final logo red (RGB)

 

Public Services Committee

Corrected oral evidence: Homecare medicines services

Wednesday 28 June 2023

4 pm

 

Watch the meeting

Members present:  Baroness Morris of Yardley (The Chair); Baroness Bertin; Lord Laming; Lord Porter of Spalding; Lord Shipley; Baroness Stedman-Scott; Lord Willis of Knaresborough.

Evidence Session No. 4              Heard in Public              Questions 38 - 48

 

Witnesses

I: Joe Bassett, Assistant Director of Procurement, Pharmacy and Healthcare Services, East of England NHS Collaborative Procurement Hub and Chair, National Homecare Medicines Committee; Claire Foreman, Director of Medicines Policy and Strategy, NHS England; David Webb, Chief Pharmaceutical Officer for England, NHS England.

 

USE OF THE TRANSCRIPT

  1. This is a corrected transcript of evidence taken in public and webcast on www.parliamentlive.tv.

24

 

Examination of witnesses

Joe Bassett, Claire Foreman and David Webb.

Q38            The Chair: Welcome to this sitting of the Public Services Committee inquiry into home medicines. We have three witnesses before us today. I will ask them to introduce themselves and their role, and then I will turn to the first question. Claire, I will start with you.

Claire Foreman: Thank you. Good afternoon. I am the director of medicines policy and strategy at NHS England. That covers a broad policy remit—medicines access, medicines optimisation and medicines net zero.

David Webb: Good afternoon. I am the Chief Pharmaceutical Officer for England. My role is in giving clinical and professional advice to senior decision-makers and policymakers, and I have a supplementary role as head of professions for pharmacy in England.

Joe Bassett: Thank you. I am the chair of the National Homecare Medicines Committee. I suspect I will be talking about what the committee does and the roles it has in a moment.

The Chair: Okay, thanks. Lord Laming, you have the first question.

Q39            Lord Laming: Thank you very much indeed. I am glad to see you. We are aware that there are two systems when it comes to the distribution of pharmaceutical services for people with special needs: that which is directed by the NHS and that which goes through the pharmaceutical companies. It would be very helpful if you could each share your distinct and separate roles in relation to the secure, speedy and efficient distribution of these important medicines to very vulnerable people.

Claire Foreman: NHS England’s Commercial Medicines Unit is the part of our organisation that leads on organising national frameworks for medicines, and in this case it also procures four frameworks for four clinical areas that relate to home care. It is important to say that our commercial medicines unit is responsible for about 4% of the overall total of homecare provision through those frameworks. The frameworks cover home parenteral nutrition, enzyme replacement therapy and lysosomal storage disorders, pulmonary hypertension and bleeding disorders. Three out of those four are for services that have the level of complexity that your question implied. In the case of bleeding disorders, that is a simpler dispense-and-deliver model.

Our commercial medicines unit puts that framework in place, and it allows trusts to draw off that and therefore supply their patients. The commercial medicines unit performs a role in monitoring the performance of those frameworks. The other thing to say about my role is that we are also supporting and a member of the National Homecare Medicines committee. Joe will explain that in a bit more detail, as it relates to other frameworks for homecare medicines.

David Webb: My role is about the clinical application and professional support for those services. You will have heard from colleagues that there are those commissioned by manufacturers themselves and those provisioned by the NHS. Joe will take us through the different tiers in those arrangements.

Regarding the quality of care, Claire and I work together quite closely, and we have instigated a piece of work based on concerns that have been raised about homecare services in NHS England to understand the range of arrangements that are in place and the accountabilities that go with that. One or two things have been really helpful in helping us frame that initial piece of work.

The first is a conversation with the British Society for Rheumatology about the experiences of its patients. The second is speaking to my colleague Alison Strath, the Chief Pharmaceutical Officer for Scotland, about the review for home care that Scotland wants to undertake and what the touchpoints might be between our piece of work and its piece of work. Lastly, it is really important that, in moving our piece of work forward, we take account of the findings of this committee. You will have delved into an amount of evidence and surfaced a number of issues that we should take account of in that work.

Joe Bassett: You have rightly identified the two major categories of homecare medicines services provision into which we can separate things: the manufacturer-commissioned services, which are the derivation for homecare medicines services provided in England; and the NHS-commissioned services, which were introduced later to provide the value for homecare medicines services for products and therapies that were not brought to market by the manufacturer with an attached and bundled funded manufactured service alongside them.

The National Homecare Medicines Committee provides support for the chief pharmacists, who are individually responsible for the services that are provided to patients in their trust. It provides a national focus for those services and a mechanism for us to work with a number of stakeholders, such as the regional homecare specialists representing the individual trusts in their region, as well as ICB leads and other commissioners. We have representation from the homecare industry, the ABPIthe pharmaceutical manufacturersand the NHSE commercial medicines unit.

The procurement and contracting routes for these services are derived from the local service provision, and the contracts are established through NHS framework agreements, or directly where it comes from a manufacturer-commissioned service. A few references have already been made to framework agreements. It is important to add to what Claire said about the CMU’s provision of national framework agreements for specialty areas.

We also have regional NHS collaborative hubs providing regional framework agreements from which NHS trust members can procure local NHS-funded and NHS-commissioned homecare medicines services. For the most part, the manufacturer-commissioned services are considered a local arrangement, and they are directly arranged. They are not purchased underneath one of those NHS framework agreements. They are locally established. I hope that addresses the question.

Lord Laming: That is most helpful. If we think about the patient—

Joe Bassett: As we do.

Lord Laming: The patient depends on the reliable and timely delivery of essential medication. Which one of you threeor is there somebody elseis accountable to make sure that this happens? There is a tremendous number of players in this field. Is one of you accountable for the efficiency of the service and picking up when things go wrong, is it somebody else entirely, or is nobody accountable?

Claire Foreman: The question about accountability is really important. Joe will take us through a bit more of the detail, but it might be helpful to say two things about accountability. One is that we have used lots of phrases about procurement, commissioning and so on. The bottom line is that trusts will have a kind of contract for these services, and it is really important that the contract performance is managed at the contract level. Joe will say a bit more about some of the key performance indicators that are included in contracts. We would expect that where those contracts are not being met, that stimulates a conversation. That is also part of the wider place of where we are on accountability across the NHS at the moment, where the new arrangements are really about trying to empower the local NHS, providers and integrated care systems with the support of regions and the national team.

