Podiatrists Injecting Botox! Just where does the foot end?

Posted on the 27 June 2012 at 11:10

The thorny issue of just who should and shouldn’t be allowed to inject botulinum toxins (e.g. Botox®) into paying customers, aside from who practically can and can’t has raised its ugly head again. Following recent debates over beauty therapists, dental hygienists and other non-medics involvement in this marketplace, we now see Podiatrists or foot specialists wanting to get in on the action too with training companies and insurers prepared to back them and actively promote this business option to them.

(Cue music...)

The toe bone's connected to the foot bone,
 The foot bone's connected to the ankle bone,
 The ankle bone's connected to the leg bone...
but it’s a long old way to the face (bone)!”

Joking aside, it has come to our attention, and that of the many and varied industry associations and key opinion leaders within the UK medical aesthetic industry that some training companies are openly targeting and promoting training courses in prescription only botulinum toxins (and dermal fillers) direct to ‘Healthcare Professionals’, in this instance those registered as Podiatrists.

This latest ‘nonsense’, as dismissed by some, is provoking all sorts of debate and anger amongst trade associations which represent medical professionals such as Doctors and Nurses, as well as regulators like the IHAS Treatments You Can Trust Register of Cosmetic Injectable Providers, and industry suppliers, participants and medical indemnity insurers most of whom do not support this specialty’s involvement with facial aesthetics. In fact, all the manufacturers of botulinum toxins licensed for aesthetic use in the UK have openly stated that they do not support the use of their products by anyone other than Doctors, Dentists, Nurse Independent Prescribers and Registered Nurses; so what is going on, why are so many other ‘people’ wanting to and being given the means to wield this drug in the faces of unsuspecting members of the public and is this really a huge problem for the industry?

We didn’t have to go far in our hunt to find podiatrists offering services to the public as ‘qualifed aesthetics practitioners’ now happily promoting dermal filler and botulinum toxin injections, some even with a banner outside the clinic declaring that they now do Botox! – A complete no-no in terms of medicines regulations given its POM status! Here are just a few of the operators that we found from a quick Internet search showing a wide distribution across the country – Holistic Health Facial Aesthetics just outside Newcastle-Upon-Tyne run by Podiatrist Michelle Scott and The WalkWell Clinic in Rugby where Podiatrist Vicky Morley now includes facial aesthetics. The latter is the clinic with the banner, who also compound their lack of awareness of the regulations governing the advertising of prescription only toxins to the public as they are quite prepared to promote it on Twitter as well.

As well as new operators, we found a variety of companies offering such training courses to podiatrists, including this one run by MasterClass Presentations Ltd in Tamworth; a company which was set up by two Health Professionals and runs a variety of courses for UK Doctors, Dentists, Nurses and Podiatrists in facial aesthetics and mesotherapy.

They proudly state on their website; “Many Podiatrists work in close proximity to aestheticians and for years it was a source of untold frustration to many that, for example, RGN’s with diplomas could train in facial aesthetics injections but Podiatrists with good honours degrees often complemented by Health PGC’s PGDip’s, Masters or PhD degrees were denied such training. After a substantial amount of work convincing insurers and underwriters that Podiatrists could be an exceptionally ‘safe pair of hands’ and developing what is widely regarded as the most intensive syllabus of learning in its field, we were able to start training LA qualified Podiatrists as aestheticians and it has been the success story of the decade.”

Another company who is at the forefront of this push is Fluent Health Academy, a training company based in Bolton who offer a 2 day, combined foundation course in Botox and dermal fillers from £1,150.

Fluent Health Academy is run by Directors Lisa Moore and Michael Wilshaw. Lisa whose past CV, freely available on LinkedIn, includes being Head of Podiatry at NHS Sefton and owner of a private podiatry practice for 7 years from 1998 is clearly championing the inclusion of practitioners from her specialty within the aesthetic industry. Michael, an experienced manager within the NHS, joined Lisa as business adviser and aid to their growing franchise business model for trained practitioners.

They introduce themselves on their own website as:

“We are an exciting, clinically experienced and registered training centre providing medical Aesthetics courses and non invasive injectable cosmetic surgery for health care professionals such as Doctors, Dentists, Podiatrist, Paramedics, Dental Nurses & Nurses who can evidence they meet our minimum entrance criteria.”

They go on to say on their site:

“After the basic foundation course you will be able to offer injectable cosmetic surgery treatments to your patients such as Botulinum Toxin A (Botox) and Dermal Fillers increasing your earning potential exponentially. As all of our courses are recognised by Hamilton Fraser, the leading Insurance broker in the industry, on production of the "Fluent Health Certificate of Completion", you will be guaranteed to get insurance with them after successfully completing our courses.”

All sounds so simple...and easy!

As well as taking a stand at a recent Society of Chiropodists & Podiatrists conference, a quick Internet search revealed some of their promotional activities direct to Podiatrists, including posts on forum site www.podiatry-arena.com where they offered podiatrists a £150 voucher code for a discount on the training course.

Despite targeting this specialty, it seems that not all within the podiatry world are supportive or interested in this deviation from their existing profession. One forum member, a podiatrist in both the NHS and Private Practice wrote:

Whilst I am rather vocal about Podiatric recognition, using our full scope of practice etc. I must say if I were ever looking into getting Botox, dermal fillers I would not see a Podiatrist. Surely this is also a mine field waiting to happen, can you imagine the press PODIATRIST MADE ME LOOK LIKE I HAD A STROKE. All practitioners have adverse outcomes, but particularly practising outside your anatomic speciality is just asking for trouble and could potentially give us bad press.

