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  1. Introduction

Non-surgical aesthetic treatment is one of the fastest growing healthcare sectors within the UK, with the industry estimated to be worth £3bn per year by the end of 2022. The range of treatments available include Botox, dermal fillers, hair restoration, skin peels, tattoo removal, skin lightening and permanent makeup.

Surprisingly, the England and Wales are the only country in the world to have an unregulated aesthetics industry. Whilst 20/20health would like to stress that there are many excellent practitioners who provide quality patient care, there are deep concerns over the level of patient care from less scrupulous practitioners.

Patients are often enticed into undergoing treatments having been promised unrealistic goals, often with cheaper (and, in some cases, fake) products, impacting upon the patient’s health and wellbeing. There is currently no formalised system of redress for patients who have suffered from negligence.

There are severe concerns that members of the public are jeopardising their health in what remains an unregulated blackhole.

  • The Problem

England and Wales’s non-surgical aesthetic industry is currently unregulated. There are no mandatory requirements requiring practitioners to join a representative/regulatory organisation, no standardised training requirement, little knowledge amongst practitioners of the level of insurance required, no obligation to practise in licensed premises, no ethical standards in advertising and no supervision of the quality of product which can be used.

  • Advertising and Marketing

The first problem with an unregulated aesthetic industry concerns advertising and marketing. Aesthetic practitioners can advertise their services with little regulatory oversight. The marketing tool of choice is social media, where advertising algorithms can target specific social groups with relative ease.

There is disquiet that this regulatory loophole has allowed less scrupulous practitioners to specifically target the vulnerable. Celebrities, role-models, influencers and trend-setters must bear their share of responsibility. The recent obsession with attaining the perfect body and the “body beautiful” has negatively impacted the mental health of the vulnerable, as they often attempt to achieve the impossible.

There have been numerous examples of dishonest aesthetic practitioners targeting vulnerable people, promising unrealistic and unattainable cosmetic results cheaply, with poor quality product, sometimes paying for treatment they can ill-afford.

In some situations, the treatment is inappropriate and not required. No thought is sometimes given to underlying client vulnerability and mental health issues, such as Body Dysmorphic Disorder.

Even the less vulnerable, with no mental health issues, are sometimes unaware that they are making ill-informed decisions to the detriment of their mental and physical health.

Simply put, there are potentially thousands of people every year who could be enticed into undergoing treatment which, at best, is unnecessary, and at worse, could have catastrophic consequences for their health.

  • Training and Qualifications

It would no doubt come to a surprise to many patients that there is a current lack of any regulated, standardised training requirement for anyone wishing to administer non-surgical aesthetics and no official accreditation of training providers.

Currently, there is no need for a practitioner to demonstrate any medical knowledge, nor do they need to show any medical qualifications before administering non-surgical aesthetics.

20/20health would like to stress that whilst there are many excellent practitioners with many years of clinical experience, it is inevitable that such a deregulated area within the health sector can encourage the less honest to practise what can be very financially rewarding.

Course providers do exist, many of whom provide excellent tuition. However, even this area of aesthetic medicine is unregulated, with no mandatory independent accreditation and no supervision from a relevant regulatory authority. Little is therefore known about the standard of tuition provided and the legitimacy of the qualification provided.

Apart from placing the patient in immediate risk, it has been known for insurance policies to become null and void for even honest practitioners, when details of their training was disclosed in the event of a claim, thereby restricting one avenue of redress for the patient.

Even the most honest of professionals are sometimes unwittingly caught in this trap.

Proper training goes beyond the immediate provision of treatment; it concerns proper knowledge of the products, appraising which treatment is suitable to use in each situation and the appropriate aftercare once treatment has been provided.

Aesthetic treatments can be hazardous (some are by prescription only), and infection, temporary paralysis and other side effects can occur, even to the most honest and experienced of aesthetic providers.

The wellbeing of the patient may be placed in danger is the aesthetic provider fails to identify and know how to resolve complications as they arise.

In short, there are too many providers of qualifications, too little scrutiny of the provisions provided, no register of official accredited providers and no policing of the standard of training provided.

The impact this can have on the patient can be profound, both at the time of treatment and in the subsequent hours, but also if redress becomes necessary.

  • No Mandatory National Directory of Aesthetic Practitioners

There is currently no legal obligation for a national directory of practitioners administering aesthetic medicine in England and Wales. It is impossible to know who is practising non-surgical aesthetics medicine, nor what treatments they are administering, nor where they are practising.

That practitioners do not need licensed premises further compounds this issue.

At present, practitioners are advised to join a regulatory body, who have their own directory of members. But membership of these groups is voluntary only and is by no means mandatory, and even honest practitioners can be put-off by the membership fee and perceived lack of benefit. Whilst these voluntary organisations often have their own training criteria prospective members must meet, such criteria is often not known to the public.

