Alison Davis, Chair, National Clinical Homecare Association (NCHA) – Supplementary written evidence (HMS0012)

RE: Homecare Medicines Services Inquiry

 

Executive Summary

 

Thank you for inviting us to provide written evidence to the enquiry.

 

The provision of homecare medicine services which are specialist pharmacy services is complex and involves multiple stakeholders, creating several opportunities for the process to deviate from expectations.

 

Providing services to over 550,000 patients, processing in excess of 116,000 prescriptions per month and making circa 2.85 million deliveries per annum has not been without its challenges and we recognise that some providers have encountered issues to a lesser or greater extent.

 

It is our observation that throughout this enquiry there appears to be disparity between the reports of the patient groups and medical societies and those of homecare providers and their regulators. Reports from all sides do accurately reflect experiences but we believe it is in the scale of the issues where the disparity lies. A 1% failure rate of the industry delivery volume would result in circa 28,500 patients’ supplies being impacted. Whilst this can be significantly impactful for the affected patients, it is not indicative of a systemic failure of the industry as a whole.

 

The provision of specialist pharmacy services such as those provided by homecare providers does not factor anywhere in Government Policy or strategy. As a result, there is no named individual, team, or department accountable and responsible for these services which provide essential services to almost 550,000 patients at a cost to the treasury of in excess of £4 billion. It is the belief of the NCHA that if this were the case, significant progress could be made in the further developing services which meet the needs of patients not only for today but also for the future. Bringing healthcare closer to home forms a fundamental part of NHS priorities not only ensuring equity and parity of access to healthcare for all patients but can also provide positive solutions to the current NHS backlog crisis by releasing hospital and workforce capacity. Whilst the Government talks about bringing care


closer to home, homecare is largely overlooked and so having a senior policy maker responsible for homecare would be hugely beneficial in providing policy solutions to one of the biggest healthcare challenges.

 

An electronic Prescription Service (EPS) for secondary care. The ability to send and receive a prescription through a single system would not only increase efficiency and reduce risk, but it would also create a single patient record accessible to any part of the health system. A secondary care EPS supported by a centrally configured payment agency similar to the NHS Shared Business Services Agency could operate in the same way primary care EPS does in that rather than a provider needing to submit invoices to the referring hospital, they could be reimbursed in the same way community pharmacists are, reducing administrative burden for all parties creating a significant improvement of financial oversight by NHSE and reducing the working capital burden on homecare providers.

 

Systems interoperability and easier adoption of innovative technology with a government mandate for all hospitals to use the same technology and systems, for example the same secure email domain.

 

Standard pricing frameworks and equity with the NHS regarding access to pricing for high-cost drugs. In many cases, homecare providers are required to purchase medicines at “list” price but invoice the NHS at patient access scheme or contract prices. Rebate claims are then submitted by the homecare provider directly to the pharmaceutical manufacturer to claim the difference between the two financial values. This is not only labour intensive but creates significant working capital costs the burden of which is carried by the homecare provider.

 

Services are commissioned via several routes.

 


NHS



 

NHS Services are tendered under Public Procurement Policy and Regulations and using the standard specification for homecare and are governed by the NHS Standard Terms and Conditions for the Supply of Goods and Services. With Framework Agreements, hospitals can choose which provider they wish to contract with for the provision of the service.

 

Pharmaceutical Industry


 

Approximately 80% of medicines homecare services are supported financially by the pharmaceutical industry i.e., they pay the costs of the service elements directly to the homecare provider which can include dispensing, delivery, nurse training and/or administration and telephone-based patient support programmes. The NHS pays the cost of the drug which may include an allowance for the service elements funded by the pharmaceutical organisation.

 

Where services are provided via the pharmaceutical industry, a contract is in place between the provider and the contracting pharmaceutical organisation and an agreement in place with the commissioning hospital. In most cases this is in the form of a Master Services Agreement or Service Level Agreement with or without a Work Order.

 

As is the case with services commissioned directly by the NHS, the choice of which homecare provider to work with is decided by the hospital. Once a service has been set up, hospitals retain the choice to move patients should they wish, and there is a defined process for the transition of patients between providers.

 

There is not a standard funding route for prescription medicines and services as there is variability depending on the prescription medicine itself. In some cases, the commissioning hospital “pass through” the cost of the drug directly to NHSE, in others the costs come directly out of the hospitals budget.

