Homecare medicines services: an opportunity lost Contents

Chapter 7: Who is responsible?

Political ownership

104.Pharmacy-related issues such as prescription delays, electronic prescription and pharmacy management are crucial in the performance of homecare medicines services. The Minister responsible for homecare medicines services is the Minister of State for Health and Secondary Care.184 However, pharmacy services are within a separate portfolio, that of the Minister for Primary Care and Public Health.185 The Minister of State for Health and Secondary Care, Will Quince MP, did not think that the separation of portfolios in this area was “in any way an impediment to what we do.”186 He stressed that all Ministers spoke daily, referring to an open plan office within the Department of Health and Social Care. While we acknowledge that ministerial portfolios often overlap, we note that the separation of homecare services from pharmacy services could create confusion in accountability. As we outline in this chapter, this is in the context of an already difficult environment.

Accountability and oversight

105.Sciensus, the biggest provider in the sector, described the current system of accountability as “very complex”.187

106.The National Homecare Medicines Committee has no “formal responsibility or accountability for homecare provision across the entirety of the NHS.”188

107.The trust Chief Pharmacist is responsible for the quality of services provided to patients. However, when we asked David Webb who, as Chief Pharmaceutical Officer is the professional lead for pharmacists and pharmacy technicians, what levers Chief Pharmacists had to discharge their responsibilities, should issues continue, he told us that these were “limited”. He acknowledged that the “ultimate sanction” was moving provider but this was limited by the availability of other providers, was a “significant amount of effort” and could introduce new risks for patients.189

108.Chief Pharmacists are responsible for homecare services in their area but in most cases they do not have the powers or levers to fulfil that responsibility.

109.Chief Pharmacists must have the powers and resources to ensure high quality homecare medicines services in their area. This should include powers and responsibility to develop and support alternative ‘back up’ provision to deliver homecare medicines services, such as through local pharmacies. This would both empower trusts in their market position, and create a more resilient homecare system.

Patient recourse

110.We heard that patients do not always understand who to contact with complaints, nor how to access recourse. Ruth Wakeman, representing Crohn’s & Colitis UK, told us: “patients are in the dark about who is actually responsible”.190 Richard Bateman accepted that a lack of clarity “must look very frustrating from a patient point of view.”191

111.The Royal Pharmaceutical Society has published guidance on complaints in homecare services192 but, as noted in Chapter 2, some patients have experienced difficulty accessing the complaints services of homecare providers or knowing to whom to complain. The CQC explained that poor complaints systems are “a theme across these services”.193 The British Society for Rheumatology agreed that there was a “significant oversight in the design and suitability of patient complaint systems”. It argued that this contributes to a lack of awareness from the regulators. It stated that if one patient makes multiple complaints, this will be captured as only one complaint.194 The British Association of Dermatologists states that: “There is often no complaints procedure”.195

112.The Parliamentary and Health Service Ombudsman reported to us a case of a patient who had suffered the effects of “failings in care and poor service continued over several years.” The patient, ‘Mr K’, had not been advised of how to escalate his complaint to an appropriate regulator until June 2020, “despite him asking on several occasions over the 2017 to 2018 period.” The Ombudsman found that “failings in signposting meant that Mr K could not have his concerns and complaint addressed sooner.”196

113.Difficulties in accessing complaints systems are particularly concerning given the perspective of the CQC. When asked how patients would identify the relevant regulator to contact, Sarah Billington said this would be “via the provider”,197 but she then said: “From the patient’s perspective, they are patients of the acute trust. They are patients of the hospital.”198 As was suggested by Phil White, former Chair of the Welsh Homecare Medicines Committee, these responses demonstrate a lack of clarity about whom enforcement action should be raised against..”199

A responsible person

114.Richard Bateman, member of the Royal Pharmaceutical Society Hospital Expert Advisory Group, reported that, since regional Chief Pharmacists are responsible, there are “multiple local conversations trying to deal with the same issues.”200 He argued that raising issues on a regional level prevented teams “linking in with people at a level who can make systemic changes.”201 Asked about this, Claire Foreman, Director of Medicines Policy and Strategy at NHS England, emphasised the importance of local management and empowering local areas. She stated that “it is really important that the contract performance is managed at the contract level”.202 This relates to management of individual arrangements rather than providing a point of contact and accountability for the sector as a whole.

