Consultation outcome

The licensing of non-surgical cosmetic procedures in England: consultation response

Updated 7 August 2025

Introduction

Background and objectives

Non-surgical cosmetic procedures have become increasingly popular in recent years. Not only has the sector expanded to meet this demand, it has also been instrumental in creating and driving it, embracing innovation and new technologies to offer an increasing range of more easily accessible treatments with large variation in complexity, techniques and invasiveness. This demand is forecast to continue increasing.

However, regulation of the sector has not kept pace with this development and expansion. The current landscape is fragmented and does not offer a robust system to protect the public from harm.

The aesthetics industry comprises a wide spectrum of practitioners with diverse qualifications, training and experience, including aesthetic practitioners and regulated healthcare professionals from a range of disciplines. Additionally, the sector operates from a wide variety of locations, ranging from Care Quality Commission (CQC)-regulated clinics to consumers’ own homes.

All cosmetic procedures have some risks and can lead to serious injury or harm if not performed correctly. There is currently no legislative framework to instil common standards for qualifications, training and infection control across the breadth of the sector, to provide levers of enforcement for those organisations tasked with upholding public safety, or to create reliable systems of redress for consumers in the event of something going wrong.

In response to these concerns, in July 2022, section 180 of the Health and Care Act 2022 (the 2022 Act) came into force. This gives the Secretary of State for Health and Social Care the power to introduce regulations to:

• prohibit individuals from carrying out specified cosmetic procedures, unless they have been licensed to do so
• require the premises from which specified cosmetic procedures are carried out to be licensed

The 2022 Act defined a cosmetic procedure as:

“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”

As set out in the 2022 Act, licences would be issued by local authorities. Schedule 19 of the act made further provision about the regulations, including provision for:

• the imposition of fees
• the creation of criminal offences
• financial penalties

The aims of the licensing scheme were to:

• introduce nationally recognised requirements and standards covering the education, training and qualifications required for the administration of those treatments covered by the scheme
• provide assurance that the premises in which non-surgical cosmetic interventions are carried out meet hygiene standards
• ensure that individuals carrying out procedures have appropriate indemnity and insurance arrangements in place

On 2 September 2023, after a period of stakeholder engagement, the previous government launched a consultation on the scope of a licensing scheme, in accordance with the requirement in the 2022 Act for the Secretary of State to consult such persons as they consider appropriate before regulations are made. As well as proposals for licensing, the consultation also made proposals on introducing restrictions around the performance of those cosmetic procedures deemed to pose particularly high risk of harm if improperly performed. This consultation was the first to be conducted with the public on the then government’s proposals.

Stakeholder engagement

In developing the proposals in the consultation, the Department of Health and Social Care (DHSC) conducted extensive engagement with a range of stakeholders from across the sector. This included representatives from:

• professional associations of aesthetic practitioners and healthcare professionals operating in the sector
• representatives from statutory professional regulatory bodies overseeing healthcare professionals
• CQC
• representatives from the Professional Standards Authority (PSA) accredited registers programme
• representatives from local government
• legal professionals

We have also liaised with officials in the devolved governments to share information on the approaches being taken across the UK to improving public safety in this area. A roundtable event was chaired by the then Minister for Mental Health and Women’s Health Strategy in summer 2023, prior to the consultation being launched. We will continue to engage with stakeholders as this work progresses and are grateful to all those who have contributed to date.

We raised awareness of, and encouraged participation in, the consultation through our DHSC communications channels and through targeted communications delivered directly to relevant stakeholder organisations.

Summary of responses and government response

This section sets out the consultation proposals and gives a high-level summary of the responses received and the themes which have emerged. It also provides the government response to these issues and sets out next steps for the development of licensing and associated regulation.

The ‘Analysis of responses’ section below contains a fuller discussion of the questions asked and the themes raised in the consultation questions, and information on response rates and demographics.

What was proposed

The consultation was the first to be held on the previous government’s proposed regulation of the aesthetics sector and focused on several aspects pertaining to the scope of the regulation, namely:

• which cosmetic procedures would be subject to regulation
• restrictions on which practitioners should be permitted to perform certain procedures
• age restrictions for those undergoing procedures

The consultation proposed a 3-tier system of categorisation for cosmetic procedures depending on the risks, including:

• the level of complexity
• the degree of invasiveness
• potential complications associated with the procedure

The categories proposed were:

• green: procedures with the lowest risk of complications - all practitioners are eligible to perform licensed procedures where they meet agreed standards
• 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). Qualified and regulated healthcare professionals are eligible to perform these procedures without oversight where they meet agreed standards
• red: procedures with the highest risk of complications - these specified high-risk procedures are of sufficient complexity and invasiveness that they should only be performed by suitably qualified and regulated healthcare professionals. These procedures would be brought into CQC regulation, thereby falling outside of the scope of the licensing scheme. Any provider offering these procedures would need to be registered with CQC, ensuring that these procedures are performed only in CQC-regulated premises

The consultation therefore proposed that, to adequately protect public safety, 2 separate regulatory mechanisms would be required:

• a licensing scheme for green and amber procedures, introduced through the powers granted through the 2022 Act and administered by local authorities
• additional regulation to classify red procedures as CQC-regulated activities which could only be performed by suitably qualified and regulated healthcare professionals

The consultation listed the specific procedures which would fall within each tier (while indicating that these lists were not exhaustive and may be subject to change). A glossary providing further information on the procedures was included in the consultation document.

The consultation further proposed that the licensing scheme would 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 General Medical Council (GMC) registered doctor and was carried out by a specified healthcare professional. This proposal was in line with the age restrictions already in place for botulinum toxin (Botox) injections and cosmetic filler procedures through the Botulinum Toxin and Cosmetic Fillers (Children) Act 2021.

As detailed in the consultation document, there are many interlinked issues to consider in the development of licensing and associated regulation, including:

• education and training standards
• insurance
• infection control and hygiene qualifications
• a fees model

Although these themes were not the specific subject of this consultation, respondents offered a number of important views on these and other issues, not all of which can be addressed or answered at this stage.

High-level summary of responses

Over 11,800 consultation responses were provided, and the feedback received demonstrated widespread support for the introduction of regulation in the sector to improve public safety. The consultation has highlighted the range of work still to do to develop a practicable and proportionate system of licensing and associated regulatory oversight for the non-surgical cosmetics sector, including further work needed to arrive at fully informed decisions on many of the specific issues covered in the consultation.

An overview of themes from the consultation analysis and the government’s response to these are set out below.

Restriction of high-risk procedures, the 3-tier system and categorisation of procedures

While a wide range of views were received regarding the proposals for the tiering of procedures and associated restrictions on which practitioners would be able to perform them, the majority of respondents agreed with the consultation’s proposals that specified high-risk procedures are brought into CQC regulation and may only be performed by suitably qualified and regulated healthcare professionals.

The majority of respondents also agreed with the proposed 3-tier structure, though others suggested alternative ways of mitigating risk. For example, some respondents disagreed with the tiering system entirely, proposing instead that the focus should be on training and qualification standards. Some respondents felt there should not be an amber category, only green and red, and that oversight was not needed if suitable training and education standards are mandated. Further comments regarding the amber category in particular are discussed below.

A few organisations advocated for 4 tiers of risk stratification. The proposed systems include an extra tier which would restrict certain procedures to being administered by prescribing healthcare professionals or by non-prescribing healthcare professionals under the supervision of a prescribing healthcare professional.

The questions in the consultation which asked for views on the suggested categorisation of procedures (within the 3-tier system) generated a wide range of opinions. A view frequently expressed was that any determination of the risk associated with any procedure should be based on an assessment of a range of factors, such as:

• the medicines and equipment used (including any risks the equipment poses to the person operating or using it)
• the level of depth or penetration of the procedure
• potential interventions which might be required to manage any complications
• the area of the body on which the procedure is performed - responses highlighted, for example, that dermal filler procedures performed to certain areas of the face, such as to the nose or around the eyes, involve increased risk

Several responses described how risk is based not only on the procedure being performed, but also on the physical and psychosocial condition of the individual undergoing the procedure. Several responses across the range of questions asked in the consultation cited concerns about how psychological vulnerabilities, such as body dysmorphia and other disorders and concerns relating to body image, coupled with the influence of social media, are driving an increase in people seeking to undergo cosmetic procedures. Therefore, some respondents suggested that an assessment of a client’s psychological wellbeing, including consideration of the client’s motivation for wanting to undergo a cosmetic procedure and of their expectations regarding the results, should be a central part of the pre-procedure consultation process.

A wide range of views was received on how the specific procedures proposed for inclusion in licensing and associated regulation should be classified, with a number of alternatives proposed. This is discussed in the ‘Analysis of responses’ section below. Various procedures not currently within scope of the scheme were proposed for inclusion. Significantly, there was very strong support from local government for some or all of the procedures currently subject to registration under the Local Government (Miscellaneous Provisions) Act 1982 to be added to the scheme, namely:

• tattooing
• cosmetic piercing
• electrolysis
• semi-permanent skin colouring
• acupuncture

It was largely proposed that these be included in the green category, although a smaller number of responses advocated for the amber category being more suitable.

Government response

The wide range of views received on these issues demonstrates the breadth of activity undertaken by the sector and has reinforced the government’s view that a tiered classification system for procedures based on risk and invasiveness is an appropriate and proportionate way of structuring a system of regulatory oversight of the sector. The majority of respondents were in agreement that the most invasive procedures warrant legislative safeguards beyond those which can be provided through the powers granted for licensing. This has reaffirmed the government’s intention to introduce a licensing scheme and to also legislate to ensure that those procedures deemed to pose the highest risk to public safety are brought into CQC oversight and restricted to being performed by suitably qualified and regulated healthcare professionals.

The consultation has coincided with a period of increasing scrutiny of the safety of the cosmetics sector. Recent years have seen some elements of the sector becoming much bolder in the type of procedures they are prepared to offer their clients, with concerning implications for public safety. Since the consultation was run in 2023, the government has been extremely alarmed by widespread media reports in recent months of highly invasive treatments being performed by inadequately trained practitioners. Ministers were especially saddened to hear of the death of Alice Webb in September 2024 at Gloucestershire Royal Hospital following undergoing a non-surgical Brazilian butt lift.  

Following these troubling reports, many stakeholder organisations have expressed serious concern about non-healthcare professionals performing procedures which are invasive to the point of being considered to be surgical in nature. The Joint Council for Cosmetic Practitioners (JCCP), the Chartered Institute of Environmental Health (CIEH) and the British Beauty Council (BBC) requested guidance be prepared to support enforcement by local authority authorised officers in tackling the dangers posed by buttock augmentation and other body contouring procedures. The guidance on Buttock augmentation and other body contouring procedures, published in October 2024 and co-signed or endorsed by a range of organisations operating in the aesthetics sphere, states: 

After consultation with experts and competent authorities, it is agreed that any procedure designed for buttock, breast or genital augmentation, using dermal fillers or grafted autologous fat, is considered to be a surgical procedure. We note that only the Royal Colleges of Surgeons provides regulated qualifications/certification that set the standards of competence in the performance of such invasive procedures. Further, based on the available evidence, the risks, the ability to mitigate those risks, and the proficiency to manage the adverse events and complications when they arise, are such that these procedures should only be performed by appropriately trained specialist (plastics) surgeons and fully qualified General Medical Council registered medical doctors who possess additional qualifications to undertake surgical procedures and have proven and ongoing competence in the performance of BBL procedures.

In light of the tragic death of Ms Webb, Save Face has been campaigning for ‘Alice’s law’, which would make it illegal for anyone other than a registered plastic surgeon on the GMC specialist register, operating from a CQC-regulated environment, to perform buttock augmentation procedures using hyaluronic acid dermal fillers. Similarly, in response to media reporting of liposuction being inappropriately performed, in November 2024 the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) issued a statement on protecting patient safety in cosmetic surgery, advocating for stricter regulation of the industry. 

Ministerial concerns around these events, continuing stakeholder calls for action, and the responses received to the consultation have reaffirmed the need for robust regulatory action to protect public safety. Due to the elevated level of risk which high-risk procedures pose, the government will therefore prioritise initial work in this space on the introduction of legislation which will ensure that those procedures deemed to pose the highest level of risk (including procedures aimed at augmenting the breast, buttocks and genitals with dermal fillers) can only be performed by suitably qualified regulated healthcare professionals working for CQC-registered providers.  

We will continue to engage with CQC to explore how this could be implemented in line with its existing legislation, alongside ongoing work with stakeholders to determine the other specific procedures where these restrictions are needed. The proposed changes will be detailed in a public consultation, to be launched early next year. 

Although the work outlined above has been prioritised, the government recognises that regulatory action is needed on the broader range of procedures being offered by the sector if public safety is to be protected. Officials will therefore continue the work instigated by the previous government to develop and implement local authority licensing for lower-risk procedures. 

We agree that further work is needed to understand the risks posed by specific procedures to ensure that regulation is both robust and proportionate. The responses to the current consultation have been helpful in identifying and suggesting where further work or review is needed to better understand these risks. For example, we have received useful feedback on the technical aspect of various procedures, particularly procedures which can be administered at a range of strengths or to varying depths of penetration. The consultation proposed that laser and chemical peel procedures sit across different categories based on these factors and many comments we received proposed that a similar approach should be adopted for other procedures based on these variables.

We recognise the fast-moving nature of the sector and how new techniques and products are coming to the market, and will continue to consider how these innovations might be incorporated into systems of regulatory oversight. We intend to work with relevant stakeholders to explore these issues to better evaluate the risks associated with procedures within the scope of the regulatory proposals to ensure that decision making is suitably informed by relevant expert input.

Based on the views expressed through the responses to this consultation, we are not proposing at this stage to remove any of the procedures currently included within the scope of the licensing scheme or associated regulation, nor are we proposing to add any further procedures. Specifically, we are not proposing to include those procedures which are currently subject to registration through the Local Government (Miscellaneous Provisions) Act 1982 or those subject to local licensing schemes under various local acts. The intention in developing regulatory oversight of the sector has been, and continues to be, to focus on those procedures which are currently subject to little or no regulatory oversight.

We recognise, however, that many local authorities and those who work in licensing have cited concerns in their responses about the potential for duplication of oversight and fee requirements for those businesses that offer a mixture of activities which are currently subject to registration and those that will be subject to licensing when the scheme becomes operational. We also note that some respondents hold the view that the current registration scheme is not fit for purpose for ensuring public safety in relation to the activities it governs. While we do not intend at this time for licensing to include those activities subject to registration, we will continue to work with stakeholders from local government to understand their concerns and prevent unnecessary duplication or bureaucratic burden.

