Training Standards: Interview With Professor David Sines

Vicky Eldridge
By Vicky Eldridge

Vicky Eldridge is an award-winning journalist, editor and copywriter, with 18 years’ experience in aesthetics.

Attempts to find a training provider in aesthetics can be a minefield, especially when it comes to injectables such as toxins and fillers. With so many courses out there and more springing up on a monthly basis, how do you ensure that the course you choose is being provided by an ethical training provider who is not also dabbling in practices such as remote prescribing, prescribing to non-medics or training un-regulated practitioners? 
As the damming front-page news last month about “black market botox” highlighted, the lack of regulation continues to put patients at risk in inadequately trained and unqualified hands. 
In the absence of any legal requirement for formalised training in the UK to be able to provide injectables, it can be hard to choose the right route. With courses ranging from fast-track weekenders to three-year degrees, finding a course that suits your requirements and provides the right amount of in-depth theoretical and practical hands-on training means many practitioners do not know where to start. 
In 2018, the Joint Council for Cosmetic Practitioners (JCCP) and the Cosmetic Practice Standards Authority (CPSA) published their Education & Training Standards and Competency Framework for Cosmetic Practice, which applies to the vocational, further education and higher education sectors. 
This framework builds on the previous Health Education England education and training standards framework that the Department of Health adopted in 2015. The JCCP is the current ‘custodian’ of these standards. But because these standards and frameworks are not legally enforceable, there is a “void within the aesthetics sector with regard to public protection and patient safety” (source: JCCP 10-point plan).  
Whether you are just starting out or are an experienced injector who wants to further their training or branch into more advanced or new indications, a career in aesthetics means you are always learning and reflecting on your experience. 
We sat down with Professor David Sines, CBE, Executive Chair and Registrar for the JCCP, to see where we are now regarding training standards, with a specific focus on botulinum toxin, and what the future holds. 
The interview 
Consulting Room: One of the biggest debates we see in aesthetics is around who should and shouldn’t be performing injectables. What is your take? 
David Sines: I think we should start by thinking about who are we talking about in terms of regulated healthcare professionals? So clearly, we have our appropriately trained doctors, nurses, dentists, prescribing pharmacists and designated allied health professionals. In our opinion these are those who can legitimately administer fillers and botulinum toxin injections safely and effectively.
Our allied health professionals such as physiotherapists, podiatrists, paramedics and operating department practitioners all complete regulated three-year undergraduate degree programmes that cover advanced anatomy and physiology and prepare these practitioners to inject safely. They are all regulated by one of the government-approved healthcare regulators – The Health Care Professions Council. 
Practitioners without PSRB (Professional Statutory Regulatory Body) registration will not be accepted onto the JCCP register to administer botulinum toxins and dermal fillers. These treatments involve significant risk and require a qualification at the postgraduate level (level 7), which is in the interest of patient safety. 
CR: Specifically, when it comes to botulinum toxin, what are the laws as people often get confused about who can legally prescribe or administer them? 
DS: Prescription-only medicines can only be prescribed by a prescriber. And a prescriber can only prescribe for a patient that they have assessed each individual person face-to-face. They can also prescribe for a third party, such as a beautician. Unfortunately, that is not illegal. But, and here’s the big but. In my opinion, they can only do that if they have seen the patient themselves, face-to-face, to assess them and assure themselves that they are satisfied that the actual person who’s undertaking the injection is competent and safe to administer the injectable toxin. In other words, they must check that the third party for whom they are prescribing the medicine is safe and can assume responsibility for any aftercare if a complication arises under the continuous oversight of the prescriber who prescribed the medicine in the first place. 
The JCCP has published guidelines relating to expected prescribing practice, which is a very straightforward paper. We have also produced and published another paper on what defines a “cosmetic” or ”medical/medically-related” treatment. The All-Party Parliamentary Group (APPG) has advised also that there should be a legal definition of what constitutes cosmetic treatments. Our aim when writing this paper has been to stimulate debate within the aesthetics sector of who should be legally entitled to provide specific invasive cosmetic procedures. 
CR: What about training? Where are we at now in terms of standards, and who can access it? 
DS: In its July 2021 report, the APPG said that there should be one national standard for education and training for high-risk and potentially harmful and invasive procedures, such as the injection of toxins, deep penetrative lasers, the administration of dermal fillers and the intravenous application of vitamins and ‘platelet rich’ plasma which we consider should only be administered by appropriately trained healthcare professionals.
Such training requirements should apply also to doctors, nurses, beauty therapists, anybody. So, we are advocating that it is not enough just to advise that I am a trained and regulated health care professional to confirm that the practitioner possesses the required knowledge and standard of proficiency to practise safely in the aesthetics sector. Rather, health care professionals should be required to demonstrate that they have acquired the same standard of education and training as anybody else who operates within the aesthetics sector. In other words, post-initial education and training should be at the Level 7 as defined by Health Education England and the JCCP.
The APPG agrees with the principle that there should be one national standard, which has yet to be confirmed, but which should build on the HEE, JCCP and CPSA non-surgical cosmetic practice, education and training frameworks, and also include any required National Occupational Standards. We consider the JCCP Education and Training Framework meets these requirements, but we acknowledge (and would welcome) further review and national consultation prior to the implementation of a national enforceable education and training standard for the aesthetic sector within the United Kingdom.
The JCCP’s standards for the recognition of approved education and training providers and qualifications divides the standards into five ‘domains’, each presented with defined criteria. 

