Remote prescribing of Botox by Doctors over telephone and internet banned by GMC

Posted on the 10 July 2012 at 11:42

This week the General Medical Council (GMC) will issue new rules to its members, UK Doctors, stating that the practice of remotely prescribing prescription only botulinum toxin products, such as the brands Botox, Vistabel, Azzalure, Dysport, Xeomin and Bocouture will no longer be permitted and Doctors must see a patient face-to-face before issuing a prescription for the drug; (although they may still delegate the administration of it to someone under their supervision, such as a nurse).

This means that the ongoing loop-hole of writing prescriptions for Botox following a telephone call, fax, email or voice over internet connection (i.e., Skype etc.) will from this week mean that a Doctor is practicing outside of the GMC rules and could face disciplinary charges in the form of a fitness to practice hearing.

"There are good reasons why these are prescription-only medicines and we believe doctors should assess any patient in person before issuing a prescription of this kind," said Niall Dickson, chief executive of the GMC.

The story broke on the BBC London Evening News on 9th July which highlighted an investigation into the practice of remote prescribing services following concerns that were raised to the broadcaster. The BBC sent a researcher undercover to investigate operations by infiltrating training sessions with one of the UK’s largest purchasers of botulinum toxin products, Dr. Mark Harrison, who runs Harley Aesthetics a company which provides training courses and remote prescription services for registered nurses up and down the UK.

For £30 per call, nurses subscribed to his services are able to telephone Dr. Harrison on his mobile phone, whereupon he would speak to them and their patient and issue a prescription for the cosmetic injectable treatment without ever seeing the patient face-to-face.

Dr. Harrison was secretly filmed by the BBC candidly remarking to a room full of trainees on a variety of practices which leave many within the industry sharply inhaling, such as obtaining Botox via prescriptions made in the names of friends and family so that a stock of the drug could be obtained ready for injecting patients immediately – something which even Nurse Independent Prescribers (who can legally prescribe themselves as well as Doctors) are not able to do (i.e. stock must not be held, the practitioner must wait for the drug to be delivered in the name of the patient and treat on another day).

Dr. Harrison also pointed out that although ‘a little bit naughty’ if nurses were unable to reach him for a remote consultation, perhaps due to poor mobile phone signal, and wanted to treat a patient there and then, they could do so and he’d ring the patient after the treatment to conduct a retrospective consultation! This puts the nurse in a position whereby they would be injecting a patient with a prescription only medicine (POM) without any form of written prescription prior to treatment; a serious issue for patient safety.

The practice of remote prescribing has already been condemned by the Nursing and Midwifery Council (NMC) who state that nurses engaging in treating patients with botulinum toxins following a remote consultation will be going against the NMC standards and thus risk their registration (which could be withdrawn following a disciplinary hearing) if they operate via that business model.

Commenting to the BBC, Dr. Harrison said he had performed more than 50,000 remote consultations since 2005, with no adverse affects on patient health. He told them that the use of prescriptions in one person's name for the treatment of others was "common, almost universal practice throughout the aesthetics industry" and concluded; "I can confirm that I take my professional and moral obligations to both the patients who have treatments and the nurses who use the service extremely seriously."

Dr. Harrison is by no means alone in providing remote consultation services, this practice is widespread amongst individuals and smaller service providing companies,  also extending to dentists who have prescribing powers. As the Director of the biggest organisation offering remote prescribing services within our industry it must be no surprise to Dr. Harrison that he was targeted by an investigation such as this to highlight the issues and dangers surrounding remote prescribing of botulinum toxin products.


Consulting Room Director Ron Myers says;


This unequivocal statement from the GMC would seem to be the final nail in the coffin for remote prescribing business models of Botox for cosmetic purposes. The NMC have been clear on this for a while, but the GMC now comes into line and should halt the march of non-prescribers of any speciality seeking to offer this treatment via a remote consultation business model.

This decision has become increasingly important as we have even seen these prescription medicines getting into the hands of people without any medical qualifications. The insurers and underwriters now need to look had at the people that they are covering with indemnity insurance and take appropriate action.

I'm hoping that we also see moves to restrict the use of (more dangerous) dermal fillers by beauty therapists as medical devices come under more scrutiny in the near future.


Mai Bentley RGN NIP, Director of Training at Intraderm Limited told us;


The GMC, NMC and MHRA have been totally aware of this situation for over two years but no significant action has been taken until now. We have tried hard to raise awareness amongst nurses about the many problems associated with some remote prescribing services but this was not welcomed by some doctors, nurses and companies within the aesthetic industry. We have always been concerned that many nurses have been misled as to the legalities of some remote prescribing services but with little support from the appropriate governing bodies and the aesthetic industry, this has been impossible to address in the correct manner.
 
