Regulation and licensing of non-surgical cosmetic procedures: consultation analysis and response
Summary of feedback from recent consultation and wider engagement, with revised proposals for regulation of non-surgical cosmetic procedures and an explanation of legislative next steps.
2: Findings from the consultation
This section is structured around the questions posed by the consultation. However, it includes insights gained from both the consultation and, wider correspondence and engagement with stakeholders.
When setting out quantitative information from the consultation the number of respondents who gave a particular answer to a closed question has been included. When there is an explanation of the views people have shared, this section sometimes refers both to the reasoning expressed in free text responses as a part of the consultation and, where relevant, to views expressed in other correspondence or engagement.
The tables below provide the figures for responses to each question. All percentages are rounded to the nearest whole percentage.
Summary of findings
Respondents to the consultation and other stakeholders the Scottish Government has engaged with are supportive of efforts to make the non-surgical cosmetic procedures sector safer and better regulated, although there are differences in views on the best way to achieve this.
There is broad support for the principle that some procedures can be safely undertaken in a licensed setting, and a majority agreed with the Scottish Government’s proposals for which procedures should be in this group.
There is also broad support for the principle that some procedures can only be safely undertaken by an appropriate healthcare professional and the majority agreed with the Scottish Government’s proposals for which procedures should be in this group.
There is less support, and less agreement amongst stakeholders, for procedures that the Scottish Government has proposed should be restricted to a Healthcare Improvement Scotland (HIS) regulated premises, but which could still be undertaken by a non-healthcare professional practitioner. Views on these procedures are often correlated with the background of those responding, however, the largest group of respondents did not declare an association with the sector. Those who currently work in the regulated, clinical part of the sector were more likely to propose that such procedures should be restricted to a healthcare professional. Those who work in the currently unregulated, non-clinical part of the sector are more likely to believe that such procedures should continue to be undertaken outwith a clinical context (but still accept the value of a licensing scheme). The procedures under contention include some of the most commonly available and undertaken ones, including injections of dermal fillers and Botox®.
The overall consideration of views demonstrated different approaches to risk, and different understandings of how risk can best be mitigated, and these views were again frequently correlated with the background of the respondent. Many respondents from all backgrounds emphasised the importance of safety, but some highlighted the belief that the Scottish Government’s proposals would impose restrictions beyond those that were necessary to support public safety and also raised the impact of what they perceived as unduly onerous restrictions on businesses.
There was strong support for many of the practical aspects of proposals made, such as the requirement for a dual licensing system for procedures taking place outwith a HIS regulated setting, and for local authorities and HIS to have appropriate powers to enforce their proposals.
There was also strong support for an age restriction on non-surgical cosmetic procedures to be set at 18.
Detail of findings by consultation question asked
Views on the proposed grouping of procedures (Questions 1-4)
The initial questions in the consultation related to the proposed grouping of procedures, specifically the allocation of individual procedures to one of three groups. The first three questions outlined the suggested groupings for each procedure, and the level of regulation proposed for each group:
- Group 1: Procedures which should be undertaken in either a licensed premises or in a HIS regulated setting.
- Group 2: Procedures which should only be undertaken in a HIS regulated setting.
- Group 3: Procedures which should be undertaken in a HIS regulated setting by an appropriate healthcare professional.
Respondents were asked to indicate how they thought each procedure should be regulated, with the option to choose one of the following response options:
- Should be undertaken in either a licensed premises or in a HIS regulated setting.
- Should only be undertaken in a HIS regulated setting.
- Should be undertaken in a HIS regulated setting by an appropriate healthcare professional.
- No regulation required for this procedure.
- Don’t know.
In the tables in this section the headings for the first three of these options are shortened to “Group 1”, “Group 2” and “Group 3”, but respondents in the consultation were given the full titles as listed in the bullets above.
Question 4 was a free text question asking for other comments on the proposed groups. Some respondents to the free text question (question 4) used this as an opportunity to make wider comments beyond the scope of the question. Those were noted and are included in the relevant section.
The grouping of procedures is central to the proposals, as it will dictate how different procedures are treated: who can undertake them, and in what settings. All these questions had a high response rate. Scottish Government has also received many comments in correspondence, or in meetings with stakeholders where the grouping of procedures was discussed. People or respondents either made general comments on the groups or provided specific information about individual procedures making a case for them to be included in a different group. These views have been included alongside the responses to the question received in the consultation.
Respondent views on procedures proposed as Group 1
Question 1 asked about procedures that were proposed as Group 1 procedures. The proposal was that these should be undertaken in either a licensed premises or in a HIS regulated setting. On average, across the procedures in this group, around half of responses (52%) agreed with the level of proposed regulation for Group 1. Around a third felt that more stringent regulation should be applied; 20% at the level proposed for Group 2 and 15% at the level proposed for Group 3. Around one –in ten (10%) felt that no regulation should be required for the proposed Group 1 procedures. Agreement with the proposed regulation was reasonably uniform across the five specific procedures proposed as Group 1, ranging from 47% agreement for “Use of lasers for tattoo removal” to 56% agreement for “Laser hair removal”.
| Procedures | Group 1 | Group 2 | Group 3 | No regulation | Don’t Know |
|---|---|---|---|---|---|
| Microneedling | 52% | 18% | 15% | 12% | 2% |
| Chemical peels on the outer layer of skin | 51% | 19% | 15% | 13% | 2% |
| IPL/LED therapy | 53% | 18% | 13% | 13% | 3% |
| Laser tattoo removal | 47% | 24% | 20% | 6% | 4% |
| Laser hair removal | 56% | 22% | 12% | 8% | 2% |
| Average across all | 52% | 20% | 15% | 11% | 2% |
Between 2089 and 2111 respondents answered each part of this question, equating to at least 95% of respondents for each question. The averages presented in Table 1 for each procedure exclude respondents who did provide an answer and are based on the total number of respondents who did provide an answer. The average across all percentages is based on respondents who gave an answer to all 5 procedures, which equates to 97% of respondents who gave an answer to at least one. Mean percentages are rounded to the nearest whole number, so each row may not sum to 100%.
