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

Executive Summary

In April 2023, the Chief Pharmaceutical Officer (CPO) announced an Independent Medicines Homecare Review (the ‘Review’) in response to reports of failings of the standards of care provided across Scotland and the increasing demand for medicines homecare provision. This review ran at broadly the same time as a similar review within the NHS in England through the House of Lords – many of the themes encountered are similar, and it will be critical that home nations collaborate to deliver mutually beneficial recommendations.

The Review was commissioned to:

• evaluate the existing approaches to the supply of secondary care-initiated medicines and associated care to patients in the community in Scotland, and
• make recommendations on improvements to services to ensure continued value and sustainability in models of secondary care medicines supply.

There are substantial benefits to medicines’ homecare and high-quality care is being delivered to patients daily, across Scotland. It is encouraging to note the alignment between all stakeholders on the key principles of services in safe and effective care. Similarly, there is a shared willingness between parties to work more closely together to improve. This provides a solid basis for the implementation of the recommendations within this Review.

Membership of the Review Project Board and the Review Reference Group, and the terms of reference of both are detailed in the report (Appendix 1 and Appendix 2). The Review Reference Group reflected the skills and expertise required to appropriately represent stakeholder groups from the medicines’ homecare community.

The review focused on:

• governance, quality assurance and leadership of medicines homecare
• communication and collaboration
• service design and patient care

A range of methods were used, including a ‘Call for evidence’ questionnaire to stakeholder groups (Appendix 3 and Appendix 4), and targeted stakeholder engagement. Patient views were integral to the Review. A public engagement exercise was undertaken by the Health and Social Care Alliance Scotland (the ALLIANCE) to gather patient views. [1]

The Review identified a range of concerns and systemic issues in all focus areas, particularly national oversight, governance, accountability, communication, collaboration and patient-centredness. There is strong evidence that continual growth in medicines homecare requires additional resource to sustain services. Patient numbers have almost doubled since December 2018, reflecting the benefits to patients and NHS boards, but this growth has not been matched with the systemic improvements required to sustain the scale of service.

There is an urgent need to enhance and support policy and strategic oversight, while delivering clarity on the expectations on senior leaders. Regulatory models in Scotland require development to assure those accountable of the safety and security of services. Performance management will be revised at a UK level, and Scotland must be an active participant in this while revisiting its own structures to ensure Key Performance Indicators (KPIs) drive quality of care. More broadly, we must ensure that medicines homecare services are designed and selected to the benefit of patients and the NHS in Scotland.

Collaboration between the complex range of stakeholders requires redesign. Robust feedback mechanisms between parties will increase the ability to adapt and improve. There is a need for greater clarity of responsibility at the interface of care, ensuring that patients receive the best care throughout and at a minimum are not subject to harm at this stage of their journey. Digital solutions form a critical component of the future model, but require a more strategic approach, which can be achieved by collaboration across organisations and UK nations. Complaints processes can be overcomplicated and require revision in line with a single strategic vision.

Patient care is best served by collaboration in the design phase, and there is a need to step back and holistically review current medicines homecare schemes. Additionally, due consideration within clinical communities of when medicines homecare is best utilised, would resolve inequities and target resource. There is an urgent but highly complex need to develop and implement a role for community pharmacy, initially with low technology medicines homecare services. This is linked to the importance of providing choice to patients in their care, and the need to enhance the input of patients in the design of services. By developing a strategic approach to shared care arrangements, and workforce planning within both NHS and private sector organisations, patient care can be made more robust and sustainable.

Focussing across short, medium, and long-term developments, the recommendations in this report provide the foundations for improvements to facilitate the design and implementation of high-quality, integrated, patient-centred service that are efficient and sustainable.

Implementation of the recommendations in this review will require an Implementation Board to be established with representation from across pathways, including patients. This Board should report directly to the CPO in Scottish Government and have the authority, accountability, and support to be efficient and effective.

I believe the recommendations in this report provide the future direction for effective, efficient, and sustainable models of secondary care-initiated medicines supply in Scotland particularly Medicines Homecare Services.