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Developing patient group directions

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VOL: 97, ISSUE: 36, PAGE NO: 37

Jane Chapman, BSc, RGN, HVDip, DipN, CPT, is a clinical services manager, Camden and Islington Community Health Services NHS Trust

Sarah Raynor, RGN, RSCN, is clinical services manager, Camden and Islington Community Health Services NHS Trust;Vari Drennan, RGN, RSCN, is senior lecturer in primary care nursing at the Royal Free and University College Medical School, London

Group protocols, which are now known as patient group directions, are a means of ensuring that specified groups of patients receive prescribed medication in an efficient and timely manner that capitalises on the skills and knowledge of nurses.

Group protocols, which are now known as patient group directions, are a means of ensuring that specified groups of patients receive prescribed medication in an efficient and timely manner that capitalises on the skills and knowledge of nurses.

The Crown report (Department of Health, 1998) stated that many of the existing clinical protocols used to prescribe, dispense and administer medicines did not comply with the Medicines Act 1968. The report acknowledged the need for clarification of the legal status of what it termed 'group protocols' and specified a set of criteria to which they should conform (Box 1).

Identifying the local issues
Camden and Islington Community Health Services NHS Trust reviewed a number of situations related to the supply and administration of medicines for public health purposes (as opposed to the treatment of illness) during the 1990s, and some protocols were subsequently produced.

This cumulative experience, collected in different service areas within the trust, was used to address the recommendations laid out in the Crown report on group protocols. Two processes were then undertaken:

- A mapping exercise which aimed to identify situations requiring group protocols and highlight existing protocols that needed to be reviewed;

- The development of a trust template for group protocols.

Initial mapping work began in the trust's pharmacy department, but it soon became evident that nurses played a central role in most of the identified situations. The process therefore developed into a multidisciplinary network coordinated through the trust's nursing policy group, and a number of clinical situations were identified as having or requiring group protocols to enhance patient/client care.

The mapping exercise included an examination of current protocols against the 1998 Crown criteria and revealed problems in the existing protocols. It also highlighted situations in which there was the potential for nurses to be involved in supplying or administering medicines without either named prescriptions or agreed group protocols. There then followed information sessions for staff on the implications of the report. This increased demand for a trust-wide template for writing group protocols.

Developing the template
The template was based on the Crown report criteria and locally agreed criteria for protocol development (Box 2).

A draft template was prepared and the consultation broadened to the trust's pharmacy advisory committee, medical director and co-director of nursing. It was agreed that endorsement would be the responsibility of the trust board. The lead clinician responsible for preparing any group protocol would be required to present it to the pharmacy advisory committee. The authorisation of individual practitioners was confirmed as the responsibility of the relevant clinical service manager and lead consultant. For consistency throughout the trust, templates were devised for each of these functions.

The professional development nurse who led the development of the templates went on to use them in the production of a group protocol for school immunisation sessions. This was the first group protocol to be endorsed by the pharmacy advisory committee in 1999 and it has been used as a model or 'worked example' by others writing protocols, both within Camden and Islington and across a number of regions. A sample of the trust's protocol template is given in Box 3.

The supply and administration of medicines under group protocols benefits both users and staff. Nurses report greater job satisfaction and increased morale through enhanced autonomy while clients have shorter waiting times and less fragmented care. Staff appraisals in services using group protocols show unanimous approval for the extension of protocols and development of nurse-led clinics.

The templates have provided a framework that meets clinical governance requirements and supports multidisciplinary service development. They have helped disparate services to grapple with the concepts inherent in group protocols.

In August last year, modifications to the Medicines Act 1968 were brought into effect, legitimising patient group directions (PGDs). At Camden and Islington Community Health Services NHS Trust, the legal criteria for the development of PGDs have been carefully compared with the criteria that underpinned the trust's template for writing group protocols. The additional requirements were minimal but significant. They included:

- The need for the involvement of a local microbiologist in the development of PGDs for antimicrobials;

- Additional information on situations in which PGDs could be used for 'black triangle' drugs (those recently licensed and subject to special reporting mechanisms) and medicines used outside the terms of the Summary of Product Characteristics. These amendments have been incorporated into a trust-wide template for PGDs.

The launch of the new templates coincided with the review date of some of the first group protocols that were endorsed by the trust. Linking changes in legislation with practitioners' experiences of using group protocols will facilitate the development of robust PGDs. This approach has now been extended to the development of PGDs for use in general practice in collaboration with primary care groups and the health authority.

The second Crown report (Department of Health, 1999) suggests that group protocols may continue in future as the option of choice in situations such as mass school immunisation programmes. However, it also describes potential developments for nurses in relation to the prescribing, supply and administration of medication as well as proposals to extend nurse prescribing. Some of these proposals remove the need for group protocols in some situations.

Patients may benefit from nurses being able to vary the dose of medication already prescribed - as in the role of a dependent prescriber rather than through the use of a PGD. The role of the proposed regulatory body will be important in determining the optimum method of prescribing, supplying and administering medication in particular situations.

The trust's experience shows that innovative solutions to service delivery problems can be achieved by an evaluative culture looking beyond individual services. These templates, created through multidisciplinary consensus on best practice, allow that experience to be practically shared and developed by other services.

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