Some respondents to question 4 (the free text box) indicated that they thought that the Group 1 category was described in a confusing way in the question. It was described as procedures that “should be undertaken in either a licensed premises or in a HIS regulated setting.” The proposal assumed that any procedure which is available under a licence can also be carried out in a HIS regulated premises. However, some respondents felt that this provided room for interpretation: for instance, that the Scottish Government may interpret respondents who chose Group 1 for these, or any other procedure, as not giving a clear preference, or as support for restricting these procedures to a HIS setting as well. Agreement with this question when analysing responses was taken as meaning that these procedures should be available under licence. Where people chose “no regulation” this was interpreted as meaning they did not think a licence should be required.
The support for at least some procedures to be included in the proposed Group 1 can also be taken as support for the principle of regulating some procedures under a license. Considering the written responses to question 4 and the comments made during engagement it is clear that respondents do think that some procedures can be undertaken in a licensed setting safely, and that healthcare professionals do not need to be involved in these procedures, which are broadly, but not universally, considered lower risk. This was qualified by some concerns about the nature of the licensing model. Questions 5-10 of this consultation asked about the licensing model. The responses to those questions are set out under a separate heading.
The free text responses to question 4 showed that some respondents considered that regulating procedures to be undertaken in either a licensed premises or in a HIS regulated setting was insufficient. These respondents set out that they felt that this approach would not sufficiently prioritise public safety, that it cannot sufficiently ensure that practitioners are suitably trained. Some respondents set out that because this approach did not require a medical or healthcare professional to be involved in the procedure it would not be sufficiently safe. These were the most mentioned themes in the responses to question 4.
Significant variation in views on the appropriate level of regulation for Group 1 procedures was evident based on respondents’ reported involvement with the industry (Table 2). Those associated with an unregulated setting were most likely to agree with the proposed level of regulation for Group 1 (60%). Disagreement from this group of respondents was more commonly associated with the view that there is “no regulation required for this procedure” (26%), rather than supporting a greater level of regulation (13%).
Conversely, those not involved in the industry and those associated with a regulated setting were reasonably aligned with their views on the appropriate level of regulation for Group 1 procedures. Around half (49% and 52% respectively) agreed with the proposed regulation, but these cohorts were far more likely to feel a greater level of regulation was appropriate (40% and 42% respectively) and much less likely to feel no regulation was required (8% and 5% respectively).
| Declared connection to sector | Group 1 | Group 2 | Group 3 | No regulation | Don’t know |
|---|---|---|---|---|---|
| Not involved in sector | 49% | 21% | 19% | 8% | 3% |
| Involved in regulated or medical setting | 52% | 27% | 15% | 5% | 2% |
| Involved in currently unregulated Setting | 60% | 9% | 4% | 26% | 2% |
| Not answered | 59% | 16% | 8% | 11% | 6% |
Respondent views on procedures proposed as Group 2
The consultation proposed that certain procedures carrying a higher level of risk be included in Group 2. The proposal was for Group 2 procedures to be carried out in a HIS regulated premises by either a healthcare professional or trained non-healthcare practitioners under the supervision of an appropriate healthcare professional.
| Procedures | Group 1 | Group 2 | Group 3 | No regulation | Don’t Know |
|---|---|---|---|---|---|
| Mesotherapy | 21% | 22% | 50% | 4% | 3% |
| Injections of toxins e.g. Botox® | 18% | 15% | 62% | 3% | 2% |
| Injections of drugs | 18% | 16% | 61% | 3% | 2% |
| Injection of semi-permanent dermal fillers up to 2ml | 19% | 15% | 61% | 3% | 2% |
| Other injections for cosmetic or lifestyle purposes | 20% | 17% | 57% | 3% | 3% |
| Medium depth peels | 20% | 25% | 49% | 3% | 3% |
| Photo rejuvenation | 22% | 28% | 34% | 5% | 11% |
| Radiofrequency | 23% | 30% | 33% | 6% | 8% |
| High frequency ultrasound | 22% | 31% | 34% | 5% | 7% |
| Cryolipolisis | 19% | 27% | 44% | 4% | 6% |
| Average across all | 20% | 22% | 51% | 4% | 5% |
The most common response for each of the ten procedures in this group was that they should only be undertaken by appropriate healthcare professionals in a HIS regulated setting, which would place these procedures in Group 3. On average across all 10 procedures, half (51%) of respondents felt that the Group 2 procedures should be within Group 3, whilst 22% agreed with the proposal for Group 2. A fifth (20%) felt that they should be in Group 1, and a minority (4%) felt that no regulation was necessary.
Between 2098 and 2115 respondents answered each part of this question equating to at least 95% of respondents for each question. The averages presented in Table 2 for each procedure exclude respondents who did provide an answer and are based on the total number of respondents who did provide an answer. The average across all percentages is based on respondents who gave an answer to all 10 procedures, which equates to 94% of respondents who gave an answer to at least one. Mean percentages are rounded to the nearest whole number, so each row may not sum to 100%.
