Closed consultation

The licensing of non-surgical cosmetic procedures in England

Published 2 September 2023

Applies to England

Introduction

Recent years have witnessed a growing prevalence and normalisation of non-surgical cosmetic procedures. This has been associated with the rise of social media, the increasing accessibility and affordability of high street providers and aesthetic clinics and the advancement of technologies and products applied in this field. Procedures such as botulinum toxin (commonly known as Botox) anti-wrinkle injections, cosmetic fillers (commonly known as dermal fillers), chemical peels and energy-based treatments are growing in popularity, with new procedures rapidly emerging onto the market. Evidence suggests that most non-surgical cosmetic procedures are carried out by private providers.

According to published statistics from the British Beauty Council, the cosmetic and personal care sector supported a total GDP contribution of £24.5 billion and tax contributions of £6.8 billion to HM Treasury in 2022. The sector mainly comprises small and medium enterprises and the majority of business owners in the industry are women.

In April 2022, the Health and Care Act gave the Secretary of State for Health and Social Care the power to introduce a licensing regime for non-surgical cosmetic procedures in England. The purpose of the scheme is to ensure that consumers who choose to undergo a non-surgical cosmetic procedure can be confident that the treatment they receive is safe and of a high standard.

Any licensing scheme for non-surgical cosmetic procedures must strike a balance between protecting the public and building confidence in the safety of the aesthetic industry, while respecting consumer choice and encouraging innovation. All procedures have some risks and can lead to serious complications if not correctly done. These risks are greater where the person carrying out the procedure is not sufficiently knowledgeable or trained, where they use unregulated products, or when the procedure is carried out at unsuitable premises.

The current regulatory framework places few restrictions on who can perform non-surgical cosmetic procedures. The government recognises the concerns about the lack of regulation in this field and the potential dangers that this poses to the public. We want to ensure public safety and public protection through a regulatory framework that enables consumers to make informed and safe choices when undergoing procedures which have the potential to cause serious injury or harm.

At present, competent practitioners who operate to high standards of best practice in relation to training, health and hygiene often find themselves in competition with practitioners and businesses with low levels of competence and who lack appropriate training in the procedures they offer. Although many providers within the aesthetics industry provide treatment in line with best practice when it comes to patient safety, licensing will ensure consistent standards and protect individuals from the potentially harmful physical, emotional and psychological impacts of poorly performed non-surgical cosmetic procedures.

The licensing scheme will ensure that those who offer specified procedures:

• are suitably knowledgeable, trained and qualified
• hold appropriate indemnity cover
• operate from premises which meet the necessary standards of hygiene, infection control and cleanliness

Under the proposed scheme, which will be operated by local authorities in England, practitioners will need to be licensed to perform specific non-surgical cosmetic procedures and the premises from which they operate will also need to be licensed.

It should be noted that this is the first consultation on the licensing scheme. In this consultation, we are seeking views on:

• the procedures in scope
• restrictions on which practitioners should be permitted to perform procedures
• age restrictions for those undergoing such procedures

Further work - including stakeholder engagement and public consultation - will be needed to determine the principles that will underpin the scheme including education and training standards, infection control and cleanliness, indemnity requirements and licensing fees.

Introductory questions

Do you currently work in the cosmetic procedures sector as a practitioner who administers non-surgical cosmetic procedures?

• yes
• no

Do you have relevant qualifications specific to working in the non-surgical cosmetics sector?

• yes
• no

If you answered yes, please list your relevant qualifications.

Have you undergone any non-surgical cosmetic procedures in England?

• yes
• no
• prefer not to say

If you answered yes, what was the procedure or procedures?

Were you satisfied with the outcome of your procedures?

• yes
• no

Please explain your answer.

Were you satisfied with the expertise and approach of the practitioner who performed the procedures?

• yes
• no

Please explain your answer.

Do you feel you were adequately informed about what to expect and any potential risks before undergoing the procedures?

• yes
• no

Please explain your answer.

Current regulatory landscape

The aesthetics industry comprises both regulated healthcare professionals (including nurses, designated allied health professionals, dentists, doctors and pharmacists) and aesthetic practitioners such as beauty therapists. The key principle underpinning the licensing scheme is that all those who practise invasive non-surgical procedures should be competent and safe for members of the public.

Current regulatory controls are fragmented. There are existing training standards for practitioners, such as the National Occupational Standards (NOS) in beauty aesthetics, in addition to competency frameworks developed and held by professional bodies, but there is no legislative framework to mandate that all practitioners are required to meet both training and infection control standards in order to carry out procedures.

The September 2020 report The ugly side of beauty: improving the safety of cosmetic treatments in England, published by the Chartered Institute of Environmental Health (CIEH), found 90% of respondents to its consultation on the regulation of cosmetic interventions supported the introduction of a national licensing scheme to improve the safety of cosmetic procedures.

The CIEH report references commonly used legislation to regulate non-surgical cosmetic procedures. There are various pieces of legislation, with significant local variation. This includes:

• the Local Government (Miscellaneous Provisions) Act 1982 allows (but does not require) local authorities to put in place arrangements for the registration of certain cosmetic treatments, including cosmetic piercing, electrolysis, tattooing and semi-permanent make up, in addition to acupuncture. Some local authorities have also created byelaws relating to staff hygiene and the safety and cleanliness of the premises, furniture, and equipment
• a small number of local authorities in England have also introduced local licensing schemes which vary in the number and type of treatments they cover. These include:
  • Nottingham (under the Nottinghamshire County Council Act 1985)
  • Essex (under the Essex Act 1987)
  • Birmingham (under the Birmingham City Council Act 1990)
  • London (under the London Local Authorities Act 1991)

The CIEH report identified that local authorities are also using a range of other legislation to regulate elements of businesses providing these treatments, including the Health and Safety at Work etc Act 1974 and Health Protection Regulations 2010.

We will continue to work closely with relevant stakeholders to assess how the proposed licensing scheme will interact with these existing legislative requirements in order to minimise duplication of oversight and bureaucracy.