When it comes to the four areas that I talked about for the commercial medicines unit, our head of unit will be working with the trusts that use those frameworks to make sure that those KPIs are being monitored. Where they are not being met, that would trigger the contract action, which would include, for example, meeting the provider, trying to understand what is going on, trying to resolve the issue and so on. It is ultimately linked back to that framework arrangement and those contracts.

Joe Bassett: Let me take that a bit further. Regarding the management, accountability and responsibility for home care, neither the NHMC nor I as chair hold any formal responsibility or accountability for homecare provision across the entirety of the NHS. Individual chief pharmacists at a local level hold responsibility for the provision of services for their patients. The National Homecare Medicines Committee provides a structure and support network to the representatives of those chief pharmacists in the form of regional homecare specialists and various other stakeholders, who provide support, documentation, guidance and templates as well as facilitate, rationalise and centralise meetings to minimise the duplication that happens at a local level.

The NHMC is beholden to the chief pharmacists locally, and we provide a support framework around them to allow them to manage those services as efficiently as possible—avoiding individual trusts having to have individual conversations where they are greater than individual issues. There is a tiering approach, where local issues are managed locally, but where issues sit beyond the individual locality there is a mechanism to allow the regional specialists to have a collaborative discussion with their chief pharmacists in the region and engage the homecare provider where the issue sits at that point. Similarly, at a national level we are able to engage with the market, and do so on behalf of the collaborative of chief pharmacists across England.

Lord Laming: I have one more question, if I may. There is a huge difference between providing support and being accountable.

Joe Bassett: Correct.

Lord Laming: We heard evidence that the CQC had examined an arrangement where there had been thousands of instances of failure to deliver the right medicine at the right time in the right way. Who is responsible for making sure that that does not happen again? Is there any way in which we as a committee can rest peacefully in our beds at night, knowing that somebody is sorting this out?

Joe Bassett: There is certainly an understanding and a recognition of individual issues that patients experience through homecare medicines services; those challenges can be very concerning and serious for the individual patients affected. We are keen to work with chief pharmacists and other stakeholders to drive the improvement of homecare medicines services. I will just draw out what Claire referenced about a couple of the KPIs that are being reported, so that we can understand the context of what we are discussing here.

Fundamentally, it is my view that homecare medicines services are safe, and they are valued by patients. The latest patient satisfaction surveys from our four largest homecare providers show that between 86% and 99% rate their overall experience of the homecare service as either “good” or “very good”. That used a sample size of 23,000 patients. From the same four largest homecare providers, the KPI data presented to the NHMC supplier engagement sub-group show approximately 430 formal complaints and incidents per month, which certainly need investigation and working through, but that equates to about 0.1% of the 410,000 active patients for those services.

As this committee has already heard, the impact on patients can be significant. We need to work with individual chief pharmacists and the industry to learn from each incident and improve the services, but I do not believe that there is a fundamental issue with homecare services as they are provided at the moment. What needs to happen is further refinement, improvement and efficiency to continue to allow us to support patients as the market continues to grow.

Lord Porter of Spalding: You will have checked the evidence sessions that we have had before, and I am sure that you could understand and feel as well as hear the level of frustration in the room. That is largely because we really do not know this field at all. It was brought to us because somebody whom we know had a bad experience, and we were not sure whether it was just a one-off—one or two bad suppliers—or more manifest than that.

The first evidence session certainly gave us all a strong feeling that we were sitting on top of quite a major service area failure, albeit a very small area of the totality of what the National Health Service does. None the less, it was a large service area failure. Then last week, we heard it was only 2%. Your figures show even less than 1%. Have we got it wrong? Are the professional groups which represent patients, which were very good at advocating that case in the first session, just very good advocates and not necessarily very good witnesses, or is the system so complicated that you can all hold a different end but it is all the same stick? If that is the case, whose interests does it serve to have it so complicated? I do not think your evidence session today will make us any wiser than we were before we started because you will add a whole level of more complicated layering over the top of what was already messy.

Putting it in easy terms for people such as me to understand, a couple of us think, Can’t we just give it to Amazon and let it get on with it?, because Amazon delivers just about anything you want from anywhere in the world at any point in time—you can have it tomorrow if you want it. That is probably unfair. Do not comment on the Amazon bit; I had to get it off my chest.

You said that you deal with only 4% of the totality. Is that 4% by cash volume or patient volume? Of the £4 billion that we spend on this as a country, how much is potentially profitable money, and how much are we giving to drug companies, no matter who they are, and taking that out of the equation from the homecare bit anyway?

David Webb: I will comment on the complexity side of things, and Joe might comment on the value side. You have unearthed a complicated picture that is quite hard to understand even when you are working in the area. For patients, it is quite difficult to know how to navigate this.

Lord Willis of Knaresborough: Why do you not simplify it?

David Webb: I was just coming to the fact that Claire and I are instigating this piece of work to try to get some clarity through the system. The issue with the distributed model as it stands is that the contractual levers are with the individual hospitals because they establish the contracts with the homecare providers. In the case of the manufacturer-commissioned services—the drug company services—which are about 70% of the total, they commission the provider and then the hospital pulls down a service-level agreement with that provider. This means that individual trusts are managing a whole range of contracts.

About 16 months ago, I was a trust chief pharmacist. There is a huge amount of effort involved in managing these contracts and being aware of the impact on your patients, even though they are necessarily at some remove from your geographic location. One of the advantages of home care is that you can provide innovative medicines without pulling people back constantly for repeat fills of those medicines, and you can support the so-called high-tech end of homecare medicines, which involves provision of nursing support and more complex devices, as opposed to the perhaps more straightforward thing that the analogy with other distance providers might suggest.

