The Government's long-awaited Health and Care Act will be formally enacted in July 2022 and received Royal assent on 28 April 2022. The Act will include the following clause:
‘Licensing of cosmetic procedures
(1) The Secretary of State may, for the purposes of reducing the risk of harm to the health or safety of members of the public, make regulations—
1. (a) prohibiting an individual in England from carrying out specified cosmetic procedures in the course of business, unless the person has a personal licence;
2. (b) prohibiting a person from using or permitting the use of premises in England for the carrying out of specified cosmetic procedures in the course of business, unless the person has a premises licence.
(2) In this section—
‘cosmetic procedure’ means a procedure, other than a surgical or dental procedure, that is or may be carried out for cosmetic purposes; and the reference to a procedure includes—
(a) the injection of a substance;
2. (b) the application of a substance that is capable of penetrating into or through the epidermis;
3. (c) the insertion of needles into the skin;
4. (d) the placing of threads under the skin;
5. (e) the application of light, electricity, cold or heat;
‘licensed premises' means premises in respect of which a premises licence is in force’
The publication of the new Act of Parliament will herald a national consultation exercise, led by the Department of Health and Social Care in England, to determine the range of aesthetic treatments that should form part of the new licence in England. It will also establish the education and training standards that will need to be put in place to enable practitioners to demonstrate to local licencing authorities that they possess the skills, knowledge and competencies necessary to practise legally and safely.
In preparation for the national consultation exercise, the Joint Council for Cosmetic Practitioners (JCCP) and the Cosmetic Practice Standards Authority (CPSA) have set out a shared narrative and call to action.
The Joint Council for Cosmetic Practitioners and the Cosmetic Practice Standards Authority
The JCCP and CPSA are sister organisations. The CPSA is an expert group of clinical specialists, with patient/public representation, that prioritises experience, evidence and patient safety. It sets standards that anyone who wishes to perform non-surgical cosmetic treatments must meet, whatever professional background they are from. Practitioners who meet these standards can join a register held by the JCCP. Members of the public can select a practitioner from the register, knowing they meet the standards established by the CPSA.
The JCCP and the CPSA were both established in response to a review into cosmetic practice, led by Professor Sir Bruce Keogh (Department of Health and Social Care, 2013). This review followed in the wake of the Poly Implant Prosthèse (PIP) breast implant scandal. The Keogh review (2013) also focused on non-surgical cosmetic treatments and highlighted several areas of concern.
In recent years, the non-surgical sector has expanded exponentially, and the CPSA estimates that such procedures now account for nine out of 10 cosmetic interventions, with the remainder being surgical. Together, the JCCP and CPSA have developed a code of practice for practitioners who provide non-surgical cosmetic interventions. Among other things, it requires practitioners to promote safety and patient wellbeing, always seek consent, provide adequate information, consider patients' psychological and emotional needs and have indemnity and liability insurance.
The JCCP is accredited by the Professional Standards Authority (PSA), which is accountable to Parliament and oversees the regulation of healthcare professionals working in occupations that involve statutory regulation (for example, doctors, registered nurses, dentists, pharmacists and designated allied health professionals). The PSA also accredits registers of healthcare practitioners in those areas that are not yet regulated by law. The JCCP operates a PSA-accredited register for practitioners in the fields of non-surgical cosmetic treatments and hair restoration surgery. The JCCP and the CPSA operate across the UK in England, Scotland, Wales and Northern Ireland.
» … nothing less than joined-up governance and the closure of loopholes within the current regulatory landscape will be acceptable if we are to truly seek to serve and protect members of the public from unwarranted variation in regard to the standards and quality of service that they should expect from aesthetic practitioners «
Treatments and current challenges
The JCCP and the CPSA have been established to set both practice and education/training standards for and to consider both the benefits and the risks associated with non-surgical, anti-ageing treatments and hair restoration surgery. The treatments currently included are:
- Botulinum toxin injections
- Dermal fillers
- Skin rejuvenation, including microneedling and skin peels
- Laser and light therapy
- Hair restoration surgery.
