British Society for Rheumatology – Supplementary written evidence (HMS0010)
BSR Feedback from Homecare Medicines Inquiry Evidence session 21/6/2023
Following on from the evidence session you held on 21.06, including representatives from the Homecare Industry and the regulators, we at BSR thought it would be good to write to the committee with some feedback which we believe will help the committee in its deliberations.
There are three areas we would like to provide context and detail on following on from evidence submitted by these witnesses. Two relate to claims made Alison Davis, Chair of the NCHA and one relates to claims made by the representatives of the Regulators.
Feedback on evidence given by the NCHA.
It is the opinion of BSR that two pieces of information supplied to the committee by the NCHA were misleading and designed to give the committee a false impression of the performance of the industry.
The first of these statistics is the claim made that 98% of medicine deliveries ‘arrive on the day they are intended’. This statistic was given to the committee, we believe, to give the impression that 98% of patients are receiving their medications on time. It is the view of BSR members that this is not the case. In our written evidence we supplied survey data collected from our members in 23% of all NHS trusts in England which reported that on average 9 patients per month (range from 0.5 to 70) are missing doses as a result of issues with Homecare providers. If that average were applied to every trust in NHS England that would mean, within just Rheumatology Homecare services, 23,220 patients would be missing doses every year. Although we cannot say this is the case for certain, as we don’t have a holistic and verified set of data to analyse, information gathered from 23% of all trusts is statistically significant as a sample and obviously paints a drastically different picture to the one given by the NCHA in your evidence session.
We would therefore ask the committee to challenge and scrutinise the statistic given by the NCHA: how did they come to the figure that 98% of deliveries arriving ‘on the day they are intended’? Does that mean these deliveries are arriving within the time they are measured against within their Service Level Agreements? We believe these SLAs stipulate there is a target time for medicines to be dispensed to patients after both initial referrals to Homecare Services and once prescription requests are made. These target times are very important for condition management and mitigating the risk of harm and we ask the committee to challenge the industry on how they are performing against these measurements.
It is important to note that there is a difference between a delivery arriving ‘when it is intended’ i.e on the day a delivery has been booked in with a patient, and when the medicine was supposed to have been dispensed to a patient, i.e the length of time following a patient having been referred to a Homecare Provider, or a prescription request being raised. This is a vitally important distinction as delays in medicines reaching a patient are often occurring before the delivery stage, in the processing of patient registration and the processing and handling of prescriptions.
We have been told by the NCHA in our own meetings with them that prescription handling and processing is an issue within some Homecare Providers, particularly some of the larger providers servicing the majority of patients, due to the number of prescriptions being handled and insufficient processes in place within these companies to ensure that paper prescriptions are processed and accessible to the company’s customer support systems. For example, a lack of a sufficient number of staff within Homecare companies processing facilities, or an insufficient amount of IT resourcing for things like scanners. The NCHA told us these issues are felt particularly acutely when problems occur in the system and backlogs of prescriptions arriving within businesses build up, leaving vital medicine prescriptions sat in company in-trays.
As stated previously we therefore believe the first statistic provided, i.e ‘98% of deliveries arriving on the day they were intended’, was given to mislead the committee about the state of their performance.
Furthermore, BSR believes it is important to recognise that the data given to the committee by the NCHA as evidence is gathered, processed and reported entirely by the industry itself. There is no oversight or verification of how these statistics are gathered and reported. Within effect, the industry is marking its own homework.
In our written submission we made clear that BSR would like to see greater transparency and accountability on the reporting of performance data in the Homecare Industry and in this area made the following recommendations for the committee to consider;
Government commits to review and co-produce with stakeholders a simplified framework of KPIs.
Government commits to making data publicly available on the quality, reliability and safety of homecare medicines services and that information around patient safety is independently verified.
Providers commit to investing in gathering feedback from patients and increasing survey return numbers.
Following the inquiry evidence sessions we would go further to add that we believe it is important that these industry & NHS KPIs are regularly verified and audited by an independent body.
This statistic was given to the committee, we believe, to give the impression that delays in processing prescriptions is being caused by delays in the NHS, rather than with problems with a Homecare provider/s.
Committee members rightly asked in the session how it was possible for prescriptions to be taking so long to leave hospital pharmacies and members were right to be sceptical of this claim.
After the NCHA made this claim BSR spoke to Consultant Rheumatology Pharmacists who confirmed the current process, and expectations, in NHS Pharmacies to manage and process prescription requests for the Homecare sector to dispense. This is what they said;
“...our hospital pharmacy homecare team (technician led) work towards an SLA of having prescriptions processed and sent to homecare providers within 2 working days from receipt of prescriptions from the specialty team (NB they receive them screened as we screen them ourselves as a rheumatology specialist pharmacist team before sending to the hospital pharmacy homecare team). I do not have exact audit / outcome data to hand but the adherence to this SLA is very high. It certainly isn’t where the delays are happening for our team. The prescriptions are still posted to the homecare provider so an example timescale is below:”
“Rheumatology team prescribe and screen homecare prescriptions and take to the hospital pharmacy team e.g. on a Thursday
Hospital pharmacy homecare team process and post prescriptions within 2 working days e.g. on the Friday and Monday.
