Are Insurers a Practical Key to Regulating the Aesthetic Industry?

You wouldn’t drive a car if you couldn’t get insurance, so will taking away medical indemnity policies for non-medics such as beauty therapists, podiatrists and physiotherapists stop the tidal wave of entry to the facial cosmetic injectable marketplace?

It’s been very interesting to see the impact that the recently announced GMC guidelines regarding remote prescribing of Botox has had on the segment of the aesthetic industry affected, namely nurses (and other medical and non-medical specialities) receiving remote prescriptions for Botox (and other brands of botulinum toxin) from Doctors.

The paradox for me is that this is not new news for the large number, (and we are talking hundreds here) of nurses involved in this business model as the NMC issued a statement in April 2011 stating:

“The advice, ‘Remote prescribing and injectable cosmetic medicinal products’ makes clear the NMC’s position that remote prescriptions or directions to administer should not be used to administer injectable cosmetic medicinal products such as botulinum toxin (Botox®).”

The GDC also issued a statement in May of 2011 stating:

“Remote prescribing should not be routinely used to facilitate treatment, or in the provision of non-surgical cosmetic procedures such as the prescription or administration of injectable cosmetic medicinal products.”

Both of these statements published a year ago had little effect on the industry; but it’s taken a high profile Doctor (recently suspended by the GMC) to make the whole industry (nurses, insurers and suppliers alike) sit up, take notice and examine this practice.

However, this isn’t the end for non-prescribing nurses who have a significant botulinum toxin business model, as so called “buddy prescribing” does appear to be a potentially workable (if less profitable) route for going forward; (more details to follow in future blogs about the exact mechanism of this model as it is still being debated).

The key for me is the positioning of insurers in this debate.

Hamilton Fraser (the largest specialist broker in the aesthetic industry) claims to have been clear in its policies with the recently issued statement:

“Hamilton Fraser Cosmetic Insurance has always made its position clear in respect of remote consultations and the prescription of medicines in the absence of the patient. All malpractice insurance policies offered to our clients are conditional on the practitioner following the professional guidelines laid down by their governing bodies, in this case the GMC, GDC and NMC.”

We are not sure about other insurers, but certainly one might have questioned the nurses (and remote prescribers) insured by Hamilton Fraser (as both parties are involved from a patient perspective) and the potential value of their insurance cover in the event of a claim and a clever lawyer getting involved?

Whatever your views on the legalities of remote prescribing in facial aesthetics, (which may indeed still be challenged by interested parties), with insurers and the NMC being explicit for some time now, why has it taken the GMC statement for everyone to suddenly look at this issue from a “risk management” perspective if they have been involved in this model for some years?

It’s hard to tell – but it does show the influence that some individuals can have over others in persuading them to follow them in pursuit of their business model and monetary aims.

Some estimate that Dr Mark Harrison (via his company Harley Aesthetics) built up a group of over 400 nurses receiving remote prescriptions for botulinum toxins at a cost of £30 per telephone call. Many other Doctors and Dentists have sought to replicate this profitable model and have also prescribed for podiatrists, physiotherapists, and beauty therapists.

We have raised awareness of these issues in several blogs over the years such as Should beauty therapists be allowed to inject Botox & dermal filler? and Podiatrists injecting Botox, just where does the foot end? – and when we try and pin this down, there is often a similar scenario to the above with someone “championing the cause” and actively persuading insurers to cover them. This has included large insurance brokers such as Hamilton Fraser (and Marketform, the underwriters) who have recently decided to suspend all new applications insuring supplementary prescribers including  podiatrists for botulinum toxin.

They will review their position regarding the supplementary prescribers that they currently cover following Sir Bruce Keogh’s cosmetic surgery report that should be published in March 2013.

Hamilton Fraser have always taken the stance not to insure beauty therapists, but they (and Marketform) have cited numerous cases where other underwriters and brokers have had an appetite for this business and provided insurance cover.

