In June this year BACN and PIAPA issued a joint statement criticising voluntary registration bodies such as Save Face. Regulation is a hot topic that many in the industry feel passionately about, and the statement sparked a debate about whether private voluntary registers are helping to push up standards and accountability, or misleading patients and creating a two-tier system. A social media frenzy ensued, leading Save Face to defend itself on Twitter, stating: “It is sad that supposedly credible practitioners are going out of their way to publicly reject a fit for purpose model of self regulation.” We asked two leading practitioners for their personal opinions to try to make sense of the arguments.
“We firmly believe that no nurse, doctor or dentist should feel the need to join a fee-charging voluntary registration body...”
The British Association of Cosmetic Nurses (BACN) and Private Independent Aesthetic Practices Association (PIAPA) would like to clarify how we address instances of patient dissatisfaction where treatment is provided by a member of a professional body who is registered with a governing council and how this differs from the process adopted by a ‘voluntary registration body’.
A number of voluntary registers are in operation in the aesthetics sector operated by private companies, the most recent example being Save Face. These bodies do not have the power to accredit any individual or company with regard to medical competence – this is the role of the governing councils such as the General Medical Council (GMC), Nursing and Midwifery Council (NMC) and General Dental Council (GDC).
It is our official position that a practitioner is accredited to practice by their relative governing council and medical insurers. We firmly believe that no nurse, doctor or dentist should feel the need to join a fee-charging voluntary registration body to reassure the general public as to their professional competence.
Medical professionals have worked hard to acquire their qualifications and understand their obligations to do no harm unto their patients. It is solely the role of the respecting governing bodies to determine fitness to practise and the duty of individuals to highlight when a fellow colleague is failing in their levels of care.
Under new guidelines both the NMC and GMC have introduced measures to address practice within their various disciplines and those who have chosen to work independently. This includes producing evidence of CPD and training, checks and reflections with a fellow medical practitioner in your specific field and proof of professional indemnity insurance. The BACN and PIAPA have both participated in the recent NMC Revalidation Pilot established to develop procedures for revalidating the medical skills of nurses.
Both the BACN and PIAPA will continue to support members in their choice to act freely and responsibly within the realms of regulation and good practice. We both support additional checks being made with regard to non-medical practice issues such as the quality and standards operated with regard to clinics or premises where treatments are taking place. However, having a ‘kite mark’ in this area in no way gives a guarantee with regard to the treatments being provided, this can only come from the governing medical councils.
Any voluntary register that is offering guarantees of professional practice beyond a premises check could not sustain this position if challenged by a patient. Any complaint would always find its way back to the governing councils. The voluntary registers therefore cannot offer any kind of guarantee of patient safety or access to a process for complaints without the approval of the governing councils.
Aesthetics is an independent and ever-evolving area of medicine and it is our individual and collective duty to pro-actively encourage the public to seek information from the official medical registers and empower them with the confidence to ask the right questions over qualifications, training and indemnity. The BACN and PIAPA will continue to work with the Government, governing councils and other professional associations to deliver new forms of accreditation that the public can see and that will give them reassurance about who is carrying out their treatment.
BACN / PIAPA joint statement. Yvonne Senior, PIAPA Chair and Sharon Bennett, BACN Chair.
“If we wish to instil confidence that we practise to the high and consistent standards expected by the public, then we must accept the need to be more accountable”
Having considered the recent statement dismissing the value of voluntary registers I wonder if an important opportunity to improve the credibility and safety of aesthetic medicine is being missed.
Whilst I don’t disagree that the regulatory bodies NMC, GDC and GMC have the ultimate sanctioning power when it comes to regulating their members, I believe that the statement which seeks to discredit voluntary registers shows a fundamental lack of understanding as to the intentions of such voluntary registers.
There is a problematic level of ignorance amongst the general public about how to select a practitioner to provide aesthetic treatments. Practitioners should have a detailed understanding of the relevant anatomy and the product that they are injecting and be able to comprehensively evaluate a patient’s previous medical history and their suitability for treatment. The practitioner should also be able to evaluate the patient’s psychological suitability and expectations from treatment, as well as knowing how to manage any complications.
Patients often do not appreciate the importance of the essential training required to develop this level of knowledge and experience and that they would be unwise to pick their practitioner purely based on price. In my opinion, patients should consider whether the practitioner is competent to take care of them, can provide a comprehensive consultation and can advise appropriately on possible treatments, providing enough information (including the risks and downtime / possible side-effects) to enable them to make an informed choice.
Although the regulatory bodies recommend that patients “check out” their practitioner, they don’t advise on what, where or how this can effectively be done. Voluntary registers such as Save Face provide an easy and accessible resource for obtaining information regarding treatments and suitable practitioners (who have been assessed regarding their training, qualifications and use of appropriate products and protocols in appropriate premises), but also to provide an avenue when looking for help and support if there is a problem.