In 2021, the Botulinum Toxin and Cosmetic Fillers (Children) Act was introduced. The act made it a criminal offence to administer injectable toxins or a filler by way of injection for a cosmetic purpose to a person under the age of 18 in England, even if they have the permission of someone over 18. The act also made it an offence for anyone to arrange or carry out these procedures on anyone under the age of 18.

This consultation seeks views on whether we should restrict the treatments to be captured through the licensing scheme to persons over the age of 18. This will be in line with existing age restrictions on botulinum toxin injections, cosmetic fillers, tattoos, teeth whitening and sunbed use.

Aesthetic practitioners

There are several voluntary industry associations within the aesthetic industry for non-healthcare professionals. These include the:

• British Association of Beauty Therapy and Cosmetology (BABTAC)
• National Hairdressing and Beauty Federation (NHBF)
• UK Spa Association (UKSA)

Members can be removed from these associations for breaching the professional codes of conduct.

As stated previously, there are no mandatory training requirements for practitioners, but NOS were approved in 2020, with further NOS developed in April 2021. These NOS were developed by SkillsActive and the Hair and Beauty Industry Authority (Habia) in conjunction with stakeholders including employers and professional and industry bodies. The NOS framework forms the basis of qualifications regulated by the Office of Qualifications and Examinations Regulation (Ofqual).

Regulated healthcare professionals

The UK healthcare regulators are responsible for ensuring that professionals on their registers have the necessary skills and knowledge to be registered and function within their scope of practice. For example, all medical doctors must register with the General Medical Council (GMC), hold a licence to practise and meet the expected standards set out in the GMC’s Good medical practice to work in the UK.

The regulators do not set specific standards for non-surgical cosmetic procedures but are clear that registrants choosing to undertake non-surgical cosmetic procedures must have the skills and knowledge required to do so and should follow the requirements of any relevant guidance and legislation. Regulatory bodies can investigate and take action in line with their fitness to practise processes if a registrant poses a risk to patient safety and/or to public trust in the profession.

Accredited registers for non-surgical cosmetic procedures

The Professional Standards Authority’s (PSA) Accredited Registers Programme provides assurance to the public when choosing health and care services, by independently assessing organisations which register practitioners who are not regulated by law. Two organisations - Save Face and the Joint Council for Cosmetic Practitioners (JCCP) - currently hold PSA-accredited voluntary registers for cosmetic practitioners:

• Save Face operates a voluntary register for doctors, nurses, dentists and prescribing pharmacists who provide non-surgical cosmetic treatments. This register covers regulated healthcare professionals only. Save Face assesses the competency and suitability of the practitioner to carry out each procedure and inspects every clinic location to ensure it meets its standards for accreditation
• Joint Council for Cosmetic Practitioners (JCCP) operates a voluntary register open to all practitioners working in the fields of cosmetic treatments. Practitioners must demonstrate evidence of competence and proficiency to join the JCCP register in accordance with its prescribed standards. JCCP also operates a non-PSA accredited register for Approved Education and Training Providers and Qualifications

Care Quality Commission (CQC)

CQC is the independent regulator of health and adult social care activity in England. CQC registers and regulates providers carrying out one or more of the regulated activities as set out in schedule 1 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. All providers of regulated activities in England must comply with the requirements and fundamental standards set out in regulations made under the Health and Social Care Act 2008. Providers of regulated activities include NHS bodies (for example, NHS trusts, NHS foundation trusts), adult social care providers, independent providers and voluntary sector organisations.

The regulated activity of surgical procedures applies when a surgical procedure is carried out by a healthcare professional for:

• the purpose of treating disease, disorder or injury
• the purpose of sterilisation or reversal of sterilisation
• cosmetic purposes, where the procedure involves the use of instruments or equipment which are inserted into the body
• the purpose of religious observance

CQC monitor and inspect services to see whether they are safe, effective, caring, responsive and well-led. Where poor care is identified, CQC will take action. The actions taken will depend on how serious the problems identified are, and how they affect the people who use the service. These actions can include:

• issuing warning notices
• imposing conditions for a given time
• placing a provider in special measures
• issuing fixed penalty notices
• prosecuting cases where people are harmed or placed in danger of harm

Any providers of a regulated activity must meet CQC’s fundamental standards of safety and quality, or risk enforcement action. This supports the provisions of health and social care services which provide people with safe, effective and high-quality care.

Medicines and Healthcare products Regulatory Agency

The Medicines and Healthcare products Regulatory Agency (MHRA) regulates medicines, medical devices and blood components for transfusion in the UK. MHRA is responsible for the regulation of medical devices and intends to bring into scope of the UK medical devices regulations products for which a manufacturer claims only an aesthetic or another non-medical purpose, but which are similar to medical devices in terms of their functioning and risk profile. This suite of products will include dermal fillers, which will consequently be subject to more stringent regulation. More information can be found in ’Chapter 1 - Scope of the Regulations’ of the government response to the consultation on the future regulation of medical devices in the United Kingdom.

Licensing scheme for non-surgical cosmetic procedures

The government is committed to supporting members of the public to make safe and informed choices about any non-surgical cosmetic procedure they may choose to undergo. We recognise that widespread concerns among the public, practitioners, employers and representative bodies exist about the lack of regulation in the field of non-surgical cosmetic procedures, and the dangers this poses to public safety.

Our intention is that the licensing scheme will:

• identify the procedures that present a risk to the public
• consist of 2 interlinked components: a practitioner licence and a premises licence
• be administered and enforced by local authorities, who will work with a range of partners such as environmental health officers, trading standards officers and the Health and Safety Executive
• make it an offence for an individual to carry out non-surgical cosmetic procedures without a licence
• require those people who offer procedures to:
  • be suitably trained and qualified
  • hold appropriate indemnity cover
  • operate from premises which meet the scheme’s standards of hygiene, infection control and cleanliness
• introduce a minimum age of 18 for those people seeking to receive the procedures licensed under the scheme

This consultation asks for views on the types of procedures that we propose are included within the licensing scheme. Please note, the procedures listed below are indicative examples only and may change based on the outcome of this consultation.

