My Lords, I am most grateful to the Government for tabling Amendments 153A and 157A; I will not be moving my related Amendment 169. I should declare that I am married to an academic dermatologist, and that I am vice-president of the Chartered Institute for Environmental Health.
I am very grateful to the officials with whom I have had many discussions over the issue of cosmetic procedures. These government amendments are a welcome step in the right direction, by ensuring that individuals who carry out cosmetic procedures such as Botox
fillers, threads under the skin and so on will have to meet consistent safety standards. Anything that breaches the barrier function of the skin—going through the live layer of cells of the epidermis—can cause inflammation, introduce infection and cause scarring and other reactions. The government amendments are most welcome because they are broad-reaching and tackle the real problem of people doing things to other people with no proper training and in premises that are not even properly inspected and licensed.
Perhaps I could just ask the Government two questions on this. First, when we had discussions we were considering the use of the term “energy-based device” to cover all the different modalities that can be used to get different types of radiation, whether as heat or whatever, through that layer—the barrier of the epidermis. That phrase would have captured such things in future regulations. Can the Minister assure me that subsection (2)(e) of the proposed new clause will also cover forms of energy not in the wording of the amendment, such as radio frequency and ultrasound devices, which are currently in use on the high street for cosmetic skin-tightening purposes? The idea is, of course, that they produce a small amount of scarring and tighten the skin, but if that goes wrong then you have a problem.
Secondly, can the Government confirm that, in order to obtain a licence, practitioners will be required to meet the agreed standards for training and education and that, in order to maintain their licence, they will be required to undergo appraisal and report adverse events so that such events can be collated and appropriately followed up on?
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It is important to acknowledge the wider issue around the safety of cosmetic surgery overall. The fact remains that, nine years after the Keogh review, recommendations to improve the safety of cosmetic surgery still have not been fully implemented. People who come to the UK using the term “surgeon”, which they may be in their own country but are not registered with the GMC, cannot undertake surgical procedures; even if they are registered in their own country, or if they are registered here but undertake procedures in premises that are not CQC inspected, they are acting illegally and subject to prosecution. However, there is a catch: any doctor on the General Medical Council register can undertake cosmetic procedures, whatever their training, if they do so in premises that have been inspected. No specific qualifications have been required by the GMC and there is no curriculum or assessment process, so patients can still experience unacceptable and sometimes shocking aspects of care.
There may be a solution. In 2017, the intercollegiate cosmetic surgery certification scheme, supported by the four royal colleges of surgeons in the UK and Ireland, has been developed to keep patients safe and raise standards. That scheme is supported by all relevant surgical specialties. I hope that the Government can provide assurance that they will put increasing pressure on the GMC to work towards cosmetic surgery credentialing, which will be welcome and long overdue, and that such a scheme will include not only those surgeons but people such as dermatological surgeons who may then move into cosmetic procedures.
Amendment 181, in my name and that of the noble Baroness, Lady Greengross, is about hospital rehabilitation accommodation. Rehabilitation units need to be there for people who need step-down care but cannot get home. These facilities need to have appropriate rehabilitation, such as gyms and hydrotherapy, the right range of staff, such as physiotherapists and people who can support patients psychologically as well, as they may have been very traumatised. Their environment should, overall, support recovery. We can learn from the military rehabilitation units and the new NHS rehabilitation centre near Loughborough, because there is evidence that people recover quicker in these. Then, with a good community rehabilitation plan, they can move home to improve co-ordination and integration, and continue with their rehabilitation better.
Lastly, I would like to address the amendment whose lead name is that of the noble Baroness, Lady Cumberlege, and to which I have added my name. This is a crucial part of patient safety and arises out of her very important review, First Do No Harm. I declare that I have been developing teaching materials on informed consent with the Welsh Government and that I chair the National Mental Capacity Forum. The issue of informed consent has become very important.
In clinical practice, there is always unconscious bias. This is far wider than direct funding that may go into a clinician’s pocket. There is a risk of incentives created by past successes of which the person is proud, such as funding for their department or staff, and grants that may help towards their own career progression or higher qualifications—there are myriad influences. This amendment would allow a patient to find out about a clinician to whom they may have been referred and to ascertain any issues of such influences by such a register being publicly available.
The GMC has suggested that such a register is best held at local level, but clinicians move around. Some do extra contracted sessions in other units, while GPs are self-employed. There could also be a consortium of people working in private practice. One way to hold a register that could be checked up on regularly would be if it was held by the General Medical Council. In an ideal world, it should of course be multiprofessional, but we have to start somewhere, and it would seem sensible to start with the medical register, as almost all the people to whom a patient is referred are doctors on that register—although people may sometimes have been referred directly to specialist nurses, such as wound-care nurses and so on. Holding it centrally would ensure the register is accurate and accessible; it would be kept up to date through appraisal and therefore enforceable. It could eventually become multiprofessional in scope. I hope the Government will take this concept forward.