Homecare Medicines Services (Public Services Committee Report)

Thursday 2nd May 2024 Lords Chamber

Motion to Take Note

16:14

Moved by

[Baroness Morris of Yardley]

That this House takes note of the Report from the Public Services Committee Homecare medicines services: an opportunity lost (4th Report, Session 2022–23, HL Paper 269).

[Baroness Morris of Yardley (Lab)]

My Lords, I am very pleased to introduce this debate on homecare medicines on behalf of the Public Services Committee. In opening, I thank all the witnesses who appeared before our committee for their time, expertise and co-operation with us. I thank the team who served us so well: Sam Kenny, Tom Burke, Claire Coast-Smith and Lara Orija. I personally thank all the committee members, who worked hard on this report and, I think, are pleased with it and determined to see it through.

I know that committee members will understand when I thank the noble Lord, Lord Blencathra, because without him, we would never have looked at this issue at all. I was aware of homecare medicines, I knew what an important service it is, but I had no idea of the challenges it was facing or how ineptly people were dealing with those challenges. We are grateful to him for that, but the problem that emerged was that we were not the only ones who did not know about the challenges: it seems that nobody running the service knew about the extent of the challenges either.

This is an important issue: it is a picture of how the NHS should be. It is a forward-looking service. It offers patients the opportunity to have medicines and treatments in their own home, to have choice and flexibility around their lives. It saves money for the NHS and patients, and it is something that needs to work, because it could be a vision of the future. It has increased in recent years. There are 500,000 prescriptions now, 2.8 million deliveries a year and, over the last 15 years, on average, a 10% increase in those using the service each year.

However, if you read our report, or you look at the evidence, there is one overriding conclusion that you are left with, and that is the difference of opinion between the different witnesses who appeared before us. What was frightening, almost scary, was that that difference was split into two clear groups: the clinicians and those who use the service, who talked about the many problems; and those who manage, run and regulate it, who did not seem to see any problems at all. How that lack of observation and communication has arisen must be something that the department sorts out before it can move forward.

Having said that, I feel it is a strange report. Of all the reports I have been involved with during my time in both Houses, I do not think I have ever seen an issue that I am more confident can be solved. We are not asking for more money; it is not politically contentious; it is not backward-looking, it is forward-looking; we just need somebody to grab hold of it, make the difference and make it work. This is not something that is an aspiration or something that has a 10-year forward look; this is something that can be done now. We can get it right and make life better for patients and for the NHS. In essence, homecare medicines is a market, and the hospital trusts, each trust individually, are the purchasers holding the money. They contract with two elements. One is the drug companies, the pharmaceutical companies; and the second is the homecare providers which deliver medicines and appliances to people’s homes.

What is perhaps unusual, but never mind, is that the contracts themselves are between a chief pharmaceutical officer in each trust and a large pharmaceutical company. Some 80% of the trusts have no contractual arrangements at all between themselves and the service provider, they just have a service level agreement. But that is not unusual; they are not the only part of the public sector that puts out a tender, monitors its performance, makes adjustments and gets on with it. However, if you look at what we know about the effective delivery of public services or private services, some elements have to be in place. You need information about what is going on. You need to agree performance indicators. You need to know how an organisation is performing against them. You need to know who is holding them accountable and you need to know who to go for when things go wrong. Not one of those things is in place in homecare medicine, and it is a service that is relatively small compared with many of the big public services that we run.

First, there is data, but—believe it or not—none of it is in the public domain; nor is it available to clinicians when they are advising patients on what to do. The National Homecare Medicines Committee, one of those which manage the service, collects 27 key performance indicators and passes them to the NHS, but they are never published or made available to anyone. Then there is a completely different set of KPIs between the pharmaceutical companies and the homecare companies which deliver the medicines on their behalf. There is no standard template across the country; every single one of those contracts can take a different shape. They are not published, the trusts and clinicians do not know what is in them, and they never know whether they have been achieved.

If that was not a big enough mess, on top of all of that—believe it or not—all the data is self-reported. That is not only a recipe for a service that does not work well but it means that no comparisons are possible when the NHS trust is spending money to place its contract. It has no information against which to judge either the performance of its present contractor or anyone else. Almost more important than that is that no information is therefore collected about how seriously patients suffer from service failure. No one in the NHS or anywhere else collects information about the impact on patients served by this poorly run service.

Secondly, there is no effective system of regulation. There are three regulators: the Care Quality Commission, the General Pharmaceutical Council and the Medicines and Healthcare products Regulatory Agency. They all inspect a different tiny part of the system; there is no one with overall responsibility. The problem is that this is not a high priority for any one of these regulators.

The Care Quality Commission does about three inspections a year. It does not collect complaints; there is no section in its books or charts for complaints received about homecare medicines. It has never chosen to do a thematic review and there is no evidence that we could find of a prosecution it has initiated. Whatever people who work at the CQC think about when they get up in the morning, it is not, “I wonder how homecare medicines is getting on”. When we asked those three regulators about the gaps in between the bits they inspect, they all said, “That’s fine, we don’t overlap—but there are no gaps in between”. That is not an effective system of regulation, and it helps nobody.

Thirdly, in a system such as that there would have to be infrastructure and support to go with it. Chief pharmaceutical officers in each NHS trust are busy people. They have a very demanding job, and the responsibility of sorting out the contracts with the big pharmaceutical organisations falls to those men and women. Everybody who came before has admitted that this requires specialist knowledge and that there is a huge amount of effort involved in managing the contracts and being aware of the impact on patients. The support and expertise that they would need to do that job is just not there.

Procurement hubs serving NHS trusts often have no homecare medicines specialists. Each provider has developed a different system, with no single NHS system for providers to interact with. On prescriptions, they have to re-read the evidence to make sure that somebody is not making it up. Some 6,000 paper prescriptions go into the system every day on more than 1,000 different templates—it is no wonder that nothing that comes out makes sense. It is beyond belief that in 2024, some of those prescriptions are still sent by post.

That is the environment in which we expect trusts and clinicians to make decisions about a key service, on which they are spending public money and on which clinicians need good-quality advice to advise their patients on the decisions they should take. They are not faced with any KPIs that they can monitor; they do not know how one provider performs against the other; they know that there is no effective regulatory system, that there is an inadequate infrastructure to support them, and that no one is holding the ring to keep it all together. At the end of the day, there is no one in overall charge for them to turn to for help and advice.

It is not surprising that this leads to a system that fails everyone it seeks to serve. First and foremost, it fails patients. There is no complaints system and nowhere for people to go if something goes wrong. The things that can go wrong go very wrong and are very serious: the medicines do not turn up; the wrong medicines turn up; the medicines turn up at the wrong time; the medicines turn up, but the person who was showing the patient how to inject them does not turn up; or the medicines are out of date. The catalogue of what happens in an NHS service that puts safety at the top of its priorities is frightening.

The impact for the patients is also serious: they miss medicines, become more ill and need to go back to hospital and have operations. Because no data is collected about how much harm is done, I cannot stand here with certainty and say that people lose their lives—no one can—but what we can say with certainty is that people do not recover as quickly, and they are given extra burdens to deal with because the system does not work as it should.

It also has an impact on each NHS trust. If you are not getting the service from the homecare provider—and if you have no one to complain to because the providers do not have good phone systems with somebody who picks up the phone at the end who knows you—you will go back to hospital. You will go back to the consultant who gave you the prescription or to A&E, and you will ask for help. That means that every hospital in this country, which have already paid taxpayers’ money at a time of reducing budgets to the provider to deliver the service, will have to pay again to remedy the defaults in the service.