We are also seeking views on whether the carrying out of certain procedures should be restricted to qualified and regulated healthcare professionals, or qualified and trained practitioners working with clinical oversight.

The consultation also seeks views on imposing age restrictions on who may receive such procedures.

Following this consultation, we will work closely with stakeholders in the aesthetic and beauty industries, local authorities, including environmental health officers, professional and system regulators, the devolved governments and other government departments to develop proposals on the training, hygiene, infection control and cleanliness and indemnity requirements that practitioners and premises will need to meet to be granted a licence. Proposals on these policy areas will also be subject to public consultation before regulations are introduced under the powers in the Health and Care Act 2022.

The regulations, which will set out the detail of the licensing scheme in legislation, will be subject to legislative scrutiny through the affirmative parliamentary process. This means that the regulations must be debated in and approved by both Houses of Parliament. To support implementation, guidance outlining the scheme requirements and scope will be published online.

Restriction of cosmetic procedures

The government considers that there are certain non-surgical cosmetic procedures that are of sufficient complexity and invasiveness that they should only be performed by suitably qualified and regulated healthcare professionals. The lack of current restrictions to determine who is entitled to legally perform the more invasive procedures creates a significant risk to members of the public.

Examples of the types of treatment that we are considering restricting are:

• procedures aimed at augmenting the genitals, typically using autologous fat or dermal fillers
• any injectable procedures - such as dermal fillers - undertaken to intimate areas of the body, such as the rectum, genitalia or breasts
• the combination of ultrasound and large bore cannula for the purposes of liposuction

Such procedures would not be included within the local authority licensing scheme.

The restriction of cosmetic procedures would be a 2-part process through which:

• we would set out in regulations that specified high-risk procedures should be restricted to qualified and regulated healthcare professionals only. This would mean non-healthcare professionals would not be able to carry out these procedures
• we would amend CQC regulations so that restricted high-risk procedures are classed as regulated activities by CQC (this second step is set out in the ‘CQC regulation of cosmetic procedures’ section below)

Question

To better protect individuals who choose to undergo high-risk non-surgical cosmetic procedures, we propose introducing regulations to ensure that these procedures may only be undertaken by qualified and regulated healthcare professionals.

To what extent do you agree or disagree that we should set out in regulations that high-risk procedures should be restricted to qualified and regulated healthcare professionals only?

• strongly agree
• agree
• neither agree nor disagree
• disagree
• strongly disagree
• don’t know

Please explain your answer.

CQC regulation of cosmetic procedures

As set out in the section above, the government considers that certain high-risk procedures should be restricted to qualified and regulated healthcare professionals only and therefore not included in the licensing scheme.

To ensure that regulated healthcare professionals undertaking these high-risk procedures meet the required standards of safety and quality, we propose that restricted high-risk procedures should be classed as regulated activities by CQC. This would mean that regulated healthcare professionals undertaking a restricted high-risk procedure would have to register with CQC.

The effect of amending CQC regulations plus restricting who can perform high-risk procedures (as set out in the previous section) would be that:

• non-healthcare professionals would not be able to perform specified high-risk procedures
• regulated healthcare professionals would be required to register with CQC in order to carry out restricted high-risk procedures

By law, where services are being carried out by a healthcare professional, providers have to register with CQC if they offer:

• cosmetic surgery that involves instruments or equipment being inserted into the body - this includes breast surgery, facelifts, buttock or thigh lifts, eyelid or brow surgery, nose surgery, tummy tucks or any procedure where an implant is used
• liposuction - this includes laser lipolysis (such as Smart Lipo)
• refractive eye surgery or lens implant surgery
• all types of thread lifting - for example, polydioxanone (PDO) and poly-L-lactic acid (PLLA) thread lifting

As new procedures become available, CQC continues to engage with relevant stakeholders and scrutinise the regulations to clarify whether procedures are in or out of scope of CQC registration. For example, CQC has clarified it considers large volume fillers inserted into the breast or buttocks, and performed by a healthcare professional, to be a surgical procedure and therefore, a regulated activity. This is because such fillers are injected through a large bore cannula that may require a small incision in the skin, with a large volume of filler then inserted into the body. These types of breast and buttock filler procedures present a significant risk of harm to patients.

To amend CQC’s regulations, the Department of Health and Social Care will separately consult on proposed changes to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which prescribes the types of activities that are regulated activities for the purposes of Part 1 of the Health and Social Care Act 2008 and sets out the fundamental standards that all registered providers are required to comply with.

In the next section, you will be able to give your views on the types of non-surgical cosmetic procedures that should be restricted and classed as regulated activities by CQC.

Question

To what extent do you agree or disagree with the proposal to amend CQC’s regulations to bring the restricted high-risk procedures into CQC’s scope of registration?

• strongly agree
• agree
• neither agree nor disagree
• disagree
• strongly disagree
• don’t know

Please explain your answer.

Procedures in scope of the licensing scheme

The non-surgical cosmetic procedures landscape encompasses a vast range of procedures, techniques, products and services, with wide variation in complexity and invasiveness.

The Health and Care Act 2022 included definitions of those procedures considered to have the highest potential to cause harm, while also allowing flexibility for new procedures to be covered through regulations in the future. The drafting of the act is as follows:

‘Cosmetic procedure’ means a procedure, other than a surgical or dental procedure, that is or may be carried out for cosmetic purposes; and the reference to a procedure includes:

(a) the injection of a substance

(b) the application of a substance that is capable of penetrating into or through the epidermis

(c) the insertion of needles into the skin

(d) the placing of threads under the skin

(e) the application of light, electricity, cold or heat

We do not intend, at this time, for the scheme to cover all those procedures currently subject to local authority registration under the Local Government (Miscellaneous Provisions) Act 1982, such as tattooing, piercing or acupuncture. Our intention is to cover high-risk, invasive procedures, as these procedures currently present the highest risk to the public. However, we welcome your views on the procedures to be captured within the scope of the licensing scheme below.

