Offering services can be a lifeline for community pharmacy in a time of falling reimbursements, and PGDs have an increasing role to play.

A Patient Group Direction (PGD) is a written protocol which allows certain healthcare professionals to dispense prescription only medicines without a prescription, following strict guidelines.

Qualifying HCPs can only supply and or administer medicines under PGDs if there is an advantage for the patient without compromising their safety, and every PGD has an expiry date, decided on a case-by-case basis in the interest of patient safety, which should not be more than 3 years from the date it was authorised.

Writing and ordering

PGDs should be put together by a multi-disciplinary group including a doctor, a pharmacist and a representative of the professional group expected to supply the medicines under the PGD, and it’s considered good practice to involve local drug and therapeutics committees, area prescribing committees and similar advisory bodies.

However, this doesn’t mean PGDs can or should be written for every condition. “We try to be as ethical as possible with our PGDs,” says Mike Bereza, superintendent of Angel Pharmacies Ltd and managing director of Voyager Medical. “We won’t write one for just anything – for example, we won’t write one for alcohol abuse, intense weight loss, or antibiotics. We do travel, and about ten oral PGDs, and we are happy with that.” 

As well as the ethical considerations, PGDs are not available for the supply of unlicensed medicines; dressings, appliances and devices; radiopharmaceuticals; or abortifacients. 

Legally they need to include:

• The name of the business which owns the direction
• The start and end date of the PGD
• A description of the medicine(s) involved
• The class of health professional who can supply or administer the medicine
• A signature of a doctor or dentist (as appropriate) and a pharmacist
• Authorisation by an appropriate organisation
• The clinical condition or situation to which the direction applies (the specified condition/conditions that can be treated)
• A description of patients excluded from treatment under the direction
• A description of when you should get more advice from a doctor (or dentist, as appropriate) and arrangements for referral
• Details of appropriate dosage, maximum total dosage, quantity, pharmaceutical form and strength, route and frequency of administration, and minimum or maximum period to administer the medicine
• Relevant warnings, including potential adverse reactions
• Details of any necessary follow-up actions
• A statement of the records to be kept for audit purposes.

PGDs can be bought by any “qualified healthcare professional” from the MHRA’s approved list which, as well as pharmacists, currently covers a broad range of sectors. However, there is more to it than purchasing the PGD. NICE guidance requires that before practising under a PGD, health professionals should ensure that they have undertaken any necessary initial training and continuing professional development and been assessed as competent and authorised to practise by the provider organisation.

Assesing the benefits

Tania Meagher, Avicenna’s head of membership services, says there are many positives to offering PGDs. “The main benefit is patient convenience. Customers can get access when it suits them because they don’t need an appointment,” she says, “but they also allow us as pharmacists to improve our skills. We have more and more private PGDs for products not always subsidised by the NHS – for example flu and travel vaccinations – which enables pharmacists to offer more to their local community.”

As well as the convenience factor, offering PGDs also has the potential to reduce health inequalities through access to hard-to-reach patient groups, help improve the health of the local population, and even tackle antimicrobial resistance (AMR).

“For example, there is now a PGD for strep A”, says Ms Meagher. “People with sore throats try to see their GP in winter but can’t get an appointment, so now they can go to their pharmacy, pay on average £9.95, get swab tested and in ten minutes know if they have an infection. 

“If it’s viral we can tell them to treat it with lozenges and gargling, but if it’s bacterial then we can give antibiotics – which also helps AMR because we have to do the test first to determine the cause of the infection, which means antibiotics are only offered when appropriate.” 

Where to get PGDs

A number of organisations write PGDs, and they can also be accessed via pharmacy membership/buying groups. For example, NHS England provides the winter flu jab PGD that allows community pharmacy to offer this service. There are also PGDs for locally commissioned NHS services, plus private PGDs offered by companies such as Voyager Medical, Sonar Informatics, PharmaDoctor, and Inca, and those supplied to their members by the NPA, Numark and Avicenna for example.  

For pharmacists considering offering PGDs, Mr Bereza says the barriers to entry are not financial, “but it can be all the other stuff, like training, that gets in the way”. Many PGDs (those for oral treatments) don’t require pharmacists to do any formal training, although suppliers may oblige you to undertake their online training attached to each PGD. Others, such as those for vaccinations may demand extra training to guarantee their safe administration.

After that, the use of the PGD is restricted to the pharmacist who completed the necessary training and assessment, in the premises listed in the PGD and with the authorisation of the superintendent pharmacis. Only the patient in person, their parent or legal guardian can complete the PGD form and medication can only be supplied to them.

When choosing a supplier for your PGD, Mr Bereza says always ask around for recommendations. “If in doubt, look for an established company”, he says. “Investigate how rigorous their training is – anyone can hand out a certificate – and find out what support they offer. Can you call a pharmacist if you have queries using the PGD with a patient. Ask about lock-in periods and avoid those where patients get directed to a centralised website to book appointments because there’s no guarantee they’ll get sent to your pharmacy.”

Real-world experience

Pharmacy Thames Valley LPC committee member and NPA regional representative Olivier Picard owns three pharmacies, which use the national PGD for flu vaccinations, as well as PGDs for EHC and travel vaccines.

“In terms of making Prescription Only Medicines (POMs) quickly and easily accessible to the public, PGDs are excellent,” he says. “A good example are travel vaccines, which are offered less and less on the NHS, but which people often only think about just before they are due to travel. Another is EHC, which needs to be accessed promptly and is only licensed for the first three days post sexual intercourse.”

Mr Pickard says these services are very well received by customers, and encourages any pharmacist not yet offering PGDs to look into it. “To be able to offer extensive services to patients increases access to medicine but also increases job satisfaction for the pharmacist, so if you think a PGD is required and it is commissioned in your area, see if the LPC can help you with what is needed, then consider what you can offer.”

And Ms Meagher agrees: “If you don’t already offer PGDs in your pharmacy but would like to start then see if there is a demand for a specific PGD in your area first. Everyone pretty much does flu, for example, but there may be an opportunity to run a travel clinic and do lots of malaria or yellow fever. Most pharmacists have been a part of their community for a while and know it well, so look at your local population, see what’s needed and decide if people are willing and able to pay for it.”