Concerns about the classification of procedures and the introduction of restrictions on who can perform certain procedures have been well voiced through the consultation responses. While we recognise the desire for clarity and certainty within the sector, further work is required to determine where specific procedures will sit in the proposed tiering system and to determine which practitioners should be permitted to carry out certain procedures. These issues cannot be considered or determined in isolation and it is vital that any classifications and restrictions strike a balance between being proportionate to the risk to public safety while not unnecessarily hampering the activities of legitimate practitioners. Decisions in this area need to be informed by a careful consideration of the wider range of interconnected issues as outlined above, which extend beyond the scope of this first consultation. As detailed above, initial work in this area will prioritise the introduction of regulations for the highest-risk procedures, and we will develop proposals which will be consulted on early next year. 

Age restrictions

The majority of respondents were in favour of introducing age restrictions for the procedures that will be subject to licensing in line with the proposal in the consultation (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).

Common reasons cited for agreement included young people:

• still developing physically and emotionally
• not being able to give informed consent or appreciating the potential longer-term consequences of undergoing a non-surgical cosmetic procedure
• being more susceptible to societal pressure to undergo a cosmetic treatment

It was also highlighted that this would create consistency with the existing restrictions on accessing Botox injections and filler procedures, which would be beneficial in creating clarity. Although many agreed with the proposed minimum age being set at 18, some responses advocated for the minimum age to be even higher, particularly for the higher-risk treatments, given the body is still developing. Several respondents proposed 21 as a suitable age, and a few suggested a higher age restriction.

Many respondents also agreed that treatments should be made available to under 18s if approved by a doctor and carried out by a healthcare professional. Many responses highlighted that treatments for conditions such as acne and scarring, excessive body hair and skin lesions, including skin tags and warts, should be made available, as such treatments can help to alleviate the psychological and emotional distress that the conditions can cause young people. However, some responses cited concerns that placing restrictions on which practitioners can approve the need for and perform such treatments might prevent young people from accessing these treatments in a timely manner. It was also questioned whether these restrictions would be proportionate given other healthcare professionals’ competency and scopes of practice, and the intention for licensing to create consistent standards for all practitioners regardless of professional background.

Government response

The consultation has strengthened our intention to mandate age restrictions for those undergoing non-surgical cosmetic procedures. Many respondents agreed with this proposal and offered helpful views on which procedures it may be beneficial to make accessible to those under the age of 18. We will consider these suggestions in tandem with the further work to be done on risk assessment of procedures.

Training, qualifications and education standards

One of the central themes to emerge within the consultation responses was around education and training standards. Many respondents said either:

• the focus of regulation should be on ensuring consistent education and training is undertaken by all practitioners
• the level of their agreement with the proposals in the consultation is predicated on robust standards of education and training being mandated in the sector

Furthermore, as some respondents highlighted, the current view of the risks posed by the non-surgical cosmetic procedures on which respondents were basing their responses is in part informed by the current state of the sector and the current standards (or lack of) to which its practitioners adhere. Some respondents suggested that mandating training standards for a procedure could sufficiently mitigate the risk that a procedure is deemed to pose. This would influence where that procedure sits in the tiering system and which practitioners are permitted to perform it.

Concern was voiced that the proposals for regulation placed too much emphasis on practitioners’ professional background and that this focus may limit non-healthcare professionals from performing some of the procedures proposed for inclusion in the scheme. Many responses expressed that regulation should seek to establish specific training and education standards required to perform aesthetic procedures safely (including training and standards for managing complications and requirements to undertake continuing professional development when qualified) and then ensure that all practitioners, regardless of professional background, are able to demonstrate them.

Many responses highlighted that many aesthetic practitioners have undertaken extensive training and hold qualifications specific to working in the sector. A common theme expressed was that training providers needed regulating, citing concerns around the quality of many of the courses on offer at present, particularly online courses and courses of one or a few days’ duration, and the ease and speed with which someone could claim to be a qualified aesthetic practitioner.

Various responses highlighted that aesthetic practice does not constitute a routine part of regulated healthcare professionals’ education or training and does not fall within many healthcare professionals’ scope of professional practice or specialism. Many argued that being a regulated healthcare professional therefore does not in itself demonstrate that a practitioner possesses the knowledge and skills required to perform aesthetic procedures safely. Some respondents were concerned that under the proposals set out in the consultation, such professionals, solely by virtue of being regulated healthcare professionals, are considered more qualified for, or competent at, aesthetic practice than experienced and qualified aesthetic practitioners who are not regulated healthcare professionals.

Some responses commented that aesthetic practice, which is focused on ideas of beauty and symmetry, is a separate discipline to healthcare, which has different aims, and that being a skilled aesthetic practitioner requires a knowledge base and skill set distinct to that of a healthcare professional. A related theme frequently voiced was that healthcare professionals and non-healthcare professionals alike complete the same aesthetic-specific qualifications and are therefore as qualified as each other to perform aesthetic procedures.

Conversely, a strong theme to emerge was that many or most of the procedures proposed for inclusion in regulation are essentially clinical or medical in nature and should be administered with the same standard of holistic care as any other healthcare procedure would be. These responses argue that only healthcare professionals accountable to a regulatory body and with a duty of care to their patients are appropriately trained and able to deliver this standard of care, including the standard of care required to manage any complications arising as a result of procedures.

It was questioned whether any sort of ‘grandfathering’ period (through which licensing and associated regulation would recognise or accredit practitioners’ existing qualifications or experience for a fixed period of time following the introduction of the scheme) might be put into operation to obviate the need for those with pre-existing qualifications and experience having to spend considerable time and money to retrain to meet the new requirements regulation will introduce. It was also questioned whether, if new qualifications are deemed to be necessary for a practitioner to be compliant with incoming regulatory requirements, any support will be given to assist existing practitioners to obtain them.

Government response

We acknowledge how vital the issue of education and training is to driving up standards across the sector. An important principle underpinning the licensing scheme and associated regulation is that all those who practise invasive non-surgical procedures should be competent and will need to satisfy the overseeing authorities of their proficiency. Pivotal to the design of regulation will be to consider:

• current education and training standards, systems and providers
• what good practice looks like
• how establishing robust education and training standards can help to instil this across the sector

In addition, we recognise that many practitioners across the sector are highly experienced and already strive to meet robust standards of training and education and keep their skills up to date. We will explore how such pre-existing skills and training might be acknowledged by the licensing scheme and associated regulation when it comes into operation.

Concerns around supervision and the amber category

The proposals in the consultation for procedures within the amber category to require supervision or oversight from a named regulated healthcare professional who has gained an accredited qualification to prescribe, administer and supervise aesthetic procedures generated a range of comments.

Of the 3 proposed categories of classification, there was the least amount of overall support for the amber category. A common theme was the need for further clarity on what supervision would entail and which practitioners would fall within the remit of the term ‘regulated healthcare professional’.

Responses also highlighted that some healthcare professionals’ prescribing responsibilities are restricted and can only be used in the course of their professional scope of practice (meaning the practice for which they require regulating by a statutory body) and that the performance of aesthetic procedures falls outside many regulated professionals’ scope of practice. This will need to be considered, as plans for supervision, including ensuring timely access to prescription only medicines (POMs), are explored.

Many responses, from both individuals and organisations, stated that a practitioner being suitably qualified in and indemnified for the procedures they offer should obviate the need for supervision and the associated amber category. Similarly, it was proposed that a system of different gradations of supervision be established to reflect practitioners’ differing levels of experience and qualifications. Many responses expressed concern that the requirement for supervision would limit the procedures which non-healthcare professionals would be able to offer their clients, with a resultant detrimental effect on their businesses.

The extent to which supervision is practicable was also frequently raised, particularly whether supervision should entail the supervisor being present on site whenever an aesthetic procedure requiring supervision is carried out. The additional costs that businesses would incur from requiring a supervisor was also cited as a concern.

Some responses queried whether there would be enough practitioners who meet the requirements to be supervisors to satisfy demand. Similarly, some expressed concern that the need for supervisors to be regulated healthcare professionals with prescribing rights could cause healthcare professionals to leave their NHS jobs, as acting as a supervisor for aesthetic procedures may be more lucrative and may not entail such long working hours or the requirement to work shifts.

Some expressed concern that people might undergo training to be a healthcare professional, using public money to do so, purely with the intention to work in aesthetics on qualification, without working for the NHS. 

Government response

Oversight is an important part of the proposed licensing scheme, as a means to mitigate risk. However, it is clear that many in the sector have concerns about the need for, and viability of, introducing this measure and the effect it may have on businesses.

As many respondents pointed out, oversight was not defined in this consultation and at present could still encompass a range of measures depending on the specific circumstances of the practitioner, client and the procedure being performed. Any determination on the need for a practitioner or procedure to be subject to supervisory oversight needs to be based on a detailed understanding of risk and the extent of practitioners’ (and supervisors’) capability when suitably trained.

This needs to be considered alongside our work on education and training standards, which is beyond the scope of this initial consultation. As part of this work, we will explore options for a requirement for oversight for some procedures, particularly those which require a POM either in the performance of the procedure itself or in the performance of any adjunctive procedure necessary following the primary procedure, such as hyaluronidase for managing complications of dermal fillers. As with other measures designed to mitigate risk, we remain committed to considering how this can be done proportionately.

Definitions, descriptions and bias in the consultation

Some responses cited difficulty in determining the extent to which they agreed with the consultation’s proposed categorisations of procedures and restrictions on who can perform them, without having been given clear definitions of:

• who might be considered to be a ‘regulated healthcare professional’
• what supervision would entail
• what training and educational standards practitioners would have to meet

Many respondents felt that aesthetic practice falls outside of the remit of many regulated healthcare professionals’ scope of professional practice and were concerned that regulated healthcare professionals are being unfairly seen as automatically more skilled at aesthetic practice purely by virtue of their professional standing rather than on an assessment of skill and experience specific to aesthetics.

Some responses cited concerns about the accuracy of the descriptions of procedures provided in the consultation document glossary and about the sources of the advice the government is receiving on the sector and the procedures it offers. Some respondents felt that the consultation’s proposals to restrict certain procedures to being performed by regulated healthcare professionals only, or under their oversight, have been too heavily influenced by those who advocate for the interests of the healthcare professionals in the sector. Others suggested that the proposals make too many concessions to the interests of non-healthcare professionals operating in the sector, to the detriment of public safety.

Government response

As detailed above, we will continue to work with relevant stakeholders to further develop plans for education and training requirements and supervision and to consider what requirements regulated healthcare professionals will have to meet to be eligible to act as supervisors, or how their professional scopes of practice might be recognised as part of licensing and associated regulatory oversight.

We have consulted with a range of relevant experts from across the sector to gain technical insight and to develop proposals for regulation which are accurate in their detail. We will continue to do so as we progress with the next phase of the work.

Resources to administer and enforce the scheme

Many responses described how local authority resources are already stretched with their current duties and that additional resources would be needed to operate the licensing scheme. Many cited that the aesthetic procedures proposed for inclusion in the licensing scheme are out of scope of local authorities’ current remit and that substantial training and guidance would therefore be required to equip local authorities with the knowledge required to perform the new functions licensing would entail. Similar points were made about the potential impact on CQC and its capacity to provide regulatory oversight of the high-risk procedures proposed to fall within its remit.

Several responses cited the need for robust enforcement measures to uphold public safety and the need for effective introduction of offences and penalties to deter attempts to circumvent the requirements of the licensing scheme and associated regulatory oversight.

Fees were mentioned by several organisations. It was felt that these should be set at a level to aid cost recovery, but there was some difference of opinion as to whether these should be set at a national or local level.

Government response

We recognise the additional workload that licensing and associated regulation will place on local government and CQC. We will continue to engage with them to understand the impact this will have on their resourcing and the training and guidance needs it will create.

We will aim to balance the benefits of there being a set lead-in time or a transitionary period before the proposed regulatory oversight is in full operation across England with the need to move quickly to protect public safety in this space, and we will ensure that those who introduce and operate the regulation are supported.

Duplication of systems of regulatory oversight

Many responses, particularly those received from local authorities, advocated for some or all of the procedures for which local authorities operate registration schemes through the Local Government (Miscellaneous Provisions) Act 1982 (namely tattooing, cosmetic piercing, semi-permanent skin colouring, electrolysis and acupuncture) to be brought into the remit of the licensing scheme. These responses cited concerns that the current legislation is not sufficient to embed adequate standards for these procedures or grant the powers of enforcement deemed necessary to uphold public safety.

Furthermore, concerns were raised that simultaneously operating systems of registration and licensing would create a bureaucratic burden and cause confusion for local authorities and businesses. It was highlighted that many businesses provide procedures which currently require registration and also procedures which would require licensing under the new scheme, requiring them to be subject to 2 separate systems of local authority regulatory oversight.

Similarly, some responses highlighted concerns that a new licensing scheme operating alongside existing local systems of licensing (operated through legislation applicable to specific geographical areas, such as through the London Local Authorities Act 1991) would create similar bureaucratic issues for businesses and local authorities.

Related issues were raised regarding the potential for businesses to fall within the remit of licensing and CQC registration, depending on the range of procedures they offer. Several responses proposed that, where this is the case, CQC, as the body overseeing the highest-risk procedures being offered, should assume responsibility for overseeing the full range of treatments provided by the business and that it should not be necessary for the provider to also obtain a licence from the local authority.

A further related issue was of oversight of healthcare professionals who are subject to oversight from a statutory professional regulatory body. Questions were raised as to how the various regulatory bodies involved might work together in a way which avoids uncertainty around where responsibilities lie, such as for dealing with concerns and managing poor practice, and how local authority enforcement action and CQC regulation would interact with regulators’ professional standards and fitness to practise processes.

Also raised was the issue of how the licensing scheme will interact with the accredited registers programme administered by PSA, and whether a practitioner’s registration on an accredited register would affect the requirement for them to be licensed by the local authority.

Government response

We recognise the range of regulation already in place in the aesthetics sector and the importance of minimising the bureaucratic demands placed on those operating the scheme and associated oversight and for those businesses which operate in the sector.

We will continue to work with stakeholders, including local government, the statutory healthcare regulators and the accredited registers programmes to consider how regulation would interact with the work of the other organisations who provide oversight of aesthetic practitioners and healthcare professionals.

There is already a strong history of interorganisational working in healthcare on which to draw in this regard, with professional regulatory bodies working with provider and system regulators such as CQC, the Medicines and Healthcare products Regulatory Agency (MHRA) and local governance bodies to uphold patient safety.

