In the UK, remote prescribing has been a topic of controversy for many years in medical aesthetics. In 2019, the General Medical Council issued a set of principles to help protect patient safety and welfare when accessing medication online or over the phone.1 The principles tightened prescribing rules, banning prescription-only medicines (POMs) such as toxin from being prescribed remotely.
Despite this, there have been numerous incidences where practitioners have not complied with this guidance. For example, in December 2021, Aesthetics reported on the ethical issues surrounding remote prescribing after an investigation published by The Sunday Times exposed four medical professionals running side-line businesses in which they prescribed toxin to patients they’d never met.3 In June, the Joint Council of Cosmetic Practitioners (JCCP) published a new statement on responsible prescribing for cosmetic procedures.2 It is an update from its 2019 guidance and has been published in direct response to industry complaints and with the Government’s new proposed licensing regime in mind.4
The guidelines detail the provision of stock and wholesale dealing, the requirement for informed consent, repeat prescribing, competing interests and prescribing in an emergency. The main changes in the updated guidelines are regarding delegation and the supply of POMs. The current JCCP guidance concerns all non-surgical cosmetic procedures that are either cosmetic, medical or medically-related in nature.
Following the release of the new guidelines, we spoke to JCCP Clinical Advisory Group co-chair and nurse prescriber Andrew Rankin, and chair of the British College of Aesthetic Medicine’s (BCAM) regulatory, ethics and professional standards committee Dr John Curran, to learn what the updated prescribing guidelines mean for the aesthetics industry.
Responsible delegation
The first major change in the new guidance is responsible delegation. This refers to when a prescribing practitioner delegates the administration of the medicine to a responsible and competent person. According to Rankin, the JCCP believed delegation within prescribing was leading to some confusion among the industry, so a clearer message needed to be instated.
According to the JCCP, some delegated practitioners were unable to determine the final dose after reconstitution of a medicine for parenteral administration, such as toxin. Therefore, sufficient evidence of requisite competency, including ‘numeracy and literacy’ skills to determine the dose at a given dilution, is necessary to ensure the safe administration of the medicine.2
Rankin notes, “The JCCP were receiving confusion among practitioners regarding delegation and the particular roles that practitioners had once they had delegated their patient. Therefore, we have reinforced the point that the treating practitioner understands the patient and for the prescribing practitioner to be confident that the treating practitioner they are delegating to is competent in every aspect. This includes being able to reconstitute the toxin in a sterile environment, having good mathematical skills to ensure correct dosing, and that the prescribing practitioner is assured that the treating practitioner is not advertising POMs to patients or online. This can only be ensured by the industry itself reporting incompetent prescribers and adding into the new Bill to make it lawful.”
On the other hand, Dr Curran believes that many practitioners are ignorant to the letter of the prescribing laws, rather than confused. He states, “The JCCP is doing a good job and an important one. I see examples of ignorance among practitioners on a regular basis. The prescribing regulations are already in place but too many practitioners are not aware of their professional obligations or the laws governing this important activity. Prescribing practitioners must ensure that any practitioner they delegate to is competent to receive, understand and implement instructions exactly. This will include the administration of any medicine.”
Supplying prescription-only medicines
Another main update outlined in the prescribing guidance is regarding the supply of POMs.
The JCCP is aware that it is commonly considered normal practice to supply parenteral medicines via a private prescription without the provision of any further patient direction, such as the total units of toxin needed. Prescribers often use this approach to facilitate autonomy, enabling the treating practitioner to determine for themselves the dose required for the individual patient. However, the law makes it clear that ‘direction’ is a key element of prescribing.2
Rankin outlines that supplying POMs should be done appropriately and breaking this could be committing a crime. He explains, “Concerns were raised over practitioners trying to get hold of as much POMs as they could for use in ways that are often illegal. The new JCCP guidance highlights the relevant legislation and urges practitioners to prescribe the exact measurement of toxin with the appropriate units and to ensure that treating practitioners are not keeping leftover toxin in their clinics. Practitioners should only be prescribing for the exact amount that their patient needs.”
Rankin outlines that the Human Medicines Regulations 2012 describes the appropriate laws surrounding POMs which should be adhered to and practitioners should have a read through of this document to ensure they are complying with prescribing laws.5 It is the first comprehensive, cosmetic specific prescribing guidance which aims to apply to all prescribers. Created and endorsed by the JCCP Clinical Advisory Group whose wide-ranging membership includes industry experts and regulators, it is a valuable and credible resource.
Dr Curran notes that the exact measurements of POMs will vary between patients. He adds, “The practice of medicine, particularly prescribing, is an exact science. Patients have a right to receive exactly what their clinician has prescribed, and the prescriber has a clear duty of care to ensure this happens.”
Help endorse best prescribing practice
The new guidance sets out the appropriate laws and protocols which prescribers in aesthetics should adhere to, although the JCCP also urges practitioners to refamiliarise themselves with guidance from their own professional bodies (e.g. GMC/GDC/NMC). Rankin notes, “The JCCP has considered and built on advice provided by registrants of all professional regulators as well as the MHRA. It is essential that prescribers have the knowledge and expertise to prescribe appropriately as it is pivotal for patient safety.”
Dr Curran urges healthcare professionals to report improper or unlawful prescribing that puts patients at risk. “Combined with guidance from our regulators and the MHRA, the JCCP advice gives prescribers a clear and comprehensive pathway for ethical and safe practice within aesthetics. We all have an obligation to offer support and guidance to colleagues who appear not to be practising to expected standards. However, where there is a lack of clinical insight or practices which may bring harm to patients, we are obliged to report to our professional bodies any wrongdoing.”