In a sense, what we would like to do with the piece of work we have initiated is peel back some of the layers and understand the different arrangements and the data behind them. Because the patient numbers are really significant, even small percentages having a poor experience equates, in my mind, to a number of patients, and we should be concerned about that. I reiterate Joe’s point about wanting to learn from those instances. It is very easy to default to quite a transactional view of this—it is a number of contracts, and we are managing it—when, in fact, there is a patient on the end of the supply, as there is if they were right in front of you in the out-patient setting.

That is the sort of place we would like to get to in our work. I understand exactly your question about how all these things can be simultaneously true and your point about complexity of arrangement and who we should have in mind when we are providing these services to patients.

The Chair: How much of the money is spent on things other than the drugs? There is the money that buys the drugs and the money that goes to the people—

Joe Bassett: I do not have a specific figure for you. The substantial value of the total spend through home care will be on the medicine itself. For manufacturer-commissioned products, obviously, the spend is covered through the manufacturer side, so data would not be available from the NHS’s perspective to understand that. What we can do is understand from an NHS-commissioned service what the service values are for the contracting elements of the homecare service provision.

Lord Porter of Spalding: If somebody supplies pills and potions and a person to work with them, as a country, we do not know the cost of the pills and potions or the cost of the person.

Joe Bassett: The manufacturer-commissioned services are tendered as a bundled element of the product, and they are set out by the manufacturer as additional free services alongside the product. They are not tendered by the commercial medicines unit but set out by the CMU as an individual element.

Lord Porter of Spalding: The drug companies give us free people. Is that what you are saying?

Joe Bassett: I am saying that the homecare medicines services through manufacturer-commissioned services are bundled into the price offering that is submitted by manufacturers, which is not transparent to the NHS.

The Chair: I think the consultant mentioned something like that. It is difficult to get clarity on that.

Joe Bassett: With manufacturer-commissioned services, in the price that is submitted by the manufacturer for the products, of which the majority come through NHS commercial medicines unit secondary care tendering exercises, there is no separation, in most cases, for the funded homecare service element. There are more coming through now where the manufacturer offers, essentially, what is considered an unbundled price and a bundled price, whereby there will be an option for direct hospital supply at a given price and a price for the product where it is incorporated as part of the homecare provision. But that is in a comparative minority; most are still bundled through.

Baroness Bertin: Just on the contracts point and the commercial know-how, are you confident? You have made the point that contractual levers lie with the hospitals. Presumably, that is hugely patchy. Some hospitals may be very good at negotiating their contracts. In most organisations, with most big business contracts, if you do not deliver you do not get paid. What is your view on that?

David Webb: I will start, and Claire might like to join in. Because these services have evolved, as opposed to being designed, those responsibilities have developed over time. We want to look at this, but it is right to point to the fact that the local support to manage those contracts effectively is variable.

The other element to pull in at this point is that, post the Hewitt review, we are also thinking about the role of ICBs and their position on driving up quality among providers, and whether ICBs as collaborative arrangements can achieve a scale that would enable them to be potentially more successful in managing these contracts. You are right: it is a volume of activity, and it is important to recognise that. There is often a sense that, if the patient is remote, that is almost activity that has been saved; whereas, actually, there is an amount of contract management and, as you said, following up on those performance indicators, understanding what all that means and taking risk assessments if you are thinking about moving from one provider to another. That calls for a significant understanding of how the contracts operate and the risks.

Although one might be disappointed with one provider, there are risks in migration too because you might be moving people who have had a relatively good experience to something they are less familiar with. There is a phenomenon about incumbency where people are comfortable with what they know, and the hurdle in moving from one provider to another can seem significant.

Baroness Bertin: Will procurement, which you are talking about, be part of the review that you mentioned earlier?

David Webb: At the moment, we are in the initial phases of understanding the range of arrangements, but it is important to take account of that factor—the local resource that goes into supporting that contract management function.

Q40            Lord Shipley: I have a brief question for Joe Bassett. You referred to KPIs and gave us some numbers. As I understand it, there are 61 KPIs. Where are they published, and where is the data collected published? Is it published? Is it available only to a limited number of people; in other words, are all your KPI datasets public to anybody who wants to read them?

Joe Bassett: To address the second point first, in relation to the publication of data, no, there is no published dataset for the performance data at a national aggregated level for homecare medicines services across England. As to what the homecare KPIs are and where they are published as a set, the National Homecare Medicines Committee developed the KPIs in 2013. This goes back to my earlier reference to the National Homecare Medicines Committee providing a support framework around individual trusts to allow them to manage their homecare services effectively.

Prior to the establishment of those national KPIs, individual contracting authorities, individual trusts and regional homecare framework providers established their own KPIs, and there was a lot of unnecessary variation in how they were set, captured and collected. We have established a national set, which has been iterated and developed over time. The national KPIs are published by the RPS as part of the Handbook for Homecare Services in England. They are published on the RPS website as one of the appendices to the handbook.

Lord Willis of Knaresborough: What on earth is the point of having national KPIs if you do not collect the national data, publish it and make it publicly available to be examined? I have tried to find the data because I am a strange person and I like looking at data, but it is impossible to find.

Joe Bassett: You and me both in terms of understanding the data.

Lord Willis of Knaresborough: No, I would understand the data if I could find it.

Joe Bassett: Exactly. The publication of the data is not there at the moment in terms of a national piece.

Lord Willis of Knaresborough: How can you accept that?

Joe Bassett: The national standard KPIs have been set to ensure consistency of approach from each of the individual contracting authorities that are establishing contracts for homecare services. They manage their services against that so that they are all using the same set of metrics. Within the National Homecare Medicines Committee we have a supplier engagement sub-group that monitors performance of homecare providers on an aggregated basis. We engage with the larger homecare providers on a quarterly basis, scaling down for the smaller providers. As part of that engagement, we have those providers present to us an aggregated national set on the position of their businesses at that point in time, investment, development and all the rest of it. But there is no routine data collection that is then published.

Lord Willis of Knaresborough: You have parts of it that the manufacturers should aim for where possible. They are not national standards by which you are going to hold people to account; they are just pie-in-the-sky things that you would say to a set of five year-olds. We are looking at the pharma-funded schemes, where there are supposed to be some national standards, and there are none; there are just hopes.

The Chair: There is a Division. We have to suspend the session. We will be back as soon as we can.

