The UK homecare market continues to grow. In England alone an estimated 517,000 adults received homecare through their local authority in 2011/12, and although Scotland and Wales experienced a slight dip during the same period, the number of people receiving ‘intense’ packages of homecare across the UK is steadily increasing.
It’s no great surprise. An ageing population and consecutive UK governments’ determination to move care out of hospitals and into the community – as well as concerted efforts to help people remain independent – has meant that domiciliary care is no longer a foreign concept. Moreover, as the landscape matures and homecare providers extend their capability and expertise, homecare is increasingly becoming a viable option for pathway redesign across a wide range of therapy areas. And with improving the patient experience and patient satisfaction as key drivers – and reducing expensive and avoidable hospital stays a significant priority – commissioners are recognising real value in the homecare model.
For clinical homecare providers – specialists in the supply and management of homecare medicines – the growing demand for domiciliary care has led to a similarly increased demand for their specialist services. According to the Department of Health (DH), the NHS spends more than £1bn a year on homecare medicines and a further £250m on associated homecare services. That demand is rising at an estimated 20 per cent a year and predicted to accelerate further. So far, so very good.
Except it’s not quite so simple. A February 2013 report into homecare by the Care Quality Commission (CQC) found that while many providers were delivering a good service, a minority of patients were experiencing sub-optimal service, delays and inconsistency in care. The CQC research examined homecare provision for the over 65s (in England), and found that some providers were failing to meet national standards – leading to elements of poor care happening ‘too often’.
Can’t quite Hackett
The CQC study was conducted between April and November 2012, just months after the publication of the Hackett Report, NHS Homecare Medicines – Towards a Vision for the Future. Hackett concluded that the importance of homecare medicines ‘cannot be underestimated’, and that the effective delivery of homecare services was helping to ‘transform patients’ lives’. But he also found that high quality homecare services were the exception, not the rule – and that providers and commissioners needed to redouble their efforts to develop more effective, high-value and, ultimately, safe homecare. The report called for better provider-side leadership, governance and monitoring arrangements, and urged commissioners to work more collaboratively – in partnership with patients – to design optimal homecare services.
Implementation of the Hackett recommendations began in 2013. Its work streams include a programme of patient engagement, as well as an acute trust engagement exercise to establish good clinical governance. Patient engagement work is already providing valuable insight and being used to inform all other work streams. In addition, work to examine homecare models and functionality, and to develop a standardised procurement model, is also underway. Alongside this, efforts to share best practice and develop expertise and standards to support quality clinical homecare have intensified. An NHS toolkit to support the management of homecare medicines is expected to be launched before the end of the year, while ahead of this a framework of professional standards in England has already been published. The battle for ‘home improvements’ is gathering pace.
Quality begins at home
The Royal Pharmaceutical Society (RPS) issued its Professional Standards for Homecare Services in England in September 2013. The standards, developed with the Homecare Standards Workgroup and overseen by the DH Homecare Strategy Board, build on the Hackett Report and are designed to provide a best practice framework for the implementation and delivery of homecare services. They offer clear guidance for teams commissioning and providing homecare services, outlining the standards required to help ensure patients receive a consistent, high-quality and safe homecare experience. Moreover, the standards, which Mark Hackett said he’d ‘like to see’ adopted by all providers and commissioners, hope to drive to the continual improvement of homecare services.
While ‘like to see’ infers that meeting the standards are quite some distance from being mandatory, optimising the opportunity of domiciliary care services – and in the process, helping the NHS achieve some its most crucial strategic goals – will undoubtedly rest on homecare providers’ ability to improve the quality of their services. And, equally, commissioners’ – and even pharmaceutical companies’ – ability to discern between a sub-optimal and best practice provider, will determine the sustainable success of the homecare model. It really is that important – and, as Mark Hackett said, it “cannot be underestimated”.
Collective responsibility
Although the professional standards place the pharmacy team at the centre of the safe delivery of homecare services, RPS says its guidance is equally relevant to other healthcare professionals involved in the delivery of domiciliary care. These include medical practitioners, nurses and therapists, as well as child protection officers, senior information risk officers, Caldicott Guardians and information asset owners. The latter categories not only indicate the trend towards integrated health and social care, but also the growing importance of data privacy in the move towards electronic health records.
But the role of the pharmacist is pivotal. While responsibility for individual homecare services lies with the homecare organisation commissioning the service – through a ‘cascade of delegated accountabilities’ – the standards dictate that there should be a pharmacist responsible for homecare at each level. Within every organisation a chief pharmacist ‘or equivalent’ is responsible not only for all homecare services related to medicines, but also the “integration of their homecare services will all other relevant organisations involved in the provision of the homecare service or other elements in the medication pathway – including commissioners, subcontractors or other service providers”.
Home improvements
So what do the new professional standards look like? There are ten high level standards, grouped into three domains:
Patient experience: The important issues of patient engagement, episodes of care and integrated care are explored in the first three standards. The need to provide patients with information and support to help them make crucial decisions about homecare – and beyond that, support medicine adherence – is critical. In addition, the guidelines encourage the regular assessment of patients’ medicine requirements right across the pathway – from referral through to ongoing care and monitoring – to optimise homecare outcomes. To support this – and create an accessible audit trail of documentation that underpins integrated care – commissioners need to ensure that communications models across a whole multi-disciplinary team are robust and compliant with multiple regulatory frameworks.
Implementation and delivery: Domain two comprises four standards that underpin the implementation and delivery of safe homecare services. The effective use of homecare medicines requires a robust homecare policy that includes a clearly defined multidisciplinary homecare team that supports an integrated approach to the choice of safe and clinically effective homecare services. This will need an appropriately appointed medicines management group, a specialist homecare pharmacist to lead prescribing processes and regular risk assessments. Pharmacy will also manage service procurement, medicine purchasing and the quality assurance of custom-made medicines.
Once again, the homecare team must be supported by access to evidence-based information in real time. Moreover, the pharmacist must have the appropriate governance and checks in place to assure the safe and effective storing, dispensing, administering and disposal of homecare medicines.
Governance: The final three standards outline key governance requirements. This encompasses the need for strategic and operational leadership, ensuring pharmacy has a clear vision, supported by governance and controls assurance that enable patients to get the best possible outcomes from homecare services. The chief pharmacist must lead the way – providing clinical leadership on medicines issues across the team.
The development of high quality homecare services in the UK will be a vital component in the delivery of safe, efficacious and cost-effective healthcare in an environment where the patient, quite literally, feels most at home. Homecare offers a powerful opportunity to improve care pathways, drive health outcomes and generate important cost-savings – but to maximise it, commissioners, pharmaceutical manufacturers and, ultimately, patients, must be confident that the packages of homecare being delivered are both safe and effective. The RPS professional standards are a major step towards best practice in domiciliary care – but only if they’re acknowledged and implemented across the board. It’s time for some real home improvements.
The Author
Chris Ross is a freelance journalist specialising in the healthcare and pharmaceutical sectors