Homecare Medicines Services (Public Services Committee Report)

What is perhaps unusual, but never mind, is that the contracts themselves are between a chief pharmaceutical officer in each trust and a large pharmaceutical company. Some 80% of the trusts have no contractual arrangements at all between themselves and the service provider, they just have a service level agreement. But that is not unusual; they are not the only part of the public sector that puts out a tender, monitors its performance, makes adjustments and gets on with it. However, if you look at what we know about the effective delivery of public services or private services, some elements have to be in place. You need information about what is going on. You need to agree performance indicators. You need to know how an organisation is performing against them. You need to know who is holding them accountable and you need to know who to go for when things go wrong. Not one of those things is in place in homecare medicine, and it is a service that is relatively small compared with many of the big public services that we run.

First, there is data, but—believe it or not—none of it is in the public domain; nor is it available to clinicians when they are advising patients on what to do. The National Homecare Medicines Committee, one of those which manage the service, collects 27 key performance indicators and passes them to the NHS, but they are never published or made available to anyone. Then there is a completely different set of KPIs between the pharmaceutical companies and the homecare companies which deliver the medicines on their behalf. There is no standard template across the country; every single one of those contracts can take a different shape. They are not published, the trusts and clinicians do not know what is in them, and they never know whether they have been achieved.

If that was not a big enough mess, on top of all of that—believe it or not—all the data is self-reported. That is not only a recipe for a service that does not work well but it means that no comparisons are possible when the NHS trust is spending money to place its contract. It has no information against which to judge either the performance of its present contractor or anyone else. Almost more important than that is that no information is therefore collected about how seriously patients suffer from service failure. No one in the NHS or anywhere else collects information about the impact on patients served by this poorly run service.

Secondly, there is no effective system of regulation. There are three regulators: the Care Quality Commission, the General Pharmaceutical Council and the Medicines and Healthcare products Regulatory Agency. They all inspect a different tiny part of the system; there is no one with overall responsibility. The problem is that this is not a high priority for any one of these regulators.

The Care Quality Commission does about three inspections a year. It does not collect complaints; there is no section in its books or charts for complaints received about homecare medicines. It has never chosen to do a thematic review and there is no evidence that we could find of a prosecution it has initiated. Whatever people who work at the CQC think about when they get up in the morning, it is not, “I wonder how homecare medicines is getting on”. When we asked those three regulators about the gaps in between the bits they inspect, they all said, “That’s fine, we don’t overlap—but there are no gaps in between”. That is not an effective system of regulation, and it helps nobody.

Thirdly, in a system such as that there would have to be infrastructure and support to go with it. Chief pharmaceutical officers in each NHS trust are busy people. They have a very demanding job, and the responsibility of sorting out the contracts with the big pharmaceutical organisations falls to those men and women. Everybody who came before has admitted that this requires specialist knowledge and that there is a huge amount of effort involved in managing the contracts and being aware of the impact on patients. The support and expertise that they would need to do that job is just not there.

Procurement hubs serving NHS trusts often have no homecare medicines specialists. Each provider has developed a different system, with no single NHS system for providers to interact with. On prescriptions, they have to re-read the evidence to make sure that somebody is not making it up. Some 6,000 paper prescriptions go into the system every day on more than 1,000 different templates—it is no wonder that nothing that comes out makes sense. It is beyond belief that in 2024, some of those prescriptions are still sent by post.

That is the environment in which we expect trusts and clinicians to make decisions about a key service, on which they are spending public money and on which clinicians need good-quality advice to advise their patients on the decisions they should take. They are not faced with any KPIs that they can monitor; they do not know how one provider performs against the other; they know that there is no effective regulatory system, that there is an inadequate infrastructure to support them, and that no one is holding the ring to keep it all together. At the end of the day, there is no one in overall charge for them to turn to for help and advice.

It is not surprising that this leads to a system that fails everyone it seeks to serve. First and foremost, it fails patients. There is no complaints system and nowhere for people to go if something goes wrong. The things that can go wrong go very wrong and are very serious: the medicines do not turn up; the wrong medicines turn up; the medicines turn up at the wrong time; the medicines turn up, but the person who was showing the patient how to inject them does not turn up; or the medicines are out of date. The catalogue of what happens in an NHS service that puts safety at the top of its priorities is frightening.