The committee suspended for a Division in the House.

Lord Willis of Knaresborough: I want an assurance from each of you that KPIs will be national and publicly accountable wherever review happens, so that we have a national set of statistics that we can then review and hold everyone to account, irrespective of whether they are part of a framework, an individual contract or, indeed, a new organisation that might emerge from the development. Could I have that assurance? Do you support that?

Claire Foreman: Yes.

Joe Bassett: Yes.

David Webb: Yes.

Lord Willis of Knaresborough: For the record, all three of our witnesses said yes, and asked whether they can now go. Thank you very much.

Joe Bassett: I always enjoy talking about home care.

Q41            Baroness Stedman-Scott: Lots of things have been said about KPIs, so I will not repeat some of the questions that I had, but who sets them?

Joe Bassett: Who sets the measures that are captured?

Baroness Stedman-Scott: Yes, the KPIs.

Joe Bassett: They have been developed by the National Homecare Medicines Committee. As I said earlier, the initial set was agreed in 2013. I mentioned that the committee is made up of representatives of regional homecare specialists, chief pharmacists, manufacturers and homecare providers. They were all involved in the collaborative development of the KPIs to monitor the provision of the services, and they reflect the elements of both the trusts’ and the home care providers’ provision of the service.

Baroness Stedman-Scott: That is clear. I know you said that they are not published, but who should be publishing them?

Joe Bassett: From an NHMC perspective, I mentioned earlier that we do not at present have a remit to publish the KPIs. We are able to capture and monitor data to provide support for the individual chief pharmacists, so were a remit to be provided to the National Homecare Medicines Committee, the capability is there for us to capture and publish that.

Baroness Stedman-Scott: So you do not have the power to do it.

Joe Bassett: At present, that is not part of the committee’s remit.

Baroness Stedman-Scott: That is really interesting. We were given a lot of information and, as my colleague said, we were kind of between one and the other. To clarify, we heard two figures last week: the 98.8% of deliveries figure and the 14-day figure. Can you help us get to the bottom of those? It would be helpful.

Joe Bassett: Today, I have brought the figures from the patient satisfaction survey because that is a useful holistic measure of the service that patients are receiving. In the previous session, there was reference to deliveries to patients on the appropriate day, which is one of the metrics in the KPI set around failed deliveries. At that point, there was a discussion about the point at which the clock starts and stops. 

In the definition for that there is a set for when the delivery date is agreed with the patient and whether the delivery is agreed and delivered on the agreed date. Opportunities for further delay earlier in the process are picked up in other parts of the KPI set. The deliveries figure that was referred to is part of the puzzle but, to give context to the position that we are in at the moment, recognising that there are some issues but we are not facing a major issue, I want to draw attention to the holistic view that patients provide of their overall satisfaction. A significant majority of the significant sample size are content with the service they are receiving.

Q42            Baroness Stedman-Scott: Thank you. How do you monitor the standards of homecare services? How can other interested parties do it too?

Joe Bassett: The National Homecare Medicines Committee supplier engagement sub-group engages with the homecare providers on a periodic basis. I mentioned earlier that we engage with the larger of our providers on a quarterly basis and with the other providers on a six-month or annual basis, scaling down. That is our primary route in the committee for engaging with providers on a one-to-one basis. They share with us the national aggregated performance data, and we, as regional homecare specialists, and the commercial medicines unit, as part of that supplier engagement sub-group, work with the provider, reviewing the performance it is seeing at that point in time and agreeing appropriate action.

An escalation process is tied into the supplier engagement subgroup that allows for additional meetings to be had with a provider at an elevated frequency to work through any particularly challenges it is having. That can be triggered by the provider itself as part of a self-referral, or as part of the supplier engagement routine meetings, if we are not content with the figures when the provider presents us with the national aggregated performance data. There is also a mechanism for us to liaise with the regional homecare specialists; we do that on a two-weekly basis. Where issues are flagged by the regional homecare specialists that are appearing in multiple parts of the country, we can trigger escalation.

We have very good engagement with our homecare providers for that process, but there is no mandate behind it, and the NHMC does not hold an enforcement mechanism to enforce any action off the back of those sessions. Although we have very good engagement and discussion and we work through the challenges with the homecare provider in a collaborative way, we do not have an enforcement mechanism behind it.

Baroness Stedman-Scott: Apart from you, with your good relationships with the providers, there is no mechanism for other third parties to have the information and collaboration that you talked about. Does it rely on freedom of information requests to get it?

Joe Bassett: As I said, the publication of data is not there at present. We made the commitment to take that through. The provision that we are making here with the supplier engagement group is to provide support for the individual trusts that are responsible for managing their individual homecare services. The current mechanism does not provide external output to the public. It is a collation of the regional homecare specialists, which is then delegated out and down to the individual contracting authorities that they represent.

Baroness Stedman-Scott: Thank you very much.

Claire Foreman: I know your question was mainly about looking at the data on how performance is working, but it is worth adding a couple of things. As Joe said, the CMU is part of that process. When it comes to the four frameworks that the CMU tenders for, there are two things I want to add. One is that those tenders are put out on a public portal: the standards and KPIs that are expected are publicly available. Secondly, the commercial medicines unit includes patient groups or patient representatives in its work to prepare for those tenders. That input from patient groups is really important.

Lord Porter of Spalding: On what you said about the patient survey, what does a large sample mean in numbers and as a percentage?

Joe Bassett: These are the latest patient satisfaction questionnaire results from the largest four homecare providers. That cohort equates to about 410,000 patients out of the 550,000 or so in the market overall. The number of responding patients across that cohort was approximately 23,000.

Lord Porter of Spalding: Out of 410,000.

Joe Bassett: Yes. Out of 410,000 patients, 23,000 responded to that patient satisfaction questionnaire. The annual questionnaire that is expected to be provided by each homecare provider is established on a national standard by the National Homecare Medicines Committee. Each patient is given the opportunity to feed back their views through the patient satisfaction questionnaire.

Lord Porter of Spalding: Yes, but we all know, from every survey that anybody has ever done, that unless you attach a cash payment for it, you are not likely to get a response from most people, even if they are really angry with the service. If they think you give a bad service, they do not see the point in telling you, because you have been told and you do not care, so there is no point in recording it.