In general, there was not high support for there being a Group 2 and there were several different and conflicting views why people thought this. In reviewing the free text responses, and from direct engagement with stakeholders, it has become clear that there were two broad groups of respondents advocating for the different treatment of this group. To some degree these views were correlated to background and connection to the non-surgical cosmetic procedures industry.
One group of respondents and stakeholders expressed concern that the protections outlined in Group 2 would be insufficient to ensure public safety, particularly in relation to procedures such as Botox® and dermal fillers, which were the most mentioned in this context. Some respondents to question 4 indicated that the procedures should be in Group 3 to ensure that there is a consistent role for healthcare professionals, because they felt that this was the best and only way to effectively protect public safety. Similar views were also shared in correspondence, and in engagement with a range of stakeholders. This view was correlated with healthcare professionals and those who identified as working in the currently regulated, clinical part of the sector.
Another group of respondents and stakeholders expressed concern that requiring these procedures to be undertaken in HIS regulated premises represents an excessive or undue restriction on the businesses carrying them out or the clients seeking to access them. This view was often held by those that were associated with the currently unregulated, non-clinical, part of the sector. Those holding this position were less likely to emphasise the importance of public safety. Participants in business engagement events, did emphasise the importance of public safety, but expressed a view that these procedures can be safely carried out in a licensed premises by a licensed practitioner. Participants in business engagement events could highlight their own training and experience of safe practice. In some cases, they raised the concern that over-restricting procedures would lead to less safe practice if procedures were undertaken more clandestinely. These respondents were also likely to express concern that the Scottish Government had not, at the point that proposals were drawn up, sufficiently engaged with businesses such as theirs and so did not understand their part of the sector or how it was currently operating safely.
These distinctions, between those who identified as working in the currently regulated, clinical part of the sector and those that were associated with the currently unregulated, non-clinical, part of the sector, can be seen in the different responses given to question 2. The distinctions are especially clear when considering “injectable” procedures, shown in table 4 below (mesotherapy, injections of toxins, injections of drugs, injection of semi-permanent dermal fillers up to 2 millilitres, other injections for cosmetic or lifestyle purposes). The distinction between the responses is less marked when considering the remaining Group 2 procedures shown in table 5 below. Here you can see that 71% of those involved in a regulated or medical setting were likely to believe that injectable procedures should be in Group 3, whereas only 27% of those involved in the currently unregulated part of the sector held this view. 47% of these respondents felt that injectable procedures should be in Group 1. Those who did not report any connection the sector had views closer to those involved in the currently regulated part of the sector. The distinction was also present for other procedures, but far less pronounced.
Injectable procedures such as Botox® and dermal fillers were far more likely than other proposed Group 2 procedures to be raised in responses to question 4 or in other correspondence or engagement. Healthcare professionals and those from the currently regulated part of the non-surgical cosmetic procedures sector were more likely to raise concerns about these procedures and often expressed the view that they were riskier than many of the others under consideration for Group 2; and as risky, or riskier than many of the proposed Group 3 procedures.
| Declared connection to sector | Group 1 | Group 2 | Group 3 | No regulation | Don’t know |
|---|---|---|---|---|---|
| Not involved in sector | 13% | 17% | 65% | 2% | 3% |
| Involved in regulated or medical setting | 12% | 12% | 75% | 1% | 1% |
| Involved in currently unregulated Setting | 47% | 14% | 29% | 8% | 2% |
| Not answered | 18% | 30% | 40% | 4% | 6% |
| Declared connection to sector | Group 1 | Group 2 | Group 3 | No regulation | Don’t know |
|---|---|---|---|---|---|
| Not involved in sector | 14% | 29% | 46% | 3% | 8% |
| Involved in regulated or medical setting | 16% | 33% | 44% | 2% | 5% |
| Involved in currently unregulated Setting | 47% | 19% | 13% | 13% | 8% |
| Not answered | 32% | 29% | 21% | 8% | 10% |
Respondents from both broad groups have raised significant concerns about the principle of supervision in relation to Group 2 procedures. A significant minority of responses to question 4 discussed supervision, with some specifically arguing that the principle needed to be more clearly defined. The issue was also raised by stakeholders during other engagements and meetings, including in engagement with businesses.
It is evident from these comments that many respondents did not feel the concept of supervision was clear. Again, concerns were broadly divided between those who feel that requiring supervision of a healthcare professional might be overly burdensome or undervalue the professionalism and competence of non-healthcare professionals; and those who believed that supervision offered insufficient protection, especially if it was remote or undertaken by someone lacking relevant expertise.
Later questions in the consultation were relevant to the principle of supervision. This is covered in more detail below.
Significant minority positions relevant to the treatment of Group 2 procedures were also set out in free text boxes. These included concerns about the impact of HIS regulation, government overreach or a perception that proposals had been informed by a bias against non-healthcare professional practitioners and a desire to restrict the delivery of some of the most commonly delivered procedures in the interests of those who are providing them in a clinical context.
Respondent views on procedures proposed as Group 3
Many consultation respondents agreed with the proposals for Group 3 procedures to be undertaken by an appropriate healthcare professional in a HIS regulated setting. On average across all 15 procedures more than seven in ten respondents (72%) agreed that Group 3 procedures were appropriately categorised. Around one in ten (10%) felt that these should be in Group 2, and a similar proportion (13%) felt that they should be in Group 1. A minority (2%) felt that no regulation was necessary.
