Royal College of Surgeons’ Guidelines for Consideration

The Royal College of Surgeons of England (RCS); an organisation committed to enabling surgeons to achieve and maintain the highest standards of surgical practice and patient care has published what it calls ‘landmark’ professional standards for cosmetic practice, and not just for surgeons either.

Ahead of the well-anticipated Department of Health (government) cosmetic intervention review being undertaken by Sir Bruce Keogh, which is due to publish its findings in March, the RCS has chosen to publish a 44-page document entitled Professional Standards for Cosmetic Practice aimed at all doctors, dentists and nurses involved in cosmetic practice. The comprehensive report focuses on the behaviour and competencies medical professionals should be expected to demonstrate when providing cosmetic procedures; it maintains that all cosmetic procedures, surgical or non, should be performed by those with medical training only. Various standards, as summarised below, were developed by the Cosmetic Surgical Practice Working Group made up of key professionals including surgeons, psychiatrists, psychologists and dermatologists. 

Professor Norman Williams, President of the Royal College of Surgeons, said:

“While the Colleges and professional organisations involved in cosmetic practice are neither regulators nor legislators, the profession has a responsibility to provide standards to which we would expect our members to work. We have serious concerns that not all those who offer cosmetic procedures are adequately qualified, or that patients are getting accurate information prior to treatment. We hope these standards will feed into the ongoing review of the industry led by the NHS Medical Director, Sir Bruce Keogh, and improve quality of care for patients going forward.”

The working group cites 2010’s National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report On the face of it, which revealed a lack of consistent professional standards in cosmetic surgical practice, as the impetus for these standards.

Mr Ian Martin, NCEPOD Clinical Co-ordinator, said:

"In 2008 we identified poor regulation, low volume practice, and deficiencies in training. We also identified poor standards of consent and unrealistic advertisements which had tended to stress the benefits of surgery without dealing sufficiently with potential side effects. The lack of standards and systematic audit was also highlighted. We are very pleased to note that the Department of Health and Royal College of Surgeons are now taking steps to address these deficiencies in cosmetic surgical practice and support the report published today."

In the main, the standards or guidelines amount to a recommendation that only surgeons should provide cosmetic surgery, i.e. only those who have qualified as a medical doctors and undertaken post-graduate surgical training should carry out invasive procedures such as breast surgery or liposuction; and only licensed doctors, registered dentists and registered nurses who have undertaken appropriate training should provide non-surgical cosmetic treatments such as lasers and cosmetic injectables (‘Botox’ and dermal fillers). Currently, certain cosmetic treatments can be administered by anyone, anywhere with no medical training. They also highlight that all cosmetic procedures should be carried out on licensed premises with resuscitation equipment readily available in the event of an emergency. The concept of ‘Botox parties’ or ‘filler parties’ are entirely at odds with these standards they note.

BAAPS President and advisor to ConsultingRoom.com, Consultant Plastic Surgeon Mr Rajiv Grover noted;

“The regulation of which practitioner can carry out which procedure needs clarification: EU law has some bearing on this and direction is due from a Europe-wide CEN committee in which the UK and BAAPS has representation.”

According to a survey of clinicians including surgeons, doctors and nurses carried out by the Clinical Cosmetic & Reconstructive Expo, ahead of the event taking place at London’s Olympia this October, three in five practitioners have come across beauty therapists performing these procedures (cosmetic injectables), one in five have seen hairdressers doing so, and one in ten have witnessed members of the public offering them. A staggering majority (85%) believe that current systems for regulation, such as the Government-backed voluntary register TreatmentsYouCanTrust, do not protect patients from unscrupulous practices.

The RCS guidelines also state that as standard practice, practitioners should discuss relevant psychological issues (including any psychiatric history, eating disorders etc.) with the patient to establish the nature of their body image concerns and their reasons for seeking treatment. They should not at any point imply that treatment will improve a patient’s psychological wellbeing. They note that practitioners have a duty to manage a patient’s expectations of how they will feel after treatment. They should not imply that patients will feel ‘better’ or ‘look nicer’, and should instead use unambiguous language like ‘bigger’ or ‘smaller’ to describe what that patient is trying to change. All practitioners should consider whether they should refer a patient to a clinical psychologist before proceeding with further consultations or treatments.