We welcome the report from the BBC this evening which has highlighted unprofessional practises that have been allowed to continue, unchecked by the regulatory bodies, for years and has thrown the situation into the light of the general public arena. The immediate response and announcement from the GMC today will go some way towards helping to protect the patients seeking prescription only aesthetic treatments in the future. However, earlier intervention by the governing bodies would have prevented the dreadful confusion that exists within the industry on the subject of remote prescribing. The Council for Healthcare Regulatory Excellence (CHRE) must surely need to look more closely at the role of the governing bodies in this situation.
 
The way forward for those nurses who are not already independent nurse prescribers may be challenging. The V300 independent nurse prescribing course is not the answer for everyone for a variety of reasons and prescribing buddy systems require a lot of trust and organisation on both side of the equation.
 
Nurses are responsible for their own actions under the NMC Code of Conduct and listening to the incorrect advice of medical or other nursing colleagues and pleading ignorance to the true facts are no defence.  We continue to offer confidential support and advice to those who may require it.


Dr. Samantha Gammell , President of The British College Of Aesthetic Medicine (formerly the British Association of Cosmetic Doctors) said in a statement;


The aim of the British College Of Aesthetic Medicine is to advance the effective, safe and ethical practice of aesthetic medicine and we therefore welcome the new General Medical Council (GMC) guidelines on remote prescribing.

We understand that the new guidelines will make specific reference to injectable cosmetic medicines such as Botulinum Toxin and therefore there can be no further claims of ambiguity by any medical professional. As per our Articles of Association ALL BCAM  members are expected to understand and have a working knowledge of the Code of Practice as set out by GMC and must adhere to it in daily practice.


Emma Davies RGN and founder member of the British Association of Cosmetic Nurses (BACN) stated;


The BACN has had no communication from the NMC, except to reiterate its stance on remote prescribing in aesthetics, i.e., that this practise does not meet the Standards. 28/3/2012

The BACN requires its members to abide by the NMC Code of Conduct, and Standards. We ensure our members are well informed and have drawn attention to any advice or guidance from the NMC, relevant to aesthetics.

We have been concerned for some time with Doctors presenting convincing, but misleading reassurances to nurses, that remote prescribing was legal and met NMC standards. We are relieved that the practise has been exposed and we can move forward with absolute clarity.


Yvonne Senior, Co-Founder of the Private Independent Aesthetic Practices Association (PIAPA) told us;


"I would hope that this now closes the door to Doctors who are prescribing remotely to Beauty Therapists and other non-medics."


Sally Taber, Director of the Independent Healthcare Advisory Services (IHAS) and responsible for the management of the Standards and Training principles for www.TreatmentsYouCanTrust.org.uk, responded by saying;


www.TreatmentsYouCanTrust.org.uk applauds the move from the General Medical Council (GMC) to ban Doctors from prescribing Botox®, a prescription only medicine, without conducting a prior face-to-face consultation.

The inappropriate practice of remote prescribing by Doctors has to date been one of the biggest issues within the cosmetic injectable industry. Following its launch nearly two years ago, the Department of Health backed register of regulated cosmetic injectable providers www.TreatmentsYouCanTrust.org.uk has campaigned for the GMC to review its remote prescribing guidance and close the loophole which had put patients at risk by providing unqualified providers without a clinical background with Botox®.

Botox®, a prescription only medicine, should only be prescribed to a patient following a face-to-face consultation and clinical assessment by a regulated Doctor, Dentist or an Independent Nurse Prescriber.

Relaxed attitudes to remote prescribing in the past has resulted in profit over patient safety and Botox® sold to unregulated and inappropriately qualified providers, including beauty therapists, who lack the necessary clinical background to administer injectable treatments safely. Whilst unsafe, the practice of remote prescribing in some cases is also illegal, breaking the Medicines Act 1968 for possession of a prescription only medicine in the name of an individual who is not the designated recipient of the drug.

The cosmetic injectable industry has for many years recognised remote prescribing as unsafe and totally inappropriate. The review of prescribing guidance by the GMC marks an important step in further stamping out bad practice in the industry and ensuring patient safety.


Dr Andrew Vallance-Owen, Chairman of IHAS Cosmetic Surgery/Treatments Working Group added;


As champions of best practice in the cosmetic injectable industry, and acting in the best interests of patients, www.TreatmentsYouCanTrust.org.uk  applaud the move by the GMC to dovetail their remote prescribing guidance with the other professional regulators in the UK, leaving remote prescribing behind and marking a promising future for further stamping out bad practice in the industry."


We also asked Dr. Mark Harrison for a response to both the BBC investigation and the GMC decision on remote prescribing and he provided us with this detailed reply.


Harley Aesthetics -‘a little bit naughty’

So our ‘direct to consumer’ campaign got off to a premature start with the BBC undercover nurse/reporter attending a ‘botox training day’ and exposing us for using Remote Consultations (which are both widespread and routine in the NHS) to carry out more than 50,000 Botulinum Toxin treatments without a single patient claim or complaint! But then this feature has nothing to do with patient safety despite the various ludicrous claims that ‘patients are at risk of shock or infected’ presumably the reporter meant infection-but as we all know there has never been a recorded anaphylactic reaction to aesthetic botox and in over 50,000 treatments I have not recorded a single case of infection.