Joe Bassett: That is the reason why I brought two measures today, to demonstrate both the patient satisfaction figures that we capture and the formal complaints and incidents data that the homecare providers capture. I fully accept that a number of patients will, to a degree, suffer in silence in certain cases, but we have specific guidance that we have set out for the management of complaints and incidents in home care, each of which are reported. I have shared the figures about what we see.

Lord Porter of Spalding: I admit that I am not as bothered as others are about the service being bad because I still struggle to get my head around whether we had very clever people telling us how bad it was at the start and some very clever people telling us how good it is in the middle and at the end. I am still not certain, but I want to make sure we capture as much data as possible.

Q43            Lord Shipley: I would like to pursue the issue that Lord Porter raised about the patient satisfaction survey because some big numbers were quoted. You talked about a formal complaints procedure. You also said that some will suffer in silence, but we do not quite know who they are and whether they are suffering in silence. The question is how many there are and whether they are suffering harm. I want to pursue that issue of harm. There are complaints about failure of a service, but there can be complaints about many public services that do not result in harm. The question is whether you have any evidence that individuals have suffered harm.

I will quote from the written evidence that we received from the British Society for Rheumatology, which has now been published. It said that patients are still reporting missing or delaying doses, impacting psychological and physical wellbeing’. It said that the survey sample found an average of 9 patients missing doses per month per submission (range from 0.5 to 70) and a lack of contact with new patients and delays in registration and delivery, with an average delay of 6 weeks for patients starting new medications (responses ranged from 2 to 24 weeks). Crucially, it said: Members report that this has resulted in flares and less well controlled disease amongst those patients affected, increased anxiety, and an increased use of steroids. The evidence quoted an anonymous member saying that it is an ongoing issue with delays up to 6 weeks to start medication and patients calling and needing more bridging steroids to get them through.

In the last two evidence sessions, we asked questions about harm. Last week, in answer to Lord Porter’s question to the General Pharmaceutical Council and the CQC about what evidence they have from data about whether people have suffered harm, the CQC said, We do not collect that data, and the General Pharmaceutical Council said, We do not collect that data either.

My question to you is: do you collect data, whether or not it is published? Even if you do not collect data, are you aware of anybody who could answer the question of how many people have suffered harm in a medical sense as a consequence of the way in which the service operates?

Joe Bassett: I am happy to pick that up. Within the KPI set we have an understanding and a breakdown of the incidents by category. We are able to capture from the homecare provider incidents that have a harm element. That also incorporates the provision of duty-of-candour incidents, which are the more serious of those incidents. That data is available to the chief pharmacists, who are responsible for service provision. It is captured as part of the national KPI data that is presented in the national supplier engagement meetings that I referred to earlier.

To return to the previous point, there is the fundamental of the unknown of what we do not see from patients. We can report on and share with you only the information that is captured. In this space we have published guidance for complaints and incidents in homecare medicines services. Again, that links back to the RPS handbook for homecare services. Some years ago we worked through some specific guidance for managing complaints and incidents in home care, which gave some specific and tailored guidance for certain incident types, including those with harm. That is supported by the KPIs to allow monitoring by the chief pharmacists in the local homecare teams. The data is being captured and reported, but it is not published.

Lord Shipley: Can anybody else add anything at all of relevance to the question of medical harm caused by the system not working properly? If you do not have anything, I am happy to be told that, but I just want to hear it.

David Webb: I do not think we do. I take very seriously patient experience that results in harm. We can go after more detailed information, above the transactional level of documenting it, by reaching out to providers—hospitals—for their untoward incident policies, which should capture the experiences of their patients that might relate to those issues. There is a way to create the true patient experience from the data that Joe referred to.

Lord Laming: What did you think of the evidence from the British Society for Rheumatology?

David Webb: It is concerning because, as I said at the outset, it is very easy to take a transactional view on these things and not be mindful about the consequences for individuals. To my mind, there are two important issues in this. The first is the delay to initiation and the illness impact of that. The second is the interruption in therapy and the potential escape phenomena that are associated with that.

Regarding the delay to initiation, that is probably a feature of how those services now operate, as opposed to where they started. Initially, the services were about transferring stabilised patients on to a new mode of delivery. The more recent developments are much more about initiation. The consequence of delaying initiation relates to some of the information that you have shared with us today. Both are important, but they probably reflect different process issues. A missed delivery versus a delay in starting probably reflects different problems within the homecare provider.

Claire Foreman: David is exactly right. The only thing I will add, which also picks up on Lord Porter’s earlier question, is that looking at the untoward incident data will give us the clinical view of what has happened to that patient. Of course, it is still entirely the case that an individual patient’s view may be that they have experienced those things, even if it is not recorded as a clinical incident. It is really important that we listen to that and understand the anxiety that patients may feel about their expectations when they are starting treatment and when their treatment is being delivered. That is part of the answer about how both those things can be true at the same time.

David and I met the British Society for Rheumatology and we had a very productive conversation. The Society shared some of these experiences with us. As David said, it triggered the work that we are looking into now to understand the issues better. Whatever the clinical outcomes—we need to make sure that the issues of harm are properly addressed—it is still really important if the patient feels anxious about what is happening to their service.

Q44            The Chair: I want to go back to the third question about standards and holding people to account. Do I have this right? It is a funny juxtaposition that I am not quite clear about. The committee collects the data, has these conversations and has the power to escalate. Then there are a lot of regulators, two of which we spoke to last week. When I look at the membership of the National Homecare Medicines Committee, it strikes me as a sort of advisory committee. It is a meeting of everybody concerned. It brings together everybody who has an interest in all the different parts of the business, and is a great forum for seeking views, having conversations and exchanging information.

What puzzles me is that you seem also to be the first stage in monitoring and holding people to account, and that does not lie easy with me because you are monitoring yourself. There is no element of independence; it does not look as though that is what you have been set up to do. It looks to me as though you have been set up as what I would call a very important high-level advisory committee with a lot of information. Have I got that wrong?

