Licensing and further regulation of non-surgical procedures: business and regulatory impact assessment

Annex – Summary of Responses to BRIA Survey

Introduction

The Scottish Government undertook an additional survey to help assess the impact of proposals on businesses. This built on evidence gathered through the public consultation and wider engagement. The purpose of this survey was to gather evidence specifically on the issue of the impact on businesses based on the Scottish Government’s updated proposals following the consultation to support the Business and Regulatory Impact Assessment.

The survey was issued to respondents of the consultation who indicated that they were owners, managers or employees of a business providing non-surgical cosmetic procedures (and who had agreed to be contacted). The survey was sent to 665 email addresses. Anyone with a link was able to respond and the link appears to have been forwarded to a number of other interested parties. As such, the number of respondents should not be considered a proportion of those invited to respond.

Responses

There were 591 respondents to the survey. This was a strong response with the scope to provide a robust evidence base. Respondents were asked “What type of business do you own/manage/work at?”. The responses options were:

• A clinic or other setting currently regulated by Healthcare Improvement Scotland;
• A salon or clinic not currently regulated by Healthcare Improvement Scotland but led by a healthcare professional (e.g. doctor, nurse, dentist, pharmacist);
• A salon or clinic which is not currently regulated by Healthcare Improvement Scotland and is led by someone who is not a healthcare professional; or
• Other.

The respondents who answered “other” were also asked for more detail about their business. The responses were reviewed, and in some cases, it was considered that a response should be considered alongside one of the other three main groups above. The remainder clarified that they were clients, associates of businesses providing procedures, or that they were involved in a business that providing training. In a small number of cases, it was not possible to classify the type of business. The numbers in the table below reflect where responses were categorised following this back-coding.

This question was asked to provide an understanding of the differing impact on businesses, depending on their existing level of regulation. The consultation identified that participants with different associations/links(?) to the sector were associated with differences in views on the consultation proposals. The impact on wider businesses, such as training providers, is a part of the wider consideration of the impact of Scottish Government proposals, so these responses were considered and are reflected in this write up.

Summary of responses

Many respondents, particularly those in currently regulated settings, mentioned that they were likely to incur some small additional costs but that these may be offset against potential greater consumer confidence and better safety.

Other respondents, particularly those in currently unregulated settings, predicted more negative impacts and in some cases significantly negative impacts. These included substantial additional costs and recruitment challenges around prescribers which in some cases caused respondents to feel that their businesses may no longer be sustainable.

Some respondents made it clear that they were based in England or otherwise outwith Scotland. These responses were largely framed in terms of the impact on their business if the Scottish Government proposals were implemented elsewhere. Insofar as they provided helpful evidence on the potential impact of proposals on businesses in Scotland they have been considered.

In general, the level of detail in responses was varied and only a minority gave robust details of financial impact. The evidence this provides is nonetheless helpful and has been reflected in the BRIA. Other feedback was received outwith this survey, including from several businesses who volunteered to outline details of their finances, and these have also been considered to support the BRIA.

Businesses currently regulated by Healthcare Improvement Scotland

These respondents in most cases will have experience of the requirements of Healthcare Improvement Scotland (HIS) regulation, and in most but not all cases they will be providing procedures in a manner close to or the same as envisaged in the Scottish Government proposals.

Positive/ neutral impacts

The majority of respondents in this group indicated that there would be either a neutral or a positive impact on the business they represent, or are operating in. Where a neutral impact was identified this was in many cases identified as being because the business already meets the requirements in the current Scottish Government proposals. Some respondents suggested a positive impact as more clients would use their services under the Scottish Government proposals, but these impacts were not quantified. Some of these respondents acknowledged there may be some small initial costs to their business – largely in terms of administrative time, costed in one case at £250-£500.

Negative impacts

It was clear from responses that not all of those offering procedures from a HIS registered setting are currently doing so in a way that aligns with the Scottish Government proposals, and as such some change to their business will be required. These impacts were identified by a minority of respondents in this group.

