Supply & Administration of Medicines – Establishing the rules and boundaries between
the Doctor and Physiotherapist
The supply and administration of medicines to athletes has always been a topical subject with high profile cases hitting the headlines more recently too. This can be a difficult area, fraught with practical and professional indemnity issues for team doctors and travelling teams. This particular article by DWF, medico-legal advisors to SEMPRIS, seeks to clarify the rules and boundaries around the prescribing and dispensing of medicines and specifically, the use of Physiotherapists in this process.
If you have any questions relating to the supply of medicines do not hesitate to get in touch with SEMPRIS on telephone: 0208 652 9018 DWF or email firstname.lastname@example.org.
Medicine is only categorised as licensed, unlicensed or controlled. There is no distinction between over the counter medicine and prescription only medicine in the guidance upon which this note is based; accordingly there is no distinction in our note. Licensed medicine is medicine with a valid marketing authorisation (product line) in the UK.
The extent to which a physiotherapist (physio) can administer or prescribe medicine will depend on whether they are:
- Acting with the support of the Team/Club doctor; or
- Acting independently (subject to having relevant prescribing qualifications).
1 – Acting with the support of the Team/Club Doctor
Administration and Supply – Individual Patients
According to the Chartered Society of Physiotherapists (CSP), physiotherapists (physios) are allowed to supply and administer any medicines to patients under a Patient Specific Direction (PSD).
A PSD is a written instruction from an independent prescriber of medicine (usually a doctor but not necessarily) to be administered by another healthcare practitioner to a named patient. The physio should not deviate from the written instructions given by the doctor. A written PSD is almost always necessary, though in a genuine life threatening emergency an oral instruction may be given. For the avoidance of doubt, an electronic written communication such as email or text will suffice.
There are no set requirements for how a PSD is to be structured or what it must contain. The PSD should be sufficiently detailed however as the physio cannot act outside of it.
Administration and Supply – Groups of Patients
Physios can also supply and administer medicines to patients under a Patient Group Direction (PGD). Under a PGD only licensed medicines can be supplied and administered.
A PGD is a written agreement made by a senior doctor or senior pharmacist that defines and names medicines that may be supplied or administered to groups of patients. The groups of patients may include those who have not been individually identified prior to treatment. A group of patients is defined as a group of people who fulfil a certain clinical criteria.
Unlike a PSD, a PGD must be drawn up in a specific way in order to be legally valid.
All physios can prescribe medicine through a process called supplementary prescribing.
Supplementary prescribing is when medicines are prescribed under a written Clinical Management Plan (CMP). The plan will have been made in partnership with a doctor (or dentist if relevant) and can include any licensed or unlicensed medicines as well as all controlled drugs.
Like a PGD, a CMP must meet a certain standard in order to be legally valid although these are less onerous than the PGD requirements.
After prescribing the medicine under a CMP, the physio can supply and administer the medicine in accordance with the CMP.
2 – Acting independently
Since 2014 if a physio undertakes the relevant qualifications and has the required prescribing annotations to their Health and Care Professional Council (HCPC) registration, they are allowed to independently prescribe medicine and then go on to supply/administer it.
The process by which a physio prescribes medicine independently is known simply as independent prescribing.
Independent prescribing is when a physio uses their own clinical reasoning to determine the nature and extent of any medicines to be used to manage diagnosed or undiagnosed conditions. Potentially, a physio can independently prescribe any licensed medicine and 7 controlled drugs if the following are satisfied:
- The medicine is licensed in the British National Formulary (BNF);
- The prescription is within the national and local guidelines (e.g. for dosage); and
- The condition for which the medicine is being prescribed is within their area of competence within the overarching framework of human movement, performance and function.
The 7 controlled drugs a physio can prescribe are Temazepam (oral), Lorazepam (oral), Diazepam (oral), Dihydroceodeine (oral), Morphine (oral or injected), Fentanyl (transdermal) and Oxycodone (oral). The type of medicines that a physio can prescribe will ultimately depend on what prescribing annotations they have to their HCPC registration.