National register, communications and data sharing

Communication about the incoming regulation was also raised as an issue which will need consideration. Responses highlighted how practitioners and the public will need clear information about what the licensing scheme and associated regulation will entail, to enable businesses to understand the actions they need to take to be compliant with the regulations and to assist the public in choosing a practitioner who is suitable to perform the particular procedure they wish to undergo.

Some organisations advocated for the setting up of a national register of licensed practitioners that is accessible to the public as well as local authorities, saying that this would aid consumers in identifying reputable providers, as well as supporting information sharing between local authorities. It was suggested that this work should be commenced contemporaneously with licensing being introduced to avoid the difficulties involved in compiling a register retrospectively once licensing is in force.

Some responses also advocated for a national register of approved training providers to enable the public and licensing authorities to verify the suitability of practitioners’ qualifications.

Many organisations also proposed that systems of data and information sharing between organisations involved in regulating the sector should be established to gather more information about the sector, such as mechanisms to report complaints, adverse events and complications, and to enable emerging concerns and issues to be shared and addressed promptly.

Government response

We recognise that regulation has the potential to be complex and that, to be successful in its aim to uphold public safety, it must be navigable and understandable for all those who use it, such as:

• members of the public looking to find a suitable practitioner
• businesses looking to understand what they need to do to comply with the regulatory requirements
• enforcement bodies looking to obtain information on a practitioner or an emerging trend

Information on the regulation and its requirements therefore needs to be easily accessible and the regulatory system itself needs to be responsive to be able to act promptly on concerns.

We will work with local government, CQC and other organisations involved with administering the regulatory system to ensure that a comprehensive communications package supports the implementation of each phase of regulatory oversight and that suitable systems of data collection are established to enable issues to be reported and addressed in a timely manner.

Devolved governments implications and approach

Some responses from organisations highlighted that the licensing scheme and associated regulations would be operational in England only and that the devolved governments have their own systems of oversight for the sector.

A few responses drew attention to media reporting from during the time the consultation was open that under 18s in England were circumventing the age restrictions imposed by the Botulinum Toxin and Cosmetic Fillers (Children) Act 2021 by obtaining treatments in Wales.

Some responses urged the government to work with the devolved governments to understand how their respective regulatory systems can work together to provide effective safeguards for consumers.

Government response

We will continue to work with the devolved governments to understand and share information on the approaches being taken across the UK to uphold public safety in the non-surgical cosmetics sector.

Prescribing and products

Concern was raised by some respondents around the lack of face-to-face consultations between prescribers and clients for procedures that require POMs, and the associated lack of comprehensive assessment by prescribers of the appropriateness of, or the client’s suitability for, the desired procedure.

Some responses also drew attention to the way in which current legislation in England prevents nurse independent prescribers from holding stock of prescription medicines. Concern was voiced that this is impeding timely access to prescription medicines needed in the event of an emergency or complication, such as accessing adrenaline in the event of anaphylaxis or hyaluronidase to dissolve dermal filler to prevent vascular occlusion, and it was proposed that legislation needs to be amended to rectify this situation.

Some concern was also raised about the quality of some of the products being used in the sector, particularly unregulated or unlicensed products, and the supply routes through which these products are obtained. The government was encouraged to explore this issue further and work with other regulatory bodies such as MHRA to ensure that products being accessed are deemed to be safe and obtained from reputable suppliers.

Government response

Responses received supported concerns already voiced by stakeholders regarding current prescribing practices and product accessibility. We will continue to explore with relevant regulatory bodies how legislation and guidance can be used to mitigate the risks which poor practice in these areas pose.

Safeguarding

Several responses raised concern that the consultation had not proposed measures to safeguard children and vulnerable adults who access non-surgical cosmetic procedures. It was highlighted that the current lack of regulation in the sector means there is little scrutiny of the background of those who are offering aesthetic procedures and who are not accountable to a statutory regulatory body, which poses a risk to public safety.

Government response

We recognise the importance of safeguarding to upholding public safety. Although this was not a topic focused on in this consultation, we are grateful for the comments received on this issue, and will use them to inform future work on determining the requirements that all practitioners will have to meet to demonstrate that they are safe to perform procedures on the public.

Futureproofing

There was widespread acknowledgement across the range of responses that the aesthetic sector embraces development and innovation, and that the licensing scheme and associated regulation must be futureproofed so that they can incorporate new techniques and procedures in a timely manner.

Respondents also acknowledged that existing procedures should be kept under regular review to ensure that their classification and any associated restrictions on which practitioners are permitted to undertake them remain proportionate. It was questioned where responsibility for this classification and ongoing review would lie.    

Government response

We recognise that there is still some time before regulations and accompanying guidance come into force and that new products and techniques are regularly appearing on the market. We will continue to work with stakeholders to monitor developments in the sector and consider how regulation can work to protect the public from any potential risks these innovations might pose.

Conclusion

The government is grateful to those individuals and organisations that took the time to provide their views on the questions asked. It is clear that there is widespread support for developing a regulatory system that is both proportionate and effective.

This consultation is the first to be held on the licensing scheme and associated regulatory oversight and has focused on issues pertaining to the scope of proposed regulation. In acknowledgement of the variety of issues to consider when introducing regulation in the sector, and the number of people and businesses this will affect, the consultation was designed to cover a wide range of issues and reach a broad audience. The responses received have demonstrated a wide range of opinion, not only on the proposals set out in this consultation, but also on a range of related issues which will be the focus of ongoing work to develop the licensing scheme and associated regulation. This work will be subject to further public consultations to inform a finalised design for the licensing scheme, which will be subject to Parliamentary debate before implementation.

The design of a proportionate and effective regulatory system is a complex but vital task and the views expressed by respondents to this consultation have been invaluable in highlighting where further work and consideration is needed to develop the architecture of the system.

Methodology

The consultation ran from 2 September 2023 to 28 October 2023. The survey hosted on GOV.UK contained closed (quantitative) and open-ended (qualitative) questions. Several organisations also submitted documents via the consultation platform and by email. These were analysed alongside the open-ended responses.

Descriptive statistics of the quantitative responses were produced, which are used to describe and summarise the characteristics of the consultation responses, not to make inference or prediction, or assess the interaction between variables. For each question, the distribution of responses was calculated as a percentage of those who provided an answer to that question. We have provided a breakdown for overall views on the proposal to restrict high-risk procedures to qualified and regulated healthcare professionals only by:

• type of respondent (for example, members of the public, a representative organisation or body, members of the workforce)
• professional group (for example, aesthetic practitioners, healthcare professionals working in cosmetics, other healthcare professionals)
• whether the respondent works in England, Wales, Scotland, Northern Ireland or elsewhere (for those sharing professional views)

Responses to the consultation are not representative of the groups referenced, but only of those who chose to respond to the consultation. Where groups are referred to or compared - for example, “members of the public are most likely to say…” - this refers only to members of the public responding to the consultation and cannot be taken to represent the views of the public more generally. As such, statistical significance testing has not been used to analyse results. Differences between responding groups have been highlighted using judgement.

We have assumed in analysis that respondents submitted responses in good faith which, if given, accurately represent their characteristics and their view. For example, we take at face value those selecting ‘Other regulated healthcare professional’ are indeed from this group, as verification was not sought.

For ease of reading, we have aggregated positive or negative responses. For example, if 28% were very unsupportive and 5% slightly unsupportive, we have written this as ‘33% unsupportive’. These aggregated figures are derived from the frequencies rather than the rounded percentages. In most cases, this would result in the same figure, but may in some cases result in a 1 or 2 percentage point difference from adding together rounded percentages. Results are reported as a percentage of those that responded to the question (for instance, “75% of public respondents agreed with…” should be understood as “75% of public respondents that responded to this question agreed with”). This is omitted for ease of reading, but results should be read this way throughout.

Accompanying data tables have been published alongside the consultation response. These data tables present full breakdowns for each quantitative question in the consultation, in accordance with statistical disclosure controls to protect anonymity, and provide the data used in the analysis section.

The number of respondents in each of the categories is set out in the accompanying data tables.

The consultation also included 14 open-ended questions where respondents could provide free text responses. Across all these questions, around 2.1 million words were received in just over 50,000 free text responses. This was in addition to ‘Other (please specify)’ responses which were given to add to pre-defined options shown to respondents.

In addition to responses from individuals, we also received responses from many stakeholder organisations, including 417 through the online survey platform (30 of which were submitted in the form of an uploaded document), 4 who submitted a document response directly through a mailbox, and 2 who later submitted a PDF document response. These included aesthetics and beauty businesses, charities, professional bodies, education and training providers, local authorities and academic institutions. Responses from organisations were manually reviewed in their entirety (including those submitted via email) using thematic analysis to code into themes via an iterative process with a team of policy officials and analysts. These are referred to in the analysis as ‘organisations’, ‘stakeholders’ or ‘stakeholder organisations’.

There were incidences of multiple responses being received from the same named organisation. This appears to have been due to several members of an organisation (such as a professional association) individually submitting the organisation’s agreed response. However, not all organisation responses received from the same named organisation were identical.

To analyse individuals’ responses to free text boxes, we used a machine learning technique known as topic modelling to provide an initial view on topics and themes emerging from their open text responses. Topic modelling sorts through a large body of text to find and group words that frequently appear or occur together, revealing the main themes or ‘topics’ in a text. We also conducted detailed thematic analysis of samples of responses to draw out important themes and ideas from each question. Samples were designed to cover a cross-section of respondents by demographic factors (for example, professional group) and responses to previous quantitative questions. Where free text questions followed a quantitative question (for example, “please explain your answer [to the previous question]”), these responses were understood and analysed in the context of their preceding quantitative response.

While qualitative analysis is not intended to show exactly how many people held a certain view, we have endeavoured to provide an indication of the weight of opinion in responses, using words such as ‘many’, ‘some’, ‘several’ or ‘a few’.

Individual quotes have been used, where appropriate, to help illustrate themes. These were selected either as being typical of the responses received, or that they were particularly clear examples of the theme. The quotes have not been edited, except to remove any information that could potentially identify respondents.

Analysis of responses

The following sections provide detailed analysis of how people responded to the questions in the consultation on the licensing of non-surgical cosmetic procedures. The full data used in this section can be found in the accompanying data tables.

We received 11,848 responses to the online consultation. Individuals sharing their professional views were the largest group (55%). Individuals sharing their personal views and experiences were second largest (41%). Other demographic breakdowns (age, sex, gender, nation, region) can be found in the accompanying data tables. To preserve anonymity, low values (where frequency is lower than 5) have been suppressed throughout. These values are all noted in the accompanying tables.

Introductory questions

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

There were 6,431 responses to this question, of which:

• 5,268 (82%) said yes
• 1,163 (18%) said no

This question was asked only of those sharing professional views.

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

There were 11,109 responses to this question, of which:

• 6,354 (57%) said yes
• 4,755 (43%) said no

This question was asked of those sharing personal views and experiences, and those sharing professional views.

We received 4,577 responses to the open text portion of this question through the online consultation platform. Respondents listed a wide variety of relevant qualifications specific to working in the non-surgical cosmetics sector.

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

There were 11,179 responses to this question, of which:

• 9,137 (82%) said yes
• 2,042 (18%) said no

This question was asked of those sharing personal views and experiences, and those sharing professional views. A far larger number of women responded to the consultation than men, and the share of female respondents who reported having had a non-surgical cosmetic procedure was far higher (84%) than for male respondents (56%).

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

We received 7,856 responses to this open text question. Responses were manually analysed in order to create a dictionary of procedures, including synonyms and spelling errors. This was then used to produce a standardised version of the responses, which was compared against the raw data and found to have successfully categorised more than 90% of procedures. More detail on this process can be found in the experimental analysis annex published alongside this response.

Of the 7,856 responses, 7,603 were coded into at least one procedure. The most common procedures were:

• dermal filler - 5,331 responses (70%)
• Botox - 5,095 responses (67%)
• skin boosters - 847 responses (11%)
• microneedling - 811 responses (11%)
• anti-wrinkle treatment - 648 responses (9%)
• chemical peels - 685 responses (9%)

We also broke down the most common procedures by age group. The spread of ages was broadly consistent for most procedures. The largest group of respondents overall was 35 to 44 year olds, who reported receiving the most treatments, followed by 25 to 34 and 45 to 54 year olds. Across all procedures, the vast majority of respondents who had undergone the treatment were female. Those who were aesthetic practitioners themselves were the most likely to report having had every procedure except Botox and filler (which members of the public were more likely to have had).

Were you satisfied with the outcome of your procedures?

There were 9,032 responses to this question, of which:

• 8,481 (94%) said yes
• 551 (6%) said no

Levels of satisfaction with procedure were similar across age groups and sex. There was very little variation by the kind of procedure they had, although satisfaction levels were slightly higher for microneedling, skin boosters, radio frequency treatments, anti-wrinkle treatments and chemical peels.

We received 4,494 responses to the open text portion of this question.

Some participants expressed overall satisfaction with their procedures. They praised the clarity of information provided regarding pre and post-treatment care, the cleanliness of the treatment environment, and the feeling of being well-informed about potential risks and probable outcomes. They also appreciated the thoroughness of the consultation and medical history review.

Furthermore, several respondents specifically highlighted positive experiences with their practitioners. These positive comments will be summarised alongside responses regarding practitioners in the next section for ease of reading.

However, alongside the positive experiences, concerns also emerged. These concerns revolved around specific side effects experienced after the procedure, safety anxieties, and instances where return visits for ‘fixes’ seemed to exacerbate the initial problems. Additionally, some participants reported generally poor service, citing perceptions of unprofessional practitioners, a sense of being rushed through like being on a ‘conveyor belt’ of patients, and difficulty in raising complaints about their procedures. Respondents also expressed financial concerns, including the need for deposits and challenges in obtaining refunds.

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

There were 9,024 responses to this question, of which:

• 8,424 (93%) said yes
• 600 (7%) said no

We received 4,125 responses to the open text portion of this question. These were analysed alongside responses from the previous open text question which focused primarily on the practitioner.

Consistent with the preceding quantitative question, a significant portion of respondents expressed satisfaction with their practitioner’s professionalism and communication. These individuals felt informed about the procedure, had their questions and concerns addressed, and perceived their practitioner as competent, knowledgeable and trustworthy. Specific aspects contributing to this positive perception included thorough:

• consultations
• informed consent procedures
• visible proof of qualifications
• clear communication using technical terms
• having a detailed medical history review
• comprehensive aftercare
• readily accessible support for post-treatment care

Additionally, some patients expressed a preference for practitioners with certain standards of qualification (for example, level 5 or 6), or training in specific areas such as anatomy and physiology.

