Medicine use in physiotherapy practice

Can I prescribe controlled drugs to be administered by infusion?

No. The Medicines and Healthcare Products Regulatory Agency (MHRA) has confirmed that legal advice is that controlled drugs may only be prescribed to be administered by the route set out in Misuse of Drugs Regulations (MDRs). For morphine this is 'oral' and 'injectable' routes only. An 'injection' involves a breach of the skin and the administration of a single dose, or series of doses, of the medicine. Legal advice is that an 'injection' would also include a Patient Controlled Analgesia (PCA) pump device whereby the patient controls, on demand within the limits of the prescription, the individual injection boluses provided. 

An 'infusion' has a different legal meaning to an injection in that it involves continuous administration of a controlled drug, whether by intravenous, intrathecal, intraspinal, continuous syringe driver, or epidural routes. Under MDRs, physiotherapists are not permitted to prescribe CDs to be administered by infusion.

The MHRA recognise that the wording of the MDRs is more restrictive than the wording of the Human Medicine Regulations (TMRs) which govern non-controlled drugs. We recognise that this clarification may affect physiotherapist prescribers working in End of Life (EOL) care pathways, however, it is essential that our members work within the law at all times, and this legal advice finally provides clarity.

Added: 27 Jun 2022

Can I deliver flu vaccine as part of my physiotherapy role?

Providing and delivering vaccination services as a whole is not within the scope of physiotherapy practice. However, it may be within the scope of the role of an individual physiotherapist to provide their named patient with a flu vaccine e.g., as part of community physiotherapy services or occupational health physiotherapy. As with all activities you undertake, you must be educated, trained and competent to perform the activity. If you require training in how to deliver a vaccination, your employer must provide you with appropriate training before you undertake the task. If you have any concerns about the level of training you receive please raise this with your local CSP steward.

Depending on national priority programmes, physiotherapy staff may be asked to provide vaccination clinics for their local populations as part of the NHS planning for winter. If you are employed in NHS services and you are asked to allocate physiotherapy working time to providing vaccination clinics, you should consider the interruption this may have on your physiotherapy workload. It is appropriate that physiotherapists use their capabilities to support the wider NHS workforce, but it is important that organisations take account of the impact this may have on patients accessing physiotherapy services. It will an organisational decision as to which service takes priority, and how staff are deployed to deliver services.

You do not need to be a prescriber or a qualified injection therapist to deliver vaccinations by subcutaneous injection. Patient Group Directions (PGDs) are normally used to deliver vaccination services. Your employer must have a PGD in place and you must be individually named on the PGD in order to work under it. You cannot delegate the administration of vaccines under a PGD to anyone else, for example a support worker. If you are unsure whether you are named within your organisation’s flu vaccine PGD, please contact your organisation’s Chief Pharmacist.

If you work in independent practice, it is unlikely that you will be able to offer general flu vaccination services. This is because individual physiotherapists cannot legally obtain wholesale stocks of vaccine, nor can individual physiotherapy private practices that are not CQC registered create the PGDs required to administer vaccines. People choosing to have a private vaccination should be directed to vaccination clinics or services that are widely available at local pharmacies.

Can non-prescriber physiotherapists advise patients on the use of medicines?

All physiotherapists are expected to be able to provide some level of medicines advice as this is covered in our under-graduate curriculum. For example, a physiotherapist can recommend taking paracetamol as a simple analgesic for musculoskeletal pain, as the evidence for this intervention is widespread e.g. there is a NICE guideline(34) on the matter.

Also, paracetamol is on the General Sales List (GSL) and available without supervision from an independent prescriber or pharmacist at small purchase volumes.

I am an experienced physiotherapist working with a specific patient group, can I advise on prescription only medicines?

It may also be within an individual's scope of practice to recommend that a patient seeks a prescription from their GP for a named POM if the physiotherapist has clear knowledge of the evidence and current practice for the use of the named POM and is working with the relevant particular patient group on an ongoing basis.

Be clear however that only the prescriber may change any parameter of a previously prescribed POM such as the dose or frequency of use, or to recommend stopping a course of any POM medication, and this may only be done by issuing a new prescription.

I have been asked to transcribe my patient’s medication onto a Medication Administration Record (MAR) chart, is this within the scope of physiotherapy practice?

Yes. Physiotherapists may be asked to transcribe medicines onto a community MAR, particularly as part of early discharge schemes and/or continuity of care in community settings. Delays in giving medication may have serious consequences.

The risk created by not administering prescribed medication may outweigh the risks of errors in transcribing. To reduce the risk of transcribing errors the transcribed medicines sheet should be double-checked.

Transcribing of controlled drugs can only take place in limited circumstances and you must contact your community pharmacist for advice.

Can I or my health care support worker administer and or help patients to take their own medicines during a community visit?

Yes. Where medications have been transcribed onto a community MAR chart, or have been otherwise prescribed for a patient.

What is supplementary prescribing?

This is a partnership prescribing framework. The supplementary prescriber works in partnership with a doctor to prescribe the medicines needed by an individual patient for the management of their condition using a written document called a Clinical Management Plan (CMP). The names of the medicines permitted to be prescribed must be listed in a written Clinical Management Plan that is created before prescribing occurs.

Supplementary prescribing can be used to prescribe licensed medicines, unlicensed medicines, mixed medicines and all controlled drugs. Supplementary prescribing requires additional qualification and HCPC annotation.

What can a physiotherapist who is an independent prescriber prescribe?

The physiotherapist independent prescriber may prescribe any licensed medicine from the BNF, within national and local guidelines for any condition within the practitioner’s area of expertise and competence within the overarching framework of human movement, performance and function. They may also mix medicines prior to administration and may prescribe from a restricted list of controlled drugs as set out in regulations.

What is a Patient Specific Direction?

A PSD is a written or electronic instruction from a prescriber for a medicine to be administered to an individually named patient. For example, a GP writing a prescription for a steroid for the physiotherapist to inject.  A physiotherapist must only administer the medicine in accordance with the instructions that are written by the prescriber.

Instructions should be written, although in an emergency an oral instruction may be given. For example, a pitch side physiotherapist administering Entonox.

What is a Patient Group Direction?

A PGD is a supply and administration framework. A doctor and a pharmacist define in writing the named medicines that may be supplied and/or administered to groups of patients who may, or may not have been, individually identified prior to treatment. 

In order to be valid, a PGD must meet specific legal criteria.  This includes the requirements that only licensed medicines are included in a PGD, that the health professional [physiotherapist] named on the PGD is registered with the appropriate statutory regulator [HCPC], and that the supply and administration of the drugs listed in the PGD is not delegated to anyone else. The physiotherapist must supply and administer the medicine in accordance with the instructions that are written within the PGD.