Prescribing for others can present various challenges for practitioners and is a roll that is interpreted in a number of different ways. In contrast to many aspects of aesthetics in the UK, there are some specific guidelines for prescribing in aesthetics; however, these are limited to the prescriber-patient interaction. Here, the environment/circumstances supporting the prescribing experience, prescriber/non-prescriber relationships, rolls and responsibilities and a possible model for ideal patient consultation, prescribing and management will be examined.
Legal standards and implications
Much is documented regarding the practices of prescribing in aesthetics (both in relation to a clinician's own patients and when prescribing for others). Equally, there is guidance available for patients considering aesthetic treatments. On the NHS website (NHS, 2019), there is excellent patient advice regarding how to choose a safe practitioner and signposting towards appropriate registers and questions that patients should ask. However, interestingly, the registers they signpost to do not include the Nursing and Midwifery Council (NMC), General Dental Council or General Medical Council (GMC). This can be perceived as a huge oversight, as these are the only registers that formally recognise aesthetics within the scope of their profession and, therefore, place the responsibility of the duty of care with the practicing doctor, nurse or dentist. While the other registers have a place, they are all voluntary in nature. Having a formal, current and registered medical qualification should, surely, count as the fundamental standard if the recommendation is to attend a ‘medical practitioner … on a register to show they meet set standards in training, skill and insurance’ (NHS, 2019).
» It is clear that remote consultations of any description are not permissible within aesthetic medicine, and a face-to-face consultation is required prior to the issue of an aesthetic-related prescription «
Prescribing standards
In relation to prescribing standards, the NMC originally set out a number of their own. These have since been withdrawn (in January 2019), at which point, the NMC allied themselves with the General Pharmaceutical Council (GPhC) Guidance, the most recent of which were in the consultation phase until 21 June 2019 (GPhC, 2019). However, this document is clear that ‘pharmacist prescribers who prescribe and administer non-surgical cosmetic medicinal products must be appropriately trained … They must prescribe and administer non-surgical cosmetic medicinal products only in line with good practice guidelines … and only after there has been a physical examination of the person. For this reason, it is not appropriate to carry out a remote consultation for non-surgical cosmetic medicinal products’ (GPhC, 2019).
Furthermore, ‘the JCCP [Joint Council for Cosmetic Practitioners] and CPSA [Cosmetic Practice Standards Authority] have produced guidance for practitioners who provide cosmetic interventions. Health Education England was commissioned by the Department of Health in 2015 to develop qualification requirements for the delivery of non-surgical cosmetic interventions. The aim of this work was to improve and standardise the training available to practitioners’ (GPhC, 2019).
From these standards, it is clear that remote consultations of any description are not permissible within aesthetic medicine, and a face-to-face consultation is required prior to the issue of an aesthetic-related prescription. Most commonly, this will be a prescription for a botulinum toxin product.
With the exception of those in Scotland, nurses are not permitted to keep a stock of botulinum toxin or any other similar product. Therefore, patients need to be clear that consultations and treatment appointments must be at separate times, unless the clinic in question has a doctor as their Medical Director. In such a case, the doctor can hold a stock from which the prescribing practitioner may be able to dispense. Either way, patients should be clear on the process in each clinic they approach and have a good understanding of why procedures are being followed, as well as the legalities behind them.
Guidance published by the British Association of Cosmetic Nurses (2012) is likely the most useful for nurses, as it seeks to bring together a comprehensive set of guidelines specifically for aesthetic nurses. With regard to prescribing, its advice makes it clear that prescribers must be able to:
While there are a number of standards and guidelines related to aesthetics in existence, there are fundamental requirements that flow through them all. In summary, these are:
Ethical issues
While considering the legal aspects of prescribing for this patient group, it is worth revisiting the advertising standards in the sector. There are strict advertising standards around how patients are initially made aware of prescribed aesthetic treatments and the rules around this are very clear, as stated by the Advertising Standards Agency (ASA) (2016).
Botulinum toxin injections
Botulinum toxin, the ‘trade name for a pharmaceutical preparation, produced by bacteria called Clostridium botulinum’ (ASA, 2016), is regulated as prescription-only medicine that should be injected by a confident and adequately qualified health professional. While botulinum toxin cannot be advertised to the wider public, products can be advertised to healthcare professionals, such as aesthetic nurses. The ASA also outline further rules regarding botulinum toxin, including:
These standards make it very clear that advertising a prescribed drug such as botulinum toxin is a breach of the standards and against the rules. The ASA are very clear about the circumstances in which toxins can be named and when they cannot.