In recent years, the JCCP has witnessed a growing number of harmful complications arising from such treatments, many of which have been the result of substandard treatment administered by inappropriately qualified and poorly trained practitioners. The JCCP is also seeing gross misrepresentation of the benefits of treatment, not least on social media and other online platforms. Its organisations are also aware of an emerging range of additional invasive treatments, for which we believe standards should be set and included within the scope of the new Government license. At the heart of the problem is a serious lack of independent information and advice for the public, and the simple fact that this is an area that requires statutory regulation.
The Health and Care Act (2022)
In early 2022, the JCCP played a pivotal role in influencing Parliamentarians to support an amendment that the JCCP and others tabled in September 2021 to the Health and Care Bill, which would introduce a mandated licensing regime for the more invasive cosmetic treatments and make it an offence for someone to practise without a licence and from unlicensed premises. The Government has since agreed to introduce a new system of licensing in England for non-surgical cosmetic procedures.
The JCCP and the CPSA warmly welcome this latest development, which takes the form of an amendment to the Health and Care Bill, tabled by the Government. It will give the Secretary of State for Health and Social Care the power to introduce a national licensing regime, the scope and details of which will be determined after a public consultation.
The new licensing regime is designed to safeguard people who access invasive cosmetic treatments and follows new legislation that was introduced last year that makes it illegal to administer dermal fillers and injectable toxin treatments to those aged under 18 years. The licensing scheme will introduce consistent standards that individuals carrying out non-surgical cosmetic procedures will have to meet, as well as hygiene and safety standards for premises. The Government has described the amendment as the next step on the road to the effective regulation of non-surgical cosmetic procedures and hair restoration surgery in England.
The new licensing regime complements and fits well with the JCCP's 10-point plan of action (2021), which says there should be:
- Statutory regulation to ensure that only practitioners who meet the required standards for safe and effective practice can practise legally
- National, mandatory education and training standards for all practitioners in these fields
- Clear, transparent information from service providers on risks, benefits, costs, qualifications and insurance
- A clear, legal definition of what constitutes a ‘medical’ procedure, a ‘medically-related’ service and a ‘cosmetic’ treatment
- Robust standards and regulation for the safe, ethical and professional prescribing of medications and preparations
- Tighter controls on advertising and social media posts to prevent the promotion of unsafe, unethical and exaggerated messaging about products, education, training and service provision
- A nationally agreed process for the reporting and analysis of complications and adverse incidents
- A legal requirement that all cosmetic non-surgical and hair restoration surgical practitioners should hold an appropriate level of medical indemnity insurance to provide a proper redress scheme for service users
- Nationally agreed-upon standards for the licensing and regulation of premises and treatment procedures
- A campaign to raise public awareness of the benefits and risks associated with non-surgical treatments and hair restoration surgery.
The JCCP has welcomed the advent of the new licensing scheme, but the Government needs to go further if members of the public are to be protected from unwarranted variation in the delivery of safe and harm-free aesthetic treatments. For example, we believe that further work is required to provide greater protection for members of the public in the following areas.
1. Clinicians ‘holding the needle’
The JCCP and the CPSA are calling for the statutory regulation of cosmetic treatments involving injectables, fillers, invasive lasers, ‘deep’ peels, threads, vitamin infusions and other invasive treatments and say these should only be administered by suitably trained and experienced regulated healthcare professionals. We recognise that similar restrictions might need to be extended to other invasive aesthetic treatments that fall within the scope of the proposed licences.
2. Prescribing
At the heart of the JCCP's quest to promote public protection is the principle of applying safe and legal practice with respect to the prescribing, supply and administration of prescription medicines. To that end, reference is made to best practice recommendations that the JCCP and its associated Clinical Advisory Group endorse for the benefit of responsible prescribers who operate in the cosmetic sector. From a legal perspective, we consider that all people using prescription-only medicines in the cosmetic setting must, at all times, comply with legislation if they wish to avoid the challenge of criminal notification. All prescribers are subject to professional regulatory requirements and, as such, must ensure that they prescribe in accordance with the guidance set down by their professional regulatory body and fitness to practice determinants.