The impact for the patients is also serious: they miss medicines, become more ill and need to go back to hospital and have operations. Because no data is collected about how much harm is done, I cannot stand here with certainty and say that people lose their lives—no one can—but what we can say with certainty is that people do not recover as quickly, and they are given extra burdens to deal with because the system does not work as it should.

It also has an impact on each NHS trust. If you are not getting the service from the homecare provider—and if you have no one to complain to because the providers do not have good phone systems with somebody who picks up the phone at the end who knows you—you will go back to hospital. You will go back to the consultant who gave you the prescription or to A&E, and you will ask for help. That means that every hospital in this country, which have already paid taxpayers’ money at a time of reducing budgets to the provider to deliver the service, will have to pay again to remedy the defaults in the service.

If you talk to any of the groups representing clinicians or patients, they will tell you the horror stories of how much they have to do to mitigate the weaknesses in the system. Crohn’s & Colitis UK told us that 10% of specialist nurses spend one day a week on the consequences of an inadequately delivered homecare service. The British Society for Rheumatology told us of one clinic where a nurse spends a quarter of their time chasing after homecare services. In Leeds, people have set up their own infusion unit so they can teach the patients how to inject the drugs. They provide the drugs out of their budgets to start them off, because it takes eight weeks for the provider to get their act together.

The other losers are the NHS and the country, because it is money wasted. It is the case that the NHS, the department and Ministers do not know how much money is spent on homecare services. We had four different estimates, between £2.9 billion and £4.1 billion, and I am still sure that no one knows exactly what it is.

Yet I remain an optimist. All that can be solved; it is a tragedy, but it is solvable. Part of the anger or frustration is that it has not been grabbed hold of and solved already. We might get somewhere if we put a system in place that has comparable data, if we get the regulatory system sorted out, if we put in support for procurement, if we move more to electronic prescriptions and if we put a named person in overall control, who wakes up every morning knowing that their job is to make sure this works all right.

I say to the Minister that we have been very pleased with the support and response that we have had from his department; it has been helpful throughout. They have not spelled it out, but I think that both he and the Minister who is no longer in the department were surprised at the lack of awareness of this service and the state that it is in. That is why I am an optimist: I know that we await a further report in the summer.

However, there is a tendency in government to turn to the existing structure and people to create something that is better—which is what I have worried about most. There is a lack of trust between those who have been shouting for a long time that things are badly wrong and those who have not heard them and have not done anything about them. My request to the department and the Minister is not just to do all these things but, most of all, to consult those who have the best experience of what has gone wrong and the best ideas about what could be done to make it better.

I very much hope that our report helps not just the department and the NHS to get this better but all the clinicians and patients who have not been treated as well as they should and have not had the support that they should for many years. That is the goal, and I think that it is achievable. I promise that my committee is absolutely determined not to let this go, by whatever means we can. I have no doubt that we will be back at this again. I thank the Minister and the department for the support so far and offer our every help in their future work.

I looked further into this company and found that the Care Quality Commission—a thoroughly useless body if ever there was one—had just published a report in May 2021 showing that over 9,885 patients had also failed to get deliveries of their drugs, and some had to be hospitalised. The CQC report gave the company an overall rating of “inadequate”. On patient safety it rated it “inadequate”, and on “Are services well led?”, it rated it “inadequate”. Therefore, with all these negative ratings, what did the CQC do? It listed all the regulatory breaches and asked the company to kindly send it a report on how it would behave better in future. As Bob Geldof might have said, “Is that it?”

That is one reason why I say that the CQC is a useless regulator, which our report also suggests—or hints at, in very strong terms. By the way, a month after the scathing CQC report, the company changed its name and pretended to be a completely different supplier altogether.

I wrote to the Secretary of State calling for the contract to be removed, but that did not happen because he was not properly in charge of it and he was not sure quite who was. I now get Rolls-Royce service from this company because of who I am and because I created a big stink, but the other 9,884 victims, who have conditions far worse than mine, might not be so well served.