Another says: “If people feel the need to exploit this loophole don't do it under their professional title. People who have gone before me have worked hard to get rights that have enhanced but are connected to our scope of practice. This would only erode some of the respect I think has been built for the profession.

To put minds at rest for those concerned about the views of the HPC (Health Professions Council) who regulate podiatrists, in terms of practicing cosmetic injectable delivery as a podiatrist where undertaking the procedure is well outside of the scope of practice, Fluent Health Academy advises that in fact once qualified the individual would practice and be insured as an Aesthetics Practitioner meaning that it falls outside of their HPC registration. In other words, they would not practice as a ‘Podiatrist offering Botox’ but as an ‘Aesthetics Practitioner offering Botox’ (who happens to be a podiatrist by trade!)

We approached the HPC for their thoughts on this. In a statement they said:

“We set standards for entry to our Register, setting out what podiatrists must know, understand and be able to do before they start practising. Once on our Register, podiatrists must continue to meet those standards relevant to the work they do. A podiatrist can move into new areas of practice, so long as they have the knowledge and skills to be able to practice lawfully, safely and effectively.

All chiropodists/podiatrists must practice only within their scope of practice. This means that they should only practise in the areas in which they have the necessary skills, knowledge and experience to be able to practise lawfully, safely and effectively. This requirement is set out in our standards of conduct, performance and ethics, which are available here:
http://www.hpc-uk.org/aboutregistration/standards/standardsofconductperformanceandethics/ 

In relation to facial aesthetics, they can be administered in the following situations:

• Where it is self-administered;
• Where it is administered by an appropriate practitioner; or
• Where it is administered in accordance with the directions of an appropriate practitioner

Appropriate practitioners are in this case, doctors, dentists, or, subject to certain limitations, nurse or pharmacist independent prescribers and supplementary prescribers.

This means that a podiatrist can administer facial aesthetics, such as Botox, where they are directed to by an appropriate practitioner such as a doctor. Alternatively, a podiatrist could administer specified medicines if they were following an established patient group direction (which is an instruction setting out various factors including the patients that a drug can be administered to and the conditions to be treated).

We regulate individual professions, including chiropodists/podiatrists. However, medicines legislation, which sets out the law around administration of medicines, is managed by the Medicines and Healthcare Products Regulatory Agency.”

Similarly The Institute of Chiropodists and Podistrists (IOCP) have also issued a position statement on podiatrists and facial aesthetics which is a much more detailed document. In this statement they note various points;

“...In order to clarify the situation of Podiatrists also involved in this market sector, the following key guidance points are given.

• Prescribing or administration rights may only be used within the scope of podiatry, for example prescribing purified botulinum toxin type-A for a dynamic equinus foot deformity is within scope, prescribing it for facial aesthetics is not.

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

• Botulinum toxins are prescription-only medicines throughout most of the western world, including the UK, and as such can only be obtained against a prescription issued by an appropriate practitioner. To be ‘appropriate’ that practitioner must be working within their scope of practice.

...In considering the prescribing of, for example Botox®, by a podiatrist prescriber, use of the term ‘appropriate practitioner’ used in the applicable legislation should be noted. Therefore, in the event that a podiatrist prescriber wished to prescribe and administer prepared botulinum toxin type-A for dynamic equinus foot deformity due to spasticity in ambulant paediatric cerebral palsy patients, two years of age or older where this was clinically assessed to be a suitable treatment, they would be judged ‘an appropriate practitioner’ and plainly acting within the defined scope of practice of podiatry. The foregoing procedure would naturally be subject to them having appropriate training in the product and its administration.

In the event that a podiatrist prescriber wished to prescribe Botox® for facial aesthetic treatments, this would be clearly outside their scope of practice and they would not be ‘an appropriate practitioner’. Therefore any prescription issued by them for this purpose would be in contravention of the medicines act 1968 and subsequent amendments and therefore illegal.

...It is recognised and it is indeed entirely lawful and within their human rights, that podiatrists, particularly those in private practice, may wish to gain alternative skills in, for example, manipulation therapy, herbal medicine, acupuncture, hypnotherapy, counselling or any number of other personal care related skills. Such skills where they impact on area’s that are clearly not within the scope of podiatry must however be practised as stand-alone procedures and not as ‘extensions’ of podiatry. The same conditions must apply if podiatrists choose to undertake training in the administration of facial aesthetics products. Any procedures that are performed should be demonstrably performed not as a podiatrist, but within the scope of any training that they have received in such procedures, and strictly according to law as applicable to any products used.

...In the event that someone working as an aesthetics practitioner, who was also a podiatrist (whether a prescriber or not) wished to administer botulinum toxin type-A for facial aesthetics, as in the case of any other individual they must note that to comply with the law it should only be done under the named patient-specific direction of an ‘appropriate prescriber’ who takes responsibility for such administration. Irrespective of the fact that they may be highly knowledgeable and skilled in the pharmacology and use of botulinum toxin type-A for procedures within the scope of podiatry, a podiatrist cannot be an ‘appropriate practitioner’ for the purposes of prescribing botulinum for facial aesthetic purposes.
 
In such cases the Institute, although recognising that this is not a podiatry matter, would advise individuals performing such procedures who were also podiatrists, to ensure in writing via consent forms or similar, that people to whom they administer such procedures clearly understand that this is not a podiatry procedure and the practitioner is not acting as a podiatrist.

Hence, both the regulatory body and trade association for podiatrists agree that they should only practice, as podiatrists, within the scope of their specialty which facial aesthetics in not, yet if they wish to branch into this market, they can do so along as they have received appropriate training, follow medicines regulations and above all do not practice this service in their capacity as a podiatrist. So does that mean you shouldn’t run the two services side by side in the same clinic as many are doing?

