Can supply or administration be delegated to another practitioner under a PGD?

· NHS PGD Website

NICE MPG 2 Patient Group Directions 2017 (section 1.5.3) states: ‘When practising under a PGD, health professionals should not delegate their responsibility.’

The Medicines and Healthcare Regulatory Agency (MHRA) has confirmed that:

    • Administration of an injectable medicine must not be delegated under a PGD. The only exception to this is where a medicine is supplied under a PGD but is to be administered for the purpose of saving life in an emergency as listed in Human Medicines Regulations Schedule 19, Regulation 238.
    • If the PGD only covers supply of a non-injectable medicine by the health professional named in it, then it can be given to the patient for self-administration or for administration by another person. The law requires that administration of the supplied medicine is in accordance with the PGD and so the PGD should specify that the medicine is supplied for subsequent administration and it is labelled appropriately.

 

To demonstrate the interpretation of the law in practice the below table outlines scenarios relating to delegation taken from examples of enquiries received via the SPS PGD Service and collaborative responses from PGD Service Advisory Board Members.

Scenarios

 

Can a medicine supplied under a PGD be administered by a relative or carer (e.g. when a child attends a walk in centre)?

 

It is not within the law to inject prescription only medicines to another person unless you are a prescriber or acting under the directions of a prescriber. Therefore, if the medicine supplied is an injection, it is not within the law for a relative or carer to administer this medicine.  If an injectable medicine needs to be supplied for a parent/carer or other health practitioner to administer, a prescription or PSD from a prescriber will be required to authorise the administration.

 

If the medicine is not for parenteral administration (not an injection) and a supply of the medicine is provided under the PGD (i.e. a “to take home” (TTO) pack for a non-injectable medicine), the law does not restrict who may administer the medicine with the patient’s consent. Therefore, it is within the law for a relative or carer to administer non-injectable medicines if necessary.

 

The PGD should contain details of the relevant advice that must be provided to the patient and/or their relative/carer to ensure that the medicine is administered as intended by the practitioner making the supply. Medicines that are supplied for subsequent administration outside the clinic setting must be appropriately labelled and contain a product information leaflet.

Can a community nurse supply a medicine under a PGD for administration by a care worker in a nursing home?

 

As detailed in the above answer if the medicine is an injection, it cannot be supplied under PGD for another person to administer. This is delegation.

 

If the PGD clearly only covers supply of a non-injectable medicine by the health professional named in it, then it can be given to the patient for self-administration or for administration by another person.  The law requires that administration of the supplied medicine is in accordance with the PGD and so the PGD should specify that the medicine is supplied for subsequent administration. The PGD should contain details of the relevant advice that must be provided to the patient and/or their relative/carer.

 

Where a non-injectable medicine is supplied under PGD for administration within another care setting, the organisation providing that care must decide who may be authorised to administer medicines within their local medicines policies and governance arrangements.

 

Those authorised by their employing organisation to subsequently administer medicines supplied under the PGD, e.g. healthcare support worker/care home worker, must be appropriately trained and competent to do so.

 

It is the responsibility of the care home manager to ensure that the person who produces the administration record on the MAR chart follows local medicines policies and/or procedures. Administration records must be completed by those employees who are trained and competent to administer the medicine.

 

It would be good practice for the care home to have a local “administration procedure” backed up by a robust local medicines policy to cover administration which would include record keeping.

 

See NICE SC1 Managing Medicines in Care Homes 2014  for further information

Can a PGD be used to supply low molecular weight heparin (LMWH) injection to patients in a pre-operative assessment clinic prior to admission to hospital?

 

 

Only if the patient is to self-administer the injections.  It is not within the law to inject prescription only medicines to another person unless you are the prescriber or acting under the directions of the prescriber. Therefore, if the medicine supplied is an injection, it is not within the law for a relative or carer to administer this medicine but it can be self-administered.

 

If an injectable medicine needs to be supplied for a parent/carer or other health practitioner to administer, a prescription or PSD from a prescriber will be required to authorise the administration.

 

Therefore:

·       If the LMWH injection is supplied under PGD, it can only be self-administered by the patient or would need prescribing on a medicines administration record prior to administration by another appropriate healthcare professional. Administration cannot be delegated to another practitioner using the PGD and there is no flexibility under any circumstance.

·       If a supply is made under a PGD for self-administration the practitioner acting under the PGD must counsel the patient how to administer the injection and ensure they are willing, competent and confident to do so.

Can a student nurse administer an injection that has been supplied by another registered, authorised health professional under PGD for the purpose of practising injection technique under supervision?

 

No. This is delegation by the registered, authorised health professional to the student nurse and delegation is not allowed under a PGD under any circumstance.

 

In addition, NICE MPG 2 Patient Group Directions 2017 states that PGDs are not suitable for health professionals who are undergoing relevant training, for example, for administering intramuscular injections.

 

This scenario is covered in the Q&A:

Can registered health professionals who are trainee injectors administer injections under PGD whilst being supervised?

Can a hospital secretary post oral bowel cleansing medicines to patients, who are known to need them prior to a radiological or surgical procedure, after a nurse has identified the need under a PGD? No. This is delegation of supply and is not allowed.

 

In addition, with reference to the supply of bowel cleansing medicines, organisations should refer to NPSA Rapid Response Report RRR012: Reducing risk of harm from oral bowel cleansing solutions.

