For many years, the Joint Council for Cosmetic Practitioners (JCCP) has been concerned with the unacceptable variation in the provision of insurance for aesthetic practitioners and lack of access to informed complaints and redress schemes. Accordingly, it has raised concerns with the Government that there is no legal requirement for non-healthcare practitioners to have medical insurance cover for non-surgical procedures that they provide to the public. Evidence also exists to confirm that, where medical insurance is provided for both healthcare and non-healthcare practitioners, the actual amount of medical indemnity cover provided may be inadequate to meet the actual costs associated with successful litigation claims. Furthermore, the JCCP is aware that the provision of patient/public redress schemes are not mandated within the UK, thereby exposing members of the public to receive an apology or compensation for the consequences of unacceptable practices.
The JCCP is committed to the principle that the offer of aesthetic-related insurance should be accompanied by a requirement to demonstrate relevant knowledge and competence in the provision of cosmetic treatments and in the identification and management of potential complications. There is no current requirement for this, with some insurers providing cover to non-healthcare cosmetic practitioners after the completion of a short course (1–2 days), with no assessment or assurance of competence, safety or proficiency. Associated with this issue is the need to require all practitioners to undertake appropriate and regular continuing personal and professional development (CPPD) with appropriately accredited training provider organisations to maintain and update knowledge/competence as part of annual insurance renewal.
Consequently, the JCCP believes that the UK Government should seek to introduce legislation to ensure that all health and non-healthcare practitioners have adequate and robust medical insurance cover for non-surgical procedures that they provide to members of the public. In support of this objective, the JCCP has joined with insurance provider Hamilton Fraser to develop a range of principles that are considered to represent a charter for recommended best practice in the aesthetics sector.
The need for regulation of all practitioners in this sector has been the subject of much debate since the Keogh (2013) review. More recently, voluntary registers, approved by the Professional Standards Authority (PSA) and a Government enquiry into the sector led by the All-Party Parliamentary Group (APPG) on Beauty, Aesthetics and Wellbeing, have been introduced. The APPG published its report and recommendations in June 2021, which are now being actively considered by the Government. Some of the key recommendations included in the APPG report relate to insurance:
- Recommendation 13: ‘The Government should require all practitioners to hold adequate and robust insurance cover and set an industry standard for the level of proven competence that is required to gain coverage. Any future national licensing scheme must also make this a requirement of holding a license’
- Recommendation 14: ‘Practitioners must also be required to hold regulated qualifications for the aesthetic non-surgical cosmetic treatments they provide, alongside appropriate industry-approved CPD training, to maintain and update their skills, knowledge and competence as part of annual insurance renewal, particularly as new treatments continue to emerge in the market’ (APPG, 2021).
Key areas for consideration
Requirement to be insured
At the time of writing, there is no legal requirement for non-healthcare practitioners (for example, beauty therapists) to have medical indemnity insurance cover for non-surgical procedures that they provide to the public. This is contrary to the JCCP position, which states that ‘any practitioner who undertakes any cosmetic or aesthetic procedures should be mandated to purchase and maintain adequate medical indemnity insurance for the procedures that they provide’. However, it is also the JCCP's view that insurance for invasive procedures involving the use, or injection, of botulinum toxins or temporary or permanent dermal fillers should be restricted to practitioners who are educated and trained to the standards set down both by Health Education England (HEE) (2015) and by the JCCP and Cosmetic Practice Standards Authority (CPSA) (2018). Importantly, only suitably qualified and experienced doctors should be insured to perform hair restoration surgical procedures (which is a Care Quality Commission (CQC)-regulated and restricted procedure).
» Independent verification of recognised training courses and/or schools in the aesthetics sector is required to assist insurers in making judgements over a practitioner's competence and ability to ensure patient safety «
The JCCP is also aware that evidence exists to confirm that, where medical indemnity insurance does exist, the actual amount of indemnity cover may be inadequate to meet the actual costs associated with successful litigation claims.
It is also important to differentiate between ‘full malpractice insurance’ and ‘treatment insurance’. Most therapists and beauticians will purchase the latter, as cover is restricted to evidenced bodily injury only and rarely involves legal defence costs, so the price is generally cheaper. Malpractice insurance differs from ‘treatment’ style policies, as they not only cover bodily injury, but the definition also includes mental injury, awards for lost income, pain and suffering, dissatisfaction claims and ‘good Samaritan’ acts.