Respondents who identified such concerns were more likely to be from businesses where the practitioners undertaking procedures are not one of the four professions identified by the Scottish Government as suitable to do so, or where one of these appropriate professionals is not available to perform a supervisory function. A number of such businesses identified themselves. Often these businesses were small ones with a single practitioner, for instance a nurse who was not an independent prescriber. In other cases the business identified that an appropriate professional, for instance a prescriber, was present at some but not all times where relevant procedures were undertaken. In some cases these models appear to have been adopted to accommodate other commitments, including involvement in NHS healthcare, or to allow a business to operate from a premises too small for multiple practitioners to be present at a given time.

Respondents from businesses in this position have identified different levels of impact on their business. Some indicated that they, or another practitioner in their business, were a nurse or pharmacist but not registered as an independent prescriber, and suggested that they would need to seek such registration to adapt to the proposals at a cost of several thousand pounds (plus the time this would take, and the time that that practitioner would be away from the business).

Other respondents were from businesses that would need to employ an appropriate professional or extend the hours of an existing professional working within the business. These costs were generally high, reflecting the “going rate” for the time of relevant professionals. A small number of respondents in this group reported that their business would cease to be viable as a result of these higher costs, or the difficulty in employing an appropriate professional.

As well as staffing costs, some respondents identified other costs which would need to be met in upgrading their clinic to respond to the proposals. One respondent suggested it would cost £7,000 (on a one-off basis) to make such changes.

Businesses not currently regulated by Healthcare Improvement Scotland

These businesses are those currently offering outwith HIS regulation, and as such can be expected to not currently employ or wok with a healthcare professionals on site. Some may be licensed by a local authority in respect of any skin piercing, tattooing, electrolysis hair removal or semi-permanent make up they undertake. Businesses in this group may have a relationship with a healthcare professional, for the purpose of obtaining prescriptions for medicines, such as Botox^®, which may be used in procedures. Not all healthcare professionals are currently required to register a service with HIS, and as such some businesses in this group may be led by a healthcare professional who is not a doctor, dentist, nurse or midwife, pharmacist of dental professional or pharmacy technician.

Positive/ neutral impacts

The majority of respondents did not reflect a positive impact on their business, although some had positive comments around the proposals more generally, but as discussed above these are not pertinent to the discussion of the impact of regulation on businesses.

Limited positive impact was more likely to be described by respondents from businesses currently led by healthcare professionals, even if they are not HIS regulated. The main area of positive impact identified is in relation to greater regulation of the sector improving consumer confidence.

More common were responses which were essentially neutral, or indicated that the additional costs were relatively small. Such comments were seen both from healthcare led businesses, who considered their current businesses were well placed to adapt to the proposals, or from non-healthcare led businesses whose focus was on procedures included in group 1 of the Scottish Government procedures. These businesses would be required under the proposals to participate in a licensing scheme, but would not be required to register with HIS nor would there be any need for them to employ appropriate healthcare professionals. The costs of licensing have not been confirmed (and will be set by local authorities), but respondents may be considering existing costs of licenses (e.g. for tattooing and skin piercing, which some respondents may have experience of) and consider these costs to be more manageable.

Negative impacts

The majority of comments from respondents from businesses not currently regulated by HIS were negative and a range of different costs and impacts were highlighted.

The most substantial element of the proposals identified by respondents was the requirement for certain procedures to require the supervision of an appropriate healthcare professional. These comments were received from respondents from businesses that currently employed no healthcare professionals, but also from businesses where healthcare professionals (other than the four identified in the proposals as appropriate to supervise or undertake procedures, for instance non-prescribing nurses, or professionals such as physiotherapists regulated by the Health and Care Professions Council ) were employed.

The cost of hiring a prescriber is not always given, and some responses noted the scarcity of suitable prescribers, especially in rural areas. Where a cost is estimated these costs varied, and were reported in various forms, for instance:

• Hourly rate quoted was often in the region of £85-£100
• Day rates quoted were largely in the range £200-£500
• Monthly rates quoted were largely in the range of £2,000-£4,000

Annual rates were usually quoted in relation to a business's particular scenario, and a wide range of figures were quoted. At the higher end of the range the cost of employing a prescriber for “full time” cover was given by one respondent as £70,000, whereas at the other end of the range another respondent calculated that they would require cover for two days a week, at a cost of from £19,200 a year. The assumption generally made was that it would be a nurse independent prescriber hired, not a doctor, dentist or pharmacist. The exact hiring/employment model was not discussed, nor the relationship between wages and other employment costs.