If you talk to any of the groups representing clinicians or patients, they will tell you the horror stories of how much they have to do to mitigate the weaknesses in the system. Crohn’s & Colitis UK told us that 10% of specialist nurses spend one day a week on the consequences of an inadequately delivered homecare service. The British Society for Rheumatology told us of one clinic where a nurse spends a quarter of their time chasing after homecare services. In Leeds, people have set up their own infusion unit so they can teach the patients how to inject the drugs. They provide the drugs out of their budgets to start them off, because it takes eight weeks for the provider to get their act together.

The other losers are the NHS and the country, because it is money wasted. It is the case that the NHS, the department and Ministers do not know how much money is spent on homecare services. We had four different estimates, between £2.9 billion and £4.1 billion, and I am still sure that no one knows exactly what it is.

Yet I remain an optimist. All that can be solved; it is a tragedy, but it is solvable. Part of the anger or frustration is that it has not been grabbed hold of and solved already. We might get somewhere if we put a system in place that has comparable data, if we get the regulatory system sorted out, if we put in support for procurement, if we move more to electronic prescriptions and if we put a named person in overall control, who wakes up every morning knowing that their job is to make sure this works all right.

I say to the Minister that we have been very pleased with the support and response that we have had from his department; it has been helpful throughout. They have not spelled it out, but I think that both he and the Minister who is no longer in the department were surprised at the lack of awareness of this service and the state that it is in. That is why I am an optimist: I know that we await a further report in the summer.

However, there is a tendency in government to turn to the existing structure and people to create something that is better—which is what I have worried about most. There is a lack of trust between those who have been shouting for a long time that things are badly wrong and those who have not heard them and have not done anything about them. My request to the department and the Minister is not just to do all these things but, most of all, to consult those who have the best experience of what has gone wrong and the best ideas about what could be done to make it better.

I very much hope that our report helps not just the department and the NHS to get this better but all the clinicians and patients who have not been treated as well as they should and have not had the support that they should for many years. That is the goal, and I think that it is achievable. I promise that my committee is absolutely determined not to let this go, by whatever means we can. I have no doubt that we will be back at this again. I thank the Minister and the department for the support so far and offer our every help in their future work.

16:29

[Lord Blencathra (Con)]

My Lords, I am delighted to participate in this important debate, and I regret that it is tail-end Charlie today when the report deserves much greater prominence. The only credit I can take for this excellent report is that I suggested the topic. I pay tribute to our brilliant chair and her devastating summary today, and to colleagues on the committee and to the officials, who did all the probing and heavy lifting and concluded that this is a major opportunity lost.

My personal interest is that I get two different medicines for multiple sclerosis delivered to my home. The one which sparked this inquiry is called fampridine. Most people with MS cannot lift their feet and they drag on the floor; I can trip over a dead fly on the carpet. Fampridine enables us to lift our feet by as much as 5 millimetres—that is all—but it is the difference between walking and not walking at all. To me and others, that little fact makes it a miracle drug, and I was lucky enough to get in on the trials when they started. As an aside, NICE will no longer approve it for new patients, but all those of us in the trials can keep getting it. That is grossly unjust—like many other NICE decisions.

I had excellent service until 2017, when the delivery contract was allocated to a new company; it is named in the report and I will not name it again, but it began to fail abysmally in getting the deliveries to me before the last pills ran out. I complained on many occasions and it came to a head in July 2021, when I had no delivery and no pills for 10 days. I was unable to walk—or stagger, in my case—from where I park my Ferrari at the Bar of the House even to get to this Front Bench here.

I looked up the company in Companies House, found the names of the main directors, tracked down their addresses and sent them a stinking note with my full rank and titles and a draft of my letter to Sajid Javid, the then Secretary of State, calling for the company’s contract to be terminated. The net result was that, two days later, some poor chap was dispatched on a 500-mile round trip to deliver on a Saturday my fampridine to Penrith in Cumbria.

I looked further into this company and found that the Care Quality Commission—a thoroughly useless body if ever there was one—had just published a report in May 2021 showing that over 9,885 patients had also failed to get deliveries of their drugs, and some had to be hospitalised. The CQC report gave the company an overall rating of “inadequate”. On patient safety it rated it “inadequate”, and on “Are services well led?”, it rated it “inadequate”. Therefore, with all these negative ratings, what did the CQC do? It listed all the regulatory breaches and asked the company to kindly send it a report on how it would behave better in future. As Bob Geldof might have said, “Is that it?”

That is one reason why I say that the CQC is a useless regulator, which our report also suggests—or hints at, in very strong terms. By the way, a month after the scathing CQC report, the company changed its name and pretended to be a completely different supplier altogether.

I wrote to the Secretary of State calling for the contract to be removed, but that did not happen because he was not properly in charge of it and he was not sure quite who was. I now get Rolls-Royce service from this company because of who I am and because I created a big stink, but the other 9,884 victims, who have conditions far worse than mine, might not be so well served.

When I joined the Public Services Committee, colleagues were looking for a short-term inquiry to fill a gap as we looked at suggestions for a longer inquiry. I suggested investigating the delivery of medicines at home and supplied details of my own experience. I think that initially my colleagues thought that I was perhaps exaggerating the shambles I had described, but when our excellent clerk, Samantha Kenny, looked at it, she thought that it deserved a deeper look.

My colleagues thought that there may be a bit of a mess here, and then the evidence started to come in from various patient groups such as Crohn’s & Colitis UK, and the superb report from the British Society for Rheumatology which suggested that the system was a complete shambles and cited countless examples of failure to deliver medicines on time. I think colleagues then concluded that old Blencathra was not so barking after all.

We have called the report An Opportunity Lost and that is true, but we could easily have called it “A Complete Shambles”. Those are not just our words; 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”.

That is a nice way of saying “a complete shambles”.

The then Minister for Health and Secondary Care, Will Quince MP, stated:

“It is certainly complicated. That is an understatement”.


That is, again, a nice euphemism for “a complete shambles”. As the noble Baroness said, the NHS has not a clue how much it costs. The National Clinical Homecare Association told us that the Treasury spends £4.1 billion per annum on homecare medicines, but the NHS told us it is only £3.2 billion. We asked the Minister—he said it was £2.9 billion. As we say, it is utterly shocking that no one in the NHS can give us an accurate figure for the billions spent on home deliveries, but then the NHS does not have a clue about how bad it is and how many patients have suffered. KPIs are a mess, as the noble Baroness explained.

We said in our report:

“Different sets of performance data are available to manufacturers and the NHS. This creates confusion and prevents effective monitoring … NHS England must develop and implement one consistent set of performance metrics”.


Performance data must be published.

The National Clinical Homecare Association told us that

“98.8% of deliveries were delivered on the day they were intended to be delivered on”.

That is a very clever form of words but quite misleading. Yes, 98.8% were delivered on the dates that the delivery company decided they were to be delivered on, but those were not the dates the doctors prescribed, which were always much earlier and before the medication for patients ran out. Part of these failures are delays in the NHS prescribing system and delays by the delivery company.

Chapter after chapter of our report highlights the failings of the system. Thus we say:

“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”.


Let no one misconstrue our conclusions as an attack on the private provision in the NHS. While we found myriad flaws in the provision at all levels, God help us if the NHS tried to run a courier delivery service, since that would be infinitely worse. Delivering medicines at home by couriers is eminently sensible but has to be better managed at all levels. The problems that we identified all relate to the fact that there is not one single person or NHS body in charge. Different people and organisations negotiate different contracts. There is no quality control or negotiating competence, there are no consistent KPIs to measure performance and the various regulators are all fairly useless. It seems there is no one with the power to sanction failure or cancel contracts. Worst of all, I got the feeling that the NHS rather likes it this way because when things go wrong there is no one individual or organisation to blame. They can all carry on presiding over a shambles but carry no personal responsibility for it.