A majority of respondents (55%) agreed that all Group 1 and Group 2 procedures carried out in an intimate area, such as the genitals or buttocks (except hair removal), should be included in Group 3, although a reasonable number of respondents considered that these could be carried out in a licensed or HIS regulated setting. A significant minority (36%) of respondents felt that at least some procedures in this group could move to Group 1 or 2.
Electrocautery and, cryotherapy/cryocautery received significant minority support for inclusion in a different group (37% and 36% respectively). Responses to question 4 (a free text question), as well as representations made in other engagements, challenged their inclusion in Group 3 and argued that they would be suitable for being placed in Group 1 under the local authority licensing scheme. Responses from those involved in delivering these procedures have highlighted the similarities with procedures such as electrolysis (electrocautery is frequently described as advanced electrolysis by practitioners), which is currently available under a licence under the Civic Government (Scotland) Act 1982 (Licensing of Skin Piercing and Tattooing) Order 2006.
| Procedures | Group 1 | Group 2 | Group 3 | No regulation | Don’t Know |
|---|---|---|---|---|---|
| Platelet rich plasma, biotherapy or injections of any products derived from the patient’s blood | 13% | 7% | 75% | 2% | 3% |
| Injection microsclerotherapy | 14% | 9% | 71% | 2% | 3% |
| Injection lipolysis | 15% | 7% | 73% | 3% | 2% |
| Dermal micro coring | 12% | 8% | 74% | 2% | 4% |
| Hayfever injections | 13% | 12% | 68% | 3% | 4% |
| Procedures involving intravenous fluids or processing of bloods | 11% | 8% | 77% | 2% | 3% |
| Dermal fillers for augmentation | 7% | 4% | 86% | 1% | 2% |
| Deep (phenol) peels | 10% | 9% | 75% | 1% | 4% |
| Laser treatments not specified above including deeper dermal | 14% | 11% | 69% | 2% | 4% |
| Carboxytherapy | 12% | 9% | 71% | 2% | 5% |
| Cellulite subcision | 8% | 6% | 80% | 1% | 5% |
| Electrocautery | 22% | 15% | 58% | 4% | 2% |
| Cryotherapy/cryocautery | 19% | 17% | 58% | 3% | 3% |
| Thread lifting and cogs | 9% | 9% | 76% | 2% | 4% |
| Procedures carried out on intimate areas | 19% | 17% | 55% | 3% | 6% |
| Average | 13% | 10% | 72% | 2% | 4% |
Between 2098 and 2164 respondents answered each part of this question equating to at least 95% of respondents for each question. The averages presented in Table 3 for each procedure exclude respondents who did provide an answer and are based on the total number of respondents who did provide an answer. The averages across all percentages are based on respondents who gave an answer to all 15 procedures, which equates to 91% of respondents who gave an answer to at least one. Mean percentages are rounded to the nearest whole number, so each row may not sum to 100%.
Free text responses to question 4 included a high proportion of respondents who indicated that it was important for healthcare professionals to be involved in the delivery of procedures. They indicated their support for procedures being included in Group 3 (the only group where procedures were restricted to healthcare professionals).
Given significant support for procedures such as breast and buttock augmentation to be included in Group 3, there is clearly strong support for a group 3, containing at least some of the procedures proposed in the consultation. Regarding Group 3, those in the clinical and non-clinical parts of the sector did not significantly differ in their views on most of these procedures. This aligns with views expressed at the business engagement events. Many non-healthcare practitioners and businesses offering procedures in a non-clinical setting are clear that there are certain procedures (often those listed in Group 3) that they do not consider themselves qualified to conduct and/or that they do not think can safely be carried out in non-HIS regulated settings.
Wider comments from consultation respondents and stakeholders provided on the proposed groups
Where comments were linked to the specific groupings, they are covered above, however, there are some significant overarching themes that emerged from the free text box and were echoed in wider engagement undertaken. The most raised themes were around referring to the need (or not) for qualified healthcare professionals to be involved in at least some procedures, and the need for adequate training and qualifications to enable procedures to be undertaken successfully. In some cases, it was highlighting that there are non-healthcare professionals with the training and qualifications necessary to safely undertake procedures, but in some cases, respondents thought that “appropriate” training was only available to those with a healthcare background.
There was a very significant number of responses referring to the need for public safety to be a priority. This was also a priority highlighted in other engagement and correspondence. Those prioritising public safety did nonetheless make different suggestions about the degree of regulation required to achieve this. The theme of safety also arose in comments to other questions in the consultation, for example the question relating to how regulation might affect people differently according to their financial circumstances.
Various other themes were less frequently mentioned by respondents to the consultation. Those refer to specific priorities for regulation, such as the need for consistency in standards, for a method to regulate new procedures, and the need to address the psychological and mental health needs of prospective clients. Some respondents also raised concerns about the specific impact of the proposals on NHS staffing, arguing that restricting popular procedures to Group 2 or 3 would increase the demand for healthcare professionals in the sector, and a fear that this may attract staff away from the NHS. On the other hand, some responses raised concerns about the impact on the NHS of procedures remaining unregulated, noting that the current lack of regulation leads to clients presenting with complications that practitioners are unable to manage.