What I think then happens is that you get the data and you might escalate it and have this conversation. You escalate because you do not have the powers. I am not sure whether that is right and proper; it does not ring right to me. How often do you escalate and can the people who have the power—the regulators—do anything unless you escalate? What bothers me is the relationship of your committee, which has providers on it, with the providers—inspecting them and, essentially, being the first line of accountability. That sounds to me a very cosy relationship that might not work. That is a bit complicated, but it bothers me.

Joe Bassett: I appreciate that question. The first piece is on clarification of where the membership splits out into the sub-groups. You are absolutely correct that the National Homecare Medicines Committee is a special interest network group that provides collaboration from all the players and stakeholders within the market to be able to provide a steer, guidance and advice on how it can go about delivering the best service for patients.

The supplier engagements sub-group is NHS-exclusive. It is made up of the regional homecare specialists, who represent the chief pharmacists and provider trusts within their geography, as well as the NHS England commercial medicines unit. Yes, there is a connection through the NHMC, but, no, there is not that direct accountability from one homecare provider to be part of an escalation for another. They are separated out.

One piece I wanted to pick up on from your comments is that we liaise and engage with our regulators. We are completely cognisant of the limitations that we have as a committee to be able to take enforcement action against any provider. I am very proud of the engagement that we have with the NCHA and its members. The engagement that we have through those escalation routes is very productive, and we are able to be collaborative in our working in the interests of the patient for whom we are all trying to provide a good service. But we are able to feed the link into the appropriate regulator—you had the CQC and the GPhC in previously—where there are concerns from the committee’s side for them to be able to investigate further. Obviously, that is not the only route in that those regulators have, but it is certainly one that we feed into.

The Chair: You are at a national level. Would both the chief pharmacists and the pharmacies at regional level have any power to mould this system in terms of either complaints or structuring it? Do they have any influence, or does it always have to go from them up to you and then back down again?

Joe Bassett: This ties back into what we were talking about on the regional framework agreements. We have individual NHS collaborative procurement hubs that are providing regional framework agreements for the NHS-commissioned homecare services. Many of those NHS-commissioned hubs or NHS collaborative procurement hubs will host a regional homecare specialist. That is provided to support the individual chief pharmacist in their locality. The funding is variable for those posts, but they provide the opportunity for the local chief pharmacist to feed into a regional specialist, who is able to act on behalf of that region at that level, especially if there is a regional framework agreement established by that same procurement hub. They are also able to act as the conduit between the local chief pharmacist and the National Homecare Medicines Committee.

The Chair: I have one more question on the powers of your committee. Say you thought there were not enough providers of sufficient quality in the market. Do you have any routes to change that? Can you say, We need more people to come along and provide this service. We need better competition and better standards, or does that lie elsewhere, and, if so, where?

Joe Bassett: I will refer back to the engagement we have with the National Clinical Homecare Association, which is the trade body for the homecare providers. There is a large volume of homecare providers that are in the market and able to provide service. At the minute we have quite a disproportionate spread of utilisation of those providers. Part of that is driven through the prevalence of the manufacturer-commissioned services, where there is a tendency for those services toward specific providers and larger providers.

Yes, there is a mechanism for us to engage and to share out to say that we would like more competition and more suppliers in the market. No, I do not believe that is a problem that we are facing right now.

The Chair: They have a vested interest in the market not growing, have they not, because they are the providers? Why would they say, ‘We’ll help you get more people to compete with us?

Joe Bassett: There is representation from a large volume of members. Yes, I appreciate that there is the potential conflict for an individual provider to seek to hold their cohort of patients, but I would like to make it clear that there is not a fundamental limitation of homecare providers available to provide the service. We have various mechanisms through the regional framework agreements that provide the opportunity for individual NHS trusts to utilise a wide range of homecare providers, but through one mechanism or another, whether it is the manufacturer-commissioned services or the familiarity that those trusts have with certain providers, we have a disproportionality of the spread of patients across those available providers.

Lord Porter of Spalding: Is that data available anywhere?

Joe Bassett: As to the number of patients per provider?

Q45            Lord Porter of Spalding: Yes, how that all pans out. What you are describing is a very loose version of a cartel, without it being encouraged or discouraged anyway. That is what it sounds like. We have allowed people to bolt bits on to a service that make it almost exclusive for those people to be able to choose to whom, when and where they supply their stuff. That cannot be healthy. If we at least had sight of that, we could be reassured that, No, you got it wrong. I was hearing the wrong thing in my head when you were telling that story.

Joe Bassett: The KPI data that we referenced earlier on the ability to publish and the commitment to work forwards with, yes, incorporates patient volume. Where we are able to present that, there will be the ability to provide a split of utilisation of different homecare providers.

On the comment about a loose cartel, I believe, frankly, that the freedom and the public procurement that is utilised within this space ensure that each approach that the NHS makes out specifically for NHS-commissioned services is tendered through the public procurement regulations and is open to the market. With the frameworks that we have, we have a large range of providers that are able to bid on that where NCHA membership is not any kind of criteria for award.

While it is very helpful to have the trade association there to work and engage with, it is not a channel through which every available homecare provider must pass in order to tender and bid for NHS-commissioned work.

Lord Porter of Spalding: That data is available, so we will be able to see how many did not pass through that gateway.

Joe Bassett: The KPI data that is captured shows patient volume, yesregistered patients.

Lord Porter of Spalding: If they are not members, we will be able to know that, will we not? Somewhere there will be a published list of its members.

Joe Bassett: The NCHA publishes a list of members. Yes, correct.

Lord Porter of Spalding: Then I am assuming somebody in government somewhere is going down through that list and saying, That’s really interesting. Nobody not on this list has managed to get on this list’.

Joe Bassett: There is certainly the publication of each regional framework agreement through PCRpublic contract regulations. The suppliers awarded those regional framework agreements are again published, so, yes, that is open for review.

Lord Porter of Spalding: I will have to go and capture it—

Q46            Lord Laming: The picture that we are getting—please correct me if this is wrong—is that there would have to be a dramatic failure of provision before anybody would identify that there was a failure and be in a position to do anything about it.

