Chapter 6: State of the market
87.There are a small number of homecare providers on the market. In June 2023, 26 were registered with the General Pharmaceutical Council.156 They do not all provide all services.
88.Dr Christian Selinger believed: “there is no true competition between the companies.”157 The Scottish Government Pharmacy and Medicines Division on Homecare Medicines Services stated that barriers to entering the market and competition in it include:
“… requirements for a high degree of capital given the cost of the medicines concerned and incumbency advantages linked to the disruption and cost … involved in changing provider. Economies of scale are essential to the current homecare business model.”158
89.If, as Dr Selinger suggests, this is the case in England as in Scotland, it means that, if a homecare provider is unable to deliver services to a sufficient standard, there are sometimes few, if any, alternatives for the manufacturer or the NHS body.159
90.Joe Bassett, Chair of the National Homecare Medicines Committee, argued that “ a large volume of homecare providers … are in the market and able to provide services”. He acknowledged that some providers cover a large number of patients and the manufacturer-funded services represent a “disproportionate spread … there is a tendency for those services towards specific providers and larger providers.”160 We were told that there is geographic variation in service levels offered by homecare providers, further limiting trusts’ options and reducing competition.161
91.There is a clear perception of a lack of robust competition in the homecare medicines market, in part caused by geographic variation of service levels, barriers to entering the market and poor procurement practices.
92.As part of a review of homecare medicines services, the Government should work with procurement specialists, the National Audit Office, and the Competition and Markets Authority to identify barriers to competition and effective procurement in the homecare medicines market. They should agree actions to ensure procurement by the NHS or medicines manufacturers achieves value for money.
Systems interoperability
93.Witnesses told us of a lack of IT interoperability between homecare services. Providers have developed different systems, with no single NHS system for providers to interact with.162 Sciensus estimated that around 6,000 paper prescriptions are written in the UK every day on more than 1,000 different templates.163
94.This lack of interoperability and a reliance on paper-based systems were thought to challenge streamlined and efficient services to patients, both for the providers and for clinicians in hospitals.164 The British Society for Rheumatology wrote that it took “clinicians away from patients, and pharmacy professionals away from medicines optimisation and safety oversight.”165 This view was shared by Dr Anthony Isaacs, London North West Healthcare University Trust’s Clinical Lead for Rheumatology and Clinical Chair at North West London sector Rheumatology Clinical Research Group, who reported a high volume of time it takes medical staff to complete healthcare company registration and prescriptions paper forms: “time that could be spent instead on other aspects of patient care”.166 The British Society for Rheumatology noted that it prevented tracking of patient safety and outcomes.167
95.Against this backdrop, witnesses were clear that moves towards digital interoperability were “crucial”.168
96.The key request of witnesses was that these systems were designed in conjunction with homecare providers and NHS trusts. Sarah Campbell emphasised this, along with the need for “them to interoperate with NHS systems that are also currently in use.”169 There were indications that homecare providers were moving to electronic portals, but it was feared that this might “remain an inefficient process” in that portals will continue to be separate and non-integrated.170 Dr Christian Selinger explained:
“Having several different portals that you need to register with, having to train on how to use them and having to remember all the passwords is just going to slow the process down. If the industry could come to one standard that would work with the same IT system, that would be extremely helpful.”171
97.Similarly, Dr Anthony Isaacs called for a “single homecare portal for use by all the homecare companies that also integrates in some way with NHS hospital systems”.172 The British Society for Rheumatology thought that “this needs to come from the NHS centrally.”173
98.A single homecare portal should be created and provided by NHS England. If possible this should be linked with existing online services such as the NHS App.
Electronic prescribing
99.The Electronic Prescription Service is a national digital product described as the “’carrier’ of a prescription message in a secure way between individual prescribing and dispensing systems”.174 Electronic prescribing was said to “increase efficiency and reduce risk … [and] … create a single patient record accessible to any part of the health system”.175
100.Electronic Prescription Service in primary care settings is advanced—93% of GP practices use Electronic Prescription Service, with more than 67% of their prescriptions delivered in this way. The NHS Long Term Plan states: “all providers will be expected to implement electronic prescribing systems”.176 However, prescriptions which will be delivered by homecare medicines services providers are not sent from trusts to providers using Electronic Prescription Service—they are generally sent using the postal service.177 Alison Davis was sceptical, however, of how urgently this was being addressed within secondary care. She said “NHS Digital has been working on it for more years than I care to mention. We are not there yet.”178 Similarly, Dr Selinger was clear that secondary care and homecare provision had “not really caught up” and that until five years ago fax prescriptions were required—“years after electronic prescribing for hospital inpatients had become a reality.”179
101.The Chief Pharmaceutical Officer for England believed that secondary care would need to be able to use electronic prescription systems, and that there needed to be “emphasis on its importance so that in the priority of digital development it is sufficiently visible and resourced”.180
102.In January 2023, the Government stated that work to move homecare medicines services to an Electronic Prescription Service was at an “advanced stage in preparation for consultation with National Homecare Medicines Committee during 2023”.181 When asked what steps the Government is taking to improve interoperability of information management systems between the NHS and homecare providers, the Government pointed to an Information Standard Notice which largely focuses on consistency of syntax.182 Rahul Singal, Chief Pharmacy Information Offer for NHS England, stated that the notice sets “consistent terminology for what all medicines are across all systems and agree a common standard.”183 However, he acknowledged that getting NHS providers and private companies to adopt the standard presented “a broader challenge”, including in how far NHS trusts enforce the use of the standard.
103.More urgency is required in developing Electronic Prescription Systems for homecare providers to use. These must be developed in collaboration between homecare providers and NHS trusts.
158 Written evidence from the Scottish Government Pharmacy and Medicines Division on Homecare Medicines Services (HMS0008)
161 Written evidence from Scottish Government Pharmacy and Medicines Division on Homecare Medicines Services (HMS0008)
168 Q 20 (Alison Davis). See also supplementary written evidence from National Homecare Medicines Committee (HMS0014).
176 NHS, The NHS Long Term Plan (January 2019), paras 5.4 and 6.17: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf [accessed 11 October 2023]