Patients or consumers? Queensland’s cosmetic injectables industry trials

Nurse-led injectables clinics in Queensland can no longer hold stock of botox and filler onsite. For better or worse, the small shift will change the industry.

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Queensland’s clarified cosmetic injectables rules have plunged hundreds of nurse-led aesthetics clinics into financial uncertainty. Experts are split on whether that’s a good thing.

Previously, the state-based Medicines and Poisons Act 2019 was interpreted as allowing medical cosmetic clinics completely run by registered nurses to hold stock of prescription-only cosmetic injectables so long as a nurse practitioner or doctor – who could be working via telehealth – made the order and wrote the prescription.

Last month, Queensland Health released a fact sheet confirming that only prescribers can buy S4 cosmetic injectable medicines to hold as stock at a clinic if they physically work there and exercise exclusive custody, and that registered nurses are only allowed to possess S4 cosmetic injectable medicines for the purpose of administering it.

It forces clinics to either hire a doctor or nurse practitioner to work onsite or to send patients to external pharmacies to have their Botox or filler dispensed before they can return for injection.

Either option is likely to drive up costs.

Hiring an additional staff member represents a big overhead cost for these clinics, but without the economies of scale afforded by clinics purchasing stock in bulk, patients would likely be paying more for the actual Botox or filler product.

This is the latest front in a tug-of-war that will be familiar to many doctors; the tension over whether the people accessing healthcare see themselves as a patient requiring care or as a consumer requiring convenience.

“[Cosmetic injectables] isn’t a huge industry with a lot of money at play by accident,” Cosmetic Nurses Association president Sheri Lee Knoop told Dermatology Republic.

“It’s flourished, and it’s grown because people want these treatments, right or wrong, or whatever we all might think of that.

“When you see huge public demand for something, there is always going to be somebody that provides that legally or otherwise.

“Our biggest concern is that if we make it too expensive to follow the legal and safe channels to obtain these treatments, that we’re going to end up in a situation where we’ve got an exponentially growing black market.”

The doctors

Australian College of Cosmetic Medicine medical dean Dr Ronald Feiner sees more regulation in the industry as a positive on a patient safety and medicolegal level.

“A patient’s face is very important to them, and unfortunately, [injectables] have been seen as a very minimalist treatment, almost that you could get done in a beauty therapy clinic,” he tells DR.

“Patients don’t understand that it’s a very serious treatment.

“Vascular occlusion, leading to necrosis, which can act very quickly, is potentially catastrophic to someone’s appearance.”

The perception of cosmetic procedures being somewhat frivolous contributes to what Dr Feiner sees as looser standards, particularly in relation to telehealth.

It’s unlikely, he says, that a patient would consent to having a skin cancer excised by a non-doctor on the basis of a remote consultation.

“You wouldn’t do it in dentistry, you wouldn’t do it in skin cancer work,” he says.

“You wouldn’t do it in radiology or interventional radiology. Why does it occur in this field?

“You’re not just prescribing something. You’re prescribing to sanction a procedure; it’s a very different thing than prescribing a blood pressure medication or repeat prescription for hypertension or cholesterol.”

Dr Feiner calls the idea of telehealth prescribing for cosmetic injectables “unthinkable”.

Georgie Haysom, a solicitor manager with medical indemnity firm Avant Mutual, cautioned doctors working in the sector to know which laws apply to them.

“And if you don’t know what it is, then seek some advice about it,” she tells DR.

“Don’t remotely buy a stock of cosmetic injectables for a nurse-led cosmetic injectables clinic if you don’t physically work there and don’t have control over medication.

“Don’t prescribe for administration by someone else unless you first have a consultation and you’ve checked the credentials of the person administering the injectable, because the prescribing doctor is responsible for the management of the patient that they prescribed for.”

Telehealth in general, she says, is an area that Avant has seen early career doctors fall into.