When I joined the Public Services Committee, colleagues were looking for a short-term inquiry to fill a gap as we looked at suggestions for a longer inquiry. I suggested investigating the delivery of medicines at home and supplied details of my own experience. I think that initially my colleagues thought that I was perhaps exaggerating the shambles I had described, but when our excellent clerk, Samantha Kenny, looked at it, she thought that it deserved a deeper look.

My colleagues thought that there may be a bit of a mess here, and then the evidence started to come in from various patient groups such as Crohn’s & Colitis UK, and the superb report from the British Society for Rheumatology which suggested that the system was a complete shambles and cited countless examples of failure to deliver medicines on time. I think colleagues then concluded that old Blencathra was not so barking after all.

We have called the report An Opportunity Lost and that is true, but we could easily have called it “A Complete Shambles”. Those are not just our words; the Chief Pharmaceutical Officer for England told us that our inquiry had unearthed,

“a complicated picture that is quite hard to understand even when you are working in the area”.

That is a nice way of saying “a complete shambles”.

The then Minister for Health and Secondary Care, Will Quince MP, stated:

“It is certainly complicated. That is an understatement”.

That is, again, a nice euphemism for “a complete shambles”. As the noble Baroness said, the NHS has not a clue how much it costs. The National Clinical Homecare Association told us that the Treasury spends £4.1 billion per annum on homecare medicines, but the NHS told us it is only £3.2 billion. We asked the Minister—he said it was £2.9 billion. As we say, it is utterly shocking that no one in the NHS can give us an accurate figure for the billions spent on home deliveries, but then the NHS does not have a clue about how bad it is and how many patients have suffered. KPIs are a mess, as the noble Baroness explained.

We said in our report:

“Different sets of performance data are available to manufacturers and the NHS. This creates confusion and prevents effective monitoring … NHS England must develop and implement one consistent set of performance metrics”.

Performance data must be published.

The National Clinical Homecare Association told us that

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

That is a very clever form of words but quite misleading. Yes, 98.8% were delivered on the dates that the delivery company decided they were to be delivered on, but those were not the dates the doctors prescribed, which were always much earlier and before the medication for patients ran out. Part of these failures are delays in the NHS prescribing system and delays by the delivery company.

Chapter after chapter of our report highlights the failings of the system. Thus we say:

“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”.

Let no one misconstrue our conclusions as an attack on the private provision in the NHS. While we found myriad flaws in the provision at all levels, God help us if the NHS tried to run a courier delivery service, since that would be infinitely worse. Delivering medicines at home by couriers is eminently sensible but has to be better managed at all levels. The problems that we identified all relate to the fact that there is not one single person or NHS body in charge. Different people and organisations negotiate different contracts. There is no quality control or negotiating competence, there are no consistent KPIs to measure performance and the various regulators are all fairly useless. It seems there is no one with the power to sanction failure or cancel contracts. Worst of all, I got the feeling that the NHS rather likes it this way because when things go wrong there is no one individual or organisation to blame. They can all carry on presiding over a shambles but carry no personal responsibility for it.

I get exceptionally good medical care from the National Hospital for Neurology in Queen Square, the Royal Marsden and the Lakes Medical Practice up in Penrith, but if you want to see the general bureaucratic incompetence of the NHS and why it is failing so badly in so many areas, the bureaucratic shambles that we are reporting on here is a perfect microcosm example.

However, in the report we did not just criticise but offered solutions. Theoretically, there is a Minister in charge, but he or she has no say in the running of the system, which is delegated to the NHS. The Minister should be charge and have a very senior person reporting to them. We say:

“NHS England should designate a senior, named person with responsibility for the homecare system. That person should be given sufficient powers and resources to discharge that responsibility”.

That person’s responsibilities should include:

“Setting clear national KPIs for organisations commissioning and providing homecare medicines services … Collecting data on those KPIs, and publishing data on those KPIs in a way which supports public scrutiny of the homecare medicines system … Holding relevant bodies such as individual providers, Chief Pharmacists, the National Medical Homecare Committee and pharmacy teams to account for work on homecare medicines services … Responsibly using new powers to issue appropriate penalties to under-performing providers”.

