Regulating cosmetic surgeryBMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7348.1229 (Published 25 May 2002) Cite this as: BMJ 2002;324:1229
Members of the public would be better protected if they consulted their general practitioners first
- Clive Orton (), president
Cosmetic surgery has become a growth industry and a public obsession. The demand for the top three procedures in the United States grew by 26% between 1999 and 2000, and this growth is mirrored in the United Kingdom.1 The public perception of cosmetic surgery is that it is quick and easy. In fact most cosmetic surgery operations are extremely complex and require a high degree of anatomical knowledge and surgical skill as well as aesthetic appreciation.
The public's increasing interest is accompanied by a reduction in the provision of cosmetic surgery in the NHS, so that patients look to the private sector, financing their treatment through bank loans and finance agreements. 2 3 These patients have been prey to organisations that offer discounts, privacy, and no waiting time but are not staffed by accredited surgeons.
Many patients do not seek a referral from their general practitioner because they fear an unsympathetic response or they feel that cosmetic surgery is not fundamentally medical. Self referral to a clinic is an easier option.
Standards in cosmetic clinics vary, but the clinics often send a representative to the home of the patient in response to a reply to an advertisement. These representatives are not medically qualified but recommend operations and book dates for surgery, often offering discounts if the patient signs immediately. Starved of food before having general anaesthesia and having paid the fee, the patient briefly meets the surgeon before the operation.
New government regulations insist on preoperative consultations by the surgeon and ban surgery within two weeks of consultation.4 The regulations also insist that clinics are inspected regularly and that written information is realistic.
The training of junior surgeons in cosmetic surgery is proving an extremely contentious issue since less training is now provided in the NHS than ever before and in any case many cosmetic procedures were never performed under the NHS. Cosmetic surgery therefore remains the only branch of surgery in which surgeons will start to undertake procedures on the basis of having assisted at such procedures but for which they have no hands-on training. Training programmes must include hands-on supervised training in the private sector, organised at low cost for informed patients.
The main area of controversy in the United Kingdom is about who shall be regarded as qualified to carry out cosmetic operations. Traditionally, almost all cosmetic surgery was performed by plastic surgeons, although specialists in otorhinolaryngology, oromaxillofacial surgery, oculoplastic surgery, and dermatology now teach and include cosmetic procedures in their training syllabus.
These specialties are currently working together in a joint working party of the Royal College of Surgeons of England to provide coordinated advice on training; there is no provision for a separate specialist advisory committee in cosmetic surgery, which could otherwise have provided an ideal solution. Unfortunately the royal colleges do not have a mechanism to assess the standards of unaccredited cosmetic surgeons who are currently practising.
The advice of the profession to the department of health is unanimous—that training and continuing medical education are as important in aesthetic surgery as in other branches of surgery and that doctors qualified to carry out cosmetic surgery must be accredited in the appropriate specialty, have equivalence of training, or have an equivalent European qualification. Many surgeons working in private practice and in cosmetic clinics would not meet these criteria. A two year moratorium was therefore proposed to enable the clinics to organise appropriate training for their surgeons. The suggestion that surgeons already practising cosmetic surgery should be allowed to continue was strongly opposed by the profession as it would permit surgeons who are unqualified to remain in practice possibly for decades. Despite these representations the Department of Health has now brought forward muted proposals, which demand only that surgeons be medically qualified and have attended some postgraduate courses.
The national commission monitoring standards of care intends to control the worst excesses of the cosmetic clinics and to ensure that there is an even standard of care across the private sector, whether treatment is provided by consultant surgeons or in clinics. Surgeons whose operations regularly result in dissatisfied patients complaints, and complications will hopefully be excluded from practice. With the proposed regulations, however, this will probably not happen until considerable harm will have been done to too many patients. The public would be better protected if people consulted their general practitioners first, but it is likely that the number of self referrals will increase rather than decrease. Public education through the professional bodies is important, but in the face of increased public demand, glossy advertising, and inadequate regulation only the most sanguine optimist can believe that the situation has been controlled adequately.