In a community pharmacy can a pharmacy assistant or technician who is a Level 2 smoking cessation advisor supply varenicline once the pharmacist has assessed a client under the PGD? No this is delegation.  The pharmacist must assess the client and must also supply the medicine according to the PGD. However the assistant or technician could gather background information from the patient to support the pharmacist’s assessment.  They could also provide additional information to the patient.

 

However an authorised registered healthcare professional should, when supplying under a PGD, personally make the supply of the patient pack to the patient at the time of consultation- the supply cannot be delegated to another person following assessment by the authorised healthcare professional.

In a prison setting can a Prescription Only Medicine supplied under PGD by a registered nurse be administered by another healthcare professional?

 

If the medicine supplied under the PGD is a take-away pack for a non-parenteral (non-injectable) medicine, it is within the law for the PGD to be used for “supply only”. The PGD should specify that the medicine is supplied for subsequent administration. Another person may administer a non-injectable medicine as necessary.

 

Legislation restricts the persons who may administer an injectable medicine. Injectable medicines must be administered in accordance with a prescription or the directions of a prescriber, by a registered healthcare practitioner acting in accordance with a PGD or be subject to Schedule 19 exemption where administration is for the purpose of saving life.

 

An authorised registered healthcare professional (HCP) should, when supplying under a PGD, personally make the supply of the patient pack to the patient at the time of consultation- the supply cannot be delegated to another person following assessment by the authorised healthcare professional.

 

In prisons all patients must be assessed for suitability to hold medicines supplied in possession (IP).  Where a patient is not considered suitable to have a medicine supplied under PGD in possession, this medication should not be given to the patient but should be held in the place where the patient will have their non-IP medicines supervised by another HCP, and can receive the doses alongside their other non-IP medicines.

 

PGDs and patient pre-packs must be written to reflect the Prison’s In-Possession policy i.e. support the supply of daily, weekly or monthly in-possession.

 

The preferred way for patients to receive the medicines they need is for a prescriber to provide care for an individual patient on a one-to-one basis.  Regular supply under PGD e.g. weekly supply of medication is not considered appropriate and such medication should be prescribed and dispensed individually for the patient by a pharmacist.

 

(Source: Secure Environment Pharmacists’ Group November 2017)

Can a nurse make the decision to supply a medicine under a PGD and then direct the patient to a pharmacy for a supply of the medicine (e.g. with a voucher)? No, this is delegation and is not permitted within the law.

 

The nurse may direct a patient to a pharmacist to obtain a recommended product but any decision to supply would only be made once the supplying pharmacist had independently carried out all necessary assessment of the patient and was satisfied in their own professional capacity that the appropriate medication was being supplied.

Can a HCSW (Healthcare Support Worker) administer the nasal live attenuated influenza vaccine (LAIV) to a child once it has been supplied to the child by a registered nurse under a PGD?

 

Yes, if a PGD for LAIV provides for supply for subsequent administration a supply may be made under PGD.

 

As a non-injectable medicine LAIV may lawfully supplied then subsequently be self-administered or administered by another person. Guidance has been provided that LAIV that is to be administered to the patient before they leave the clinic setting does not need to be labelled.

For the Royal College of Nursing position on Healthcare Support Workers and the administration of live attenuated influenza vaccine (LAIV) which is administered via the intranasal route, see http://www.rcn.org.uk/__data/assets/pdf_file/0009/618318/LAIV-HCSW-paper-revised-2015_final.pdf

Can a registered nurse in a hospital supply an inpatient with a medication under a PGD for subsequent administration by another healthcare professional during their admission?

 

If the PGD clearly only covers supply of a non-injectable medicine by the health professional named in it, then it can be supplied to the patient for self-administration or for administration by another person.  The law requires that administration of the supplied medicine is in accordance with the PGD and so the PGD should specify that the medicine is supplied for subsequent administration.

 

However this should not be routine practice but reserved for use where it is locally deemed necessary to improve patient care or safety.  The majority of clinical care should be provided on an individual, patient-specific basis PGDs should be reserved for those limited situations where this offers an advantage for patient care without compromising patient safety.  In all environments prescribing on an individual patient basis by medical and non-medical prescribers should be undertaken in preference to PGD use.

 

If used a PGD should contain details of the relevant advice that must be provided to the patient and/or their relative/carer including administration details.  All relevant documentation must be completed by the person making the supply under the PGD including any clinical records in line with local policy as must associated administration records.

 

Those authorised by their employing organisation to subsequently administer medicines supplied under the PGD (e.g. nurse or healthcare support worker) must be appropriately trained and competent to do so.

 

An example of this in practice is the supply of MRSA decolonisation products under a PGD by an infection control specialist nurse in an inpatient environment to prevent a delay in starting treatment although other examples may exist.

Can a pharmacist delegate the use of a PGD, that they are named on, to another pharmacist (e.g. locum) if they themselves have a day off? No.  Only the qualified professional who has been authorised to operate under a PGD can do so. They cannot delegate this responsibility to another person.

 

In this instance the locum would also need to be authorised to operate under this PGD.

Can patients be remotely assessed by the pharmacist authorised to use the relevant PGD and delegate the administration/supply of the medicines to another pharmacist, member of pharmacy team or pre-registration trainee pharmacist physically present with the patient? No.  This is delegation of supply.

 

An authorised registered healthcare professional should, when supplying under a PGD, personally make the supply of the patient pack to the patient at the time of consultation – the supply cannot be delegated to another person following assessment by the authorised healthcare professional.