In January 2016 a new voluntary regulatory register was established – the Joint Council for Cosmetic Practitioners (JCCP), chaired by Professor David Sines. Since that time the JCCP has met with challenges from many within the aesthetics industry. We spoke to David Sines about the background to the JCCP and gave him the chance to answer some of the criticisms from practitioners.
Professor David Sines
The JCCP will be running two different registers – how will it ensure the public knows and understands the difference between the two different registers and that practitioners do not make vague assertions to confuse the public?
The JCCP provides and publishes one Practitioner Register divided into two parts, each having equal weight and each being governed by the same CPSA and JCCP standards. The division of the register into two parts provides explicit and transparent line of sight for the public to be able to see at a glance whether JCCP registered practitioners are either healthcare registered clinicians or non-healthcare registered aesthetic practitioners. The division of the Register into two parts will enable members of the public to be able to search the register and see clearly via annotation the following:
- The treatment modality for which they are registered to practise
- The competence level that they have been recognised to practise at
- Whether they are recognised and regulated prescribers
- Whether they are required to practise under supervision
The two parts of the Practitioner Register are:
Part 1: Clinical Practitioners who are registered with healthcare Professional Regulated Statutory Bodies (PRSBs) that can provide oversight and work independently within the context of their scope of professional practice – GMC, NMC, GDC, GPhC, PSNI and HCPC. The JCCP has consulted each of these PSRBs and can confirm that the following categories of PSRB Registrants are eligible to join Part 1 of the register if they can evidence that they meet the stringent standards and entry requirements set by the JCCP and its sister standard setting body the Cosmetic Practice Standards Authority (CPSA):
- General Medical Council: - registered medical practitioner - doctor
- General Dental Council: - registered dentists - registered dental hygienist - registered dental therapist
- Nursing & Midwifery Council: - registered nurse - registered midwife
- General Pharmaceutical Council: - registered pharmacist
- Pharmaceutical Society of Northern Ireland: - registered pharmacist
- Health Care Professions Council: - registered physiotherapist - registered diagnostic radiographer - registered therapeutic radiographer - registered podiatrist \ chiropodist - registered paramedic - registered operating department practitioner
Part 2: Practitioners who are not in current membership with or are not eligible to join a Professional Statutory Regulatory Body / Council and who require clinical oversight for specific procedural interventions (within or outwith their scope of professional practice) – beauty therapists, aesthetic practitioners and persons who are able to be registered with a PRSB but have elected not to do so.
There is no formal curriculum recognised for aesthetics in the UK as there are many aesthetic treatments at many different levels, and practitioners come from different backgrounds with varying levels of background knowledge and experience. To accommodate this, the JCCP has developed a competency framework defining the required core and specific competencies for five modalities; this will assist education providers to develop curricula that enable practitioners to achieve the core and modality specific competencies required to be proficient practitioners, building upon existing knowledge and skills within that group. The JCCP has also developed education standards, which outline the principles and process for education providers to achieve approved education provider status for specific courses and programmes that enable practitioner groups to develop the required level of proficiency. The regulatory bodies who define and recognise specialist practice may wish to map their curriculum against the JCCP competency framework and education standards to identify whether practitioners on their specialist practitioner registers meet the JCCP competencies for specific treatment modalities.
The JCCP has declared that only those persons who can objectively evidence that they meet all of the JCCP and CPSA education, knowledge and practice-based competencies will be eligible to apply for registration with the JCCP in respect of any designated modality / scope of practice. The JCCP acknowledges also that the vast majority of applicants who will seek to join the JCCP Practitioner Register as Part 2 Registrants will be practising at Levels 4 and 5 of the HEE/JCCP Education and Training Framework and as such will not be eligible to be registered by the Council to perform Level 6 and / or 7 procedures such as dermal fillers and injectables. Persons who wish to be considered for registration by the JCCP to perform Level 6 and/or 7 procedures must evidence full compliance with the standards identified within the JCCP and CPSA published frameworks prescribed for the delivery of such procedures and comply with the JCCP and CPSA standards of supervision and oversight that require that non-PSRB Registrants must work under the oversight of a clinically competent and proficient practitioner who must determine the level of supervision required in order to protect the public and assure patient safety. Such Registrants must also have access to a PSRB prescriber at all times who will continue to be accountable for the oversight of the patient’s treatment. Remote access to prescribers is not permitted by the JCCP or CPSA.