While current legislation does not provide a requirement for the legal enforcement of face-to-face consultations, in line with the guidance set down by several professional statutory regulators (the General Medical Council and the General Dental Council and in accordance with the guidance (2021) set down by the Royal Pharmaceutical Society), the JCCP and the CPSA have set down their decision not to endorse or permit the remote prescribing of any injectable prescription medicine and medical device when used for non-surgical cosmetic treatments. When the prescriber delegates treatment to other practitioners, the JCCP reminds the prescriber that the duty of care for the patient remains with the prescriber and the decision to prescribe must be compliant with the Medicines and Healthcare products Regulatory Agency (MHRA) and professional statutory regulatory body regulations and requirements on remote prescribing. For the avoidance of doubt, our guidance applies to the routine/planned administration of medicines or medical devices that are used for non-surgical cosmetic procedures, such as (but not limited to) botulinum toxins, injected local anaesthetic, dermal fillers, hyaluronidase, tissue stimulants, vitamin infusions and injections and agents used for lipolysis. Therefore, we consider that prescribers must not prescribe such injectable medicines and devices for non-surgical cosmetic use by telephone, video link, online, at the request of others or for patients whom they have not examined personally face-to-face.
3. Tighter controls for advertising and social media
The aesthetics sector operates in a burgeoning market that is largely promoted through unregulated social media. This market is served by providers of diverse quality, who present with very varied knowledge and, often, inadequate training. It is characterised by multiple examples of commercially related conflicts of interest and the use of exaggerated social media posts that fail to advise members of the public of the emotional and psychological challenges and consequences associated with aesthetic procedures. In our view, the span of knowledge and training required to safely deliver all the possible interventions—and particularly those that include transdermal procedures—needs a framework of knowledge and skill within which safe delivery can be assured and which should be underpinned by a robust code of professional practice.
The JCCP has identified many social media posts that advertise ineffective and possibly dangerous substances administered by self-promoting individuals, many of whom lack the knowledge, experience and training required to practice safely. We have also identified many examples of social media posts involving exaggerated, harmful or false claims relating to the benefits, efficacy and/or outcomes of aesthetic treatments, some of which have resulted in psychological and emotional distress for consumers. We have discovered multiple examples of social media posts that promote elective, non-medically related aesthetic procedures to vulnerable persons; many such postings fail to describe the risks of emotional and psychological harm that some aesthetic treatments can result in if they are provided on the basis of promoting a false picture of ‘perfection’.
As such, we consider that the Government should impose greater advertising and social media regulation for specified invasive non-surgical cosmetic procedures. The impact of social media influencers and the increasing promotion and sale of aesthetic procedures online is a matter of considerable concern. This should include the provision of a logo or kitemark warning to be appended to all advertisements that relate to the promotion of aesthetic treatments that fall within the scope of the new licence.
4. Dermal fillers
In the interests of public protection and public safety, the JCCP and CPSA are of the opinion that dermal fillers should become prescription-only devices as soon as possible and should thereafter be afforded the same controls as those provided for the prescription and administration of injectable toxins. Therefore, the JCCP will campaign for the implementation of legislation to make dermal fillers a prescription-only device.
Conclusion
The UK Government's decision to introduce a licensing scheme to regulate the administration of the more invasive aesthetic treatments is a welcome contribution to enhancing public protection and patient safety. The JCCP and the CPSA are prepared and mobilised to support and contribute to the development of standards for both practice and education and training in support of the new licensing scheme. The system of regulation for the aesthetic sector is complex and multifarious. The JCCP's shared call to action remains at the heart of our strategy. In our opinion, nothing less than joined-up governance and the closure of loopholes within the current regulatory landscape will be acceptable if we are to truly seek to serve and protect members of the public from unwarranted variation in regard to the standards and quality of service that they should expect from aesthetic practitioners within the UK. The JCCP and the CPSA call on the sector to use this legislation and the forthcoming consultation to adopt high standards of practice and clinical excellence.