Policy Hub Templates

Please use the following definitions to help you decide which template is the most appropriate for your document: 

External Web Link

External web link documents contain links to information held on websites external to the NCA. For example, if the NCA has been involved in a partnership or network where a standardised document has been developed and is hosted on a website outside the NCA, creating a link to the document facilitates access and negates the need to transfer the content into the NCA format. External web links are also used to signpost to national PGDs. The NCA locally authorised master copy of the national PGD will be held by the Pharmacy team.

Local Standard Operating Procedure (SOP)

A Local SOP contains step-by-step instructions to enable the correct, consistent, and efficient undertaking of tasks and activities at a local level (i.e., a singular team/service or location that would not apply to other services/locations across the NCA). Local SOPs are consistent with relevant Trust policies and guidelines. There is a separate template and library for local SOPs: Local SOPs Library

Medicine Administration/Supply Protocol

Medicine Administration/Supply Protocols allow the issuing of medications, without a prescription, for medications of legal classification that do not legally fall under a PGD. 


  • Policies require colleagues to operate within defined boundaries. They set out the commitment of the NCA to follow a particular course of action and are informed by legislation, professional regulation, national policy directives, and codes of practice. They are a ‘must do’ document and must be adhered to. 
  • Guidelines provide advice and recommendations on how best to deal with particular issues or situations, however, there is room for professional judgement. From a legal viewpoint, in respect of clinical practice, applicable guidelines should be followed in every case where it is practicable to do so. Only where there is a good reason for departing from accepted guidelines should they be disregarded. 
  • Procedures provide fixed step-by-step sequences of activities or courses of action (with start and end points) that must be followed in the same order to correctly perform a task. This template should be used for procedures that apply across the NCA. A separate template and process exists for local Standard Operating Procedures. 

Patient Group Direction (PGD)

PGDs provide a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber.

Patient Specific Direction (PSD)

PSDs are instructions to administer medicines to a list of individually named patients where each patient on the list has been individually assessed by that prescriber.

Quick Reference Guide (QRG)

QRGs are concise documents, usually no more than five pages in length, which contain flowcharts/algorithms/diagrams/sets of instructions with accompanying explanatory notes (if required). A QRG should provide information about a specific condition, problem, or situation to aid decision-making. QRGs must be linked to a ‘parent’ policy or clinical guideline which covers the topic in greater detail and cannot be standalone documents. If a standalone document is required, authors should consider whether it would be appropriate to write a local SOP instead.


Strategies are detailed plans of action designed to achieve specific aims. 

Terms of Reference (TOR)

Terms of Reference are a description of the objectives and structure of a meeting or committee.

Written Instruction

A written instruction allows Occupational Health Services to administer medications (usually vaccines) in accordance with the written and signed instruction of a doctor. A written instruction is necessary to comply with Schedule 17 of the Human Medicines Regulations 2012.

Local Standard Operating Procedures

If you are writing a local SOP, the template can be downloaded from the Local SOPs Library

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