Patients are coming to serious harm by a lack of regulation of the private companies in the homecare medicines sector, according to a damning report by the House of Lords Public Services Committee.
The failure of regulation, noted the Lords, means that:
“No one—not the Government, not NHS England, not patient groups, not regulators—knows how often, nor how seriously patients suffer harm from service failures in homecare.”
Not only are patients being harmed, but the lack of transparency in contracts and procurement means nobody knows how much the companies are being paid, despite it being billions of pounds, which the Lords described as “shocking and entirely unacceptable.”
Over half a million people with chronic conditions in England depend upon the delivery of medicines to their homes. These types of services known as ‘homecare medicines services’ often also include help in administering the medicine. They replace care that would previously have been supplied in hospital.
The main providers are private, for-profit, companies, with Sciensus, Healthnet Homecare, and Alcura, among the largest companies involved.
The Lords committee, named no individual company in its report, but addressed the entire sector noting:
“Some patients are experiencing delays, receiving the wrong medicine, or not being taught how to administer their medicine. Where this happens, it is no small inconvenience—it can have serious impacts on patients’ health, sometimes requiring hospital care. This leaves NHS staff either firefighting the problems caused by problems in homecare medicine services, or working on the assumption that those services will fail.”
In terms of payment the Lords noted that:
“In some cases, the taxpayer is effectively paying for the service twice—once for the private provider to deliver it, and again for the NHS to pick up the pieces where private providers fail.”
The report noted failures across the board in the services: in transparency; procurement; enforcement of standards and regulation; and in infrastructure.
Estelle Morris, the chair of the committee, said: “The system has grown into a fractured and complex mess, with no one named individual or body having overall responsibility for defining and ensuring performance across the sector. It is not even possible, at the moment, to assess performance: no one is publishing any data.”
“The regulators in this sector are weak. We saw a hands-off approach where no one regulator wanted to look too hard at performance and no one is in charge.”
She said: “Accountability in the provision of homecare medicines services is key and someone must get to grips with the entire system and have responsibility for getting things right.”
The committee’s report calls for an independent review of the sector and for the government to urgently appoint an individual to lead and take responsibility for homecare medicines services.
The Guardian undertook a four month investigation of the leading homecare company Sciensus in 2023 and found the company struggling to provide a safe or reliable service. The investigation led to the CQC launching a review of serious concerns that had been raised by patients, clinicians and health groups.
The Guardian was told of instances where medication was never delivered and patients and carers could not contact the company, leaving people in tears and with extreme anxiety and in some cases in life-threatening situations.
In one incident with Sciensus, a patient died and three others were hospitalised after being administered incorrect amounts of an unlicensed version of the chemotherapy drug cabazitaxel manufactured by Sciensus.
The Medicines and Healthcare products Regulatory Agency (MHRA) partially suspended the company’s licence in July 2023 for a period of three months and then for a further nine months because the deficiencies had not yet been fully resolved.
Sciensus, is the largest provider of homecare services to NHS patients, including to treat cancer, heart disease, diabetes, dementia and HIV, and for this it is paid millions of pounds by the NHS.
Patient safety incidents are widespread. Evidence to the Lords from the industry body, the National Clinical Homecare Association, was that in 2020 there were 58,640 patient safety incidents, representing 13.7% of active patients. Although this had fallen by 2022, to 6.8%, the Lords noted that this is still a substantial percentage.
In a recent investigation of the business by the Pharmaceutical Journal, 32 trusts recorded 417 patient safety incidents relating to homecare medicines services provided to 96,846 patients during their most recent monthly reporting period, which ranged from May to July 2023. Sciensus was responsible for 66% of these incidents (277), although it provided homecare medicines to fewer than half (44%) of the patients covered in the data.
The regulation of the system is failing to ensure the safety and quality of patient care, according to the report. With the Lords noting that the regulators “appear to have a limited understanding of the sector and there appears to be no appetite to find more information.”
They describe enforcement action as “feeble” even when avoidable harm has taken place. As a result, “poor performance can go unchecked.”
Private companies are paid billions for the services, although exactly how much is actually not clear. The Lords were given three different figures for how much is spent on the area, one from the Treasury of £4.1 billion, another from government of £3.2 billion, but this was actually a figure provided by the National Clinical Homecare Association and not independently verified, and finally after pressing the government, the Lords were given a figure of about £2.9 billion.
Part of the issue is the complexity of the contract situation for homecare services, with the contracts usually with pharmaceutical companies who subcontract to a homecare provider. Commissioners include NHS England and hospital trusts. The Lords concluded that there was a lack of expertise in the commissioning bodies saying “those procuring and recommending homecare services appear ill-equipped to do so.”
As a result the Lords noted that there was “the clear commercial incentives for manufacturers to choose cheaper provision” and “there can be no reliable assurance that a provider is suitable before agreements are made.”
The Lords did note that some progress has been made since they started the inquiry, with a review underway and a commitment to publishing performance data in some form. However, the Lords note that most of their recommendations “can and must be implemented quickly. They will help to secure clearer, more effective services and provide patients with the safe and reliable care they need.”
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