Regulation and Licensing of Non-Surgical Cosmetic Procedures
The Federation of Small Businesses (FSB) is Scotland’s leading business organisation and aims to help smaller businesses achieve their ambitions. These micro, small and medium businesses compromise almost all enterprises in Scotland (99%), employ over 900,000 people and turn over £93bn.[1]
Introduction
We welcome the opportunity to respond to the Scottish Government's consultation on the Regulation and Licensing of Non-Surgical Cosmetic Procedures. We understand the intention of the proposals is to introduce ‘a model of regulation which protects the public while being proportionate’[2].
FSB supports the intention to regulate this area proportionately. The aesthetics industry has grown significantly in a relatively short period of time. Globally, the total number of surgical and non-surgical aesthetic procedures increased by 3.4% in 2023, up to 34.9 million.[3] This highlights the demand for aesthetics procedures worldwide, and the UK is no exception. The general perception of the use of aesthetics is to cosmetically alter the skin and body. While this is one of the functions of aesthetics treatments, many exist to support people who are experiencing medical conditions such as excessive hair growth, acne, skin tags and migraines.
At present, there are several options available to consumers who wish to obtain non-surgical cosmetic procedures. They may opt to have their treatment administered in a Healthcare Improvement Scotland (HIS) regulated clinic, by a registered professional (e.g. nurse, doctor, midwife, dental care professional). This gives the client an assurance that the person performing the procedure is a registered medical professional, who practices under strict guidelines and is operating in a licensed premises which are subject to inspection. A client can also opt to visit a specialist clinic, which might mean that while their practitioner is not ‘medically’ trained and the premises are not regulated by HIS, the practitioner undertaking the procedure is competent, qualified and operating to high standards, usually undertaking continuous professional development to a level consistent with medical professionals and in premises which are licensed by their local authority.
While both of these options will provide peace of mind to the prospective client, there has been a significant rise in the number of people undertaking non-surgical cosmetic procedures who are lacking in training, competency, and licensing adherence. This has given way to a rising number of cases where the client has experienced serious complications and injuries because of under qualified and regulated practitioners.
It is important to recognise that there is an overlap in the delivery of medical and non-medical treatments, and we must not discriminate against practitioners who, while they do not hold a medical degree, are competent and qualified. This should be balanced by introducing legislation which will prohibit people who are carrying out treatments with insufficient experience and qualifications, often in non-regulated and non-insured premises.
The media has well documented cases of bad practice, with a death occurring in England through a botched procedure in 2024, when a young Mum lost her life following complications during a non-surgical Brazilian Butt Lift (BBL) procedure.[4]. A similar case occurred in Glasgow in May 2024 when a woman was hospitalised after undergoing a BBL[5] Two companies and a practitioner were subsequently banned by Glasgow City Council from carrying out BBLs and Breast Augmentation surgeries within Glasgow. There is now, understandably, a sense of urgency to regulate this space in Scotland and wider in the UK, however it must be done proportionately and with the support and engagement of those working in the space, both medical and non-medical practitioners.
While we have highlighted some of the increasingly dangerous examples of bad practice, there is an abundance of examples of good practice in Scotland; practitioners who practice safely, ensuring they are well qualified by undertaking extensive training and continuing with their professional development, practising in premises which are subject to local authority registration or Health Improvement Scotland (HIS). It is important to highlight that these practitioners sit both in and out with what the Scottish Government has termed as an ‘appropriate healthcare professional’ for the purpose of this consultation.
In developing our response, we carried out several interviews with practitioners, both medically and non-medically trained. All members interviewed were supportive of further regulating non-surgical cosmetic procedures and felt strongly that there is an ongoing rise in the number of ‘bad’ practices. They provided examples of where they have undertaken remedial work to rectify botched treatments. Those who engaged with us as part of our response all demonstrated an incredibly high level of professional competence, working to a high standard to ensure that their treatments are carried out in a safe environment, applying recognised standards, and using approved products.
The views of these small businesses are critical, as they will be impacted by the proposed changes and can offer insight into current practice, as well as identifying unintended consequences which are likely to occur as a result of change.
The general view of the members we consulted, is that, in the interest of public health, there is support for the industry to be further regulated. However, there are concerns around the groupings of the procedures, the limited professions contained within the definition of ‘appropriate healthcare professional’ (AHP), the proportionality of Healthcare Improvement Scotland and the timing of the regulations.