Clear information will be provided to the public to help them understand the difference between the two parts of the JCCP register. Those who are on the first part of the register are already regulated under statute and accountable for their practice as health professionals, however, the JCCP (voluntary) register additionally indicates which cosmetic treatments that practitioner can safely provide, and to which level (for example to inject dermal filler or provide laser treatment for specific conditions). It will also specify which practitioners are legally able to prescribe treatments such as botulinum toxin (wrinkle relaxants) which is restricted to doctors, dentists and allied health professionals who hold a prescribing qualification and requires them to assess the person face to face.
Those on the second part of the register are not currently accountable for their practice to any statutory body; allowed to prescribe prescription only medicines or use them without supervision by a prescriber. Registration on this part of the JCCP register enables the public to see which treatments registrants are qualified and competent to provide, and that the practitioner is practising ethically and safely to an agreed standard defined by the Cosmetic Practice Standards Authority (CPSA). Because these practitioners are not subject to any statutory registration, members of the public with concerns about their practice currently have no means of redress. Registration of such practitioners with the JCCP, even though it is a voluntary register, provides redress for members of the public, as any concerns regarding fitness to practice of one of its registrants will be managed in the same way as the statutory regulators.
Any practitioner who makes any false claims or vague assertions regarding JCCP registration status will be subject to the fitness to practise process or if not a JCCP registrant, referred to the Advertising Standards Authority for investigation.
Aesthetics and non-surgical cosmetic interventions (NSCI) do not have any formal curriculum or specialist status – how will the JCCP ascertain the standards required for practitioners to achieve and how will it differentiate those practitioners who are already recognised as specialists within e.g. the General Medical Council (GMC) specialist register and those who are not?
The JCCP and the CPSA have worked together seamlessly over the past three years to build on and refine the previously developed and published HEE standards for Non-Surgical Cosmetic Practice and Hair Restoration Surgery (2015) with the result that a new competence framework has been published, support by a robust supervision matrix and shared joint Code of Practice. These frameworks and documents combine to produce an holistic and integrated series of standards that both determine and seek to govern the proficient practice of aesthetics in the UK. These standards and competence frameworks were formulated and co-created by over 300 expert clinicians from nationally appointed professional organisations, membership associations and educationalists. The standards were also the subject of national discussion, debate and refinement. HEE designed the original education and training standards for the sector in 2015 which were accepted by the Department of Health at that time. These education and tensing standards have now been updated and developed in consultation with the sector to embrace the new CPSA Practice competencies and supervisory requirements and to enhance and develop further the educational standards and qualification framework standards required to deliver robust and safe aesthetic practice.
The JCCP recognises that many persons who practise currently in the aesthetic sector have been recognised as being highly specialist and proficient in their defined areas of practice. Examples of such practitioners are those who are registered currently on the GMC Specialist Register. The JCCP recognises the expertise of such practitioners (and also the skills and competencies deployed by many other health care professionals). The JCCP has put in place registration processes that will enable such experienced practitioners to be able to join its Practitioner Register, subject to them being able to declare and evidence that they meet the conditions set down for entry to the Register by the JCCP.
It is also a matter of fact that the JCCP education and practice standards (and its underpinning entry requirement to its register) have been formally approved and recognised by the Professional Standards Authority. We consider that publicising the register and describing the reasons why these standards are so important will help drive the public towards practitioners who do meet the required standards. In essence, the register acts as PR for clinicians with qualifications, and if the register can grow to a point where it is the ‘go-to’ online search facility when looking for a practitioner, it will act as a gatekeeper, screening out people who cannot demonstrate their qualifications / adherence to standards. In this way the JCCP kitemark serves to signpost the public to those practitioners who have been assessed as meeting the high threshold standards for public protection set by both the JCCP and the CPSA.