The claim that the practises of Harley Aesthetics are ‘potentially endangering the life of the patient’ is contemptible. How very convenient that the 50,000 treatments, without claim or complaint, is mentioned briefly towards the end of the report. The report resorts to ridiculous sensational language merely for effect as these claims are neither present in the published literature or in the specific treatments of Harley Aesthetics.

Of course there is no story to report if it is merely concerned with some grey areas of both medical law and guidelines from professional bodies, hence having to resort to sensational journalism.

The reference to a ‘telephone salesman’ was a cheap shot that may prove expensive but perhaps it would have been more worthy of the BBC to go undercover on a ‘botox’ course training beauticians, paramedics, hygienists etc and exposing the doctors, dentists and nurses who supply them with POM to inject? 

There were numerous factual inaccuracies included there being no legal requirement for a ‘face to face’ consultation, the ‘directions to administer’ are sent from an Ipad not over the phone and Harleys  Aesthetics way of working being contrary to the NMC guideline-it is all way  more complicated then this poorly researched piece give reference to.

So what did the BBC expose other than my receding hairline?

1. The common and almost universal practise throughout the aesthetics Industry to use a single vial on more than one patient (no doubt a similar covert operation by BBC would establish this). During the training day I also highlighted the fact that this is contrary to the MHRA guidelines- but little different from a vial on insulin being used on a number of patients on an NHS ward. This practise appears to have no consequence for patient safety in a setting where only one nurse/doctor is administering the same medication to each patient at a time as opposed to a busy ward where numerous medications are given to numerous patients.

2. In extremely rare circumstances (1-2/month out of 800 remote consultations) where the patient was attending for a subsequent treatment and the nurse (for whatever reason) was unable to contact the doctor but still went ahead with the treatment, the Doctor would telephone at the first opportunity having been informed by the nurse. The decision to treat has been taken by the nurse and the doctor informed retrospectively. While this would not be uncommon in the HNS I would agree that it should not take place even extremely rarely as the nurse is exposing herself to disciplinary action.  The nurse could argue that this is a repeat prescription, as the treatment has been given previously without incident and they hold a valid ‘direction to administer’ on the patients file however the GMC do not support the use of Patient Group Directives (PGD) for aesthetic ‘Botox’ Treatment.  If the treatment was for a medical condition (low self-esteem, excessive sweating, migraine or as part of a medical treatment plan for the prevention of sun damage) then a PDG would be acceptable.  This point illustrates that these areas of medical law and the advice and guidelines of the regulatory bodies are both complex and can even be contradictory between them. No nurse would ever administer a POM on a patient who had not had that treatment previously without a prescription/direction to administer. The complaint that I left a message and did not speak to the patient is ridiculous as there was no patient to speak to as it was a ‘setup’.

These two practises can be shown to have no effect on patient safety.

The suggestion that the patient is not properly check is incorrect. Before each and every treatment the patient fills in a comprehensive medical history form (these are provided in a standard 4 Page form to the nurses). The patient is required to sign the medical history form to confirm the details are accurate and complete. This form is thoroughly checked by the nurse together with the patient (this is a routine practise in the NHS and should raise no concerns). At the start of the remote consultation the Nurse relays to the Doctor any significant information from this Form. The Doctor also specifically asked the patient about any on-going illness or medication. It is this careful consideration of the patient’s medical history by two medical professional that help with our enviable safety record.

The BBC report was inaccurate in its reporting in that the NMC guidelines on remote consultations do not apply to all treatments but only apply to the aesthetics use of Botulinum toxin but even in this case is not banned but instead special conditions are required to be met. 

I will eagerly await the new GMC guidelines which I understand are due on Friday. I am already a little puzzled as the GMC recently dropped any specific reference to Botulinum Toxin treatments stating them to be too specific. With remote consultations being common and increasingly routine in the NHS it will be interesting to see how remote consultations are considered safe and ethical in the NHS (neurology, cardiology, dermatology and general practise) but not so in Aesthetic Medicine.

Professor Sir Bruce Keogh has stated the aim that ‘remote consultations in GP and dermatology should be routine’ in the NHS within a year.

The Harley Aesthetic nurses will be hoping that I will be able to adapt the current practises of Harley Aesthetics to accommodate the new GMC guidelines. For many of the nurses it is their whole livelihood for the rest an invaluable additional family income.

For the time being it is business as usual and we continue to welcome any nurses who wish to use the services provided. Unlike our smaller competitors we have extensive legal opinion to support our way of working.

If for a moment you suppose that all the remote consultation services (including Harley Aesthetics) were to close down with the subsequent loss of many hundreds of experienced and well trained nurses- it would be easy to suppose that the various unregulated practitioners may fill the gap. Sally Taber (RGN) be careful what you wish for!”   



Watch the BBC London News Report Here


http://www.bbc.co.uk/i/b01knn0w/?t=58s

Update 11th July 2012: Please note - The link above to the full BBC London News broadcast is no longer available via the BBC iPlayer.

