The supply and/or administration, in addition to the prescription, of medicines presents risks to both patients and health practitioners. Such was the concern, in the absence of a prescription for a named individual patient, that the Department of Health requested Dr June Crown to chair a group of professionals to review the arrangements nationally.1
An interim report,2 subsequently made legal,3 recommended the use of patient group directions (PGDs) to guide practitioners, predominantly nurses, when they needed to supply or administer medicines in the absence of a prescription from the doctor or dentist.
What is a PGD?
A PGD is a written instruction for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.
PGDs provide a means of treating patients with defined medicines in specified situations without the need for a prior prescription.
Benefits for patients
An overriding requirement for a PGD is benefit for the patient. Benefits may include:
- Earlier access to care
- Earlier emergency therapy such as bronchodilation or treatment of anaphylaxis
- Earlier access where the production of an individual prescription is unwieldy, e.g. in mass immunisation.
Reducing the risk
Risk is managed by providing specific guidance, leaving nothing to the discretion of the person administering the medicines.
Exact details regarding the condition to be treated or the circumstances, e.g. family planning, are specified, together with the criteria for including or excluding certain classes of patient, whether by virtue of age, gender, symptoms, coexisting morbidity or concomitant drug therapy.
A pathway for further treatment should be identified for those patients who are excluded from treatment or who decline to have their healthcare provided in this way.
Only specified health professionals may practise according to the PGD. They are given instructions on the medication, including drug name, formulation, dose, frequency of administration and total dose. Verbal and written advice for patients must also be specified in the PGD.
Risk is reduced further by submitting the PGD to a local professional advisory group for review. This function may be carried out by medicines management goups, formerly drugs and therapeutics committees, or by clinical governance groups.
Finally, each PGD is signed by a doctor or dentist, and a pharmacist, and is authorised by the employer of the health professional supplying or administering the medicine.
In the primary care surgery, nurses are now required legally to use a PGD for the supply or administration of medicines whenever the surgery purchases, or is given, medication for administration which is not prescribed on FP10.
Which medicines may be covered by a PGD?
Medicines included in PGDs are predominantly vaccines for childhood immunisations, travel, influenza or pneumococcal protection, together with the adrenaline (epinephrine) needed for treating an anaphylactic reaction.
Other medicines might include nicotine replacement therapy, Levonelle for emergency hormonal contraception, Depo Provera for family planning, and rescue or test doses of salbutamol or terbutaline.
Deciding whether a PGD is needed
To determine the need for a PGD, convene a multiprofessional group, usually comprising a doctor, pharmacist and nurse, and identify the benefits to patients. The prescribing adviser to your local primary care organisation is a useful person to help you get started.
Model PGDs may be viewed on the internet at www.groupprotocols.org.uk4 This site also contains an algorithm to assist practitioners in deciding whether or not a PGD is appropriate in an individual situation (see Figure 1, below)
|Figure 1: How to decide whether a patient group direction is appropriate in an individual situation*|
|* Reproduced from www.groupprotocols.org.uk by kind permission of Pharmacy Community Care Liaison Group/Beth Taylor and Leigh Machell|
Benefits for GPs
Benefits to GPs include the production of an evidence-based quality standard, improved response to anaphylaxis, earlier treatment for patients, fewer appointments and subsequent FP10s to authorise.
Further benefits may arise from the use of PGDs by community pharmacists, which provides more rapid access for patients and frees up time in the surgery.
- Department of Health. Review of Prescribing, Supply and Administration of Medicines (Crown Report). London: DoH, 1999.
- Report on the Supply and Administration of Medicines under Group Protocols: Review of Prescribing, Supply and Administration of Medicines. HSC 1998/051.
- Patient Group Directions (England Only). HSC 2000/026.
- Jones P, Harris A, Parker-Jones C. Using low-cost internet as a quality medium for promoting PGDs. Guidelines in Practice 2000; 3: 47-52.