A minority of respondents were not satisfied with the expertise and approach of the practitioner who performed their procedure. These individuals expressed concerns regarding perceived motivations, level of care, or inadequate communication about the procedure.

Some suggested that certain practitioners might be primarily motivated by financial gain, leading to concerns about overcharging for simple procedures or a lack of thorough aftercare. Some also reported practitioners ‘upselling’ cosmetic procedures by pointing out perceived physical flaws.

Others expressed dissatisfaction with the outcome of their procedure, linking it directly to the practitioner’s performance. They described feeling misled about potential outcomes, experiencing undesirable side-effects, or incurring additional costs to rectify issues arising from the procedure. In some cases, respondents spoke about how their negative experience had left them with depression, anxiety and other forms of mental ill health.

Notably, many respondents used the terms ‘medic’ and ‘non-medic’ to differentiate between registered healthcare professionals and non-healthcare professionals performing aesthetic procedures (which we have called ‘aesthetic practitioners’). For clarity and accuracy, this report will consistently use the latter terminology.

Some individuals expressed positive experiences with both healthcare professionals and aesthetic practitioners. These individuals perceived both groups to be knowledgeable, although some expressed a view that aesthetic practitioners might hold a deeper expertise in facial anatomy. Additionally, some individuals held the perception that healthcare professionals might prioritise financial gain over patient care, while others expressed concerns about their potentially generalised training not being as relevant to specific aesthetic procedures. Notably, these perceptions were not universally shared, and the data indicated that individuals had both positive and negative experiences with both practitioner types.

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

There were 9,033 responses to this question, of which:

• 8,307 (92%) said yes
• 726 (8%) said no

We received 2,919 responses to the open text portion of this question.

We explored open text responses received across this question and the previous 2 questions (satisfaction with outcome and practitioner) to identify any complications identified by respondents arising from cosmetic procedures they had undertaken. We limited this to text samples where the respondent had answered ‘No’ to the previous question and therefore had a negative experience.

The most common complications we were able to identify were:

• lumpiness
• swelling
• bruising
• (filler) migration
• pain
• infection
• scars
• vascular occlusion

Several respondents described having to have fillers dissolved to manage complications that had arisen from the original filler placement procedure.

Restriction of cosmetic procedures

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?

There were 11,753 responses to this question, of which:

• 6,233 (53%) said strongly agree
• 1,123 (10%) said agree
• 495 (4%) said neither agree nor disagree
• 1,066 (9%) said disagree
• 2,836 (24%) said strongly disagree

In the consultation, we defined high-risk procedures as:

• 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

In our analysis of open-text responses, we noted that some respondents interpreted this question as the restriction of all non-surgical cosmetic procedures to qualified and regulated healthcare professionals only, rather than ‘high risk’ procedures only. Many responses, across respondent groups, expressed the question was too vague or needed more clarity around what qualifies as high risk.

As one aesthetic practitioner stated:

It is really difficult to answer that question as it doesn’t outline what the government deems to be a high risk procedure. The treatments I think should be medical only are all threads, pdo threads, cogs, breast filler, bum filler, hip dip filler. Aesthetics to me is supposed to be about making small tweaks to enhance a persons natural qualities. It’s not supposed to be about making drastic changes which I would deem threads and body filler to be.

Some respondents also expressed a view that all procedures have an associated risk, so we should not be using a risk-based approach at all.

Just under two-thirds (63%) of respondents agreed that we should restrict high-risk procedures to qualified and regulated healthcare professionals only. Levels of support were similar among those responding in a personal and professional capacity.

However, within the ‘professionals’ respondent group, we saw a large difference of opinion. Healthcare professionals overwhelmingly agreed with restricting high-risk procedures to regulated healthcare professionals, regardless of whether or not they were working in cosmetics; indeed, support was slightly higher among those not working in cosmetics (94% compared with 92%).

Aesthetic practitioners mostly disagreed (62%) with restricting high-risk procedures to qualified and regulated healthcare professionals.

Views to this question were similar across England, Northern Ireland, Scotland and Wales.

We received 6,739 responses to the open text portion of this question. In our analysis, we have separated these into the most important respondent groups.

Aesthetic practitioners

Some responses from aesthetic practitioners agreed with restricting high-risk procedures to regulated healthcare professionals only. A few expressed that this was important due to the impact on a person’s health and the risk of complications. Several highlighted that we should not extend ‘high risk’ to cover other procedures, specifically anti-wrinkle and dermal filler injections.

Many aesthetic practitioners stated that aesthetic practitioners and/or beauty therapists should be allowed to perform procedures as they are often better and/or more experienced than regulated healthcare professionals. Many expressed a view that the public have more trust in aesthetic practitioners and/or beauty therapists in carrying out non-surgical cosmetic procedures. Responses highlighted that being regulated by a professional regulator does not mean that a practitioner is safe or competent.

A strong focus was on training standards. Numerous responses raised issue with the inadequacy of training providers and specifically issues with one-day or short training programmes and highlighted the need to regulate training providers.

Stakeholders expressed that practitioners who have trained to a certain standard should be able to perform procedures. Some stakeholders also highlighted the need for all practitioners to have the appropriate insurance in place. Several responses noted that practitioners who are not regulated healthcare professionals are able to deal with emergencies and manage complications, particularly if they have the correct training. Some responses noted which qualification levels they believed all practitioners should be required to meet (for example, levels 3 to 5 and 7). A few noted that if restrictions were imposed then NHS staff would leave the NHS to carry out aesthetic procedures, which would have a negative impact on the NHS:

I think non medics can be just as competent and safety conscious as medics. There should be licensing and a competency based examination or assessment for all regardless of background. Only allowing health professionals to practice will take more of them away from the NHS. Which is happening already.

A number of responses focused on the impact that restrictions could have on their careers and specifically the financial impact on practitioners if they were unable to operate or had to retrain. Several respondents expressed they felt that the proposals were discriminatory and/or unfair:

This will affect so many people in the beauty industry that are doing a fantastic job.

Regulated healthcare professionals working in cosmetics

Many responses stated that high-risk procedures should be restricted to regulated healthcare professionals only. Several responses specified that procedures should be restricted to medical practitioners only. Some responses highlighted that regulated equates to practitioners being safe, competent and/or accountable:

Only medical professionals are educated and equipped to recognise and deal with complications. They also have the insight to their limitations and are governed by a regulatory body

Some responses expressed that all injectable procedures should be restricted to regulated healthcare professionals. A few respondents said that any procedures using a POM should only be performed by a regulated healthcare professional.

Many responses stated that only healthcare professionals have the required knowledge of anatomy to perform high-risk procedures:

Knowledge of anatomy and the risks are second nature to registered clinicians and are managed as such . We do not take on procedures outside our competence . Ignorance leads to overconfidence.

Several responses asserted that non-regulated practitioners would be unable to appropriately respond to or deal with emergencies and complications. Responses strongly indicated that restrictions are necessary due to the impact on a person’s health and the potential risk of complications. Some respondents noted that complications could be psychological as well as physical. Several respondents highlighted the cost of complications for the NHS.

A number of responses highlighted that non-regulated healthcare professionals were not sufficiently trained or were underqualified and therefore unsafe to deliver high-risk procedures. Some respondents raised issues with training providers and one-day or short training programmes. A few respondents stated that non-regulated practitioners who have reached a set qualification or standard should be able to perform any procedures:

If someone has had the relevant training and follows the correct rules and regulations then it shouldn’t matter if they are medic or non medic. By making certain treatments medic only the NHS will suffer!

Regulated healthcare professionals not in cosmetics

A significant number of respondents stated that high-risk procedures should be restricted to regulated healthcare professionals only. Many respondents also expressed that high-risk procedures should be limited to medical professionals only. A number of these responses highlighted that being regulated equated to being safe, qualified and/or accountable. Numerous responses expressed that only regulated healthcare professionals have sufficient knowledge to undertake high-risk procedures. A number of these responses focused on regulated healthcare professionals’ knowledge of anatomy and physiology.

Many responses highlighted that high-risk procedures should be restricted due to the impact on an individual’s health and the risk of potential complications. A large number of responses stated that non-regulated healthcare professionals would not be able to deal with emergencies or manage complications. A few responses noted the cost of complications on the NHS.

A few responses said that non-regulated healthcare practitioners should be allowed to perform high-risk procedures if they held a relevant qualification or met a required standard. Some respondents highlighted the need to regulate training providers and one-day or short training programmes. Several responses raised that being regulated alone does not equate to being safe or competent. Some responses highlighted that the proposals would be unfair for some non-regulated practitioners who may have a lot of experience and training. A small number of responses also suggested the proposals could create a black market for procedures.

Some respondents highlighted the need:

• to regulate training providers and one-day or short training programmes
• for a robust qualification verification system
• for a central register of practitioners
• for the correct level of insurance

Members of the public not working in cosmetics

Responses to this question were varied.

Many responses stated that high-risk procedures should be restricted to regulated healthcare professionals only. A significant number of responses narrowed this further stating that only medical practitioners should be able to perform high-risk procedures. Several respondents claimed that only regulated healthcare professionals have sufficient training and/or knowledge of anatomy in order to safely carry out procedures. A few responses noted that non-regulated practitioners should not able to perform procedures using a POM:

There’s nerves and muscles on the face. The damage to these muscles or nerves could be permanent if damaged. They use medication, so only prescribers should be able to use them, as they know interactions as well as side effects, reactions… People with medical careers background should be the only one providing these services due to being invasive.

A large number of responses highlighted the impact on a person’s health if a procedure is carried out incorrectly and the risk of potential complications. Several responses suggested that non-regulated practitioners would be unable to respond to emergencies or manage complications. Some respondents noted the cost on the NHS of managing complications arising from procedures:

Some individuals carrying out these procedures do not fully understand the risks involved and are not equipped to deal with the complications. Unfortunately the client has no come back as the person is not regulated.

A significant number of respondents stated that any practitioner who had gained a set qualification or met a specific standard should be able to perform procedures without restrictions. A few respondents raised that the proposals would be unfair for non-regulated practitioners and could have a significant financial impact if individuals were unable to continue to offer the procedures they do at present. One respondent claimed the proposal is a ‘nanny state restriction’.

Many respondents stated that non-regulated practitioners have more experience and knowledge of non-surgical cosmetic procedures than regulated healthcare professionals. Some respondents also stated that being regulated does not equate to being safe or competent. A few responses commented on the potential impact on the NHS from staff leaving the NHS to carry out aesthetic procedures.

Some respondents raised issues with training providers and one-day or short training programmes. Several responses stated that all practitioners (non-regulated and regulated) should be required to meet the same training standards in order to carry out a procedure:

There are recognised qualifications for non healthcare professionals run by medical professionals to take to carry out these procedures that are aimed specifically at the beauty industry. These qualifications should be mandatory which would enable extremely experienced beauticians to carry out targeted procedures

A few responses focused on the need for product regulation and more oversight of regulated products.

Training provider or business owner

Many respondents stated that non-regulated practitioners should be able to perform procedures if they have relevant training and have met the required standard. A number of respondents highlighted that being regulated does not equate to competency to carry out a procedure. Some responses stated that non-regulated practitioners are better and/or more experienced than regulated practitioners and have sufficient knowledge and training. A few responses noted that aesthetic practitioners are more likely to have an eye for beauty and symmetry than regulated practitioners:

I believe that most of the list on the red light but not all on the red light should only be done by medics.. I work with non medics and medics.. and non medics are more caring, more careful and more aware of causing a complication. And most of the time non medics are more knowledgeable on the face anatomy and have a better eye on the beauty harmonization

A number of respondents alternatively expressed that only healthcare professionals, or medical professionals should be able to carry out procedures. Many respondents stated that regulated practitioners are safe and competent to carry out procedures and that non-regulated practitioners are unable to deal with emergencies or manage complications from procedures:

I have seen way too many times where treatment has gone wrong and the beautician doesn’t know how to fix or help the patient.

A few respondents noted the cost to the NHS of complications from procedures carried out by non-regulated practitioners.

A significant number of responses raised issue with training providers and one-day or short training programmes. Many respondents stated that all practitioners (both regulated healthcare professionals and non-regulated practitioners) should be required to meet the same training standards in order to carry out a procedure. A few responses highlighted specific qualification levels (for example, levels 3 to 5 and 7).

Some respondents expressed that the proposals are unfair and could have a significant impact on businesses and individuals’ careers. A few respondents also noted that there could be an impact on the NHS if staff leave the NHS to work in the cosmetics industry.

Licensing professionals

A significant number of responses from those who work in licensing stated that high-risk procedures must be restricted to regulated healthcare professionals due to the potential impact on a person’s health and/or the risk of complications. Several responses said that the procedures should be restricted to medical professionals only. Some of these responses focused on the advanced knowledge of regulated healthcare practitioners, specifically in the areas of infection control. A number of responses expressed that non-regulated practitioners do not have sufficient knowledge or are not sufficiently trained to ensure patient safety. A few responses also stated that non-regulated healthcare professionals are unable to deal with emergencies or manage complications. A small number of responses noted the cost of complications to the NHS.

Several respondents stated that non-regulated practitioners should be able to perform high-risk procedures. A few respondents expressed that the proposals were not fair for non-regulated practitioners:

There are a vast amount of non medical practitioners who are have outstanding knowledge and years of experience. These practitioners provide excellent and highly professional services, education and treatments. It is ludicrous to penalise these practitioners on the fact they don’t have a medical background alone.

A number of responses raised that training providers need to be regulated and that there is a significant issue with one-day or short training programmes. A few responses stated a need for regulation of cheap or substandard cosmetic products.

Some respondents noted the proposals will help consumers make safe choices. However, a few responses also noted that we need to ensure that any scheme is futureproofed to allow for ongoing innovation:

This would be necessary provided that statutory guidance is published and regularly updated to reflect what is considered a ‘high-risk procedure’. Cosmetic procedures develop quickly, and new treatments become available which may not fall into the original regulations or guidance. There should be no ambiguity.

Organisation responses

There was a broad level of agreement from organisations with the proposal set out in the question. Many of the accompanying comments highlighted that restricting high-risk procedures to qualified and regulated healthcare professionals only was a proportionate measure given the high risk of complication associated with high-risk procedures and the impact that management of such complications has on the NHS. The consultation document gave examples of what might be considered a high-risk procedure but several organisational responses queried how ‘high risk’ is being determined and said that further detail on this was needed. Some responses highlighted that high-risk procedures should be performed only by medical professionals or those with medical training. It is unclear as to whether these respondents consider ‘medical’ to mean medical doctors (those registered and with a licence to practise with the GMC) or medical in a more generic sense akin to ‘clinical’, thereby covering other healthcare professionals.

