1. Patient group directions. Dietitians prescribing.
Sarah Illingworth
Dietetic Education Placement Tutor
London Metropolitan University

2. Aim of presentation.
To give an overview of the current legislation surrounding medicines management and how dietitians can effectively use this to improve patient care.

3. Objectives. Understanding medicines legislation.
Define and give examples of common terms used such as:
Independent prescriber.
Supplementary prescriber.
Exemptions under medicines legislation.
Patient group direction (PGD.)

4. Objectives. Provide guidance on producing a PGD and protocol.
Give examples of dietitians currently managing medicines.
Describe to work of the BDA prescribing group.

5. Prescribing.
The NHS Plan emphasised the importance of organising services around the needs of patients.
Healthcare professionals are developing methods of working more flexibly.
Changes have occurred in the management of medicines.

6. Medicines management.
The Medicines Act (1968) regulates the use of medicines in the UK.
This requires a medicine to have a marketing authorisation.
When authorisation is granted medicines are placed into one of three classifications.

7. Classification of marketing authorisation.
Prescription only medicine (POM).
Can only be obtained on prescription through a pharmacy.
Pharmacy medicine (P)
Sold in pharmacies under the supervision of a pharmacist.

8. Classification of marketing authorisation.
General sales list
Sold in general shops as well as in pharmacies

9. Mechanisms. Patient group directions Patient specific directions
Exemptions under medicines legislations
Supplementary prescribing
Independent prescribing

10. Independent prescribing.
‘Takes responsibility for the clinical assessment of the patient, establishing a diagnosis and clinical management plan, as well as a responsibility for the prescribing where necessary and the appropriateness of any prescription.’
‘National Prescribing Centre (2004) ‘Patient Group Directions’

11. Supplementary prescribers.
‘Forms a voluntary partnership with an independent prescriber.’
‘A clinical management plan is agreed for an individual patient….’
‘The supplementary prescriber manages the clinical condition, including prescribing, according to the clinical management plan’

12. Exemptions under medicines legislation.
‘ The Prescription Only Medicines Human Use Order (1997) contains some specific exemptions which allow for the sale or supply and administration of certain POMs directly to patients without the directions of a prescriber.’

13. Exemptions under medicines legislation.
Ambulance paramedics can use a range of injectable medicines to provide emergency treatment.
Examples are :
Benzylpenicillin – meningococcal septicaemia.
Metoclopramide – anti-emetic.
Streptokinase – as a thrombolytic.

14. Patient specific direction
‘Used once a patient has been assessed by a prescriber and that prescriber instructs another health care professional in writing to supply or administer a medicine directly to the patient.’

15. Example – patient specific direction.
‘ Opthamologists can give opthalmic technicians a written patient specific direction to administer eye drops so that the patient has local anaesthesia prior to seeing the opthamologist for a scheduled procedure or examination.’
‘National Prescribing Centre (2004) ‘Patient Group Directions’

16. Patient group direction (PGD).
‘Allows a range of specified health care professionals to supply and/or administer a medicine directly to a patient with an identified clinical condition without them necessarily seeing a prescriber.’

17. Example – patient group direction.
‘ Following day-case foot surgery, podiatrists can use a PGD to give patients a supply of non-steroidal anti-inflammatory drugs for post-operative pain’
‘National Prescribing Centre (2004) ‘Patient Group Directions’

18. Who can use PGDs ?
Dietitians across the UK are authorised to use PGDs.
Professionals must be registered and act within the professional code of conduct.
Professionals must be fully competent, trained and qualified to use PGDs.

19. Producing and authorising PGDs.
Produced by a multi-disciplinary group involving a doctor, a pharmacist and a representative of the professional group expected to give medicines under the PGD.

20. Producing and authorising PGDs.
Approved by local drug and therapeutic committees.
Authorised by the organisations it is to be used within.

21. Producing and authorising a PGD.
The PGD should be signed by the doctor and pharmacist involved in developing the PGD and authorising authority for the organisation in which it is being used.

22. Dose adjustment.
This is allowed in a PGD as long as the dosage range is specified.
A PGD does not give a legal framework to adjust a dose of medicine already in a patients possession.

23. Dose adjustment. Written protocols may be used to adjust medication.
The principles of writing a protocol reflect those required for a good PGD.

24. Who should I be talking to ?
Multi-disciplinary team – start with the lead clinician and pharmacist.
Drugs & therapeutics committee.
Quality teams – clinical governance, clinical audit and lead for user involvement.

25. Improving the patient experience.
Audit the use of the PGD and protocol.
Include patient stories.
Consider how to evidence an improvement in patient experience.

26. Dietitians working with PGDs.
Renal dietitians in Newcastle have been working under PGDs to streamline the processes involved in managing patients’ bone biochemistry.
More timely changes to patients medications are made.
‘G. Hartley (2006) ‘Prescribing for dietitians. Working under patient group directions.’ Dietetics Today. Volume 41, Number 6 (June)’

27. Management of Total Parenteral Nutrition (TPN).
A pilot study was completed to determine the competencies of a dietitian and pharmacist required to manage TPN.
Interventions were assessed independently and separately by a consultant surgeon and gastroenterologist.

28. Management of TPN.
Twenty two consecutive patients completed the study and the team made a total of 181 interventions.
40% of interventions were classified as safe.
53% were of significant clinical benefit.
7 % were very significant.

29. Management of TPN.
Concluded that a dietitian and pharmacist can competently manage TPN.
May be clinically and cost effective and improve patient care.
‘Farrer K.M., Harper L., Shaffer J.L., Anderson I.D., Scott N.A., Carlson G.L., (2003) ‘Management of TPN, Does is require a medical practitioner ?’ Clinical Nutrition 22 (Supplement 1) S49. ‘

30. BDA Prescribing Group. Reviewing current PGDs and protocols
Producing guidance to support the development of new PGDs and protocols.
Considering the possibility of working under the exemptions framework.
Liaising with specialist groups.

31. BDA prescribing group.
Producing a portfolio of evidence to show that patient care could be improved if dietitians were able to become supplementary prescribers.

32. Conclusions.
Work under the current legislation in medicines management.
Develop PGDs and protocols within your teams.
Audit your work.
Let the prescribing group know.