I get exceptionally good medical care from the National Hospital for Neurology in Queen Square, the Royal Marsden and the Lakes Medical Practice up in Penrith, but if you want to see the general bureaucratic incompetence of the NHS and why it is failing so badly in so many areas, the bureaucratic shambles that we are reporting on here is a perfect microcosm example.

However, in the report we did not just criticise but offered solutions. Theoretically, there is a Minister in charge, but he or she has no say in the running of the system, which is delegated to the NHS. The Minister should be charge and have a very senior person reporting to them. We say:

“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”.


That person’s responsibilities should include:

“Setting clear national KPIs for organisations commissioning and providing homecare medicines services … Collecting data on those KPIs, and publishing data on those KPIs in a way which supports public scrutiny of the homecare medicines system … 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 … Responsibly using new powers to issue appropriate penalties to under-performing providers”.


That is essential; there must be sanctions.

The fifth recommendation is:

“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”.


As in every government department I have served in and witnessed over 40 years in Parliament, the lawyers employed by the outside commercial contractors are infinitely better than government lawyers trying to negotiate contracts; they outwit and outmanoeuvre us every time.

Finally, we said that:

“Achieving value for money and increasing transparency on homecare funding”


should be another part of their individual duties.

As the noble Baroness said, the government response accepted about 90% of what we say—that is jolly good. On that basis, let us have urgent action to implement those proposals and the remaining 10% as well.

[Lord Evans of Rainow (Con)]

My Lords, I remind the House that there is an advisory speaking time of nine minutes.

16:40

[Lord Shipley (LD)]

My Lords, I was going to offer some of my time to the noble Lord, Lord Blencathra, because his contribution was so very important. It was a pleasure to listen to what he said because he has personal experience of the service, and I pay tribute to him for pointing the committee in the direction of this inquiry based on that personal experience. I also thank our chair, the noble Baroness, Lady Morris of Yardley, for her leadership of this inquiry and her forthright explanation of the problems we encountered.

This report shows the value of House of Lords committees, and I have rarely seen so much acknowledgement of a committee’s work in a government response. In this case, the words “We accept the recommendation” appear so often that the committee has clearly done something not just right but very important. There are some points of difference with the Government in their two responses, but often these are points about process or about the need to secure further information or consultation. The dialogue has been important, it will go on being important, and it is encouraging that the department is engaging positively on this and is clearly keen to do so.

As the noble Baroness, Lady Morris of Yardley, said, half a million NHS patients receive hospital-prescribed medication at home through private sector homecare medicines services. It avoids travel for the patient and is much more convenient for them, but it has to work properly since there are clear safety risks that must be avoided.

Indeed, the CQC said it had found evidence of missed deliveries and had concluded that some patients had suffered “avoidable harm”. But it seems that the Government still do not know the extent of that harm, and clearly more data is needed on how many patients have suffered a worse illness or other harm as a consequence of a service failure.

It has puzzled me why information cannot be made available on this before the summer; why does it take so long to gather the information on patient harms? It is an important matter, and it has not been helped by the Minister of State’s reply on 25 March, which seemed to hint at a problem. It said that individual supplier submissions on aggregated performance data will be collated to show aggregated market performance and that this will be in addition to existing and continued contractual reporting of performance data to relevant NHS contracting authorities, whether by local trusts or via regional framework operators. I find that very complicated; I am sure it may all be true, but it sounds very complicated. There are a lot of communication links and reporting, which it can be easy to break. It ought to be better, and it ought to be possible for the Government and the NHS to simplify that structure.

I am very glad that the Government did a desktop review via NHS England. It was urgently needed. As the noble Baroness, Lady Morris of Yardley, said, there has been no individual with overall responsibility for performance, so there is a lack of data on performance. There have been problems with regulation, on which we await further proposals in the summer update. We urgently need a consistent set of performance metrics, but I am pleased that the Government have agreed to one set. We said that the Government need to know how much is actually spent on homecare medicines services but, as the noble Lord, Lord Blencathra, pointed out, we got three different figures. It is important to know which is correct, because these are large sums of money.

I am glad that the National Audit Office will be involved in defining costs, assessing whether commercial confidentiality is justified and establishing whether the Government can be confident that the money is being spent well. We also ought to acknowledge that there is a lack of competition in the market and that, as the service expands, greater competition is needed. That should in turn lead to a reduction in costs.

I shall just address the commercial sensitivity of services by manufacturers which, as we have heard, account for 80% of the homecare medicines service. It is quite difficult to understand what value for money is being achieved because of commercial sensitivity. I just point out that we are talking about public money and the 80% of the homecare medicines service that we are talking about is a for-profit service for NHS patients.

I found the Government’s reply, in paragraph 8 of their second letter on 25 March, to be very strange. What exactly is commercially sensitive? How do we know that we are getting best value? Is it not possible to unbundle contractual matters that are genuinely confidential from those that are not? I hope that the Government will look at that and look forward to the NAO giving us advice on it.

In conclusion, the noble Baroness, Lady Morris of Yardley, was absolutely right to say that we are optimistic. There now has to be an optimism about some of the problems that we have identified, in a service that is clearly going to expand. Things have been learned about the way it has operated, but we can have optimism about it. As the noble Baroness, Lady Morris, rightly said, it is essential that those who are using the service, those who manage it and the clinicians involved all need to be consulted. Patient groups have a great deal to say, so we need and would benefit from their time and evidence.

I see this report as a trigger for action. The Government have committed themselves to delivering improvements and, if this is got right, it will improve care for a large number of people with fewer pressures on the NHS estate. But a lot of work needs to be done. If it is done properly, homecare medicines services can be a growing pillar for our future health service.

16:48

[Lord Carter of Coles (Lab)]

My Lords, it is a pleasure to serve on the committee that undertook this revelatory review, under the sure-footed guidance of our chair, the noble Baroness, Lady Morris of Yardley. I add my thanks to the support we had from the team and to the noble Lord, Lord Blencathra, for drawing our attention to this issue. As others have noted, the horror of it was hidden until he shone a spotlight on it. My interests are those as declared on the register.

Rereading our report was profoundly depressing. On the other hand, when we got the Government’s response in the letter of 25 March, my spirits began to rise because, like other noble Lords, I saw that there could be a way out. There are really two key questions. How did this mess occur? It is a spectacular own goal by the NHS. More importantly, can we be convinced that the NHS is going to do something about it? How do we get through the fine words? My questions are more about the details.

We found a casually overseen service—it was sloppy—which spends over £3 billion a year. Is it £3 billion, £4 billion or £4.1 billion? Who knows, but it is a huge amount of money. To put it into perspective, Defra spends about £2.5 billion on the whole of support for agriculture in this country. I have to say that, if this was a Defra debate, there would be a lot more people here. The point is that it is really significant, and it does not get the attention it needs. It looks after 500,000 patients, many of whom are vulnerable and have experienced appalling care, high levels of distress and, frankly, very confused financial oversight to the system.

Why did this happen? It is obvious: it was caused by a lack of organisational clarity. Who was responsible? Nobody knew. What was the accountability and effective management? There were two failures: one of the management of operations and one of regulation.

Looking forward, in a modern healthcare system, caring for the patient in the right place at the right time is important in that continuum of care, and therefore it is axiomatic and vital that getting homecare services working is central to the future of the NHS. This is not a policy matter—it is good practice: you want to get the patient into the right place. It is not a high-level policy or strategy thing; this is about operations and operational excellence. That must lie with NHSE, and it would be good to hear the Minister confirm whether that is where he thinks the first level of responsibility lies. It would also be nice to hear whether he agrees that this important service would have continued to languish had it not been for the intervention of this committee of your Lordships’ House.

