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

Introduction

Background

Medicines homecare services (homecare) deliver ongoing medicine supplies and, in some cases, associated care, initiated by a hospital prescriber (secondary care-initiated), direct to a patient’s home or another community-based setting [2].

Homecare can offer significant benefits to patients by removing the need for them to make journeys to hospital to collect medicines or to have it administered, instead having medicines delivered to their home, alongside associated care (in some cases).

In 2023 over 41,000 patients in Scotland used medicines homecare services. Since 2018 the number of patients using homecare services has increased by almost 50%, and there are now around 206,000 medicines deliveries each year, alongside almost 8000 nurse visits to provide care. [3] Homecare patients are not a homogenous group; they are from different backgrounds across urban, remote and rural Scotland, living with a wide range of diverse conditions across therapeutic areas. NHS boards also show significant variation in uptake of medicines homecare, with the highest user (NHS Greater Glasgow and Clyde) having twice as many patients accessing services than the lowest user (NHS Orkney) and the lowest mainland board (NHS Fife) when adjusted for population size. [3] [4]

More people in Scotland are now living with one or more complex health conditions. In 2021 The Scottish Health Survey estimated that 47% of adults aged 16 years and over had a limiting long-term physical or mental health condition, or illness. [5] These conditions tend to be more prevalent in older people and in more deprived groups. [5] There has been national and local efforts and initiatives to improve outcomes and reduce health inequalities experienced by patients as well as addressing inequities in access to treatment across the country. The prevalence of long-term conditions, however, places considerable strain on healthcare provision. [6]

There are over 41,000 patients in Scotland using medicines homecare services [3]

Since 2018 the number of patients using homecare services has increased by almost 50% [3]

Types of medicines homecare

The consistent evolution and introduction of innovative new medicines means that some can be easier and safer to administer via medicines homecare services. A homecare service can be categorised by complexity whether it is low technology, mid-technology or high technology with the latter being the most complex.

Low technology

medicines homecare services can include

• self-administration of oral therapy or medicinal products for external use only, excluding oral oncology
• licensed medicines or uncomplicated medical devices
• self-administration of medicines

Mid technology

medicines homecare services can include

• therapy that requires significant clinical support or diagnostic testing such as blood level monitoring as part of the homecare service
• patient training and competency assessment relating to self-administration
• medications with special storage requirements

High technology

medicines homecare services can include

• intravenous infusion
• self-administration needing advanced aseptic technique
• administration by a healthcare professional

Most homecare services in Scotland are ‘low-tech’ (dispensing and delivery) or ‘mid-tech’ (dispensing, delivery, and device training) with a small number of specialised ‘high-tech’ services, for example administration of an infusion in the patient’s home. Use of homecare services can be a cost-effective option for the NHS alleviating pressures on healthcare facilities and enable efficient use of resources by releasing time for NHS teams to deliver other work.

Medicines homecare services can be broadly split into two commissioning categories:

Manufacturer-commissioned

One or more homecare providers are commissioned by the marketing authorisation holder (MAH) of a drug to provide a homecare service to patients. As part of the manufacturer commissioned model product price, a manufacturer may offer homecare delivery at no extra cost; this is commonly referred to as a ‘bundled’ price. The NHS continues to take clinical responsibility, but the manufacturer selects, contracts, and funds the homecare provider. The NHS board may have no or limited choice of provider.

NHS-commissioned

The overarching service is contracted to one or more homecare providers. The NHS will pay the cost of the medication and additional service fees for each part of the service.

In 2023 NHS Scotland spent a total of around £293m on medicines homecare services. [7] The majority of this (£293m) was spent across six homecare providers, who delivered the majority of medicines homecare services in Scotland. Of this £293m, manufacturer-commissioned accounted for approximately £170.5m and NHS-commissioned approximately £85.5m of the total annual spend on medicines homecare services.^[1] [3]

NHS Scotland manages the service KPIs and service governance of both manufacturer and NHS-commissioned homecare.

Process and capacity

Over the past ten years, all major homecare providers have experienced periods of capacity constraints and service issues. This has been progressively more challenging from the outset of the COVID-19 pandemic resulting in some homecare providers more adversely affected than others. The increase in volume seen over the last three years, has further highlighted long-term concerns in several areas:

• Homecare providers have experienced issues around recruitment and retention of staff in a challenging market which has compounded significant capacity constraints within medicines homecare. Given the NHS is experiencing similar issues, this is unlikely to resolve in the short or medium term.
• Sudden unplanned changes in service commissioning, for example manufacturers terminating contracts with an affected provider, can create surges in demand for other homecare providers and have a knock-on impact in the wider market. It can affect patient care, particularly in the short term.
• Service issues have led to some patients missing doses, led to delays in treatment initiation and caused considerable stress and anxiety for patients.
• There is significant workload placed on NHS Scotland staff to minimise the impacts of provider service issues on patients and provide reassurance to patients who often contact their secondary care clinicians in this situation.

Typical patient journeys

Homecare medicines services are a wide-ranging area of practice and care, often involving complex, high-cost medicines and a range of service models from delivery only to administration and monitoring. For many patients, there is the added complexity of a cold chain.

