Dr Vikram Swaminathan 
Dr Jalpesh Patel
The non-surgical cosmetic injectable sector has shown tremendous growth over the past decade; however, the lack of regulation has opened this market to practitioners with a variety of backgrounds and training, ranging from highly qualified consultants in dermatology to newly trained beauty therapists. With procedures that involve a number of risks, some of which being potentially catastrophic, it was invariable that the spectrum of practitioners providing these treatments and the training they had received would eventually be scrutinised.
With stricter regulations in sight and improving education standards, the future of the aesthetic sector looks bright
In 2013, Keogh released a report, published by the Department of Health and Social Care, detailing the concerns regarding the regulatory landscape, where it was felt that ‘a person having a non-surgical cosmetic intervention has no more protection and redress than someone buying a ballpoint pen or a toothbrush’ (Keogh, 2013). Subsequently, Health Education England (HEE) were mandated by the Department of Health and Social Care to work with professional statutory regulators, royal colleges and other stakeholders to review the qualifications required for non-surgical cosmetic interventions and the qualifications required to be responsible prescribers and to make recommendations on accreditation of qualifications and course delivery (HEE, 2015b). This led to the publication of Part one: qualification requirements for delivery of cosmetic procedures: non-surgical cosmetic interventions and hair restoration surgery and Part two: report on implementation of qualification requirements for cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery (HEE, 2015a; HEE, 2015b).
» There is momentum towards tighter regulation and registration of competencies within the industry and the JCCP register is just one example of this «
These two documents provided advice on what was consensually deemed the necessary training requirements for practitioners who wanted to provide non-surgical cosmetic interventions. These core training requirements have led to the development of postgraduate level training qualifications.
Current landscape
The inception of the Joint Council of Cosmetic Practitioners (JCCP) and Cosmetic Practice Standards Authority (CPSA) was brought about to continue this work completed by HEE and the various stakeholders, with a clear role to tighten up regulation in this industry. The CPSA set standards for those who wishes to perform non-surgical cosmetic treatments and those that meet and abide by these high standards have the opportunity to join the JCCP practitioners register. Additionally, the JCCP have a register for education and training providers by quality assuring centres providing postgraduate level programmes (Level 7) in cosmetic injectables, in which the students are expected to demonstrate competency via summative assessments and in line with what was recommended by HEE. This ensures that there is rigour to standard of training provided and that a benchmark has been set for students who want to perform cosmetic injectables before they start practicing independently.
Experienced practitioners are able to show evidenced competency at assessment centres to avoid the process of completing a postgraduate qualification in entirety. Overall, this approach can help to reduce the risk profile of practitioners who wish to or are already providing cosmetic injectable treatments, plus also give patients a public platform to confirm their practitioners' competencies, rather than just seeing a foundation or advanced certification.
Training options: basic
Over the last 3–4 years, there has been an explosion of Level 7 training providers offering training for various healthcare professionals, including doctors, dentists, nurses and pharmacists, as well as other practitioners. As a potential postgraduate learner, it is important to fully explore the available market options and decide which training programme or course you are looking for. Currently, it is not a legal requirement for a practitioner to hold a Level 7 qualification or equivalent to perform aesthetic treatments independently in the UK, and not all courses are accredited by colleges or national registers such as the JCCP. As a simple guide, there are a few things that can be checked when enquiring with training providers.
Managing the quality of the qualification and the awarding body
Qualifications may be awarded through a higher institution such as a university or through an awarding body, such as industry qualifications (IQ). This will reflect on the award received upon completion (MSc, postgraduate diploma, postgraduate certificate, Level 7).
Practical exposure on the qualification
Some qualifications are theory heavy, so, if looking for more practical experience, bear that in mind. Most private sector Level 7 qualifications follow a set model where learners will be exposed to a minimum set number of clinical cases.
Considering the quality of trainers on a qualification and if there is a preference to experience a variety of trainers or be allocated a set mentor is also important.
Time spent to complete the qualification
Depending on the qualification, this usually varies from 1 to 3 years.
Ratio of trainers/teachers to learners
Some qualifications pride themselves on their learner to trainer ratio. Industry standards can vary from one-to-one mentoring through to 10 to one or more for lecture-based learning. It is also dependent on the institutions awarding requirements.
Someone's personal learning style might lean towards smaller group sessions, so it is important to find out what is on offer from the various providers. For example, RASA Academy offers a maximum learner to trainer ratio of 3:1.
Besides the core requirements, are there any additional USPs to the qualification?
