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Q&A: Patient group directions

Q: What is a patient group direction (PGD)?

Changes to legislation in 1999, designed to increase patient access to medicines, led to several legal options for health professionals to supply and administer medicine directly without the need for prescribing, one of which is the Patient Group Direction (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’.


Q: What is a PGD for?

According to NICE the purpose of a PGD is to:

·       deliver effective patient care that is appropriate in a pre-defined clinical situation, without compromising patient safety

·       offer a significant advantage to patient care by improving access to appropriate medicines

·       provide equity in the availability and quality of services when other options for supplying and/or administering medicines are not available

·       provide a safe legal framework to protect patients

·       reduce delays in treatment

·       maximise the skills of a range of health professionals.


Who can authorise PGDs?

Currently in the NHS, PGDs must be signed by a doctor (or dentist) and pharmacist AND by the appropriate authorising body that is contracted to provide the service. This may be CCGs, local authorities, NHS trusts or NHS foundation trusts or NHS England.

But independent organisations - such as dental practices or clinics, and any organisations operating as an independent medical agency, where the registered provider at the agency is registered in compliance with section 10 of the Health and Social Care Act 2008 can also authorise PGDs for NHS-commissioned services.

But the BMA says general practices should be able to write and sign off their own PGDs without having to get them countersigned by a CCG or other authorising body.


What training does NICE recommend?

Appropriate training, regular re-training and assessment of all people involved with PGDs, including those considering the need for, authorising, using and updating PGDs. The BMA says this requirement for training within general practice is unnecessary, as healthcare professionals have senior staff to advise them. GPs are best placed to determine the training needs of their own practice staff.


When does NICE say PGDs are appropriate?

PGDs ‘may be appropriate’ where medicine use is predictable, e.g. with contraception; where a patient has an acute need such as in a walk-in centre; for management of a discrete treatment episode, such as chlamydia; or for a ‘homogenous’ patient group such as at-risk people needing immunisations.

PGDs ‘should be considered carefully’ for off-label use of medicines and for black-triangle medicines, controlled drugs, and injectable self-administered drugs; where careful monitoring is needed; when caring for a small number of patients in a specific patient group where resources and expertise are lacking; and when treating the same patient with a range of medicines, where discrete episode involves more than one medicine.

Alternatives to PGDs should be sought for managing complex conditions; where uncertainty remains about the differential diagnosis; where an antimicrobial is needed; where dose adjustment is needed (eg, warfarin); where frequent monitoring is needed; and where the medicine is high-risk (eg, insulin).

The BMA says NICE should go further and make clear that certain conditions and treatments should be exempt from PGDs. It gives the examples of erectile dysfunction, which requires tests and investigations before prescribing, and asthma, where the frequency of prescribing symptomatic treatment (such as short-acting beta agonists) requires careful monitoring to guide management.