Indeed, our recent ongoing investigations into the activities of the Cosmetic Treatments and Injectables Association (CTIA) who we initialising covered in our blog on beauty therapists injecting Botox led Lorna Jackson, Editor of The Consulting Room™ to have an interesting conversation with a representative from JM Glendinning insurance brokerage, a small Yorkshire based broker who was happy to tell us that he is currently insuring 36 beauty therapists for botulinum toxin and fillers through medical malpractice insurance policies provided by Hiscox. A certain level of niaivety when it came to aesthetic industry knowledge was very apparent when talking to the family run firm.

So what have we learned over the last couple of weeks?

1. There is still a potentially workable and insurable model via “directions to administer” for nurses who can’t prescribe.
2. This may still be used in the short term by podiatrists, physiotherapists and beauty therapists if they can find a prescriber willing to do face to face consultations AND an insurance company willing to provide medical indemnity cover.

It seems clear that the route of access by non-prescribing nurses to botulinum toxins has provided a reason for other medical professionals (who don’t have prescribing status themselves) and beauty therapists to enter the market of prescription facial injectables.

Their regulatory bodies seem to take differing stances to this, with the NMC supporting nurses as long as they strictly adhere to the guideline regarding “directions to administer”.

This does not appear to be so clear for podiatrists where the Health Professions Council (HPC) and the Institute of Chiropodists and Podiatrists (IOCP) both refer to this practice as outside of the scope of podiatry, with IOCP stating:

“Podiatrists working as aestheticians must ensure that clear boundaries exist between their activities as a podiatrist and those as an aesthetician.”

Also no suppliers or product manufacturers (as far as we know) have come out in support of these groups.

The beauty therapist world is even more split, as they are not regulated as such, so we just have the opinions of the two large groups, HABIA and BABTAC.

BABTAC published in their own member magazine, Vitality, earlier in 2012 that Julie Speed, BABTAC Director is keen to be involved in the development of a level 4/5 qualification for suitable practitioners, including therapists to train practitioners to have all the necessary skills to carry out safe and effective injectable cosmetic procedures.

The big question is - what does this mean in terms of their medical indemnity cover? Are they really covered in the event of a significant problem, and is the consumer protected?

Clarity with insurers could be the practical answer to this issue?

Although insurance brokers and underwriters state, quite rightly, that they don’t want to be involved in the business of regulating the complicated world of aesthetic medicine, in practice, they are the gatekeepers to practitioners entering into this field.

From recent discussions with brokers, it is clear that some are not aware of all the intricate facts regarding prescribing and the specific risks and problems associated with botulinum toxins (and dermal fillers, where there are more problems and fewer restrictions to product access).

Suppliers, who also state that they do not want to be involved in regulating the market and seem to be unable to control the distribution channels for their products can also play their part. If they were explicitly clear in communicating with the insurance industry who they think should be using their products and why, alongside what they think is appropriate training, it would provide clear guidance from the brand owners, who, after all, should have the clearest stance on this!  In practice, this is not currently being done in a co-ordinated fashion.

BCAM, BACN, BAAPS etc. could help by providing the detail that is needed to educate the insurance industry (brokers and underwriters) about the precise details regarding best practice and access to prescription medicines alongside problems that members have had to sort out for consumers from beauty therapists and other non-medics using cosmetic injectables, that may never be reported to them anecdotally.

Insurance is a risk management game but policies seem to be being issued by some insurers without access to the fullest possible picture of the many controversial issues that abound!. This may mean that policies have holes in them for the practitioners involved.

The devil is in the detail and how many of us read (or even understand) the small print of our insurance policies?

If practitioners can’t get insured, they most likely will not offer the service. The more we can do as an industry to educate the insurance brokers issuing the bits of paper (i.e. the indemnity policies) and be crystal clear on the practitioner groups who should not be involved (and the mechanisms of access to drugs if non-prescribers), the closer we’ll get to a practical solution in making sure that the industry is at least restricted to the professionals who have the fullest possible support from the aesthetic industry in general.

We can then address other issues such as starting to raise standards of training, another “hot potato” that is probably even more difficult to address than the main topic of this blog!