House of Lords Public Services Committee report: Homecare medicines services

Eve Collyer Merritt

1. What are homecare medicines services?

Homecare medicines services deliver medication that has been prescribed in a hospital directly to patients at their home or other nominated address. In some cases, the service can also include a healthcare professional visiting to administer the medication or teach the patient how to do it themselves. Homecare services may also deliver other medical items or equipment, like dressings or needles.^[2]

Homecare services mean that people can receive treatment at home rather than at hospitals. Homecare medicines services are mainly provided by private, for-profit companies to NHS patients.^[3]

The committee report stated that around half a million people in England with chronic conditions use homecare medicines services.

There are two main models for the funding of homecare for NHS patients: NHS-funded homecare and manufacturer-funded homecare.^[4]

NHS-funded homecare: an NHS trust directly contracts a homecare service provider. This accounts for around 20% of the market.
Manufacturer-funded homecare: an NHS trust pays a pharmaceutical company for a medicine and its delivery to patients. The pharmaceutical company contracts a homecare service to deliver the medicine. There is usually a service level agreement between the NHS trust and the provider, but no direct contract. This accounts for 80% of the market.

2. What did the committee report say?

The committee acknowledged that homecare medicines could “replace some care that is currently supplied in hospital, provide improved care for patients and consequently ease pressures on the NHS”, but highlighted “serious problems with the provision and governance of these services”.^[5]

The inquiry was launched because patient groups had reported problems with homecare services, particularly delays in receiving treatment as well as medication errors.^[6] The committee found that delays caused distress, missed work and deterioration of health conditions, as well as increased pressures on the NHS. This reflected evidence from the Care Quality Commission (CQC) which found mis-deliveries and delays in its inspections of homecare services. It concluded that some patients had suffered “avoidable harm”.^[7]

The committee’s chair, Baroness Morris, summarised the report’s findings:

The system has grown into a fractured and complex mess, with no one named individual or body having overall responsibility for defining and ensuring performance across the sector. It is not even possible, at the moment, to assess performance: no one is publishing any data.
The regulators in this sector are weak. We saw a hands-off approach where no one regulator wanted to look too hard at performance, and no one is in charge.
Accountability in the provision of homecare medicines services is key and someone must get to grips with the entire system and have responsibility for getting things right. Our report calls for this as a means to begin the implementation of much-needed improvement across the sector.
More long-term, we have called for a full-scale independent review to find answers to the more embedded structural problems within the system like procurement, competition and enforcement powers and resources. We are clear that this review must not be allowed to delay the many changes that can be made much more quickly.^[8]

The committee called for:^[9]

a named individual to lead and take responsibility for homecare medicines services
the NHS to identify how many patients have become unwell or have been harmed because of a failure in homecare services, and to publish the data
a consistent set of performance metrics
the secretary of state for health and social care to review the regulatory regime for homecare medicines services and identify a lead regulator to take action against under-performing providers
the secretary of state to instruct the CQC to conduct a thematic review of homecare medicines services
clarification from the government of how much public money is spent on homecare medicines services

The report also includes recommendations on electronic prescriptions for homecare providers, procurement systems, and giving chief pharmacists responsibility and resources to oversee the quality of homecare services in their areas.^[10]

The committee also noted that progress had been made since the launch of the inquiry, with an NHS England review underway and a commitment to publish performance data. The committee recommended that the Department of Health and Social Care, by December 2023, make a ministerial statement on the findings and proposed actions for NHS England’s review, with a further statement on progress provided by March 2024.^[11]

3. What was the government’s response?

The government said that the report made “a strong case for improvements in homecare medicines services”. It committed to delivering improvements.^[12]

The government said that NHS England has been undertaking a ‘desktop exercise’, a process of information-gathering, to identify possible improvements to homecare services, including their procurement. The government said that the next step would be to analyse this information alongside the committee report to inform a future programme of work. It said that it is not possible to confirm the timeline or programme of work until NHS England has completed its initial analysis. An update is intended for summer 2024.

