JCCP Governance and the Practitioner Register Committee

First may we wish all of our Registrants and partners a most enjoyable Christmas and Festive Season. This has been a particularly busy period for the JCCP as we continue to prepare for the anticipated DHSC licensing scheme. We are indebted to you all for your continued support for the Council at this time as we progress together to realise the key objectives and systems required to enhance patient safety and public protection.

 

Update on Licensing in England

There have been many speculative comments regarding the new license and in this newsletter, we outline our updated perception on what to expect.

The DHSC completed its first consultation exercise on the 28th October, 2023 and received in excess of 11,800 responses, making this the second largest response to a DHSC consultation. As a reminder the Health and Care Act introduces a new licensing system for all practitioners who provide a range of more invasive non-surgical cosmetic procedures such as the injection of toxins and fillers that prohibits any individual in England from carrying out specified cosmetic procedures unless they have a personal licence.  It also prohibits any person from using or permitting the use of premises in England “for the carrying out of specified cosmetic procedures” unless they have a premises licence (Section 180 of the Health and Care Act, 2022). Before making regulations under this section, the Secretary of State must consult such persons as the Secretary of State considers appropriate.

The JCCP has continued to work apace to ensure that the Government should now action as a priority:

1. The design and implementation of a national licensing scheme for all premises where licenced procedures are conducted as well as practitioners of non-surgical cosmetic procedures to ensure that all those who practise invasive procedures are competent and safe for members of the public (as proposed in Paragraph/Clause 180 of the Health and Care Act, 2022).

2. A requirement for all practitioners to hold adequate medical insurance in order to provide non-surgical cosmetic procedures.

3. The development of official guidance on the training and qualification expectations for all practitioners, including knowledge and application of infection controls and first aid training.

4. The need to put an end to remote prescribing (including prohibiting the harmful practice of permitting prescribers to prescribe to third party practitioners without first ensuring that a face-to-face consultation has taken place between the prescriber and the patient). The need to put an end to the harmful practice of remote prescribing in all its forms when applied to the aesthetics sector, whilst ensuring also that only legitimate products are obtained from authorised sources.

5. The development of a system for the effective recording of adverse incidents and public awareness raising to ensure that all cases that go wrong can be tracked and improvements to safety made as a result. Members of the public need better tools and knowledge in order to protect themselves’.

 The JCCP has long campaigned for the enforcement of a mandated minimum standard to be met in regard to the education and training of practitioners who perform non-surgical cosmetic procedures. We believe this is essential to ensure patient safety, and thus should be a central pillar of a future licensing regime. The JCCP has already started work to review the Council’s JCCP/CPSA 2018 Competency Framework and is delighted to advise that our initial gap analysis of the framework provides us with confidence that it remains fit for purpose (albeit that a number of updates and additions will be required as new procedures etc. are identified by the DHSC for inclusion in the scope of the proposed license). The JCCP has also formed a new task and finish group to  consider ways in which appropriately trained and experienced practitioners will be able to demonstrate their compliance with the yet to be determined Government standards (Education, Training and Practical Competence). This group will also make proposals relating to routes to qualification, alternative routes to demonstrate compliance with the new DHSC industry standards (when they are produced) and to propose a series of ‘principles and recommendations’ for the Government to consider going forward.

This work is being transacted in accordance with the Government’s decision that ‘those who offer non-surgical cosmetic procedures to the public should be suitably trained and qualified’. The Government has also advised that ‘We recognise there is a need for nationally recognised standards covering the education, training and qualifications required for the administration of non-surgical cosmetic procedures. The Joint Council of Cosmetic Practitioners (JCCP) has already developed a competency framework covering high-risk non-surgical cosmetic procedures and there are a limited number of bodies currently able to offer training courses on non-surgical cosmetic procedures. This includes universities, colleges and private training companies. There are also a range of Ofqual-approved qualifications that are delivered by recognised Ofqual awarding bodies. We will work with the JCCP and other relevant stakeholders to consider whether further education and training requirements are necessary’, (2023). The JCCP looks forward to contributing to this agenda discussion.