Comments and responses relating to procedure risk and its relation to grouping
Some responses to question 4, along with comments received through correspondence and other channels, addressed the overall grouping of procedures and how these groupings relate to levels of risk. Many highlighted individual procedures or groups of procedures that they considered had different risk profiles compared to others within the same group. For instance, as set out above, some participants in the business engagement events highlighted electrocautery as being very low risk compared to other Group 3 procedures. On the other hand, comments from medical professionals suggested that the risks associated with dermal fillers were equal to, or greater than, all but a few Group 3 procedures; and that they were significantly higher than many of the other Group 2 procedures.
Discussions with stakeholders also revealed different approaches to, and perceptions of, risk more generally. The practitioners that engaged with government highlighted personal experiences of undertaking large numbers of some procedures with no or very low rates of serious complications. Medics highlighted the serious potential adverse events that might arise from the same procedures. In these cases, the emphasis differed between the severity of potential adverse outcomes and their likelihood. Furthermore, it was noted that some procedures carried extremely serious risks that could nonetheless be relatively easily mitigated through safe practice. As such, consultation respondents and stakeholders who disagreed about the grouping of a procedure may have done so not because they disagreed on the actual risk of procedure, but because they have a differing understanding of the most appropriate mitigation.
Respondents also took different views on the appropriate level of caution to be exercised. Some respondents advocated for a precautionary approach, and that risk should be mitigated by the most robust regulation and restriction possible. Others advocated for an approach where restrictions were introduced in proportion to the proven risk of a procedure.
Practitioner Licenses (Questions 5-7)
Responses to the 2020 consultation on the regulation of non-surgical cosmetic procedures showed that most people supported the licensing of non-healthcare premises offering these procedures. This consultation sought views on whether practitioner licences for practitioners of Group 1 procedures operating in a licensed setting should be used, and should the same be required of Group 1 practitioners operating in a HIS regulated setting.
The overwhelming majority of respondents strongly supported (1538) or somewhat supported (274) the proposal that practitioners of Group 1 procedures in licensed premises should also require a practitioner licence. The support for practitioner licences in this setting was over eight times more than those who opposed or somewhat opposed this proposal. This can be taken as an endorsement of the principle of a licensing scheme as appropriate for at least some procedures.
By contrast, most respondents disagreed (963) or somewhat disagreed (301) with the proposal that a practitioner licence would not be required for practitioners of Group 1 procedures operating in a HIS regulated setting. This was more than double the number who supported or somewhat supported the consultation proposal.
821 responses were received in the free text box. Many of the views were not directly about the licensing questions but were about the broad proposals to regulate the sector. These views have also been included in the relevant sections of this response.
The overriding theme from this free text box on practitioner licences was that all clinics should be licensed to ensure that they operate to the same standards to ensure the safety and professionalisation of the industry. Some views were expressed that licensing should fall under one regulatory body. This resonates with the view that practitioners providing Group 1 procedures in HIS regulated clinics should require a practitioner licence.
Appropriate training for practitioners of Group 1 procedures, including complications training, was highlighted as important. The third most recurring theme from the free text responses was the importance of licensing for public protection and safety and the importance of qualified practitioners in helping to achieve this.
Although not relevant to practitioner licences for practitioners of Group 1 procedures, respondents took the opportunity to state that training for the higher risk procedures (i.e. those in Groups 2 and 3) should also be required to ensure public safety and that those performing procedures should be qualified. Some respondents highlighted the need to safeguard vulnerable groups and young people from easily accessing certain procedures. Some also added that consumer confidence would also be improved by licensing while a few felt that establishment of a public facing register of licensed practitioners and premises would inform public choice and aid enforcement of regulations.
| Responses | Total | Percent |
|---|---|---|
| Strongly support | 1538 | 70% |
| Somewhat support | 274 | 12% |
| Neutral | 137 | 6% |
| Somewhat oppose | 83 | 4% |
| Strongly oppose | 126 | 6% |
| Not Answered | 49 | 2% |
There were 2158 responses to this question.
| Responses | Total | Percent |
|---|---|---|
| Strongly support | 419 | 19% |
| Somewhat support | 203 | 9% |
| Neutral | 263 | 12% |
| Somewhat oppose | 301 | 14% |
| Strongly oppose | 963 | 44% |
| Not Answered | 58 | 3% |
There were 2149 responses to this question.
Setting Standards (Questions 8 and 11)
The questions asked about setting standards of training and qualifications in a licensed setting or in a HIS regulated setting; and mandatory insurance and indemnity to compensate clients who suffer from harm because of negligence or malpractice. The question about standards for a licensed setting asked about standards of hygiene and health and safety for such premises, but the proposal took this as read for HIS settings (as standards already apply).
Across both questions respondents were overwhelmingly in favour of the proposed standards being set.
| Standards | Strongly Agree | Agree | Neither Agree nor Disagree | Disagree | Strongly Disagree | Don’t know | Not Answered |
|---|---|---|---|---|---|---|---|
| Standards of hygiene and health and safety | 83% | 11% | 2% | 1% | 1% | 0.1% | 2% |
| Standards of training and qualification | 82% | 12% | 2% | 1% | 1% | 0.2% | 2% |
| Mandatory insurance and indemnity | 85% | 11% | 1% | 0.4% | 1% | 0.4% | 2% |
Between 2153 and 2160 respondents answered each part of this question.
| Standards | Strongly Agree | Agree | Neither Agree nor Disagree | Disagree | Strongly Disagree | Don’t know | Not Answered |
|---|---|---|---|---|---|---|---|
| Standards of training & qualifications | 73% | 13% | 4% | 2% | 3% | 2% | 3% |
| Mandatory insurance & indemnity | 81% | 12% | 2% | 0.5% | 0.5% | 1% | 3% |
Between 2145 and 2146 respondents answered each part of this question.