The standards also lay out the professional duty practitioners have to their patients, including the need to ensure they have a clear understanding of the risks of the procedure, outlining consequent aftercare and being transparent about costs from the outset.

Finally, they touch on the promotion of cosmetic procedures and state that financial inducements or deals such as time-limited offers and discounts should be banned. The standards also outline the importance of having a cooling off period between the initial consultation and treatment – giving at least two weeks for invasive surgical procedures to allow patients to reflect on their decision.

Mr Steve Cannon, Chairman of the Cosmetic Surgical Practice Working Group and RCS council member, said:

“As the majority of cosmetic procedures are not available on the NHS, we must ensure that commercial interests do not compromise patient safety. With the demand for cosmetic surgery and non-surgical treatments rising year on year, it is crucial that the highest level of professionalism is maintained amongst practitioners.”

The British Association of Aesthetic Plastic Surgeons, based at the Royal College of Surgeons has welcomed the publication of the Professional Standards for Cosmetic Practice report but would like requirements to go further than the document states, particularly in regards to patient consultations and advertising.

Mr Rajiv Grover noted;

“At the BAAPS we welcome the Royal College of Surgeons’ appreciation of the urgent need for stricter controls in the cosmetic sector. This report is a step in the right direction and its content will have fed into the call for evidence of Sir Bruce Keogh’s review. At the heart of a proper patient consultation lies fully informed consent; conveying the elements of medical and psychological assessment, treatment options, providing a realistic idea of likely outcome and possible risks is essential. For consent to really qualify as “informed consent” however, the BAAPS would go a stage further than this report and unambiguously specify that the consultations must only ever be with the surgeon who will actually carry out the procedure.”

Rajiv stresses that protecting the public is nothing more than ‘Hippocratic’, and argues that advertising does not contribute to patient safety. He said;

“The protection of the public at large is nothing more than the duty of the medical profession: to adhere to the Hippocratic Oath which states first do no harm. The marketing and advertising of cosmetic procedures is neither educating nor informing, but an exercise squarely aimed at achieving sales. This clearly puts economics ahead of patient care. Although the RCS report suggests tighter control of marketing in this area with a ban on such strategies as time-limited offers, again at the BAAPS we feel there is a need to go even further - the only way to fully protect the public is to have an outright ban on advertising, as seen in some European countries and which is also applicable to prescription medicines.”

The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), which represents Plastic Surgeons on behalf of the Royal College, is a member of the Cosmetic Surgical Practice Working Party.

Tim Goodacre, Head of Professional Standards at BAPRAS and a leading consultant plastic surgeon, said:

“We welcome the report and hope it will start to address our concerns over inconsistent professional standards within cosmetic surgical practice. The report provides a good overview of existing standards which, if rigorously enforced, would help protect patients from unscrupulous practitioners.

We now need to focus on the creation of a robust mechanism for reporting surgical outcomes, both good and bad, in order to trace the ‘how, where and why’ surgeries go wrong and who is responsible. We would also like to see a more rigorous training path mandated for all those carrying out cosmetic surgery procedures and a mechanism of evaluating credentials for surgeons visiting from overseas, to ensure the highest standards of patient safety and care.

Professionalism and patient safety are our foremost concerns and BAPRAS is at the forefront of driving the highest standards of cosmetic surgical practice. We look forward to the publication of Sir Bruce Keogh’s cosmetic surgery report, which we have also been closely involved in developing, to provide guidance on ensuring a gold standard in plastic surgery safety and care, including developing training, ongoing education, standard-setting and research into better practice.”

No one can deny that the cosmetic surgery and medical aesthetic industry is in for some serious changes this year. In the last decade, various published reports and recommendations have come and gone, from reports by the then Healthcare Commission to the more recent NCEPOD analysis, all of which have failed to leave any lasting legacy; yet the quantity and quality of input and evidence received by the government from the public, practitioners and representative bodies, along with the levels of anticipation for Sheriff Keogh’s hard-hitting clean up strategy for our Wild West Aesthetic Industry is unprecedented. The entire aesthetic and cosmetic sectors are in for a considerable upheaval as we all seek to establish a long-term strategy for better regulation of the industry, improved medical practice and greater protection of the public at large from rogue practitioners, rogue practices and rogue products.

I think I’m looking forward to the day the recommendations are published more than anything else this year, including my birthday and Christmas; that’s how important they’re likely to be for us all.