Scottish regulation

Further regulation won’t cut it unless it tackles who is performing treatments, say aesthetic doctors in Scotland

In July, the Scottish Government announced plans to further regulate nonsurgical cosmetic procedures in a bid to protect the public. The pledge came after a public consultation showed overwhelming support (98%) for further regulation, with most saying that they felt that non-surgical cosmetic procedures should be conducted by trained, qualified and regulated healthcare professionals.

Although 61% of consultation respondents agreed that individuals who are not qualified healthcare professionals should be licensed, many felt that licensing under the Civic Government (Scotland) Act 1982 would not be sufficient and that more thorough regulation and oversight were necessary.

“Unless the license is policed and training with a recognised body is required, a license will not improve standards,” said one respondent.

But surgeons and doctors operating in this part of the UK say that nonmedics shouldn’t be able to perform treatments at all and that, unless further regulation focuses on tackling the influx of unregulated non-healthcare professionals coming into the market, it’s a waste of time.

“Medical healthcare professionals don’t need any further regulation,” says Dr Simon Ravichandran, founder and director of Clinetix Rejuvenation and the Association of Scottish Aesthetic Practitioners (ASAP), Dr Simon Ravichandran.

“The problem with any regulatory framework is it just creates a pathway that legitimises any particular process for undertaking the practice of aesthetic medicine,” he adds, stating that aesthetics should be a legislated practice rather than a who are not healthcare professionals to be able to do this is insane.

We need to have strict codes around who can and can’t perform these procedures. It’s fairly clear that to carry out medical procedures, you’ve got to have medical training.”

BOTCHED BUREAUCRACY

In Scotland, all registered healthcare practitioners, doctors, dentists, and nurses are required to be regulated and registered with Health Improvement Scotland (HIS) before they can undertake any cosmetic procedures in a clinic environment, explains Dr Taimur Shoaib, a consultant plastic surgeon and the clinical director of La Belle Forme Clinics, which operate in the UK and Scotland.

This system came about following the 2013 Keogh Review, which highlighted the lack of regulation and potential risk of harm from non-surgical cosmetic procedures.

In 2015 an expert interventions group was set up, and from 2016, independent clinics run by certain healthcare professionals were brought within the regulation of HIS.

However, there is no regulation on who can perform injectables in locations such as aesthetic clinics, beauty salons and hairdressers.

“At first, it was largely perceived as beneficial, as it would regulate a service that was open to being performed without high standards and the patient experience at its heart,” explains Shoaib.

“Instead, however, it created a perverse situation, whereby the people who should be the most regulated – hairdressers, beauticians, nail techs and tattoo artists – are the ones who are unregulated,” he said.

“The government didn’t consider enough ‘what if’ scenarios when putting the law into place”

“HIS only regulates healthcare professionals,” says Ravichandran. “So, anyone who is a beauty therapist can do whatever they want.”

This means that Scotland is currently in a situation where a tattoo artist can inject Botox, while Shoaib, a surgeon, would need a license to do a tattoo.

“Even though I’m a surgeon who pierces the skin all the time and am trained in reconstructive tattooing for areola pigmentation after breast cancer, I can’t perform that,” he says. “And rightly so, because I’m not licensed to do it.”

Shoaib states that this convoluted regulatory situation is a direct result of the Scottish Government laying down a law that requires the regulation of healthcare professionals, rather than the procedures and products.

He affirms that HIS is not to blame for the botched bureaucracy - the Scottish Government passed the law, and HIS were tasked to be the regulator of that law.

“The government didn’t consider enough ‘what if’ scenarios when putting the law into place,” he says. “What if hairdressers started doing this? What if all the doctors resigned and started doing this?”

HIS oversight of doctors, dentists and nurses practicing non-invasive aesthetic procedures will continue, but new proposals to allow other allied healthcare professionals to perform them and no new outlines to regulate and reign in non-HCP are ruffling feathers.

PROTECTING PATIENT SAFETY

The main reason survey respondents called for increased regulation was to reduce the risk of physical and psychological harm to the public - aestheticmed.co.uk Aesthetic Medicine 15 particularly the risk of errors that could cause burns, skin necrosis, blindness, or cross-contamination of blood-borne viruses.

Seeing as non-doctors do not have the years of training, skills and experience that the average doctor has, Shoaib argues that they would not have the contacts or links to senior doctors or surgeons who could help when a complication or adverse event occurs.

Plus, every dermal filler complication requires a prescription, which only a doctor, dentist or prescribing nurse is allowed to provide.

“It’s simply not possible for those who are unregulated to manage a complication”

“It’s simply not possible for those who are unregulated to manage a complication,” he says.

This was also a prevailing view of the public consultation respondents, with some saying they believed the NHS was “unfairly bearing the burden of cost for treating these injuries.”

Some respondents also had concerns about the psychological impact of nonsurgical procedures and the need for a high standard of ethical practice.

“There were concerns that in an unregulated sector, the public was at risk of exploitation or negligence due to a lack of professional standards, oversight and accountability”, the Government outlined in the consultation’s final report.

“We have already seen permanent complications from filler and laser treatments performed by unregulated lay people. When there is a complication the patient suffers, they don’t know what to do.

“The Scottish Government has to apply new regulations and laws to prevent further damage and reassure the people of Scotland that, if there are any potential complications, they will be looked after”, says Shoaib.

WHO AND WHAT SHOULD BE REGULATED?

In response to the findings, the Scottish Government said, “It is clear from the consultation responses that there is strong public support for further regulation of non-surgical cosmetic procedures that pierce or penetrate the skin.

The responses also show support for pharmacists who provide independent services to be regulated by HIS in the same way as other health professionals.”

HIS, which currently regulates independent clinics run by certain healthcare professionals, indicated that it would not favour further regulation allowing individuals other than healthcare professionals to perform non-surgical cosmetic procedures.

However, the regulatory body did recommend that their oversight should also be extended to pharmacy professionals. 267 individuals responded to the question of whether pharmacists should be regulated by HIS to do aesthetic treatments in the same way as other healthcare professionals.

Around half of the respondents (of those agreeing and disagreeing with the statement) felt that pharmacists should not be able to offer these procedures with the view that they did not have the required knowledge or clinical skills to do them or manage complications.

Several of the consultation respondents also noted that all products used for non-surgical cosmetic procedures should be categorised as prescription-only medicines and so would be subject to more rigorous regulation.

They felt that to ensure high standards and safety for the public, the products used, as well as the practice of the procedures, should be regulated. Shoaib says that he believes that anything that pierces the skin should be regulated.

“Tattooing and piercing are regulated. But in aesthetics, there is a gap where people can perform cosmetic injectable treatments without having any regulation whatsoever,” adding that further regulation will change the face of the industry.

“People need to know that they are going to be much safer in receiving these treatments.”

The people have spoken, but now it is up to the Scottish Government to take on the public’s recommendations and bolster the regulation around non-surgical treatments. We will be watching closely as the pledge proceeds.