 

The JCCP’s Response to the DHSC Licensing of Non-Surgical Cosmetic Procedures First Consultation Paper DHSC Consultation – October 2023

The JCCP response to the DHSC consultation paper congratulated the Government for taking this first key step to enforce statutory regulation of the non-surgical aesthetics sector in England but advised of the need to extend the principles enshrined within the new scheme to the devolved nations in Scotland, Wales and Northern Ireland. We also emphasised the need for new regulatory regime to identify and put in place a national mandated standard for education and training for all aesthetic practitioners who perform invasive procedures as a condition of practice and should protect members of the public by requiring all practitioners to evidence possession of adequate medical insurance and indemnity, complaints procedures, fitness to practice compliance and the provision of consumer access to redress and compensation schemes. The importance of ensuring that all licensed practitioners operate from appropriately licenced hygienic and safe premises is also considered by the JCCP to be essential. The JCCP also reiterated that in their opinion all aesthetic practitioners should provide evidence of full compliance with all standards that are proposed in the future to underpin a national system of licensing for the aesthetics industry. For this to be achieved dialogue will need to take place between the MHRA, the CQC, Local Government Licensing Authorities, the Professional Standards Authority, Professional Associations, Professional Statutory Regulatory Bodies, The Institute of Licensing,  Trading Standards Authorities, the Health and Safety Executive and the Chartered Institute of Environmental Health to ensure that there is no compromise to patient and public safety.

The JCCP’s response also advised that all aesthetic procedures that are considered to be invasive, complex or present with a higher risk of complications should be restricted and limited exclusively to qualified and regulated healthcare professionals. Furthermore, the JCCP urged the DHSC to put in place a robust and stringent scheme of regulatory enforcement that is supported by a legislative framework that mandates all practitioners to comply with nationally endorsed and implemented education and training standards, fit and proper person ‘tests’, robust insurance set at appropriate levels for medical indemnity, complaints procedures and access to redress schemes and compliance with the need to work from safe, hygienic and health-protected premises.

We advised that members of the public require additional assurance to confirm that registered healthcare professionals will meet the new standards set down by DHSC within the context of the new practitioner license, whilst also recognising their right to autonomy and clinical decision-making without supervision (unless they do not possess a prescribing qualification and use prescription only medicines as part of their aesthetic practice). We consider that is therefore essential that registered healthcare professionals who do not hold a nationally recognised and mandated prescribing qualification should also require supervision from a prescriber when prescription only medicines form part of the patient’s treatment plan or where they may otherwise become necessary to treat complications. This will require further determination and consideration. The JCCP also calls upon the DHSC to set out proposals and parameters to define whom they regard to be a suitable and responsible ‘professional health care practitioner’. We consider this to be a fundamental requirement since there are many healthcare professional groups that are regulated by professional statutory regulatory bodies whom we do not regard to possess the requisite competence, experience and knowledge to perform nonsurgical cosmetic procedures or to provide supervision of oversight to non-professional healthcare practitioners.

The JCCP also strongly advised agreement with proposals to seek significant changes to CQC  regulations to include restricted high-risk non-surgical cosmetic procedures within the scope of the CQC's registration system. We have advised that the DHSC should engage as soon as possible to determine the extent to which any proposed scheme of regulation that encompasses the more invasive and complex procedures can be enforced by the CQC in the absence of a significant change in the current scope of regulatory enforcement practice. The JCCP’s response was predicated on the need for the DHSC to introduce robust powers of enforcement to ensure that non-healthcare practitioners are not permitted to administer any restrictive procedure that falls within the scope and definition of the ‘RED’ category as proposed within their consultation document. In order to achieve these objectives, the JCCP considers that the CQC will also need to expand its definition of the ‘Treatment of Disease, Disorder or Injury’ (TDDI) to provide scope for the inclusion of a range of aesthetic procedures that are either ‘medical’ or  ‘medically related’ in respect of their description/definition and the use of medicines in accordance with the terms of their licenses.

The JCCP confirmed its support for the Government’s proposals to introduce a ‘Red’, ‘Amber’ and ‘Green’ risk stratified system. We stated that any risk stratified system of classification should be predicated upon a measured, and proportionate approach, regarding the extent to which the designated aesthetic procedure presents a risk to the emotional, psychological, and/or physical health and well-being of the individual. We also advised that the JCCP does not support the imposition of unnecessary or disproportionate oversight measures where procedures are considered to be controlled or mitigated by other means, such as by the manufacture and utilisation of ‘failsafe devices’, many of which are used within the cosmetics sector, as opposed to the aesthetics industry.