 

Single process for contracts- Whilst there is a standard specification template each supplier has to complete a tender for each region every four years. This requires mass duplication of stock information, regional nuances, and includes the onboarding, registration, patient contact timelines which creates inconsistencies in services for providers in often manual processes. This is often a barrier for entry for new suppliers. One submission for core service provision will lead to National oversight, standardisation of service deliverables and removal of administration for both the NHS and suppliers.


Response to follow up questions sent to NCHA 4th July 2023

 

During the oral evidence session on June 21st, 2023, in reference to registration and prescription documents, I stated that “it can take several weeks for those documents to be written by the clinical team in the clinic or on the ward before they make their way to the homecare provider, and an average of 14 days before they even come to the homecare company”.

 

During the oral evidence session, I made reference to two timelines. The contractual minimum timeline for repeat prescriptions to be supplied to their homecare provider is 10 working days following the providers request for a prescription. From data analysed within some homecare providers, they are reporting the average number of days from prescriber’s signature to receipt within the homecare organisation is 14 days. This is impacting deliveries to patients and increasing internal operational pressure within the homecare organisation as requests for prescriptions are made to the hospital teams based on the anticipated date of the patients next delivery, usually starting 6 weeks in advance of the anticipated delivery date. Where prescriptions are received closer to this date, this increases the risk of the homecare organisation not making successful contact with the patient to schedule their delivery. Homecare providers have developed planned, repeatable processes in order to supply medicines to patients, when the receipt of prescription deviates from this process, operational teams are diverted to deal with the exceptions which in turn creates more pressure on their operational teams.

 

An example of the prescription process flow can be found below.


 

 

Question

 

We have received supplementary evidence from the British Society for Rheumatology. They sourced views from “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”. They said:


There is clearly a discrepancy here. Would you like to respond to these views?

 

Response

 

The example you have provided demonstrates best practice, but I believe the responses above do not represent the practices in the vast majority of departments and hospitals throughout the UK. The lack of compliance to the timelines in the National Specification for Homecare and significant amount of variability across referring centres throughout the UK results in significant operational pressure being created within homecare organisations. Patients of the NHS Teams who do provide prescriptions in accordance with the specification are impacted by the volume of prescriptions provided late.

 

Question

 

You stated that, “98.8% of deliveries were delivered on the day they were intended to be delivered on.”

Please can you confirm what “the day they were intended to be delivered on” means?

Please can you provide some information on the percentage which were delivered after the clinician had intended?

Do you have statistics on patient satisfaction? Please could you share them?

 

Response

 

The 98.8% statistic reflects the number of deliveries that were successfully attempted/made by the homecare provider on the day agreed with the patient. This is not necessarily the date the clinician intended as this date is agreed directly with the patient based on their reported stock holding and their availability. Prescribers do not routinely enter information onto prescriptions regarding required delivery dates. In 2022, the statistic for successful deliveries on the agreed date including delivery failures due to act or omission of the referring centre or patient is approximately 94.7% with 4% of deliveries failing on the planned date due to patient not being available and 0.1% due to referring establishment and 1.2% due to homecare provider. With respect to the issues raised relating to harm we would respectfully point out that within the overwhelming majority of routine planned deliveries there is also a built-in contingency relating to the patient stock holding and a two-week buffer stock period would be the industry norm.


 

 

 

There is a nationally approved patient satisfaction questionnaire (supplied with this letter) which is conducted annually by homecare providers. The results of such surveys are presented to the NHS during their National Supplier Engagement meetings. The NCHA does not collect the results of individual members satisfaction surveys.

 

Question

 

You stated that: “there are some incredible people who work at local, regional level and national level in the NHS, but they have no power.” Please could you explain what you mean by having “no power”?

 

Response

 

The National Homecare Medicines Committee is a sub group of the Pharmaceutical Market Support Group and the National Pharmaceutical Supply Group, which sit as sub groups of Specialist Pharmacy Service which resides within the Commercial Medicines Unit which is part of the Commerical Medicines Directorate of NHSE. The committee can make recommendations but does not have any authority to develop or deliver strategic plans.

Individuals within hospitals and regions, can identify areas where homecare medicines services could deliver benefits for patients but


there are no national targets related to homecare services so there are no key drivers to permit the development of such services.

