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It was in the late 1950s that the Psychologist Leon Festinger first developed his theory to explain how members of a cult were persuaded by their leader, Dorothy Martin that the earth was going to be destroyed by a flood on Tuesday 21st December 1954, and that the cult members alone would be rescued by aliens [1]. Many within Martin’s cult prepared for the predicted doomsday scenario by giving up their jobs and disposing of their belongings.

The prophesied Armageddon failed to materialise, but rather than abandoning their mistaken beliefs, Martin and her cult members’ conviction to the group became even stronger, they fervently evangelised that it was they, the chosen few, who had indeed saved the world from complete and utter annihilation. By adapting to this new belief, the group then justified their latest doctrine and managed to avoid any disharmony amongst the group itself, Festinger subsequently labelled this behaviour as ‘Cognitive Dissonance’.

Festinger’s [2] theory on cognitive dissonance suggested that the majority of us have an inner drive to hold all our attitudes and beliefs in harmony and avoid disharmony (or dissonance). Cognitive dissonance is thus defined as the anxiety or discomfort experienced by a person who simultaneously holds two or more conflicting or contradictory beliefs, ideas, or values.

In my Editorial for The Journal of Aesthetic Nursing [3] I explored the dissonance and division that aesthetic nurses were experiencing up and down the country from both their peers and the non-health groups, it was apparent that the moves being made towards an all-inclusive regulatory framework were not being generally well received.

“Despite the regulation, registers and guidance introduced this year, there are deep, cavernous and gaping flaws opening up. There is also palpable resentment, a growing hostility and a ‘them and us’ culture developing within the non-health movement.”

Many of us practising within aesthetics are currently experiencing an uncomfortable tension and witnessing powerful conflicts within the sector, particularly over how it is being sculpted, shaped and dissected and some of us are left wondering whether or not aesthetics, as we have known it over the past two decades, has any future enshrined within medicine or indeed health, especially so when we are being forced to accept the concept that anyone can become an aesthetic practitioner.

Frustrated by the lack of communication from the Joint Council of Cosmetic Practitioners (JCCP) and the decision to include the lay groups within this new all-inclusive register, we made the decision to ask our delegates at the 6th Annual Aesthetic Nursing Conference in Liverpool to vote on the issue. To the best of our knowledge aesthetic nurses had not been given a vote on whether they wanted to be included on any register that included hairdressers and beauticians. Indeed, many felt that the new era of inclusivity was a very mixed message from the Department of Health, yes Health and not the Department of Beauty, and this would only go to further reinforce and trivialise the message on cosmetic or aesthetic treatments when as we know, some of these treatments can have serious life-changing and life-long complications.

We considered that it was now incumbent on us to give our delegates, who had taken time out of their very busy schedules to attend conference a free vote and that this was overdue. It struck me that those who subscribe to many professional associations often report that they are not being heard and rarely if ever, get to vote on many of the very important regulatory issues we face today in aesthetics. There are a myriad of reasons, that I don’t intend to address here why we often permit policy to be shaped by ‘others’, but on this particular matter and this particular time we felt that aesthetic nurses rightly deserved a say.

I had never proposed a motion of no confidence before and we were really not sure how the vote would go, although the mood music was on full volume and I was hearing that regulated groups should not be on any register with those who are unregulated. In my presentation to the floor we discussed the ludicrous current situation in the UK where the provision of medical aesthetics to the general public, who in his final report Keogh [4] described as “often vulnerable” and “taking their safety as a given” by beauticians and other non-health groups, is supported without any published evidence base to suggest this is a safe practice. We were also very concerned about what appears to be wholly inadequate consenting processes by these cohorts, many of us reported that patients are being poorly informed about their treatment options, risks and complications when undergoing such interventions and procedures when choosing a non-health provider.

The motion that conference had ‘no confidence in the non-health groups delivering facial cosmetic injections to the public’ was witnessed and recorded as a unanimous vote with none against and no abstainers.