A central theme expressed was that the standard of relevant training and experience is important in mitigating against the risks posed by undergoing aesthetic procedures, rather than the professional background of the practitioner. The wide variation in quality in training courses was also noted. Responses expressed that healthcare professionals do not routinely receive training in aesthetic procedures and that aesthetics is not within the scope of many regulated healthcare professionals’ scope of professional practice, meaning that being a healthcare professional accountable to a regulatory body is not in and of itself an indicator of competence.

Conversely, it was highlighted that many aesthetic practitioners have completed aesthetics-specific qualifications, often investing significant time and money to do so. Many responses explained that healthcare professionals often receive their training in aesthetic practice from non-healthcare professionals, and that healthcare professionals and non-healthcare professionals alike complete the same aesthetics-specific training.

It was highlighted that the term ‘regulated healthcare professional’ requires further definition.

There was concern expressed that introducing restrictions on which practitioners would be permitted to perform certain procedures will have a detrimental impact on aesthetic practitioners’ businesses. Although this question did not discuss the concept of oversight or supervision (this was discussed in the question relating to the ‘amber’ category), one organisation’s response to this question (submitted by several of its members) voiced concern about the concept of oversight for aesthetic practitioners and advocated for gradations in the level of supervision required for non-healthcare practitioners to recognise the varying levels of training and experience.

We received several identical responses which stressed that all aesthetic procedures are high-risk and medical in nature, emphasising that focus has been put on the ‘beauty’ aspect of the outcome of the procedure rather than the ‘medical’ nature of the procedure itself. Some responses advocated for all such procedures being restricted so they may only be performed by doctors and nurses, citing the benefits that these professionals’ duty to provide a standard of patient care determined by their regulatory bodies would bring to the sector.

CQC regulation of cosmetic procedures

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?

There were 11,414 responses to this question, of which:

• 5,102 (45%) strongly agreed
• 1,687 (15%) agreed
• 1,221 (11%) neither agreed nor disagreed
• 1,303 (11%) disagreed
• 2,101 (18%) strongly disagreed

Three-fifths of respondents (60%) agreed with bringing the restricted high-risk procedures into CQC’s scope of registration. Those responding in a personal capacity were slightly more likely to support this (63%) than professionals (57%).

Among those responding in a professional capacity, there were mixed views. An overwhelming majority (89%) of healthcare professionals not working in cosmetics supported this change, with a smaller majority (71%) among healthcare professionals working in cosmetics.

Aesthetic practitioners were more mixed, with 35% agreeing that the restricted high-risk procedures should be brought into CQC’s scope of registration, and 49% disagreeing.

Responses to this question were similar across the UK with a majority supporting the change in each nation. Levels of support were lowest in England (56%) and highest in Scotland (65%).

We received 3,686 responses to the open text portion of this question. In our analysis, we have separated these into the most important respondent groups.

Aesthetic practitioners

While some respondents felt that the level of regulatory oversight afforded by CQC was necessary for some high-risk procedures, many aesthetic practitioners disagreed with this proposal. A common theme voiced by aesthetic practitioners was that trained and qualified aesthetic practitioners should not be limited in their practice and that they are often more experienced and qualified in aesthetic procedures than healthcare professionals. Some respondents cited concerns that the proposal would adversely affect aesthetic practitioners’ businesses through limiting what procedures they would be able to perform. Concern was raised by some respondents about having CQC involved in regulating aesthetic procedures, saying that their registration fees are expensive or that CQC would not have the capacity to do so:

CQC im sure has quite enough to do without diverting their attention to procedures which are safe in the hands of suitably qualified professionals

Regulated healthcare professionals working in cosmetics

Many regulated healthcare professionals working in cosmetics agreed that restricting high-risk procedures to CQC-regulated providers would help to provide the level of safety required for these procedures:

Bringing these high risk medical procedures under the scope of practice of the CQC would be a positive step toward protecting patients. The described procedures are mostly invasive with a higher risk of complications (almost always requiring medical intervention) that can lead to significant morbidity (and even mortality) for patients.

Some responses highlighted that, as CQC regulation applies only to regulated healthcare professionals, practitioners who are not subject to professional regulatory oversight are able to perform high-risk procedures without being subject to CQC regulation.

A few responses drew attention to the recommendation in the 2017 report by the Nuffield Council on Bioethics that the Department of Health should act to extend the remit of CQC to all premises where invasive non-surgical procedures are provided, and highlighted the view that the management of all complications from aesthetic procedures should be performed by a CQC-registered provider under the remit of the regulated activity of treatment of disease, disorder or injury (TDDI).

A few responses stated that CQC regulation would not tackle the safety issues in the sector due to the fact that regulated healthcare professionals are already overseen by and accountable to a regulatory body, whereas there is a lack of such accountability for non-regulated practitioners.

Some responses focused on training issues, highlighting that consistent standards and equity of access to training are important to improvement in the sector:

We need to improve access to courses for all individuals to improve safety standards across the board. Excluding non medics from courses does not help them to achieve this.

Regulated healthcare professionals not in cosmetics

There was strong agreement from this group to the proposal in the question, with many adding comments to explain how they thought that CQC regulation would ensure the appropriate level of safety in the sector:

The CQC is a recognised body that inspects premises and enforces a minimum standard. They can police clinics and ensure that good standard of care is being delivered. The more invasive procedures, and those procedures with higher risk profiles, require this type of framework and governance

However, a few responses cited concerns that CQC does not have the required knowledge of the sector and its activities to be able to regulate it effectively, and questioned whether CQC regulation would lead to improvements in public safety. One response suggested:

If CQC does regulate this, the inspectors carrying out the inspection function must have a background in aesthetic/cosmetic procedures.

Members of the public not working in cosmetics

There was a range of responses from members of the public on this question. Many respondents agreed with the proposal and commented that regulation was needed to uphold public safety. However, several respondents commented that CQC regulation was unnecessary.

Others said that consistent training standards would be important to improve safety. Some comments advocated the view that non-healthcare professionals are often very experienced and highly trained:

You could have a newly qualified nurse practicing Botox or an aesthetic therapist with decades of experience. I know who I’d rather be seen by.

Some responses highlighted concerns about poor quality training courses, and a few respondents highlighted concerns about the cost to the NHS from managing complications of poorly performed procedures.

Training provider or business owner

The comments detailed a good level of agreement with the proposal, with many highlighting the benefits that CQC regulation of high-risk procedures would have for patient safety:

Being CQC-registered gives the public the opportunity to make informed decisions as to who to visit, while ensuring minimum standards of care and hygiene are upheld.

Several respondents commented that regulated healthcare professionals are not necessarily more skilled at performing aesthetic treatments solely by virtue of their professional background. Several responses highlighted that CQC regulation is not needed if suitable training standards are in place. A few responses cited concerns that, as CQC regulation pertains to healthcare, it is not relevant or applicable to the aesthetics sector:

CQC is for health care professionals not cosmetic and Beauty.

A few responses aired concerns that the proposal would limit the activities of non-healthcare professionals, with a detrimental impact on their businesses.

Licensing professionals

There was a broad level of agreement from licensing professionals on the proposals behind the question, with many saying that CQC is well established and well placed to provide regulation of high-risk procedures:

CQC have the required expertise and knowledge to assess these procedures and the competence of practitioners, they also already deal with these professions regarding other matters.

Several responses highlighted how CQC is familiar with assessing medical procedures. However, one response took the opposing view, strongly disagreeing that CQC should regulate high-risk procedures, saying:

They are cosmetic procedures, not medical

A few responses also drew attention to the fact that CQC does not regulate non-healthcare professionals, who might be performing the same procedure as regulated healthcare professionals who fall within the remit of CQC regulation:

I agree that this high-risk procedures should be put into CQC’s scope of registration. However currently as we know if a non medical / healthcare practitioner carried out this treatment, then CQC cannot deal with them, only if they are members.

A small number of responses queried whether CQC would be effective in regulating aesthetic procedures. CQC’s capacity to undertake these responsibilities was questioned, and a few responses raised concerns about how often enforcement action is taken by CQC, and the ability of CQC to identify concerns if their inspections are only of one day’s duration.

Organisation responses

There was a good level of agreement that, given the risk of harm that high-risk procedures are deemed to pose to the public, it would be proportionate to bring them into CQC’s scope of registration. CQC is considered by many respondents to be an experienced regulator with expertise in the types of procedures proposed to be brought into CQC’s remit. Many responses from local authorities stressed that regulation of high-risk procedures such as those proposed in the consultation document requires a level of clinical expertise which local authorities do not possess. Responses cited the additional benefits which oversight by CQC would bring, such as their legal powers of inspection and the implementation of their systems of data collection, audit and process monitoring into the cosmetics sector.

There were also some responses which said that CQC oversight was not necessary for the aesthetics industry and that a system of licensing with associated training and qualification standards would be sufficient to safeguard the public.

CQC’s resourcing and their ability to oversee the procedures which might fall within their remit under the consultation proposals was highlighted as a potential issue. A few responses highlighted that, prior to 2010, laser and intense pulsed light (IPL) treatments were regulated by CQC, and stated that this requirement had added significantly to CQC’s workload and had not been enforced adequately.

Several responses from local authorities cited concerns about the potential for dual systems of oversight between local authorities and CQC and the unnecessary overlap and bureaucracy this would create. Several responses suggested that if a business were to provide procedures which fall within CQC’s scope of regulation and procedures which fall within the scope of the local authority licensing scheme, the business would register with CQC, which would be responsible for overseeing all of the business’s procedures, and there should therefore be no requirement for the business to also obtain a licence from the local authority to permit the administration of those lower-risk procedures which require a licence.

It was suggested that CQC will need to expand their definition of the regulated activity of TDDI to include aesthetic procedures that are considered to be being performed for medical or medically related reasons. Several responses proposed that the management of complications of aesthetic procedures should be performed in a CQC-registered establishment under the remit of TDDI. Some organisations suggested that CQC should regulate more than just procedures deemed to be high-risk, and should include medium-risk procedures, or all aesthetic procedures.

Several responses from regulatory bodies queried how CQC regulation of services would interact with the regulation provided by the regulatory bodies which oversee healthcare professionals and where enforcement responsibilities would lie. The definition of ‘regulated healthcare professional’ and which particular professionals might be included was also highlighted as an issue which required further clarity.

Although the consultation document gave some examples of what might be considered to be high-risk procedures and several responses concurred that the examples given are high-risk, several responses said that the term ‘high risk’ required further definition.

Again, although supervision was not a theme of this question, one organisation’s members advocated for a supervision matrix for non-healthcare professionals, as outlined above.

Procedures in scope of the licensing scheme

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?

There were 11,588 responses to this question, of which:

• 4,356 (38%) strongly agreed
• 2,615 (23%) agreed
• 1,218 (11%) neither agreed not disagreed
• 1,410 (12%) disagreed
• 1,989 (17%) strongly disagreed

A majority (61%) of respondents support the 3-tier classification system based on the risk that different cosmetic procedures present to the public. Support was slightly higher among members of the public (63%) than among professionals (58%).

Within the professional group, as before, there was a difference of opinion, with 38% of aesthetic practitioners supporting the 3-tier system compared with 81% (outside cosmetics) and 74% (inside cosmetics) of healthcare professionals.

A majority of respondents across the UK supported the 3-tier system, with lowest support in Northern Ireland (54%) and highest in Scotland (59%).

We received 4,126 responses to the open text portion of this question. In our analysis, we have separated these into the most important respondent groups.

Aesthetic practitioners

Many respondents in this group disagreed with a 3-tier classification system. Some of the responses stated that the proposal was too simplistic, or that it would not work in practice as all procedures have a risk of complications. Several responses raised issues around enforcement and the policing of the system in practice:

The tier system is ridiculous again and irrelevant. ALL procedures are serious, that’s why we’ve paid thousands for training by experts in thier field and have a full understanding of how to deal with all emergencies if they should arise. Aesthetic treatments are equally risky when you are carrying them out, none are more serious than another.

A number of responses stated that additional tiers should be added, or that certain tiers should be removed. Other responses raised issues with the procedures listed in the respective tiers. Many responses disagreed with the proposed amber category and the concept of oversight. Several responses highlighted a need for a clearer definition of oversight.

A number of respondents did agree with the principle of a 3-tier classification system. A few respondents expressed the view that some procedures should only be carried out by regulated healthcare professionals. A small number of responses stated that injectables, including Botox and dermal fillers, should be restricted to the red tier or to regulated healthcare professionals.

Several responses focused on the need to regulate training. Many responses focused on a need for all practitioners (regulated and non-regulated) to meet a certain qualification or standard to perform a procedure. Some responses stated that complications could be dealt with by non-regulated healthcare professionals with adequate training. Several respondents stated that the proposed system was discriminatory or unfair for non-regulated practitioners:

I feel that if the people training to administer these treatments are trained correctly to a high standard then whether they are a medic or a non medic shouldn’t come into it. I feel that non medics will be discriminated on the basis they didn’t train in medicine.

Regulated healthcare professionals working in cosmetics

Many respondents agreed with the principle of a 3-tier classification system. Several respondents agreed with tiering, while also adding caveats, for example, that the tiers need to be future-proofed, the procedures in the tiers need to be continually updated, and products need closer regulation. A few respondents stated that the tiers would be good for the public in terms of raising awareness of the risk associated with procedures.

A significant proportion of respondents disagreed with the proposed 3-tier classification system. Some respondents thought it would be too complex in practice, and a few respondents stated that it would not prevent bad practice. Many respondents raised that the majority of these procedures are medical procedures, not cosmetic procedures. Other respondents stated that all procedures should only be carried out by regulated healthcare professionals.

Some respondents in this group disagreed with the amber category or disagreed with the idea of oversight. A number of responses highlighted that injectables, including Botox and fillers, should be restricted to regulated professionals or on the red list. A few respondents raised that there needed to be a clearer definition of oversight, while others called for clear definitions of other terms - for example, ‘invasive procedure’ and ‘high-risk procedure’.

A small number of respondents raised that it should not be framed as regulated professionals versus non-regulated professionals but rather about meeting an agreed standard. A few responses raised that the proposed 3-tier system could be unfair for un-regulated professionals.

Regulated healthcare professionals not in cosmetics

Many responses strongly agreed with the principle of a 3-tier classification system. Many responses stated that the 3-tier system is clear and that it would protect the public from the risk of poorly performed procedures. Several responses highlighted a need for more work on the categorisation of procedures in each of the tiers. A few responses raised that the licensing scheme must take into consideration that new procedures are constantly emerging.