Raising questions
Non-prescribing nurses will need a prescriber to be able to provide and administer toxins to patients. However, this raises the question of whether this is all they need in this scenario and if that is all they get from the prescriber they choose to work with. Equally, the question of whether it is merely a prescription that prescribers should be providing is raised, as every practitioners' ethics and standard of training is not always known, in addition to whether they require additional guidance, support, mentoring or coaching to successfully set them off on their aesthetics journey. Nurses usually provide much more than a simple prescribing service due to feelings of professional responsibility, while still charging a minimal amount.
Looking at what the legal requirements are regarding general prescribing for aesthetic patients, it is very clear from the GPhC and the GMC that, before the prescription can be issued, and if the product is not being held on stock by a doctor (or doctor/nurse in Scotland), the patient must have a face-to-face consultation. In previous guidance (before aligning with the GPhC), the NMC were also very clear that the responsibility of the treatment outcome for the patient remains with the prescriber. In this case, a full treatment plan should be discussed with the nurse who undertakes the injections. The prescribing nurse needs to be fully assured of the administering nurse's competency, aligned with their ethics and be available to support the other practitioner should they run into a problem with a product ordered by the prescribing nurse.
Competent, confident and experienced
It is my opinion that anyone who is prescribing on behalf of another needs to be absolutely assured that the aesthetic practitioner administering the treatment is completely competent, confident and experienced, as well as being able to recognise and manage complications. Equally, it is clear that a practitioner (whether they can prescribe or not), who is new to the industry has yet to build the competence and experience to safely administer injectable aesthetic treatments in isolation of anyone else. It is always wise to connect with other local practitioners who can offer support and guidance, should an untoward incident occur.
» Formal mentoring, one-to-one support, prescribing services and clinical training can all be components of this post-basic support package enabling a new practitioner to thrive «
Practitioners who are new to the industry may seek the support of a prescribing practitioner following their initial training in basic aesthetic techniques, this will be essential if they are a non-prescriber. Even prescribing practitioners who are new to the industry should refrain from prescribing for this patient group until they have sufficient experience and expertise for this to be within their scope of competence.
However, as there is no formal requirement to seek additional support, there is the potential for new practitioners to be naive in terms of how isolated their working can be, the complications they may encounter and how to manage the same and the complete array of techniques that can be used to achieve the desired outcomes. Furthermore, from a business perspective, there is often a lack of appreciation of the ‘slow burn’ when it comes to getting an aesthetic business off the ground, with some false perceptions around how lucrative aesthetics is in the initial stages, as well as the length of time required to establish a business to the point where it is a success.
Increasing support through mentorship
Throughout the industry, it is becoming far more widely recognised by experienced and new practitioners alike that more support after the post-basic training is required. It is a subject frequently discussed on the various online forums and the anecdotal evidence linking new aesthetic nurses with feelings of lacking competency, anxiety and stress. There are a number of mentoring and support programs available to new practitioners throughout the UK that mainly rely on the new practitioner themselves recognising the need to increase their knowledge and competency base to access the services. Equally, the range of mentoring and support services within any one program can vary widely, with most offering advice and support around clinical techniques and practice, usually an element of anatomy and, sometimes, a business element. The quality, duration and cost of these courses varies widely, but do show that there is a need to build on post-basic training and competency levels.
Conclusion
While it is possible to work within the current standards and act simply as a prescribing practitioner for another nurse, it is my conclusion that, often, this practice is an insufficient service that neither supports the patient or the non-prescribing nurse, and leaves the prescribing practitioner in a very vulnerable position should anything go wrong with the treatment.
To protect both the prescriber and non-prescribing nurse, as a minimum, a full treatment plan should be agreed at the time of the patient consultation. However (particularly with regard to those nurses new to aesthetics), a structured mentoring service can offer much more professional support, a greater element of protection and gives a direct advantage to the patient who will benefit from the additional support their practitioner is receiving. This, in turn, will have a direct positive impact on the new practitioner's business, despite an enhanced mentoring service requiring a greater amount of investment to access it.
Any new practitioner within the field of medical aesthetics can unwittingly find themselves in an isolated and vulnerable position. Working with an experienced doctor, nurse or dentist can be invaluable for a professional new to this field. Formal mentoring, one-to-one support, prescribing services and clinical training can all be components of this post-basic support package enabling a new practitioner to thrive.
However, it should be accepted that provision of these services is labour-intensive and demanding on the provider and, therefore, should be costed appropriately by the provider and built into the initial business costs of the new practitioner.
When prescribing for others, the clear standards stipulated by all the regulating bodies should be adhered to, as should the related advertising standards.