A typical ‘treatment only’ policy will provide an aggregate policy limit of indemnity between £500 000 and £2 million per policy year, whereas medical malpractice policies generally start with limits of £2 million and extend up to £10 million for invasive and experimental procedures. It is often the case that most claim awards relate to litigation and legal defence costs by qualified personal injury firms rather than in-house insurance claim handlers. Due to this, the JCCP would expect the minimum level of cover to be £2 million, with the norm for those offering toxins, fillers and laser treatments starting at £5 million.
Need to belong to a redress scheme
At the heart of public protection and informed choice is the need to provide the public with access to redress schemes. Within the UK, redress schemes are not mandatory for many sectors. However, where they cannot resolve a dispute in-house, the Alternative Dispute Regulations (ADR) (2015) places a requirement on all UK businesses selling to consumers to point the consumer to a certified ADR scheme and declare whether they intend to use that scheme. The regulations also require that ADR providers wishing to gain certification must meet certain standards regarding independence, impartiality and quality of expertise.
In the JCCP's opinion, membership with a complaint resolution body should be a requirement of insurance.
Demonstrating knowledge and competence
To gain insurance, there should be a requirement to demonstrate relevant knowledge and competence in the provision of cosmetic treatments. It is not for insurers to decide whether a certain practitioner can be deemed competent in the practice of a procedure by attending a certain course or completing a programme of study. Independent verification of recognised training courses and/or schools in the aesthetics sector is required to assist insurers in making judgements over a practitioner's competence and ability to ensure patient safety. Insurers are not qualified to manage and ‘vet’ training qualifications. However, in the event of a claim, insurers can, and do, seek advice from medical experts as to the suitability of training when considering competence.
At present, no recognised national education and training standard exists in the UK for the cosmetic industry, but this is a key recommendation set down by the APPG. It is very difficult to approve training courses and qualifications without the determination and enforcement of such a national industry standard. Insurers firmly support the work undertaken by the JCCP and the CPSA, who have assumed responsibility for, and updated, the HEE (2015) framework. The JCCP is now responsible for updating and implementing the HEE framework and works in association with the CPSA to continuously update national education and training standards for the aesthetics sector.
The JCCP also operates an education and training register of approved education and training providers and qualifications. However, this work is at an early stage of development, and insurers face having to deal with the myriads of training companies and courses that have opened over the past 5 years. The insurance industry needs this issue to be addressed urgently and calls for the Government to introduce a mandatory standard for education and training for the sector as a matter of priority.
Premises inspection
Secondary legislation measures are in place that have been implemented by some local authorities in the UK to inspect and monitor practitioner compliance with infection control and health protection premises standards. However, the determination and inspection of compliance with such standards is not universal. Therefore, the JCCP has joined forces with the Chartered Institute of Environmental Health to lobby the UK Government to introduce primary legislation to mandate the implementation of a national system of local authority governed licensing and inspection in the UK. This would afford greater public protection and patient safety by requiring all salons and clinics to be registered with either the CQC and/or with their local authority licensing team.
Prescribing safely
In line with several professional statutory regulators (the General Medical Council and the General Dental Council and in accordance with guidance set down by the Royal Pharmaceutical Society), Hamilton Fraser does not endorse or permit the remote prescribing of any prescription medicine when used for specifically for non-surgical cosmetic treatments. Hamilton Fraser Cosmetic Insurance also expects all prescribers to note that, when they delegate treatment to other practitioners, they ensure that they retain oversight for the patient's treatment journey and are familiar with the patient through an initial face-to-face consultation and diagnostic assessment of the patient's suitability for treatment. Therefore, prescribers must not prescribe such medicines by telephone, video link, online or at the request of others for patients whom they have not examined personally or in any way contrary to statutory professional guidance. Prescribers are often pulled into malpractice claims when the treatment is administered by non-prescribing practitioners, regardless of whether the non-prescriber has adequate malpractice insurance or not. The name and qualification held by all prescribers must be made available to members of the public.
Display of insurance certificates
The JCCP believes that practitioners should be compelled to display insurance certificates on their websites, in a prominent position in their trading clinics and within a formalised terms-of-business document that is shared with the patient/consumer. It should also be a condition that up-to-date and adequate insurance is held on file for inspection if so required. The CQC and local authority environmental health enforcement officers should request sight of such evidence as part of their inspection process.
Conclusion
The JCCP believes that there is much more that needs to be done to protect both the public and aesthetic practitioners. The JCCP will continue to campaign alongside other key stakeholders for change while delivering best practice within the current regulatory frameworks. The JCCP endorses the principles outlined in this article and recommends their further implementation within and across the aesthetics market.