharmacies had run down their stocks of oxygen, they rose to the occasion, and many were happy to do so, because they did not want to let down the many patients with whom they had formed close relationships.
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That action serves to underscore the importance, resilience and flexibility of the pharmacy network and its commitment to patient care, but the Government clearly fail to appreciate that point. A letter to me from Lord Warner dated 27 April 2005 stated:
"As you will appreciate more is required of the service providers under the new service contract than the delivery and collection of oxygen cylinders".
That statement displays a complete lack of understanding of the role of pharmacists, who, when they delivered oxygen, were on hand to advise on and monitor use. Furthermore, they would often deliver medicines and advise on their usage at the same visit. In fact, that arrangement provided a fully integrated medicines management approach delivered into the heart of the community and reaching some of those in society with the poorest health, which is just the sort of thing that the Government claim they want to see much more of in their latest White Paper.
What of the future? Local arrangements are being implemented to sort out the problem in the short term. I pay tribute to the local practitioner committee in Hampshire and Isle of the Wight, which has been proactive and negotiated arrangements with the primary care trust to ensure that patients receive supplies and that pharmacists are not left out of pocket for helping out.
We must ask ourselves whether it is right to keep the service in the hands of three large suppliers—the number has decreased from four to three because of a takeover—which are likely to struggle with the peaks and troughs of demand. In the past, if a local pharmacist could not supply oxygen, there was usually one not very far away who could step into the breach very quickly. In an emergency, most pharmacists were keen to supply within an hour. The current target is four hours, which is too long for some people to wait for oxygen, and it has been missed in the first month of the introduction of the new contract. There have been reports of people having to wait until the next day for what has been deemed an emergency supply of oxygen. That never happened with pharmacies, because of their individual professional responsibility and commitment to patient care.
On Tuesday, I was disappointed when the Minister of State, Department of Health, the right hon. Member for Liverpool, Wavertree seemed to suggest that because only half of the pharmacy network supplied oxygen, the system was not good enough. In reality, in any local neighbourhood, everybody knew where the oxygen was and worked together to ensure that the patients received a decent supply. Again, there has been a lack of understanding about the system's flexibility and the way in which it worked on the ground.
The Government say much about patient choice and it is a shame that that commitment did not extend to oxygen supply. I therefore read with some interest in Chemist and Druggist about their new campaign for choice in oxygen, which pharmacy trade bodies, multiple wholesalers and individual contractors back. I do not believe that they have got around to asking patients yet, but my feedback and postbag lead me to believe that they would also support it. The National Pharmaceutical Association suggested that the service could be reintroduced as a beefed-up, enhanced service. I hope that the Government will consider that proposal.
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When the Under-Secretary responds, I hope that he will be open and candid about the faults and problems that have arisen. Warm words about those who have bailed out the system are not enough. Patients and their relatives have experienced stress, and deaths have been attributed to the failure of the service during the handover. Only an apology will be sufficient.
2.45 pm
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