The domains are:

  • Capacity to deliver high-quality courses, admission criteria & accreditation
  • Alignment with defined standards and clarity of information provided to potential participants 
  • Quality of the course or programme delivery
  • Quality of assessment for the course or programme 
  • How evaluation of the course or programme occurs and how it is used to improve provision quality 
To be formally approved by the JCCP, education and training providers submit information with supporting evidence to demonstrate how their course/programme meets the defined standards to enable participants to meet the core and modality-specific competencies for safe practice. An annual review is also undertaken of each approved education and training provider to evaluate whether their course/ programme provision still meets the required standards set by the JCCP.
CR: The goal, as we understand it, has always been statutory regulation, and you have made fresh calls for that in light of the recent Times investigation. Can you tell us more about that? 
DS: We have called for the Government to immediately introduce legislation to regulate the sector in the UK and have advised that those invasive procedures, such as the injection of toxins (and the other invasive treatments noted above), should only be administered by appropriately trained healthcare professionals. 
So, the key two questions are, will such a scheme of regulation become legally enforceable? And what will such a framework look like and what will be included within a new system of licensing or regulation? We believe that this is becoming increasingly likely that there will be a public consultation layer this year on those two questions. 
We believe that the treatments (that should fall within the scope of licensed/statutory regulation) would be anything above Level Five in our framework, augmented by a range of newer invasive treatments for which new standards will need to be set. We have already said we will present our JCCP/CPSA framework up for national consultation and would be very happy to revise it in partnership with a Government consultation exercise should be requested. 
Choose wisely
If you are seeking to train in toxins, do your research. The standards for training and education providers are available on the JCCP’s website, along with guidance for prescribing. 
Ask other professionals who you trust and who they have done their training with. If you are part of an association such as the British College of Aesthetic Medicine or the British Association of Cosmetic Nurses, you can always seek guidance from them. 
Ensure your training provider has the experience, knowledge and appropriate levels of training themselves to instruct you? Ask what is their background and expertise? Enquire also about the names, experience and qualifications of those who will be assessing and examining you. 
Where are they providing the training? Is it in an appropriate clinical environment? Are you treating your own model so you can see the outcomes of the treatments you provide during training? Is there patient follow-up and post-training support? Does the course cover advanced anatomy and physiology, as well as hands-on training? Are they using toxins approved for use in the UK – Botox, Azzalure (Dysport), Bocouture (Xeomin)? What about instruction in infection control and complications assessment and management?
How many other delegates will you be training with, and what is the ratio of trainers to delegates? If there are 100 of you in a room and one trainer, are you really going to be getting the right level of support? And finally, what do other people say about the course? Peer-to-peer reviews are invaluable. 
There are many good training providers out there offering botulinum toxin training. We have some listed on the following pages. A final word of advice, do not try and cut corners when it comes to your training. There may not currently be a legal requirement for you to demonstrate proficiency and competence in botulinum toxin treatments, but as PSRB-registered practitioners, you do always have an ethical and moral obligation to do no harm to your patients and the standards at which you train to are an integral part of that. 
Professional Health Care Statutory Regulatory Bodies and their Associated Professions that are Recognised as Being Eligible for Consideration to Join the JCCP: 
This article was written for the Consulting Room Magazine.
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