 

Question

 

Members would be very keen to see the KPI data that you report into the NHS. I think you undertook to provide that to the Committee in the session (p12). Please could you forward the spreadsheet you undertook to provide?

 

Response

 

NCHA agreed to supply the template for the KPI reports, it is my understanding that attendees from the oral evidence session held on the 28th June agreed to supply the data that homecare providers send to them on a monthly basis.

 

All providers collect 61 key performance indicator information in accordance with Royal Pharmaceutical Society (RPS) Professional Standards for Homecare Services Appendix 19, the template of which is available on the Royal Pharmaceutical Societies website (supplied


with this letter). These KPI’s cover all aspects of the services provided including delivery performance, prescription medicines and ancillary items, clinical episodes, quality and governance and finance performance.

 

This information is provided monthly by homecare providers to each hospital they work with and regionally to the homecare leads. Where national contracts are in place and contracted through NHSE, this data is supplied at a national level to NHSE. The National Homecare Medicines committee are also supplied with the national data from providers, and these are reviewed by them with the providers individually at National Engagement meetings.

 

The NCHA presents national data at their All-Members meetings and annually at its national conference.

 

Data available to the NCHA includes the information below.

 

The graph above demonstrates that there is no significant deteriorating trend in the percentage of formal complaints by active patients. In 2022, formal complaints were recorded as 1.8% of active patients. It is also noteworthy, that these are the total number of complaints recorded, not all of which will be upheld or are reported in accordance with Appendix 19 guidance on formal complaints.

 

Homecare providers are committed to patient safety and record KPI’s for patient safety incidents. These are recorded as a percentage of


active patients. All patient safety incidents are recorded, regardless of hospital, patient, or homecare provider causation.

 

The data below, indicates that over the last 2 years there has been a reduction in the number of patients safety incidents and demonstrates an improving trend.

 

Reporting of Duty of Candour events provides detail of notifiable safety incidents. Whilst the KPI definition requires reporting as a percentage of active patients, this is not truly indicative of the number of events that occur within homecare provider organisations Where providers are performing (in 2022) 2.85 million deliveries, the of Duty of Candour reports as a percentage of deliveries would demonstrate a reporting culture and the overall safety of the services provided.


 

NCHA members have invested significant financial resources to develop innovative methodologies to safely meet the needs of patients and the increasing demands of the NHS. We recognise the requirement for this enquiry to remain focused on the issues reported by Patient Groups and Medical Societies, but we would welcome the opportunity for further discussion or supply additional information regarding these developments.

 

11 July 2023

 

Accompanying documents

 


*addendum to the evidence submitted by email to the Clerk of the Committee on 12 October 2023

 

In 2020 there were 427,604 active patients receiving clinical homecare services and a total of 58,640 reported patient safety incidents which would equate to 13.7% as a percentage of active patients. However, as outlined in the response send on the 11/07/2023, this does not fairly represent the level of activity.

In 2020, there were 2,404,677 delivery events so the number of reported patient safety incidents as a percentage of activity undertaken for the active patients is 2.4%

 

In 2022, there were 535,921 active patients and 36,339 reported patient safety incidents which equates to 6.8% of active patients. There were 2,854,698 deliveries performed, therefore the number of reported patient safety incidents as a percentage of activity undertaken in 2022 was 1.3%

 

If you review the two data sets. The movement in the number of reported patient safety incidents between 2020 -2022 is;

 

 

It is noteworthy that Appendix 19 of the Homecare Standards Appendices references the National Reporting and Learning Service definition of a patient safety incident as “"any event that led to actual harm to a patient or had the potential to harm a patient” Homecare providers report all incidents, regardless of root cause so it cannot be assumed that the numbers reported are as a result of homecare providers act or omission. There are 15 Patient safety incident types,


Medication error (medication administered)
Medication error (medication not administered)
Medical device error
Treatment/procedure error not medication or medical device related
Clinical assessment error
Consent/confidentiality
Safeguarding

Disruptive, aggressive behaviour towards staff
Patient accident
Infection control
Communication related error
Administration/documentation related error
Time related implementation of care error
Infrastructure
Unclassified patient safety incident

 

A graph of a number of patients Description automatically generatedPlease find below the chart with a data table which provides the actual numbers.