This site is intended for health professionals only

At the heart of general practice since 1960

Myths about what healthcare assistants can and can't do REALLY need to be debunked

Dr Paul Cundy argues that requiring a patient specific direction before giving an injection or vaccine is unnecessary and has no basis in law

Hacking through the branch ends of the Scottish pine the bright red air ambulance eases its nervous way to the ground. Skids barely touching the heather, two fluorescent-clad saviours leap forward, ‘doctor’ and ‘paramedic’ emblazoned across their shoulders. They cross the ground and arrive at the scene; upturned tractor, trailer, scattered fence posts and impaled driver, a freshly hewn three-inch stake through his abdomen. A quick check of the pulse - nothing - signs of ventricular fibrillation tracks across the ECG screen like some desperate life ending wave.

‘Quick, I’ll get the line in, you give him the adrenaline,’ commands the doctor as he begins ripping open plastic packs.

The paramedic unshoulders his pack, parting zip after zip, compartment leading to compartment.

‘Where is it?’ he hisses through clenched teeth.

‘Hurry up we’re losing him, for god’s sake give him the adrenaline,’ barks the doctor.

‘I know I know but I can’t find it,’ is the exigent reply, the victim’s agonal gasp seemingly contributing to the conversation.

Hands searching, the paramedic’s face at last relaxes, anguished contortions dissipate as calm comes over him.

‘Here it is, everything will be fine now.’

He stands astride the impaled body offering the doctor the NHS form and gently asks: ‘You’ll need to sign here, here and over the page here, it’s a Patient Specific Direction, I can’t give anything to anyone unless its signed…’

Fanciful you might think, but not so far from the reality we will soon face unless someone stands up to the tripe being peddled by nursing advisors, CCG experts, the Royal College of Nursing, the CQC, the RCGP and, yes, even the BMA.

‘As your competent and trained employee I can’t give this patient who has been invited to a flu clinic, who has turned up at the flu clinic, who is on time for his appointment, who wants a flu jab, who is eligible for a flu jab, who is a registered and well-known patient and whose GP and Government both want him to have a flu jab and why not? Because I can’t scratch my arse - let alone stick something as dangerous as a flu vaccine into a patient’s arm unless I have a signed Patient Specific Direction.’ What utter rubbish.

Just like dying 14 days from one’s death certificate, a myth has been created around the administration of vaccinations and injections to patients that needs to be debunked and rapidly so. It is a myth that is beginning to gain traction and is now infesting even the sanest and most common-sensed of practices. So where does it come from? There are many sources but as an example, let’s take a look at the BMA’s guidance on the subject which says:

The Human Medicines Regulations 2012 do not permit nurses, or other registered health care professionals (HCPs), who are not qualified prescribers to administer or supply prescription only medicines (POMs) unless one of three types of instruction is in place:

1 A signed prescription
2 A signed Patient Specific Direction (PSD)
3 A Patient Group Direction (PGD)

This is, I am afraid, simply wrong. I am not disputing points one or three. It is the space in between that is the problem, the space inhabited by healthcare assistants (HCAs), by physician’s associates (PAs), by trained up receptionists, by returning but no longer registered nurses, by charity workers - anyone in fact who’s not a prescriber or to whom a PGD does not apply. In fact anyone who simply wants to help. Unless you hadn’t noticed there aren’t enough GPs now or in the near future, the workload is expanding inexorably and even the government recognises we need more hands on deck to help out. If those hands come pre-bound behind their backs then they’re not going to be much use.

The BMA guidance quotes the Human Medicines Act 2012. Funny, but I’ve read every single word of the Act and its appendices and I can find the word prescription in it, I can find PGD and the words Patient Group Direction but can I find PSD or the phrase Patient Specific Direction, or even Patient Specific, or Patient Direction? No I can’t, because the phrases do not appear. So here’s the thing, if this is the Act that determines the law on injected medicines but it doesn’t define a PSD how can anyone, let alone the BMA, be telling me that I must use one? In the simplest terms - if it doesn’t exist in law it can’t be enforced.

So what does this law actually say about giving jabs? Paragraph 214 is where it begins:

Sale or supply of prescription only medicines

214(1) A person may not sell or supply a prescription only medicine except in accordance with a prescription given by an appropriate practitioner.
(2) A person may not parenterally administer (otherwise than to himself or herself) a prescription only medicine unless the person is —
(a) an appropriate practitioner other than an EEA health professional;
(b) acting in accordance with the directions of such an appropriate practitioner.

The first part is pretty easy - prescription only medicines can only be provided - supplied - if there is a prescription.

The second part deals with things that are put into patients other than by mouth, ie, injected. Its only conditionality on 214(1) is that there has to be a prescription for any POM but note it does not have to exist before the administration, you can administer from stock.

The second part also says injections can only be given to a patient if (a) the person giving it is an appropriate practitioner (as defined in the following 214(3) which includes doctors, dentists, etc) or…

Wait for it, here it comes…

If the person giving it is being directed to do so by an appropriate practitioner as outlined in (b).

