Improving management of Patient Group Directions (PGDs) during organisation change

The aim of the project was to standardise and improve the PGD development and authorisation processes across the county of Devon.
The objectives were:
- To ensure that organisations had a robust methodology to identify, develop, review and authorise PGDs, collaborating across organisational boundaries if possible.
- To ensure timely review of PGDs, in order to maintain effective and timely delivery of patient care in primary care.
- To review and standardise the need for, format, content and implementation of existing PGDs across primary care in Devon.
- To ensure appropriate organisational authorisation, allowing PGD use to continue during a period of organisational change.
- To use new technology to achieve this objective, help reduce journey times across Devon, and facilitate better attendance and ownership at the PGD review group.

Prior to the collaboration, there were three separate PCTs: NHS Devon, NHS Torbay, and NHS Plymouth. Each of these organisations had completely separate arrangements for the development and authorisation of PGDs. In 2011 these three PCTs merged into a single cluster, which was the followed by the abolition of PCT and the establishment of CCGs.

Following guidance (which has since been included into NICE Medicines Practice Guidelines), a review of the existing PGD processes were undertaken and the following actions were taken:-
Development of a single collaborative approach to develop PGDs.
- Review of existing PGDs, assessing continuing need and appropriateness, and consideration whether these PGDs should be the commissioner's or provider's responsibility.
- Adoption of single PGDs for the whole county before the existing expiry dates in different organisations.
- Ensuring governance procedures were developed, particularly regarding organisational sign off and preparation for organisational change.
- Adoption of robust mechanism to ensure that GP practices and other users of PGDs had procedures in place to ensure the safe and effective delivery of medicines via a PGD mechanism. These actions were discussed by PCT medicines management teams, and were considered to be important, both in terms of improving efficiency by reducing duplication, and ensuring more robust clinical governance oversight.

A multidisciplinary group was set up, with representation from the three PCTs, in order to consider best practice from the three previous areas, and consider further changes using best practice guidance.

This group considered:
- Appropriate terms of reference for a PGD working group, including membership, lines of accountability, and review processes
- The establishment of a PGD development work plan, prioritising those PGDS with the shortest review date or important clinical need (e.g. changes in immunisation schedule)
- A single PGD template for the county, designed using best practice guidance and current organisational templates, in order to maintain a recognisable and useable document for clinical staff
- Method of cascading to GP practices and other stakeholders
- Development of a development and authorisation`algorithm', taking in to account the need for separate corporate organisational sign off for the two newly created CCGs
- Ensuring robust version control and document security, including signatures, PDF format, and document retention was all in one place.

One of the main barriers to working collaboratively across the two CCGs could have been the vast geographical footprint of more than 2,500 square miles that they cover.

As a result, a process was established which allows a single PGD to be produced for adoption by two separate governance processes in the distinct organisations. The use of electronic signatures has not been adopted as there was no need to alter a functioning process.

The group has representation from each of the four teams. As meetings are held quarterly, for all members of the team to travel to meet four times a year would create a financial burden to the NHS reimbursing travel costs, and would also create a time drain on individuals, given the large area over which we work. Hence, the PGD - Virtual Review Panel was born. This makes use of the technology available to us via web conferencing. This technology, which includes live document sharing via the internet, video conferencing and teleconferencing, allows for these meetings to be undertaken effectively. This functionality allows for 'extraordinary meetings' to be scheduled at short notice. This allows us to be reactive as well as proactive. We maintain an annual face to face strategic meeting. As a result of this project, there have been savings, both in terms of staff time and travel costs.

Issues were encountered while aligning the PGD production workstream with the two separate governance processes in each respective CCG. Safeguards were built into the governance process to ensure this had no detriment on patient care.

Governance processes were reinforced as a result of the introduction of the group. The group is chaired by a CCG deputy Chief Nursing Officer, and we have introduced robust authorisation and development work plans. The introduction of the group means that there is a high level of debate and scrutiny around PGDs, and there are often amendments which are required before sign off. The NICE PGD Medicines Practice Guidelines which was published in August 2013, was a really useful resource to support the maturing of this group. This was further reinforced by attendance of a representative of the group at the NICE Medicines Practice Guidance away day. This meant that NICE had not only provided the PGD-VRP group with a hard copy of guidance to support the work they were doing, but also the ability to share experiences with counterparts from CCGs all over the country, and see how others have used and interpreted the guidance to improve the systems and processes.

The NICE MPG blank PGD template was considered by the group and compared to our current template. No alterations were required to the original, but the document was useful for the group to validate their current template against, and stimulated healthy debate.

Prior to attendance at the PGD NICE good practice workshop, the group did not fully understand the role of the PGD website, or its credentials. Since meeting with the owner/contributor this is being used for FAQs and as a reference.

As mentioned, this has reduced workload, freeing up time, while web conferencing has allowed minimal miles to be travelled, and allowed reduced variation between settings for the care patients receive.

With a combined workforce of 29 pharmacists in four teams across Devon, PGD work can be distributed evenly, reducing workload for all involved, as the authoring pharmacists can attend the web conference from their desks for only the time that they are needed.

Embrace the 'new' NHS, challenge your usual way of working, and look for opportunities to work collaboratively. Look for ways to allow technology to improve the effectiveness and efficiency in ways of working. The Devon PGD Virtual Review Panel is an excellent example of this.

Success may not be easy. It's important when reviewing different organisational documents that 'different' doesn't mean 'wrong'. There are possibly several ways of implementing something effectively. As a result, the possibility of success is more likely if a group has a common purpose, and has agreed the possible objective benefits of making changes.

With regard to technology, don't make the assumption that because it works on your computer, that it will work somewhere else. There may be technical barriers to overcome.

Another success of the PGD-VRP is the acceptance of the need for regular review of processes.