However, a shorter report on the investigation is available here  - http://www.bbc.co.uk/news/uk-england-london-18777104


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 which are somewhat ‘grey’ or confusing and at times controversial. We support the decision by the GMC to ban Doctors for partaking in remote prescribing services for botulinum toxin products and hope that the General Dental Council will follow soon with similar explicit rules for its members. Patient safety and best practice is at the forefront of making this industry better for all.

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




Update 10th July 2012


British Association of Cosmetic Nurses Response to the BBC news item on 9/07/12 relating to remote prescribing in aesthetics, and in particular, botulinum toxin (Botox) - Press Release – for immediate release 10th July 2012

"The British Association of Cosmetic Nurses (BACN) has been representing nurses in aesthetic practice for the last four years. The role of the BACN is to inform, advise and educate our members, and require them to practise within the law and to the highest professional standards. The Nursing and Midwifery Council (NMC) role is to safeguard the health and wellbeing of the public and ensure the highest standards of practice, all nurses working in the United Kingdom should be registered with the NMC.

Aesthetic practice is unusual in that the majority of multi-disciplinary training in aesthetics is carried out by highly specialised, experienced autonomous nurse educators.

Working closely with the Journal of Aesthetic Nursing the aesthetic nursing community continues to drive education and practice standards through educational conferences, workshops, seminars and peer reviewed academic articles, driving collaboration with allied health care professionals.

The BACN has been concerned for some time that some doctors offer reassurance to nurses that remote prescribing is accepted practice and meets NMC standards, this is not the case, as in NMC New Advice for Botox – Nurses and Midwives, published on 1st April 2011 and the NMC Standards for Medicines Management published on 9th October 2007. We welcome the fact that the practice has been highlighted and we look forward to clarity from the General Medical Council (GMC).

Nurses who have undertaken the Nurse Independent Prescribing (NIP) Course and satisfied the examiners at the NMC, and maintain both their general nursing qualification and NIP qualifications are legally able to prescribe and administer botulinum toxins and all other prescribable items within their area of competence, and have equal prescribing rights to all UK doctors. The NIP qualification has a pass mark of eighty percent for pharmacology and one hundred percent for mathematics.

Non-prescribing qualified nurses working in partnership with doctors or nurse prescribers are also working within the correct legal framework, when their patients are consulted by the prescriber who then delegates an order to administer to the nurse. This consultation process involves a physical face to face full consultation and examination by the prescriber."



Update 11th July 2012


Private Independent Aesthetic Practices Association (PIAPA) Response to the BBC news item on 09/07/12 relating to Remote Prescribing in Aesthetic Medicine. Press Release – for immediate release 11th July 2012

For the last six years Private Independent Aesthetic Nurses Association, PIAPA has supported and provided on-going education for aesthetic nurses across the North of England.  Promoting a framework for information support and education to all of its members. Whilst it is not our role to police our members they are required to practice within the law and the standards set out by the regulatory body, Nursing and Midwifery Council (NMC). As a group we look forward to receiving the same clarity on injectable cosmetic medicines from the General Medical Council (GMC) as was issued in an NMC statement on the 28/03/12.

Hopefully the issue of specific guidelines for injectable cosmetic medicines will help towards preventing exploitation of loopholes arising from claims of ambiguous interpretation of medicine standards from the medical profession.

As a support and education group for nurses practicing aesthetic medicine in the North of England. We have taken a proactive approach to practicing within the law and guidelines by encouraging our members to undertake the Independent Nurse Prescribing programme. In order to maintain public safety and fulfil their obligation to meet NMC guidelines. This is a rigorous programme and examination which enables nurses to legally prescribe within their area of competence. As a group we offer mentorship and a great deal of individual support including a small bursary toward costs. 

Remote prescribing to nurses is the tip of the iceberg; we have had a number of concerns for some time relating to the issue of training and remote prescribing. Remote prescribing to other groups who do not fall within the three regulatory bodies, for Nurse Doctors and Dentists. We refer to situations in the North West which we are sure are not isolated cases, where sadly a few medical Doctors and Dentists have proactively recruited and trained non-medical professionals e.g., Beauty therapists in the administration of Botulinum toxin and providing remote prescribing for these groups.

Our questions as a group are;
How does public safety fit with this particular model? Will a new GMC stance on this matter remove this practice or will it continue in a more subversive manner, and will insurers continue to give false security by insuring these people?

Or will greed and market forces prevail?

Yvonne Senior
Chair of PIAPA 




Update 12th July 2012


Official Press Release from General Medical Council (GMC) issued on 12th July 2012 - Permission for republication granted.

New GMC guidance - doctors must not remotely prescribe Botox

Doctors are to be banned from prescribing Botox by phone, email, video-link or fax under new guidance from the General Medical Council (GMC), it was announced today (12th July).

The change means that doctors must have face-to-face consultations with patients before prescribing Botox and other injectable cosmetics to ensure they fully understand the patient’s medical history and reasons for wanting the treatment.

