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Homecare medicines services: an opportunity lost Contents

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Homecare medicines services: An opportunity lost

Chapter 1: Introduction

What are homecare medicines services?

1.Homecare medicines services (referred to as homecare in this report) deliver medicines and assist patients to administer them in their homes, rather than in hospitals. They are specialised medical services—drugs may need to be delivered at a certain temperature or they may be difficult to administer. Homecare staff sometimes attend patients’ homes to administer medicines, to teach patients how to administer to themselves or to remove ancillary items such as sharps bins.

Figure 1: Homecare from hospital to patient

2.Homecare can be suitable for a wide range of conditions and treatments, so there are many considerations when determining whether a patient is suitable to receive homecare. In most cases, patients will discuss with their clinician whether homecare would be helpful. Once the decision to proceed with homecare is made, the NHS will pass the patient’s prescriptions to a private homecare company (a ‘provider’). The provider will then arrange to deliver the medicines and any associated care to the patient in their home.

3.We were told that homecare had “potential to transform the lives of patients”,1 and that it has great potential as a way to alleviate pressure on hospitals.2 When it works, it was described as “fantastic for patients”.3 Dr Christian Selinger, a Consultant Gastroenterologist and Chair of the Inflammatory Bowel Disease section of the British Society for Gastroenterology, told us that homecare “is a wonderful model for the patient because they do not have to spend as much time on it and they are much more independent. It also saves the environment because there is no travel and all that involved. When it works it works really well”.4

4.Despite this potential, key Government policy documents such as the NHS Long Term Plan and the NHS Long Term Workforce Plan make no reference to homecare.5 We have been unable to find any thorough explanation of how the system functions.

5.Homecare medicines services have significant potential to deliver high-quality care to patients in their homes and reduce pressure on hospitals. They should be a key part of future planning and resourcing for the NHS.

Models of delivery

6.Around 500,000 patients receive homecare services in England. There are around 2.85 million deliveries per year.6

7.Since 2011, the sector has grown by 150%.7 The number of active patients has grown 10% per year over the past 15 years. During the COVID-19 pandemic the use of homecare increased dramatically. In 2020 the number of active patients increased by 15%, and by 17% in 2021.8

8.Health is a devolved matter, so there are separate systems of homecare in Wales, Scotland and Northern Ireland. This report therefore primarily concerns homecare in England. Our inquiry has, however, taken note of a review underway in Scotland, which has a similar system and which has identified many of the same problems we have encountered in England.9 The report’s conclusions and recommendations may therefore be of interest to homecare services across the United Kingdom.

9.On the whole, homecare services are delivered by a private provider. There are, broadly, three models of delivery:

(a)NHS-funded homecare is where an NHS trust contracts directly with a private homecare provider to deliver services to their patients. The NHS trust pays for the medicine and the homecare service. This model accounts for around 20% of the homecare market.

Figure 2: NHS-funded homecare

(b)Manufacturer-funded homecare (sometimes called ‘pharma-funded homecare’) is where an NHS trust purchases a drug from a drug manufacturer. That manufacturer may offer, or be asked to offer, a homecare service. The manufacturer will then, separate from the NHS, contract with a third-party homecare provider to deliver the service to the patient. The NHS pays the drug manufacturer for the medicine, the cost of the homecare service is included. The manufacturer then pays the homecare provider separately. This means that the NHS has no direct contractual relationship with the homecare provider treating the patient, although there is usually a service level agreement between the NHS trust and the provider. This model represents around 80% of the market.

Figure 3: Manufacturer-funded homecare arrangements

(c)Private health companies can provide homecare to their patients. This constitutes a small percentage of overall services and does not draw on public funds or the NHS. We therefore do not focus on this model.

10.Those in leadership roles in the homecare sector unanimously acknowledged that the system is complex. The Minister for Health and Secondary Care, Will Quince MP, stated: “It is certainly complicated. That is an understatement.”10 David Webb, the Chief Pharmaceutical Officer for England, told us that our inquiry had unearthed a “complicated picture that is quite hard to understand even when you are working in the area.”11 Joe Bassett, the Chair of the National Homecare Medicines Committee (see table 1), said “even from the inside there are multiple cogs moving around.”12 Dr Rick Greville, a Director at the Association of the British Pharmaceutical Industry, the trade body for drug manufacturers, referred to “the complexity, governance and due diligence required of multiple individual and organisational stakeholders to establish, let alone deliver effective and efficient homecare services.”13

11.Other witnesses stated that the “excessive level of complexity” made the system difficult for patients to navigate.14

12.The homecare sector is highly complex, to the extent that even people working at senior levels find it difficult to understand. This is entirely unacceptable and indicates an urgent need for review and simplification.

