Homecare Medicines Services (Public Services Committee Report)

Lord Allan of Hallam Excerpts

Thursday 2nd May 2024 Lords Chamber

[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.