The nurses

Ms Knoop, a practising cosmetic injectable nurse herself, agrees that the industry is in need of more regulation but rejects the idea that more regulation should mean a doctor or nurse practitioner be physically present in a clinic.

“The statistics show us that patient safety does not increase by having doctors and nurses work alongside each other at all times,” the Cosmetic Nurses Association president says.

“Patient safety is affected if there is an adverse event and there is not a doctor on hand to assist a nurse … but we would also have situations similar in other medical models, where the doctor or nurse practitioner has to be contacted in order to become involved in escalation of care.”

Doctors are rarely onsite in jails or aged care facilities, she says, nor would there be enough doctors willing to work in cosmetic injectables clinics to keep up with patient demand.

Like Dr Feiner, Ms Knoop says the patient perception that cosmetic treatments are casual – “it’s portrayed to patients as ‘run in in your lunch hour, have a quick jab and go back to work’” – has affected safety expectations.

Unlike Dr Feiner, she doesn’t see tightening the rules as the most viable solution.

Her big concern is the formation of a black market.

“We already have had incidences of late where botulinum toxin and fillers have been purchased from sites like Alibaba or stock has been brought in from abroad and used illegally by non-healthcare professionals masquerading as nurses or doctors here in Australia,” Ms Knoop says.

She is also concerned that, in situations where the clinic does not have a prescriber onsite, patients will misuse dispensed Botox or filler.

“If the doctor or nurse practitioner gives you a script to have Botox and … you hot-foot it down to the local pharmacy and you don’t come back, you are now in possession of extremely lethal poison that you could potentially injure yourself with and or injure others with,” Ms Knoop says.

“You could go home and self-inject or you could shop around for a cheaper injector who’s going to charge you a cheaper administration price.”

Ms Knoop isn’t alone in these concerns.

Gold Coast cosmetic injectables clinic owner and registered nurse Jess Horne tells DR that her clinic has opted to look for a doctor to work onsite because she felt the pharmacy dispensing option was too risky.

“I don’t like the idea of the medicines being given as a script to the patient,” she says.

“They’re going to the chemist, they’re picking up their medicines and then we have to [believe] that, number one, the medicines had [continuous] cold chain [storage] and, number two, that they’re going to return.”

Ms Horne also believes that the industry is in need of better regulation but that having a prescriber onsite isn’t necessarily the correct fix.

“The incidence of side effects, I have to say, is extremely low,” she says.

“Over 10 years, I’ve had one complication that we had to manage and I did that with the help of telemedicine.

“I was able to look after this patient and I was able to get support from a doctor in one second.”

The common ground

All three clinicians interviewed for this story agreed that there should be a standardised pathway to becoming a cosmetic injectables nurse.

Under AHPRA, the only requirements are that the person carrying out the cosmetic procedure is authorised to administer the injectable under the relevant state or territory drugs and poisons legislation – i.e. usually a registered nurse or a supervised enrolled nurse.

There are various different courses on offer from private companies. The entry-level courses tend to run for three days or less.  

With no official AHPRA endorsement for cosmetic injectable nurses, even the Cosmetic Nurses Association has no visibility on how many nurses there are in Australia.

“We think the number of nurses participating in injectables is around 2000 to 3000, but we’ve had a lot leave the industry in the last 18 months that we’re aware of,” Ms Knoop says.

“That number is flexing all the time, and I actually have no way of knowing if that’s accurate or not.”

Estimates for Queensland alone put the number of cosmetic nurses between 600 and 1000.

Training standards are the area that Ms Knoop believes are in dire need of regulation.

“We have put a submission to AHPRA suggesting that … registered nurses, in particular, have a minimum amount of time and experience in nursing before they come into the industry,” she says.

“We have also suggested that there’s a minimum training standard that’s endorsed and that you need to have certain basic training standard modules – ethics and clinical governance being an important one – completed as part of your minimum training requirements before you start seeing patients.”