Homecare Medicines Services (Public Services Committee Report)

Baroness Morris of Yardley Excerpts

Thursday 2nd May 2024 Lords Chamber

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.

--- Later in debate ---

[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.