Some responses agreed with the 3-tier system but disagreed with the amber category. These responses stated that amber and red procedures should only be carried out by regulated professionals. A few responses stated that injectables should only be carried out by regulated professionals.

A significant number of responses stated that only regulated professionals should carry out all procedures. Many of these responses raised the risk of complications and the implications for the NHS. 

Some responses highlighted that the 3-tier system would not work in practice as it would not prevent bad practice or prevent non-regulated professionals from carrying out restricted procedures. A few responses stated that there also needs to be a closer focus on the regulation of training and training providers.

Members of the public not working in cosmetics

A large number of respondents in this group agreed with the principle of a 3-tier classification system. Many of these respondents highlighted the risks associated with procedures and the need to protect the public. Several respondents noted that further work is needed to establish which procedures should be listed in each tier.

Many respondents also stated that the tiers would be good for the public in terms of raising awareness of the risk associated with procedures:

Is a further informative way of communicating the seriousness or otherwise of the procedures.

A significant number of respondents disagreed with the principle of a 3-tier classification system. Many of these respondents stated that all cosmetic procedures have risks and that all procedures should, therefore, be classified in the same way. Some respondents stated that all procedures should be carried out by regulated professionals because of the risk, while others stated that non-regulated and regulated professionals should be required to meet the same standard in order to carry out a procedure:

There should not be a tier system just regulated training for all

Some respondents disagreed with specific tiers or procedures included in the tiers. A small number of respondents noted that we should expand the tier system to include more tiers:

Good intention, 3 seems restrictive, 5 would allow for better understanding

Several respondents stated that procedures that use injections and Botox and dermal fillers should be carried out by regulated professionals only. A few respondents stated that we should ban large volume filler procedures to the breast and buttock.

Some respondents highlighted a need for clearer definitions and examples, including of ‘high-risk procedures’ and ‘oversight’.

Training provider or business owner

Many respondents in this group agreed with the principle of a 3-tier classification system. However, many responses highlighted that more work is needed on the categorisation of procedures. Some responses also raised that new procedures would have to be assessed quickly to ensure that regulation remains fit for purpose into the future. Some respondents agreed with the 3-tier classifications but disagreed with placement of some of the procedures in the tiers.

A number of respondents raised more significant issues with the principle of a 3-tier classification system. These responses raised that all procedures have an associated risk, that only healthcare professionals should carry out non-surgical cosmetic procedures, or that only healthcare professionals are able to effectively deal with complications resulting from procedures. Some responses raised that the proposal is unfair or could discriminate against unregulated professionals. A few responses stated that the proposals could have a significant impact on women and on women’s businesses.

Some responses raised specific issues with the amber tier and the concept of oversight. Several responses stated that injectables and Botox and fillers should be restricted to regulated professionals only. A few responses raised that the proposals would have an impact on the NHS and could lead to procedures being performed on the black market:

This again would take health care professions away from health care. There simply will not be enough HCPs to oversee every injector. This will send a lot of injectors underground which will have a huge negative impact

A number of responses raised that there is a need to regulate training providers. Several responses stated that all practitioners should be required to undertake the same training or meet the same standard in order to carry out a procedure, regardless of whether they are regulated or not.

Licensing professionals

A significant number of responses in this group agreed with the principle of a 3-tier classification system. Several responses raised that the tier system will be good for public safety and that it is dangerous that regulation is not already in place. Some responses raised that we should include procedures registered under the Local Government (Miscellaneous Provisions) Act 1982. A few responses queried whether 3 tiers are sufficient given the number of procedures potentially in scope of the licensing scheme and associated regulatory oversight.

Many responses raised the need for clearer definitions and guidance. Some responses asked for more information on the placement of procedures in each of the tiers and how this would be future-proofed when new procedures come onto the market. Several responses raised whether there would be duplication if providers were to offer multiple procedures across different tiers:

As long as there is a very clear way of determining where the treatments falls, I’m not worried if its colour coded or an alternative. However I would like to see clear instructions on where a salon would sit if they offer a range of different treatments which cover multiple tiers. For example if they offered 4 treatments, but 1 was in red tier, then all procedures would be looked at by the CQC.

A number of responses disagreed with the principle of a 3-tiered classification system. Some responses stated that all procedures should be carried out by regulated professionals, while some responses raised that amber procedures should be restricted to regulated professionals only. A small number of responses stated that any procedure using an injectable should be restricted to regulated professionals only:

I am not sure how a ‘tier system’ would work. Any procedures that include injectables, blood or body internal procedures should be undertaken by a medically qualified practitioners

Several responses stated that all practitioners (regulated and non-regulated) should be required to undertake the same training and meet the same standard. A few responses stated that all practitioners should be required to have a level 7 in aesthetics:

Medics are not experts in Aesthetics. A level 7 is needed for all experience in Aesthetics. They do not have this in any degree given on science or biology. All medics and non medics should be level 7 in Aesthetics

Organisation responses

Although there was a good level of agreement on using a tiering system to classify procedures based on risk, with responses saying that it will create a system which is simple to understand for consumers, practitioners and enforcers, many responses expressed that any categorisation of procedures must be based on a thorough analysis and assessment of the risks involved in each procedure and questioned what risk assessment processes had taken place when deciding the classifications proposed in the consultation document.

Concerns were voiced that the 3-tier categorisation is too simplistic, does not capture the nuance of what is involved in administering a procedure and does not factor in the full range of risks associated with undergoing a cosmetic procedure.

Responses stressed that an assessment of risk should be broader than a consideration of the risks involved in performing the procedure and should:

• be based on a thorough assessment of the consumer’s physical, psychological and emotional condition
• include an exploration of elements such as:
  • the scope of the procedure
  • the use of any equipment involved (including the power level, depth of penetration and the potential for harm to the practitioner or operator)
  • the level of oversight or supervision needed
  • the use of POMs
  • the potential for any complications to occur and the ability to manage any that might arise

Some responses highlighted the need for any classification of procedures to be based on robust data, and some questioned who would be responsible for determining and reviewing the classification of procedures to ensure they are and continue to be proportionate.

Further concern was raised that using a red-amber-green system of categorisation could imply to consumers that green procedures do not entail any risk, whereas in reality undergoing any cosmetic procedure includes an element of risk. Several responses detailed that it is procedures proposed as being included in the green tier which result in the highest number of complications and that rates of complications and insurance claims should be considered when determining risk.

A couple of responses advocated for a 4-tier stratification of risk. One advocated for the creation of a new tier which would allow for both fillers and toxins to be administered by non-prescribing healthcare professionals under the supervision of prescribing CQC-registered healthcare professionals. A further response included proposals for the following categories:

• blue (unsupervised)
• green (supervised)
• amber (prescribing healthcare professionals unsupervised, non-prescribing healthcare professionals supervised)
• red (regulated healthcare professionals in CQC registered facilities)

The proposals for an amber tier provoked several comments. Many respondents highlighted that the concepts of supervision and oversight required further definition. As with the responses received to other questions, a matrix was advocated for, proposing that the level of supervision required should be dependent on the practitioner’s training, qualifications and experience. Furthermore, several responses suggested that supervision should not be required at all if the practitioner is experienced and has obtained a suitable level of Ofqual-regulated qualification. Concern was raised that proposals for amber and red categories would have a negative impact on the practice of aesthetic practitioners, limiting the procedures they would be able to perform and being detrimental to their financial viability.

Based on these concerns, many responses questioned the accuracy or appropriateness of the proposed classification of particular procedures within the wider 3-tier structure. For example, a few responses highlighted the discrepancy between the proposal to include dermal fillers in the amber category (thereby allowing them to be administered by non-healthcare professionals, albeit under the oversight of a qualified and registered healthcare professional) and the summary of product characteristics information included with the dermal filler, which stipulates it should be administered only by suitably qualified healthcare professionals. Other responses drew attention to the failsafe mechanisms which many pieces of equipment used in the aesthetics sector, such as laser equipment, have built in, and said that these had to be considered when risk assessing procedures. Responses advocated for further consultation with the industry on these issues to ensure that any risk assessment was suitably informed by expert opinion. Some responses questioned what sector input had been received by the government in drawing up the proposed classifications, and cited concerns about inaccuracies in the consultation document. 

The need for future proofing was identified in many responses to ensure that future procedures, techniques, devices and products could be incorporated into the tiering system, as well as monitoring existing procedures and techniques to ensure their categorisation remains appropriate.

Many local authorities highlighted the range of regulatory systems being operated in the aesthetics sector through local licensing regimes and the Local Government (Miscellaneous Provisions) Act 1982 and called for unification of regulation through the licensing scheme to avoid local authorities having to administer, and businesses being subject to, multiple separate regulatory systems.

Current issues with nurse prescribers’ inability to hold stocks of emergency medicines were also mentioned. Concern was raised that this restriction was preventing timely access to medicines required to deal with complications or emergencies and needed to be rectified in the interests of public safety.

Green: procedures with the lowest risk of complications

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

The consultation proposed that the green category includes, but is not limited to, the following procedures:

• microneedling
• mesotherapy
• 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 and sun damage)

There were 11,533 responses to this question, of which:

• 4,031 (35%) strongly agreed
• 3,967 (34%) agreed
• 1,001 (9%) neither agreed nor disagreed
• 1,265 (11%) disagreed
• 1,269 (11%) strongly disagreed

Over two-thirds (69%) of respondents agreed with the categorisation of procedures in the green category. Support was similar across members of the public and professional respondents.

There was more consistency between professional respondents to this question. Just over two-thirds (68%) of aesthetic practitioners agreed with this question, compared with 73% of healthcare professionals not working in the cosmetics sector and 68% of those working in the sector.

A majority of respondents across the UK supported the categorisation of the procedures in the green category. Support was lowest in Northern Ireland (63%) and highest in England (69%).

We received 3,168 responses to the open text portion of this question. In our analysis, we have separated these into the most important respondent groups.

Aesthetic practitioners

Several respondents stated that they felt the treatments proposed for inclusion in the green category are suitably low risk. Some responses caveated this by explaining that they agreed as long as suitable training and qualification standards were met.

Some respondents offered suggestions as to how some procedures should be reclassified, either through moving them from the green category to a higher category, or through moving a higher categorised procedure to the green category. A few responses suggested, for example, that Botox and filler procedures should be added to green.

A few respondents disagreed with the proposed categorisation due to holding the view that undergoing any of these procedures entails risk:

This doesn’t make any sense. All of these procedures can have extreme consequences if not performed correctly

A few responses said that education, training and recognition of the experience of practitioners should be the focus:

As I said before It should be based on qualifications and experience not a RAG system

Regulated healthcare professionals working in cosmetics

Several respondents voiced their support for the proposed green category treatments based on the lower levels of risk they are deemed to pose, providing that training and education standards are met:

The majority of treatments listed pose little to low risk of harm, if performed by suitably trained people. The level of training must be stated and also a minimum standard must be set for this training ensuring everyone has adequate education.

Conversely, a few responses flagged concerns with the assessment of risk these procedures are deemed to pose:

There are many procedures in that category that carry great risk. There are those that include breaking the skin and those that are using laser energy. In my professional opinion, a beautician should not have the privilege to perform such treatments. They should stick to hair styling and at best facials.

Some suggestions were made as to how some procedures should be reclassified. In particular, several responses cited concerns about risks associated with no-needle fillers, proposing that, due to the risks such as vascular occlusion and tissue damage, they should be moved into a higher category or banned altogether. A few respondents also aired the view that microneedling should be broken down and classified according to the depth of the procedure, and a few responses cited concerns that laser treatments should be moved to the amber category.

Regulated healthcare professionals not in cosmetics

Although many responses voiced agreement with the proposal that the procedures are low risk and can be performed by any suitably qualified and licensed practitioner, some responses highlighted that undergoing these procedures still entails risk and that terming these procedures as ‘green’ may give the impression that they are risk free:

Any procedure that breaks the skin risks introducing infection especially if non-sterile equipment is used. Also procedures that expose the skin to radiation increase the risk of cancers. Calling these procedures ‘Green’ gives the impression there is no risk which unfortunately isn’t the case.

Several responses proposed that all or some of the procedures should only be performed by certain practitioners. A few respondents also voiced concerns about lasers and no-needle fillers and said that they warranted being placed in a higher category.

Members of the public not working in cosmetics

There was a strong level of agreement with the proposals for the green category, with many respondents saying they are satisfied that the proposed procedures could be administered by suitably trained and qualified aesthetic practitioners as well as healthcare professionals:

This kind of procedures can be performed even by non clinical staff

However, a few respondents felt that aesthetic practitioners should not be performing these procedures. Several respondents proposed that various procedures in the green category should be moved into different categories, and that procedures in other categories should be moved to the green category. A few responses proposed that any procedure which breaks or breaches the skin should be classified higher:

All those that break the skin or have potential to cause severe burns Should move to amber or red

There were differing views as to whether injection treatments should be included in the green category. Laser treatments were identified by a few respondents as being higher risk and for reclassification, and a few responses also cited concerns about the risks involved with chemical peels.

Training provider or business owner

There was a good level of support for the proposal, many responses adding the proviso that suitable standards of training and qualification must be met:

I believe these are lower risk but certainly not risk free. They require a trained professional who is very aware of any potential side effects, contra indications and how to manage any adverse reactions

Some responses expanded on the importance of education and training. Responses reflected views that any practitioner can obtain the necessary qualifications and, conversely, that only medical professionals’ training can equip practitioners with the necessary knowledge:

Some make sense but others can still be risky and there is no way non medical professionals can under the layers and complexity of the skin without having had medical training meaning more risk of complications.

Regarding comments referencing specific procedures, several respondents expressed concern about the risks of no-needle fillers, saying that these should be placed in a higher category or banned entirely. A few respondents also advocated for laser procedures to be regarded as higher risk.

Licensing professionals

Licensing respondents highlighted the low level of risk of the proposed procedures and highlighted the need for suitable education and training standards:

Agree that this should be the case if practitioners have recognised qualifications.

Some respondents suggested that laser treatments should be moved to a higher category and that microneedling, microblading and micropigmentation should be classified in a higher category.

A few responses also advocated for procedures subject to local authority registration under the Local Government (Miscellaneous Provisions) Act 1982 to be included in this category, with the exception of acupuncture which was felt to not meet the definition of a cosmetic procedure.

A few responses also cited concerns about the risks posed by no-needle fillers, proposing that they be classified in the amber category.

Organisation responses

Many responses agreed with the categorisation, saying that the procedures included were low risk, or agreed in the main while proposing that some procedures be moved to a different category or said that some procedures should be added to the green category. Similarly, many respondents said that they agreed with the categorisation subject to suitable training standards being met.