115.Alison Davis, Chair of the National Clinical Homecare Association, the trade body for providers, saw a need for “strategic oversight at a much more senior level … nobody is accountable.”203 Sarah Billington, representing the CQC, could not “name a particular person in NHS England” responsible for homecare services.204 Richard Bateman called for “better accountability right the way through, from the homecare providers, through the trusts and to senior levels in the NHS.”205 He thought: “there needs to be a clear route to escalate issues to a higher national level. I believe this should be a senior, named person within NHS England”.206 The Cystic Fibrosis Trust felt that “without a single entity having a full oversight of the sector, bringing effective solutions will be a challenging task.”207

116.The Chief Pharmaceutical Officer would be “very interested in exploring” who would take the lead in changes to homecare systems and who would take responsibility.208 The Chief Pharmaceutical Officer is one potential option—as the professional lead for pharmacists, the post holder is senior enough to drive systems change and is at the heart of NHS England. The Secretary of State for Health and Social Care, or a minister in that department, could take the political ownership of the system.

117.The Minister for Health and Secondary Care, Will Quince MP, stated: “Ultimately, we are responsible in every way. However, the delivery of the service is wholly the responsibility of NHS England, devolved to individual trusts.209” However, without levers to discharge their responsibility for homecare, it is difficult to see how staff in individual trusts can be accountable on this issue.

118.NHS England should designate a senior, named person with responsibility for the homecare system. That person should be given sufficient powers and resources to discharge that responsibility. Responsibilities should include:

(a)Setting clear national KPIs for organisations commissioning and providing homecare medicines services to use.

(b)Collecting data on those KPIs, and publishing data on those KPIs in a way which supports public scrutiny of the homecare medicines system.

(c)Holding relevant bodies such as individual providers, Chief Pharmacists, the National Medical Homecare Committee and pharmacy teams to account for work on homecare medicines services.,

(d)Responsibly using new powers to issue appropriate penalties to under-performing providers.

(e)Ensuring trusts or hubs procuring homecare medicines services have access to sufficient financial and expert procurement advice and information, including template legal agreement frameworks, so they are able to effectively deliver value for money services and influence the homecare medicines services market.

(f)Achieving value for money and increasing transparency on homecare funding.

184 Written Answer HL9201, Session 2022–23

186 Q 56 (Will Quince MP)

187 Written evidence from Sciensus Pharma Services (HMS0006)

188 Q 39 (Joe Bassett)

189 Q 54 David Webb

190 Q 3 (Ruth Wakeman)

191 Q 18 (Richard Bateman)

192 Royal Pharmaceutical Society, Homecare Standards, Appendix 19: https://www.rpharms.com/recognition/setting-professional-standards/homecare-services-professional-standards [accessed 26 October 2023]

193 Q 30 (Sarah Billington)

194 Supplementary written evidence from British Society for Rheumatology (HMS0010)

195 Written evidence from British Association of Dermatologists (HMS0002)

196 Written evidence from Parliamentary and Health Service Ombudsman (HMS0007)

197 Q 24 (Sarah Billington)

198 Ibid.

199 Written evidence from Phil White (HMS0016)

200 Q 18 (Richard Bateman)

201 Q 21 (Richard Bateman)

202 Q 39 (Claire Foreman)

203 Q 20 (Alison Davis)

204 Q 33 (Sarah Billington)

205 Q 21 (Richard Bateman)

206 Supplementary written evidence from Royal Pharmaceutical Society (HMS0013)

207 Written evidence from Sciensus Pharma Services (HMS0006)

208 Q 47 (David Webb)

209 Q 51 (Will Quince)

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