That is essential; there must be sanctions.

The fifth recommendation is:

“Ensuring trusts or hubs procuring homecare medicines services have access to sufficient financial and expert procurement advice and information, including template legal agreement frameworks, so they are able to effectively deliver value for money services and influence the homecare medicines services market”.

As in every government department I have served in and witnessed over 40 years in Parliament, the lawyers employed by the outside commercial contractors are infinitely better than government lawyers trying to negotiate contracts; they outwit and outmanoeuvre us every time.

Finally, we said that:

“Achieving value for money and increasing transparency on homecare funding”

should be another part of their individual duties.

As the noble Baroness said, the government response accepted about 90% of what we say—that is jolly good. On that basis, let us have urgent action to implement those proposals and the remaining 10% as well.

I am very glad that the Government did a desktop review via NHS England. It was urgently needed. As the noble Baroness, Lady Morris of Yardley, said, there has been no individual with overall responsibility for performance, so there is a lack of data on performance. There have been problems with regulation, on which we await further proposals in the summer update. We urgently need a consistent set of performance metrics, but I am pleased that the Government have agreed to one set. We said that the Government need to know how much is actually spent on homecare medicines services but, as the noble Lord, Lord Blencathra, pointed out, we got three different figures. It is important to know which is correct, because these are large sums of money.

I am glad that the National Audit Office will be involved in defining costs, assessing whether commercial confidentiality is justified and establishing whether the Government can be confident that the money is being spent well. We also ought to acknowledge that there is a lack of competition in the market and that, as the service expands, greater competition is needed. That should in turn lead to a reduction in costs.

I shall just address the commercial sensitivity of services by manufacturers which, as we have heard, account for 80% of the homecare medicines service. It is quite difficult to understand what value for money is being achieved because of commercial sensitivity. I just point out that we are talking about public money and the 80% of the homecare medicines service that we are talking about is a for-profit service for NHS patients.

I found the Government’s reply, in paragraph 8 of their second letter on 25 March, to be very strange. What exactly is commercially sensitive? How do we know that we are getting best value? Is it not possible to unbundle contractual matters that are genuinely confidential from those that are not? I hope that the Government will look at that and look forward to the NAO giving us advice on it.

In conclusion, the noble Baroness, Lady Morris of Yardley, was absolutely right to say that we are optimistic. There now has to be an optimism about some of the problems that we have identified, in a service that is clearly going to expand. Things have been learned about the way it has operated, but we can have optimism about it. As the noble Baroness, Lady Morris, rightly said, it is essential that those who are using the service, those who manage it and the clinicians involved all need to be consulted. Patient groups have a great deal to say, so we need and would benefit from their time and evidence.

I see this report as a trigger for action. The Government have committed themselves to delivering improvements and, if this is got right, it will improve care for a large number of people with fewer pressures on the NHS estate. But a lot of work needs to be done. If it is done properly, homecare medicines services can be a growing pillar for our future health service.

Although the report is succinct, I shall focus on three things: transparency, information technology and accountability. On transparency, any good system that focuses on quality and cost must have data. That is the key to it. The Government’s response was very encouraging. It was nice to read—I think that they understand the issue and they are getting people to work on it. Let us just hope they can come up with something effective.

However, on recommendations 7 and 8 and the question of debundling that other noble Lords referred to, I could not quite understand the response—the point about commercial confidentiality. As other noble Lords commented, this is public money; we should get access. Also, it is remarkable that we cannot get anonymised data setting out these things hierarchically. I cannot understand it, so perhaps the Minister might do that. I encourage him to get his department to look at the P&L accounts of the pharmaceutical manufacturers and those of the people who provide the service. The balance of power seems to lie at the back end with the manufacturers, rather than focusing where the service needs to be at its best. The money should go at the front end where it hits the patient. I think he will be as surprised as I was when I looked at those accounts. Some 80% of homecare is delivered in this bundled fashion, which impedes direct management. If we have intermediaries for various sources, particularly the pharma companies, contracting here and subcontracting there, we have to get a direct accountability framework. I shall come back to that in a moment.