Earlier this year, Director of Fluent Health Academy Michael Wilshaw posted on his Twitter feed that accreditation for their training courses with bSOAP (now renamed tSOAP) was going through.

tSOAP, the Society of Aesthetics Practitioners is a not for profit professional body who claim to be ‘seeking to further the aesthetics profession and the interests of individuals engaged in that profession’.

On their website they go on to say;

“As the public demand for cosmetic injectable treatment continues to rise, so too does the demand for qualified practitioners. Once qualified existing clinicians are often dismissed by their current professional bodies as the skill is deemed as “out of scope” and not recognised by their insurance. Yet this has not stopped clinician’s continuing to practice. Aesthetics practitioners need support and professional recognition, much like they did when practicing as a nurse, podiatrist, dentist, paramedic or Doctor. tSOAP has been established as the first Multidisciplinary Professional Body for fully trained or clinicians wishing to train in injectable aesthetics.”

tSOAP will only accept membership applications from clinicians whom have been on an ‘approved training course’, such which Fluent Health Academy is hoping to be listed as.

We approached tSOAP for comment however they were unable to respond in the time frame needed; we do hope to have comment from them very soon.

When we asked Fluent Health Academy for a comment on their decision to promote courses specifically to the podiatry profession, (as well as to Doctors and Nurses), they told us that; “Unfortunately at the moment Fluent Health Ltd is not in a position to comment or be quoted in such articles due to other commitments”.

We also approached aesthetic industry insurer Hamilton Fraser, who have backed this training course for their comment.

Managing Director, Eddie Hooker said; “In 2010 Hamilton Fraser began trialling medical malpractice insurance cover to Podiatrists who are registered with the HPC and are qualified supplementary prescribers who are also permitted to administer local anaesthetic. Since this trial began, which involves 50 such practitioners, we have only received one notification of a potential claim. From a statistical point of view this volume of both practitioners and potential claims represents a very low risk to insurers. Provided practitioners continue to act within Standards of Conduct, Performance and Ethics set down by the HPC we are able to continue to provide insurance cover for Podiatrists under certain circumstances.

We continuously review and monitor the performance of all practitioner types and treatments to ensure that the risk to the industry, consumers and insurers remains at or below an acceptable level. We are aware that due to the size and diverse nature of this industry there will always be a difference of opinion as to which practitioners should be undertaking which treatments. Whilst we are not, and do not wish to become regulators for the cosmetic industry, it is right that we continue to take into account all available points of view so that we can provide protection in a responsible manner when we are approached with new opportunities.

Podiatrists themselves may argue that they are better qualified to administer cosmetic injectables than some nurses as according to NHS Careers, “...to become a podiatrist...a recognised course of study leading to a Bachelor of Science (BSc) honours degree in podiatry... full-time course takes three or four years to complete...courses are modular...half the time being hands-on clinical experience.” A career in nursing is not always predicated on a degree, with diplomas of higher education and BTEC national diplomas all being routes to the profession.

As noted, current legislation permits podiatrists to administer or supply prescription only medicines under a patient group direction whereby a written instruction for the supply or administration of medicines to a certain group of patients is agreed and signed by a Doctor. Almost a year ago, the Department of Health and the Medicine and Healthcare products Regulatory Agency (MHRA) issued a public consultation on proposals to introduce independent prescribing for physiotherapists and podiatrists. This consultation concluded on 30th December 2011 and so far no follow up has been published.

Depending on your point of view the theory that podiatrists are more qualified than nurses may well be true, however many would also find it hard not to agree that there is a world of difference, and for most people at least 5 feet (excuse the pun!) of difference between say using Botox for plantar hyperhidrosis (which few podiatrists do anyway) and using that same drug in the glabellar frown lines as clearly facial anatomy differs significantly to that of the foot which they have studied for 4 years and subsequently practiced on. That’s not to say that all nurses have good knowledge of facial anatomy either, but the collective ‘we’ must draw the line somewhere on which healthcare and medical practitioners can truly be regarded are ‘qualifed’ and ‘safe’ to work in this arena for the sake of public safety at least.

At the recent FACE Conference in London, Consultant Ophthalmic Plastic and Reconstructive Surgeon Omar Durrani noted that there are 15 cases of blindness reported in clinical papers due to the use of dermal fillers, apparently in the hands of ‘experts’!

So does this really just come down to money? We know that a cash strapped NHS is cutting podiatry services, leaving many within the profession out in the cold and facing a choice – Do I go into private practice and hope there are enough people with foot complaints who are willing to seek a private referral and pay for something which was once freely available on the NHS? Or do I diversify and find the nearest ‘cash cow’ that will generate more income for me and pay my mortgage – top of the list being the facial aesthetics market? A similar parallel could be drawn with the recent surge in dentists moving into facial aesthetics who find themselves in a similar situation where NHS work dries up and become unprofitable, private practice is crowded so facial aesthetics seems like a handy income generating adjunct. Yet at least dentists already spend all day looking at and dealing with facial anatomy which podiatrists don’t; so is a 2 day course really going to teach them all they need to know – we doubt it!

At The Consulting Room we always aim to be independent, unbiased and above all accurate in our presentation of the facts about a topic, especially those as controversial as this. We hope we have been able to give a voice to all sides of the debate and present the evidence thus far so that you, the reader, can judge for yourself.

This situation would perhaps not exist were there not the backing from the medical indemnity insurers so please join us by answering our quick poll where the question is – Do you think that Hamilton Fraser should be insuring podiatrists to carry out facial aesthetic injections including botulinum toxins?

Please feel free to discuss and debate this issue using the comment system below.