During the consultation period, FSB was grateful to engage with the relevant Scottish Government Policy Lead for this consultation. As part of the New Deal for Business Group, FSB has worked to support the redevelopment of the Business and Regulatory Impact Assessment (BRIA) to ensure better assessment of the small business impact of new policy and regulations. Unfortunately, with regards to this consultation, a BRIA has not been published alongside the proposals. Following an initial meeting with the relevant Policy Lead, we discussed the BRIA and significance for engagement with the small business community. We are pleased our comments have been taken onboard and will work with officials to support targeted engagement with our members in the near future.
The impact of the beauty industry in the UK
The British Beauty Council’s ‘Value of Beauty’ report[6] produced data in relation to the economic impact of the UK personal care industry throughout 2023:
- During 2023, the personal care industry made a direct contribution to the UK GDP of £13.5 billion (this rose to £27.2 billion when taking into consideration the supply chain and employee spending).
- The industry’s workforce increased by 10% on the previous year, rising to 418,000 in 2023.
- Economic activity sustained by the beauty and personal care industry supported £7.3 billion in tax revenues, of which £3.6 billion was contributed directly by the sector and its workforce.
The growth of the industry sits ahead of publishing, chemical manufacturing and the creative arts and entertainment industries. This demonstrates the importance of this sector to the UK economy, further bolstered by the evident bounce back following the pandemic and cost of living crisis.
While the growth of the industry has brought significant benefits to the economy, patients, and practitioners, with it has come the need for reform of regulation. In Scotland, there has been a developing regulatory environment reaching as far back as 2013 when following the publication of Sir Bruce Keogh’s UK ‘Review of the Regulation of Cosmetic Interventions’ report, the Scottish Government established the Scottish Cosmetic Interventions Expert Group (SCIEG), which subsequently published a report.
The recommendations from this report have been implemented in stages, with the ‘regulation’ recommendations split into three phases. The first phase, requiring health care professionals to register independent clinics with HIS has been introduced. Phase 2 – pertaining to this consultation – requires high risk procedures to be ‘provided by, or on behalf of, regulated health professionals who have an appropriate level of expertise’. This recommendation is fairly broad, and the consultation provides an opportunity to discuss who should be defined as a 'regulated health professional’ and what constitutes ‘an appropriate level of expertise.’ This recommendation also states that ‘compulsory licensing by local authorities should be required for all cosmetic practitioners delivering specific cosmetic procedures’.
We agree that this minimum standard of licensing (local authority) should be applied to practitioners delivering the cosmetic procedures listed in the consultation. We provide further information on licensing later in our response.
As noted above, there have been several highly publicised cases of botched treatments and complications following procedures, in addition to membership and professional bodies reporting surging complaints. This has resulted in industry bodies calling for government action and stricter regulation of some procedures.[7]
Groupings and settings
In 2022, England introduced the Health and Care Act. This gave the UK Government powers to introduce a licensing scheme for practitioners who operate in England. Following a consultation based on a ‘red, amber, green’ structure in 2023, there have been no further announcements by the UK Government on when any regulations may come into force. Wales introduced new licensing rules in November 2024, which are only applicable to acupuncture, body piercing, electrolysis, and tattooing, however, to date, there has been no indication that the Welsh Government are considering regulating on procedures similar to Scotland and England.
The SCIEG report highlighted that a consistent approach across the UK would be beneficial, stating ‘harmonisation of regulation was viewed favourably to mitigate the risk of cross-border tourism’.’ It is important that a consistent approach is developed, given the risk to public health.
Below is a comparison of England’s proposals for regulation with the proposals contained in this consultation for Scotland. The majority of the groupings are similar, and it appears that the groupings have been modelled on the English proposals of a framework. It is unclear whether the views of medical and non-medical professionals who are carrying out these procedures have been taken into account, as they are well placed to advise on which categories procedures should sit in and who should be deigned an ‘appropriate person’.