Following on from the Aesthetic Nursing Conference, we noted that Save Face Ltd. then “unanimously voted” to withdraw their engagement from the procurement process for the JCCP register, they “decided to step away from the process”. This unexpected statement from Save Face Ltd. was interesting, particularly so, as they had been fully and entirely engaged with the JCCP since its inception. This month we read a press release from the British Association of Cosmetic Nurses (BACN) on the JCCP with a survey for their member’s views on the JCCP.

But is all this too little too late?

Festinger’s theory on cognitive dissonance suggests that when we are in an absurd situation, which I firmly believe we are, our minds try to rationalise it and we create or invent a more comfortable illusion to create harmony. We are now witnessing practitioners experiencing and displaying cognitive dissonance. For example, decision making increases dissonance and we are being asked to make a decision about whether to sign up to this register, forced compliance – I didn’t want to join the register (cognitive) but I did (action), and then there is the effort we spend on something, effort is usually seen as a positive reward, but if that effort is misplaced and quite frankly an utter waste of time and money we invariably will still give praise, it is just in our nature.

I am on record as boycotting the Health Education England (HEE) stakeholder engagement process and still remain firmly of the belief that some of the self-appointed experts had no place at the HEE expert table. I publicly challenged why they were included, the reply came back loud and clear “because they were there anyway”. I predicted that without the risk assessments or clearly identifiable standards the basis for this was built on the wrong premise and this was nothing more than an experiment with a hypothesis that patients will only be safer when we volunteer to upskill the unaccountable and unregulated groups. I am rather hoping my prophesising fails.

Can I please again suggest to my aesthetic colleagues that they closely “examine their relationships with the non-health and beauty sectors, and ask themselves why they are facilitating them through training and prescribing services… [4].”



1. Festinger L, Riecken H, Schachter S: When Prophesy Fails. New York, USA: Harper-Torchbooks; 1956.
2. Festinger L: A Theory of Cognitive Dissonance. Evanston, IL: Row & Peterson; 1957.
3. Editorial. Journal of Aesthetic Nursing 2016;5(10):473.
4. Keogh B. Review of the Regulation of Cosmetic Interventions – Final Report. 2013.


Editorial commentary


Dalvi Humzah
Aesthetics Sub-Editor, PMFA News; Consultant Plastic Reconstructive & Aesthetic Surgeon, West Midlands / Gloucestershire.


“Man is born free, and everywhere he is in chains. One man thinks himself the master of others, but remains more of a slave than they are.” The Social Contract – Jean-Jacques Rousseau.

“I disapprove of what you say, but I will defend to the death your right to say it.” Voltarean Principle / Evelyn Beatrice Hall.

In this issue of PMFA News we have a passionate view of an experienced medical practitioner discussing the current dissonance in the field of aesthetics. This year has seen some major changes within the field of aesthetics – the surgical specialty is considering credentialing and the non-surgical sector is trying to find an identity. This is not the first time this dissonance has occurred – while still in the EU our medical colleagues worked together to get recognition to continue providing non-surgical interventions in the face of the EU legislation. Many of you who have been abroad will have seen that the delivery of non-surgical interventions is very varied; in many countries this is tightly regulated whilst the UK is in a crisis of confidence. Who should be allowed to inject and deliver non-surgical interventions is a problem that has to be addressed and is fundamental before any other issues are considered. There may not be a straightforward answer, but without this we will continue to ‘live in chains’ and whilst we consider ourselves to be masters we are clearly not.

How an individual’s or a group’s views are represented in a committee is a question that is relevant – June 2016 saw the UK use a referendum to overturn a 40-year relationship in Europe, a relationship that the Government wanted to maintain. It is therefore interesting to hear how committee representatives truly represent their group’s views without having an open discussion on issues. Perhaps a ‘time-out’ is required for members to be asked direct questions and then policy decisions made to represent the views of the many and not the vocal few.

A very good friend and colleague recently discussed the issues of professionalism – this has become of paramount concern. The dissonance we have discussed has unfortunately led to many deep seated views being expressed. In these times of uncertainty we must keep the Voltarean principle alive. Opposing views are the fuel for our debates and discussions from which we can forge a stronger specialty – however, we need to maintain our ‘professionalism’ and avoid disparaging our colleagues or other non-medical groups. We must keep the prime concept in mind – primum non nocere – central to any discussion or decision: the safety of our current and future patient is of paramount importance. The lack of evidence of harm is not necessarily a proof of safety and being evidence-based, we need to ensure that proof is established before decisions are made.