Update 28th June 2012 


Reponse from tSOAP - the Society of Aesthetics Practitioners:

"As a society we represent qualified clinical practitioners who are both eligible and capable of prescribing and / or administering botulinum toxin A and dermal filler treatments safety, including Doctors, Dentists Nurses and a range of appropriately qualified and registered AHP professions. The latest guidance from the Department of Health (Dec 2005, Gateway Ref:5910) to patients clearly identifies that patients must only be treated, (i.e. Duty of Care undertaken) by a prescribing clinical professional, i.e. a Doctor or Dentist. With the following confirmation that 'The Doctor or Dentist may delegate the administration to a suitably qualified and competent other person'.

What is clear is that since this guidance was produced the Department of Health has extended the scope of practice for a broad range of clinicians, including Nurses and certain AHP professions within the NHS. Already a range of professionally qualified AHPs have clinical 1st and post graduate degrees with qualifications to undertake minor surgery and supplementary prescribing within the present range of NHS services. It is a high probability that these treatment and prescribing capabilities will be further extended by the end of 2013. Therefore, a range of Nursing and selected AHP grades and professions will have the capability to independently as well as supplementary prescribe for a range of treatments and conditions. So far the NMC are the only body to presently provide clear guidance to its members on the boundaries for prescribing Aesthetic treatment drugs.

The qualifications and capabilities of all clinical professionals are both relevant and important to accommodate in the strive for regulation, safety and quality within the Aesthetics sector. We would only ever support the prescribing and administration of botulinum toxin A and dermal filler products by appropriately registered and qualified clinicians. However the move to restrict both practice and training by profession rather than professional registration, clinical qualifications to practice or fully assessed capability is a degenerate rather than progressive move in the fight to establish standards and regulation in the sector.

We would like to see a range of standards made legally mandatory, with baselines for training and practice including professional registration, POMS and LA certification before clinicians are eligible to train or go on to practice lawfully. These and other standards should apply to and across all professions to ensure patients are able to access treatments that will be safe, convenient and professionally delivered."



Update 3rd July 2012 


Committee of Medicine Statements

The Medicines Committee has sought and received approval from the College of Podiatry Board of College Governors/Podiatry Academic Board on two matters of College of Podiatry policy.

The first issue relates to College policy on the use of botox by podiatrists.

1. Following advice from the Medicines Committee, the College of Podiatry takes the view that the use by podiatrists of botox for the purposes of facial aesthetics falls outside the recognised scope of podiatric practice. Whilst the College acknowledges the legitimate use of botox by podiatrists for treatments relating to the foot, ankle and associated structures, in line with current evidence, it does not support the use of botox for the purposes of facial aesthetics by podiatrists. Members who choose to undertake the use of facial botox treatments, if qualified to do so, should do so in a capacity other than that of a podiatrist.

Members will be aware that, at present, podiatrists are able to undertake training to become supplementary prescribers, and the Department of Health AHP Medicines Project is seeking to attain independent prescribing rights for podiatrists and physiotherapists. Should this move be successful, podiatrists would have further prescribing rights than they do at present. In order to ensure our policy remains up to date, the Medicines Committee sought and received College approval for the following statement relating to the prescribing of medicine by podiatrists:

2. Following advice from the Medicines Committee, the College of Podiatry has endorsed the following statement relating to the prescribing of medicines by podiatrists:

"The College of Podiatrists /Society of Chiropodists & Podiatrists agree that it is necessary to direct those members who are engaged in the practice of prescribing of medicines to ensure that they concern themselves only with those medicines which are relevant to the treatment of disorders affecting the foot, ankle and associated structures, in line with current practice and consistent with published professional guidance".

Add Comment

To leave a comment you need to be logged in as a Cosmetic Community Member or a Clinic.

Please Click Here to login / register with the Cosmetic Community.

If you are a Clinic Click Here to login to the partners area of Consulting Room.

Blog Comment(s) [23]

So once again it seems that even when other less modern and supposedly advanced countries look to tighten up regulation see 'Move to stop botched ops (in South Africa)' highlighted in the current Consulting Room News section, the UK does nothing!

It is time the professional medics i.e. the doctors nurses, dentists, surgeons who have training, qualification and actual ability to administer and PRESCRIBE these treatments stopped fighting each other and formed a united front.

These are prescription only medicines because they should be prescribed by someone who knows what they are doing and I believe administered by the same person who prescribed. Utilising loopholes which are meant to enable home treatments by parent or carers for profiteering is not correct and should not be allowed.

When did we stop putting the poor unsuspecting patient first in this country?

If our industry involved banking the government would be on it like a shot instead they bury their heads in the sand and assume the ostrich position!

Martyn Roe | http://consultingroom.com/

Got to lay some of the blame on "training companies" who allow non medical people on the courses then certify them. Also some of the blame lies with insurance companies who then go on to indemnify the unholy alliance.

A company local to me has trained a PA in botox and fillers and I remember once being on an "advanced course" where one of the delegates was a vet with no basic aesthetic experience!

Fab Equizi

Without, and perhaps, even with legislation, market forces will continue to attract unqualified injectors to this field and the number of trainers willing to train anybody, will grow.

I am concerned that the public may be mislead and confused by the titles, 'aesthetic medical practitioner' 'aesthetic specialist', 'medical aesthetician' go ahead and make some up, whilst you are at it, add some letters after your name. Qualification is implied. If the public have the option of visiting a doctor, surgeon or nurse, but CHOOSE to go to a podiatrist, tattoo artist, massage therapist, taxi driver.....etc, then, so be it. I call for a standardisation in the titles we use, perhaps; l'cosmetic doctor', 'cosmetic nurse' and suggest dentists presenting themselves as doctors, qualify their title with BDS. Perhaps we must consider publishing our registration numbers?