Within many European countries NSCI are the remit of medical practitioners. The recent vote at a national nursing conference appears to indicate a strong desire that ‘non-medical practitioners’ should not be involved in the injectable treatment of patients. Should the JCCP seek the views of the professionals and make appropriate representation of the medical professionals’ view?
The JCCP takes very seriously the views of all stakeholders. In the UK, despite the Keogh recommendations, the government has not taken the move to enforce statutory regulation for cosmetic treatments or restrict the use of injectables to medical and allied health professionals. The JCCP is aware of the ongoing debate and strength of feeling and has taken the views of its stakeholders regarding restriction of injectable treatments to those with current Professional Statutory Regulated Body (PSRB) registration to the Department of Health and Social Care for further consideration.
The JCCP and the CPSA were co-created to respond to the significant gap caused by lack of mandatory and statutory regulation in the UK and the resultant threat to patient safety and public protection. Both bodies will continue to campaign assertively for this to take place. The many stakeholders who have united across the industry to work with the CPSA and JCCP have a continued responsibility to assist with the further development and implementation of our agreed and shared practice and education and training standards. All of this needs to be done in the context of a co-ordinated approach to demonstrate our united commitment to patient safety and public protection.
The JCCP and CPSA accepted that whenever we all attempt to do something as complex and difficult as to regulate a new and rapidly growing sector there will be issues and strong opinions voiced. Constructive opinions are welcomed in that they serve to assist in the refinement of public protection procedures. However, we recognise equally that there are many vested interests in the sector and for some attempts to regulate the sector is both challenging and unwelcome. We encourage all practitioners, professional bodies and those parties who supply services and products to the sector to come forward to engage constructively and purposefully with us to move the debate forward in support of our declared intention to improve standards and practice and to influence the Government of the need to introduce statutory regulation within and across the sector.
Understandably, many people working within the industry have taken a cautious approach to the work of the JCCP, questioning how effective a non-compulsory register could be, how it differs from existing registers, who runs it and who profits from it. While the vast majority of involved professionals have seen this an opportunity to unite and shape the future of the industry, willing to work together to find the best possible solution to areas of contention, there has also been a level of dissent, which is inevitable with any new venture involving the systems of work, livelihoods and principles of a disparate group of professionals. Unfortunately, this has led to misinformation which we seek to address with the facts outlined below, outlining the aims and rationale behind many of the JCCP’s key decisions.
Regardless of opinion, the JCCP considers that inclusivity is essential as long as standards are maintained to protect the public.
Some doctors and nurses are adamant that the JCCP should not be open to all professional groups currently involved in the practice of NSCI and that those with no formal medical or healthcare training should be excluded. Contrary to this are equally ardent views that the Council should not solely consist of those with the highest level of medical training, given that this would not represent the vast number of people actually conducting these treatments.
The JCCP has listened actively to these concerns and is consulting and listening actively in recognition of these concerns in the interest of public safety as its priority. Notwithstanding this we acknowledge that non-medical professionals already operate widely within this sector, and at present this is permitted in law in the UK. As a result of our current ‘listening exercise’ the JCCP will undertake to consider review its decision to register those non healthcare professionals (who are registered currently with a Professional Statutory Regulator) who inject toxins and dermal fillers at Level 7 (as defined in the JCCP/CPSA standards framework) at its next trustee Board meeting at the end of July.
In all other specialities training is provided by a variety of bodies that are not regulated by any of the professional bodies; in the UK the system of revalidation for medical practitioners allows training providers to provide CPD through the different colleges and bodies. The individual practitioners choose the training dependant on their revalidation requirements. What remit does the JCCP have to control aesthetic training providers and effectively prevent development in the arena of educational provision in the aesthetic sector?
There are a number of issues to be addressed here.
