by Lee Cottrill
Business Development Director
SkinViva Training Academy is proud to have an extremely passionate and proactive Facebook support community of over 500 members (known affectionately as ‘Skinjectors’) who are all previous delegates of aesthetics training in BOTOX® and dermal fillers.
The community is often the centre of hot debate and this week, I have been part of an interesting discussion about whether a prescribing nurse can prescribe for a patient where the person administering the treatment is NOT a nurse. Specifically, in this case, the debate centred around paramedics who have recently been contacting me to say how hard it is to find a prescriber.
Former delegates and paramedics Neil Rooney (from Wakefield) and Claire Shaw (from Lincoln) both contacted me to say that often their experience has been that nurses decline to prescribe for their patients because they are nervous about if NMC guidelines allow them to or if their insurance covers them.
Neil Rooney comments:
“It’s an ongoing battle that I face most days in the aesthetics world, as a paramedic some prescribers (especially doctors) have refused to prescribe for me and yet paramedics have Masters in Critical Care, ECP degrees and paramedical science diplomas etc. In fact, our skill base is the same as a band 5 nurse.
“My next quest therefore will be to take the V300 prescribers qualification myself”
So, on behalf of the paramedics, I took up the challenge to do some digging into whether it’s OK for prescribers out there to prescribe for patients where it’s another role/profession doing the injecting of the botulinum toxin.
As I understand it, fears over insurance is often the primary reason that nurse prescribers are declining to help paramedics with prescribing for their patients. To understand this further, I contacted major UK aesthetics insurance brokers Hamilton Fraser and Cosmetic Insure.
Insight from Insurers
Jack Styles from Hamilton Fraser responded
“Our acceptance criteria in respect of administrating Botulinum Toxin is restricted to registered Doctors, Dentists and Nurses. Having said that, the prescribing aspect of the coverage will extend to other medical professionals. We don’t have an issue with our Nurses prescribing for Paramedics, so long as the consultation is performed by the Nurse and is carried out face to face. Of course, the Nurse should ensure that the third party practitioner has completed their own Botulinum Toxin training and also has insurance in place to cover them for the administration.”
I was also pleased to get a comprehensive response from Janine Revill at Cosmetic Insure who commented:
“There are certain criteria before we will allow prescribing nurses to prescribe for others i.e. they have to have been practicing aesthetic injectables for a least 2 years or 2 years as a prescribing nurse within the NHS and 1 year in Aesthetics. We have no problems in a Nurse Prescriber prescribing for a paramedic. They can actually prescribe for any practitioner that we will insure directly for injectables. As with any ‘prescribing for others’ there are checks that the prescriber has to make to ensure that they are not invalidating their own insurance, specifically:
The Prescriber checks the qualification of the practitioner e.g. the practitioner has completed an injectable course for the use of Botox
The Prescriber only prescribe face to face (no remote prescribing) and assess the person receiving the treatment in person
The Prescriber provides the practitioner administering the injectable treatment with specific relevant instructions e.g. dosage etc
The Prescriber views the methods of the Practitioner providing the treatment to ensure competent and only fulfils the script if they are confident of such
Records are kept detailing all of the above”
PIAPA – Private Independent Practices Association
Next I thought I’d get some advice from the professional associations. The Private Independent Practices Association (PIAPA) – a peer support group for practitioners in the aesthetic and cosmetic industry in the north-west England – were extremely helpful and quick to respond. Amy Senior, Head of Communications at PIAPA explains:
“To my knowledge a nurse can prescribe for anyone as long as they have assessed the patient physically in a face-to-face consultation and their insurance covers them to do so. However, even if someone else performs the procedure, the accountability does not shift from the prescribing nurse which is why they should be confident of the qualifications and abilities of the person carrying out the treatment should this come into question. Please see below from NMC Standards of Proficiency for Nurse and Midwife Prescribers
Practice standard 2 – Accountability 2.1 You are professionally accountable for your prescribing decisions, including actions and omissions, and cannot delegate this accountability to any other person 2.2 You must only ever prescribe within your level of experience and competence, acting in accordance with Clause 6 of The Code: Professional standards of practice and behaviour for nurses and midwives (NMC, 2015). 2.3 If you move to another area of practice you must consider the requirements of your new role and only ever prescribe within your level of experience and competence
“If a hearing is brought to the NMC regarding a patient they prescribed for but didn’t physically treat, realistically to defend themselves, a nurse should be able to demonstrate that they had satisfactory evidence to show that the administrator was competent in both technique and qualification including the ability to deal with a medical emergency before prescribing on their behalf. They also need to be able to show their own understanding and knowledge of the drug they are prescribing for the purpose it is prescribed.
“It’s obviously somewhat of a grey area and quite a ‘catch 22’ especially for any nurses or even pharmacists who haven’t done their prescribing qualification and rely on others to offer that service. Where it becomes problematic is when prescribers are not consulting properly with the patient and reeling off prescriptions to individuals with little to no medical background. In the case of a paramedic you could argue they are just as qualified and perhaps more than many as they are more equipped to deal with an emergency than many medical professionals.”
Next, I engaged with our Nurse Prescribers in our Facebook support community. Sharynne Pretty (from Sleaford) commented:
“This is no different to a nurse prescribing for another nurse – as long as competency has been achieved by the practitioner and the prescriber conducts the consultation and is satisfied the practitioner has competence. There shouldn’t be an issue. My concerns are around prescribers conducting a consultation and administration on the same day. This suggests ‘stock’ which, nurses are not allowed to carry. No issues with consultation and then order as a prescription but not on the same day. I have advised my clients that they ask to see the prescribed Botox, in their name.”
So in summary, it seems there is no issue with a nurse prescriber (or other prescriber) prescribing for patients where the person carrying out the treatment is not a nurse.
Ultimately however the prescriber has accountability for the patient care in relation to the prescribed drug (whether they are the one treating the patient or not) and so the key issue is that the nurse can evidence the competence of the professional who is carrying out the treatment, and is satisfied that the professional also has in place professional indemnity insurance.
Lee Cottrill is Business Development Director for SkinViva and SkinViva Training.
He specialises in business change and project management. He also gives a portion of his time pro bono to the Joint Council for Cosmetic Practitioners (JCCP) which is responsible for non-surgical aesthetics qualifications and a register of practitioners in the UK
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