|
|
Scotland Group 1 |
England Green |
|
Description |
Low risk (e.g. microneedling, IPL, identified chemical peels, specific use of lasers) |
Low risk (e.g. microneedling, IPL, chemical peels into viable epidermis, microblading, non-ablative hair laser removal) |
|
Eligibility |
Licensed practitioners |
All practitioners |
|
Oversight |
N/A |
N/A |
|
Regulation |
Local authority licensed setting or HIS setting |
Local authority licensing scheme |
|
|
Scotland Group 2 |
England Amber |
|
Description |
Medium risk (e.g. injections of toxins/drugs and semi-permanent fillers, medium depth peels) |
Medium risk (e.g. injections and semi-permanent fillers to face, electrocautery, vitamin and mineral injections, medium depth peels) |
|
Eligibility |
AHP or supervised by an AHP |
Healthcare professionals. Non-healthcare professionals require licensing. |
|
Oversight |
Suitable trained practitioner, overseen by a healthcare professional |
Overseen by a named regulated healthcare professional (with accredited qualification) |
|
Regulation |
HIS setting only |
Local authority licensing scheme |
|
|
Scotland Group 3 |
England Red |
|
Description |
High risk procedures (e.g. electrocautery, injections*, liposuction, deeper chemical peels, dermal fillers of 2ml or more in one site, cryotherapy, lasers which target deeper epidermis, IV and infusions) |
High risk procedures (e.g. all thread lifting procedures, deeper chemical peels, hay fever injections, lasers which target deeper epidermis, IV and infusions) |
|
Eligibility |
Doctor or nurse prescriber |
Specific healthcare professionals only |
|
Oversight |
N/A |
N/A |
|
Regulation |
HIS setting only |
CQC setting only |
*Fat dissolving agents, hay fever, Platelet rich plasma, biotherapy or injections of any products derived from the patient’s blood, weight loss, microsclerotherapy, IV fluids or blood processing for lifestyle purposes,
While there is merit in grouping procedures and applying a consistent approach across the UK, we believe deeper discussion with industry requires to be undertaken to fully understand where each treatment should be placed and if there are circumstances where flexibility can be built into the framework.
Feedback from one of our members suggested that the groupings of the procedures demonstrated a lack of understanding of their level of risk and how they are performed. Our small business members are keen to engage with the Scottish Government to offer further information on what some procedures entail, in order that some of the proposed groupings might be revisited. This would lead to a more accurate understanding of the procedures, level of risk they carry and who is qualified to deliver them. As noted above, we look forward to supporting this engagement with government officials leading the development of these proposals.
Health Improvement Scotland
Healthcare Improvement Scotland (HIS) regulate NHS hospitals and services, along with independent healthcare services. HIS stipulates that you must register with them if you run an independent clinic and are a ‘healthcare professional’ (this includes but is not limited to doctors, dentists and dental care professionals, registered nurses, and midwives). Healthcare professionals who work in an NHS setting are not required to register with HIS.
HIS require those registering to pay a fee to register, £3,500 - £5,000 and then an annual continuation fee of between £1,202 - £3,500.[8] From a small business perspective, this is a significant sum of money. Our research found that small businesses who are obligated to register with HIS felt that the fees are disproportionate, the service received for the fees is minimal, and there is a lack of public awareness around the function of HIS.
Our members also reported confusion around the value of the fees and how they are used to develop a ‘value for money’ service. They reported meeting with inspectors who showed a lack of understanding around medical equipment and maintenance and suggested that the Register of Independent Healthcare Services does not operate to its full potential, with most clients unaware that it exists or around the credibility of it.
Save Face in England is a good example of a service for clients who wish to access non-surgical cosmetic procedures and are seeking competent, qualified practitioners, operating in a licensed environment. Save Face is a government approved register run by a team who understand the value of independent assessment and verification. It is an easy-to-use website where you can quickly locate a treatment in your preferred area, undertaken in an approved clinic. They additionally support the public with complaints and complications.
There is a strong feeling among our members that a review of the current structure of HIS is needed. In developing our consultation response, we heard suggestions that HIS may be hampering small businesses who are carrying out essential services. For example, FSB has a member who delivers preventative dental care in rural areas of Scotland, reaching out to communities who would otherwise be unable to access this care without a significant journey onto the mainland. This member also delivers dental care to elderly people residing in care homes, who may wait an unacceptable period of time for an NHS registered dental practitioner to visit. However, the current fee structure would see her charged an unsustainable increase in her registration fee should she expand her provision of her services.