This is a fast-changing industry, and we want to ensure that the regulations can be adapted as new procedures come to the market. This flexibility is essential to ensure that the licensing scheme can be future proofed to continue to apply to the highest risk procedures. We therefore propose that we do not list all procedures in the regulations, but rather cluster procedures into categories. The specific procedures covered by the scheme will then be set out and named in accompanying guidance.

All cosmetic procedures have some risks but we recognise that there are concerns about the serious risks associated with certain non-surgical procedures. We, therefore, propose that there are different categories depending on the risks (including level of complexity and degree of invasiveness) and potential complications associated with the procedure. The categories are as follows:

1. Green: procedures with the lowest risk of complications. All practitioners are eligible to perform licensed procedures where they meet agreed standards.
2. Amber: procedures with medium risk of complications. Non-healthcare professionals must be licensed and have relevant oversight by a named regulated healthcare professional (who has gained an accredited qualification to prescribe, administer and supervise aesthetic procedures). This is based upon the principles of the clinical oversight model recommended within Professor Sir Bruce Keogh’s 2013 Review of the regulation of cosmetic interventions and Health Education England’s (HEE) Qualification requirements for the delivery of non-surgical education and training (2015). Qualified and regulated healthcare professionals are eligible to perform these procedures without oversight where they meet agreed standards.
3. Red: procedures with the highest risk of complications. In line with the proposal on CQC regulation of cosmetic procedures outlined above, bringing specified high-risk procedures into CQC regulation, so that they fall outside of the scope of the licensing scheme. We are also proposing to restrict these procedures to qualified and regulated healthcare professionals only.

We propose that any procedure that requires a prescription-only medicine (POM) must, at the very least, be overseen by a qualified and regulated healthcare professional. This includes any procedure that uses a POM directly, for example, injectable toxins; and/or any adjunctive procedure that uses a POM alongside the primary procedure to assist or complement it, for example, lidocaine for anaesthetic purposes, or hyaluronidase for managing complications of medical devices such as dermal fillers. This recognises the risks associated with certain procedures and the need for practitioners to have access to - and support from - experienced clinicians who are able to deal with medical emergency situations and complications and have independent prescribing rights.

The specific criteria that practitioners must meet to be eligible to provide clinical oversight will be determined as part of the next phase of this work when the training and qualifications framework is agreed. Similarly, the requirements for clinical supervision for specific treatments will need to be reviewed when the training and qualifications framework is in place.

Many non-surgical procedures performed for cosmetic purposes also have recognised medical and therapeutic benefits and are therefore often performed to treat an identified medical issue. Where a non-surgical cosmetic procedure is provided by or under the supervision of a healthcare professional as listed in schedule 1 paragraph 4(4) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, or by a team that includes a listed healthcare professional, and is being performed as part of treatment for a disease, disorder or injury, the procedure may meet the criteria for the CQC regulated activity of treatment of disease, disorder or injury (TDDI). Should a procedure be considered to be TDDI and fall within the remit of CQC regulation, it would be outside the scope of the licensing scheme. TDDI does not include interventions carried out purely for cosmetic purposes.

Question

The 3-tier system uses green, amber and red to categorise procedures depending on the risks (including level of complexity and degree of invasiveness) and potential complications associated with the procedure.

To what extent do you agree or disagree with using the 3-tier system to classify the different categories for cosmetic procedures based on the risk they present to the public?

• strongly agree
• agree
• neither agree nor disagree
• disagree
• strongly disagree
• don’t know

Please explain your answer.

Below we have set out the proposed classification for the types of procedures that we expect to be included. Please note that the procedures listed are indicative of the types of procedures that will be included in the licensing scheme - they are not a final or complete list and may change based on the outcome of this consultation.

We ask you to review each of the categories and to answer the questions below. You will be able to provide answers on:

• whether there are any other non-surgical cosmetic procedures that should be added to the licensing scheme
• whether any of the suggested procedures should be removed from the licensing scheme
• whether any of the suggested procedures should be moved to another category (green, amber or red)

A description of each procedure can be found at annex A.

Green: procedures with the lowest risk of complications

All practitioners are eligible to perform licensed procedures where they meet agreed standards.

We propose this includes, but is not limited to, the following procedures:

• microneedling
• mesotherapy
• intense pulsed light (IPL) and light emitting diode (LED) therapies
• chemical peels that involve destruction only into viable epidermis (the outermost layer of the skin)
• ‘no-needle’ fillers including pneumatic devices that use intense pressure to pass substances through the epidermis
• micropigmentation (semi-permanent make up), including microblading and nanoblading
• non-ablative laser hair removal
• photo rejuvenation (the use of a laser to treat skin conditions including wrinkles, acne scarring, sun damage)

Questions

To what extent do you agree or disagree with the categorisation of the procedures listed in the green category?

• strongly agree
• agree
• neither agree nor disagree
• disagree
• strongly disagree
• don’t know

Please explain your answer.

Do you think that any changes should be made to the listed procedures?

• procedures should be added
• procedures should be removed
• moved to another category (amber or red)

Please explain your answer.

Amber: procedures with medium risk of complications

Licensed aesthetic practitioners must have relevant oversight by a named regulated healthcare professional (who has gained an accredited qualification to prescribe, administer and supervise aesthetic procedures). Qualified and regulated healthcare professionals are eligible to perform these procedures without oversight where they meet agreed standards.