So what does this mean in plain English? My interpretation is that it means anyone (a person) can be directed (acting in accordance with the directions of) by a doctor (an appropriate practitioner) to give an injection (parenterally administer… a prescription only medicine). Full stop. Note the distinct absence of the words ‘patient’ or ‘specific’ or ‘signed’.

Now the Act doesn’t define what a ‘direction’ is so we have to look to the Oxford English Dictionary which says it is ‘the management or guidance of someone or something’ or a ‘general aim or purpose’.

So stringing it all together this means; I, Dr Paul Cundy, can say to my HCA, ‘please give that patient a flu jab’, and my HCA can do it and they are covered under paragraph 214(2)(b) of The Human Medicines Act. Full stop.

Does the HCA have to be trained? Yes. Do we need to make an appropriate assessment, keep a record, check for contradictions and reactions? Yes, yes, yes. Does there have to be a signed Patient Specific Direction in place? No.

For those interested, if you read through the Act you will see that 214 defines the baseline. The following regulations define exceptions to that baseline such as PGDs, emergency prescribing and other situations but nowhere in those exemptions is there anything about a PSD.

So how should the BMA guidance be worded? My suggestion is the correct position should be:

The Human Medicines Regulations 2012 do not permit nurses, or other registered health care professionals (HCPs), who are not qualified prescribers to administer or supply prescription only medicines (POMs) unless one of three types of instruction is in place:

1 A signed prescription

2 A direction from a doctor (which can be verbal)

3 A Patient Group Direction (PGD)

Am I wrong?

Dr Paul Cundy is chair of the GPC’s IT committee and a GP in south-west London. This piece is written in a personal capacity

Rate this article  (4.9399999999999995 average user rating)

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Readers' comments (33)

  • Thanks you, there is a lot of bullshit being sprouted around,
    I think the cqc myth busting also needs looking in to as well , especially when there are many things being required which were never part of the GP contract

    Unsuitable or offensive? Report this comment

  • I'm a hca and yes PSD'S are a pain in the bum. For flu clinics I get the paperwork done the night before and have a group one so seeing 30 patients I only need one signature from prescriber. Also b12 PSD'S last a year. If you work it out so it's easy then it can be done without fuss. Anyone in my general clinic that needs a flu I have permission from my lead to give and sign after. Yes it's against the rules but it works and the boxes are ticked.

    Unsuitable or offensive? Report this comment

  • Dear 7:54
    Sorry to be pedantic and wanting boxes to be ticked but you have described yourself as a Practice Nurse in the header but as a HCA in the text.
    Unless you have two separate contracts this seems to be a mistake

    Unsuitable or offensive? Report this comment

  • Dr Cundy, I like this article. More please!
    Perhaps you could do a follow up article on the myth of "district nurse authorisation forms" that apparently NMC is insisting to be signed by a GP.
    Perhaps Pulse could start a campaign with a series of articles on these perennial thorns in GP sides. We need to be bureaucracy busters for GP to survive.
    14 day rule with coroner is another good topic you mention. It is 28 day rule in Northern Ireland I understand so could surely be doubled without much bother- until you see the useless cremation regulations guidance issued 2012.

    Unsuitable or offensive? Report this comment

  • Paul, I could not agree more.

    Unsuitable or offensive? Report this comment

  • I had to do a DN authorisation for a telephone prompt for oral amoxicillin which the patient already had, even though they were in receipt of the prescription and the box with instructions on. No joke. the DN refused to phone the patient without this.

    what is the NHS coming to.

    Unsuitable or offensive? Report this comment

  • Oh yes....and how many of you GPs have actually taken the time to train and mentor your HCAs....oh and of course assessed every patient as to whether they are eligible for the flu jab? No my guess is that your PN has probably done that for you. Similar to all the forthcoming changes with childhood imms this Autumn. Happy to take the payment but not support the staff. And you wonder why General Practice can't attract Nursing/ Support staff

    Unsuitable or offensive? Report this comment

  • Can't help but agree with Nurse at 10:48. Once upon a time I'd have been happy with a verbal request but no longer. And the reason why is when there is an issue who is going to carry the can? Why of course the nurse or HCA because the GP has written and signed nothing and can deny everything and the courts, protection societies etc. will say you have no proof and so it it the nurse / HCA who did wrong.

    Unsuitable or offensive? Report this comment

  • Nurses. Can't live with them. Would love to live without them. Blah.blah. blah. I bet the nurses a@10.48 and 12.45 had to write up a protocol before they responded. I expect they will respond to this probably by demanding more admin time.
    The stories I could tell. They make London Underground workers look reasonable.

    Unsuitable or offensive? Report this comment

  • Actually 4.13 I'm a lead nurse trained to Masters level and an independent prescriber so don't need a protocol thank you. Thankfully my PM and GPs appreciate the members of their Nursing team inc HCAs.

    Unsuitable or offensive? Report this comment

View results 10 results per page20 results per page50 results per page

Have your say