Other work

2011 Hackett review

13.An independent review of homecare medicine supply commissioned by the then Department of Health was published in 2011. This report, Homecare Medicines: Towards a Vision for the Future, identified several value-for-money issues and made recommendations on improved governance arrangements for the delivery of homecare services.15 Several of these, for example the recommendation that the trust Chief Pharmacists should be the responsible officer for services, and the call for a set of professional standards to be developed, have been implemented. The Government’s policy paper following the review primarily focused on how providers and commissioners could “work together to achieve significant savings”.16

NHS England research

14.We heard from NHS witnesses that “work is currently under way … to better understand all the issues currently impacting on homecare”.17 There are two phases to this.

(1)The first stage to “fully inform [the NHS’] understanding of the issues impacting homecare medicines” involves “a desktop exercise” and conversations with stakeholders. NHS England “expect this stage to complete by the autumn”.

(2)The second stage is “consideration of what potential actions are needed”, including who should take actions forward, how and “the resource implications.” NSH England stated that until the first stage was completed: “it is not possible to confirm the timeline or what the product of the work will be.” The Minister for Health and Secondary Care, Will Quince MP, was similarly unable to give a hard timeline for this work,18 stating “it will not take very long”.19

15.This work falls short of the “full scale national review” called for by organisations such as the British Society of Rheumatology20 and is narrower in scope than a review taking place in Scotland, which is due to finish in December 2023.21 The Minister stated that, there were things that “without needing to see the paper-based exercise, I know we need to get on with and do. Nevertheless, a lot more has been brought up. You can jump at these things, but it is more important to take a little bit of time to get it right”.22

16.While we welcome the current work on homecare medicines services, we are concerned that it is vague, lacks specific commitments, and has no clear leadership. Serious problems in homecare have been apparent for over a decade. It is now time for urgent action. Consideration of resource implications must acknowledge future savings resulting from increased efficiency and value for money in a reformed system.

17.The Department of Health and Social Care should, by December 2023, make a ministerial statement on the findings and proposed actions for NHS England’s work on homecare. A further statement should be provided by March 2024 on progress on these actions.

Governance bodies

18.We took evidence from and about several relevant organisations in the sector, including governance bodies. For clarity, we have identified them in the table below.

Table 1: Relevant bodies within homecare

Name of body	Role
Oversight and regulatory bodies
National Homecare Medicines Committee (NHMC)	The National Homecare Medicines Committee acts as “the national focus for developing and improving administration and governance processes for medicine homecare services”.23 It includes representation from NHS England, homecare providers, pharmaceutical manufacturing associations and the Care Quality Commission.
Care Quality Commission (CQC)	The Care Quality Commission, a public body, is the independent regulator of health and social care in England. It monitors, inspects and regulates services performing regulated activities under the Health and Social Care Act 2008.
Medicines and Healthcare products Regulatory Agency (MHRA)	The Medicines and Healthcare products Regulatory Agency regulates medicines, medical devices and blood components in the United Kingdom.
General Pharmaceutical Council (GPhC)	The General Pharmaceutical Council is the independent regulator for pharmacists, pharmacy technicians and pharmacy premises in the United Kingdom.
Other
Association of the British Pharmaceutical Industry (ABPI)	The Association of the British Pharmaceutical Industry is a trade body for drug manufacturers.
Commercial Medicines Unit (CMU)	The Commercial Medicines Unit is an NHS England team which works on behalf of the Department of Health and Social Care and the NHS to support those who buy pharmaceuticals for hospitals across the NHS in England.24
Marketing Authorisation Holders (MAHs)	Individuals or companies who hold legal authorisation to sell pharmaceuticals. In homecare services, they are generally drug manufacturers who contract with homecare providers to provide a service.
National Clinical Homecare Association (NCHA)	The National Clinical Homecare Association is the trade body for homecare providers.
Regional Procurement Hubs	Regional NHS centres of procurement expertise which can assist hospital trusts to establish or manage homecare contracts.
Royal Pharmaceutical Society (RPS)	The Royal Pharmaceutical Society is the professional membership body for pharmacists and pharmacy students.

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