Enforcement powers for Local Authorities and HIS (Questions 9 and 16)
The consultation asked for public views on enforcement powers for local authority officers and HIS.
Respondents were very strongly in favour of providing local authority officers with powers to remove licences from premises or practitioners who cannot demonstrate compliance with standards established by the Scottish Government. This positive response was also reflected regarding providing local authorities powers to bar individuals from holding a licence if they are associated with serious or repeated non-compliance with established standards. Responses in favour of increased enforcement powers were at 90% for each.
| Local Authority Powers | Strongly Agree | Agree | Neither Agree nor Disagree | Disagree | Strongly Disagree | Don’t know | Not Answered |
|---|---|---|---|---|---|---|---|
| The removing of a licence from premises or practitioners | 76% | 15% | 3% | 2% | 1% | 1% | 2% |
| Barring individuals from holding a licence | 81% | 12% | 2.% | 1% | 1% | 0.4% | 2% |
Between 2156 and 2157 respondents answered each part of this question.
Responses also showed overwhelming support for HIS to have powers of inspection, including of entry and inspection of unregistered settings where they have reason to think registration is required.
| Responses | Total | Percent |
|---|---|---|
| Agree | 1907 | 86% |
| Disagree | 140 | 6% |
| I don’t know | 85 | 4% |
| Not Answered | 75 | 3% |
There were 2132 responses to this question.
Views on Licences for Vehicles (Question 10)
The consultation asked for views on whether local authorities should be able to license vehicles as a licensed premises. Just over half of respondents stated that vehicles should not be eligible for a licence by any local authority; although a notable number felt that local authorities should have the discretion to issue such licences. A not insignificant number stated that vehicles should be eligible for a licence in all local authorities.
| Responses | Total | Percent |
|---|---|---|
| Local authorities should have discretion to decide whether a vehicle can receive a licence as a premises | 501 | 23% |
| Vehicles should be eligible for a licence in all local authorities | 159 | 7% |
| Vehicles should not be eligible for a licence in any local authority | 1169 | 53% |
| I don’t know | 318 | 14% |
| Not Answered | 60 | 3% |
There were 2147 responses to this question.
Supervision for Group 2 procedures in HIS regulated services (Question 12)
The consultation proposed that Group 2 procedures could be safely carried out by a trained practitioner who is not a healthcare professional, but that such practitioners should be supervised by an appropriate healthcare professional. The consultation sought the public views on specific aspects of the role of the supervising healthcare professional.
An absolute majority of respondents agreed with each of the proposals presented in the consultation:
- That the healthcare professional should conduct any initial consultation with clients (noting here that approximately a quarter of that number disagreed);
- That the healthcare professional should prescribe medications that may be required during the procedure or for the management of any complications;
- That the healthcare professional should remain onsite for the duration of the procedure;
- That the healthcare professional should be responsible for ensuring the practitioner is suitably trained for the procedure;
- That the healthcare professional should be responsible for ensuring the procedure will be undertaken safely; and
- That the healthcare professional should be themselves suitably trained and qualified in the procedure being undertaken.
The greatest disagreement with the above proposals was regarding healthcare professionals remaining onsite, which was approximately one third of those in favour of the proposal. Some of the responses to this question were split according to the background of the respondent, with those from the currently unregulated, non-clinical part of the sector less likely to support elements of supervision. A majority of the currently unregulated, non-clinical part of the sector respondents disagreed with the following proposals: that the healthcare professional should conduct any initial consultation with clients; and that the healthcare professional should remain onsite for the duration of the procedure.
| Supervising responsibilities | Agree | Disagree | Don’t know | Not Answered |
|---|---|---|---|---|
| Supervising healthcare professional - Conduct the / any initial consultation(s) with the client | 73% | 19% | 6% | 3% |
| Supervising healthcare professional - Prescribe any medications (e.g. Botox®, lidocaine) required during the procedure, or required for the management of any complications that arise | 79% | 11% | 6% | 3% |
| Supervising healthcare professional - Remain available on site for the duration of any procedure | 70% | 21% | 6% | 3% |
| Supervising healthcare professional - Be responsible for ensuring the practitioner is suitably trained for the procedure. | 82% | 11% | 4% | 3% |
| Supervising healthcare professional - Be responsible for ensuring the procedure will be undertaken safely | 80% | 12% | 4% | 3% |
| Supervising healthcare professional - Be themselves suitably trained and qualified in the procedure being undertaken? | 89% | 5% | 3% | 3% |
Between 2133 and 2142 respondents answered each part of this question.
Group 3 procedures performed by certain healthcare professionals (Questions 13 and 14)
The consultation sought views on whether Group 3 procedures should be undertaken by a suitably qualified healthcare professional working within their scope of practice, or whether the procedures should only be performed by certain healthcare professionals. Most respondents were in favour of the second option, that procedures should only be performed by certain healthcare professionals, but a significant minority supported the first option, that Group 3 procedures should be undertaken by any suitably qualified healthcare professional working within their scope of practice.
| Responses | Total | Percent |
|---|---|---|
| These procedures should be undertaken by a suitably trained and qualified healthcare professional working within their scope of practice, but not otherwise be limited. | 907 | 41% |
| These procedures should only be undertaken by certain healthcare professionals please see list in next question and tick all that apply. | 1172 | 53% |
| Not Answered | 128 | 6% |
There were 2079 responses to this question.