Central to our response was our advice that the Government should undertake to ensure that all procedures that involve the use of a prescription only medicine that is part of the actual procedural application, as an adjunctive requirement, such as the use of Lidocaine or Adrenaline, or any procedure that could involve the use of a prescription only medicine to manage an urgent complication arising from an aesthetic procedure should be supervised by a professionally, regulated prescriber who is present on site when the procedure itself is conducted. Should this not be agreed then we advised that any such procedure should be moved to the Government’s proposed ‘Red’ category in the interests of public protection and patient safety.

We also advised the Government that was considered it necessary to define what is meant by ‘supervision’ and ‘oversight’, and also to determine who could be considered to be an appropriate supervisor for specific procedures. We stated that the concept of supervision would need to be determined in accordance with a risk assessment undertaken for each of the procedures that are determined to be included under the ‘AMBER’ category, on a procedure - by - procedure basis. The JCCP considers that a proportionate approach to the definition of supervision should be taken on the basis of risk to members of the public related to the level of complexity, invasiveness and the potential for complication that the procedure itself might present or where there is consistent evidence of abuse of or lack of compliance with current regulations. The definition of supervision and oversight also needs to unequivocally determine where supervision should be provided on site, under the ‘line of sight’, remotely by telephone contact, or by some other means (e.g., peer or team supervision).

The JCCP also advised the Government of that a number of procedures that are currently included in the three categories require further examination and evidence to confirm which category they should ultimately reside within. We refer specifically, for example to procedures, relating to lasers and light, chemical peels, and those procedures that rely on the use of devices, many of which have been produced with self-limiting controls to mitigate potential harm. This is a highly complex area that will require further consideration. We recommend therefore that further enquiries (regarding scope, parameters and operating principles) are undertaken in the areas of, for example, lasers and light, radiofrequency and electrocautery with the aim of determining which category they should fall within prior to agreeing their final allocation within the three tier system.   We also advised of our significant concerns regarding the use of the generalised term ‘Dermal Fillers’ which we consider must only be administered at the very least under the direct supervision of an appropriately trained and experienced health care profession prescriber (with some procedures being restricted within the ‘Red’ category under CQC oversight). We regard there to be significant and varied issues with regard to the manufacture, supply and administration of such devices.

We also related that that there will be an increasing number of procedures that will enter the market over the next few years, which would need to be included within the concept and principles of the practitioner license, and as such ‘future proofing’ will be essential. Therefore, whilst at this stage it is important to list specific procedures by name, it will also be important to ensure that the adoption of this approach does not restrict the opportunity to add additional procedures as they emerge in the future.

Whilst not being a prescribed requirement within this consultation document we advised that all practitioners should be encouraged to undertake and engage in peer review and ongoing CPD and where possible to join online ‘communities of good practice’ to remove some of the challenges associated with isolated practice in the industry, and to encourage openness, transparency, and the reporting of potential complications etc. We also advised that all laser-related procedures should be reviewed prior to attribution to any category by a Laser Protection Advisor. We considered that the adoption of this additional protective measure would lead to uniform compliance with nationally approved standards in alignment with current special treatment licenses.

Unsurprisingly the JCCP reasserted its view that all licensed procedures should only be provided in designated premises that have been inspected for the purposes of the license and from premises that comply with the requirements of the procedures offered (and where the practitioner is available to provide emergency aftercare if complications arise). We also stated that the JCCP does not support mobile working whereby practitioners attend client’s own homes for the purposes of administering cosmetic procedures.

Finally, we advised that the JCCP fully supported the Government’s recommendation to implementing a minimum age requirement of 18 years for all of the procedures to be included in new licensing scheme EXCEPT when they are performed by medical practitioners or by another healthcare professional on the instruction of a medical practitioner as is currently the case under the Botulinum Toxin and Cosmetic Fillers (Children) Act 2021 s1(4).

 

Supervision Task and Finish Group

The need to further define what is meant by ‘supervision’ and ‘oversight’ is regarded to be a very important issue that warrants detailed analysis and consideration. For this purpose, the JCCP’s Clinical Advisory Group (CAG) has formed a task and finish group to prepare a report on the various types of supervision/oversight that are required to ensure the safe and effective administration of Procedures that the Government determines for inclusion of the  ‘amber category’ as set out in their consultation paper (August, 2023). Our working hypothesis advised that any effective framework of supervision must achieve a number of objectives:

- It should recognise that public protection is its primary goal.