Although the report is succinct, I shall focus on three things: transparency, information technology and accountability. On transparency, any good system that focuses on quality and cost must have data. That is the key to it. The Government’s response was very encouraging. It was nice to read—I think that they understand the issue and they are getting people to work on it. Let us just hope they can come up with something effective.

However, on recommendations 7 and 8 and the question of debundling that other noble Lords referred to, I could not quite understand the response—the point about commercial confidentiality. As other noble Lords commented, this is public money; we should get access. Also, it is remarkable that we cannot get anonymised data setting out these things hierarchically. I cannot understand it, so perhaps the Minister might do that. I encourage him to get his department to look at the P&L accounts of the pharmaceutical manufacturers and those of the people who provide the service. The balance of power seems to lie at the back end with the manufacturers, rather than focusing where the service needs to be at its best. The money should go at the front end where it hits the patient. I think he will be as surprised as I was when I looked at those accounts. Some 80% of homecare is delivered in this bundled fashion, which impedes direct management. If we have intermediaries for various sources, particularly the pharma companies, contracting here and subcontracting there, we have to get a direct accountability framework. I shall come back to that in a moment.

On digital, electronic prescribing has been really slow, and if you cannot get the information out, you cannot get the drugs to the patient. You cannot plan or do these things properly. It is absolutely fundamental. Instead, we have pieces of paper flying around—these are decades-old systems. The key to this is getting the IT to work for electronic prescribing, but also getting that data back into the integrated care record. These patients are not stuck just in homecare; they go back into the acute hospital and the community, and they have comorbidities. The question is: how do those servicing them look across the care spectrum with one record of care? Can the Minister tell us when he thinks we might find some integrated care record so that all those phases can become apparent to support patients?

The nub of the problem is accountability. This was chaos; everybody we spoke to had no idea who was responsible. It was most remarkable, as other noble Lords have noted, and I have never been in a situation like it. But we are where we are. Clearly the Government accept this situation, and clearly our report has been a catalyst for change. How do we get clarity of roles, responsibilities and decision rights, if we are to unwrap this whole shambolic situation? I hope the Minister can tell us whether, when these reports come forward—possibly in the summer, ahead of the recess—he will be able to publish an accountability framework. Until we see that, and see how the pieces fit together, although we might have a lot more words we cannot focus on who we can go to, in the operations particularly. Where will this famous SRO sit? To whom will it be accountable? Who will be accountable to it, and what decision rights will it have? Unless we get that right, all our aspirations will not be met.

As regards regulation, one might say, as the noble Lord, Lord Blencathra, noted, that the CQC has failed in this respect. Light-touch regulation is one thing; dereliction is another. We must be sure of two things. First, there can be only one regulator—multiple regulators always fail. We need a super-regulator, which has to be the CQC—we have not got time for legislation. Secondly, the CQC has to be made effective and has to come to an arrangement with the two other organisations that underwrite quality.

The NHS is in a most difficult position; it is under unprecedented pressure on every front. As the noble Baroness, Lady Morris, noted, this is not about money; this is about organisation, management, detail and covering that ground. We are encouraged by the fact that the Government have accepted, or nearly accepted, so many of these recommendations, but the fact remains that this has to be about access and getting things right as we go forward. I hope that the Minister can tell us with some confidence what next steps he intends to take in order, when this comes back in the summer, to tell us that the way forward is there.

I end by saying this. It is clear that the Government have found this report quite useful. Since our committee is always looking for interesting things to do, maybe the Minister will point to one or two other things we could look at in order to help him.

16:57

[Lord Willis of Knaresborough (LD)]

My Lords, I begin by thanking again the noble Baroness, Lady Morris of Yardley, for her excellent chairmanship of a challenging inquiry. I echo her thanks to the committee clerks and staff for their inspirational work in assembling pertinent witnesses and materials for the committee.

The fact that the Government have responded positively gives hope that we will see not only significant changes to the current organisation but an opportunity to build a home medicine service that will make a profound difference to millions of future patients. I must confess, having listened to the noble Lord, Lord Blencathra, for 27 years, that when he sought the support of the committee for the inquiry, I was somewhat sceptical that this was an area of significant concern. I apologise. Not only was he right in exposing a major challenge to the NHS but, midway through the inquiry, I became a recipient of homecare medicine services, when diagnosed with pulmonary fibrosis—a serious, chronic, life-changing disease. What is more, I discovered, via the Cystic Fibrosis Trust, that 87% of its members in receipt of homecare medicines had experienced problems with home delivery. I understood then the concerns of the noble Lord, Lord Blencathra, and of the leading charities whose members are involved in the service.

I wanted to know a little bit about the service. It began in 1995, and I suspect that the noble Lord, Lord Carter, might even have been around at that time in the Government. I came across a most interesting publication by the Department of Health, which produced in 2011 a detailed review of the service entitled Towards a Vision for the Future. It is worth reading again. I am sure the Minister will have read that review, and he will be embarrassed by its conclusions, because it made exactly the same conclusions about the state of the service in 2011 as our report has done now. Thirteen years later, despite a 300% increase in patients and costs, nothing had changed or improved. I recognise that both the Minister, in discussion, and the Government, in response to the report, have accepted several of our key recommendations, but so much remains to be dealt with.

Can noble Lords imagine any business with half a million customers not knowing how much money is being spent or where it is being spent, particularly when sums from £2.9 billion to £4.1 billion are involved? Yet that remains the case. An initial response was that the service cost £3.2 billion, and then, according to the National Clinical Homecare Association, £4.1 billion, which was then reduced to £2.9 billion. The Government then said £3 billion in their response. The confusion comes because there is no accurate way to measure the cost of delivery, which prompted the committee to seek an in-depth explanation, only to be told, as Members have clearly stated, “commercial sensitivity”. In actual fact, the real reason is that there are no clear requirements to meet nationally agreed criteria for service delivery and component costs. Therefore, the critical breakdown does not exist.

The Government have accepted the need for national key performance indicators, but the idea that the National Clinical Homecare Association and the homecare providers should provide all the criteria for identifying costs is unacceptable. Could the Minister say whether the statement coming in the summer will include the National Audit Office to certify expenditure? Given that 80% of expenditure is on drugs and medicine, will the Royal Pharmaceutical Society be the lead adviser on the core national priorities to the new home medicine service leader? Speaking of the leader, could the Minister explain why, given the overwhelming role of the pharmaceutical services, the chief pharmacist was not considered as the key person to lead this service? If not them, who will it be? We would like to know.

One of our key recommendations, which was supported by the Government, is an end to the antiquated method of handwritten and fax-delivered prescriptions between consultants and providers. However, it was disappointing to read that the data systems, which are absolutely crucial to the future of the service and which are so appallingly absent at present—an issue fully accepted by the Government—will be provided by a sub-committee of the National Homecare Medicines Committee. That is not acceptable. We are in this mess because that committee, which is in league with commercial providers, failed to provide the data required to build the service in the past.

The absence of core national data seriously affects patients, who all too often have to cope with missed deliveries of drugs, sometimes forcing them back into hospital and perhaps even causing unfortunate premature deaths. We asked the NHS for statistics to see how serious this was. What was the answer? “Sorry, they’re not available”. The same answer came from the Care Quality Commission. I will not repeat what the noble Lord just said, but I plead with the Government not to get this wrong. Data is absolutely essential. What is more, if homecare is to be expanded substantially to reduce burdens in the NHS on primary and secondary care, then getting leadership, data and finance right is crucial.

This leads me to regulation, which other Members have spoken about. I know, having worked for some 10 years as a consultant to the NMC and the RCN, and having chaired the York and Humber applied research collaboration for five years, that regulation in the NHS is a major challenge, and not one that can be easily sorted out. However, we must be given a structure that integrates its work far more effectively. I totally agree that there should be a single consultant and that it should be a powerful voice. The idea that that will happen soon is, quite frankly, not realistic.