Andrew Burd
Editor, PMFA News; Locum Consultant Burns and Plastic Surgeon, Nottingham University Hospitals NHS Trust, UK.


From the outset I have wanted PMFA News to be a platform for debate and discussion on issues that relate to the wide field of plastic and maxillo-facial surgery and aesthetic medicine. The editorial by Cheryl is thought-provoking and very much welcome. In 2013, in the very first issue of this magazine I wrote an article titled ‘From PIP to DC-CIK to the Sorcerer’s Apprentice’. I was looking at the government response to the PIP scandal in the UK which resulted in the Keogh report on cosmetic transformations and contrasting this with the government response in Hong Kong to the DC-CIK scandal. The former related to breast prosthesis made from non-medical grade silicone whilst the latter concerned a form of immuno-therapy normally used for cancer that was being given as a ‘beauty / wellness’ treatment. For those who are new to the magazine I would recommend reading it as it illustrates how polarised views were three years ago, and the fact that little progress has been made since is indeed a salutary reminder of what a minefield we are in (FROM PIP TO DC-CIK TO THE SORCERER'S APPRENTICE: A MEDICO-POLITICAL MINEFIELD - PMFA NEWS VOLUME 1 ISSUE 1 OCT/NOV 2013).

I think the Keogh report was political pandering that did nothing to clarify very genuine concerns and indeed trivialised the whole issue of cosmetic transformations by reference to toothbrushes and ballpoint pens! In both cases, pressure groups tried to take advantage of the lack of regulation to protect their own financial interests rather than prioritising patient / client safety. In Hong Kong, the specialist doctors were trying to claim exclusive right to invasive procedures (which include injections) whilst in the UK both doctors and aesthetic nurse practitioners wanted exclusive access to ‘cosmetic’ patients. In both cases the numerically much larger non-medical beauty industry was and is regarded as a threat.

There are a number of problems though which bedevil the debate and a major one is what constitutes a ‘beauty treatment’ as distinct from a ‘cosmetic transformation’? In both jurisdictions, the practice of tattooing was conveniently overlooked and the primary focus has been on the money-making injectables market. Primary qualifications and assumed skill sets are used to claim exclusive access to patients, but I think this is fundamentally wrong. I am a plastic surgeon and proud of my training, background and experience. But I know quite a few rogues in my specialty: greedy, ambitious people, full of ego and false platitudes. But is it not the same for all specialties, professions, disciplines?

And this thing about ‘vulnerable people’ needing protection from avaricious practitioners. The unfortunate fact is that there are plenty of greedy and manipulative people out there who are quite prepared to destroy the name and reputation of caring and competent practitioners if their, often unrealistic, expectations are not met. So, what is to be done? As I pondered this I idly clicked through the BBC website and came across a startling article. A brilliant out of the box idea, why not make runways circular!? (

I am only floating this as a very preliminary idea but let us accept that the government allows people to buy a product that they know causes cancer: cigarettes. They allow the sale of alcohol that wreaks havoc on society and personal health. They allow the promotion of obesity in fast food, high sugar content drinks. So, let us forget this ‘vulnerable people’ distraction. We need some regulation, but on what basis?

What if we say that any local cosmetic intervention that induces sufficient pain that the control of the pain is an essential part of the treatment must be administered by a registered health professional? For the ‘no pain’ local cosmetic interventions then they are free game no matter what the miniscule risk might be? But as with cigarettes and alcohol there should be a tax from which society can benefit and a caveat emptor exclusion of liability which will stop the frivolous and often malicious lawsuits that are a bain on the lives of all practitioners both medical and non-medical. I leave you with two words: ‘cat’ and ‘pigeons’.




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Cheryl Barton

Journal of Aesthetic Nursing; Nurse Lead, Aesthetika Clinic, Sheffield, UK.

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