Defining Hospital at Home

Hospital at Home, including virtual ward, services are defined as a safe and efficient alternative to NHS bedded care that is enabled by technology. These services support individuals who would otherwise be in hospital to receive the acute care, monitoring and treatment in their own home.

This includes either preventing avoidable admissions into hospital or supporting early discharge out of hospital.

National Guidance

NHS England

NHS Guidance on Pharmacy Services and Medicines Use within Virtual Wards (including Hospital at Home) states the following:

‘Medicines can be supplied and administered under a Patient Group Direction (PGD) to pre defined groups of patients, without a prescription. The health care professional working under the PGD is responsible for assessing that the patient fits the criteria set out in the PGD. Before a service is designed or commissioned using PGDs and before a PGD is developed, it must be ensured that PGDs are appropriate, legal, and that relevant governance arrangements are in place.’

Royal Pharmaceutical Society

The Royal Pharmaceutical Society has published Interim Professional Standards for Hospital at Home, including Virtual Wards, Pharmacy Services.

NICE

NICE guidance on PGDs states: ‘Provide the majority of clinical care involving supplying and/or administering medicines on an individual, patient-specific basis. Reserve patient group directions (PGDs) for limited situations in which this offers an advantage for patient care, without compromising patient safety, and where there are clear governance arrangements and accountability.’

Considerations

Clinicians of many specialities will be involved in Hospital at Home services, including prescribers.

Prescriber availability

The availability of prescribers within these services mean the potential need for PGDs is likely to be very limited.

Legislation

Organisations must be mindful if considering PGD use in Hospital at Home services as there are legislative restrictions which will limit their use.

Organisations are responsible for ensuring that any PGD they develop is not only legal and clinically appropriate within the care pathway but is not used to overcome inefficiencies within systems.

Service design

More than one organisation may be involved in the provision of Hospital at Home services. If this is the case consideration should be given to how the service is commissioned/provided as this may affect how PGDs can be legally used.

For further information refer to following SPS resources:

• How to develop a Patient Group Direction
• Patient Group Directions in Complex Commissioning Scenarios
• Authorising Independent Healthcare Provider (IHP) PGDs
• PGD use in services provided by multiple organisations

Remote consultations

The legal framework for PGDs does not state that an individual must be present for a supply of a medicine to be made. Therefore remote consultation prior to making a supply under a PGD is permissible and a supply can also be made in the absence of the individual themselves.

As with all consultations the healthcare professional undertaking a remote consultation must ensure that the principles of shared decision making are upheld.

For further detail, including on how supply of medicines within remote consultations can be legally managed see Patient Group Direction use in remote consultations.

Antimicrobials

Antimicrobials should only be supplied or administered under PGDs where there is a clear clinical need and use follows local/national guidance.

NICE MPG2 states:

1.1.10 Do not jeopardise local and national strategies to combat antimicrobial resistance and healthcare-associated infections. Ensure that an antimicrobial is included in a PGD only when:

• clinically essential and clearly justified by best practice guidance
• a local specialist in microbiology has agreed that a PGD is needed and this is
  clearly documented
• use of the PGD is monitored and reviewed regularly

Delegation

Parenteral medications supplied under a PGD can only be self-administered or administered by the healthcare professional who has made the supply under the PGD – this administration cannot be delegated to a carer or another healthcare professional. This restricts who can administer a parenteral medication supplied under a PGD.

For further detail see Delegation of roles under a PGD.

Care homes

PGDs cannot be used by care home staff.

However they may be used by registered healthcare professionals from an external provider who is able to operate under PGDs (e.g. NHS Community Services provider) caring for an individual within a care home to administer or supply medications.

Subsequent administration of non-parenteral medicines supplied under a PGD may be undertaken by trained care home staff following local policy/SOP.

For further detail see Using oseltamivir under PGD for care home residents.

End of life care

Specialist clinicians and GPs will be involved in an individual’s end of life care (EoLC) and so able to prescribe on an individual, one to one basis.

As a result the potential need for PGDs in EoLC is likely to be very limited, if at all, and there are several legislative restrictions which organisations must be mindful of if considering PGD use.

For further detail see Patient Group Direction use in End of Life Care.

Labelling of supplied medicines

Any medicine supplied under a PGD needs to be appropriately labelled.

NICE MPG2 states:

1.5.4 When supplying a medicine(s), provide an appropriately labelled pack. Health professionals (other than pharmacists or dispensing doctors) should not split packs.

For further detail see Labelling requirements for medicines supplied under a PGD.

Transport of medicines

Any medicines to be supplied or administered under a PGD which are transported as part of Hospital at Home services must be transported in line with local governance policies/SOPs and be subject to appropriate local risk assessment.

See also RPS Professional guidance on the safe and secure handling of medicines.

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