We propose this includes, but is not limited to, the following procedures:

• botulinum toxin injections
• semi-permanent dermal fillers injected into the face only
• biorevitalization injections and/or any injection of hyaluronic acid
• vitamin and mineral injection procedures
• platelet rich plasma (PRP) therapy for cosmetic purposes and Biofiller
• injection microsclerotherapy (spider vein treatment)
• weight loss injections
• carboxytherapy and/or the infusion of gases under the skin
• cellulite subcision
• injection lipolysis with a POM
• cryolipolysis
• high intensity focused ultrasound (HIFU), including intimate use
• radiofrequency treatments
• plasma ablation or plasma fibroblast
• non-ablative lasers (excluding photo rejuvenation and laser hair removal)
• medium depth peels that involve full thickness destruction of entire epidermis into upper dermis (the inner layer of the 2 main layers of the skin)
• POM treatments applied topically for cosmetic purposes, such as prescription strength vitamin A and hydroquinone for the treatment of pigmentation problems or for skin whitening
• electrocautery
• the combination of 2 or more technologies to create a hybrid device. For example, the combination of radiofrequency and microneedling to treat lines, wrinkles, sagging skin, acne scars and stretch marks
• cryotherapy and/or any cryocautery procedure that freezes the skin in order to remove skin lesions such as skin tags, age spots and warts

Questions

To what extent do you agree or disagree with the categorisation of the procedures listed in the amber category?

• strongly agree
• agree
• neither agree nor disagree
• disagree
• strongly disagree
• don’t know

Please explain your answer.

Do you think that any changes should be made to the listed procedures?

• procedures should be added
• procedures should be removed
• moved to another category (green or red)

Please explain your answer.

Red: procedures with the highest risk of complications

Can only be carried out by qualified and regulated healthcare professionals working out of CQC registered premises. Such procedures would not be included within the local authority licensing scheme.

We propose this includes, but is not limited to, the following procedures:

• all thread lifting procedures, including PDO thread and cog lifts
• hair restoration surgery
• procedures aimed at augmenting any part of the body, in particular the breast, buttocks and genitals, typically using autologous fat or dermal fillers
• dermal micro-coring
• hay fever injections for reducing redness or blotches on the skin
• the combination of ultrasound and large bore cannula for the purposes of liposuction
• deeper chemical peels such as phenol peels
• lasers which target the deeper layers of the dermis. For example, CO2 lasers, where used for extensive fully ablative resurfacing
• the provision of any green or amber procedure where the circumstances of the provision meet the criteria for the procedure to be classed as the CQC regulated activity of treatment of disease, disorder or injury (TDDI)
• all intravenous injectables and infusions

Questions

To what extent do you agree or disagree with the categorisation of the procedures listed in the red category?

• strongly agree
• agree
• neither agree nor disagree
• disagree
• strongly disagree
• don’t know

Please explain your answer.

Do you think that any changes should be made to the listed procedures?

• procedures should be added
• procedures should be removed
• moved to another category (green or amber)

Please explain your answer.

Minimum age of client

The Botulinum Toxin and Cosmetic Fillers (Children) Act 2021 made it an offence for a person to administer botulinum toxin, or a filler by way of injection for a cosmetic purpose, to a person under 18 in England. The act also made it an offence to make arrangements to undertake, or arrange for another person to undertake, these procedures on a person under 18 in England.

The act was introduced in recognition of the fact that those procedures carry risks to physical health, including infection, blindness and, in rare cases, death and there are psychological implications associated with changing physical appearance. Young people are particularly vulnerable as they are developing physically and mentally, and there are ethical implications around the extent to which they can give informed consent to procedures.

We therefore propose that the licensing scheme requirements or conditions will prohibit practitioners from performing any procedures included within the scheme on people under the age of 18 unless the procedure has been approved for use on a person under 18 by a GMC registered doctor and is carried out by a specified healthcare professional.

This licensing requirement will prevent such procedures being made routinely available to under 18s in line with age restrictions on botulinum toxin injections, cosmetic fillers, tattoos, teeth whitening and sunbed use.

Question

Our intention is that licensed procedures should be restricted to those above the age of 18 unless approved by a doctor and carried out by a healthcare professional. To what extent do you think that these procedures should be age-restricted?

• all of the procedures should be age-restricted
• some of the procedures should be age-restricted
• none of the procedures should be age-restricted

Please explain your answer.

We will also consider, as part of the development of education and training requirements for the scheme following this consultation, whether licensed practitioners should also be aged 18 and over.

Stakeholder engagement

The range of non-surgical cosmetic procedures available to consumers is vast, and the drawing up of the scheme regulations requires detailed consultation with a range of stakeholders.

We have engaged with a range of representative bodies from the aesthetic industry, healthcare regulatory bodies, those running existing accredited registers for cosmetic practitioners, local authority enforcement colleagues and the Local Government Association. This is to ensure that the proposals set out in the consultation are representative of a wide range of stakeholder views, including those working in the aesthetics industry and those responsible for protecting public safety. We are also coordinating with colleagues in the Scottish and Welsh Governments to understand what their plans are for regulatory change in relation to non-surgical cosmetic procedures.

We would like to thank representative bodies, practitioner groups, and local authority environmental health officers who have assisted by contributing advice and evidence which has enabled us to shape the proposals presented in this consultation.

The consultation is a continuation of this activity, and we will highlight the opportunity to respond with key stakeholders. Following the consultation, we will reach out to relevant stakeholders as we begin to develop the regulations that will underpin the licensing scheme.

Next steps

We invite responses to this consultation through the online survey until 11:59pm on 28 October 2023, after which will follow a period of analysis and consideration of the information provided to us.

We will seek to publish the details of the responses received and our finalised policy positions in a timely way to ensure progress is made on this important work.

From the date the consultation closes and throughout 2024 and 2025, we will work with expert groups on the elements that will underpin the licensing scheme, including education and training standards, insurance, infection control and hygiene qualifications and a fees model.

This will inform future public consultations on specific elements of the licensing scheme, which will include assessments on the economic and equality impacts of the proposed changes.

We will then work to finalise the regulations and implement the licensing scheme. We anticipate there will be a set lead in time or a transitionary period before the licensing scheme is in full operation across England.

Question

Do you have any other comments on the issues raised in this consultation?

• yes
• no

If you answered yes, please explain your answer.