As an independent prescriber, a physio can delegate (to another healthcare practitioner) the supply and administration of medicine under a PSD. However, as mentioned above, only senior doctors or senior pharmacists can delegate work under a PGD.
1 – When acting with the support of the club/team doctor
A PSD may include instructions to mix licensed medicines only before they are administered to a named patient. Under a PGD, a physio will never be allowed to mix any kind of medicines.
If agreed in the CMP, a supplementary prescriber of medicine can mix licensed medicines before administration.
2- When acting independently
An independent prescriber of medicine may mix two or more licensed medicines before administration to an individual patient.
For the avoidance of doubt, under no circumstances should a physio mix unlicensed medicines or controlled drugs.
It is very important to note that physios registered in the UK are not allowed to prescribe medicines whilst overseas, regardless of whether they are acting as a supplementary prescriber under a CMP or as an independent prescriber.
Information for Team/Club doctors
Guidance is contained in the General Medical Council (GMC) guidance – “Good practice in prescribing and managing medicines and devices” (the “GMC Guidance”).
In the GMC Guidance paragraph 30, a doctor is under a duty to contribute to the safe transfer of patients between healthcare providers. A key part of this is delegating care responsibilities and referring patients. The mechanisms for delegating the supply/administration/prescription of medicine to a physio are outlined above but there are a number of factors a doctor should consider before doing so.
- Whether they are able to provide up to date information about medicines to the physio; and
- Whether they are able to quickly incorporate any changes to a patient’s medicines into their patient record and communicate these with the physio.
If a physio recommends to a doctor that the doctor prescribe a particular medicine to a particular patient, the doctor should first satisfy themselves that the prescription is needed, appropriate and within their competence to prescribe (paragraph 37 of the GMC Guidance).
Before a doctor delegates the assessment of a patient’s suitability for a medicine to a physio (who is an independent prescriber), the doctor should consider whether the physio has the qualifications, experience, knowledge and skills to make the assessment. They must also ensure that they give the physio enough information to make the assessment and check that they know how to properly acquire consent from the patient (paragraph 38 of the GMC Guidance).
If a doctor recommends to a physio that they should be the one to prescribe a particular medicine to a patient, a doctor must consider whether the physio has the competency to do so. The physio needs sufficient knowledge of the patient and medicine, a suitable amount of experience and the necessary information to prescribe. Only then should a doctor recommend that a physio prescribe medicine to a patient (paragraph 40 of GMC Guidance).
Information for Team/Club Doctors regarding telephone Consultations
Before prescribing for a patient via telephone, video-link or online, a doctor should satisfy themselves that:
- They are able to make an adequate assessment through this medium;
- They can establish a dialogue with the patient in order to gain their consent;
- They have sufficient knowledge of the patient’s health and their medical needs; and
- They have given due consideration to the limitations of the medium of communication, any need for physical examination and the need to access medical records.
Gold Standard example
A football team is on an away trip without a doctor but they have a physio who is not able to independently prescribe. When a player becomes ill, this is the gold standard response.
- The team physio, together with the player, calls the team doctor;
- The doctor has a full consultation with the player and indicates that he will prescribe a particular medicine;
- The doctor then discusses the supply and administration of the medicine with the physio;
- The doctor instructs the physio under a PSD how the medicine will be supplied and administered (the PSD will most likely be a text message in this situation); and
- The physio follows the instructions contained in the PSD to treat the player.
- If you are the physio, never prescribe, supply or administer medicine independently unless you have the relevant qualifications.
- If you are a physio, never mix unlicensed medicines or controlled drugs and never prescribe medicines when outside the UK.
- Both the physio and the doctor should sufficiently satisfy themselves that the patient requires the medication in accordance with the BNF and GMC Guidance.
- Both the physio and the doctor should document all actions taken in the patient’s records, including where applicable the recording of the PSD, PGD or CMP.
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