Independent Review of Medicines Homecare in Scotland: review report and recommendations

Conclusions and recommendations

Conclusions

This Review Report is submitted to Scottish Government for consideration and decision making around the implementation of the improvements required to ensure that medicines homecare services in Scotland:

• are of a consistently high quality
• support patients to live well, and
• are viable and sustainable for all stakeholders.

This Independent Review has identified a range of opportunities to improve. The current issues in the oversight, commissioning and delivery of homecare are multifaceted, but when taken holistically, the recommendations, once implemented, would address the challenges faced and deliver a sustainable, high-quality service to patients and a range of advantages to NHS boards and other organisations involved.

A whole system approach to medicines homecare in Scotland will allow efficiency opportunities to be identified in all aspects of service delivery, including reduced clinical variation, targeted shared-care arrangements, patient experience, workforce, procurement, and service models. The effective use of digital solutions and new technologies is a clear efficiency opportunity. Targeted work, including horizon scanning of new medicines, and development of the community pharmacy model, will lead to efficiency gains, improved quality, and cost avoidance to NHS Scotland.

Implementation of the recommendations within this report will require the establishment of an Implementation Group, with stakeholders including patients and the third sector, and with the necessary support, resources, and delegated authority, reporting directly to the Scottish Government.

The overarching findings and recommendations support the need for:

• Improvements in the governance of medicines homecare. This includes role clarity for senior leaders, definition of the regulatory model, enhanced policy oversight, unified KPIs and improved oversight of new opportunities.
• Enhanced collaboration and communication. This includes improved mechanisms between organisations responsible for care, clarity of responsibility for care at the interface, development and adoption of new and existing digital solutions and a consistent and high-quality approach to the management of complaints.
• Developments to service design and patient care. This includes review of the complexity and volume of manufacturer-commissioned homecare schemes, enhanced collaboration in access and medicines homecare patient initiation, consensus on best practice in identifying patient groups, development of community pharmacy as an alternative model, enhanced consideration of patient choice within design, input from patients to service design, recommendations on shared care and the resource required across different organisation.

Timescales have been described as:

Short term -within 12 months

Medium term -within 36 months

Long term -within 48 months

Recommendations

There is an overarching recommendation for the Scottish Government to consider each of the 22 Review recommendations and commission the necessary resource and work to implement these within the suggested timeframes.

Recommendation 1: The Scottish Government has well-informed policy oversight of medicines homecare services to more effectively enable the Chief Pharmaceutical Officer to discharge their responsibility for overall strategy, leadership and governance of medicines homecare. This:

• is underpinned by appropriately resourced and robust reporting mechanisms,
• includes a strategic NHS Scotland governance group with appropriate membership, role, remit, and accountabilities, and
• is supported by enhanced Scottish representation on the National Homecare Medicines Committee.

Benefit: The risk of patient harm is reduced when medicines homecare provision strategy and operational delivery is aligned through national oversight and local reporting.

Timescale: Short term

Recommendation 2: A Once for Scotland approach must be taken to define and improve role clarity for senior leaders across organisations involved in medicines homecare including clarity of delegation, governance, accountabilities, and responsibilities.

Benefit: The risk of patient harm is reduced when safe, high quality and person-centred medicines homecare provision is in place. This is underpinned by strong leadership, robust governance and clear roles and responsibilities.

Timescale: Medium term

Recommendation 3: A well-defined and transparent regulatory model is agreed for medicines homecare in Scotland with robust governance and clear delegation, accountabilities and responsibilities, at all levels.

Benefit: The risk of patient harm is reduced when care is well-regulated and identifiable causes of harm acted upon within a clear regulatory model.

Timescale: Medium term

Recommendation 4: Scotland should take a key role in the development of medicines homecare Key Performance Indicators at UK level which focus on the quality of patient care and are linked to enhanced governance and stakeholder engagement and management.

Benefit: The risk of patient harm is reduced, and patient experience of medicines homecare is improved when relevant KPIs, that include a focus on service quality, are developed, reported against and improvements implemented.

Timescale: Medium term

Recommendation 5: In line with a reviewed access to medicines policy, service planning related to horizon scanning of new medicines, changes to the licensing of existing medicines, and supply routes is undertaken nationally to ensure that new opportunities are exploited to the benefit of patients and all other stakeholders, in a coordinated and robust manner.

Benefit: The risk of service failure is reduced when there is a planned and co-ordinated approach to using medicines homecare services.

Timescale: Medium term

Recommendation 6: NHS boards, homecare providers and commissioners (Marketing Authorisation Holders and/or NHS Scotland National Procurement) have a timely communication mechanism to enable early resolution of issues. This recognises the complexity of current arrangements and is available to all stakeholders involved in medicines homecare in Scotland.

Benefit: The risk of patient harm is reduced, and patient and staff experience improved when there are clear channels of communication between, and among, NHS board, homecare providers and commissioners.

Timescale: Medium term

Recommendation 7: There is immediate clarity of roles and responsibilities for engaging patients in medicines homecare to ensure that patient quality of care is always maintained.