On digital, electronic prescribing has been really slow, and if you cannot get the information out, you cannot get the drugs to the patient. You cannot plan or do these things properly. It is absolutely fundamental. Instead, we have pieces of paper flying around—these are decades-old systems. The key to this is getting the IT to work for electronic prescribing, but also getting that data back into the integrated care record. These patients are not stuck just in homecare; they go back into the acute hospital and the community, and they have comorbidities. The question is: how do those servicing them look across the care spectrum with one record of care? Can the Minister tell us when he thinks we might find some integrated care record so that all those phases can become apparent to support patients?

The nub of the problem is accountability. This was chaos; everybody we spoke to had no idea who was responsible. It was most remarkable, as other noble Lords have noted, and I have never been in a situation like it. But we are where we are. Clearly the Government accept this situation, and clearly our report has been a catalyst for change. How do we get clarity of roles, responsibilities and decision rights, if we are to unwrap this whole shambolic situation? I hope the Minister can tell us whether, when these reports come forward—possibly in the summer, ahead of the recess—he will be able to publish an accountability framework. Until we see that, and see how the pieces fit together, although we might have a lot more words we cannot focus on who we can go to, in the operations particularly. Where will this famous SRO sit? To whom will it be accountable? Who will be accountable to it, and what decision rights will it have? Unless we get that right, all our aspirations will not be met.

As regards regulation, one might say, as the noble Lord, Lord Blencathra, noted, that the CQC has failed in this respect. Light-touch regulation is one thing; dereliction is another. We must be sure of two things. First, there can be only one regulator—multiple regulators always fail. We need a super-regulator, which has to be the CQC—we have not got time for legislation. Secondly, the CQC has to be made effective and has to come to an arrangement with the two other organisations that underwrite quality.

The NHS is in a most difficult position; it is under unprecedented pressure on every front. As the noble Baroness, Lady Morris, noted, this is not about money; this is about organisation, management, detail and covering that ground. We are encouraged by the fact that the Government have accepted, or nearly accepted, so many of these recommendations, but the fact remains that this has to be about access and getting things right as we go forward. I hope that the Minister can tell us with some confidence what next steps he intends to take in order, when this comes back in the summer, to tell us that the way forward is there.

I end by saying this. It is clear that the Government have found this report quite useful. Since our committee is always looking for interesting things to do, maybe the Minister will point to one or two other things we could look at in order to help him.

Can noble Lords imagine any business with half a million customers not knowing how much money is being spent or where it is being spent, particularly when sums from £2.9 billion to £4.1 billion are involved? Yet that remains the case. An initial response was that the service cost £3.2 billion, and then, according to the National Clinical Homecare Association, £4.1 billion, which was then reduced to £2.9 billion. The Government then said £3 billion in their response. The confusion comes because there is no accurate way to measure the cost of delivery, which prompted the committee to seek an in-depth explanation, only to be told, as Members have clearly stated, “commercial sensitivity”. In actual fact, the real reason is that there are no clear requirements to meet nationally agreed criteria for service delivery and component costs. Therefore, the critical breakdown does not exist.

The Government have accepted the need for national key performance indicators, but the idea that the National Clinical Homecare Association and the homecare providers should provide all the criteria for identifying costs is unacceptable. Could the Minister say whether the statement coming in the summer will include the National Audit Office to certify expenditure? Given that 80% of expenditure is on drugs and medicine, will the Royal Pharmaceutical Society be the lead adviser on the core national priorities to the new home medicine service leader? Speaking of the leader, could the Minister explain why, given the overwhelming role of the pharmaceutical services, the chief pharmacist was not considered as the key person to lead this service? If not them, who will it be? We would like to know.

One of our key recommendations, which was supported by the Government, is an end to the antiquated method of handwritten and fax-delivered prescriptions between consultants and providers. However, it was disappointing to read that the data systems, which are absolutely crucial to the future of the service and which are so appallingly absent at present—an issue fully accepted by the Government—will be provided by a sub-committee of the National Homecare Medicines Committee. That is not acceptable. We are in this mess because that committee, which is in league with commercial providers, failed to provide the data required to build the service in the past.