We then need to really pull together to look at supply, because it is doctors and perhaps dentists and nurses, who may legitimately obtain these products, who are training and supplying these other groups!

Finally we need to get our own training and education in order. If we are honest, aesthetic medicine is an entirely new specialism, different in many ways from our general training. One could say, mostly new and additional learning is required. BUT, we do know, what we don't know and we do have an education which prepares us for continued learning, and we certainly have access to plenty of CME. This makes us safer....or one would hope so.

Emma Davies RGN | http://www.cosmeticnurses.org

A PA as in personal assistant Fab? Really?

To make sure we have the right medical delegates on our courses we check their professional registration prior to booking and ensure they bring photographic identification with them on the day. We don't train podiatrists but we do get enquiries from them, when they are advised they are not eligible to train they state that they do minor surgery and inject anaesthetics all the time so maybe that is why some training providers are offering training to them...

Cosmetica Training

Are Podiatrists not already registered professionals with ability to PRESCRIBE medicines????? Surely you should be looking to the unregistered people doing this that are not professionally registered, such as the many beauticians, or the PA's referred to here. Minimum entrance criteria to training could resolve this. I know of one podiatrist that is actually a surgeon, who is going to tell him that he is not "qualified" to deliver a botox treatment when he has been performing independent surgery for years!
I think this debate will continue as Physiotherapists will also have extended prescribing rights (independent prescribing) soon and may well be the next to enter the market.

[EDITOR COMMENT: To avoid any confusion, please note that these comments are not attributed to Sue Thompson, Commercial Project Manager at Allergan, but someone else with a similar name.]

S. Thompson

I agree with Emma Davies that with or without legislation market forces are driving the industry. The genie appears to be well and truly out of the bottle and no amount of chest thumping or indignant sound bites will banish it.

To date the response to regulating or even legitimising the knowledge base of the speciality has been piecemeal with no real political will. What may help is a more cohesive approach where all stakeholders especially suppliers and insurers along with members of the regulated medical professions groups and organisations pull together and set out a strategy for the future. My fear for INPs and RGNs is that experience tells me when the proverbial happens down the line due to a void of rules and regulations the void becomes with very restrictive over regulation.

At this point we will not be masters of our own destiny.

Yvonne Senior RGN | http://www.piapa.co.uk

I found this to be a very interesting article. As you may be aware from my name, I am mentioned in this article as one of the podiatrists advertising facial aesthetic treatments. I feel that every point made is a valid point, I also feel that if the courses that I have attended and qualified from are fully legal and recognised by national insurers why should I not continue to advance in medical skills? We are medically trained professionals and have completed a medical Batchelor of Science degree. I fully agree with the last paragraph from tSOAP update 28th June 2012. With regard to my training for Facial Aesthetics, I spent many weeks studying the anatomy of the face, pharmocology of Botulinum Toxin type A and type B, Hyaluronic Acid based Fillers and also others. I also did my own back ground research on the Medicines Legislation. I think that all of this has got a little out of control and many people are taking this matter a little too personally. It is probably only a matter of time, as mentioned in a previous post that physiotherapists and paramedics may also be able to undertake such courses due to their medical qualifications. I also think that Emma Davis is correct in saying that there should be a recognised title. To bring this to an end I would like to lastly mention that I feel that I am competent to administer Botulinum Toxin Type A into the face and if my clients choose to come to me for treatment, this is their own decision and they are fully aware that I am NOT treating them as a podiatrist ( I have this written on the consent forms!).

Vicky Morley

Thank you for your comments Vicky, they are very much appreciated. We hoped to present all sides of this issue and really get to the nitty gritty of it with some healthy debate on the issues, so your contribution as someone who is formally a podiatrist but now practicing in medical aesthetics in a very valuable opinion. We would agree that recognition of qualifications and titles and formal boundaries as to which specialties have the skills to practice in facial aesthetics need to be properly established to alleviate in-fighting and address patient safety issues, particularly as the government has passed this arena into the self regulatory agenda and Europe currently sees all of this as Doctors only, which is not how the UK works. Your detailed explanation of your training and how you practice is very helpful to this disscussion. We hope others will join you in sharing their stories and opinions.

Lorna Jackson | http://www.consultingroom.com

I underwent training in psychiatry, dermatology, anatomy, surgery, pharmacology and therapeutics. I would not dream, however, of extracting teeth, fitting shoe inserts or managing diabetic or ischaemic feet. As Tim Flynn said at FACE, where does the foot stop?
What training does a podiatrist have in facial anatomy and physiology? It is just greed and totally inappropriate.

Dr David Eccleston | http://www.medizen.co.uk

I think that you have a valid point David, with all your training mentioned there is no doubt that you are highly skilled medical individual. If you choose not to extract teeth, fit shoe inserts or manage ulcers that is your decision but there is nothing stopping you from doing those with training if you wanted to. The training that I have had on facial anatomy is the same training that I had in anatomy of the lower limb and foot, minus the dissection of course. The lady that planned and taught the anatomical section of the course is very interesting as she is a podiatrist (by background) who is now at Durham University teaching & lecturing medical students aspiring to become doctors. A little ironic I think. There is nothing to say that podiatrists as well as other medically qualified professionals cannot advance in their medical skills. I am just a little ambitious. Who knows I may become a doctor yet.