Claire Foreman: If that is the impression that you have been given, we probably need to try a bit harder to help you with that. Joe has explained in quite a lot of detail some of the collaborative arrangements. Given that individual trust pharmacists are accountable and given that trusts are holding these contracts, Joe has talked about a space in which people are coming together to share information about how providers are performing to work out where there are problems and how to work through and talk to those providers to try to resolve some of those problems.

I can see that your worry is where the one place is, but I would not want the committee to go away thinking that those collaborative arrangements that Joe has been talking about do not provide a really important place for people who are accountable, for those elements to come together and share the experience and try to work together to improve those services for patients.

Joe Bassett: The inference I took from that question is that there will have to be big problems at a national level for any action to be taken. What we are talking about here is a tiered approach, where you have local chief pharmacists empowered through their contractual arrangements, and they have the information and the data routinely provided to them through their contracts to be able to take local decisions where there are individual issues happening at a local level.

The structure that is built through the National Homecare Medicines Committee enables the appropriate action to be taken where you have issues that extend beyond a single contracting authority or a single trust. Where you have issues that extend into a regional level, regional action can be taken, and where you have issues that extend into a national level, national action can be taken. It is not about hitting a mark for a national action; it is about all the steps that are taken, from individual chief pharmacist level up, to being able to provide that support.

Lord Laming: The evidence we had from the CQC was that a provider had failed in almost 10,000 deliveries before the CQC decided to investigate. That is quite a serious failure in respect of very vulnerable patients. What we are trying to get at is: is there a fail-safe system, or do you have to wait until it suddenly gets exposed that there has been a dramatic failure before anything happens?

David Webb: The information that is available to you locally as a chief pharmacist should reveal those problems before you get to the extent of misadventure that you are pointing to. You have access to the KPIs that enable you to see comparative performance. That does not swim against the information that you have told us about as to the findings of the CQC. As part of the work that Claire and I want to do, our commitment would be to understand better what those trigger points might be and how we might get to a situation where the kind of regulatory action is triggered at what would appear on the face of it to be quite a late stage of impact.

It is those two things. It is the availability of information locally to enable you to make a decision. As I mentioned previously, sometimes that is a risk assessment. Are you going to stop putting new patients with a particular provider because you are not content with its performance? Then you look across and you need to be content that the homecare provider you might use has satisfactory performance, through to more significant actions, which is about transferring the whole of a patient cohort, and the risk assessment you have to make on that in terms of other people you will destabilise just by the act of movement. These judgments have to be framed by an understanding of what is happening locally and informed by the information that you have to help you.

Joe Bassett: Very quickly, to add to that point, in that particular instance the NHMC was already acting and intervening prior to the CQC’s involvement. The ability for the information to move through what I appreciate can seem a very complex system enables us to have the visibility and understanding and provide some of the trigger points into the regulators for them to be able to take action.

Q47            Lord Willis of Knaresborough: First, thank you all very much for your evidence this afternoon. It has been interesting. You have been very frank and free with us, and we appreciate that. Can I just raise one point in relation to what you have already said in response to Lord Porter? Does not one particular provider have about 80% of the business?

Joe Bassett: I do not know the percentage, but certainly one provider has a substantial volume. I mentioned the four providers; that equates to 45%.

Lord Willis of Knaresborough: One provider has 45% of £4 billion. It is a pretty significant contract that this particular group has.

Joe Bassett: Multiple contracts rather than single, but, yes.

Lord Willis of Knaresborough: Lord Porter is quite right to raise this as a major issue.

My question is: if you were designing a new system from the ground up—you have all hinted that we would not have this system if we were starting afresh, and I am delighted that a review will be commenced—what would the new system look like? Can we start with you, David? This should be much more to do with pharmacological services than logistics, but that seems to dominate.

David Webb: We would design in such a way that we started to take account of the different ways of providing medicines. What tends to happen with home care is that it initiates and then it grows. We understand that the annual growth is significant in this activity. The benefits that it brings are the—

Lord Willis of Knaresborough: I know all that. Where are we going to start? What is it going to look like? Who is going to be leading it? Who is the person we will go to who will take responsibility? Will it be the Secretary of State, for instance? Will it be the Chief Pharmaceutical Officer? Who will it be?

David Webb: In creating that new environment, I would be very interested in exploring that.

Lord Willis of Knaresborough: You explore it. Just tell us who you think should be leading it. With respect, with your position, you and the area officers should have far more power than they seem to have.

David Webb: I say explore because it is multifactorial. It is really important that we think about the network of community pharmacy, for example, and how that might be involved in the provision of medicines. As Joe mentioned, there are issues with the bundling of service and medicines cost. If one unbundled the cost of delivery from the cost of the medicine, that might create an opportunity to deliver medicines that are different.

Lord Willis of Knaresborough: Let me just follow up the pharmacy question. I was staggered last week to hear that the mere idea of interoperability between you and the home pharmacological services and the local pharmacological services could not be put together, and that we could not use one to support the other. What is your view of that? In this new review would that be—

David Webb: Digital interoperability is absolutely essential. The electronic transmission of prescriptions between different hospitals to different homecare providers would be a significant step forward. For that Electronic Prescription Service – the EPS as it is called, that system, we would need to make sure that the same priority was given to the element that relates to home care as it is to other initiatives; for example, the movement of EPS into secondary care as a whole, which would enable out-patients—not necessarily homecare patients—to receive their hospital out-patient prescription at a community pharmacy. All those things hinge around secondary care being able to use EPS. In that digital transformation, we should be putting emphasis on its importance so that in the priority of digital development it is sufficiently visible and resourced to do that.

Lord Willis of Knaresborough: I wonder whether Joe and Claire would agree with that.

Joe Bassett: Forgive me, Claire, for jumping in. In terms of the provision of homecare medicines services, the reliance on wet signature to date remains a fundamental problem, as well as communication across the organisational barrier between the trust—

Lord Willis of Knaresborough: How do you solve it? I am looking for solutions.

Joe Bassett: As a committee we have worked through and established a digital strategy in 2020 to set out what the requirements of the homecare market were for digitalisation within this space. We have engaged with NHS Digital, now merged with NHS England, and continue to do so on the rollout of EPS into secondary care. That remains the long-term approach. What the committee has done along with the NCHA—

Lord Willis of Knaresborough: You are moving away now. You are going down one of your roads. Do you feel that the interoperability of pharmacological services would be a step forward in trying to make this: yes or no?