Prescriptions usually arrive with the homecare provider after a couple of days e.g. by the Wednesday and Thursday.”
“Urgent prescriptions are emailed in advance.”
Although this timeline does demonstrate that the system is not working as rapidly as we may expect in a modern Health Service, it does demonstrate that the claim Hospital Pharmacies are taking 10 days to process prescriptions to be inaccurate.
We would remind the committee that the statistics given as evidence by the NCHA are self-reported and we believe, in this context, have been cherry picked to mislead the committee and misdirect responsibility for faults in the system away from the companies which are ultimately profiting from its current design.
In our written evidence to the committee, as well as making clear recommendations for the need of transparency on data, we also called for the need to develop an interoperable e-prescribing system that will eliminate delays that are evidenced in the system and not currently in the control of either the NHS or Homecare providers. These recommendations were;
Government commits to publish a firm timetable to move homecare medicines services away from a paper based prescribing system, addressing any outstanding regulatory barriers that currently stand in the way.
Where electronic prescribing is made available, training and new processes are co-produced and delivered with clinicians.
Registration (at the point of care) and prescribing processes use digital solutions that reduce the administrative burden upon clinicians.
Finally, we would like to move on to evidence submitted orally by the CQC and GPhC.
The CQC representative stated in their evidence they play a ‘pro-active role’ with stakeholders to ensure high standards including with BSR.
In the evidence submitted by the regulators a comment was made by the CQC representative that they hold a ‘pro-active’ relationship with Stakeholders, including BSR. We feel this this assertion to the committee mischaracterises the relationship we have had with both the CQC and the GPhC in relation to our on-going concerns with Homecare Medicines Services. So much so that we feel the need to outline to the committee the timeline of engagement we have had with the regulators over the course of the last year.
We approached both regulators in the Autumn of 2022 after our members and patients reported significant disruption with Homecare Services. This disruption was significant enough for the NHS, via the National Homecare Medicines Committee, to initiate a performance management escalation process with Sciensus, the largest Homecare provider in the sector. The initiation of this escalation process by the NHS did not precipitate a ‘pro-active’ set of engagement from the regulators. We and/or sector partners did not hear from them about these issues, we approached them.
During initial contact with both regulators, which was carried out by BSR in the interest of making them aware of our concerns, both regulators stated that underperformance within the Homecare industry was not ‘on their radar’. It was our view that this lack awareness was odd at the time, given that disruption was being widely reported and the NHS itself had instituted an escalation process on the sectors largest provider. However, we felt the need to give the regulators the benefit of the doubt and following discussion with them submitted evidence of disruption within the Homecare sector in over 20 NHS trusts and Health Boards in England and Scotland (we also approach the Care Inspectorate in Scotland where appropriate.)
After receipt of this evidence, to the best of our knowledge, both regulators decided to take no further action and we have not heard from either organisations since submitting our evidence. We believe their decision to take no further action contradicts the tone of the evidence they submitted to you, as we believe our evidence showed that patients were being put at risk of harm as a result of underperformance within the sector.
In way of informing the committee we have also attached the evidence we submitted to the CQC and GPhC for you to review yourselves, so you can make your own judgement on whether their decision to take no further action was appropriate in the circumstances.
BSR understands that the GPhC carried out an inspection of one Homecare Provider in the Spring of 2022, and that the outcome of that inspection was that the pharmacy function was rated as meeting the regulators standards. However, just a few months later disruption and poor service was so significant that the NHS put that same provider in an escalation process, meaning either the standards being set by the GPhC are not adequate to ensure safety, or that Homecare companies are so lacking in resilience that just a few months can make the difference between a good service and a failing service.
We think this is an important area where the committee may want to consider recommendations and in our written evidence we submitted two recommendations relating to this area;
Furthermore, we also believe that the lack of awareness and responsiveness of the regulators concerning underperformance in this area represents a significant oversight in the design and suitability of patient complaint systems and we made the following recommendations we would like the committee to consider to rectify this.
The system of complaints must be clear to patients and clinicians and should be made publicly available on the providers’ websites. It must clearly set out an escalation process to satisfactorily resolve issues.
Patients and clinicians need to be made aware when speaking with provider’s customer service teams when their complaints are not registered as formal complaints and categorised as incidents and therefore not being formally escalated.
30 June 2023