Under current GMC guidance doctors must adequately assess the patient’s condition before prescribing remotely and they must be confident they can justify the prescription. Where doctors cannot satisfy these conditions, they must not prescribe remotely.

The new guidance, which comes into force on 23rd July, updates and strengthens these rules.

It introduces a complete prohibition on prescribing cosmetic injectables, such as Botox, without a physical examination of the patient. Doctors who continue to prescribe Botox or similar products remotely will be putting their registration at risk.

The GMC recognises that remote prescribing may be appropriate for some drugs and treatments for some patients but stresses that doctors must consider the limitations of any electronic communication with their patient.

The guidance, which will be issued to every doctor in the UK, states: ‘You must undertake a physical examination of patients before prescribing non-surgical cosmetic medicinal products such as Botox, Dysport or Vistabel or other injectable cosmetic medicines. You must not therefore prescribe these medicines by telephone, fax, video-link, or online.

Niall Dickson, Chief Executive of the GMC, today said: ‘We recognise that patients can benefit from communicating with their doctor by email, phone, or video-link or fax and that is fine as long as it is done safely, but our new guidance makes clear that doctors must now not prescribe medicines such as Botox remotely.

These are not trivial interventions and there are good reasons why products such as Botox are prescription only. We are clear that doctors should assess any patient in person before issuing a prescription of this kind. So while remote prescribing may be the right answer in many situations, this is not one of them.'

Katherine Murphy, Chief Executive of the Patients Association, added: ‘The Patients Association welcomes all guidance that strengthens rights and helps inform choice. Face to face appointments give patients the most appropriate opportunity to question clinicians directly about their care. Doctors must encourage a partnership approach, ensuring that patients are equal partners in their care and the decisions made about it.

The new guidance on remote prescribing is part of wider updated guidance, Good practice in prescribing and managing medicines and devices which is set to be published later in the year and followed an extensive consultation on this issue with almost 200 responses received from medical, pharmaceutical and other health care professions and patient safety organisations.’

A copy of the new remote prescribing guidance can be read on the GMC’s website www.gmc-uk.org/guidance/ethical_guidance/13594.asp




Guidance on remote prescribing of Botox by the General Dental Council (GDC)

"Remote prescribing of Botox and other non-surgical cosmetic procedures (for example via telephone, email, or a website). Remote prescribing shall not be used in the provision of non-surgical cosmetic procedures such as the prescription or administration of Botox or injectable cosmetic medicinal products."




Update 19th July 2012


The Association of Nurse Prescribing statement:

“The ANP are pleased to hear that the GMC have advised doctors they must not prescribe POMs remotely for nurses to use on people receiving aesthetic treatments. This is safer for the people undertaking aesthetic treatment and safer for nurses administering such medicines rather than without a qualified prescriber seeing the patient first. Nurses who work within aesthetics and use POMs within their treatments, must ensure that they work with qualified prescribers who have the relevant aesthetic treatment experience themselves.

The ANP are clear that any nurse prescribing must have the prescribing qualification and the competency in the disease or care area and therefore are able to prescribe knowledgably and safely.”

Dr Barbara Stuttle CBE
Chair

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) [15]

In a climate of mistrust and suspicion stemming from the 'PIP Implants' fiasco, this has certainly not done any favours for the aesthetics industry at all. As a consumer facing profile, I find it both dissapointing and concerning the inappropriate practice of remote prescribing by Doctors, I am contacted weekly by scores of patients whereby 'aesthetic treatments have gone wrong' the biggest concern in these situations is the obvious clear lack of regulation and regard for patient safety, this has to change and I welcome this strongly.

Antonia Mariconda | http://www.thecosmediccoach.com

Botox is a medical treatment. It requires continuous training & education & an in-depth knowledge of muscle physiology to be performed correctly, which is why it should only be injected after a face to face consultation with by a doctor.

Dr Daniel Sister

Dr Harrison it seems has been made a scape goat and as he suggests is a victim of unjust journalism for the every day routine remote prescribing of the aesthetics industry. So just who can and cannot prescribe BOTOX legally if remote prescribing is now taboo? this guidance from NICE seems pretty clear, and its not just Drs and nurses!

http://www.npc.co.uk/improving_safety/improving_quality/resources/single_comp_framework.pdf

But surly this industry should not be made profession specific but moreover concentrate on some minimum standards accompanied with generic entry standards; such as the ability to prescribe legally and a clinical degree to ensure patient safety.

Of course the down side to this argument is that such standard setting will often mean that many nurses already practicing in this industry will fail to meet them and many companies using Patient Specific Directives to deliver treatments by non prescribing nurses will loose a lot of money, or is control and market monopolisation really the crux of this debate?

[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 wholeheartedly applaud the stance taken by the GMC here.

Greedy non-specialist charlatans abound in this so-called industry - this is timely.

James McDiarmid

Plain and simple, It is against GMC guidance to raise a prescription for any drug using a fictitious patient name or in the name of a family member for use by someone else. If found doing so, any doctor, dentist or independent nurse prescriber could be referred to the GMC/GDC/NMC.