Vicky Morley

Having spent the last 18 years in the aesthetic market, I have heard every argument from every different medical and non-medical speciality about why they feel they should be involved in the facial injectables market. Frankly the issue is not one of skill or training. I have an honours Biology degree (which included anatomy), can recite the muscles of the face and have been on more training courses and seen more different people inject in 18 years than the vast majority of aesthetic practitioners. I'm pretty good with my hands and am sure that I could get a needle in the right plane and push a plunger. Unfortunately, in today's market (with my knowledge and contacts) I could easily get a training certificate and find someone who will prescribe for me - and a broker who would provide me with a policy. However, I also understand the risks and finer points of this business that are extremely important to consider. These include a friendly referral network in the event of having a problem (and it will happen); a true understanding of support for me and the exclusions of the policy that I have bought to ensure that I am covered if the s**t really hits the fan. A business plan and supporting marketing budget to compete against sophisticated aesthetic clinics, and other local doctors and independent nurse prescribers who have years of experience in this market. I know that If I sat down and looked at all the investment required, likelihood of attracting customers and making profit vs the potentially very large risks involved (plus the guilt that I may feel in the event of having a protracted problem with a client where I had no ready network for potential support) - my answer would be that this just was not worth it!

Unfortunately podiatrists are being aggressively marketed to and being sold training courses without having a full and proper understanding of all of the issues outlined above. This is particularly relavent when we explore the technicalities of the law relating to remote prescribing. When, say for example, a dentist who has not been on a training course for injectable treatments issues prescriptions on behalf of a supplementary prescriber (whether a podiatrists or any other speciality) and the organisation responsible for regulating them washes their hands of them when they are "acting as an aesthetician". When this scenario is explicity pointed out to insurers/underwriters (especially when prescribing is "off licence" - i.e. toxin use outside of the glabellar area), they start to get a little jittery. At the end of the day no-one seems to be really sure if - when picked apart by lawyers - an individual podiatrist thinking they have indemnity cover actually has what they think they've bought if the worse happens and a patient/client brings a case to court. If their regulatory body (Health Professionals Council) will explicitly not support them, the practitioner and consumer are in the hands of the broker and underwriter and the contract that they have signed regarding medical indemnity. It's not uncommon for insurers to ask the opinion of medical experts when specific claims arise - these are unlikely to be podiatrists in the case of facial aesthetics. As we can find no support amongst Doctors, suppliers and distributors, one can imagine that a medical opinion and report may be negative? I also wonder if the consumer signing the consent form to say that the podiatrist is not acting as a podiatrist when injecting them with botulinum toxin really understands the implications of this - or whether the podiatrist does from a legal perspective?! The point I'm making here is if podiatrists have no support from the HPC or any other podiatry organisations, and if none of the brand owners (suppliers) of toxins support this speciality in the use of their drug, and if issues around the legality of remote prescribing - which have raged for years - are also in question; the potential "risk reward" scenario that any sensible person must evaluate when getting into any new business sector does not look favourable. Notwithstanding the difficulties of competing (not as a podiatrist, but from a podatrist's practice?) against fully fledged medical aesthetic clinics would also seem to provide another barrier to entry that makes it difficult for any podiatrist to drive through serious volume in order to learn the subtleties of using facial injectables (where multiple thousands invested in multiple training courses/meetings is actually required in order to achieve a good, safe standard). Anyone thinking that they can set up a successful cosmetic injectable practice by attending a one day training course does not have a clue about what this industry is really about. Podiatrists undoubtedly have a better case than beauty therapists for getting involved in the use of prescription medicines for facial aesthetic treatments - but I still think its a step too far. Lets see what happens as this story unfolds over the coming weeks & months.

Ron Myers | www.theconsultingroomgroup.co.uk

I have just read an article in this month's Professional Beauty......CIBTAC have said that 'the government' have recognized that NVQ 3 beauty therapists can carry out injectables and are offering funding to pay for botox and filler training to beauty therapists returning to work after a career break or who have been unemployed for a while. One client told me that she'd heard that diabetics could do botox and fillers by virtue of the fact that they are experienced at injecting ........it really is a case of buyer beware nowadays!!

Cathy Walker RGN

Writing is on the wall for all remote prescribers - whether they are nurses, podiatrists or any other non - prescriber. GMC issues statement today banning Doctors from issuing remote prescriptions for Botox for cosmetic teatments: www.bbc.co.uk/news/uk-england-london-18772674
Business model would seem to now be uninsurable?

Ron Myers | www.theconsultingroomgroup.co.uk

As Chairman of the Medicines Committee of the College of Podiatry, Society of Chiropodists & Podiatrists, I can confirm the position of the College and Society on this issue. The following statement has been endorsed by both the Board of Trustees of the College of Podiatry and the Council of the Society of Chiropodists & Podiatrists:

The College of Podiatry takes the view that the use by podiatrists of botox for the purposes of facial aesthetics falls outside the recognised scope of podiatric practice. Whilst the College acknowledges the legitimate use of botox by podiatrists for treatments relating to the foot and associated structures, in line with current evidence, it does not support the use of botox for the purposes of facial aesthetics by podiatrists. Members who choose to undertake the use of facial botox treatments, if qualified to do so, should do so in a capacity other than that of a podiatrist. Members who choose to undertake the use of facial botox treatments, if qualified to do so, should do so in a capacity other than that of a podiatrist and will have no redress to the Society for support should such practice be brought into question or a claim against the member be brought.

Dr Alan Borthwick

Podiatrists can only prescribe using the Supplementary Prescribing model - so why are they being insured to undertake Cosmetic Injectables?

The Medicines Committee of the College of Podiatry takes the view that the use by podiatrists of botox(R) for the purposes of facial aesthetics falls outside the recognised scope of podiatric practice. Whilst the College acknowledges the legitimate use of botox by podiatrists for treatments relating to the foot, ankle and associated structures, in line with current evidence, it does not support the use of botox for the purposes of facial aesthetics by podiatrists. Members who choose to undertake the use of facial botox treatments, if qualified to do so, should do so in a capacity other than that of a podiatrist. Members who choose to undertake the use of facial botox treatments, if qualified to do so, should do so in a capacity other than that of a podiatrist and will have no redress to the Society for support should such practice be brought into question or a claim against the member be brought.

