The distinction between medical and cosmetic is important because it determines how practitioners should align themselves with the relevant regulation
In the previous issue of the Journal of Aesthetic Nursing, I introduced the new Clinical Advisory Group (CAG), an independent group formed by the Joint Council of Cosmetic Practitioners (JCCP) to investigate and to make recommendations to the JCCP regarding matters that impact patient safety and professional practice in the cosmetic sector (Rankin, 2021). In that article, I discussed the safe and ethical supply of products in a changing regulatory environment. For this paper, I will highlight another project to which the CAG has dedicated its resources as an area of priority. Reviewing the fundamental nature of medical aesthetic treatments, with a view to defining their medical or cosmetic nature, has been a conceptual challenge. I hope to add some clarity to this work, addressing some possible areas of misunderstanding and highlighting areas for thought in reflective practice.
The medical model
The starting point is to appreciate that, in the wider context, regulated healthcare professionals provide their services with the highest standards of patient care and of competence. What some have described as the ‘medical model’ is the foundation of this idea, one that can naturally lead to the conclusion that, by practising according to these standards and within this model, the treatments that are provided are fundamentally medical.
The work of the CAG in no way serves to undermine this concept, but, rather, accepts it as a starting point and develops it objectively. There is then a second area of understanding that must lead medical practitioners to accept that, irrespective of resolute understanding of the medical nature of the procedures that are provided, the perspective of those who regulate practitioners is different. Therefore, a key objective of this work is to close this gap in understanding, which will involve acceptance through insight on the part of the regulators, but also, perhaps, some open-minded reflection on the part of professional practitioners.
The driver for this work has been the COVID-19 lockdown restrictions. Restricting practice through legislation, which determined that medical procedures were exempt from restriction, forced medical aesthetic practitioners to evaluate cosmetic practice in the light that the decision to open at that time could have had legal consequences. Through its continuing work with the Department of Health and Social Care (DHSC), the JCCP succeeded in beginning to narrow the gap in understanding, such that the advice received from the Government later in the pandemic began to change. However, even in these instances, its application varied considerably between local authorities, with some professional practices forced to close. Still, wherever the interests of a regulator and those of a cosmetic practitioner coincide, there remains a gap between what is intrinsically known as a practitioner and what is considered as acceptable evidence for regulators.
Differentiating the professionals from the non-professionals
To provide evidence, the first measure looked to is intent. From the assessment and diagnosis, the intended benefit of the treatment must be considered. Some intentions, such as ‘softening lines’, ‘lifting brows’ or ‘improving symmetry’ are, for the purposes of regulators, purely cosmetic, rather than medical. The distinction is important because it determines how practitioners should align themselves with the relevant regulation. Below are some possible examples from a regulator perspective, given the above intended outcomes:
- Care Quality Commission (CQC): not subject to registration
- Medicines and Healthcare products Regulatory Agency (MHRA): off-label prescribing for botulinum toxins
- Government: closure during COVID-19 restrictions
- HM Revenue and Customs (HMRC): subject to VAT.
Practitioners understand that the benefits to patients typically extend beyond the treatment of ‘lines and folds’. However, it is the progression from this sense of awareness of these wider benefits to one of objective, measurable determination that forms the basis of the practitioner's intention. Furthermore, in a sector that is compromised by low and varied standards of practice, it raises a bar to differentiate the professional clinician from the non-professional or amateur therapist.
These wider benefits may be physical or psychological, but, either way, it is key to determining whether a procedure is medical or cosmetic in nature that the practitioner investigates the problem further. Supported by recognised assessment tools, one can objectively determine both the impact of the presenting problem and the consequences of this impact. An inability to function in performing routine activities, for instance, might be an example of such consequences. If clearly and objectively specified, they will form the basis of determining a measurable outcome that is beyond that of a simple improvement in lines and folds.
From a regulator's perspective, evidence of this process of determination of a medically related intended benefit—initial assessment, diagnosis, treatment plan and outcomes assessment—will now likely lead to a different outcome:
- CQC: registration may or may not be required, depending on the initial assessment and diagnosis
- MHRA: prescribing within the terms of botulinum toxin licence
- Government: subject to further consideration of ‘need’ or urgency within a professional ethical framework, COVID-19 restrictions may not apply
- HMRC: no VAT applied.
It follows that, where a patient is unable to provide sufficient information to enable a medically related determination, a regulator would consider the procedure to be cosmetic, even when performed by a regulated healthcare professional within a professional framework, and it should be recorded as such.
Conclusion
This is a superficial overview of a challenging subject, and there is much else for the practitioner to consider. Furthermore, formally defining the situation, as the CAG has done, and distinguishing medical and cosmetic factors is new work requiring further review and development. As part of their reflection, practitioners should consider their competence in these areas to evidence the ability to diagnose in general terms and, more specifically, in relation to the psychological or other specific component. Reviewing the evidence-based assessment tools and the extent to which they serve the practitioner's needs is a matter requiring attention. Finally, when and how other experts are introduced to best serve the interests of patients in what can be complex situations is a matter of priority. The JCCP and CAG see this work as a contribution towards firmly positioning the cosmetic sector as a credible, robust professional discipline, with the evidence to support that position.