The absence of core national data seriously affects patients, who all too often have to cope with missed deliveries of drugs, sometimes forcing them back into hospital and perhaps even causing unfortunate premature deaths. We asked the NHS for statistics to see how serious this was. What was the answer? “Sorry, they’re not available”. The same answer came from the Care Quality Commission. I will not repeat what the noble Lord just said, but I plead with the Government not to get this wrong. Data is absolutely essential. What is more, if homecare is to be expanded substantially to reduce burdens in the NHS on primary and secondary care, then getting leadership, data and finance right is crucial.

This leads me to regulation, which other Members have spoken about. I know, having worked for some 10 years as a consultant to the NMC and the RCN, and having chaired the York and Humber applied research collaboration for five years, that regulation in the NHS is a major challenge, and not one that can be easily sorted out. However, we must be given a structure that integrates its work far more effectively. I totally agree that there should be a single consultant and that it should be a powerful voice. The idea that that will happen soon is, quite frankly, not realistic.

An immediate solution would be to create a lead regulator with the authority to insist on requirements from other regulators without having to seek the approval of the Secretary of State. If the CQC is to be given that task—and as the protector of patients, it should be—it must be empowered and encouraged to conduct in-depth reviews. It told us it could not do in-depth reviews unless the Secretary of State told it to do them.

That leads me finally to the patients themselves. The 2011 report concluded that,

“moving forward, patients and patient representatives should have a much greater role in design, operation and monitoring of homecare … services … Patients are at the heart of homecare medicine and should be listened to”.

Crucially, our report sought an assurance from the Government that patients and key organisations involved would at least be asked for their advice and be involved with any future policy changes, because nowhere in the Government’s response or, quite frankly, in the evidence from officials do patients take a prominent role—which is exactly the same as in the 2011 survey.

In her letter to the Minister, the chair made a special plea for this anomaly to be changed. I admire and appreciate the fabulous service that the leading charities give to patients and their families. They deserve our utmost thanks, but the Government must do more. Now is the time to put patients at the heart, not the periphery, of future discussions. I sincerely hope that, when the Minister produces what I trust will be a ground-breaking response before the Summer Recess, we will all be able to cheer from the rooftops. I live in hope.

We have some data, but I am not sure whether it currently paints a positive picture. IT systems have been developed with no single NHS system for providers to interact with, which means, as has been mentioned by the noble Baroness, that around 6,000 prescriptions are written in the UK every single day on more than 1,000 different templates.

One provider reported that, between October and December 2020, 9,885 patients had medicines missed or delayed. We do not know how much money is spent, as has been highlighted in this debate. It could be £4.1 billion, £3.2 billion or £2.9 billion—the truth is that we simply do not know. It is important that we get that figure quickly. We cannot accept the Government always hiding behind confidentiality and contracts as reasons why we cannot see some of the data; in the end, this is taxpayers’ money, and we need to make sure that it is being spent in the correct manner. The lack of transparency is a worry, as are failures in procurement and the reluctance to enforce standards, as my noble friend highlighted in his usual way at the beginning of the debate. The report makes clear that this is a difficult market with poor infrastructure.

I mentioned earlier that public services are about people. Many people with Crohn’s and colitis rely on homecare medicine services. When it works well, homecare offers people with inflammatory bowel disease the opportunity to receive treatment in the comfort of their own home, reducing the cost of travelling back and forth to hospital and the impact of treatment on their work or education. It can also reduce pressures on NHS services by allowing people to receive their medication at home. Unfortunately, delays, cancellations and incorrect deliveries of homecare medicine services are jeopardising people’s health and causing significant stress and worry for people living with Crohn’s and colitis, for example.