A regulated directory would force all practitioners to meet the appropriate level of training, demonstrate suitable insurance cover, undergo annual CPD and provide them with the mechanisms to stay up to date with the recent industry developments. Stringent membership criteria will discourage the dishonest practitioners from seeking membership, making it harder for them to practise.

This goes to the heart of informed choice. The public would be encouraged to seek treatment from regulatory approved practitioners, discouraged from using unscrupulous practitioners, who in turn would find it harder and harder to practise.

An official directory, endorsed by statutory instrument, would enhance consumer choice confidence in their treatment.

No other form of medical care is so relaxed, and this can only put patients at risk whilst stopping many of them from making informed decisions.

  • No Directory of Treatments

There is also no directory of the treatments used for non-surgical aesthetics, with much the same problems highlighted in Section 2.3. above.

One additional issue caused by the unregulated aesthetic industry is the concern over whether due diligence and appropriate testing are conducted as new aesthetic treatments are developed. Many within the industry are apprehensive that the safety of patients could be compromised as unsafe treatments could be used.

With such little knowledge of what treatment is being used and by whom, it is unsurprising there have been cases of patients being treated with fake or substandard treatment.

The lack of informed choice detailed in Sections 2.1. and 2.3. above, means that some patients decide to be treated by practitioners who will use treatments inappropriate to the patient’s cosmetic needs.

An additional concern over this lack of regulatory framework is what happens in the event of any complications following treatment. All non-surgical cosmetic procedures are accompanied by a real risk of infections and other side-effects, often needing additional medical attention.

A lack of directory puts patients at risk, as medical staff not privy to the original non-cosmetic procedure would lack the knowledge of what treatments were used and may therefore be unsure as to how to proceed with remedial medical care.

Such delays could cause long-term harm, both physical and mental, to the patient.

A directory of approved non-cosmetic treatments, published to all NHS primary care trusts in England and Wales is required. It should be a legal requirement, after each procedure, for aesthetics patients to be handed information concerning the treatment administered, much like a prescription. This can be served onto any subsequent medical staff in the event of any complication.

  • Lack of Redress

The issues mentioned in the above Sections can result in an additional serious outcome for the patient; a lack of redress for the patient in the event of complications.

A lack of a regulatory organisation denies patients with a complaint with the process in which to seek remedy. Patients with genuine concerns are often forced to seek remedy within civil law, and in extreme cases, through law enforcement.

In 2018, a bogus doctor was imprisoned for four years for Grievous Bodily Harm by administering two women with fake Botox.

Such a state of affairs is inappropriate for the present day.

A regulatory body, membership of which is mandatory, with a process of redress, will go far in assuring the public and protecting genuine practitioners.

  • The Government Response

The government published its study into the aesthetics industry in January 2016, the result of which was the formation of the Joint Council for Cosmetic Practitioners (the JCCP), a voluntary register of aesthetic practitioners in the UK.

The JCCP’s register is divided into two; Register 1 is a list of approved education, training and accreditation providers. Register 2 is a list of practitioners who have met the standard of Register 1.

Since its formation, the JCCP had worked tirelessly to encourage all stakeholders to join one of the two voluntary Registers, as well as campaigning within healthcare for better governance and management of non-surgical aesthetics. Unfortunately, and despite its great work, the greatest weakness of the JCCP is that membership is voluntary.

To be truly effective, and to resolve the issues detailed in Section 2 above, all registers in this area of healthcare must be mandatory. It is inappropriate for an industry worth £3bn a year with potentially harmful side-effects for the public, for any register to be voluntary.

Due to successful lobbying from the JCCP and other relevant bodies (such as Save Face, the ACE Group and BCAM), the government announced in February 2022, an amendment to the Health and Care Act 2022. This amendment aims to adopt the JCCP’s ten-point plan (published 2021), as well as empowering the government to introduce a compulsory licensing scheme for practitioners in England. Consultations are currently taking place to determine how this will be implemented.

The decision will be introduced via secondary legislation.

The ten-point plan advises on the need for statutory regulation, mandatory training and continual professional development, prescribing of treatments, advertising regulations, patient after-care, insurance, premises and consumer awareness.

Much of the subsequent enforcement of the JCCP’s will be devolved onto local authorities, both as the licensing authorities but also as the managers of local enforcement officers, who will be charged with the supervision and policing of the new legislation.

  • Issues With the Government Proposals
  • Uncertainty

As was said in Section 3, at the time of writing (October 2022), the government is yet to decide how best to proceed. There is, therefore, the real possibility that any reform will remain voluntary rather than mandatory.

The current issues facing non-aesthetic treatment in this country could well remain. Furthermore, any such reform is not yet guaranteed, leaving consumers and genuine practitioners in the same problematic environment that they are currently in.

Until this uncertainty has been resolved, there is the real danger that the good work undertaken so far in this sector will be undone.

There is also the distinct possibility that despite any new regulations, unregistered practitioners will not be banned from practising. In short, very little could change.