An immediate solution would be to create a lead regulator with the authority to insist on requirements from other regulators without having to seek the approval of the Secretary of State. If the CQC is to be given that task—and as the protector of patients, it should be—it must be empowered and encouraged to conduct in-depth reviews. It told us it could not do in-depth reviews unless the Secretary of State told it to do them.

That leads me finally to the patients themselves. The 2011 report concluded that,

“moving forward, patients and patient representatives should have a much greater role in design, operation and monitoring of homecare … services … Patients are at the heart of homecare medicine and should be listened to”.

Crucially, our report sought an assurance from the Government that patients and key organisations involved would at least be asked for their advice and be involved with any future policy changes, because nowhere in the Government’s response or, quite frankly, in the evidence from officials do patients take a prominent role—which is exactly the same as in the 2011 survey.

In her letter to the Minister, the chair made a special plea for this anomaly to be changed. I admire and appreciate the fabulous service that the leading charities give to patients and their families. They deserve our utmost thanks, but the Government must do more. Now is the time to put patients at the heart, not the periphery, of future discussions. I sincerely hope that, when the Minister produces what I trust will be a ground-breaking response before the Summer Recess, we will all be able to cheer from the rooftops. I live in hope.

17:06

[Lord Mott (Con)]

My Lords, it is a pleasure to take part in this debate on homecare medicine services. I thank the noble Baroness, Lady Morris of Yardley, for opening this very important debate. I also thank her for being incredibly supportive since I joined the Select Committee in January. As a new member of the Public Services Select Committee, I take this opportunity to thank noble Lords who I sit on the Committee with for such a warm and supportive welcome when I first joined. I also thank Crohn’s & Colitis UK for the briefing before today’s debate.

As we have heard, homecare medicine services could transform patient care, but currently the service is not working for the majority of patients. We often hear large numbers given in speeches, and I may use some today, but we must never forget that public services are used by people who may not have access to tech or the knowledge of how to use it and who are often living in difficult and challenging circumstances. Our focus must always be on how we improve the lives of those who rely on our public services. We should embrace change and ensure that all partnerships are explored in the pursuit of excellence. Public sector, private sector and not-for-profit collaboration will allow us to achieve excellence.

I will focus on the problems in the first part of my remarks, although I fear I may be repeating some that have featured in noble Lords’ contributions, and I will end with the positives. Homecare medicine services can transform patient care, and I have confidence in the Minister to deliver. It is a surprise that, although thousands of people depend on medicine delivered to their home, no one has any idea how often patients suffer from service failures. It is not just the Government who are unsure about how many patients are involved, but NHS England, patient groups and regulators, as has been mentioned already today. This lack of knowledge, data and information is a real concern. Without data, you cannot set KPIs or manage the service efficiently.

We have some data, but I am not sure whether it currently paints a positive picture. IT systems have been developed with no single NHS system for providers to interact with, which means, as has been mentioned by the noble Baroness, that around 6,000 prescriptions are written in the UK every single day on more than 1,000 different templates.

One provider reported that, between October and December 2020, 9,885 patients had medicines missed or delayed. We do not know how much money is spent, as has been highlighted in this debate. It could be £4.1 billion, £3.2 billion or £2.9 billion—the truth is that we simply do not know. It is important that we get that figure quickly. We cannot accept the Government always hiding behind confidentiality and contracts as reasons why we cannot see some of the data; in the end, this is taxpayers’ money, and we need to make sure that it is being spent in the correct manner. The lack of transparency is a worry, as are failures in procurement and the reluctance to enforce standards, as my noble friend highlighted in his usual way at the beginning of the debate. The report makes clear that this is a difficult market with poor infrastructure.

I mentioned earlier that public services are about people. Many people with Crohn’s and colitis rely on homecare medicine services. When it works well, homecare offers people with inflammatory bowel disease the opportunity to receive treatment in the comfort of their own home, reducing the cost of travelling back and forth to hospital and the impact of treatment on their work or education. It can also reduce pressures on NHS services by allowing people to receive their medication at home. Unfortunately, delays, cancellations and incorrect deliveries of homecare medicine services are jeopardising people’s health and causing significant stress and worry for people living with Crohn’s and colitis, for example.

A Crohn’s and Colitis UK survey in 2023 found that nearly two-thirds of people with IBD had experienced problems with homecare in the previous six months, including delays or cancellations. Those failures led to nearly half experiencing a flare, one in nine ending up in A&E and one in 20 requiring surgery. One lady living with Crohn’s disease told the organisation:

“Every month continued with missed and delayed deliveries and being unable to contact the home care company. My hospital team had to intervene every time. On top of the daily challenges that my condition presents, the stress, anxiety, and time spent making sure I got my drug became unsustainable. It was too much”—


far too much. Sadly, her story is not unique. When IBD medication is delayed or missed, there is a strong risk that it loses its effectiveness and no longer helps to manage symptoms, which can result in a flare-up. A Crohn’s or colitis flare can lead to bleeding, abdominal pain, fever, joint pain, mouth ulcers, fatigue and mental health deterioration. Careful monitoring and control of IBD is vital for people to be able to work, study, socialise, maintain relationships and live life the way that they want to. Unreliable homecare medicine services jeopardise this.

It is currently unclear exactly how many people have been harmed by homecare failures, how much money is being spent on these services and who is ultimately responsible for them. We need to make sure that homecare medicine services are monitored and governed far more effectively, as we have heard today. Perhaps the real point is that no one seems to own these key services. As noble Lords will know, when a service is an orphan, progress is limited, accountability is lacking and patients suffer.

The report is an opportunity lost—for now—but it is clear that, if we can make some changes, homecare medicine services could be transformational. Reliable homecare medicines can change patients’ lives, improve quality of care and quality of life and start to make a real difference. This would allow NHS resources to be redeployed.

I am heartened by the substantial progress that has been made since the report was launched. The NHS England review to establish the facts is fundamental to ensure that we are starting from a position of fact that will allow the transparency required, start to allow patients and providers to understand the marketplace and allow patients to have the confidence to improve their health and to start to take the pressures off the NHS.

I thank the Government for their work in this space and their commitment to take the issues raised with them by the committee seriously. Having read both the Government’s letters to the committee on this topic, it is evident to me that good progress is being made here. It is reassuring that the Government accepted a large number of the recommendations in the report and are fully engaged in productive work to return a final position on some of the others.

I note that, importantly, NHS England’s desktop exercise is now complete, and I was delighted that stakeholders, including patients, had been involved in that. I look forward to reading it once it is published. I was also heartened to read that NHS England will now move to focus on and take action in the most pressing areas of patient experience and performance, and continue to engage with key stakeholders as its work moves forward.

Lastly, I note the fact that NHS England will appoint a senior responsible owner for this work, which is incredibly good news for this sector. I look forward to hearing more details about the position and the appointment to it, and to reading the Government’s summer update to the committee on homecare medicines services. I know that my noble friend the Minister is a strong advocate of using data to drive up standards and performance. This gives me confidence that we will see the change required. I am looking forward to his response today. It is worth remembering that it is the little things that mean a lot.

17:15

[Lord Allan of Hallam (LD)]

My Lords, I am grateful to the committee for looking into this service, which is important to so many people, as we have heard, and involves significant if not fully understood public expenditure. I think we have it to the nearest penny on national insurance; we appear to be in that kind of rounding on this form of expenditure.

As someone who is still learning about many aspects of the NHS service, I am also extremely grateful to the noble Baroness, Lady Morris of Yardley, who gave us a masterclass in how to present a problem very efficiently and concisely and then describe possible solutions to it. Anyone can just pick up the report or her speech and understand what is going on in short order, which is extremely appreciated.