Likewise, any nurse administering a drug to a patient, without a valid prescription, is breaking NMC guidance in any walk of medicine. Imagine the consequences of doing that on a ward drug round!

I would also argue that any doctor, dentist or nurse found to be encouraging another health care professional to act in contravention of their own professional guidelines should be asked to account for their actions by their own regulator.

If an antibiotic or analgesic cannot be prescribed remotely in a fictitious name or be administered with out a prescription, why do some doctors, dentists and nurses think that the potent Botulinum neurotoxins are different?

Remote prescribing was introduced to save lives in remote communities, not to treat wrinkles.

Nigel Mercer (Former BAAPS President)

It is such a pity it took a BBC undercover team to highlight the issue before the GMC decided to step up to the mark. The issues of remote prescribing have long been acknowledged and debated. The NMC has been aware of this practice but have failed to enforce their own "guidelines", leaving practitioners open to misleading and inaccurate information fed via wholly commercial enterprises. Long overdue.

Hayley Lyon RN NIP

We wait with keen interest to see the GMC guidance related to this storyline.

The implications are obviously significant for the aesthetics sector, however the issue is put in proportion when you consider the wider implications in mainstream health services. I especially have concerns for the impact on the expansion of telemedicine in the NHS which will literally affect millions of patients and their access to care if the advantages that have been gained from technology advances and extended legitimate scope of practice amongst clinical professions have to take a leap backwards.

I ask all involved to think beyond the end of their noses when making a stance on this issue. In addition to the turnover of your aesthetics practice it could also be your friends and relatives that may possibly have to regularly travel for their long term conditions management in the future, rather than being medically cared for in their own comfort and surroundings, if the guidance affects some of the excellent care practice that have been developed for patients in the community.

Onto the storyline involving Dr Harrison in this instance; employing a secret journalist seems to be more of a personal attack than a mature method of presenting a valid argument. Isn’t this supposed to be a debate about professionalism and standards ? If so then how do those involved see their own professionalism when they look in the mirror? Hardly the people that we should take a leaf from.

We have previously seen this approach in areas of acute medicine with damaging effect on all involved in the service and especially in the trust and confidence that we work had to win and maintain with the public and our patients.

Surely the instigators have more credibility than to hide in the shadows and set someone up ? I hope that Dr Harrison is able to take advice and follow through with the people involved to make sure that they and others have acted legitimately (i.e. within professional conduct) and lawfully (without breaking identity or fraud law) if only to put some heads on poles to stop this unprofessional and seemingly malicious method in the future. It affects us all in our credibility with the public and should be stamped out wherever possible.

This is an important point of principle that the Harrison case has made topical, which we should act on irrespective of the guidance on prescribing that we anticipate from the GMC.

In the meantime, by the end of the week we should be able to move away from speculation and chest beating and have clear, understandable guidance that gives us a framework to consistently work within. I also hope that we do not find ourselves in a position where our personal commercial interests have led to a detrimental limitation in the care of vulnerable and isolated patients that we treat in the community with legitimate remote prescribing, care management and telemedicine within the NHS.

I also hope that the activities within the aesthetics industry are conducted with more dignity in future so as not to further damage our reputation and credibility with patients and the public.

We wait with keen interest to see the GMC guidance related to this storyline…..

Steve Tyrie

As an example of people seeking to offer prescription only medicines who are not prescribers themselves. The following email landed in The Consulting Room inbox today:

"I am a fully qualified Advanced Personal Trainer. I am also a qualified Obesity & Diabetes Practitioner, at Level 4 Status on the Register of Exercise Professionals (REP's).

I am also a qualified Clinical Nutritionist & Sports Massage Therapist.

I have run my own Health & Fitness company for over 5 years. My qualifications include extensive Physiology & Anatomy training.

Can you please tell me if I am permitted to undergo training to administer Botox?"

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

I believe Dr Tyrie makes some important points above. However it should be noted that considerable effort has previously been made to present a ‘mature and valid argument’ to Dr Harrison, amongst others. Previous responses to blogs and indeed his response to this one demonstrate that this is falling on deaf ears.

Dr Harrison runs the risk of being accused of arrogance. Further I am sure many of my nursing colleagues would find the position he takes both patronising and one of inappropriate superiority. I would like to make it clear that I have several friends who provide remote prescribing services. To my mind the concern is less the issue of remote prescribing and more how it is ‘sold’.

I hope Dr Harrison takes a step back and analyses the situation in a critical and honest fashion. I find it concerning that he maintains his position in the face of overwhelming opposition, essentially defending the indefensible. His comment concerning extensive legal opinion to support his practice is irrelevant. The discussion is not common or criminal law but professional guidelines and nurses have always risked losing their registration by accepting Dr Harrisons rather biased and financially motivated version of policy. The NMC have made this clear, it is not open to legal interpretation.