Those who selected that only specific healthcare professionals should undertake these procedures were asked which healthcare professionals these should be. Respondents had the opportunity to select more than one profession, and this was reflected in the higher number of responses. The strongest support was for medical practitioners (doctors) to be considered an appropriate healthcare professional in this context. This was followed by registered nurses, and dental practitioners. There was less support for midwives, pharmacists, dental care professionals and pharmacy technicians to carry out procedures.
| Healthcare professionals to undertake Group 3 procedures | Total | Percent |
|---|---|---|
| Medical practitioners (Doctors) | 1475 | 67% |
| Dental practitioners | 1112 | 50% |
| Dental care professionals | 372 | 17% |
| Registered nurses | 1190 | 54% |
| Registered midwives | 653 | 30% |
| Registered pharmacists | 606 | 27% |
| Registered pharmacy technicians | 197 | 9% |
| Not Answered | 707 | 32% |
There were 1500 responses to this question.
Services that should register with Healthcare Improvement Scotland (Question 15)
The consultation sought views on whether current exemptions to the requirement to register with HIS should continue to apply. This exemption currently applies to NHS primary care (GP) practices, dental practices that offer NHS services and community pharmacies.
Most respondents agreed that these settings should be required to register with HIS if they offer non-surgical cosmetic procedures. Those who agreed far outweighed those who disagreed.
| Setting | Agree | Disagree | Don’t know | Not Answered |
|---|---|---|---|---|
| GP practices | 79% | 12% | 5% | 4% |
| Dental practices | 78% | 12% | 6% | 4% |
| Community pharmacies | 75% | 12% | 8% | 5% |
Between 2105 and 2128 respondents answered each part of this question.
Views on Age restrictions (Questions 17-19)
Views were sought on what measures or restrictions, if any, should be in place to restrict access to non-surgical cosmetic procedures by young people including the associated risks.
There was an error in the initial consultation in one of the questions (18) which invited respondents to indicate the appropriate age for each group of procedures. The initial layout of the question did not allow the same age to be chosen for all groups, and a small number of respondents highlighted this through correspondence. As soon as the issue was identified the question was revised, and respondents who had already answered the consultation, and indicated that they were content to be contacted about the consultation, were invited to respond to a separate revised question. Given the responses received we do not believe this issue has undermined confidence in the responses received.
Well over half of respondents said that there should be an age limit under which clients should not be allowed to undertake non-surgical cosmetic procedures. However, there was still a number, albeit many fewer, who felt that there should be no lower age limit, but that any procedures for someone under 18 should be performed by a healthcare professional, similar to the proposals for Group 3 procedures.
| Proposed age limits | Total | Percent |
|---|---|---|
| There should be a lower age limit under which clients should not be allowed to undertake an NSCP (different ages are considered in Question 18) | 1368 | 62% |
| There should be no lower age limit under which clients should not be allowed to undertake an NSCP, but all procedures for under 18s should be treated as a Group 3 procedure and be required to be carried out by an appropriate healthcare professional | 592 | 27% |
| I don’t know. | 154 | 7% |
| Not Answered | 93 | 4% |
There were 2114 responses to this question.
When asked what the age limit should be for each proposed procedure group, if they were to be set, most people said that the lower age limit should be 18 and over for each group. This was the clear majority position of respondents for all three procedure groups, with the proportion choosing this option particularly high for groups 2 and 3.
| Age Limits for procedure groups | Limited to clients aged 18 and over | Limited to clients aged 16 and over | Limited to clients aged 16 and 17 who have parental / guardian’s consent, or otherwise to clients aged 18 and over | No age limitations |
|---|---|---|---|---|
| Group 1 | 64% | 12% | 21% | 3% |
| Group 2 | 84% | 4% | 10% | 2% |
| Group 3 | 88% | 2% | 8% | 2% |
Between 1696 and 1705 responded to this question in the main consultation. A further 53 respondents answered this question in a supplementary closed consultation, which was sent to respondents who had answered the consultation before the oversight identified above was corrected.
Question 19 of the consultation also asked separately about age limits for procedures in intimate areas (such as the buttocks or genitals). An even greater majority of respondents agreed that these procedures should only be available to clients 18 of age or over.
| Response | Total | Percent |
|---|---|---|
| Agree | 1930 | 87% |
| Disagree | 116 | 5% |
| I don’t know | 100 | 5% |
| Not Answered | 61 | 3 % |
There were 2146 responses to this question.
How regulation of sector might affect people differently based on their financial situation (Question 21)
978 respondents provided a response to the question asking for views on how the introduction of licensing and regulation of the non-surgical cosmetics sector in Scotland might affect people differently based on their financial situation. A range of views were shared, and some respondents used this question to comment primarily on the impact on businesses. The views in that regard are considered below.
The most shared view was that safety should be the primary consideration. These responses emphasised the importance of ensuring that qualified practitioners meet minimum safety standards. Many respondents highlighted the need for procedures to be performed only by registered professionals and called for clearer standards to guide practitioner conduct. It was suggested that such measures would help individuals make informed decisions.
The next most common response addressed equitable access to procedures for people, regardless of their financial status. How people felt about this varied widely. A considerable number of respondents felt that consideration needed to be given to how increased costs associated with licensing and regulation could be managed, so that people with less money could still have access to the services that they want. Suggestions were provided by some. For instance, prices could be set or fixed for procedures, or that subsidies could be made available to help people access what they wanted. However, there was also a substantial number of respondents who clearly articulated that these treatments are cosmetic, and in many cases a luxury good, and therefore, consideration of affordability should not be a factor in making decisions here.
