Non-medical prescribing including PGDs

Prescription drugs in immediate medical care

• Patient Group Directions
• Patient Specific Directions

In recent years immediate medical care has expanded to include nurses and paramedics responding on behalf of BASICS. The use of non-doctors brings new challenges, not least in supporting their role through the use of prescriiption only medications. 

Registered nurses can following an appropriate course register as an independent prescriber which allows them to use the full remit of prescribed drugs in the same way as their medical colleagues can. For those nurses who are not Independent prescribers patient group directions may apply subject to the relevant regulations being met.

Registered paramedics by virtue of their registration are allowed to carry and use a range of prescribed medication which includes morphine. Additionally, like nurses they are one of the approved healthcare professions who can use patient group directives.

Patient group directions explained

The Department of Health guide Medicines Matters is the authoritative document on patient group directions (PGD) and other forms of the non-medical supplies prescription drugs.

PGDs allow named health care staff from a limited range of health care professions to administer drugs against a pre-defined protocol to un-named patients and as such are a viable tool in the provision of immediate medical care.

The specified health care professions: 

• nurses,
• midwives,
• healthvisitors,
• paramedics,
• optometrists,
• chiropodists and podiatrists,
• radiographers,
• orthoptists,
• physiotherapists,
• pharmacists,
• dieticians,
• occupational therapists,
• prosthetists and orthotists,
• speech and language therapists.

For a PGD to be a legal document it must meet certain criteria both in how it is drawn up and how it is laid out as well as to the signatories to each group directive. PGD cannot be used generically and apply to named practitioners.

Patient group directives must be drawn up by appropriate persons to include a pharmacist and a doctor and their use is to be overseen by a member of the relevant profession to ensure that the named individuals are appropriately trained and experienced so as to safely administer drugs against the patient group directive. 

From 2003 onwards non-NHS organisations have been able to use patient group directives that these are restricted to Independent hospital agencies and clinics registered under the Care Standards Act 2000, Prison healthcare services, Police services, the Defence medical services and most relevant to BASICS schemes for services funded by the NHS but provided by the private, voluntary or charitable sector.

Patient group directions may allow for flexible dosages and for ‘off-license’ use provided such use is supported by best clinical practice.

As regards controlled drugs; nurses and paramedics can supply and administer Schedule 4 and Schedule 5 controlled drugs using a patient group directive.Midazolam although a schedule 3 drug can be included in a PGD.  A common misconception is that nurses can administer diamorphine for cardiac pain using a patient group directive; the regulations allow for this only within hospital emergency departments and coronary care units. It is anticipated that a change in the law will enable nurses to administer opioids under a patient group directive in the relatively near future.

The Home Office view on possession of controlled drugs is summarised below in a written response (from March 2010) from the Head of Drug Legislation at the Home Office:

"To confirm, when PGDs were first introduced into the Misuse of Drugs Regulations 2001 (MDR) in 2003, no corresponding change was made to Reg 10 to give authority to those acting under PGDs to possess the relevant controlled drugs. However, the Home Office has taken a view that the written instructions set out in the PGD may be adequate for compliance, supported by the explicit authority in the MDR o [sic] a person acting under a PGD to supply or offer to supply the relevant controlled drugs. It would be a nonsense for someone to be able to supply a controlled drug but at the same time be in unlawful possession of that drug. We accept that specific authority to possess is the preferred position to put the issue beyond doubt. A clarifying amendment will be made. It would be disappointing if this drafting position was adversely impacting on the availability of medicines and the care to patients."

Patient specific directions explained