If there is a problem which raises the issue of professional competence or negligence, these organisations can advise on how the patient can address this, recommending a referral to the appropriate governing body if required. An often overlooked implication of being on voluntary registers is the implicit obligation of the registered practitioner to behave professionally and ethically, with the risk of being referred to the governing body if there are concerns about their practice.
I believe that there is an inherent problem if all practitioners do not work together with a common aim of raising standards within aesthetic medicine. Surely it would be better for all these organisations (BACN, BCAM, PIAPA, Save Face, TYCT) to focus on delivering a consistent message to patients about checking out their practitioner and the value in being fully informed.
The culture of petty bickering that currently exists between all of these organisations is confusing for the general public, with the focus being more on who should be regulating the industry rather than who should be providing the treatment. This also alienates the very practitioners that would benefit more from joining forces in signing up to these organisations, standing behind the shared aims and values. This leaves the door open for all the aesthetic cowboys who would never engage with any of these regulatory bodies and can therefore woo the ignorant public with the promise of a ‘bargain treatment’.
Ultimately, if we in aesthetic medicine wish to be taken seriously by our colleagues in different professions, and if we wish to instil confidence that we practise to the high and consistent standards expected by the public, then we must accept the need to be more accountable. Details regarding our qualifications and experience must be more transparent, with less spin and gloss from clever marketing. We must put patients before profit. A very important element of this, in my view, would entail accepting a more consistent and generalised approach to monitoring our skills and competencies; surely voluntary registers are an appropriate step in this direction?
Dr Sam Robson, Medical Director, Temple Medical, Aberdeen, UK.
Dr Robson is on the Advisory Board for Save Face but is writing here from a personal perspective.
“Voluntary registers will drive a two-tier system where rogue practitioners can continue unhindered”
In the UK, the cosmetic interventions industry now exceeds three billion GBP, with the non-surgical sector outstripping surgical interventions by an overwhelming margin. Accounting for an estimated nine out of every 10 interventions performed.
However, the sector is highly fragmented with inadequate regulatory frameworks, leaving patients and the public at risk of poor and unsafe care. Procedures are performed by virtually anyone and the sector has been likened to a “data free” zone – deficiencies highlighted by Sir Bruce Keogh.
Although the Keogh Review noted examples of excellent practice, it specifically called for a mandatory Register of Practitioners for all of those who engage in non-surgical cosmetic practice in order to achieve consistent standards of good care. Conversely, it took a highly critical view on the alternative voluntary system, with potential for development of a two-tier system where rogue practitioners could continue with poor standards practising ‘under the radar’.
Voluntary registers such as Save Face would lead to a system where conscientious practitioners would join and thus be subject to regulation. However, unethical practitioners would not ‘volunteer’ for entry and continue to practice in an unregulated fashion. All doctors are heavily regulated by the GMC and currently further guidelines are being developed for doctors who engage in cosmetic practise. There is concern that the most highly trained individuals will be subject to the most stringent regulation, whereas those non-clinicians who do not have any professional regulatory body can continue to practice and engage in identical practice, but remain completely unregulated.
A mandatory register would ensure a minimum standard of practice without exception for the diverse cohorts of practitioner ranging from beautician to consultant plastic surgeon.
Non-surgical cosmetic procedures such as botulinum toxin and dermal filler injections, chemical peels, and laser and other device-based systems, were pioneered primarily by dermatologists for the treatment of disease. Over the years, the applications have expanded into the cosmetic arena. It is easy to understand that with any medical procedure associated risks exist, however small. One must be mindful that the change in application from medical to ‘cosmetic’ does not necessarily mitigate the inherent risks of the procedure itself, and will be compounded by inconsistent standards of training and professionalism. Further levels of complexity must also be noted, due to potential psychological issues at play in the ‘cosmetic’ patient.
A survey carried out by the British Association of Dermatologists cited its members had genuine concern about missed diagnoses such as skin cancer, and inappropriate treatment of skin disease, with ‘cosmetic’ treatments carried out by a range of practitioners in the private sector. In addition, the risk of chronic, permanent and debilitating adverse events were highlighted, with dermal filler injections and laser / light-based treatments of most concern.
The non-surgical cosmetic sector will continue to push boundaries with the development of new procedures and technologies. Growth of this industry is welcomed, but development of proportionate regulatory frameworks are required to safeguard patients and the public. The diverse range of practitioners, and the blurring of boundaries between ‘cosmetic’ and disease, only compound the complexity of such regulation. Voluntary registers will drive a two-tier system where rogue practitioners can continue unhindered. A mandatory register of practitioners is the best option to ensure a consistent minimum standard of care in this highly diverse and disjointed sector.
Dr Tamara Griffiths, Consultant Dermatologist and
past President, British Cosmetic Dermatology Group.
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