Many practitioners continue to perform higher risk procedures, such as dermal fillers, without first having achieved the education and training required to evidence that they are qualified to do so
I have worked in the independent healthcare sector since I joined London Bridge Hospital as Director of Nursing in the late 1980s. I have been promoting enhanced and improved patient safety in aesthetic and cosmetic practice ever since. Now I am a volunteer trustee of the Joint Council for Cosmetic Practitioners (JCCP) Charity, with responsibility for the oversight of advertising standards, premises standards and standards for handling patient complaints raised by members of the public that relate to aesthetic practitioners.
I have witnessed the non-surgical aesthetics sector evolve, from being a sub-set of cosmetic surgery practice to becoming a specialism in its own right. With it have evolved clinical techniques, procedures and pharmaceutical products drawn from medical practice, designed to alter appearance to meet a desired end. Unlike general medical and surgical practice, and without the pressure of independent oversight of its regulators, aesthetic practice has not been underpinned by a scientific evidence base and has evolved in a somewhat piecemeal fashion, without application or enforcement of the requisite concomitant proofs of safety for its practice. Furthermore, nor has it found a common sense of mutual professional identity. Professionalism needs to be addressed and in parallel to promote the need for representative organisations to work together to promote patient safety and public protection and to have respect for each other, rather than follow a tribal agenda that is professionally divisive and counterproductive to holding practitioners to account against one standard of practice proficiency. The present disarray results in duplication and confuses members of the public and hence presents a significant risk to public protection.
Injectable cosmetics
In parallel, the profession of beauty therapists has added some of the practices of the medical specialisms to its own menu, the most noticeable crossover being injectable cosmetics and, in particular, injections of botulinum toxin, a substance regulated by the Medicines and Healthcare products Regulatory Agency (MHRA) and permitted to be prescribed only by practitioners who are recognised by statute as prescribers. The administration of such toxins without the oversight of a registered healthcare practitioner has been regarded by some to put members of the public at risk. Conversely designated registered healthcare professionals are qualified to administer injectable aesthetic procedures if they undertake relevant post-qualifying training to acquire the required level of advanced knowledge and applied practice competence to perform such post-qualification procedures safely and effectively.
Irrespective of title, all practitioners are driven by a desire to provide patients with the standard of service that the patient requests regarding the enhancement of attributes related to their appearance. However, despite this motivation to work with patients and members of the public, evidence exists to confirm that agreement on what constitutes safe, ethical and professional practice remains elusive among those who practise in this specialism. At the heart of this matter is the fact that many practitioners continue to perform higher risk procedures, such as the insertion of lip enhancers (dermal fillers) or injecting toxins without first having achieved the education and training required to evidence that they are qualified to do so (for example, there are many practitioners who currently perform such procedures without a professionally regulated qualification and who do not possess the equivalence of a Level 7 qualification, as advised by the JCCP).
The risks this free market brings to patients have been commented on forcefully in many reviews, most notably in 2006, and again in 2013, by Professor Sir Bruce Keogh. The remedies are obvious: adherence to uniformly agreed and adopted practice standards, quality training, possession of a regulated ‘license to practice’, a code of practice, fitness to practice procedures, supervision arrangements, recordkeeping, product assurance, the use of common terminology and a commitment to ethical, just and honest practice.
» The absence of such a collective voice and positive collaboration in the aesthetics industry is an unfortunate characteristic of the sector at this particular time «
Bringing order into the profession
There are many professional groupings of practitioners that are seeking to introduce better order into the specialism such as the British College of Aesthetic Medicine (BCAM), British Association of Cosmetic Nurses (BACN), Private Independent Aesthetic Practices Association (PIAPA), ARC and the numerous beauty therapy organisations such as the British Association of Beauty Therapy and Cosmetology (BABTAC), the British Beauty Council, Habia and the Hairdressers and Beauty Therapy Federation. Unfortunately, over the past 5 years, many of these groups have failed to reach agreement or consensus on a range of standards-related issues or over the scope of permissible practice performed by members of the industry. One example of such ‘disputes’ has related centred on the right to administer prescription-only medicines. Hopefully, this will also shortly be extended to include dermal fillers, with the consequence that only appropriately trained practitioners part of a regulated workforce will be permitted to perform such risk-related procedures. However, there are many standards and issues where no such dichotomy exists and where, for the public benefit, all should work to the same professional standards in the interests of patient safety and public protection.
One other major divisive challenge that threatens patient safety is the fact that there is no industry-wide regulation of what cosmetic procedures may be performed. The JCCP and the Cosmetic Practice Standards Authority (CPSA) have developed practice and education/training qualification standards relevant to all known non-surgical cosmetic interventions and are now about to consider the rapid development of additional standards for emergent and existent ‘orphan treatments’. These standards have been widely accepted across the industry but other organisations continue to produce their own standards (as has been evidenced in the beauty industry). Surely, we should all support the CPSA, rather than duplicate, and add our voices to ensuring that patient safety is positioned as our primary concern in the UK, as true professionalism should dictate?
Consumer safety and furthering the industry
The JCCP is the guardian of the Department of Health and Social Care's previously agreed standards for the sector, which were produced by Health Education England in 2016. These standards were transferred to the JCCP in 2018. In my mind, the JCCP Charity and the CPSA are therefore bodies that has Government support to set standards, to register those who meet them and to oversee standards of conduct. The JCCP and the CPSA place public protection and patient safety as the focus of their activities.