A Crohn’s and Colitis UK survey in 2023 found that nearly two-thirds of people with IBD had experienced problems with homecare in the previous six months, including delays or cancellations. Those failures led to nearly half experiencing a flare, one in nine ending up in A&E and one in 20 requiring surgery. One lady living with Crohn’s disease told the organisation:

“Every month continued with missed and delayed deliveries and being unable to contact the home care company. My hospital team had to intervene every time. On top of the daily challenges that my condition presents, the stress, anxiety, and time spent making sure I got my drug became unsustainable. It was too much”—

far too much. Sadly, her story is not unique. When IBD medication is delayed or missed, there is a strong risk that it loses its effectiveness and no longer helps to manage symptoms, which can result in a flare-up. A Crohn’s or colitis flare can lead to bleeding, abdominal pain, fever, joint pain, mouth ulcers, fatigue and mental health deterioration. Careful monitoring and control of IBD is vital for people to be able to work, study, socialise, maintain relationships and live life the way that they want to. Unreliable homecare medicine services jeopardise this.

It is currently unclear exactly how many people have been harmed by homecare failures, how much money is being spent on these services and who is ultimately responsible for them. We need to make sure that homecare medicine services are monitored and governed far more effectively, as we have heard today. Perhaps the real point is that no one seems to own these key services. As noble Lords will know, when a service is an orphan, progress is limited, accountability is lacking and patients suffer.

The report is an opportunity lost—for now—but it is clear that, if we can make some changes, homecare medicine services could be transformational. Reliable homecare medicines can change patients’ lives, improve quality of care and quality of life and start to make a real difference. This would allow NHS resources to be redeployed.

I am heartened by the substantial progress that has been made since the report was launched. The NHS England review to establish the facts is fundamental to ensure that we are starting from a position of fact that will allow the transparency required, start to allow patients and providers to understand the marketplace and allow patients to have the confidence to improve their health and to start to take the pressures off the NHS.

I thank the Government for their work in this space and their commitment to take the issues raised with them by the committee seriously. Having read both the Government’s letters to the committee on this topic, it is evident to me that good progress is being made here. It is reassuring that the Government accepted a large number of the recommendations in the report and are fully engaged in productive work to return a final position on some of the others.

I note that, importantly, NHS England’s desktop exercise is now complete, and I was delighted that stakeholders, including patients, had been involved in that. I look forward to reading it once it is published. I was also heartened to read that NHS England will now move to focus on and take action in the most pressing areas of patient experience and performance, and continue to engage with key stakeholders as its work moves forward.

Lastly, I note the fact that NHS England will appoint a senior responsible owner for this work, which is incredibly good news for this sector. I look forward to hearing more details about the position and the appointment to it, and to reading the Government’s summer update to the committee on homecare medicines services. I know that my noble friend the Minister is a strong advocate of using data to drive up standards and performance. This gives me confidence that we will see the change required. I am looking forward to his response today. It is worth remembering that it is the little things that mean a lot.

What we see increasingly in other areas is real-time performance data rather than periodic collection of performance indicators. Real-time data is more useful and certainly less prone to the kind of gaming that can be done with KPIs. We see that in the NHS where people work to get to their quarterly target; they rush the drugs to the noble Lord, Lord Blencathra, because they want to tick that one off to meet their target, but you cannot cheat real-time data in the same way. I hope that the Minister will consider that. Certainly, if I were the owner of a contract I would want to know in real time whether the thing that I contracted for was actually being delivered.

When someone visits a home to deliver a product, or if they are going to provide a service, it is very easy these days to log that using commonly available tools. This does not have to be a big bureaucratic exercise. It can be a click or two, and then that data goes to the person who contracted with the service so that they know it has been delivered. We all experience this in our daily lives. I will use the comparison that when I order drugs for my cat, which I do, I am told when they are going to arrive. When they arrive, the button is clicked and the person who supplied those drugs knows that they have been delivered. If it is good enough for my cat, it is certainly good enough for half a million people who receive these services.

That is especially important if it is a market in which a buyer is paying a main contractor—in this case, the medicine manufacturer—who then subcontracts the delivery part of the service. Once it gets more complex, that is no reason not to have real-time data but a reason to prioritise having it, so that you do not end up playing pass the parcel. The noble Lord, Lord Blencathra, said he wondered if people sometimes do not want to know the breakdown, because they do not have to own it. No: someone needs to own this. If I were a clinician or a manager in an NHS trust and I had 500 or 1,000 patients dependent on the homecare service, I would want to know in real time what they were getting. I would expect everybody in that chain to pass the data back, so I could see whether it was working or whether something had broken down.