  • Reliance Upon Local Authorities

As described in Section 3, much of the enforcement of the proposed changes will be devolved onto local authorities. At first thought, this appears to be sensible. Afterall, there be licensing applications for premises, which is already a local authority power.

It is also unrealistic to expect police forces to supervise the changes; police investigate once the suspicion of a crime is being, or has been, committed. It is not yet known if failure to abide by the new changes will become a criminal office.

Instead, the supervision and policing of any new criteria will pass to local enforcement officers, the civil enforcement team for each local authority in England.

Local Authorities have been placed under tremendous pressure since the Coalition Government of 2010. They have been required to provide ever greater services to their residents under ever tightening budgets.

The enforcement of any regulatory changes will be reliant upon the priorities and demands of each individual local authority. There is no guarantee that the enforcement of non-surgical aesthetics will be a priority for every local authority. In some areas of England, it may not be enforced at all.

The perception (however erroneous) of aesthetics being a luxury enjoyed by wealthy middle-aged individuals may remain. The attention of local authorities may be diverted into other areas (caused by budget constraints), areas considered to be more deserving of civil enforcement.

Furthermore, priorities of local authorities change, reflecting the political reality prevalent at the time. Enforcement of any regulatory changes may fluctuate depending upon the prevailing mood of the time.

There is the real possibility that the dangers currently facing the consumer will remain.

  • Public Awareness

The importance of public awareness has been a constant theme throughout this report and should remain an important consideration in all future statutory changes to the sector. Raising the public awareness into the dangers of unscrupulous practitioners is an important facet to the JCCP’s ten-point plan and should be welcomed.

However, there remains the real possibility that unregistered and unscrupulous practitioners will remain practising. Not only is it impossible to know of their existence, unfortunately, if they do not currently register voluntarily, then it is doubtful if they would do so if required mandatorily.

Simply put, it is not in their business interests to do so.

JCCP places great emphasis on working in partnership with social media companies. Whilst this is a worthy ambition to have, recent parliamentary committee interaction with the largest companies has demonstrated the futility of attempting to work with them. There is a distinct possibility that the issues (and the subsequent dangers to the public) explained in Section 2.1. will continue regardless of what legislation or regulatory instrument is introduced.

The only difference being that such advertising may become a criminal offence; if, indeed, the perpetrator can be identified and brought to justice.

A more constructive approach would be to commission a public information campaign, to highlight the dangers referred to throughout this document and to improve consumer awareness of the choices they face. There is also a role for other healthcare professionals, as other forms of treatment (should as mental health for vulnerable individuals) maybe more appropriate than non-surgical aesthetics.

  • 20/20health Response: Protecting the Public and Genuine Practitioners

20/20health notes the excellent work that has been undertaken by the JCCP in recent years and supports the JCCP’s ongoing commitment to improving the regulatory blackhole which is the non-surgical aesthetic industry.

It is also important to acknowledge that there are many excellent aesthetic practitioners in England. Indeed, 20/20health would like to emphasise that the majority of practitioners in England are members of a regulatory body, are insured and would only treat patients when it is appropriate to do so, using genuine treatment.

Unfortunately, as this document has explained, even the most scrupulous of practitioners may find themselves an unwittingly victim from less scrupulous supplier or trainer.

As was explained in Section 4, whilst the proposals go some way in rectifying the problems, in some cases they do not go far enough and in others, have intrinsic weaknesses which could undermine the future viability of the potential reforms.

20/20health concludes that there are two groups who need protecting in any future reform; the consumer (for the reasons explained throughout the document) and the practitioner.

It is important to remember that the practitioner is a key component of the future of aesthetics, and it might be a reasonable belief that the current proposals forget that. Being members of a proper regulatory framework is to the benefit of genuine practitioners. There will be better training, better representation, valid insurance better public perception of the services provided. All of which are to the practitioner’s benefit. It is therefore in the interests of the entire industry to be a part of the reform.

There are two additional areas of the sector which need discussion. Firstly, the potential risks of remote consultations by prescribers issuing prescriptions for non-prescribers to administer. The JCCP has already highlighted this as a concern and we feel that the public are totally unaware of the importance of this aspect.

  • 20/20health’s Proposals

20/20health therefore proposes the following:

  • That a series of consultations be held, under the leadership and guidance of 20/20health, between all relevant stakeholders. This will include current representative bodies, campaign groups, practitioners, and manufacturers and suppliers.
  • That this group will formulate a strategy and proposals to rectifying any potential concerns of the regulatory proposals, thereby building on the work already undertaken by the JCCP. The focus of this new group shall be on protecting the public and also the genuine practitioner.
  • That this new group, under the leadership and guidance of 20/20health, lobbies the relevant policy makers, interested parliamentary groups and government officials to bring about proper change to the unregulated aesthetics sector.
  • That there is a review of the role of prescribers within the sector.

Invitations to stakeholders to join the consultation will be sent immediately.

Author: Michael Ilsemann, Consultant (20/20health)

Date: 18th October 2022

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