Features
Remote prescribing
Remote prescribing is a big issue for aesthetic nurses, one that, for many, cuts to the core of their livelihood. Dr Vrajesh Ruparelia discusses the regulations and guidance the medical bodies offer
There has been considerable debate on how nurses should best practise aesthetic medicine. This often focuses on their ability and method to obtain prescription-only medications (POMs), especially botulinum toxin (BTX) for chemical denervation. Updated guidance issued by the Nursing Midwifery Council (NMC 2009) on injectable cosmetic treatments has provided much-needed clarity.
Cosmetic prescribing guidelines, which include the supply and administration of injectable medicines, from other relevant statutory bodies such as the General Medical Council (GMC 2008) and Medicines and Healthcare products Regulatory Agency (MRHA 2008) will be reviewed. It is reassuring the advice given is generally consistent among these three organisations. The Department of Health (DH 2010) has issued guidance on nurses' use of BTX.
Many cosmetic practitioners use remote prescribing when unable to obtain POMs, such as BTX and sclerosants. A prescriber—usually a clinician, dentist or even an NIP—will send a written prescription to the cosmetic practitioner by fax or post. This often occurs without a prior face-to-face consultation with the patient.
RP is used to issue prescriptions following online consultation services and for treatments such as impotence and obesity. RP is not unique to this country; it exists in the US where it is viewed as a grey area of practice. Despite concerns, there is no legal requirement in the UK for the patient to undergo a face-to-face, but RP should be reserved for urgent cases.
Standards
The NMC explored RP with aesthetic nurses in May in an informal forum. They were advised to cease using these RP services to not contravene NMC standards, which all nurses and midwives much comply with or face removal from the NMC register.
Some interpreted this as rather harsh, but this advice has not changed since 2007, when the NMC issued standards for safe practice in the management and administration of medicines (NMC, 2007). Standard 11 is most pertinent to RP where it states “remote prescribing should only be used in exceptional circumstances where medication (not including controlled drugs) has been previously prescribed and the prescriber is unable to issue a new prescription, but where changes to the dose are considered necessary…” It is unlikely that the delivery of POM for a cosmetic indication will qualify as an “exceptional circumstance”; in many cases it would be the patient's first prescription.
Non-prescribing nurses may continue to deliver POM injectables if they work closely with a prescriber, especially if the patient undergoes a face-to-face consultation first. Some have suggested the development of “patient specific directions” to circumvent this problem. However, this method may be cumbersome and raises clinical governance issues.
The advice against RP has been reiterated in an updated position statement on cosmetic injectables (NMC, June 2009). This guidance highlights that other POMs commonly used in aesthetic medicine, such as local anaesthetic for pain relief and sclerosing solutions for microsclerotherapy, will require a prescription/direction to administer them. However, as dermal fillers are medical devices they do not require a prescription/direction to administer.
The GMC has provided guidance on RP as part of their Good practice in prescribing medicines—guidance for doctors (GMC, 2008), saying that a telephone or “other non face-to-face medium” may be appropriate for prescribing medicines and treating patients when:
• you have responsibility for the care of the patient;
• you are deputising for another doctor responsible for the continuing care of a patient or;
• you have prior knowledge and understanding of the patient's condition(s) and medical history and you have authority to access the patient's records.
It may be difficult to justify all of these reasons for prescriptions for aesthetic procedures, particularly as further guidance says the patient's condition should be adequately assessed. As aesthetic medicine is such a visual speciality, the prescriber may find it problematic to fully appreciate patients' requirements without initially seeing them.
The guidance also says that when all the conditions for the delivery of RP cannot be met it should not be used. Nevertheless, nurses' use of RP for aesthetic treatments contravenes the standards set by the NMC. Nurses are required to abide by the NMC's professional code of conduct, even if there is divergence of views from other medical professions.
In a recent survey supported by the British Association of Cosmetic Doctors, over three-quarters of doctors questioned did not agree with RP and felt this practice was too hazardous as it allowed unexamined patients to be treated. (BACD, 2010).
Recent changes in legislation—The Medicines for Human Use (Miscellaneous Amendments) Regulations, 2009—have enabled nurse and midwife prescribers to prescribe independently unlicensed medications for patients, similar to doctors and dentists (NMC, 2010). NIPs can also prescribe off-label/off-licence medications (using the prescribed medication beyond the terms of its licence). However, they should only do so where it is considered best practice. For example, Vistabel and Azzalure are formally indicated only for the temporary improvement in the appearance of glabella lines but are commonly used to treat wrinkles elsewhere on the face.
Stockpiling
Although NIPs have similar prescribing privileges to doctors and dentists, their handling of medications is significantly different. NIPs cannot order and receive supplies of POMs without each POM being prescribed for a specific patient. This allows the longstanding principle of prescriber prescribes and dispensed by the pharmacist to be retained (DH, 2010).
Consequently, NIPs will be unable to treat new patients at their first consultation unless employed within the same medico-legal entity such as a clinic that can store POMs. Self-employed nurses are, of course, separate legal entities from these medical establishments (MRHA, 2008). The Department of Health and the MRHA do not expect this to change (DH, 2010).
A POM that has been specifically prescribed for a patient and then used to treat another patient(s) is considered fraud and unlawful, such as the multi-use of a large vial of BTX that has been prescribed for a named patient and is then used to treat several patients for their facial wrinkles.
It has been suggested that using patient group directions (specific groups for supplying or administering named medicines possibly not identified before treatment) and instructions for a named patient (usually written, to be supplied or administered with a specific medicine—the dose and route of administration should be specified) could circumvent the problems of using RP services.
But for medicines that treat wrinkles the GMC says patient group directions are inappropriate as general directions are inadequate. It reconfirms that sufficient assessment is required before injecting on an individual basis, so possibly a new patient-specific direction is required each time (GMC, 2008).
The MHRA has stated that patient group directions should be used for medications within their licensed indications and in only exceptional circumstances can they be issued. In essence, patient group directions for Vistabel and Azzalure can be used for managing only the glabella (their licensed indication), which is impractical (MRHA, 2008). As the delivery of a patient-specific direction does not require assessment by a nurse, this is not consistent with the ethos of full assessment before treatment.
Although, a patient-specific direction may allow non-prescribers to obtain and deliver BTX in the face legally, it will require logistical foresight to have the patient assessed first and is likely to be an inconvenient way of working for many self-employed mobile nurses. This additional expense and time may impose such constraints that their practice is no longer financially viable.
Nurses remotely prescribing for cosmetic treatments contravenes their professional code of conduct; consequently, they could face removal from the NMC register if reported. This has been highlighted in a recent NMC meeting.
It is important for NIPs to understand that a POM is the property of the named patient. It becomes fraud and is unlawful if used for another patient. Although there is a general convergence of guidance from the various health statutory bodies regarding the prescription of cosmetic POMs and the role of RP, for nurses it important that they follow the standards set out by the NMC.
As an NIP, being able to prescribe POMs for cosmetic procedures you wish to undertake on your own patients allows you to work within the current NMC standards of medicine management.
Dr Vrajesh Ruparelia BSc (Hons) BDS, aesthetic dentist and tutor at Entire Learning, which works with De Montfort University. This article has been reviewed by a staff member of the NMC and tutors of the nurse prescribing faculty at De Montfort University