This is echoed in those who deliver non-surgical cosmetic procedures, many of which provide essential services for issues such as skin tags, moles, or acne scarring. Services that would otherwise require to be carried out under the NHS, and which would require the patient to wait a considerable period of time given current waiting list times. Additionally, some members told us anecdotally that NHS GPs and consultants often refer their patients to private clinics to access treatments that are not available on the NHS.
Listening to member feedback as we developed our response has led us to conclude that a review of the current HIS regulation framework for independent healthcare is needed. We have heard that the current fee structure is disproportionate to small businesses, with the registration and inspection process providing an unreasonable level of scrutiny, which often conflicts with expert opinions and practical common sense.
In light of the proposals being brought forward here, consideration should be given to reform of the current structure or creating a new service which includes a new definition of a ‘healthcare professional’ (when referring to non-surgical cosmetic procedures). A public awareness campaign which will provide both industry and potential clients with assurance that the provider they have selected is qualified and that they comply with standards and regulations, shiuld also be considered.
Age limits and vulnerable people
We agree with the general stance that people under the age of 18 should not be able to access procedures for cosmetic reasons. We are also in agreement that there will be circumstances where people under the age of 18 may require NSCPs for other reasons and that exceptions should be made. Some reasons cited for this by our research included facial scarring, facial skin tags and warts. It is important that the procedures are analysed closely to determine which are for purely cosmetic purposes (e.g. fillers) and which will support young people who may otherwise encounter negative body image and subsequent mental health decline (e.g. removal of skin tags or severe acne treatment).
Regulatory burden on small businesses
The Scottish policy landscape is awash with a multitude of new and impending regulations and requirements, creating a complex environment for businesses to operate in. The majority of small businesses struggle to find additional time out with dealing with their day-to-day operational duties and can be unsure of what will be expected of them in the future. Over the course of the last few years, there have been consultations published proposing changes on a number of different areas. The following is a non-exhaustive list:
- The Circular Economy Bill
- The Visitor Levy (Scotland) Bill
- Building Community Wealth in Scotland
- Draft Energy Strategy and Just Transition Plan – delivering a fair and secure zero carbon energy system for Scotland
- Restricting Alcohol Advertising and Promotion (with a further consultation expected)
- Heat in Buildings Bill
- Single-use food containers and other single-use items
- The Deposit Return Scheme
- Charging for single-use disposable beverage cups
We welcomed the First Minister’s acknowledgment that there is a need for ‘more concrete actions and fewer strategy documents’ in his speech on 17th May 2024.[9] Combining a reduction of strategy and consultation documents with assessing the disproportionate impact of new policies on small businesses through comprehensive Business and Regulatory Impact Assessments (BRIAs), will mean that there are less administrative and regulatory burdens placed on small businesses.
FSB’s ‘Big Small Business Survey’ conducted in 2023, found that over a tenth of Scottish SMEs already spend more than eight hours – a full working day – on compliance each week. FSB Scotland have participated in the New Deal for Business Regulation sub-group and were pleased to participate in the development of a revised BRIA template which incorporates a fuller assessment of how new regulations will impact on the operation of small businesses. As noted above, a BRIA has yet to be produced for this consultation process. We look forward to the Scottish Government’s production of this BRIA, with the required small business focused section.
The future of aesthetics regulations and recommendations
In summary, FSB is supportive of regulating and licensing non-surgical cosmetic procedures. However, there are several key points we ask the Scottish Government to consider following the consultation.
- That the definition of what an ‘appropriate healthcare professional’ be further considered, in conjunction with industry, to ensure that those who are significantly experienced and qualified are not penalised because they do not fit inside the definition. There is an abundance of great examples of practitioners who have their clients’ wellbeing at the core of what they do, practise within guidelines, and uphold high standards, and that this should be recognised when discussing this definition.
- That the groupings of procedures should be further considered, in collaboration with practitioners. Engagement with industry, specifically small businesses, is key in designing regulations which accurately reflect risk and compliance. It is critical that we hear from both medical and non-medical practitioners throughout the engagement process.
- That consideration is given to how equitable HIS fees are and whether the service that independent clinics receive is proportionate to the fees paid.
- That in light of the regulatory changes, consideration is given to reviewing the current framework for independent clinics, perhaps even establishing a new body, which will be more functional for both practitioners and consumers, and provide a tangible service to those subscribing to it with funds delivered from the service reinvested into developing the industry.
Further information
For further information, please contact Vikki Manson, Deputy Head of Policy at FSB Scotland: [email protected]