The many groupings of practitioners joining with the JCCP and the CPSA may be the best way to promote and seek to achieve public protection and patient safety. We need to join up with professional associations to promote professionalism in the industry, to foster co-operation and to provide a single voice that influences the public and educates on industry matters. It is also a matter of concern that the rise of social media influencers and the increasing promotion/sale of products and procedures online is a further example of negative effect on consumer safety.
The market itself is also diverse and operates in the absence of a single regulatory framework or standard of practice. The JCCP operates within a burgeoning market for non-surgical cosmetic interventions that is largely promoted through social media. There are chains of clinics and some standalone clinics that invest in the highest standards of safety, quality and customer satisfaction. Maintaining these standards is expensive and charges are higher. At lower levels of safety, this market is served by providers of diverse quality, very varied knowledge and, often, inadequate training. It is characterised by multiple examples of commercially related conflicts of interest.
In the JCCPs view, the span of knowledge and training required to deliver safely all possible aesthetic interventions (and particularly those that include transdermal procedures) requires a framework of knowledge and skill within which safe delivery can be assured, underpinned by a robust code of professional practice (such as that published by the JCCP/CPSA in 2017 and 2020). However, by lacking a joint effort from these practitioner groupings, the way remains open to a ‘rush for the bottom’ or subjugation in prices and standards, leading to inadequate quality control, compliance and regulation across a large part of the market and a reduction in public safety. It is very frustrating when other specialisms go from strength to strength by communicating with each other and by respecting each other's knowledge. The absence of such a collective voice and positive collaboration in the aesthetics industry is an unfortunate characteristic of the sector at this particular time.
The problem with marketing and advertising
Part of the reduction in standards also relates to poor and misleading advertising. In the JCCP's view, ‘marketing communications must be prepared with a sense of responsibility to consumers and society.’ Yet, irresponsible, and misleading advertising is commonplace. For example, the JCCP has witnessed a number of cosmetic training company marketing advertisements that have been published in industry publications and online from a number of (unregistered) training providers who have made unjustifiable claims about their courses being accredited or their qualifications being recognised. Many appear to be aimed at attracting fee-paying students from among prospective or existing practitioners, some of whom have either no background in the sector or whom possess inappropriate or lower level qualifications. The unfounded promise is that the advertiser can ‘qualify’ them to deliver highly profitable procedures by attending a 1-week course when this could not possibly be achievable within the CPSA standards. The JCCP has also discovered that inflated and misleading statements of the provider's educational status are being used by some training providers to reinforce the academic validity of their courses (for example, it is currently popular to add ‘Uni’ or ‘Academy’ to the provider's name), as are exaggerated claims for the authenticity and currency of accredited certificates issued.
With its focus on public protection, the JCCP believes that all workers in this industry should be committed to the responsible advertising of aesthetic products and services, which do not mislead customers as to informed choice, consent, risk, benefits and expected outcomes. Therefore, the JCCP believes that it should advocate responsible advertising by all providers operating in the sector. The JCCP works with the Advertising Standards Authority (ASA) to promote responsible advertising.
Following recent cases, the ASA has issued warnings to a number of advertisers about the misleading advertising of aesthetic procedures. A queue of further inaccurate and misleading advertisements published by some training organisations is also awaiting consideration with the ASA. One common thread that has been identified is that some trainers do not themselves have the correct qualifications to train members of the public or to assess the level/standard of knowledge and practice competence to enable a trainee to practise competently and safely. This represents a further example of the lack of professionalism and public protection.
The JCCP and the Mental Health Foundation have also identified an array of examples where the misuse of social media has resulted in exaggerated and false claims being presented to the public with regard to the benefits, efficacy and outcomes of aesthetic treatments, some of which have resulted in psychological and emotional distress for consumers (in particular, younger people who have been adversely influenced by unethical social media posts and claims).
With specific reference to Facebook, Kevan Jones MP wrote to the ASA's Chief Executive Officer, Guy Parker. Following this, the ASA issued Enforcement Notice: Advertising Botox and other botulinum toxin injections. However, further work is required by the ASA, since such advertisements remain in the windows of many high street premises.
Advertising appropriate education and training is regarded to be essential if the public are to be protected. The JCCP has constructed 5 ‘domains’, which all JCCP-approved training providers must meet, each being required to produce supporting criteria against which they are assessed:
- Capacity to deliver high quality courses, relevant admission criteria and academic accreditation at the correct level
- Alignment with JCCP/CPSA standards and clarity of information provided to potential participants
- Quality of the course or programme delivery (is it a good learning experience? Does it develop knowledge, skills and values?)
- Quality of assessment for the course or programme (does it produce competent practitioners?)
- How evaluation of the course or programme occurs and how it is used to improve provision quality.
Appropriate premises
Where procedures risk infection, leading to collateral damage or harm to the patient, then infection control must be excellent. Effective infection control cannot be achieved without due regard to the premises' standards demanded by the JCCP, whether or not the clinic is subject to Care Quality Commission (CQC) inspection. For example, I have been shown garden sheds, kitchens and nail bars being used to treat patients with transdermal procedures, such as fillers. Subjecting members of the public to the inherent infection-related risks conveyed by the use of such premises is unprofessional, unsafe, dangerous and unacceptable.
As a Professional Standards Authority-accredited register, the JCCP has set and published the minimum standards it expects registered practitioners to achieve in respect of the premises from which they practise.