- It should be proportionate such that it facilitates access to appropriate procedures from appropriate practitioners.

- It should be flexible enough to permit the inclusion of new procedures and make allowance for the varying needs of customers and the practitioners performing them. However, it should not be so flexible as to be open to undue interpretation or abuse.

- It should encourage transparency.

- It should define accountability.

- It should be enforceable. 

CPD Partnership Arrangements

The JCCP has agreed to commission a task and finish group to consider how best to make proposals to oversee and ‘accredit’ CPD activities delivered by various and diverse training providers i.e., those who are supplying CPD activities for practitioners. This would also make recommendations to ensure that CPD requirements for practitioners are met and vetted through a rigorous (yet to be determined) audit process. The JCCP has agreed to work with the national CPD Standards Office to co-produce a report based on the following objectives:

- To determine and ensure a consistent understanding of professional standards for continuous learning

- To agree and promote a clear definition of what constitutes ‘good CPD’ and appropriate learning activities.

- To identify the minimum standards of CPD provision and practice.

- To ensure the standards remain relevant and are updated in line with industry changes.

- To make proposals for ongoing quality assurance of approved CPD activities.

- New Education and Training Providers

 The JCCP continues to expand the number of Education and Training providers who have been admitted to their Register of Approved Education and Training Providers. The following organisation has recently been added to the JCCP’s Register of Approved Providers:

The University of Manchester PGDip/MSc in Skin Aeging and Medical Aesthetics (Botulinum Toxins and Dermal Filler procedures).

 

Advertising and Marketing Issues – Our Work with the Advertising Standards Authority

 The JCCP continues to witness a significant increase in the number of exaggerated, untruthful and false advertisements that are posted on social media. We are also continuing to see gross misrepresentation of the benefits of treatment, understatement of the risks and exaggerated and false claims relating to the provision of education and training.

We therefore work very closely with the Advertising Standards Authority and are contributing to the Government’s ‘Online Safety Bill’ to seek to reduce the number of inaccurate, exaggerated and potentially harmful advertisements on social media postings regarding nonsurgical cosmetic procedures and the posting of advertisements that offer education and training to practitioners that do not meet the standards required to equip practitioners with the educational knowledge and competencies to enable to practise safely and proficiently.

The ASA continues to respond on a weekly basis to multiple complaints raised by the JCCP by publishing many new rulings that will affect both registered healthcare practitioners working in aesthetic practice and lay practitioners. All practitioners need to be aware of the rulings relating to the publication and advertising of medicines and devices, such as botulinum toxin and dermal fillers. One significant ruling received from the ASA (following a complaint raised by the JCCP against an education and training provider in November, 2023) advised that ‘While we acknowledged that CPD training was a widely recognised form of ongoing professional development and training, we understood that there was a distinct difference between a CPD certificate and a recognised qualification. We understood that CPD training sat outside of the qualifications framework and could not offer recognised qualifications, such as a National Vocational Qualification. Because prospective students would have understood from the ad that they would be “FULLY QUALIFIED” after completing the course, when in fact the course was designed as an introduction to the topic, and further training and experience would be expected to be completed in order to work independently, and because the ad made reference to achieving a qualification, when in fact students would receive a CPD certificate, and not a recognised qualification, we concluded that it was likely to mislead. On that point, the ad breached CAP Code (Edition 12) rules 3.1, 3.3 (Misleading advertising) and 3.7 (Substantiation)’.

A further ASA ruling related to the promotion of cosmetic surgical procedures in Türkiye. The ASA advised that advertisements were identified for investigation. Two of our trustees, Dawn Knight and Sally Taber, the JCCP’s lead person’s for complaints, made a major contribution to the ASA investigation. The JCCP has logged at least 25 deaths as a result of cosmetic tourism to Türkiye. The ASA considered that references to “inner beauty” and “permanent beauty” together with the advertisement’s images implied that having a body that did not conform to prevailing beauty standards of slimness was a source of concern that could be rectified by surgery.  The ASA considered the advertisements  ‘exploited people’s insecurities and perpetuated pressure for them to conform to body image stereotypes and therefore concluded that it was socially irresponsible’. The ASA also considered that while the ‘purpose of the advertisements was to promote cosmetic surgery abroad the tone, including the wording and visuals, focused on the travel, and it was likely to detract from the seriousness of the surgery offered’. The Committee of Advertising Practice (CAP) Guidance on cosmetic interventions stated  that marketers should not imply that invasive surgery was a “minor procedure”, and ads should not mislead as to the likely commitment required for pre-consultation, surgery, recovery and post-operative assessments. It was also reported that that the ‘surgery being promoted would take place abroad which raises the potential for additional risks, such as whether the doctors and treatment providers would have the same standards of care and safety as in the UK.  It also raises the question of how any arrangements for follow-up care and dealing with any complications which arose would be managed’. The ASA said it considered the advertisements ‘could be interpreted as suggesting that surgery was a decision that could be undertaken lightly as part of a holiday, without serious consideration of the nature of the intervention and therefore concluded that the overall presentation of the advertising materials  was likely to be seen as trivialising cosmetic surgery’.

