1. Homecare Medicines: Reducing the risks Professor Ray Fitzpatrick Clinical Director of Pharmacy Royal Wolverhampton NHS Trust Co Chair Standards and Handbook Workstream of the National Homecare Strategy Board

2. Background Homecare is a Rapidly growing market value circa £1.5bn 200,000 patients receiving medicines via the homecare route 2011 Department of Health commissioned a review of homecare services. Review led by Mark Hackett CEO University Hospital Southampton NHS Foundation Trust. Report published November 2011

3.   NHS has used homecare services for patients since 1995. However, in the last four years there has been a rapid development of services without the necessary controls to ensure common standards of best practice.   Examples of good practice but wide variation across NHS Key Recommendations:- Collaborative procurement processes to be developed National Standards to be developed NHS internal homecare governance processes to be strengthened with the Chief Pharmacist at the centre working alongside the Chief Medical and Nursing Officers of the Trust Patients to be engaged in development and commissioning of homecare services Key Findings in Hackett Report

4. Implementation April 2012 Strategy board established to take forward the key recommendations in Hackett report. Board established several work streams   Patient Charter – clear specific charter to enable patients to understand their homecare services and how they can influence them   Homecare Standards and Handbook – Royal Pharmaceutical Society approved standards with aligned documentation in a Handbook   Governance – a guide to good governance for acute trusts using homecare services   Systems – initial recommendations to the NHS on short term system solutions and an output based specification for a new Homecare system solution   Procurement – recommendations associated with improving the procurement models for use within the NHS and improved transparency of SLAs through a shared management system

6. Homecare Standards and handbook: reducing the Risks with Homecare medicines http://www.rpharms.com/unsecure-support- resources/professional-standards-for-homecare- services.asp

7.   Patients’ charter   Homecare Service Information for Patients & Carers   Registration and consent form   Patient satisfaction questionnaire   Medicine Pathway   Individual Care Plan   Suitability and Needs Assessment for individual patients   Clinical Records   Clinical Service Protocols and Reports   Non-clinical Home visits Protocols and Reports Domain 1 The Patient Experience

8. 2.1 Contractual framework required for a Homecare Service   Homecare Services Aims and Rationale   Homecare Service Specification   Tender of Request for Proposal and Adjudication Criteria   Service Level Summary or Service Level Agreement   Technical agreement   KPI’s   2.2 Operational Guidance for Running a Homecare Service   Prescriptions   Temperature controlled storage   Custom made medicines and imported medicines   Key holding guidance   Adverse weather guidance   Homecare Service Review Meeting Agenda   Transferring Patients between Homecare Providers Domain 2 Implementation and Delivery of Safe and Effective Homecare Services.

9.   Homecare Strategy & Policy   Patient Confidentiality, Data Protection and Information Sharing   Recommendations from the IT workgroup   Managing Complaints   Patient Safety & ADR Reporting   Quality Assurance and Risk Management   Audit of compliance with the RPS Professional Standard   Clinical Trials   Workforce Planning Job Descriptions   Regulation and External Accreditation Domain 3 Governance of Homecare Services. Domain 3 will be of particular interest to chief pharmacists seeking to establish or review their governance arrangements for homecare

10.   I maintain robust governance on medicines dispensed in house, so homecare medicines should be no different   As majority of medicines delivered through homecare are PbR excluded commissioners will require compliance with RPS Standard Reducing the Risks: A Chief Pharmacists Perspective Standard 8.1 The Chief Pharmacist or equivalent ensures that the organisation maintains a clear vision for homecare services, optimal use of homecare medicines and sharing best practices across homecare organisations.. Why do I need a handbook?

11. Developing a Homecare Strategy Where am I now What are my gaps to comply with RPS standards What do I need to do to fill the gaps My Strategy What homecare do we do already? SWOT analysis

12. Strategy - Review Current Homecare Therapy areas Current Therapies   Stable HIV patients currently provided through homecare.   Rheumatology patients receive biologics through Pharma schemes managed by the clinic   Paediatrics, gastroenterology and renal Issues   Homecare not suitable for every patient.   Not managed by NHS. Acquisition of Cannock hospital will more than double number of patients   Need to understand the rationale. Are there better alternatives for the patient?

13. Strategy - Review Governance Arrangements Strengths   All prescriptions processed through pharmacy (clinical screening, ordering and invoicing).   Good financial governance.   Good patient level information on homecare usage and expenditure   A member of my procurement team has a specific homecare role.Weaknesses   Homecare has developed in a relatively unplanned way apart from HIV.   No homecare pharmacist or team   SLA’s not monitored closely.   No monitoring of KPIs   No audit of homecare services and providers. .  No forward planning of which medicines delivered via homecare.

14. My Homecare Strategy 1.Revise medicines policy to cover medicines delivered via homecare. Example homecare policy in handbook. 2.Establish a homecare team resourced from gain sharing agreement with commissioners. Example JD’s for Homecare Pharmacist and Technician in handbook. 3.Review appropriateness of current homecare therapies and identify alternative models if necessary and what additional homecare services local patients and commissioners would like to have 4.Establish robust SLA’s with homecare providers (see handbook), monitor KPIs (internal and providers) 5.Team to develop robust risk management arrangements for homecare medicines particularly in the light of recent NPSA alert

15. Summary   First Hackett report identified homecare market has grown rapidly in recent years with wide variation in NHS ability to manage these.   Patient safety alert issued in April 2014 highlights the risks of missed doses with homecare medicines   To reduce risks with the delivery of medicines via homecare services a number of work-streams established under national homecare strategy board.   RPS Homecare standards published in September 2013 provide a framework for us to work to.   The Homecare Handbook published earlier this month contains guidance on how to meet these Standards.   IT workstream still to be completed and handbook needs to be updated regularly

16. To reduce risks associated with homecare medicines, we need to take control!