Here, I think about another initiative that the Minister is keen on, which is virtual wards. We do not send people home and ask them to tell us in three months whether the service on the virtual ward was delivered. The clinician is there with real-time data about what is happening to that person at home. I do not see why the homecare medicine service should be any different. If you can easily collect the data, it should be going back to the clinicians so that they can see whether there is a breakdown and, as other noble Lords have said, plan to fill the gap if they need to. This is critical for the patient interest. This kind of visibility of real-time data is possible. It is even more ambitious than the KPI recommendation, but I hope that the Minister will commit to looking at how it could be built.

The other piece of transparency that has been referred to, particularly by the noble Lord, Lord Carter, is the transparency of costs in recommendation 5. I was also struck by the government response citing commercial confidentiality. That did not work for me, frankly. There should absolutely be commercial confidentiality at the point at which you award a contract, before somebody has signed the deal. However, there is no reason for a high degree of commercial confidentiality to continue after the deal has been signed unless it is because of the imbalance of lawyers. The noble Lord, Lord Blencathra, spoke about that. If I were a lawyer for a company, I would say to the NHS, “You have to keep it all secret once I have signed the deal”. The NHS does not have to agree to that. The NHS can say: “As a condition of the contract, we want this data to be put out there and we are not going to agree a contract that has commercial confidentiality in it beyond that which is strictly necessary”.

The report rightly talks about competition in this space. The way to encourage competition is to let the market have as much information as possible so, when the next round of contracting comes up, you can draw on what the cost base was for the previous contractors. That is not in the contractors’ interests, but it is in the public interest. I would expect to see that filtering through. I hope the Minister will look again at this. The block use of commercial confidentiality was in the government response, but we need to get much more granular and find out if there are real reasons or if it is simply for the convenience of the contractor or because it had better lawyers when doing the negotiation. We should be able to take that out.

I now want to speak to a favourite theme, which is the stubborn persistence of paper-based systems in the National Health Service; they are lurking around way beyond their sell-by dates. We have excessive tolerance for this. It is flagged in recommendation 11. It really hurts to see that inefficiency persist when we have actually already paid for the electronic system; we are just not using it. If you have not built the system, that is one thing, but we have built an electronic prescription system yet this important service has somehow just not bought into it; that is really painful.

The government response did not have any timeline for when this will be delivered. It expressly said that the Government cannot give a timeline. I know the Minister will be uncomfortable about the persistence of the paper-based system and I hope he can give us additional assurances on that today. Can we please be less tolerant about people not using the electronic system? It benefits everyone, including the contractors. They will save money if they move over to the electronic system. They may have inertia, but I think we can be insistent, given that it is for everybody’s benefit.

I would like us to be more ambitious. We need to be mammals about this and not be overly sensitive to the fate of dinosaurs who choose not to evolve. In saying that, I am not talking about the service users, many of whom are really familiar with the technology. I am talking about the service providers, some of whom are not moving on. If they do not want to move on, I worry about why they are still in this business. We need people who are willing to move on and use the latest tools.

It is a very useful report. There are many other recommendations to which I hope the Minister will respond positively. I hope he will particularly pick up three areas that I and other noble Lords have highlighted. First, NHS service managers should have real-time access to performance data for homecare medicine services, just as they would for the other services that they are delivering. It is reasonable to expect providers to offer this capability. Secondly, there are benefits in being much more open about the costs of service delivery. We should not use commercial confidentiality inappropriately to stop this. Thirdly, we should be aggressive—I would use that adjective—in moving everything on to the electronic prescription service. We have paid for it, and we should use it.

I again thank the committee and the noble Baroness, Lady Morris, in particular for her introduction to this. I echo the positive note and the fact that, as she said, these are things that can be done now—that is critical. We do not want a response that says things will be done in a year or two years; we want things that will be done in 2024.