More specifically, in response to Dr Harrison’s point 1)

Because something may be common practice does not make it right and serves only to propagate the error (sharing vials that have already been dispensed). He is very much mistaken if he believes it is common practice to teach in this way; I certainly do not.

It further undermines credibility to proffer erroneous information e.g. the example of an insulin vial. No nurse would use part of a multidose insulin vial for a patient, which had been dispensed for another. The normal NHS scenario is that the vial of insulin in any given ward or department has not been dispensed but is stock. Prescriptions are then made for various patients from this stock vial which is legitimate and continues to apply equally to Botox etc. This alone implies a lack of knowledge of basic prescribing principles.

2) The nurse could argue that this is a repeat prescription, although why anyone would want to tread on such thin ice makes little sense. Perhaps more importantly I have spoken to a number of Dr’s concerning this issue, some who intend to change their service to a face to face one; something that potentially could apply to beauty therapists. The industry problem then merely changes to one of repeat prescribing ad infinitum.

Further, whilst it has been several years since I have worked in the NHS, I have never met a nurse that was happy to accept a remote prescription unless in extraordinary circumstances. I would be surprised if much has changed and given Dr Harrison’s dogmatic and blinkered view I am sceptical as to his view of its prevalence.

Finally, is it appropriate for Dr Harrison to impose safety as the sole benchmark to justify the practice? It does not allow for the probable unreported incidents. It is clear that it is not best practice and that it is financially driven, serving only to undermine the overarching principles which should motivate us. Regarding the comment to Sally Taber, I’m not sure it is she that needs to be careful at the moment. Where Sally is earning popular support and respect, Dr Harrison receives largely criticism, which I think speaks for itself. Surely it is self-evident that in the total absence of remote prescribing there should be no unregulated practitioners to ‘fill the gap’.

Andrew Rankin

Sledge Hammer to Crack a Nut

My Name is Maria I have been running my own business as a beauty therapist for the last 30 years over these years I have taught in colleges various aspects of Beauty Therapy and taught Anatomy and physiology to level 3 also ITC which is a 3hour written exam on Anatomy and physiology. I consider myself and I am referred to as a professional I have been working with IPL and semi permanent make up to the highest standards. I am very confident working with needles and have taught electrolysis. I have recently qualified in injecting Botox and Fillers with a recognised qualification.
I was planning to go into Injecting Botox and Fillers as my main income and have altered my business plans to suit this. I am now devastated to find myself in this position without a viable business due to this decision about the acquisition of Botox
Surely I am not the only one who finds themselves unable to proceed with my plans and unable to support my financial commitments.

This decision to make Botox unavailable to professional people like myself who work in a regulated and controlled environment is totally wrong because the situation that will now arise is that unregulated and untrained people will start to do these procedures with materials they have acquired on the internet, this will not stop the need and want for Botox treatments it will just push it underground and onto the back street surely there is a much better way for people like myself to acquire Botox in a regulated and controlled area.

The practice of acquiring Botox via a Doctor prescription must surely be changed to a Registration system still controlled by having to prove your qualifications and detailing clients name address D.O.B before ordering the Botox all professionals in this field needs to be named on the register as well as a copy of insurance.

You have to ask yourself is there an alternative agenda going on here with regards to the Botox and the people who are able to get this ,use this, and benefit from this , is this the case of the market being limited to a small group of practitioners who wish to control the market.

What will happen is that unethical and untrained people will move into the gap to fill this market

When will the BBC and other broadcasting media wake up and realise they are being used to promote peoples agenda weather this being controlling the market or raising funds for their particular cause.

maria pawlyszyn

The recently announced new guidance by the GMC on remote prescribing for Botox has caused the greatest ripple the Aesthetic Medical industry has ever seen. In a field described as ‘Medical’ we have witnessed an onslaught of non medical people jumping on the band wagon to inject potentially dangerous drugs into the naive public.

Certain drugs are available only on prescription for good reason. If they were so harmless then we could all purchase them over the counter. In the correct hands these products are very safe to use for a multitude of medical conditions and aesthetics. However the potential remains for things to go wrong if administered incorrectly.
These new guidelines set a precedence in an otherwise unregulated industry. Those of us who have been practicing in an ethical and professional manner for many years hope sincerely that these changes will provide the protection and safety to the general public that is long overdue.

It does however pose the question of how the big companies who make huge profits through remote prescribing plan to proceed. There is also the concern that illegal and black market ‘Botox’ type products will increasingly creep into the market.

The general public need to be made aware of the importance of seeking advice and treatment from a professional medical practitioner. Having an aesthetic procedure is not a trivial affair much to the belief of many.

I welcome the new guidance with much relief and hope that medical aesthetics gains its rightful place in the practice of medicine. My only regret is the effect this will have on the many excellent aesthetic nurses who have relied on remote prescribing for their business.

Dr Lisa Delamaine | http://www.personamedical.co.uk/

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. Hamilton Fraser will only indemnify the practitioner if they are acting under the direction of an authorised prescribing practitioner, such as a doctor, dentist or nurse prescriber, and the patient has had a face-to-face consultation with that prescribing practitioner.

