22
ASSISTANCE & REPATRIATION
To prescribe or not to prescribe…
Gerry Bolger, chair of the Royal
College of Nursing In-flight Nurses
Association, discusses the issue of
administration of medicines by British
in-flight nurses overseas
The practice of using registered nurses by
assistance companies to repatriate patients
is well established. This article discusses
the complex issue of safe administration
of medications to patients in transit.
This article is written from a UK nursing
regulatory perspective and reflects the
guidance and regulatory requirements
from the Nursing and Midwifery Council
(NMC), the regulator of registered nurses
and midwives. As such the solutions
proposed may not be transferrable to
nurses on the nursing registers of other
countries.
Regulation, regulation, regulation
UK registered nurses transferring patients
are required to comply with their
regulatory requirements regardless of where
they are located. In the UK, the NMC
was established to safeguard the health and
wellbeing of the public and is responsible
for setting the standards of education,
training and conduct for nurses and
midwives. The NMC has issued standards
for medicines management, which
clarifies many issues, including the related
In each country, some
medicines are restricted
and having them in one’s
possession can result in stiff
penalties locally
legislation and best practice for medicines.
However, because of the nature of in-flight
practice, further guidance has been written
by the RCN In-flight Nurses Association
(now the Critical Care and In-flight Nurses
Forum) in conjunction with the NMC,
the government’s Department of Health
and pharmacists to advise its members of
the issues related to in-flight practice, and
to offer solutions to the problems that
commonly arise in this field. This work is
quite detailed, and as such, this article will
outline the main issues and solutions.
With the in-flight administration of
medicines, the issue becomes more
complex because there is also the need
to consider the law of the country being
visited, especially in relation to the carriage
of some medication. In each country,
some medicines are restricted and having
them in one’s possession can result in
stiff penalties locally. As such, good
clinical governance by in-flight assistance
companies should reduce such risks.
In the UK, medications fall into four
categories:
• General Sale List (GSL) – these are
simple over-the-counter medications
such as paracetamol, which can be
bought without any prescription and
without the input of a pharmacist;
• Pharmacist only medicines (P’s) – these
can be supplied without a prescription
but require the authority of a
pharmacist;
• Prescription Only Drugs (POMs)
– these are the majority of drugs,
which require a prescription from an
independent prescriber. In the UK,
some nurses can obtain ‘independent
prescriber’ status following the
©CEGA
appropriate training and supervision,
and record that qualification with the
NMC. Doctors and dentists are also
independent prescribers;
• Controlled Drugs – these are medicines
that are restricted drugs as laid out in
the Misuse of Drugs Act 1971, which
both classifies their restriction against
their habitual risk and some storage
conditions.
There will be very few circumstances when
a registered nurse should be carrying a
controlled drug in-flight, as these require
a Home Office license. Failure to declare
any controlled drugs – especially on re-
entry into the UK, or in fact any country,
without the appropriate documentation
and local permits – is likely to result in
arrest, and potentially prosecution locally
the assistance company or
underwriter could be exposed
to a claim, and pose the nurse
to regulatory investigation
should anything go wrong
 ASSISTANCE & REPATRIATION 23

and may result in the nurse facing a
regulatory investigation, which would be
undertaken by the NMC. Across Europe
and in many other countries, there are
variations on the restriction of some
medications, relating to both the strength
and the legal classification. As such,
this can be a minefield for an assistance
company and their in-flight nurse. The
simple fact is that it is best to check.
Some nurses have traditionally carried a
small but varied range of medications,
but this could mean that a nurse could
inadvertently fall foul of the law of the
country they are in, or transiting through.
Should in-flight nurses carry
any medication?
For an in-flight nurse to administer any
medicine, it must first be prescribed to
the named patient. Once a medicine
is prescribed, it can be administered
by anyone. Even giving paracetamol
to a patient without a prescription is
technically prescribing. Although in
the UK some nurses can become an
independent prescriber, and these nurses
are allowed to prescribe a wide range of
medicines, this is not common across
Europe or other countries.