There was a strong level of support from local authorities for some or all of the procedures subject to registration under the Local Government (Miscellaneous Provisions) Act 1982 to be added to the green category. Several responses raised concerns about the use of no-needle fillers, citing the harm they can cause, with some responses calling for them to be moved to a higher risk category or banned entirely.

Of the procedures proposed for inclusion in the green category, several responses advocated for laser and IPL treatments to be moved to the amber category. It was also proposed by several respondents that any procedure involving the skin should be moved to the amber category. In addition, some respondents proposed moving microneedling and micropigmentation into a higher risk categorisation.

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

There were 6,676 responses to this question, of which:

• 1,979 (30%) said that procedures should be moved to another category (amber or red)
• 3,603 (54%) said that procedures should be added
• 1,680 (25%) said that procedures should be removed

Views were similar between members of the public and professional respondents.

Aesthetic practitioners were more likely than other professional groups to say procedures should be added to the green tier, whereas healthcare professionals working in cosmetics were more likely to say procedures should be moved to another category or removed.

We received 3,401 responses to the open text portion of this question.

There were challenges when analysing the data for this question and the corresponding questions for the amber and red categories which meant the respondents’ views were not always clear. The main challenges were:

• respondents mentioned procedures that they felt should change category but did not always specify which new category they should be moved to
• suggested moves from the amber category were often unclear as to whether they should be subject to more or less stringent rules
• it was not always clear if, when a procedure was suggested for removal from a category, the respondent meant that it should be relocated to another category or removed entirely from the scope of licensing (for instance, some respondents felt that hay fever treatments for skin are not suitable as a cosmetic treatment and should be removed from the scheme)
• some respondents suggested that certain procedures might be classified in more than one category depending on factors such as the procedure’s location on the body, the depth of penetration or the equipment used
• repetition from responses across different categories

For the open text portion of the question asking whether any procedures should be moved, removed or added to the green category, of the sample reviewed, the most common procedures proposed for moving to the green category were Botox injections and filler procedures (some respondents specified facial filler procedures).

Many respondents cited concerns about no-needle fillers, describing how it is less easy to control the placement of the filler than when using a needle and advocating for them to be moved to a higher tier or suggesting they should be banned entirely.

Radiofrequency, fat dissolving and vitamin injections were also proposed by several respondents for inclusion in the green category, while laser and peel procedures, mesotherapy, microneedling and micropigmentation were identified in several responses as needing to be moved into a higher category. A few respondents proposed that body piercing should be added to the green category.

Some respondents said that all non-surgical cosmetic procedures should be included in the green category, whereas a similar number said that all the green procedures should be moved to amber.

Organisation responses

A common theme of the responses received by organisations is that further breakdown or consideration of the procedures is required in order to make a determination on where in the tiering system they might best sit. Regarding microneedling, some organisations suggested that this may need dividing between categories, so that procedures involving a certain needle length or penetrating to a certain depth are placed in the amber category. Similarly, regarding mesotherapy, several responses advocated for the procedure being moved into the amber category, but some responses said that it should be broken down into injectable and non-injectable types of procedure which should then be considered separately. While a few responses said that laser procedures should be moved to green, several said that laser procedures, along with photorejuvenation, should be moved to amber or should be subject to further consideration.

Many organisations cited concerns about no-needle fillers, suggesting that they be recategorised in the amber or red category, or banned entirely. Some organisations suggested further consideration should be given to the risks posed through a review of devices. Some organisations suggested micropigmentation be added to amber. One suggested that as semi-permanent skin colouring is currently subject to registration under the Local Government (Miscellaneous Provisions) Act 1982, either micropigmentation should be removed from licensing or all the procedures covered by the Local Government (Miscellaneous Provisions) Act 1982 should be added.

Organisations suggested a range of procedures be added to the green category. The most commonly suggested procedures were those currently subject to registration under the Local Government (Miscellaneous Provisions) Act 1982, namely tattooing, piercing, semi-permanent skin colouring, electrolysis and acupuncture. Several responses also suggested moving radiofrequency into the green category. Several responses also suggested that further scoping work should be done on the suggested amber procedures of radiofrequency, electrocautery, cryocautery and combination modalities and technologies, as this may affect the view of risk posed by these procedures and whether they are deemed to be more appropriate to be included in the green or amber categories.

Some procedures not proposed for inclusion in the licensing scheme were also proposed by respondents for inclusion in the green category, including wet cupping, eyelash extensions and eyelash perming, procedures commonly performed at nail bars, and the use of ear candles.

Amber: procedures with medium risk of complications

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

The consultation proposed that the amber category 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

There were 11,464 responses to this question, of which:

• 3,201 (28%) said strongly agree
• 2,599 (23%) said agree
• 876 (8%) said neither agree nor disagree
• 1,966 (17%) said disagree
• 2,822 (25%) said strongly disagree

Overall, 51% supported the categorisation of the amber category procedures. Views put forward in response to this question were similar from members of the public as from professionals. There was a significant difference of opinion between aesthetic practitioners (only 30% of whom supported the amber categorisation) and healthcare practitioners (65% of those not in cosmetics and 68% of those in cosmetics supported the amber categorisation).

Support was slightly mixed across the UK, with respondents from Scotland least supportive of the amber categorisation (46%) and Northern Irish respondents most supportive (55%).

We received 4,189 responses to the open text portion of this question. In our analysis, we have separated these into the most important respondent groups.

Aesthetic practitioners

Many aesthetic practitioners disagreed with the proposals for the amber category. Reasons cited included the skill, experience and qualifications of aesthetic practitioners, including in dealing with complications, obviating the need for supervision from a regulated healthcare professional who may have undergone less training in aesthetics and be less experienced in the field. Several respondents cited concerns that the proposals for supervision would be inoperable or detrimental to businesses, particularly small businesses:

While accountability is essential, the proposed plans disproportionately affect non-medical practitioners offering treatments rated as amber or red in the RAG rating scheme. Many of us risk losing our livelihoods or being forced into an inoperable working model. This, in turn, could lead to increased reliance on government assistance, placing additional strain on resources.

Many responses highlighted the importance of robust qualification and training standards and a few responses stressed that this should be the focus of work to instil safety standards in the sector.

Several comments proposed that a variety of treatments should be moved to a different category. There was support from a few respondents for radiofrequency to be moved to green and support for Botox and fillers to be moved to green. Conversely, some respondents suggested all injectables be moved to red.

Regulated healthcare professionals working in cosmetics

There were mixed comments received on this question. Some respondents felt that the procedures proposed for inclusion in the amber category should be restricted to healthcare professionals only:

No person without a medical background should be able to complete any procedure listed within the amber category.

A few respondents raised specific concerns that recognising the signs of skin cancer or melanoma requires specific training and therefore cryotherapy or other removal of skin tags or warts should be performed only by suitably trained medical practitioners.

Several responses advocated for some of the procedures in the amber category to be moved to red, particularly Botox and fillers. Concern was also raised about the risks involved in weight loss injections.

Several responses said that the concept of supervision or oversight needs to be further clarified, and a few cited concerns about current prescribing practices, specifically prescribers prescribing without having seen the client face to face.

Regulated healthcare professionals not in cosmetics

Although one respondent proposed that all amber procedures should be moved to green, a strong theme to emerge from the comments was that these treatments should be administered only by healthcare professionals. Several respondents further highlighted that they thought supervision was not sufficient to maintain public safety:

All of the above, by the very act of what they are, should ONLY be carried out on licenced CQC premises and be undertaken ONLY by a qualified and registered health care professional. By allowing health care professionals to supervise unqualified ( and by that I mean without a degree in medicine, nursing, dentistry) is quite frankly ludicrous.

Some respondents said most or all of the proposed procedures should be moved to the red category. Of those responses which mentioned specific procedures, injectable treatments, particularly dermal fillers and Botox, were proposed by some respondents to be higher risk than the amber category proposal.

Members of the public not working in cosmetics

While there was some agreement with the proposals for the amber category, many respondents’ comments expressed disagreement, citing a wide variety of reasons. Several responses proposed that all or many of these procedures should be reclassified as red procedures or should be carried out only by healthcare professionals:

None of these should be performed by anyone other than a licensed medical professional

Some responses proposed that injectable treatments in particular should be classified higher.

However, several responses highlighted the skill and experience of many non-healthcare professionals and proposed that, with suitable training, they are just as capable, if not more so, as healthcare professionals of performing these procedures:

There are non medics with much more training and experience who do better jobs

Several responses raised the issue of supervision and oversight. Some respondents felt that this was an unnecessary measure if the practitioner is suitably trained, qualified and experienced, whereas other responses proposed that supervision should involve the supervising healthcare professional being onsite at all times a procedure requiring supervision is performed, or that the introduction of supervision would still not be adequate to maintain patient safety and that amber procedures should be performed only by medical professionals.

Training provider or business owner

Many respondents disagreed with the proposed categorisation, with a variety of different reasons being cited. Several respondents felt that oversight was not necessary if the practitioner is qualified and insured in the procedures they are offering. In addition, several felt that the operation of a system of oversight would be impractical:

The amber tier should be green as long as the individual is a fully qualified professional, with adequate insurance performing such procedures from safe and hygienic premises. I already have a clinical oversight but to have one full time standing next to you whilst performing such procedures is unrealistic.

Some respondents raised the issue of qualifications, saying that healthcare professionals do not necessarily obtain relevant aesthetic experience and qualifications as part of their training, and that all practitioners complete the same aesthetics-specific training regardless of professional background. Conversely, a few respondents advocated for amber procedures to be limited to medical professionals only.

Among comments received about particular procedures, Botox injections and dermal fillers were proposed by some respondents as needing to be moved to red. Radiofrequency, electrocautery and HIFU treatments were suggested by some to be moved to green.

Licensing professionals

A mixture of comments was received from those working in licensing. Some agreed with the proposals for the amber category but there was also a good deal of disagreement, with some responses saying that these procedures should be performed only by medical professionals. A few responses stressed that the emphasis should be on ensuring robust education and qualification standards, rather than on the categorisation of procedures. A few responses expanded on this, stating that level 7 qualifications should be required to perform the procedures in amber.

Several responses discussed the issue of oversight or supervision. Some questioned what this would entail. Views as to what level of oversight would be suitable varied, with proposals for remote and onsite supervision being suggested.

A few responses highlighted concern about the effectiveness of current oversight practices related to prescribing in the sector, including around a lack of face-to-face consultations with the prescriber:

Typically Practitioners are supposed to have face to face prescribers for botox and fillers, however, this does not happen in practice and there are barely any face to face consultations in my experience of inspections/enforcement. Therefore, the oversight should be used with caution as it is open to abuse.

There was also some concern expressed that the proposals for amber do not acknowledge the skill and experience of non-healthcare professionals practising in the sector:

I’m very worried that there is risk of unintended consequences. I wholeheartedly believe public safety is paramount and fully agree with the introduction of a licence and the need for regulation. I welcome the development of licence as it will help to provide clarity for practitioners, insurers, manufacturers and the public. I’ve heard a great deal of concern across the sector that the competency of highly competent, qualified, professionals may be called into question with the suggestion that some procedures might be classed within the amber category and need oversight. We had hoped that a licence would mean we could address the incompetent, unqualified, un-insured people who daily are impacting on public safety. Caution and reflection is needed to ensure the licence does not unfairly impact and penalise those professionals in our industry who are trusted, ethical, competent and highly professional, and who day-in day-out, provide an excellent service to millions of clients.

Organisation responses

While there was a good level of agreement with the proposals for the amber category, a large number of responses from organisations expressed reservations around the concept of oversight. Many responses queried how oversight and supervision would be defined, with several highlighting that this could include face-to-face or onsite supervision, remote supervision from a supervisor who is located within a certain travelling time from the practitioner, or team or peer supervision. Several responses from the same organisation called for a supervision matrix, saying that the level of supervision required should be dependent on the practitioner’s qualifications and experience. Some responses said that if a practitioner is appropriately trained and is suitably qualified to what is deemed to be the required standard, they should not need supervising. Some responses raised concerns that healthcare professionals might not have much (or any) specific aesthetic training or experience and the supervisee might therefore be more experienced and knowledgeable on aesthetic procedures that their supervisor.

A common theme was that introducing requirements for supervision would have a detrimental impact on practitioners’ businesses, and some responses voiced concerns that this would cause some practitioners to circumvent the requirements for supervision by practising illegally. A few respondents felt that the treatments included in the amber category pose varying levels of risk and that the level of supervision required for a particular procedure should be proportionate to the risk the particular procedure is deemed to pose.

Several responses from local authorities cited concerns that they currently lack knowledge on the procedures proposed in the amber category, and that training and guidance would be needed to enable local authority enforcement officers to be able to effectively regulate those performing these treatments. A few responses said that medical input would be required, with one response proposing that medical professionals could participate in inspections with licensing officers, similar to the approach taken in animal licensing, where vets attend zoo inspections with licensing officers. Some responses also cited concerns about the additional resources local authorities would require to be able to provide effective oversight of these procedures.

The consultation received some responses, including from product manufacturers, which highlighted that the consultation’s proposal that Botox and fillers be included in the amber category was contrary to the summary of product characteristics and product information leaflets for these products which state that the product should be administered by healthcare professionals or practitioners. Some responses cited concerns about current prescribing practices, particularly how many prescribers are breaching professional standards by omitting to conduct a face-to-face consultation with the patient prior to issuing a prescription, and the use of unlicensed products purchased through the internet.

Some responses proposed that a further breakdown of the procedures proposed for inclusion was needed. In particular, it was proposed that the use of dermal fillers in high-risk areas such as nose, frown lines, tear trough and non-facial areas should be included in the red category.

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

There were 6,566 responses to this question, of which:

• 3,652 (56%) said that procedures should be moved to another category (green or red)
• 1,319 (20%) said that procedures should be added
• 2,373 (36%) said that procedures should be removed

Views were similar between members of the public and professional respondents.

‘Procedures should be added’ was the least selected option among all professional groups, but was lowest for aesthetic practitioners (12%).

We received 3,554 responses to the open text portion of this question.

Of the sample reviewed, Botox injections and dermal fillers were the procedures most commonly proposed for being moved to the red category. Some respondents further broke down dermal fillers, identifying procedures to high-risk areas such as the tear trough, glabellar and nasolabial areas for recategorisation in the red category. Other procedures commonly featured in respondents’ comments for being moved to red included PRP and biofiller and weight loss and vitamin and mineral injections. Some respondents felt that the weight loss and vitamin and mineral injections are only appropriate to be used when treating a medical disorder.