I am also especially pleased to be taking part in a debate with my noble friend Lord Willis. We shared an office for eight happy and productive years at the other end of the building, but we very rarely get to speak in debates with each other. It may be a decade or two since this last happened.

The Minister will not be surprised at the area I wish to focus on in my remarks, which is the gap between how the NHS works and the state of the art for other services in our lives. I encourage the Government to be perhaps even more ambitious than the report says. I hope that I am pushing at an open door with this particular Minister.

Homecare medicines are of course more complex than other products delivered to the home, so there is no simple comparison with an Amazon-like service, but some of the tools used in these other services are certainly relevant and provide a benchmark for what is possible, if you are trying to deliver the best possible service in 2024. As we work through the report’s recommendations and the Government’s response, I want to look first at recommendation 3 on KPIs, which many participants in the debate have mentioned.

What we see increasingly in other areas is real-time performance data rather than periodic collection of performance indicators. Real-time data is more useful and certainly less prone to the kind of gaming that can be done with KPIs. We see that in the NHS where people work to get to their quarterly target; they rush the drugs to the noble Lord, Lord Blencathra, because they want to tick that one off to meet their target, but you cannot cheat real-time data in the same way. I hope that the Minister will consider that. Certainly, if I were the owner of a contract I would want to know in real time whether the thing that I contracted for was actually being delivered.

When someone visits a home to deliver a product, or if they are going to provide a service, it is very easy these days to log that using commonly available tools. This does not have to be a big bureaucratic exercise. It can be a click or two, and then that data goes to the person who contracted with the service so that they know it has been delivered. We all experience this in our daily lives. I will use the comparison that when I order drugs for my cat, which I do, I am told when they are going to arrive. When they arrive, the button is clicked and the person who supplied those drugs knows that they have been delivered. If it is good enough for my cat, it is certainly good enough for half a million people who receive these services.

That is especially important if it is a market in which a buyer is paying a main contractor—in this case, the medicine manufacturer—who then subcontracts the delivery part of the service. Once it gets more complex, that is no reason not to have real-time data but a reason to prioritise having it, so that you do not end up playing pass the parcel. The noble Lord, Lord Blencathra, said he wondered if people sometimes do not want to know the breakdown, because they do not have to own it. No: someone needs to own this. If I were a clinician or a manager in an NHS trust and I had 500 or 1,000 patients dependent on the homecare service, I would want to know in real time what they were getting. I would expect everybody in that chain to pass the data back, so I could see whether it was working or whether something had broken down.

Here, I think about another initiative that the Minister is keen on, which is virtual wards. We do not send people home and ask them to tell us in three months whether the service on the virtual ward was delivered. The clinician is there with real-time data about what is happening to that person at home. I do not see why the homecare medicine service should be any different. If you can easily collect the data, it should be going back to the clinicians so that they can see whether there is a breakdown and, as other noble Lords have said, plan to fill the gap if they need to. This is critical for the patient interest. This kind of visibility of real-time data is possible. It is even more ambitious than the KPI recommendation, but I hope that the Minister will commit to looking at how it could be built.

The other piece of transparency that has been referred to, particularly by the noble Lord, Lord Carter, is the transparency of costs in recommendation 5. I was also struck by the government response citing commercial confidentiality. That did not work for me, frankly. There should absolutely be commercial confidentiality at the point at which you award a contract, before somebody has signed the deal. However, there is no reason for a high degree of commercial confidentiality to continue after the deal has been signed unless it is because of the imbalance of lawyers. The noble Lord, Lord Blencathra, spoke about that. If I were a lawyer for a company, I would say to the NHS, “You have to keep it all secret once I have signed the deal”. The NHS does not have to agree to that. The NHS can say: “As a condition of the contract, we want this data to be put out there and we are not going to agree a contract that has commercial confidentiality in it beyond that which is strictly necessary”.

The report rightly talks about competition in this space. The way to encourage competition is to let the market have as much information as possible so, when the next round of contracting comes up, you can draw on what the cost base was for the previous contractors. That is not in the contractors’ interests, but it is in the public interest. I would expect to see that filtering through. I hope the Minister will look again at this. The block use of commercial confidentiality was in the government response, but we need to get much more granular and find out if there are real reasons or if it is simply for the convenience of the contractor or because it had better lawyers when doing the negotiation. We should be able to take that out.

I now want to speak to a favourite theme, which is the stubborn persistence of paper-based systems in the National Health Service; they are lurking around way beyond their sell-by dates. We have excessive tolerance for this. It is flagged in recommendation 11. It really hurts to see that inefficiency persist when we have actually already paid for the electronic system; we are just not using it. If you have not built the system, that is one thing, but we have built an electronic prescription system yet this important service has somehow just not bought into it; that is really painful.

The government response did not have any timeline for when this will be delivered. It expressly said that the Government cannot give a timeline. I know the Minister will be uncomfortable about the persistence of the paper-based system and I hope he can give us additional assurances on that today. Can we please be less tolerant about people not using the electronic system? It benefits everyone, including the contractors. They will save money if they move over to the electronic system. They may have inertia, but I think we can be insistent, given that it is for everybody’s benefit.

I would like us to be more ambitious. We need to be mammals about this and not be overly sensitive to the fate of dinosaurs who choose not to evolve. In saying that, I am not talking about the service users, many of whom are really familiar with the technology. I am talking about the service providers, some of whom are not moving on. If they do not want to move on, I worry about why they are still in this business. We need people who are willing to move on and use the latest tools.

It is a very useful report. There are many other recommendations to which I hope the Minister will respond positively. I hope he will particularly pick up three areas that I and other noble Lords have highlighted. First, NHS service managers should have real-time access to performance data for homecare medicine services, just as they would for the other services that they are delivering. It is reasonable to expect providers to offer this capability. Secondly, there are benefits in being much more open about the costs of service delivery. We should not use commercial confidentiality inappropriately to stop this. Thirdly, we should be aggressive—I would use that adjective—in moving everything on to the electronic prescription service. We have paid for it, and we should use it.

I again thank the committee and the noble Baroness, Lady Morris, in particular for her introduction to this. I echo the positive note and the fact that, as she said, these are things that can be done now—that is critical. We do not want a response that says things will be done in a year or two years; we want things that will be done in 2024.

17:25

[Baroness Wheeler (Lab)]

I too congratulate my noble friend Lady Morris on her usual thoughtful, thorough and robust introduction to this excellent report. I commend the whole committee for shining a laser-like spotlight on such a vital service, upon which half a million people with chronic health conditions living at home depend. Homecare medicines services are some of many services provided to NHS patients that are not publicly well known or understood by the majority of people accessing the NHS, but, as we have heard, they provide and utilise huge NHS expertise and physical and financial resources—over £3 billion per year, as the Government now estimate.

The forensic, in-depth reviews that Lords and Commons committees undertake of such services—which range across NHS provision and underpin the importance of providing quality patient care and safety across the NHS as a whole—are an essential part of parliamentary scrutiny. Today, we have heard support and insight from other committee members across the House—I note my noble friend Lord Carter and the noble Lords, Lord Blencathra and Lord Shipley—and I welcome their perspectives and reinforcement of the committee’s work. I particularly thank the noble Lord, Lord Blencathra, for suggesting the topic in the first place.

The report provides a very thorough analysis of what homecare medicines services cover, their strengths and the significant problems encountered by service users, as well as the recommended ways forward to improve the provision of high-quality care to patients in their homes, which can reduce pressure on hospitals and other NHS services that have to pick up the pieces when delivery services fail.

Since the committee members have stressed that they are open to suggestions, I say that I personally hope that the committee can in the future undertake similar important work on other vital services that are often out of the spotlight. One such service is the continence service, which impacts across major conditions such as heart failure, stroke and dementia, costs the NHS similar sums of billions of pounds a year and involves home delivery of medicines and supplies to patients and hospitals. I realise that this is an issue for another day, so I will leave these thoughts with the committee.