Benefit: The risk of patient harm is reduced, and patient experience is improved when staff across the medicines’ homecare pathway are clear about roles and responsibilities of all those involved in medicines homecare provision, particularly at the interface of care.

Timescale: Short term

Recommendation 8: Rapid national assessment is required in consideration of the adoption of existing, and widely available, digital technologies to enable an immediate move away from paper-based communications within and between medicines homecare providers and NHS Scotland.

Benefit: The risk of patient harm is reduced, and staff experience improved when there is an effective, efficient and equitable communication system in place.

Timescale: Short term

Recommendation 9: There is a standardised approach to developments and improvements of digital solutions within medicines homecare. This includes a robust and rapid approach to the approval of technologies, led and determined by the needs of NHS Scotland, for adoption and information governance.

Benefit: The risk of patient harm is reduced, and staff experience improved when there is a strategic, structured and equitable approach to developing and implementing digital solutions.

Timescale: Short term

Recommendation 10: Secondary care-initiated medicines are prescribed via a nationally agreed digital solution, across all care settings, to enable digital connectivity between medicines homecare providers, NHS boards and community pharmacies. This must align with existing national digital prescribing programmes.

Benefit: The risk of patient harm is reduced, and staff experience improved when teams across all care settings use a single nationally agreed digital solution.

Timescale: Medium term

Recommendation 11: People who use medicines homecare services must have access to a consistent complaints approach, with NHS Scotland oversight, to ensure:

• appropriate accountability and governance
• consistency in how complaints are handled
• complaints are managed and responded to within agreed timeframes
• quality standards are maintained
• patient trust and transparency is maintained
• patients’ rights are upheld, and
• continuous quality improvement and learning.

Benefit: Patient experience is improved when they have access to a user friendly and consistent complaints process. The risk of patient harm is reduced when organisations implement learning from complaints.

Timescale: Short term

Recommendation 12: There is a review of manufacturer-commissioned homecare schemes in Scotland. This is assessed in the context of the complexity and volume of these schemes, clinical considerations, and geographical variation to ensure that there are optimal schemes available to patients and NHS boards.

Benefit: The risk of service failure is reduced when there are person-centred, equitable and sustainable services available to patients.

Timescale: Medium term

Recommendation 13: A plan is developed to minimise variation in access to patient support programmes and to address the sustainability of these.

Benefit: The risk of patient harm is reduced when there is coordinated, sustainable and equitable access to patient support programmes across Scotland.

Timescale: Medium term

Recommendation 14: The approach to design and delivery of new medicines homecare services in Scotland is based on a robust analysis of service needs, to ensure optimum value and sustainability for all parties.

Benefit: The risk of service failure is reduced when all parties collaborate in development and review.

Timescale: Medium term

Recommendation 15: A national consensus is reached for when medicines homecare is an appropriate care approach, in line with professional guidance.

Benefit: The risk of patient harm is reduced when there is clear guidance for clinicians to initiate patients on medicines homecare.

Timescale: Medium term

Recommendation 16: Community pharmacy must be deployed as an alternative supply route within the medicines’ homecare model in Scotland. This should be developed based on clinical care provision and will require new contractual frameworks.

Benefit: The risk of service failure is reduced, and patient experience improved, when there is diversification in medicines homecare supply routes.

Timescale: Medium term

Recommendation 17: There must be no detriment to all stakeholders where community pharmacy is used as an alternative medicines’ homecare model.

Benefit: The risk of service failure is reduced when new models of medicines homecare delivery do not negatively impact stakeholders.

Timescale: Medium term

Recommendation 18: There is a revised approach, designed with input from all stakeholders, to accepting manufacturer-approved low technology schemes in NHS Scotland. This should be implemented in parallel to developing and piloting alternative homecare models and should address service resilience issues.

Benefit: The risk of service failure is reduced when all relevant stakeholders contribute to service design in a systematic and structured way and the most efficient approaches are implemented.

Timescale: Medium term

Recommendation 19: Patient choice must be a key consideration when NHS Scotland and homecare providers work collaboratively to design models for medicines homecare services, in alignment with the varying delivery models and patient requirements.

Benefit: The risk of patient harm is reduced, and patient experience is improved when patients have choice within their care package.

Timescale: Short term

Recommendation 20: Patients are fundamental to the design and delivery of medicines homecare services. A national patient forum must be established, which is embedded in revised governance and oversight approaches to medicines homecare in Scotland. This should align with wider work undertaken across the UK.

Benefit: Patient experience is improved when patients participate in service design.

Timescale: Short term

Recommendation 21: A Once for Scotland approach to shared care of medicines is developed, agreed and implemented.

Benefit: The risk of patient harm is reduced when there is a person-centred approach, across the medicines’ homecare pathway, to shared care of medicines.

Timescale: Medium term

Recommendation 22: NHS boards and homecare providers must review their current workforce planning to ensure that there are appropriately resourced homecare teams (based on established evidence and best practice) to provide patients with high quality and person-centred services. This is underpinned by quality standards to ensure patient safety.

Benefit: The risk of patient harm is reduced, and patient experience improved when services are well resourced with skilled staff.

Timescale: Short term