 

Adverse Incident Reporting

The JCCP continues to advise all practitioners of their duty to raise concerns where they believe that patient/ public safety or care is being compromised by the practice of colleagues or the systems, policies and procedures in the organisations in which they work. They must also encourage and support a culture where staff can openly and safely raise concerns. By far the easiest way to report an adverse event is via the Yellow Card app, which is available to download from Google Play for Android or the Apple Store for iPhone. Reports can also be filed via the Yellow Card website (https://yellowcard. mhra.gov.uk). ACE Group World encourages members to report adverse events or incidents by completing a form in the members’ section of the website (https://uk.acegroup.online/report-a- complication) or via the app for iPhone users. ACE Group World   reports

to the MHRA on behalf of members. The JCCP is also working with the MHRA and ACE Group World to support the design and implementation of nationally agreed process for the reporting and analysis of complications and adverse incidents. The JCCP has also introduced a new on lines complaints portal to assist in this process (helpfully assisted by Dr. Steven Land and Emma Stock). The JCCP has previously issued guidance to support all practitioners in determining their requirement to report an adverse incident or ‘near miss’. This guidance can be found on the JCCP website.

The JCCP also reminds practitioners of their requirement to hold an appropriate level of medical indemnity insurance to provide a proper redress scheme for service users.

 

Practitioner Register Matters

We remind colleagues  that JCCP has decided to continue to offer free membership to those persons who are insured with Hamilton Fraser for a further period of two years. All registered healthcare practitioners who have ‘Professional Indemnity Insurance’  with Hamilton Fraser will be offered the opportunity to ‘opt in’ join the JCCP Practitioner Register (subject to an agreed set of additional criteria). As such free membership of the JCCP will continue to be offered to Hamilton Fraser registrants at the point of their annual renewal.

We also take the opportunity to remind you that we have amended our annual cycle of renewal of practitioner registration to a bi-annual cycle. We introduced this change from the 1st of June 2023. A few weeks prior to the anniversary of your initial joining date, a member of our Registry team will email you to seek confirmation that you remain compliant with the following conditions:

- Appropriate insurance in place

- You continue to self-declare against the JCCP’s statement (see below)

- You have a complaints policy in place.

- You currently have no professional fitness to practice matters pending or outstanding.

Every two years, we will ask you to provide us with additional confirmatory evidence to re-validate your membership of the JCCP. These requirements will not be any different to our current procedures. A copy of the JCCP’s updated ‘Terms and Conditions of Registration’ document that relates to the Practitioner Register may be accessed here. This document has been updated to reflect our move to a two-year renewal process and includes a new section on Registrant appeals.

These changes reflect our commitment to make more use of professional self-declaration as part of our risk-based approach to accessing and remaining on the register. It also represents a move towards a closer alignment with, and the avoidance of duplication of, the requirements of the professional statutory regulators.. Many of you will be familiar that such procedures and processes are deployed by professional statutory regulators, such as the GMC, GDC, NMC, HCPC and GPhC etc. A copy of the JCCP’s updated Registrant Self-Declaration requirements may be accessed here.

We also advise you that we have been requested by the Professional Standards Authority to obtain data from each registrant regarding Equality, Diversity and Inclusivity (EDI). This request has been asked of all PSA Accredited Registers. As such, we will be approaching you at the date of your registration renewal with a request to complete a simple EDI questionnaire, which we trust you will complete and return by the requested date.

 

Additionally, a PDF version is available for download by clicking here.

 

 

Professor David Sines PhD CBE                                                                  Andrew Rankin

JCCP Executive Chair and Registrar           Chair JCCP Practitioner Register Committee       

 

6th December 2023