Following advice from the Medicines Committee, the College of Podiatry has endorsed the following statement relating to the prescribing of medicines by podiatrists: `The College of Podiatrists /Society of Chiropodists & Podiatrists agree that it is necessary to direct those members who are engaged in the practice of prescribing of medicines to ensure that they concern themselves only with those medicines which are relevant to the treatment of disorders affecting the foot, ankle and associated structures, in line with current practice and consistent with published professional guidance`. Should a Prescriber prescribe in a capacity other than that of a podiatrist they will have no redress to the Society for support should such practice be brought into question or a claim against the member be brought.

Sally Taber, Secretariat of Treatments You Can Trust, is concerned that podiatrists are using remote prescribing: `...in particular, at a time when a review of cosmetic interventions is going ahead, we seem to be observing a lowering of standards`, she says. The College of Podiatry has endorsed a statement to say that, following advice from the Medicines Committee, it takes the view that the use by podiatrists of botox for the purposes of facial aesthetics falls outside the recognised scope of podiatric practice.

What the Health Professions Council says: `We set standards for entry to our Register, setting out what podiatrists must know, understand and be able to do before they start practising. Once on our Register, podiatrists must continue to meet those standards relevant to the work they do. A podiatrist can move into new areas of practice, so long as they have the knowledge and skills to be able to practise lawfully, safely and effectively. All chiropodists/podiatrists must practice only within their scope of practice. This means that they should only practise in the areas in which they have the necessary skills, knowledge and experience to be able to practise lawfully, safely and effectively. This requirement is set out in our standards of conduct, performance and ethics, which are available here: http://www.hpc-uk.org/aboutregistration/standards/standardsofconductperformanceandethics/

In relation to facial anaesthetics, these can be administered in the following situations:

* where it is self-administered;
* where it is administered by an appropriate practitioner; or
* where it is administered in accordance with the directions of an
appropriate practitioner.

Appropriate practitioners are, in this case, doctors, dentists, or, subject to certain limitations, nurse or pharmacist independent prescribers and supplementary prescribers.

This means that a podiatrist can administer facial anaesthetics, such as botox, where they are directed to by an appropriate practitioner such as a doctor. Alternatively, a podiatrist could administer specified medicines if they were following an established patient group direction (which is an instruction setting out various factors, including the patients that a drug can be administered to and the conditions to be treated).`

Charlotte Urwin, Policy Manager of the Health Professions Council, concludes:
`We regulate individual professions, including chiropodists/podiatrists.
However, medicines legislation, which sets out the law around administration of medicines, is managed by the Medicines and Healthcare Products Regulatory Agency (MHRA).`

Sally Taber goes on to say: `We have evidence of a Podiatrist who applied to be on Treatments You Can Trust and lied, saying she was a Dentist. This was picked up as she was using Remote Prescribing. Also, the Chief Executive of the company training Podiatrists was found out to be breaking MHRA rules by advertising botox parties in conjunction with the fraudulent use of logos - I am very saddened by this practice when Treatments You Can Trust is trying to raise standards.`

Sally Taber | http://www.treatmentsyoucantrust.co.uk/

The Department of Health announced today that the extension of practice for physiotherapists and podiatrists and the legitimacy of extending their capabilities to supplementary and independent prescribing as being 'safe and good for patients and patient choice'.

Are the arguments above saying that patient choice and safety is less relevant than to the practice which is going on in mainstream medicine ?

Steve Tyrie

Announcement from the Department of Health on 24th July 2012 -
Physiotherapists and podiatrists set to gain prescribing powers

"Patients could benefit from faster access to medicines such as pain relief and anti-inflammatories thanks to proposed new prescribing powers for advanced practitioner physiotherapists and podiatrists, Lord Howe announced today.

Once suitably trained, physiotherapists and podiatrists in the UK would be the first in the world to be able to independently prescribe medicines where clinically appropriate.

Physiotherapists would be able to prescribe medicines for issues such as chronic pain and respiratory diseases like asthma. The opportunity to prescribe pain relief and other medicines would help many patients to respond more quickly to their treatment.

Podiatrists who treat patients with a wide range of conditions including diabetic foot ulcers and arthritic disorders in the foot and ankle would be able to prescribe medication, if required, more promptly.
"

SOURCE:
Physiotherapists and podiatrists set to gain prescribing powers

Lorna Jackson | http://www.consultingroom.com

I am a Podiatrist and I have recently undertaken a course in facial aesthetics with Fluent Health including administering Botox and dermal fillers and I scored the highest marks that they had ever had, the company train doctors, dentists, nurses and podiatrists, so I scored higher than these other professionals yet my skills are being questioned? A mental health nurse trained with me but because she has a nursing degree she is more qualified than a Podiatrist? It does not make sense.
I do agree that there needs to be a governing body for facial aesthetics like you have the HPC for allied health professionals. It just seems that as usual Podiatrist have to fight their corner and reitorate what we are and make people recgonise what we can do, but this happens most days even within the NHS because most professionals do not know or understand the skills we have.

