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.
“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:
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".