PGD use in commissioned services

Commissioning of NHS and publicly funded health services has become increasingly complex with many services provided by a number of providers with sub-contracting/commissioning arrangements and sometimes more than one commissioner may be involved.

When Patient Group Directions (PGDs) are used to provide commissioned services, determining which organisation is responsible for developing, implementing, authorising, adopting and managing PGDs can be complicated. There is no ‘one size fits all’ model and varying systems have been developed.

Scope

This article summarises several considerations to support and guide both commissioners and providers (commissioned organisations) on the principles to consider when developing PGDs for NHS or publicly funded services. Not all considerations will be relevant to all organisations and structures but you are advised to consider the advice as a whole to support and guide any decision-making process. Ensure governance processes of your organisation and the organisations you work with are followed.

How the service is commissioned

Where delivery of a commissioned service requires the use of PGDs, it is important to know who the commissioner is. This could be a single organisation (i.e. an Integrated Care Board (ICB), NHS Trust or Local Authority) or multiple organisations with one as a lead commissioner.

The lead commissioner should take responsibility for PGDs but they may delegate some or all of their responsibility to the commissioned provider.

The initial agreement laid out in a Memorandum of Understanding (MOU) or similar agreement should define this. The legal standing of the provider organisation will dictate the degree to which responsibility for PGDs can be delegated by the commissioner or lead commissioner.

Memorandum of Understanding (MOU) or contract between services

An MOU or contract should be agreed before any PGD processes begin and this should be considered as part of the tender process. An MOU should clearly state all the responsibilities involved in PGD development and use: from writing and authorising PGDs to adoption and implementation. The MOU should consider factors such as review, document management and any training requirements, including which organisation will be responsible for each function.

This must be agreed and recorded in each authorising organisation at Board level to ensure that the activity is accepted within each organisation’s clinical governance framework.

Independent Healthcare Providers

Independent Healthcare Providers (IHPs) are not legally able to authorise PGDs for use by NHS or publicly funded services; this is important when deciding who will authorise PGDs and will need consideration and agreement in any MOU.

IHPs may produce PGDs if they have the necessary resource to do so. In this case these PGDs need to be authorised by the commissioner or lead commissioner – such arrangements should be set out in an MOU.

Multiple service commissioners

Where multiple organisations are involved (i.e. one commissioner or multiple commissioners jointly commissioning the same service from one or more provider) all parties must be involved in an MOU and a lead commissioner may be identified as agreed.

Where a lead commissioner is identified to act to authorise a PGD/s on behalf of other commissioning organisations, it is essential that all involved organisations have the necessary governance processes in place to ensure any authorisations undertaken by the lead organisation are formally noted. This should be reflected in the MOU.

Authorising PGDs

Only these organisations can legally authorise PGDs for use in NHS or publicly funded services:

• ICBs
• Local Authorities
• NHS trusts or NHS foundation trusts
• Special health authorities
• NHS England
• UK Health Security Agency

If the provider organisation is an IHP then the commissioning organisation will be required to authorise the PGDs.

The commissioning organisation may wish to retain this function and authorise the PGDs even if the provider organisation can legally authorise PGDs – this would need to be agreed as part of an MOU.

It may be decided that the provider organisation will authorise its own PGDs if it is legally able to do so – again this needs to be agreed as part of an MOU.

How the service is provided

Multiple providers

Where multiple organisations are involved, all parties must be involved in an MOU and a lead provider may be identified as agreed.

Where a lead provider is identified to act on behalf of other provider organisations it is essential that all involved organisations have the necessary governance processes in place to ensure any action undertaken by the lead organisation are formally noted. This should be reflected in the MOU.

If a provider is not involved in producing or authorising a PGD they must have a clear process for adopting the PGDs required to provide the service, and this should be detailed in the MOU and agreed within the organisation’s governance processes.

Sub-contracting of service provision

Where a provider subcontracts all or part of a service provision there should also be an MOU in place either between the provider/s and the sub contracted organisation/s. If possible, it should be part of a single MOU with the commissioner/s to ensure transparency and clear lines of responsibility.

All use of PGDs including adoption processes should be documented in each organisation’s governance processes.

PGD management

Developing PGDs

This will need to be considered as part of an MOU, agreeing who has the required resources and who will undertake this role. This should also be considered as part of any tender process.

Funding of PGD development

Consideration may need to be given to any funding of resources required to produce PGDs if no ‘in house’ resource is available or if additional resources would need to be funded. This should be considered and agreed as part of the MOU and tender process.

Multiple authorising organisations

If there is more than one commissioner of a service or more than one provider, all of whom are legally able to authorise PGDs, then a single PGD can be authorised by multiple organisations. Each organisation would need to complete their own governance process to authorise PGDs and this may become time consuming if multiple organisations are involved. Any amendments or changes made to a PGD during its valid life would also need to be re-approved by all authorising bodies.

Alternatively one of the organisations can approve the PGD on behalf of all involved if this is agreed and detailed in the MOU.

Development/governance processes

Any organisation producing and/or authorising PGDs should have the appropriate structure in place, including any related policies and procedures. NICE provide further guidance.

The organisation producing the PGD will require the approval of the PGD working group or other internal governance body before the PGD is submitted for authorisation.

The organisation authorising the PGDs will be required to ensure that the PGD is submitted to the authorising body’s governance process as detailed in the local PGD policy.

It must be decided as part of an MOU how the involved parties who are not authorising the PGDs will also note the PGDs as part of their own governance processes, when adopting PGDs produced/authorised by another organisation.

The time such processes take will need to be considered.

Reviewing and updating

This is essential to ensure PGDs are well managed, both in terms of timely planned reviews and changes that are required during the lifetime of a PGD, due to changes in SPCs and any supporting guidance. The party responsible for these actions will also need to ensure all required governance processes are met.

Communication to those working under the PGD is important at the time of either a completely revised PGD being issued, or any changes to existing PGDs being made. This helps ensure they are always using the most up to date versions.

Consideration also needs to be given to intranet/internet sites which host the active versions of PGDs and who will be responsible for maintaining these resources.

Implementation

Usually the responsibility for implementation of PGDs would be with the provider organisation. However where there is more than one provider involved or there is sub-contracting of the service provision this will need consideration and clarification as part of the MOU.

Training

Provision of training for staff required to operate under PGDs would usually be the responsibility of the provider organisation. However where there is more than one provider involved or there is sub-contracting of the service provision this will need consideration and clarification as part of the MOU.

Document/archive management

The responsibility for document management will need to be detailed within the MOU. It would be expected that the lead commissioner would hold the final versions of the PGDs and be responsible for their ongoing management and archiving.

All records must be held securely in line with records management guidance and local governance procedures.

Staff authorisation records

The responsibility for document management needs to be detailed within the MOU. It would be expected that the provider holds the staff authorisation records and is responsible for archiving.

All records must be held securely in line with records management guidance and local governance procedures.

Related resources

Further information can be found in the following SPS articles:

• Patient Group Direction use in Primary Care Networks
• PGD use in services provided by multiple organisations

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