Some qualifications will offer a dedicated mentor or tutor to provide guidance and support throughout enrolment.
Other providers may have opportunities to gain further skills through affiliated training experiences, which may be exclusive to their learners only.
Access to webinars and online content varies between providers. For those who are time-poor during the day, a more online-focused qualification may be most suitable.
Lastly, some qualifications may also have a specialty focus, such as dermatology, device-based treatments or injectables.
With Level 7 training providers on the rise and attracting nurses, doctors and dentists, it is important to research and enquire with providers
Qualification approval by an industry regulator such as the JCCP
Most qualifications are either approved through an awarding body or higher institution. Some are also approved by a regulatory organisation, which means that the qualification would be recognised by the regulatory body as meeting their standards of education and training.
Treatment modalities and interventions
Core training usually offers competencies in botulinum toxin and dermal fillers. However, there is variability in learning objectives between course providers.
At a basic level, upper face botulinum toxin interventions and nasolabial, lip and marionette dermal filler treatments tend to be taught. Some providers will offer variations on this core curriculum to include other dermal filler interventions at core level.
A broad range of theory and techniques may be explored but clinical experiences can be restricted to certain interventions.
Application process
Most private providers offer an open enrolment or qualification registration process. Universities and some private providers will have set cohort enrolment periods and may even include and application and interview process.
Practitioner groups able to enrol
In the UK, healthcare practitioners from a variety of backgrounds are able to undertake aesthetic medicine training and achieve core competencies. This includes doctors, dentists, nurses and pharmacists. There is variance with who qualification providers can enroll. This is often decided by their awarding body or institutional faculty.
Some may wish to enrol with a qualification more tailored or supportive towards their profession; often, the curriculum and training experiences will be more suited to the individual's professional background and prior education.
Further training: advanced
Beyond core competencies, there remains no clear president for a practitioner wishing to develop their competencies or learn new skills. Currently, a variety of private sector organisations offer further training, often termed advanced days or masterclasses. Additionally, pharmaceutical organisations will offer their key customers continuing professional development (CPD) activities and further training opportunities, ranging from workshops through to conference days. To access these, practitioners are encouraged to make contact with their local product representatives and see what further learning opportunities may be available. Beyond this, there are opportunities to keep up-to-date and explore new products at the conferences.
Generally, the private providers offer CPD-based short courses, usually 1–2 days, where a practitioner can enrol to experience or learn aesthetic new interventions and skills. It seems a little strange that someone could potentially complete core training, such as a foundation day, and immediately go onto an advanced course the next day. In reality, some thought needs to be applied to this concept, as it can potentially be misleading to patients as they may perceive their practitioner to be at an advanced level by course certificate but may not have developed any suitable competencies or experience yet.
Online learning packages and suites are growing in number and accessibility. Practitioners, product manufacturers and distributors have developed online learning platforms, often with a variety of tutorial and video-based content. For the time-conscious practitioner, these open up alternative options to further training without the need to attend a course or event.
Future landscape
There is momentum towards tighter regulation and registration of competencies within the industry and the JCCP register is just one example of this. It is known that organisations such as the British Association of Cosmetic Nurses (BACN) and British College of Aesthetic Medicine (BCAM) are moving towards stratification of members with an assessment process. Full membership may only be achieved upon successful completion of these assessments. This could separate practitioners into groups based on competencies, more in line with what would be seen within other healthcare specialties.
The General Medical Council (GMC) have started a phased introduction of credentialing for doctors working within certain discrete specialty areas of practice that are unregulated and may carry significant patient safety risks, to formally recognise expertise in this specific area of practice (GMC, 2019). One of the first areas included in the phased introduction is cosmetic surgery. As this approach is tested and develops, it may be that aesthetic medicine becomes a credentialled speciality for certain healthcare professionals to register under and be recognised as experts by their regulatory body.
Standard setting and regulatory processes are not only just for the practitioner, but also relevant to trainers and educators within the industry. Most private education providers are required to show their aesthetic trainers understand core teaching, education and assessment theory and can evidence their competencies in this. Often, this involves the completion of a Level 3 award. For 1-day courses and other CPD-style educational activities, this does not necessarily apply. Organisations are looking to improve the standard of educators and assessors within the industry and have recently launched a voluntary registration of educators within the sector as the first phase (www.bsaea.co.uk).
Aesthetic medicine continues to grow as a speciality. As more practitioners enter the field, it is important to understand the training opportunities, potential future needs and regulatory requirements to continue as a practitioner within this specialty to futureproof your practice.