Summary of conclusions and recommendations
What are homecare medicines services?
1.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. (Paragraph 5)
2.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. (Paragraph 12)
3.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. (Paragraph 16)
4.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. (Paragraph 17)
The problem
5.Delays in providing homecare services can negatively impact on patients physical and mental health. For some, impacts can be serious safety issues and include patients being admitted to hospital or requiring surgery.(Paragraph 32)
6.In some cases the failure of provision of homecare medicines is so severe, or so predictable, that NHS services are compelled to use their resources for services which should be delivered by homecare providers. The NHS can pay twice—once for the homecare provider and, when that fails, to provide the service themselves. (Paragraph 33)
Transparency
7.There is an irreconcilable gulf between the views of clinicians and service users, and that of the leadership and governance bodies in the homecare sector on how well it is performing. While this is a complicated system with multiple variables, we are persuaded by the weight of evidence from service users that there are real and serious problems in the sector. (Paragraph 39)
8.No one—not the Government, not NHS England, not patient groups, not regulators, knows how often, nor how seriously patients suffer harm from service failures in homecare. This indicates a significant failure of oversight and hinders the ability of NHS England to ensure patient safety. (Paragraph 44)
9.NHS England must identify how many patients have become unwell or have been harmed because of a failure in homecare services. They should ensure that this information is published and shared with relevant parties. It should also form part of the ministerial statements we have requested by December 2023 and March 2024. (Paragraph 45)
10.Different sets of performance data are available to manufacturers and the NHS. This creates confusion and prevents effective monitoring. (Paragraph 52)
11.NHS England must develop and implement one consistent set of performance metrics. (Paragraph 53)
12.Publication of performance data and greater inclusion of patient perspectives in that data are welcome. However, there is a risk that the performance data could be published in such a diluted form that it becomes meaningless. How frequently the data is published, how detailed it is and whether the data is validated will matter hugely. (Paragraph 57)
13.The Chief Pharmaceutical Officer for England should ensure that the KPI data is published in a consistent, standardised form which is sufficiently specific and regular to ensure meaningful public scrutiny. (Paragraph 58)
Purchasing
14.The Government does not know how much money is spent on homecare medicines services. It is therefore impossible to make any assessment on value for money. Given that the figure is most likely several billion pounds per year, this lack of awareness is shocking and entirely unacceptable. (Paragraph 60)
15.The Government must clarify exactly how much public money is spent on homecare medicines services. (Paragraph 61)
16.Though there is substantial variation, in many cases, those procuring and recommending homecare services appear ill-equipped to do so. In some cases, expertise is missing; in others, there is insufficient information. Given this, and the clear commercial incentives for manufacturers to choose cheap provision, there can be no reliable assurance that a provider is suitable before agreements are made. (Paragraph 73)
17.Given the substantial public cost of homecare medicines, improving procurement processes should be an urgent priority. In their current form, neither the National Homecare Medicines Committee nor regional procurement hubs are equipped to lead the change required. (Paragraph 74)
18.The review must outline necessary steps towards establishing a central resource of experienced procurement professionals to assist in establishing homecare medicines services. This must be available to all those establishing agreements, whether they are manufacturer- or NHS-funded. (Paragraph 75)
Regulators
19.The regulatory model for homecare is failing to ensure the safety and quality of patient care. The regulators appear to have a limited understanding of the sector and there appears to be no appetite to find more information. Enforcement action taken against providers, even where avoidable harm has taken place, is feeble. There appears to be no appetite to issue penalties against non-compliant homecare providers. Poor performance can go unchecked. We note the discrepancy between the approach the CQC takes towards small residential homes and that taken towards homecare medicines providers. (Paragraph 84)
20.The Secretary of State should review the regulatory regime for homecare medicines services, considering in particular the lack of enforcement action taken by the CQC against homecare providers where avoidable harm has occurred. The review should identify a lead regulator with the skill and the breadth necessary to take necessary action against providers which are under-performing. These urgent actions should also be reflected in the longer-term review of healthcare regulation. (Paragraph 85)
21.The Secretary of State for Health and Social Care should instruct the CQC to conduct a thematic review of homecare medicines services. (Paragraph 86)
State of the market
22.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. (Paragraph 91)
23.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. (Paragraph 92)
24.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. (Paragraph 98)
25.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. (Paragraph 103)
Who is responsible?
26.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. (Paragraph 108)
27.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. (Paragraph 109)
28.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. (Paragraph 118)
Next steps
29.Following the interim findings of the NHS England review, and by no later than April 2024, the Government should establish and fund an independent review into the homecare system. This review must not delay the enactment of those measures which we, and others, have identified. The review should consider:
(a)The potential role of homecare as a pillar of the future health service;
(b)The extent and impact of existing problems on patients and the NHS;
(c)A radical new approach to transparency and information sharing;
(d)Support and resources required for effective procurement;
(e)Steps to develop a tougher and more proactive regulatory approach;
(f)Steps to encourage a competitive and fair market for providers;
(g)Digital infrastructure to support effective delivery; and
(h)Robust governance and accountability arrangements, including ministerial oversight. (Paragraph 121)