Annex A - glossary of procedures

The annex comprises of a glossary of examples of the types of procedures referred to in the consultation, separated by category.

The injection of a substance

Botulinum toxin injections

Botulinum toxin injections (commonly known as Botox) are used in the face to reduce lines and wrinkles, such as crow’s feet and frown lines, by relaxing the underlying muscles.

Semi-permanent dermal fillers

Semi-permanent dermal fillers are substances, such as hyaluronic acid, which are injected to contour and plump fine and deeper lines and augment features.

As set out above, we are considering restricting a minority of the highest risk fillers procedures to certain qualified and regulated healthcare professionals. This includes the use of fillers to augment the breast, buttocks and genitals.

Biorevitalization injections

The skin is injected with small doses of pure hyaluronic acid with vitamins to encourage the production of collagen and elastin across the skin.

Vitamin and mineral injections

Injections of vitamins and minerals, or ‘cocktail’ mixtures of both, including vitamin B12, vitamin C and vitamin D3, may be used for well-being purposes such as the regulation of sleep, mood, hydration, immunity and appetite cycles and energy boost. These procedures may be delivered by intramuscular injections (into the muscle) or by intravenous injection or infusion (directly into the vein and bloodstream).

Mesotherapy

Mesotherapy is a skin rejuvenation treatment usually involving the injection of a ‘cocktail’ of active ingredients, such as vitamin, minerals or pharmaceutical preparations, within or between various layers of the skin or under the skin (intradermally or subcutaneously). Multiple techniques can be used to target different areas in the skin.

In no-needle mesotherapy, also called transdermal mesotherapy, substances are applied topically to the skin, and mild ultrasonic waves are used to transport the substances into the skin cells. The procedure is most frequently used for skin rejuvenation, hair loss and cellulite purposes.

Platelet rich plasma (PRP) therapy

PRP involves the extraction of blood which is processed to remove red and white cells to leave plasma containing platelets. PRP is regulated in different ways depending on the characteristics of the product and the purpose for which it is supplied or administered to a patient or client.

If used for a medical purpose, PRP is considered by the MHRA to be a medicinal product. If an unlicensed product is used this can only be under the permitted exemptions in the Human Medicines Regulations 2012. PRP which is not used for medical purposes will not fall under medicines regulations.

Its use for cosmetic purposes, such as in the face (often referred to as the ‘vampire’ or ‘Dracula’ facial) or in intimate areas of the body, involves the reinjection of the resulting solution for skin and hair rejuvenation.

PRP may be further modified with heat and chemicals to form a gel which is used like a filler for volume.

Injection microsclerotherapy

Microsclerotherapy is a technique used to treat spider or thread veins. A chemical substance, ‘sclerosant’, is injected using fine needles to irritate the inner wall of the veins, causing them to stick together and the vein to disappear.

Injection lipolysis with a POM

The injection of a POM to emulsify fat cells which are then metabolised.

Hay fever injections (for reducing redness and blotches on the skin)

Kenalog® (triamcinolone), a prescription-only steroid injection for alleviating the joint pain, swelling and stiffness, may be used to alleviate red and blotchy face symptoms associated with hay fever. Note: Kenalog is not licensed for use in hay fever symptoms but may be prescribed ‘off-label’ for treating it.

Weight loss injections

Prescription-only medicines used in obesity management may be used for cosmetic purposes.

Carboxytherapy

Carboxytherapy involves the infusion of carbon dioxide under the skin, either administered via an injection or using a non-needle device, with the aim of increasing blood flow to that part of the body. Uses include skin improvement, cellulite removal and the stimulation of hair growth on the scalp.

Adjunctive procedures

Adjunctive procedures are those used alongside the primary cosmetic procedure being undertaken to assist or complement it. Examples include the use of local anaesthetic injections for numbing the body before dermal fillers are used, or the use of hyaluronidase for dissolving dermal fillers. Note: hyaluronidase is a POM which is not licensed for use in dissolving dermal fillers but is used ‘off-label’ for correcting problems with dermal filler injections.

The application of a substance that is capable of penetrating into or through the epidermis

Chemical peels

A chemical solution is used which penetrates the skin to a predetermined depth to remove dead skin cells and stimulate the growth of new cells. The aim is to improve the appearance of the skin - for example, by reducing age spots and evening out skin tone.

There are 3 types of peels: superficial, medium and deep:

• superficial chemical peels, where skin cells are removed from the epidermis, are included under the green category. These peels exfoliate the skin deeply to stimulate new epidermal growth and collagen production. Regular treatment is needed to maintain the effects. Acids commonly used include lactic, glycolic and tartaric acid
• medium depth peels, involving full thickness destruction of entire epidermis into the upper dermis (the inner layer of the 2 main layers of the skin), are included under the amber category. The acids used in these peels are able to penetrate the epidermis and the upper dermis. These peels are usually carried out using trichloroacetic acid (TCA) at concentrations between 35% and 50%. Other acids are sometimes used, including glycolic, pyruvic and salicylic acid. A combination of acids can also be used
• deep chemical peels using phenol or otherwise intended for use at the level of the reticular dermis (the thick bottom layer of the dermis). Deep peels remove the epidermal, upper dermal and can reach the deep dermal layers of skin, the reticular layer. A local anaesthetic and sedative may be needed to numb any pain. Heart and blood pressure monitoring is also required because phenol can affect heart and kidney function

Face masks and other ‘spa’ products that are not designed to penetrate the outermost layer of the skin, the epidermis, are excluded from the scheme. No licensing requirements will apply in relation to their use.

The topical application of prescription medicines for cosmetic purposes

Examples of these types of treatment include:

• prescription strength topical vitamin A (retinol), and its synthetic equivalents, which is sometimes used as an alternative to a chemical peel
• hydroxyquinone for the treatment of pigmentation problems or for skin whitening

‘No-needle’ fillers including pneumatic devices

There are a number of types of non- or no-needle procedures. For example, needle-free devices operate by creating enough pressure externally against the tissue to ‘push’ filler into the skin.

