Private companies took over supplying oxygen cylinders to homes
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The Welsh NHS has been criticised for its lack of preparation for changes to how home oxygen services are provided.
A report for the auditor general for Wales said the cost of supplying home oxygen via a private company was underestimated by £4m.
The timescale for starting the new service was tight and the company given the contract for supplying the oxygen was unable to cope with demand.
The assembly government said patients were now happy with the service.
Specialised oxygen equipment at home is often used by people with long-term respiratory conditions such as cystic fibrosis and emphysema, as well as patients with heart, pulmonary and cancer problems.
Without it they would effectively be forced to live in hospital.
Previously, patients needed a prescription for every oxygen cylinder, which was then supplied by the local pharmacy.
In 2006, private companies took over the supply of oxygen cylinders in England and Wales. But the poor implementation left patients struggling to obtain their cylinders.
A report by auditor general Jeremy Colman said the intended benefits of the oxygen changes had still not been fully realised.
The cost to local health boards for the supply of home oxygen under the new contract, which was awarded to Air Products Plc, is about £6m a year - higher than the original estimate of £2m, the report said.
It said the figure was based on inadequate information provided by the NHS on likely demand for the service.
The report found that the timescale for preparations for the new contract did not provide any contingency in the event of problems.
It also said patients were not made fully aware of the new service until late in the changeover.
'Chaos'
Mr Colman said: "The change in the arrangements for home oxygen services was not well managed and the reasons why those arrangements failed were foreseeable.
"It is disappointing that some of the intended benefits to patients have yet to emerge.
"It is even more disappointing that previous lessons around contingency planning, risk management and communication with those affected or responsible for delivering change were not applied in this case."
Among the recommendations made in the report was that the assembly government should now oversee better communications by health boards when announcing changes to services.
Phillip Parry, chairman of Community Pharmacy Wales, which opposed the changes, said: "The whole unnecessary incident was managed chaotically, and it was also extremely distressing for our patients."
A Welsh Assembly Government spokesman pointed out that the report said it had responded swiftly to the initial problems.
But he said: "We acknowledge that the transition was not as straightforward as we would have wished. These difficulties were not unique to Wales - England experienced the same problems.
"A fully-integrated service is now being delivered and surveys show that patients are very satisfied."
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