Joe Bassett: Yes.

Lord Willis of Knaresborough: You do. What do you say, Claire?

Claire Foreman: I agree.

Lord Willis of Knaresborough: Can I ask you to agree on something else? Why do we not get rid of the committee altogether and put it back in the department and work with the pharmacological services so that you cut out one stage altogether and you start to have national agreements with national contracts that are delivered locally? Is that another step forward? I am looking for efficiency and effectiveness and the rights of patients to know whether this is good or bad. I want to do it that way.

Claire Foreman: I will link that to your question about what the future might look like. My first point is that this is why David and I have asked for this piece of work to be done. We have talked about the complexity, and it is so important to me that we make sure that we fully understand all the problems so that we can work out what is the right thing to do to fix those problems.

Lord Willis of Knaresborough: Claire, I am sorry to interrupt you. We are very short of time. It is impossible to have an effective review if, in fact, you start with the principle, How do we fit the existing groups within something new?You really have to start with something that will have a complete look at it, pull out the core bits, and then add from there. You seem to be looking at the silos that have been built up and saying, How do we fit them in again?Am I wrong? Tell me if I am wrong.

Claire Foreman: I do not think you are wrong. I am saying that we are looking at all the issues. Actually, we might discover that there are small things that can be done to fix the problem. We have to be very careful about assuming that what we have now is entirely wrong. We have heard a lot of the information from Joe and others about the benefits of the current arrangements and how they have evolved. They have evolved for a reason in the way that they are. We started this work on the basis that, at times, the arrangements are not meeting the needs of patients, and we need to be really clear about that.

From my perspective, the other bit is that we are moving in a direction more generally that is about empowering local providers for them to work individually or together through things such as provider collaboratives, working with their local integrated care boards and integrated care systems. It will be important that we make sure as we go forward that we balance off that set of arrangements, which are about making sure there is clarity about who is responsible at that local level, with the things that we need to do to increase at a regional or a national level the support when there are problems. A lot of our discussion is about when it breaks down, but a lot of the arrangements that we have been talking about are delivering a choice for patients to have their medicines at home and they are delivering for patients. It is about how we make sure that we are really clear about the bits that are failing, and failing patients’ expectations, and that we build from there to try to fix that problem.

Lord Willis of Knaresborough: My interest in this goes beyond. I do not believe you can have an NHS system in the 21st century that does not, in fact, move a significant number of patients out of hospital—out of primary and, indeed, secondary care—and into home care. The idea of virtual units within people’s own homes depends on this service becoming a Rolls-Royce service of huge magnitude. That is the vision. I was hoping you might come along and say, We have a vision to do this so much bigger, rather than Let’s just repair the damage. Get excited. I am finished now, Chair.

Q48            The Chair: I am really conscious that we have kept you 50% longer than the time we indicated. There is about to be another vote, and it puts us into all kinds of formal difficulties if I have not closed the meeting by the end. This is a really big question. We might take a risk with two little questions.

Could you give us some idea of the timeframe? Phil’s question is quite important. What we have asked before is: how much of a problem do you think there is? You are saying something slightly different from our previous witnesses, I think. You are saying, Yes, we hear what you say. There is a problem. What Phil is saying is, ‘There’s a bigger problem. Seize the chance. Do you not seize the chance and think, Here’s an opportunity. Go for it, because you do not see that there is a problem, or just because the constraints in which you work make it rather difficult for that to happen?

Would everybody agree if I finished with those questions and then we will bring the hearing to a close? Joe, I will start with you because I started with Claire last time, and I will work up to Claire.

Joe Bassett: In terms of a timetable for the piece of work, I will leave that for David and Claire to run through. I am absolutely supportive of the opportunity that is here. At a high level within government there is a strategy looking at trying to provide care closer to home and care in the home. I have been very impassioned about home care for some time as to the value that it can provide to patients and the opportunity that it has to improve the care that we provide to out-patients so that they can continue to live as normal lives as possible with whatever condition they are experiencing. I am certainly an advocate of looking at an opportunity to work through, but I am also cognisant of the fact that this is a complex system, and even from the inside there are multiple cogs moving around, and I am very keen that we take the time to understand what the implications of the different changes will be before we double-foot into an approach.

David Webb: In terms of excitement, I think the excitement is the issue you point to. We have spoken very much, have we not, about the delivery of medicines? But home care is also about the delivery of nursing support and complex technical interventions. We will start to realise the vision of moving more people away from the acute provider environment and into that sort of virtual home. That side of things is very exciting and I think is specifically a homecare function. Some of the other options I talked about would be more on the medicines delivery side than that very technical focus. On timescale, Claire and I are right at the instigation of this piece of work.

The Chair: At the start.

David Webb: I think it is going to be a two-phase piece. We will do some initial work to understand the magnitude—

The Chair: Our report will be published before yours.

David Webb: Yes, and we would want to take account of your findings.

The Chair: Okay, that is helpful, thanks. You have the last word, Claire.

Claire Foreman: The timing, therefore, works out really well, because we want to be able to receive the outcomes of this inquiry into the work that David and I have been talking about. I suppose, like the others, I am excited too. The other bit about timing is, of course, that there is lots of work going on thinking about things such as the workforce plan, the major conditions strategy, and so on. The timing is right to not only be thinking about how we can address some of the issues that started your inquiry in the first place but to move forward. We would also like to offer you something for your report that might help with some of the explanation of the complexities. We will provide some further information for you.

The Chair: Any diagrams, or the way that money flows through the system, or anything like that, would be helpful. That would be marvellous. We have timed it perfectly. It just gives me time to thank you all. We are very appreciative of the openness with which you have spoken to us and the patience with which you have taken our questions.

We are very keen on this area. We really want to try to make a difference. We are very grateful for that and for the extra time that you have given us today. If there is anything that you wish you could have covered in greater depth, we are still taking written evidence, and it can still go in the report and it will be published, so that would be very welcome. Other than that, on behalf of us all, I thank you.