The government also said that it will update the committee in summer 2024 on whether data can be provided on patient harms.^[13]

On regulation, the government said that it needed to “do more work before committing to making any changes to the regulatory regime or considering a thematic review”.^[14]

The government accepted the committee’s recommendation to develop and implement a consistent set of performance metrics. It said that the National Homecare Medicines Committee will work with homecare providers to gather data.^[15] It said that a review of existing key performance indicators was underway before the committee’s inquiry commenced, and the new measures would be rolled out in January 2024, with full reporting expected by autumn 2024.

The government accepted the recommendation of providing clarification on how much public money is spent on homecare medicines services.^[16] It cited a figure of £3bn for December 2022 to November 2023 for NHS England’s direct spend on homecare medicines only. Information on services provided through manufacturers and NHS non-medicines spend was not provided due to commercial sensitivity.

The committee’s recommendation on electronic prescribing was also accepted. The government said that NHS England is working with the National Homecare Medicines Committee Digital Sub-Group to support electronic prescribing.^[17]

The government did not fully agree with the recommendation for chief pharmacists to have power and resources in relation to homecare services. The government stated:

The role and responsibilities of a trust chief pharmacist are delivered within the framework of governance set and enabled by their trust board. Executives of NHS trusts and foundation trusts, including chief pharmacists, are accountable to their boards for the performance of the functions for which their organisation is responsible.[…]
Many chief pharmacists and their host trusts will secure investment into procurement and contract management teams to ensure delivery of services and to meet the standards required. The development of business continuity plans should be a part of this internal trust process and may require cross organisation or region level working to mitigate short term, planned and unplanned, service outages.

The government accepted the recommendation that there should be a senior named person with responsibility for homecare medicines services. It said the role, responsibilities and accountabilities would be agreed and confirmed as part of the ongoing desktop review by NHS England.^[18]

4. What has happened following the government’s response?

Following the government’s response, the committee wrote to the secretary of state for health and social care, Victoria Atkins, asking further questions, including:^[19]

How much money is spent on homecare medicines services, and why this is currently described as ‘commercially sensitive’?
What consultation exercises are to be conducted with patient groups and clinical groups to ensure that their needs are addressed?
What the timelines are for the NHS’s desktop review?
How will the person accountable for homecare will be supported to carry out their responsibilities?

The committee asked for clarification on the collection of performance data, including whether or not the data collected contains information on the harm suffered by patients.^[20]

At time of writing the government had not yet responded.

The committee also wrote to the National Audit Office (NAO) requesting that it assess the value for money of homecare schemes.^[21] As a result, the NAO met with Department of Health and Social Care and NHS England to have an initial discussion about the NAO’s role in improving understanding about the cost of homecare medicines services.^[22] The NAO committed to write to the committee with information on:

what is known about the cost of the services
the limitations in determining the costs, including any restrictions about commercial confidentiality
details of how the government gets assurance that funding is spent appropriately

Patient organisations have also addressed the government’s response. In a joint statement, eight patient groups praised the government for accepting recommendations, including the commitments to improve data and to appoint a named individual to lead and take responsibility for homecare medicines services.^[23] However, the organisations said they were disappointed the government did not accept the recommendation to conduct a full-scale review, and urged greater urgency in tackling issues.

Crohn’s and Colitis UK highlighted the joint letter to its members, and added:

We know that many of you have struggled with homecare medicine services. From delayed and cancelled medicine deliveries, to medicines that arrive without a nurse, or hours spent on the phone trying to get an answer. These are just some of the issues that you have told us about.
We are disappointed that the government has not acknowledged the harm and distress that homecare services have caused some of you. Throughout our year-long campaign on this issue, the levels of despair, frustration and helplessness amongst patients and clinicians has become plain. The role of homecare medicines services is to make life easier, not harder for those who are reliant upon them, and the Lord’s inquiry has shown that is currently not the case.^[24]