In other areas of defined specialist practice, practitioners are already regulated professionals undertaking further professional development to achieve the defined competencies of specialist practice in that specialism or sector, as defined by their regulatory body. Their knowledge and proficiency is assessed before they can claim specialist practitioner status. Despite the prevalence of aesthetic practice, defined competencies for specialist practice have not previously existed. The JCCP has, in partnership, with a wide stakeholder group defined core and modality specific competencies for a wide range of different aesthetic treatments. Education providers who wish to develop programmes of study to enable aesthetic practitioners to develop proficiency in a specific modality (such as those leading to specialist practitioner status), should use the JCCP Competency Framework for Cosmetic Practice and Standards for Education & Training Providers to guide the development of their curricula if they wish to appear on the JCCP register of Approved Education & Training Providers. Rather than prevent development, the provision of the new JCCP Competency Framework and Standards for Education Providers should help to develop a wider and higher quality of educational provision delivered by reputable education providers who meet the JCCP’s defined standards,
CPD is a different issue – it is the way that regulated professionals demonstrate they are keeping up to date with all aspects of their practice to revalidate their professional registration. Practitioners choose the CPD they undertake in relation to their identified needs to enable them to practise safely, competently and effectively. This is the same for aesthetics.
In the absence of such defined competencies, and in a sector with such a plethora of education and training providers, providing courses (from one day to the duration of a full postgraduate master’s programme), is often difficult for practitioners to evaluate the appropriateness of different courses to meet their own learning needs.
The Department of Health mandated Health Education England (HEE) to produce education & training standards for aesthetic practice in 2013. I chaired the HEE process to produce the resultant education and training framework standards during 2013/4. The standards were successfully presented to the Department of Health (supported by Sir Bruce Keogh, CQC, the PSBRs and Royal Colleges) in October 2015. The standards were subsequently accepted in January, 2016 and a new voluntary regulatory register was established (as recommended in the HEE Report) – the Joint Council for Cosmetic Practitioners (JCCP). I was asked to chair this new body in January 2016.
Progress to date has been significant and the JCCP has now produced a revised sector wide education, training and practice competence framework that builds on and enhances the 2015 HEE Education & Training Framework. This framework was transferred by HEE to the JCCP in May 2018 and is now formally owned by the JCCP.
The new education & training framework and standards was published in July and is now available on the JCCP website. It can be used by the JCCP to register practitioners and by education and training providers to develop qualifications and programmes that accord with the JCCP’s education and training standards, which will replace the former HEE framework.
Since that time the JCCP has worked to create and design the Council in line with PSA standards and has established a formal Committee with the specific remit to review, enhance and revise the original HEE framework in line with new standards developed by the Cosmetic Practice Standards Authority (CPSA). The result has been the production of a new ‘JCCP Competency Framework’ that can be used by the JCCP to register practitioners and by Education and Training Providers to develop qualifications and education / training programmes that accord with the JCCP’s education and training standards.
The JCCP is aware that many training providers have been using the existing HEE framework to develop programmes and qualifications. Whilst this continues to be regarded as good practice, the JCCP now wishes to enter into discussion with education and training providers to determine how the new JCCP education and training standards and competence framework can be used to enhance and upgrade programmes and qualifications. Alignment to this new framework will be an entry requirement for those Education and Training Providers who wish to be recognised as JCCP Approved Education and Training Providers and included in the JCCP Register of Approved Education and Training Providers that will be launched in July 2018.
The JCCP acknowledges that it has no statutory right of obligation to ‘regulate the sector’ with regard to education and training standards but it has received wide support from many education providers who have declared their interest in seeking ‘approved’ status as becoming registered on the JCCP’s Education and Training Register. Acceptance onto this register will only be permitted after a rigorous quality assessment and site audit visit to the educator / trainers premises.
JCCP approved Education and Training Providers will be accredited and endorsed by the JCCP as meeting the highest standards of quality by:
- Ensuring that all parties who have been admitted to the JCCP’s Registers have met the agreed industry qualifications, benchmarks and abide by the standards of practice and behaviour as determined by the Cosmetic Practice Standards Authority (CPSA) and the JCCP.
- Ensuring that approved education and training providers are also able to provide explicit evidence of how they meet the JCCP’s education and training standards as described above.
- Adhering to the principles as required to operate a ‘voluntary register’ in the health sector by the Professional Standards Authority (PSA) which has approved the JCCP Practitioner Register and the JCCP Education and Training Register.