Katie Blackburn

As someone who has qualified as a nurse and a Podiatrist I am shocked by some of the comments above. I would be the first to admit that whilst nursing I had a limited knowledge of what Podiatrist were taught on their 3year course and rather arrogantly presumed my nursing qualification would mean the course would be something of a walk in the park for me. My foolish ignorance was soon addressed when I discovered that I would have to attend evening classes to acquire more A levels if I intended to study this subject and gain acceptance on the course, but that on completion I would receive better pay, working hours etc with the NHS than as a nurse, I wonder why?
The question in my mind is- why are nurses allowed to administer Botox? Controversial maybe? I understand that Dentists have an exceptional grasp of facial anatomy, and that Doctors (with the correct training) as they are not all experts in facial anatomy. The average GP would have to cast their minds back and revise the subject.
I don't recall performing dissection classes as a nurse, even though I was theatre trained.I do recall dissecting whole limbs including pelvic region as a student Podiatrist and being surprised at the depth of knowledge needed on whole body and disease process "just to treat feet"
I'm ashamed now of just how arrogant & ignorant I was prior to my Podiatric training, and of how I viewed our hospital chiropody service.
I also feel that this whole subject is more to do with protection of income (as I have watched the price of BotA injections and dermal fillers plummet in recent years) than patient safety or choice :-) how refreshing it would be to read an honest post on just this subject. "I don't want Podiatrists injecting cosmetic treatments, however good at it they may be, as it is reducing my client base and I see it as a threat to my business"

Surely the point is to stop non health professionals such as beauty therapists from injecting rather than targeting extremely competent injectors just because it appears few people have a grasp of the breadth and depth of their training and knowledge.

Beverley Groves

As a State Registered Podiatrist with two degrees and a LA certificate, I have seriously considered taking a course in the aesthetic administration of Botox and fillers. I have attended such courses as a model, being 'practised' upon by doctors, dentists and nurses. They usually attend the practical course for one or two days, it would seem, with some practitioners attending further 'one-to-one' practical application sessions.
Generally, the training is of a high standard although some delegates are not as competent as others. I have no doubt that I, as a Podiatrist, would be able to undertake the same training course and apply my newly learned skills as well as any of the trainees that I have encountered. However, after so little practical training and examination, would I want to charge members of the public large amounts of money to inject into their faces? Would I feel qualified enough? In truth, I would be somewhat alarmed if I discovered that the Aesthetic Cosmetician that I was relying on to inject materials into my face, had only undertaken two days of practical training before being let loose on me, regardless of their underlying qualification.
Might it not be better if courses for professionals with local anesthetic certificates, but outside the triumverate of doctor/dentist/nurse, lasted for a much longer period of time, and covered facial anatomy, prescribing, pharmacology etc. indeed, all of the areas which we Podiatrists are said to be lacking in. Delegates would have to carry out a certain number of hours of practical training during the course, bringing clients back in after two or three weeks to see the effect of their administrations. (At present, whenever I have attended as a model, the delegate has practice in administering Botox or fillers, but I have never been asked to show them how I look after the full effect has
been achieved......sometimes I have been grateful when it has worn off, when the target area has not quite been hit with the needle!) Surely, if the delegate who has given me the 'stroke effect' - not a good look - during the course of their training, doesn't know that they have done it, they won't know that they're doing it to a paying client a week later when they're out there as a fully qualified and insured aesthetic cosmetician, will they? I would far rather take a course over a period of months, gathering certificates for each of the areas deemed necessary for safe, competent, confident and insurable practice, with continued practical treatment of clients so that the effects of my administrations can be observed and recorded, than spend one or two days with limited hands-on experience with no knowledge of the outcome.
So how about it? Does such a course exist...and if not....come on, let's get to it.

Coral Pearce

Thank you for contributing your comments Coral. As you are a podiatrist it's very interesting to hear your views on this subject. I think we would all agree that better training and regulation of the standards of Botox and filler training would be a huge benefit to all, most importantly for patient safety with competent practitioners. Understanding the anatomy, the application and the potential complications and management thereof can never be fully learnt in one day.

Lorna Jackson | http://www.consultingroom.com

Across most of Europe aesthetic medicine is perceived as only available from doctors. Unfortunately over the last decades in the UK, on grounds of cost alone, there has been a gradual erosion of what it is to be a doctor and practice medicine medically. More and more medical things have been done by non medical people purely because they are thought to be cheaper for the NHS.

This situation has gone so far now that many nurses consider themselves part of the medical profession rather than the nursing profession, a paramedical one. To many excellent and experienced nurses out there my comments may seem objectionable but that was the thin end of the wedge and we can now all see for ourselves how 'thick' the wedge is getting.

I have no objection to anyone performing any medical treatment what so ever. All they have to do is apply, be accepted and complete between 5 and 7 years of medical training. From that point we will all give them the entirely honorary title of doctor.

It has already gone way too far. Medical treatments should be performed only by medical personnel with appropriate medical training. By which I mean they must hold an MB BS or an MB ChB. They can then also be dentists, podiatrist, nurses, vets, lawyers and anything else they so wish provided they have the appropriate qualifications for that as well....

The clue is in the title. It is called aesthetic medicine as it should be performed by medics.

Before I get shot down in flames by the thousands of extremely good nurses out there who already perform these treatments with due diligence and excellent care I have not said who is good or who is bad, just who is appropriately qualified to perform any medical treatment.

Now if in some way you want to define these treatments as non medical then that is a different argument.

For what it is worth I have in my time trained many nurses in aesthetics with the explicit understanding that they would work under the auspices of an experienced doctor and at no time have I ever approved of, or been involved in the remote prescribing model of Botox use. With hindsight that may have been less than rigorous.

Many have stated in the list above that this is all about money and holding on to shares of the pie. I think it is about the definition of a doctor and the definition of medicine and this unfortunately is unlikely to be a popular stand.

I welcome all feedback in person, online, email etc. I am only one voice but I do firmly believe what I have said.

Dr Paul Cronin

I have just read an article in this month's Professional Beauty...

samual