Homecare Medicines Services (Public Services Committee Report)

Baroness Wheeler Excerpts

Thursday 2nd May 2024 Lords Chamber

[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.