Cryotherapy

Cosmetic cryotherapy uses ultra-cooled nitrogen gas to target areas such as the face, scalp and neck to enhance the appearance of the skin.

Cryocautery

Cryocautery uses compressed gas at low temperatures to ‘freeze’ and remove or reduce a diverse range of blemishes and skin imperfections such as skin tags, age spots and warts.

The insertion of needles into the skin

Semi-permanent make up: cosmetic and advanced micropigmentation

Semi-permanent make up techniques involve the insertion of a sterile single-use needle underneath the upper layers of skin to deposit pigmented granules. This procedure may be used for eyebrow enhancement, lip liner enhancement and blush, eyeline enhancement, and on scalp and skin imperfections. Eyebrow techniques include:

• microblading with a blade-shaped tool to create hairlike strokes, with the microfeathering technique mimicking natural hairs
• nanoblading, with the use of a finer nano-needle
• ombre powder brows, which involves a digital machine or handheld tool used to insert tiny dots of pigment

Micropigmentation may also be used medically on areas of skin affected by a health condition, such as creating the illusion of a nipple for women who have had a mastectomy. Advanced micropigmentation includes the eye area, areola, scar imperfections, vitiligo and chloasma (hyperpigmentation triggered by hormonal changes in pregnancy).

Microneedling, also known as collagen induction therapy

Microneedling uses fine needles to make miniscule micro-injuries to the skin. This triggers the body’s wound healing process and collagen production, stimulating healthy surrounding tissue to repair the damage and rejuvenate the skin. Techniques include a manual dermaroller or an electronic microneedling device. No-needle alternatives stimulate exfoliation of the skin without puncture wounding.

Cellulite subcision

A micro blade is used to separate the bands of fibrous connective tissue under the skin, allowing the skin to spring back resulting in a smoother appearance and reducing the appearance of cellulite. This treatment usually requires injectable local anaesthetic and can require the use of preventative antibiotic treatment.

Dermal micro-coring

A series of small punctures are made in the skin, removing its entire depth in the form of a ‘core’ similar to a biopsy. By repeating the process enough skin is removed to lift and tighten as an alternative to a face lift. This treatment can require adjunctive treatment of local anaesthetic with adrenaline.

Liposuction with fat transfer using a cannula, including treatments such as VASER

A large bore cannula (a small hollow flexible plastic tube, which is inserted into a vein using the tip of a fine safety needle) is used for the purposes of liposuction, to suck out small areas of fat which are then transferred to other areas of the body.

Vibration amplification of sound energy at resonance (VASER) liposuction uses ultrasound waves to break up and liquefy fat cells, making them easier to extract.

The placing of threads under the skin

Thread and cog lifts - for example, polydioxanone (PDO) and poly-L-lactic acid (PLLA) threads

Thread lifts are used to treat general signs of ageing, such as sagging skin as a result of the deflation of underlying tissue. This technique may also be used on the neck or body.

Permanent or dissolvable threads are inserted underneath the skin of the face to tighten it, induce collagen production and define facial contours. Poly-L-lactic acid (PLLA), poly lactic-co-glycolic acid (PLGA) and polydioxanone (PDO) threads are examples of resorbable surgical sutures - over time, they break down and are absorbed by the body, so their effects are temporary (1 to 3 years).

This treatment is recognised as a surgical procedure for registration with CQC when applied by registered healthcare professionals, or those under their supervision.

The application of light, electricity, cold or heat

Electrocautery (diathermy)

Electrocautery uses heat from an electric current to destroy tissue. Its cosmetic uses include the removal of skin tags, milia, telangiectasia and cherry angiomia. Advanced electrocautery techniques may be used to remove or reduce a diverse range of blemishes and skin imperfections.

High intensity focused ultrasound (HIFU) for cosmetic purpose

HIFU directs energy to layers deep underneath the skin to encourage contraction and lifting, lessen scars, stretch marks and cellulite and improve skin elasticity. It is sometimes described as the ultrasound face lift.

HIFU can also be used in intimate rejuvenation, for non-surgical feminine tightening.

Radiofrequency treatments

Radiofrequency uses the heat from radio waves to cause controlled tissue damage and promote cell renewal. It may be used on its own or combined with other mechanisms to tighten the skin as an anti-aging treatment.

Cryolipolysis

Cryolipolysis, often referred to as cool sculpting or fat freezing, uses cold temperature to break down fat cells, which are particularly susceptible to the effects of cold, unlike other types of cell. It may be used on stubborn pockets of unwanted fat in for example, the chin, buttock or arms. Those cells which are ruptured or ‘lysed’ are then absorbed into the body and excreted.

Light-emitting diode (LED) treatments

LED light therapy is administered using masks, lamps or handheld devices. It can be used on various skin conditions and concerns, such as acne, fine lines and psoriasis as light works directly on photoreceptors in the skin. It may also be used for facial ‘rejuvenation’.

Intense pulsed light (IPL) treatments

IPL uses high-intensity pulses of visible light to improve the appearance of a range of skin problems such as vascular lesions, port wine birthmarks, broken facial veins and rosacea. It can also be used for hair removal.

Laser treatments

Laser is a very high energy beam of laser light. Different lasers can be set to different wavelengths of light, so their strength and depth of penetration can be varied. The laser beam heats up water in skin cells, at a specific depth, causing them either to vaporise or injure them in a controlled way.

Lasers may be used for various indications including tattoo removal, hair removal, treatment of skin lesions and wrinkles.

Laser hair removal works by gradually heating the skin with a laser to a temperature that effectively damages the hair follicles and prevents re-growth. In photo rejuvenation, the laser is used to treat skin conditions including wrinkles, acne scarring and sun damage.

Non-ablative lasers cause controlled tissue injury in the dermis but leave the epidermis intact. Fully ablative lasers completely remove the epidermis and some of the dermis by vaporising skin cells.