The JCCP has also entered in to a Memorandum of Understanding with the education regulator Ofqual who have acknowledged the work undertaken by the JCCP in setting education and training standards for the sector. In that agreement it is cited that:
“There will be circumstances where collaborative working between us will be the best way to enable us to discharge our respective regulatory, statutory, and corporate responsibilities effectively and efficiently. These areas of common interest include, but are not limited to the design development and delivery of high quality qualifications, in the area of non-surgical aesthetic treatments (including hair restoration surgery).”
The JCCP has also reached a formal understanding with the Advertising Standards Authority (ASA) to reduce the current existence of education and training provision that seeks mislead trainees and practitioners to assume that they are ‘accredited to practise’ following participation in courses that provide ‘false’ assurance about standards etc. The intentions set out in the ASA and JCCP statement of understanding is set out below:
“The recently adopted JCCP and CPSA Code of Practice foregrounds the importance of the Advertising Codes and guidance; this will send an important message to JCCP members about the need to advertise responsibly. In the course of its regulatory activities, the JCCP will encounter examples of advertising which it considers might be in breach of the Advertising Codes. The JCCP will undertake to advise the ASA of such concerns. In such circumstances, it is appropriate that the ASA, as the first line of control, assesses and, where necessary, investigates such material. The ASA will therefore be receptive to referrals of such complaints from the JCCP on an ongoing basis. From time to time it may also be useful for the ASA and the JCCP to review the quantity and nature of those referrals and the compliance of the sector more generally. By fostering an ongoing relationship, the ASA and the JCCP may identify opportunities for our two organisations to work together to encourage responsible advertising across this sector, particularly as the JCCP develops its regulatory influence. The JCCP and CPSA are at one with the primary objective of ensuring public safety when it comes to the process of considering and then undertaking non-surgical cosmetic treatments and hair restoration surgery.”
There has been much debate on the background of the JCCP with it still being listed as a company – does it run as a company and charity, and why do you think many practitioners have not supported the initiatives proposed by the JCCP?
The JCCP is a registered UK Charity and is a not-for profit company with charitable status as listed by Companies House and listed on the ‘UK Charity Commission Register’. Over 250 stakeholders, the GMC, NMC, HCPC, GPhC and the GDC and the majority of the key Professional Associations have declared their support for the JCCP.
There are three reasons given some members of the profession have questioned the validity of the JCCP:
- The inability of the JCCP to enforce regulation due to lack of Government intent (at present) to introduce statutory regulation for the sector.
- Misinformation and the need to describe and publicise the work of the JCCP and CPSA objectively, accurately and effectively to members of the public, to practitioners and other members of the industry.
- Challenges relating to the inclusion of non-health care professionals (who administer certain procedures) on the JCCP register.
Aesthetics is a highly political arena where the best interests of the public are not always at the forefront of the agenda. Genuine, ethical practitioners have been highly frustrated by the lack of clarity and regulation in the sector, and all the competing agendas and financial implications make it difficult to achieve consensus on the way forward.
The inclusive nature of the JCCP, seeking to voluntarily register proficient practitioners from differing backgrounds including those without PSRB registration has been challenging, but was the mandate from the Department of Health to support the establishment of the JCCP. Whilst statutory regulation remains unsupported and enacted by government, a voluntary register can only go so far in resolving the issue of public safety. For a voluntary register to be effective, two things are important:
- The public must look to it for reassurance of the proficiency of the practitioners on that register. Here is where the media could really assist by raising awareness of JCCP in a positive way so that it becomes the norm when considering treatment to check the proficiency and practice standards of the practitioner you choose.
- Practitioners must see it as a worthwhile investment to be on that register because it differentiates them from other practitioners and increases client confidence and ultimately increases their business. Here is where the media could assist by providing clear information and clarifying myths regarding the JCCP register.
The key focus of the JCCP is to improve public safety by improving standards of aesthetic practice. It is a major paradigm shift in the cosmetic sector and as with such cultural shifts, can take up to five years to become embedded. Many practitioners do support the initiatives being developed by the JCCP but are also influenced by misinformation, and political agendas.