The important starting point on homecare medicines services, heavily underlined by speakers today, is addressing accountability and who is responsible for the whole service. I welcome the DHSC’s and NHS England’s willingness, in the Government’s response to the committee, to recognise the disjointed complexity of the current system, which has largely evolved over the years without a coherent overview and strategy. I also welcome their recognition of the need to come to grips with how HMS operate today and move forward in the future.

Appointing the NHS England senior responsible officer responsible for HMS nationally is just the first step—a crucial point well reinforced today. When appointed, that senior officer, working with the national HMS committee, will face huge challenges identified by the committee and acknowledged in the Government’s response. These include developing consistent performance metrics and updating and rolling out new KPIs, with regular publication of performance data in standardised form to ensure that comparisons can be made and lead to better scrutiny, transparency and improved patient care. All these are promised for a report back to the committee in the summer.

The committee also underlined the importance of ensuring that homecare medicines services are part of, and included in, the NHS long-term workforce plan, or the social care equivalents when they are finally developed. It is astonishing that these two strategies do not include HMS. I look forward to the Minister telling us how this happened and the steps now being taken to address this significant oversight. How is the work on the vital information and data—so essential, as we heard, to assessing the patient experience and identifying the harm that delays, errors and misdeliveries cause patients—progressing under the desktop exercise, in advance of the promised summer report back to the committee on what data is available to assess patient harm?

The Government’s response also accepts that significant improvements must be made in the HMS procurement process to achieve value for money, in developing experts who understand the service and in the support offered to NHS trusts on drawing up and managing procurement contracts. My noble friend Lord Carter, as we know, has huge expertise in this area, working with NHS trusts on productivity, contract development and operational management across NHS trust operations. He has raised a number of key areas on this important aspect of the report, and I look forward to the Minister’s response, particularly on how we move forward towards operational excellence and integrated care records. The committee’s recommendation for government to start work now with the National Audit Office and the CMA to identify barriers to effective procurement makes sense in the light of the current disjointed and impossible-to-navigate system—another summer report-back item. Perhaps the Minister can explain why this work cannot begin now to help NHS England assess future options.

Today’s contributions have all drawn heavily on the crucial evidence of service failures from key patient groups. I join noble Lords in paying tribute to them and to the British Society for Rheumatology for its leading, co-ordinating role in gathering and presenting patients’ first-hand evidence to the committee. We have heard many examples today. The comments from two Cystic Fibrosis Trust respondents sum up what patients can experience. One says:

“It’s terrible … the times are a nightmare and missed deliveries can take ages to rearrange … it’s a horrible system”.


The other says that

“it is a massive burden and on top of everything else we need to do and have to deal with”.

The latter is a familiar sentiment from patients and their carers across many health and social care services.

As my noble friend Lady Morris underlined today, the committee fully acknowledges the “irreconcilable gulf” between the views of clinicians and service users and the leadership and governing bodies of the homecare sector on how well the service is performing. But it rightly underlines that it is

“persuaded by the weight of evidence from service users that there are real and serious problems in the sector”,

despite HMS being a complicated system with multiple variables. The example from the noble Lord, Lord Blencathra, regarding the delivery of his medicines and the testimony of the noble Lord, Lord Willis, clearly demonstrate this. Indeed, one of the most stark conclusions from the committee—the noble Lord, Lord Blencathra, referred to it, but it is worth repeating—is that:

“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”.


It is this and the complexity of the system that need to be urgently addressed. It is so important to have accurate and consistent performance data across providers and the services involved to measure the impact of poor performance on patients in the public domain. What are the expected timescales for the newly appointed senior HMS officer and the National Homecare Medicines Committee to develop a strategy and implementation plan for HMS, and how will service users be consulted and involved?

The failure of the regulatory model for homecare comes in for equally heavy criticism from the committee, which describes it as

“failing to ensure the safety and quality of patient care”;

having

“a limited understanding of the sector”

and “no appetite” to find out more; and having only “feeble”—indeed, “toothless”—enforcement action against providers, even where avoidable harm has occurred. The Government recognise that more work has to be done before deciding on undertaking the thematic review called for by the committee—that will be one more summer update to the committee.

Can the Minister confirm that meaningful discussions have begun between the CQC, the General Pharmaceutical Council and the MHRA? Are they just focused on identifying

“opportunities for strengthening collaboration, communication and transparency”,

as referred to in the Government’s response, or will they include more structural issues, including a leading regulator where providers are underperforming and overall responsibility for a patient complaints system? How will the role undertaken by the CQC for its—currently relatively few—HMS provider inspections be levelled up to the much tighter approach taken in inspecting small residential care homes?

With noble Lords’ indulgence, I refer lastly to a related but non-HMS issue: medicine blister packs for people living at home, which are assembled by pharmacies and either collected by patients and carers or delivered to their home. The Minister and I always seem to talk at cross-purposes about this. When I raise the issue, he stresses that they are not suitable for everyone, which I fully agree with, but I always emphasise how essential they are in the delivery of domiciliary personal and social care for people living in the community or in care homes. Care workers often administer these drugs to the client in their homes. This process ensures that the drugs are taken properly and safely and are not missed. Care staff can do this only using blister packs. They would not sort out the daily doses from multipacks, which I as a carer was recently offered. Our local Boots chemist, a large chemist, has stopped providing this essential service. Where it is not provided or where the chemist closes down, the task would again fall back to the carer. This is an important issue related to our discussions on HMS and it needs to be recognised as an essential part—where appropriate—of safe care in the community. I hope I have provided food for thought in the context of today’s debate.

Finally, this has been an excellent debate and I once again congratulate the committee on its searching report and very practical recommendations on ways forward. There has been a good start made on addressing the key problems, and optimism, in the Chamber at least. But, as the British Society for Rheumatology has stressed, both NHS England and the DHSC still have a long way to go to demonstrate that they understand the scale of the problems that need to be tackled if HMS is to achieve its full potential.

17:35

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

My Lords, I am a bit slow in getting up. I will blame my son Xavi, who is in the Gallery. I was playing with him a bit too much this weekend, so I apologise. Now I am up, I will be fine.

I start by thanking noble Lords, and particularly the noble Baroness, Lady Morris. This is a very important area about which, I freely admit, 10 days ago I knew very little. I guess it was my noble friend Lord Blencathra who raised awareness in the first place, but I think this has been an excellent example of what the House of Lords does really well, which is to realise that there is an area that needs looking at.

On the question from the noble Lord, Lord Carter, about whether we found a report useful: yes, definitely. I have a couple of ideas and I think the noble Baroness, Lady Wheeler, has some good ideas on some of the next steps. I thank all noble Lords on the committee for their contributions and I am pleased that it is felt that the department has responded positively. I must admit that, in briefings, you can always tell when officials get it, are keen and have the bit between their teeth—and that is definitely the feeling I got here.

I will spend a few minutes unpacking something that impressed me: it really came home to me just how important this is, not just in terms of patient treatment today but for how we all want to deliver the service in the future. I call it the four Ps, on why I think this is important. First, there is prevention. I think we all agree that more prevention needs to begin at home, with home treatments and home testing services, to create a fantastic service in this area.

The second P is primary care: we want more care in the community and that is going to happen only if we have these sorts of services working really well. Noble Lords have heard me say it many times, but Bromley-by-Bow is a perfect example: they are treating patients with type 2 diabetes and CBT patients in their home rather than in hospital. But that can happen only if we have a really gold-plated homecare service, which they are able to provide in that very small instance. What we are really talking about today is the professionalisation of that type of service, so we can offer it much more widely.