Plasma ablation or plasma skin resurfacing

Plasma ‘fibroblast’ is a high energy device that reacts with a gas to form a hot plasma to target small areas of the skin. The plasma tip releases a targeted current just above the skin, creating multiple micro-injuries throughout the skin’s layers to encourage tissue regeneration and collagen production. It may be used for wrinkle reduction and skin tightening on the face, commonly the eye area, but can also be used on the neck and body.

Combination modalities

The combination of 2 or more procedures or technologies being executed in combination with the intent to give an enhanced outcome. For example, procedures that combine radiofrequency and microneedling.

Other

Hair restoration surgery

Hair transplant surgery is a cosmetic surgery usually carried out under local anaesthetic using 1 of 2 methods. Follicular unit transplantation involves the removal of a thin strip of skin with hair from the back of the head. This is divided into small pieces, each containing 1 to 4 hairs, which are grafted into tiny cuts made in the scalp. Alternatively, follicular unit extraction involves the removal of individual hairs which are then grafted into tiny cuts made in the scalp.

Annex B - privacy notice

Summary of initiative or policy

The government brought forward an amendment to the Health and Care Act 2022 which gives the Secretary of State for Health and Social Care the power to bring into force a licensing scheme in England for non-surgical cosmetic procedures.

The purpose of the scheme is to ensure that consumers who choose to undergo a non-surgical cosmetic procedure can be confident that the treatment they receive is safe and of a high standard. Under the proposed scheme, practitioners will need to be licensed to perform specific procedures and the premises from which they operate will also need to be licensed.

In this consultation we are seeking your views on:

• the types of treatments that we propose are included within the licensing scheme
• whether any procedures should be carried out only either by qualified and regulated healthcare professionals or under their clinical oversight
• whether procedures permitted to be carried out only by qualified and regulated healthcare professionals should only be carried out by Care Quality Commission (CQC) registered providers
• whether potential age restrictions should be imposed on those receiving specified procedures, in line with age restrictions on botulinum toxin injections, cosmetic fillers, tattoos, teeth whitening and sunbed use

Data controller

The Department of Health and Social Care is the data controller.

What personal data we collect

People responding to this consultation are asked to provide their email address. Individuals (that is those who are not responding on behalf of an organisation) are also asked to confirm what their profession or job role is and asked to confirm the geographical area in which they work. Those responding on behalf of an organisation are asked which sector their organisation operates in, and where their organisation operates services.  

Respondents are asked whether they currently work in the cosmetic procedures sector as a practitioner who administers non-surgical cosmetic procedures and whether they hold relevant qualifications.

Respondents are asked their age, sex and whether the gender they identify with is the same as their sex registered at birth.

Respondents are asked whether they have undergone any non-surgical cosmetic procedures and, if so, asked to provide details of the experience.

How we use your data (purposes)

The information described above will be collected as part of the online survey response to this consultation. Email addresses are collected with the aim of allowing the department, if respondents give their permission, to contact them about their response and to notify them in future of any further consultations or policy announcements related to this consultation.

Data about respondents’ job role, work location, age, sex and gender, qualifications, data on organisations that respondents may be responding on behalf of, and information on any non-surgical cosmetic procedures they have undergone will be used in the analysis of the consultation to help the department understand how people from different groups respond to the consultation’s proposals.

Legal basis for processing personal data

Under Article 6 of the United Kingdom General Data Protection Regulation (UK GDPR), the lawful bases we rely on for processing this information are:

• Article 6(1)(e) - processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller, namely the Secretary of State’s duties under the Health and Care Act 2022, as referenced above
• any special category data you choose to disclose in response to this survey will be processed under Article 9(2)(h) - processing is necessary for the provision of health and social care treatment or the management of health or social care systems and services on the basis of domestic law

Data processors and other recipients of personal data

The consultation is hosted via an online platform owned by SurveyOptic, who are a contracted supplier of DHSC. SurveyOptic will delete any personal data in line with the retention and disposal periods outlined below, or earlier if instructed to do so by DHSC.

International data transfers and storage locations

Personal data received will be stored in the UK by DHSC and SurveyOptic.

Retention and disposal policy

Personal data shall be retained for no longer than 24 months following the closure of the consultation in October 2023 to allow time for analysis and publication of the government’s response to this, and future consultations, and in case we need to seek clarification on any comments from respondents.

How we keep your data secure

Personal data held by the department is stored securely on our records management system and shared only between DHSC employees linked to this project.

Your rights as a data subject

By law, data subjects have a number of rights, and this processing does not take away or reduce these rights under the EU General Data Protection Regulation (2016/679) and the UK Data Protection Act 2018 applies.

These rights are:

1. The right to get copies of information - individuals have the right to ask for a copy of any information about them that is used.
2. The right to get information corrected - individuals have the right to ask for any information held about them that they think is inaccurate, to be corrected.
3. The right to limit how the information is used - individuals have the right to ask for any of the information held about them to be restricted, for example, if they think inaccurate information is being used.
4. The right to object to the information being used - individuals can ask for any information held about them to not be used. However, this is not an absolute right, and continued use of the information may be necessary, with individuals being advised if this is the case.
5. The right to get information deleted - this is not an absolute right, and continued use of the information may be necessary, with individuals being advised if this is the case.

Comments or complaints

Anyone unhappy or wishing to complain about how personal data is used as part of this programme, should contact data_protection@dhsc.gov.uk in the first instance or write to:

Data Protection Officer
1st Floor North
39 Victoria Street
London
SW1H 0EU

Anyone who is still not satisfied can complain to the Information Commissioners Office. Their website address is www.ico.org.uk and their postal address is:

Information Commissioner's Office
Wycliffe House
Water Lane
Wilmslow
Cheshire
SK9 5AF

Automated decision making or profiling

No decision will be made about individuals solely based on automated decision making (where a decision is taken about them using an electronic system without human involvement) which has a significant impact on them.

Changes to this policy

This privacy notice is kept under regular review, and new versions will be available on our privacy notice page on our website. This privacy notice was last updated on 2 September 2023.