Without the appropriate independent
prescribing training and the possession of
a registered independent qualification or
other appropriate mechanisms – such as
the medicine being prescribed, or homeley
remedy protocols (homeley remedy
protocols allow a nurse to administer an
extremely limited list of medications that
are GSL list and P-classed medications
only) – the assistance company or
underwriter could be exposed to a
claim, and pose the nurse to regulatory
Failure to declare any controlled drugs … are likely to result in
arrest, and potentially prosecution locally and may result in the
nurse facing a regulatory investigation
investigation should anything go wrong;
for instance, an anaphylactic reaction
So how can nurses safely
administer medicines?
Firstly, as the guidance recommends, a
doctor must prescribe all medication that
the patient is discharged with from their
overseas care setting. As the patient is
crossing an international boundary back
into the UK or other country, the nurse
requires a written authority to administer
the medications. This should be sent with
the nurse by an appropriate independent
prescriber who works for the assistance
company. This can be faxed to the nurse or
even to the clinical setting and collected at
the time of discharge.
Secondly, should a patient require
supplementary medication, such as simple
analgesia, the nurse can carry other GSL
medications but they will still require
to be added to the list of medications
prescribed. Or if a stronger medication is
required this is dispensed locally with the
patient. This protects both the nurse and
the assistance company.
Thirdly, homeley remedy protocols, can be
put into play.
Some assistance companies may think
this is overly bureaucratic, but this is
in fact best practice, because unless
the nurse is an independent prescriber,
which requires appropriate training and
supervision, companies will have to
have a clear awareness of the medication
needs of the patient. The authority to
administer is similar to having a PGD,
which is an authority for a nurse to supply
and to administer a medication in the
absence of a doctor in accordance with
the requirements on the Medicines and
Liquid medications, such as insulin, and hypodermic needles
… equally require a doctor’s letter stating they are required
or risk being impounded by airport authorities
Healthcare Products Regulatory Agency
(MHRA) website. However, because
assistance companies are not National
Health Service employers, or not registered
with the Care Quality Commission, PGD
regulations would not normally apply.
In the UK, it is recognised that many
patients live with long-term conditions
and are on long-term controlled drugs,
and as such the HMRC (UK Customs)
has issued guidance on controlled drugs
and on the amount of drugs that can
be brought back into the UK without
an import license. The key issue is that
the medication MUST be accompanied
by a letter from the prescribing doctor,
confirming the drug details (name form –
e.g. liquid or capsule; strength; and total
quantity) and should follow the guidance
in the HMRC Guidance Notice 4, 1998.
Liquid medications, such as insulin, and
hypodermic needles and syringes, or other
such medicines, equally require a doctor’s
letter stating they are required or risk
being impounded by airport authorities.
By applying these straightforward
approaches, the assistance company,
underwriter, nurse and, ultimately, the
patient is protected.
In summary:
• Nurses must comply with the
requirement of the regulatory body of
the country of registration; as such, this
will differ country by county.
• UK registered nurses must administer
medicines in line with NMC
requirements.
• All medication must be prescribed prior
to administration.
• Prescribed medication belongs to the
named patient.
• In-flight nurses should carry an
authority to administer a named
medicine to a named patient.
• Controlled drugs need a separate letter
from the prescribing doctor as do liquid
medicines and needles.
• Assistance companies should have good
clinical governance in place to support
practitioners, and manage medications
and equipment requirements across
international boundaries.
Gerry Bolger
is the pro-
gramme di-
rector for the
Quality in
Caring work
within the
Chief Nurs-
ing Officer’s
(CNO)
Directo-
rate at the
Department
of Health in
England. As well as being a registered
nurse, Gerry holds a Masters’ degree
in health management. He has led the
Royal College of Nursing In-flight
Nurses Association as their chair for
eight years and has been involved in
clarifying issues on medicines adminis-
tration in that role.