We welcome the recent clarification from the GMC on this issue.

For the past 20 years Hamilton Fraser’s aim has always been to assist the cosmetic industry to improve the standards performed by its practitioners. The provision of the correct insurance is an important tool to protect practitioners and aid the growth of the sector. The recent announcements will help clarify any important exclusions to the insurance policies we provide.

Eddie Hooker | http://www.cosmetic-insurance.com

Hi Maria Pawlyszyn
After reading your post I feel sympathetic to your predicament. However, I think experienced practitioners would agree that it is not 'a sledge hammer to crack a nut'. Lisa's comment above is pertinent. The effect of this on the industry is remarkable, yet many would agree that it wasn't so much a case of if, but when and how.
Therefore one wonders who trained you and agreed to prescribe for you? Why/in what way do you feel your qualification was recognised. This seems strange - there isn't really a recognised qualification (in the true sense of the expression) for any of us. Botox and filler training is just an extension of our already recognised medical or nursing qualification. This brings me to an important point: experience comes over years, not days on a questionable training event. Emergencies do and will happen and I can assure you that it takes significant experience to deal with them when they do. A 1 day BLS course is not enough. Using a needle and knowledge of A&P represents a small fraction of the required skills. With respect, it is your understandable ignorance of all this and more, which leaves you feeling the way you do. I am confident many if not all my colleagues would agree.

Andrew Rankin

Clarifications on 'Directions to Administer'

I raised a confusion about the NMC statement on remote prescribing of cosmetic medicinal products (e.g. Botox) - http://www.nmc-uk.org/Nurses-and-midwives/Regulation-in-practice/Regulation-in-Practice-Topics/Remote-prescribing-and-injectable-cosmetic-medicinal-products/


In which they say; "remote prescribing OR directions to administer should only be used in exceptional circumstances" and "a nurse can only administer if she has a prescription OR direction to administer following a prescriber seeing the patient face to face." I thought this was confusing and contradictory and could lead some people to think on the one hand that any direction to administer for Botox was not allowed as it wasn't for 'exceptional circumstances', yet be confused by the second statement which seems to allow them.

Mai Bentley kindly gave me the following response to clarify, which I thought would be useful to the blog:

======================================
A direction to administer is basically the instructions that a nurse must follow to administer a drug. It tells the nurse the name of the drug, the dilutent required, the amount of dilutent to use, the route of the drug e.g. intramuscular, orally etc, the dose to be given and so on. It must be for a specific named patient and must be signed by the prescriber and placed in the patient notes. It must comply with NMC Standards for Medicines Management 2007.

The direction to administer should ALWAYS be given to a non prescribing nurse before she administers a drug in any setting not just an aesthetic one.

They are saying that a direction to administer given remotely i.e by telephone or other remote means is only acceptable for emergencies. For example, a nurse was given a remote message to administer adrenaline in an emergency anaphylaxis case a few weeks ago. Had she not done so the patient would have died. This is true remote consultation as it should happen for an emergency. There was not time to get someone to see the patient face to face because she would have died in the meantime.

What they are saying is that a direction to administer should normally be given to a nurse after a face to face consultation with the patient.

So, in summary, they are not saying that directions to administer are for emergency or exceptional use only. They are saying that directions to administer that are produced remotely are only for exceptional circumstances. Directions to administer produced in a normal fashion after a face to face consultation are fine for every day normal use because that is how hospitals work!

Nurses in hospitals etc work every day with a direction to administer written in the form of a medication record chart on the end of a patient bed. If non prescriber nurses could not follow directions to administer, they would not be able to give any drugs and the NHS would collapse!

Again, it is the word REMOTE that is important.

======================================

Thanks Mai

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

The extraordinary events of the current two weeks have forced me to reflect upon where aesthetic nursing may be travelling to and who are licensed drivers.

I would caution against any knee jerk reactions and the adoption of anything resembling prohibition. A Botox speak-easy really! One has to wonder who would emerge as the Eliot Ness and who would be AL Capone in this scenario.

In the rush to professionalise our speciality we need caution against a rigid model.

We need to learn the lessons from the NHS. Who greatly improved education is some areas but in other areas threw the baby out with the bath water.

We should as a group step back, take a breath and look at the principles within the circle of reflection ask the important questions about who is mandated to lead and regulate and where commercial and trade interests want to influence this.

We need to build on some good work and good people and take our future in our own hands treating the title, Nurse, with the respect it deserves.

Sadly some of the current situation has arisen because we have not influenced our own destiny enough and aesthetic medicine has become a free or all with every profession allied to medicine jumping on board, and worst still beauty therapists. We need to unravel this situation with minimum damage to nurses who are usually the fall guy when things go badly wrong.

I don`t feel Maria is fully responsible for her own predicament, I feel it`s our medical and nursing colleagues that have allowed this, however to compare A&P at level 3 with medical and nursing training combined with extended training including Cadavar work just demonstrates the old adage, you don?t know what you don?t know, until you know it.

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