A small number of responders addressed the issue of lower income communities accessing procedures. They raised the issue of introducing regulation to protect these communities from unqualified practitioners, unsafe treatments, and therefore increased risk of complications.
A small number of respondents suggested that raising awareness about the risks of unregulated treatments, and the importance of choosing licensed providers, could be achieved through public education campaigns.
Impact of regulation on businesses
In addition to the points directly addressing the question asked about impact on individuals with lower incomes, many respondents also provided information on how they thought the changes might impact businesses, particular business owners, and the NHS; as well as suggesting some mitigations. Views on this issue were also shared in correspondence and in engagement events with businesses.
The impact that these regulations might have on employment and small business was raised. Many respondents, correspondents and participants in engagement events set out that they thought the proposals (which would increase regulation) might result in potential job losses, financial strain, and broader economic impact. The view was expressed that this would be felt by non-healthcare professional practitioners, and that these proposals were unfair, particularly towards experienced non-healthcare professionals who are currently operating safely and ethically. Some respondents thought that these regulations would ‘level the playing field’, given the additional regulation that practising healthcare practitioners in this sector already face. A small number of respondents raised questions about the high costs and therefore the value that the current HIS inspection regime has. There was a small number of respondents who expressed the concern that this regulation might cause an increase in illegal or clandestine practice.
People set out ways in which business might be supported to mitigate some of the issues presented above. These suggestions included financial support for businesses, training being offered - possibly funded by the government, and tiered (depending on the size of the business) or subsidised, licensing fees for self-employed individuals and small businesses to support them to be able to comply with the proposed licensing requirements. Further suggestions by a few respondents suggested that a phased or gradual introduction of any new regulations, to allow currently operating practitioners adequate time to prepare for any new requirements, would ensure a fair transition.
A small number of people thought that introducing the proposals set out would have a significant impact on the NHS with, healthcare professionals with prescribing qualifications leaving the NHS for the aesthetics sector, a comment also made by a small number of respondents to question 4.
Impacts on protected characteristics, island communities and the rights of children and young people (Questions 20, 22 and 23)
The consultation also asked for views on:
- How, if at all, the introduction of licensing and regulation of the non‑surgical cosmetics sector in Scotland might affect anyone based on their protected characteristics. This was answered by 816 respondents.
- How the introduction of licensing and regulation of the non‑surgical cosmetics sector in Scotland might affect access to safe, high‑quality services in island communities. This was answered by 816 respondents.
- How the introduction of licensing and regulation of the non‑surgical cosmetics sector in Scotland and the potential of age restrictions might affect respecting, protecting, and fulfilling the rights of children and young people as set out in the UN Convention on the Rights of the Child. This was answered by 820 respondents.
There were a range of comments received in relation to the impact of the proposals on particular population groups. Overall, there was a sense that safety was of greatest importance, but other concerns were expressed.
Protected characteristics
In general, many respondents felt the proposals would have a positive impact on all groups, bringing equity, inclusivity, consistent standards, and confidence in services. It was felt that improved training could better address the needs of certain groups, such as disabled or transgender people, and the provision of clearer information about procedures would benefit everyone.
There were more comments around young people than any other group. Some respondents felt that the proposals would ensure protection for young people from potentially harmful procedures or procedures which are unsuitable for those of a young age. Others were of the view that young people should still have access to treatments that would benefit them, for example for acne scarring, and that treatments for medical reasons should continue to be available.
The potential for a disproportionate effect of increased regulation on women was also raised by some respondents. Respondents said this was because women are more likely to own businesses in this sector, and they are also more likely to seek these treatments and, with the introduction of new regulations, may face higher costs.
Child rights and wellbeing
The consultation asked how the proposed licencing and regulation scheme and associated age restrictions might impact on the rights of children and young people. Many respondents answered this question to express a view that an age limit of 18 and above for all cosmetic procedures would be appropriate, with some suggesting that younger people could receive some treatments if necessary for medical purposes or with parental consent. Similar views were also expressed by businesses offering services, with many saying that they voluntarily restricted their services to adult recipients.
Several respondents felt that the proposals would help to protect children and young people’s rights to health, safety, and wellbeing, prevent exploitation and act in their best interests. Although some respondents suggested that it was important to balance this with children and young people’s right to have their voices heard and their views considered, this was not considered to be as important as the overall need to protect them from harm, as their bodies are still developing physically and emotionally. In addition, it was recognised that some children and young people are heavily influenced by social media and peer pressure and have not yet developed the capacity to make decisions that could affect them in the long term.
Many respondents pointed to the need to ensure that children and young people still had the right to access treatments for medical or psychological reasons if required, regardless of age. Others suggested that education and awareness campaigns would allow children and young people to make better informed decisions.
Island communities
Views were sought on how the introduction of licensing and regulation of the nonsurgical cosmetics sector might affect access to safe, high-quality services in island communities. Respondents were not required to state their geographical location. A quarter of those who responded to this question welcomed the improvements to services that regulation would bring, while slightly fewer felt it would bring fairer access to services and safety in island communities.
Some respondents did think that that licence fees might prove prohibitive for smaller businesses, as would a lack of healthcare practitioners for supervision and prescribing. A range of suggestions were put forward to mitigate these risks, for instance, allowing visiting practitioners to offer services in healthcare premises, reducing licence fees in island settings, subsidised accommodation for visiting practitioners and flexible compliance measures such as allowing remote consultations and mobile services.