The Royal Pharmaceutical Society developed a process map to demonstrate the individual patient journey from decision making around the viability of the homecare service to dispensing a prescription and paying for the homecare service (Appendix 5)

The following patient accounts demonstrate the varied and individualised uses of medicines homecare.

Patient 1 – Hunter lives in Falkirk and accesses a low technology homecare service (an oral tablet). He manages his conditions well but gets frustrated when he can’t get through to the service on the phone. Hunter’s preference would be to get his medication from the community pharmacy next to his work.

Patient 2 – Ayisha accesses a medium technology homecare service (an injectable biologic). A nurse comes to see her twice a year, but she probably needs more support. Ayisha was admitted to hospital last year because of a polypharmacy issue. Ayisha’s general practitioner (GP) practice is not fully aware of her situation. It took two months to start her homecare medications and a year to titrate down the additional painkillers she got in the interim.

Patient 3 – Lawrence lives in Dornoch in the Highlands and accesses a high technology homecare service where an intravenous medicine is administered in his home fortnightly. It is never the same staff that come and see him every fortnight. Recently, two out of the last ten visits have been rescheduled. Lawrence has had to make significant adjustments to his life to make sure that he is at home to receive his medicine.

Geographical equity

Approximately 20% of our population live in rural Scotland. Remote and rural communities are growing at a faster rate than the rest of Scotland and have higher levels of older people. [8]

A study of older people in Scotland found that patients can face challenges in relation to healthcare in remote and rural communities; problems accessing care; centralised healthcare services; distance; travel costs; waiting times; service hours; relatability of the GP; starting the care process again; utilisation of emergency services; health deterioration; and making trade-offs between safety and accessing healthcare. [9]

There are inherent challenges around access and the convenience of accessing medicines for older adults and those living alone within remote and rural areas. [10]

The Scottish Government’s Achieving Excellence in Pharmaceutical Care strategy 2017 committed to enhancing access to pharmaceutical care in remote and rural communities and the provision of improved pharmaceutical care for people being cared for in their own homes. [8]

In the context of medicines homecare, patients who do not live in the central belt are only served by deliveries one or two days a week. Those living on the Scottish islands, are often not served by medicines homecare delivery services directly and receive products via Royal Mail or other subcontracted delivery companies. This often also leads to the local NHS board being required to make arrangements for clinical waste. We should be concerned about accessibility and governance for these patients. A related issue is that if there is a problem with the delivery, there is limited opportunity to resolve it quickly. Most companies only deliver on Monday to Friday during working hours.

"Some of these [patients] receive their medicines by Royal Mail, on occasion these have been left on the doorstep and spoiled due to being exposed to the elements. Some geographies experience poorer services despite being on the mainland because they are determined by providers to be remote or rural. Some providers use Royal Mail post for rural areas, and this can extend the date of delivery.” (NHS board)

"In rural areas, over half the respondents (51%) reported delays or cancellations to their homecare services, compared to more than 1 in 4 (28%) in urban areas... Respondents living in rural areas were also more likely to report that their repeat prescription was not processed properly… Respondents in both rural and urban areas reported difficulties in contacting their homecare delivery provider, with almost 1 in 3 (30%) in rural areas and almost 1 in 5 (18%) in urban areas reporting this.” (Patient group)

Prescribing, dispensing and reimbursement of medicines in Scotland

Community pharmacies in Scotland are independent contractors and are funded for services they provide through NHS contracts and other non-NHS sources. There are no NHS patient prescription charges in Scotland. All Scottish community pharmacies must offer core clinical services and a national medicines supply service by dispensing against NHS prescriptions.

In addition to dispensing fees which are paid per item dispensed, reimbursement to community pharmacies for supplying medicines against an NHS prescription is complex. The basic method is that advance payments are made to support contractor cashflow while actual payment for the prescriptions submitted is calculated. Actual payments are usually made two months in arrears from submission e.g., January’s submission is paid at the end of March.

Part 7 of the Scottish Drug Tariff is used to set the reimbursement price for around 850 commonly prescribed medicines to ensure medicines supply through community pharmacies does not exceed pharmacy funding limits. [11] It is the responsibility of the community pharmacy to secure the best price they can for the medicines they purchase to ensure their costs are covered by the tariff price. Community pharmacies do not pay VAT on medicines purchased from wholesalers for dispensing against NHS prescriptions. Figures from 2023 show that in NHS Scotland over 110 million items were dispensed. The net cost of prescription items dispensed was £1.52 billion. [12]

In hospital most medicines are purchased using national contracts to achieve the best value for the NHS, and most branded and more expensive medicines for rare conditions are supplied through this route [13]. Hospitals pay for their medicines through their central funding allocation. Under the current UK VAT arrangements, there is a financial benefit to hospitals that use homecare services. If a hospital pharmacy supplies an out-patient medicine, VAT applies. However, if a homecare or community pharmacy supplies the same medicine, the transaction is zero-rated.

Although this arrangement is currently beneficial to the NHS when using medicines homecare services, there is no long-term guarantee that this will remain the case. There is also no clarity on how the medicines homecare market (both NHS and private sector) would respond were the UK Treasury to revise VAT arrangements.

The cost of medicines supplied via medicines homecare services was an estimated £293m, which is around 30% of the total (approximately £1bn) spent on secondary-care medicines, in 2023. [7]