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The changing face of cosmetic interventions

In the wake of the PiP implant scandal, the scrutiny of how the cosmetic interventions industry is regulated has become as meticulous as society’s scrutiny of fine lines and wrinkles. Sarah Whitehouse looks at what steps are being taken in the UK and Ireland to try to reduce the risks

The cosmetic interventions industry in the UK is big business. Worth £2.3 billion in 2010 and estimated to rise to £3.6 billion by 2015, it has expanded at such a rate that existing regulatory frameworks are now glaringly inadequate. The chances of a patient encountering poor quality products, poor quality treatment, and poor quality aftercare is surprisingly high – and for non-surgical procedures, there is no guarantee of redress.

On the surgical side – for procedures such as facelifts, liposuction, or breast implants – surgery is performed by cosmetic surgeons: experts in the field. But on the non-surgical side – for procedures such as dermal fillers, Botox, or intense pulsed light (IPL) treatments – anyone can carry out cosmetic interventions, even if they are not medically trained. An example of this is in beauty clinics.

The majority of the market growth has been seen in the non-surgical interventions sector. In a recent MPS survey of members in the UK and Ireland, 16% of non-plastic surgeon practitioners said they carry out cosmetic interventions. Of those, 53% carry out Botox injections always or often, and 40% perform dermal fillers with the same degree of frequency. Forty per cent of doctors carrying out these procedures are GPs.

Regulating the industry

In both the UK and Ireland, steps are being taken to clamp down on cosmetic interventions carried out by doctors, nurses, and others, who are not appropriately qualified or indemnified to do so safely and skilfully. In April, the UK’s Department of Health published its final report into the Review of Regulation on Cosmetic Interventions. Some of the key recommendations include:

  • A register of everyone who performs surgical or non-surgical cosmetic interventions
  • Classifying dermal fillers as a prescription only medical device
  • Ensuring all practitioners are properly qualified for all the procedures they offer
  • All non-surgical procedures must be performed under the responsibility of a clinical professional who has gained the accredited qualification to prescribe, administer and supervise aesthetic procedures
  • A ban on special financial offers for surgery
  • An advertising code of conduct with mandatory compliance for practitioners
  • Compulsory professional indemnity in case things go wrong
  • An ombudsman to oversee all private healthcare, including cosmetic procedures, to help those who have been treated poorly.

In the view of the Royal College of Surgeons in England, their guidelines, Professional Standards for Cosmetic Practice, state that only licensed doctors, registered dentists and registered nurses should provide any cosmetic treatments (including laser treatments and injectable cosmetic treatments).

In both the UK and Ireland, legislation is pending that will make indemnity or insurance for all practitioners become obligatory, and the Medical Council would be able to stop a practitioner from practising if he or she did not have adequate cover. This would make sure patients could access compensation.

In both the UK and Ireland, legislation is pending that will make indemnity or insurance for all practitioners become obligatory, and the Medical Council would be able to stop a practitioner from practising if he or she did not have adequate cover

When things go wrong in healthcare, it is important to investigate, explain and apologise. Dr Nick Clements, Head of Medical Services at MPS, says: “MPS strongly believes that practitioners should have appropriate indemnity arrangements to ensure that no patient who suffers avoidable harm is left uncompensated. There is a need for clarity on who is responsible for ensuring appropriate indemnity arrangements are in place.” Both the UK and Irish suggestions regarding the regulation of the cosmetic interventions section recognise the importance of adequate and appropriate indemnity.

But will the proposed changes be far-reaching enough to regulate the cosmetic interventions industry? Fifty eight per cent of MPS members surveyed are not sure. Clearly, the changes needed to the industry are far from cosmetic – real strides need to be made in terms of keeping a register of qualified practitioners and ensuring accountability. Proposed European Union standards could end free consultations for cosmetic procedures, help cut out ‘pressure selling’ of cosmetic procedures and help to safeguard patients. The Irish Association of Plastic Surgeons supports these proposals and has also launched its own patient information website providing a register of qualified plastic surgeons.

A risky business

One of the main areas of risk for cosmetic interventions is a lack of informed consent. Dr Clements says: “For consent to be valid, the patient must be competent, the patient must have sufficient information to make a choice, and the patient must be able to give their consent freely. Patients should, where possible, be given time to consider their options before deciding to proceed with a proposed treatment.”

It is clear that what patients do not need is to feel hurried into making a decision because of time-limited deals, or financial inducements, as is often the case with cosmetic interventions. The UK Department of Health’s report recommends that the following “socially irresponsible” advertising practices for cosmetic interventions should be prohibited:

  • Time-limited deals
  • Financial inducements
  • Package deals, such as ‘buy one get one free’
  • Offering cosmetic procedures as competition prizes.

In Ireland, the Medical Council already puts constraints on the use of misleading photography in advertising. Doctors are warned against using photographic or other illustrations of the human body to promote cosmetic or plastic surgery procedures, as they may raise unrealistic expectations amongst potential patients.

One of the main areas of risk for cosmetic interventions is a lack of informed consent

Dr Paul Heslin, a GP based in Dublin, Ireland, agrees with the importance of informed consent: “Consent should involve someone neutral, external to the selling of the procedure, as well as the selling clinic, but with the appropriate knowledge.” He also believes it is important to discuss the potential for complications openly: “The patient should see a few photos of the worst-case outcomes – like an anti-smoking programme – because this area is lucrative and there is a tendency to oversell the benefits.”

Managing expectations

When taking informed consent, managing often unrealistic patient expectations can throw up another challenge for practitioners. Unregulated advertising can compound the problems. Asking the patient what would be a “good outcome” for them if they undergo a procedure can help identify whether their expectations are realistic and achievable. Both the practitioner and the patient must agree on the intended outcome.

Patients who have been closely involved in discussions about the options available, the potential solutions, and the risks involved, are less likely to take legal action should an unsatisfactory result occur, particularly if these discussions are well documented. Although patients considering cosmetic interventions should satisfy themselves that they are aware of the potential risks, doctors carrying out the procedure should take responsibility for ensuring that careful screening of the patient is conducted, including assessment of their psychological profile, and any vulnerability they may have.

There is, with all regulation, a fine line between ensuring adequate regulation and introducing a further layer of bureaucracy. The aim of both sets of suggestions so far is to protect patients against rogue practitioners and unsafe practice, whilst not preventing qualified GPs and specialists from carrying out similar procedures for non-cosmetic reasons.

Given the growth and range of procedures carried out by disparate practitioners – some of whom aren’t even regulated, such as beauty clinics – it is more important than ever to ensure there is accountability for quality of care in cosmetic interventions. The proposed suggestions for regulation go some way to address accountability and the need for appropriate indemnity, but more work needs to be done – and quickly – to change the face of this rapidly expanding industry.

One of the main challenges is to bring cosmetic interventions in line with other specialties. Speaking of a lack of regulation and checks on qualifications, one MPS member surveyed states: “There would be public outrage if this was happening in specialties such as neurosurgery or cardiac surgery. Why should this be allowed to happen to patients who are vulnerable to manipulative advertising?”

MPS indemnity doesn’t extend to product liability

MPS sets its subscriptions based on the risks associated with negligence, rather than risks associated with product liability.

If a doctor has a claim brought against them purely for product liability, MPS indemnity would not usually cover this.

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