My third P is of course patient care, brilliantly described through his own personal experiences by my noble friend Lord Blencathra, and the effect that that had on him, but also with the Crohn’s disease example set out by my noble friend Lord Mott, and the realisation that, as annoyed as we all often are when we wait all day for a delivery that does not turn up, in these cases we know that there are real-life consequences. Those consequences do not impact only the individual involved; they have knock-on consequences for the rest of the health service if patients have to go into hospital for that treatment instead.

Fourthly, I see the future in the area of precision medicine. I have started to understand that, by seeing what the likes of BioNTech and Moderna are doing, using mRNA to fight cancers on your behalf. This is personalised treatment, which moves away from the model of mass manufacturing in big pharma factories to a point-of-care delivery of services. That is why it is so vital to get this right.

The report’s title, An Opportunity Lost, is a perfect way to capture what we are trying to do here. We all understand that it is a complicated area, and there are very clear reasons why a lot of it is delivered through the pharmaceutical industry. It makes sense to have that service connected to it all, particularly as a lot of their treatments become more complex.

I think all noble Lords would agree with the point of the noble Lord, Lord Blencathra, that we do not want the NHS to deliver on these areas, and that it has enough on its plate already. As the noble Baroness, Lady Morris, said, we need someone who is going to grab hold of this. Leadership and management 101 is that you need someone to lead a business, and that is clear here. We will be appointing and announcing that person very shortly. I cannot say it yet but, from some of the comments made today, I think that noble Lords will agree that it is a logical appointment. I probably should not go further than that. NHSE and its service delivery will be included in all of this. To the point of the noble Baroness, Lady Wheeler, all of this should absolutely begin now. A lot of this job is to make a fragmented service coherent.

As to what their job list should be, noble Lords set this out very clearly, and it is set out very clearly in the recommendations. I hope that that is clear in some of our responses, but I shall try to add some flesh to those bones. Number one on the job list is clearly data, and a common set of KPIs is fundamental to this. I was completely unclear on the sentence that the noble Lord, Lord Shipley, read out—it was probably more than one sentence. I was none the wiser, so there is definitely a mark of “could do better” there. As the noble Lord, Lord Mott, said, we need clarity, a common system of measurements and complete transparency all the way through, accompanied by a clear complaints system. No business in the world would get anywhere without that fundamental data, in as close to real time as possible.

Secondly, I completely understand why the regulatory lead has evolved in this way. It is natural that the MHRA looks after the medicines aspect, such as efficacy and any side effects. It makes sense that the General Pharmaceutical Council looks after some of the dispensing aspects, but at the core of these homecare services is the delivery of treatment. As the noble Lord, Lord Willis, suggested, that is why the CQC is the natural lead for doing that. I will not comment on the assessment of noble Lord, Lord Blencathra, on its involvement in this to date, but it is about making it very clear that it is a priority. That is key: what we have tried to do will be the future, so it should be a priority.

On the question from the noble Baroness, Lady Wheeler, my understanding is that meaningful conversations have begun towards that. It is quite clear that the CQC would be the natural lead because this is mainly about treatment and the delivery of healthcare services.

The third important thing on the job list is digital. It is amazing just how basic things are there. I am completely with the noble Lord, Lord Allan, that we should expect an Amazon-style delivery. We are all very used to that these days, where you get a message that your delivery is on the way. Providing that sort of information is not rocket science. We should definitely look at that, so that the service is at least as good as his cat’s service, if not—I hope—a lot better.

The fourth job is to provide clarity on the costings. As the noble Lord, Lord Willis, and others have said, the commercial confidentiality aspect should not be an issue. All we are saying is that, if they are charging £100 for an item, which includes both the medicine and the service delivery, there is an element—£20 or whatever it is—associated with the service delivery. My suspicion is that the power is with the pharma company here—that goes to some of the points raised by the noble Lord, Lord Carter. Often, the service is the tail-end Charlie in the whole set-up. As the noble Lord, Lord Carter, said, this is just basic operational and service delivery. We need to make sure that it is a very clear part of it in the contractual sense that the noble Lord, Lord Allan, referred to.

We need to do some training with our contractual negotiators. This is not just about driving down the price of the medicine—which I think we would all guess is the primary part of the negotiation—but, where there is a treatment component, is about making sure that the delivery is key. If the noble Lord, Lord Hunt, were here, that is exactly what he would say about value-based procurement. Small things going wrong with that can have huge consequences not just for the patients, as we have seen with the examples raised today, but through knock-on costs for the rest of the service.

For what I hope will be a constructive way forward, I propose that the senior responsible officer—the leader for all this—will be appointed soon. With noble Lords’ permission, I would like to invite him or her and the relevant NHS people to a round table with the noble Baroness’s committee. With them having had a bit of time to get their feet under the table, but not so much that they have already gone down the path too much, it would be excellent to have a hopeful round-table conversation. I hope that will be a constructive way forward to make sure that they are setting off on the right track.

As ever, when we finalise this all, I will write on any points that I have not covered, particularly on blister packs. We probably have been talking at cross purposes, so I will make sure that the point is understood and taken back.

In conclusion, this is definitely useful. As I say, I will come back to the committee with more thoughts, but one thing off the top of my head is that in the whole area of precision medicine there is just such an opportunity there for a whole new way of treating cancer—I hope that one day it will replace chemo, which we know is a blunt tool. There is a whole mechanism there for delivering which we will need to build on in these homecare-type areas, and that could be a very interesting area for the committee to look at.

I have learned a lot from this area, and I thank your Lordships for shining a light on it. I hope that noble Lords feel that we are getting the right attention paid to all of it. However, we absolutely need to continue to hold feet to the fire, and I know we can rely on all noble Lords, quite rightly, to make sure that we do that.

17:50

[Baroness Morris of Yardley (Lab)]

My Lords, I thank everyone who has contributed to a very good discussion built on a very good report. I do not want to keep us long because I do not think there is a lot else to say at this point.

We have been through a number of hurdles, and I absolutely understand where the Minister is coming from—10 days ago, he was not aware of the problems, but that is a description of us all, apart from the noble Lord, Lord Blencathra. The first hurdle to jump was to get people in key positions aware of the problem, and that has been achieved. Secondly, I think there is a joint determination to do something about it and a feeling that it cannot wait. Thirdly, there is some agreement on some of the things we can do, and a willingness to have an open discussion on how we might do some of the more problematic things. I am particularly grateful to the noble Lord, Lord Allan, for stretching my mind and knowledge on what might be possible in terms of digital technology—things I had not even thought of.

The other thing that has been important today, which I was very keen that we do, was to get a next step. These good ideas fall between discussions, and things happen and no one picks them up again. I am therefore absolutely confident that I can speak for the committee in accepting the invitation to attend a round table after the announcement is made. I think that, from our point of view, that is a very good next step, along with the announcement of the person in charge and the further letter expected from the Minister’s department in the summer. Therefore, that is our next step, and I am sure that there will be more steps after that.

I just want to say one thing, which is a note of caution —it was referred to, I think, by the noble Lord, Lord Willis. The Minister will have to make his own judgment, but I think the overriding impression in our committee was that it was really hard work to get those already managing the system to accept that there was a problem. It was really tough to get them to that stage, and I am not sure that they got there; they might have got there in their own minds, but they did not acknowledge that to us. Because of that, the committee has a concern as to how much they are going to push this forward, but, more than that, the clinicians and the patients have concerns as well. The Minister may want to reflect on that and do what he can in whatever decisions he takes.

My last sentence is this. All those things are good, but we have absolutely raised expectations of those who use the service, the clinicians and the trusts, and we cannot let them down because they do not deserve that. I finish by thanking everybody for their contributions, and I look forward to further discussions. I beg to move.

Motion agreed.

House adjourned at 5.53 pm.