Cosmetic surgery: regulation required

The remit of NCEPOD does not just cover practice within the NHS but also within the independent sector. Cosmetic surgery is, perhaps, the most controversial area of independent practice and certainly one that is currently a major growth “industry”. It has become more available, socially acceptable and financially achievable for a wider cross-section of society. In 2008 the British Association of Aesthetic Plastic Surgeons (BAAPS) reported a 275% increase in breast augmentation operations since 2002.1 Cosmetic surgery differs in one major respect from other types of surgery in that it is mosly undertaken as a lifestyle choice as opposed to curing or ameliorating a disease. There is also a lack of a definition of cosmetic surgery which adds to the misinformation and confusion surrounding the practice. The term is often used interchangeably with “plastic surgery” or “aesthetic surgery”. This lack of definition stems, in part, from the fact that it is not an official surgical specialty in its own right, but involves practitioners of plastic surgery, oral and maxillofacial surgery, ENT, ophthalmology and dermatology among others. This lack of defined specialisation in the UK has implications for ensuring that surgical procedures are carried out by appropriately qualified surgeons. According to The Care Standards Act 2002, practitioners performing cosmetic surgical procedures in the independent sector must have undergone basic medical training and those registered after 2002 must be on the specialist register of the GMC. However, the lack of a cosmetic surgery specialty makes regulation difficult. According to the Care Standards Act, all independent clinics and hospitals that provide cosmetic surgery in England must be registered and inspected by the Care Quality Commission (CQC). In Wales they must register with the Healthcare Inspectorate of Wales (HIW) and in Northern Ireland, with the Registration and Quality Improvement Authority (RQIA).2 In 2004, the Healthcare Commission (now the CQC) carried out an extensive review of the provision, safety and quality of cosmetic surgery practice in England and presented its findings to the Chief Medical Officer in the 2005 report Provision of cosmetic surgery in England: Report for the Chief Medical Officer Sir Liam Donaldson.3 In the same year, the Department of Health took the Healthcare Commission report into consideration and published Expert Group Report on the Regulation of Cosmetic Surgery to the Chief Medical Officer.4 These two studies reviewed regulated cosmetic procedures as well as reviewing staff training and development, consumer information, patient records and clinical audit. Both reports indicated a need for better information and regulation of the practice of cosmetic surgery and several recommendations were made to Government. Since publication of these reports there has been a review of the national minimum standards,5 as well as the publication of guidelines for good medical practice in cosmetic surgery, by the Independent Healthcare Advisory Services, in 2006.6 The NHS Modernisation Agency also looked at plastic, reconstructive and aesthetic surgery within the NHS and provided recommendations for good practice, which involved a more coordinated approach to delivery of optimum service within a local stakeholder commissioning group framework.7 With its On the face of it report NCEPOD aimed to investigate key areas of variation in the practice of cosmetic surgery in the NHS and the independent sector. The study reviewed basic information regarding structure, function and locations of cosmetic practice. It did not include those aesthetic or cosmetic procedures undertaken to manage disease processes. NCEPOD considered the study to be a first step in identifying the variations in organisation and practice of cosmetic surgery. The data returns showed that many providers do not participate in national audit. Of 1,093 identified sites 760 were eligible. Only 361 of those eligible returned the questionnaire and 52.5% did not return questionnaires despite repeated follow-up and reminders. This suggests that they are unaware of their obligation to take part in the work of the confidential enquiries.

Occasional procedures

Throughout medicine it is now becoming a commonly accepted dogma that performing procedures occasionally is unacceptable practice. The report showed that, when it comes to cosmetic surgery, there are numerous surgical teams who undertake procedures that they rarely perform. The report found that it is the more difficult procedures that are undertaken most rarely. There were 31 sites doing the relatively common and straightforward breast augmentations, who do them less than 10 times a year. This is occasional surgery by any standards. For breast reduction, which is relatively complex surgery, 79% of centres undertaking it, did so on less than 20 occasions a year. There were 84 centres doing between 1 and 10 breast reductions in a year. No doubt some of the consultants are working in the private sector in their spare time, so that one member of the team may be doing these procedures more regularly in the NHS and hence in their overall practice. As a consequence of the disparate provision of care the report also found an alarming lack of basic equipment available in theatre, of proper recovery facilities HDU facilities and in out of hours surgical cover. In small centres the unit cost of providing this sort of equipment and back-up becomes prohibitively expensive.