These themes were shared between the different types of businesses, however respondents who were other healthcare professionals, or were involved in businesses where other healthcare professionals worked, were more likely to highlight that the impact was as a result of the Scottish Government decision not to include such professions in the proposed list of appropriate healthcare professionals, whereas other respondents focused on the principle of supervision more generally.

Other costs were identified by respondents:

• The cost of HIS registration, again different figures were quoted for this, although the registration cost for an independent clinic is fixed at £3,745, and annual continuation £1,787 (multi-handed clinic only undertaking non-surgical and non-dental procedures – figures for 2025-26 - Independent healthcare regulation fees information booklet: 2025-2026. – Healthcare Improvement Scotland)
• The cost of providing upgrades to a premises or meeting other costs necessary to successfully register with HIS (£4,000- £15,000 quoted)
• The cost of additional training (£2,000-£15,000 quoted)
• Administrative costs (£1,000-£4,000 PA quoted)
• Increases in insurance premiums – with one respondent suggesting this could be as much as a 15-25% increase, albeit with the absolute figure not given.

Where respondents identified that their business would not be sustainable under the Scottish Government proposals, and where a single or main reason was given for this, the reason given was usually either the difficulty of hiring an appropriate healthcare professional, or that the cost of hiring such a professional would make the overall business model unsustainable. Some respondents indicated that they believed that, although the proposals allow non healthcare professionals to provide some procedures under supervision, this would not be sustainable for anyone, and only prescribers undertaking procedures themselves would be able to successfully or profitably operate businesses offering such procedures.

Numerous respondents did suggest that their businesses would or would be likely to close (or, in more general terms, that other businesses would close) with commensurate loss of employment and loss of livelihood for the respondent. Such sentiments were directly expressed in around a quarter of responses, and were implied in more. Some respondents indicated that bankruptcy would follow, especially where there were liabilities linked to the businesses, for instance a multi-year contract for rent of premises, debt incurred to hire equipment, etc. Other responses highlighted that this may lead to unemployment for other people working in the business.

Other respondents indicated that prices would have to increase, with a commensurate impact on the accessibility of procedures. Other set out that they have to date spent significant sums (some individuals specifying tens of thousands of pounds) on training and qualifications that may now be wasted if they cannot continue to practise.

Multiple respondents highlight that the sector is predominantly female-led, and that the proposals will disproportionately affect women’s businesses, economic independence, and family stability.

Other

While not specifically invited, some of the respondents reflected on the impact on businesses other than the ones they owned, worked at or managed. In addition, six respondents who identified as “other” in response to the question about their business identified as training providers, and other respondents identified themselves as working for a pharmacy that supplied the sector or as a manufacturer of products used in non-surgical procedures.

These responses identified a “ripple effect” for other businesses, with most comments focused on the impact on training providers, with fewer viable businesses seeking their services. Some responses identify that training providers are already seeing some impact as uncertainty around training requirements, and the viability of businesses has led to a decrease in demand for training courses.

Cross-cutting themes

The purpose of this survey was primarily to consider business impact and the responses from clients or other associates of businesses were only considered where relevant detail on impact on businesses was provided. Views on the proposals (as opposed to the impact) are also not considered in detail, although, in summary, a salient perception captured was the view that: even if some businesses were negatively affected, they still supported greater regulation. Others indicated that they were supportive of more regulation but felt that the impact on their business was disproportionate.

Some respondents made points that set out personal or sectoral impacts that were not direct business impacts and were not necessarily associated with belonging to a certain part of the sector. These are noted below:

• Many respondents describe a significant, and in cases severe, depth of emotional and psychological distress as a result of the uncertainty and threat to their livelihoods.
• A sense of unfairness has been described by many respondents, with regulated businesses feeling they have borne costs for years, and non-prescribers and other non-healthcare practitioners feeling unfairly excluded from being able to work in future, despite their skills.
• A small number of the respondents warned that higher prices and reduced availability could push clients to unregulated, underground, or “black market” providers, increasing public health risks.