Radiofrequency was the procedure commonly suggested for being suitable to be moved to green. Other procedures identified by respondents for movement to green included electrocautery, cryocautery and cryotherapy (although there was also a lesser amount of support for these procedures being moved to the red category), combination technologies and HIFU. One respondent suggested that HIFU to intimate areas should be administered by healthcare professionals only.

There was also a strong level of support for all the amber procedures to be moved to green, and a smaller amount of support for all the amber procedures being moved to the red category.

Organisation responses

Many responses said that Botox injections should be moved to the red category. A few felt that they were suitable to be moved to green. A few responses drew attention to the summary of product characteristics for Botox injections and said that, as this states that the product should be administered only by healthcare professionals, a subcategory should be created which would permit non-CQC registered healthcare professionals to administer them. This would avoid having to move Botox injections into the red category to comply with the terms of the summary of product characteristics and in the process preventing healthcare professionals not subject to CQC oversight from performing them. A similar measure was also proposed for dermal fillers for the same reasons.

A variety of other comments were received about dermal fillers. Several organisations felt that dermal fillers should be moved to the red category. Some advocated for all permanent fillers specifically to be moved to red. Some identified procedures targeting high-risk areas of the face such as the tear trough or nasolabial area as for potential inclusion in the red category. A few responses said that the use of hyaluronidase to treat complications of filler procedures should be added to amber. Some responses mentioned no needle fillers, saying that these could be moved from green to amber but should be subject to further review to inform this decision.

Weight loss injections and cellulite subcision were proposed for potential transfer to the red category. Vitamin and mineral injection procedures were also proposed by several respondents for inclusion in the red category. It was suggested that, as vitamin and mineral injections can be administered by a number of different methods, further clarity was needed as to how this procedure would be differentiated from the intravenous injection and infusion procedures proposed for inclusion in the red category.

Injection lipolysis with a POM was proposed by several respondents for transfer to the red category. Some respondents said that injection lipolysis with a medical device or cosmetic product (such as Lemon Bottle) should be included in amber.

Several of the procedures proposed for inclusion in amber received a good level of support for being moved to the green category. Many respondents caveated this by saying that this was dependent on suitable standards of training being adhered to. Radiofrequency treatments and electrocautery were 2 such treatments, although some responses said that further work needed to be undertaken to consider how the varying strengths, wavelengths and ranges used in the different types of these procedures might affect their placement in the tiering system. HIFU was also proposed by several respondents for transfer to the green category, although it was also proposed that HIFU should be placed in amber but when performed on intimate areas should be a red category treatment. Combination technologies also received support from some respondents to be recategorised in green, as did cryotherapy and cryocautery procedures. However, one response said that, as clinical skill is needed to diagnose skin lesions to identify skin cancers, cryotherapy and cryocautery should be included in the red category.

Several responses advocated for all amber procedures to be moved to the red category. In contrast, a similar number advocated for them all to be moved to the green category. Some respondents said that procedures which require the use of prescription medications, either in the course of the procedure or in adjunctive use, should be subject to onsite supervision by a prescriber or be moved to the red category.

Several additional treatments were proposed for inclusion within the green category. Some respondents suggested that several of the procedures covered by the Local Government (Miscellaneous Provisions) Act 1982 should be included in amber, although there was not as strong support for inclusion in amber as there was for including them in the green category. Clinical investigations such as blood tests and ultrasound, hormone and steroid injections, ozone therapy, teeth whitening by light or lasers, wet cupping, tooth jewellery, and body modification such as tongue splitting and branding were among the additional procedures proposed for inclusion in the amber category.

Red: procedures with the highest risk of complications

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

The consultation proposed that the red category includes, but is not limited to, the following procedures:

• all thread lifting procedures, including polydioxanone (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 TDDI
• all intravenous injectables and infusions

There were 11,399 responses to this question, of which:

• 5,183 (45%) said they strongly agreed
• 2,990 (26%) said they agreed
• 946 (8%) said they neither agreed nor disagreed
• 1,024 (9%) said they disagreed
• 1,256 (11%) said they strongly disagreed

Overall, 71% said they agreed with the categorisation of the procedures in the red category. Support was similar between members of the public and professional respondents. Aesthetic practitioners were the least supportive of the categorisation (57%). Healthcare professionals both working in cosmetics (85%) and not working in cosmetics (90%) were extremely supportive of the categorisation. Support for the categorisation of procedures in the red category was consistent across the UK.

We received 2,406 responses to the open text portion of this question. In our analysis, we have separated these into the most important respondent groups.

Aesthetic practitioners

A variety of opinions was received from aesthetic practitioners regarding the proposals for the red category. Some comments expressed that the procedures in question were sufficiently high risk to warrant the restrictions the categorisation proposed, but others felt that the proposed restrictions were unnecessary if suitable training standards are fulfilled:

Again I believe these should not be restricted to medics only with a 1 day CPD course. This should be EVERYONE has to do a level 7 qualification in AESTHETIC procedures.

With regard to specific treatments, thread lift procedures were mentioned by several respondents. Some felt that these procedures pose sufficient risk to warrant being performed by medical professionals only, whereas it was also suggested that the risk of these procedures is not comparable with other procedures also proposed for inclusion in the red category. A few responses explored this issue further, proposing that different types of thread lift system pose different levels of risk and should be differentiated accordingly in the tiering system:

I agree with all bar PDO Mono Threads - COG threads absolutely but mono threads I completely disagree and think they should be green/amber at the most.

Regulated healthcare professionals working in cosmetics

There was strong support for the proposals for the red category. However, a few responses cited concerns about the proposal to include in the red category ‘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 TDDI’:

All these are dangerous procedures which should be carried out by qualified and regulated healthcare professionals with the relevant training, only within CQC registered premises. Public safety is better protected in this way. However, I disagree with the wording of the paragraph where procedures on the green or amber lists have to be carried out only by registered professionals if we are treating DDI. In other healthcare environments, many procedures are delegated to members of the team with the relevant training / qualifications but not necessarily regulated professionals. I think the wording should made provision for this instances.

Several comments referenced specific procedures. One proposed that hay fever treatments did not need to fall under CQC regulation, and another said that PDO threads are far safer than the other treatments proposed for inclusion in the red category. Regarding Botox and fillers, one respondent said:

As mentioned previously all dermal filler and botulinum toxin procedures should move into the red category but don’t necessarily require CQC regulation.

A few respondents further advocated for some or all amber procedures to be moved to red. One respondent went further, saying:

All procedures in green amber and red should only be allowed to be carried out by regulated healthcare professionals or medical professionals with no dispute. The aesthetic world would become more safe which is vital for clients.

Regulated healthcare professionals not in cosmetics

Many respondents highlighted the need for stringent regulation of the proposed procedures, and some felt that the proposal did not go far enough. One respondent felt that these procedures should be limited to medical professionals only. A few respondents felt that the red category should encompass more procedures than those proposed in the consultation. A handful of responses cited concerns about discrepancies between the level of risk posed by the procedures proposed for inclusion in the category.

Several responses commented specifically on the proposal for CQC to regulate these procedures. While a few supported the need for CQC to oversee the most complex procedures, a few suggested that CQC regulation was not necessary. These respondents felt that the non-surgical nature of the procedures did not warrant them being subject to CQC oversight, or thought that if the practitioner was already registered with their professional regulatory body or was experienced in providing the red procedures then CQC oversight would not be needed. A few responses also cited concerns with CQC’s effectiveness as a regulator.

A few responses identified the need for specific standards of qualification and training for all practitioners regardless of professional background.

Members of the public not working in cosmetics

Many of the respondents who agreed with the proposals for the red category cited in their accompanying comments the level of risk these procedures are deemed to pose. However, as for the other groups, some responses suggested that qualifications and training should be the deciding factor in who should be permitted to perform particular procedures:

I think anyone should be able to carry out these with the correct qualifications and training, not just health care. It would save the nhs, as people are going into the nhs to get qualified and then leaving to setup their own business to earn more money.

Several respondents proposed that various procedures be moved to different categories, for example:

I agree with the majority of the red treatments. However, intravenous injectables and IV are done by non medics in hospitals so why does this come under the red category. I think this should be moved to amber

PDO threads, (not cogs) should be Amber

Hay fever injections - move to amber and undertaken by a regulated pharmacy.

Training provider or business owner

Several respondents agreed with the proposals for the red category, highlighting the increased level of risk associated with the proposed procedures. However, several responses argued that non-healthcare professionals should be able to administer treatments if they have the appropriate training.

A few responses proposed that CO₂ laser treatments did not need to be placed in the red category and could be performed by non-medical professionals, or under the supervision of a medical professional. A few responses also proposed that hay fever injections could be moved to amber or green, although one respondent said that they should only be administered by a hospital specialist.

Licensing professionals

There was a strong level of agreement with the proposals for the category. Many comments highlighted the level of risk and complexity involved in the procedures proposed for inclusion, and the need for specific training. 

Some responses advocated for other procedures to be added to the category, or proposed that they should only be performed by qualified and regulated healthcare professionals:

any blood based products should be added to this group as high risk to infection if not regulated as RED

A few responses highlighted that the proposed procedures are outside the remit of local authorities’ experience at present and would need to be regulated by those who are familiar with the procedures:

All should be regulated by qualified medical healthcare professionals with experience of all the treatments. Local Authority licensing schemes employ licensing officers who do not have any health practitioner training or qualifications, or Environmental Health Officers who although they have health and safety procedures training are not medically qualified.

A few responses disagreed on the grounds that the focus should be on education and training standards for the sector rather than tiering of procedures, and that suitably qualified non-healthcare professionals were capable of performing these procedures safely:

this makes sense but, again, there might be beauty therapists with the necessary qualifications that could safely undertake such treatments. This will be for the industry to prove though.

Organisation responses

There was a strong level of agreement with the proposed categorisation for red procedures, with many organisations identifying that the complexity and invasiveness of the proposed procedures merited them being limited to being performed only by regulated healthcare professionals operating from CQC-regulated providers. However, some responses advocated the view that non-healthcare professionals should be able to perform the procedures if they were able to demonstrate the necessary qualifications and training.

Some local authorities felt that medical knowledge would be required to regulate treatments in the red category. They therefore felt that these procedures were outside their remit and that it was appropriate that they should be overseen by CQC. It was highlighted that effective communication would be needed between CQC and local authorities and that where businesses offer a range of procedures that would fall within the remit of CQC registration and local authority licensing, CQC, as the body responsible for overseeing the highest risk procedures, should be responsible for overseeing all the activities carried out by the business to avoid the need for dual oversight.

Some responses highlighted that the definition of laser procedures proposed for inclusion in the red category needs to be further clarified with regard to the techniques used or layers of the skin targeted. Some responses also proposed that more detail was needed on the depth of penetration or the percentage of active ingredients of the chemical peels proposed for inclusion in this category. A few responses also mentioned thread procedures, saying that a distinction should be made between the different levels of risk involved in mono threads and lifting threads.

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

There were 4,588 responses to this question, of which:

• 1,542 (34%) said that procedures should be moved to another category (amber or green)
• 1,989 (43%) said that procedures should be added
• 1,432 (31%) said that procedures should be removed

Views were similar between members of the public and professional respondents.

Aesthetic practitioners were more likely to say procedures should be moved or removed from the red category, whereas healthcare professionals and policy, regulation and licensing professionals were more likely to say they should be added.

We received 2,058 responses to the open text portion of this question.

Many of the sampled comments expressed that several of the procedures proposed for inclusion in the red category do not fall within the remit of non-surgical cosmetic procedures. Procedures included in this were 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, the combination of ultrasound and large bore cannula for the purposes of liposuction and dermal micro-coring.

Numerous respondents argued that hay fever injections should be removed from the red category, many of these suggesting they be removed from licensing entirely due to them being deemed inappropriate for use as a cosmetic treatment. Many other respondents advocated for them being recategorised specifically as an amber procedure.

Thread lift procedures were also identified as a procedure which would be suitable for moving to the amber category. A few suggested they could be reclassified as green procedures. Intravenous injections and infusions were also proposed for transfer to a lower category by many respondents.

Many respondents advocated for filler procedures to be added to the red category. Some specifically identified filler procedures to the face. A smaller number suggested Botox injections should be added. Several respondents said that all amber procedures should be included in the red category.

Organisation responses

Thread lifting procedures provoked a variety of comments. Several respondents felt that these procedures could be moved to the amber category. Some differentiated between different types of thread lifting procedures, saying that smooth threads entailed a lower level of risk to cog threads and could be moved to amber or green.

Some of the procedures proposed for inclusion in the red category were felt to be outside the scope of a consultation on non-surgical cosmetic procedures. Hair restoration surgery and the combination of ultrasound and large bore cannula for the purposes of liposuction were felt by some respondents to be surgical in nature and not suitable for inclusion.

Dermal micro-coring and procedures aimed at augmenting any part of the body, in particular the breast, buttocks and genitals, typically using autologous fat or dermal fillers, were also felt by some to fall within the remit of surgery, although there was also some support from a few respondents for these procedures to be moved to amber. Some comments proposed that the buttocks and breast were no more vascular than the face and so did not warrant being considered to be higher risk than fillers performed on the face.

Some responses advocated for the Royal College of Surgeons to redesignate some of the procedures as being surgical in nature, thus providing an extra layer of protection for the public.

Several respondents said that hay fever injections are not suitable for use as a cosmetic treatment and should be removed from the licensing scheme. Other respondents felt that they could be categorised in amber or green.

Laser procedures received several comments. While some felt that laser procedures in general or ablative or CO₂ lasers specifically could be moved to a lower category, some differentiated procedures based on the body area they are performed on, saying that any laser or IPL treatment performed within the periorbital rim or any gynaecological-related laser treatments should be classified as red procedures.

There was some support voiced for all permanent filler procedures to be added to the red category, and for the inclusion of any procedure which involves the use of a POM if onsite supervision for such procedures by a prescriber is not implemented.

Many comments received about which procedures should be added to red echoed the comments received for the questions on the green and amber categories. Botox and filler procedures, vitamin and mineral injections, fat dissolving injections using a POM and weight loss injections were those procedures most commonly proposed for being moved to the red category. A few respondents advocated for body modification procedures to be included in the red category.

As with previous responses, a handful of comments were received about the category and its constituent procedures as a whole, saying that all the procedures in the red category should be moved to green or to amber, or saying that all amber or all non-surgical cosmetic procedures should be added to the red category.

Minimum age of client

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?

There were 11,708 responses to this question, of which:

• 9,418 (80%) said all of the procedures should be age-restricted
• 2,192 (19%) said some of the procedures should be age-restricted
• 98 (1%) said none of the procedures should be age-restricted

Four-fifths of respondents said they thought all of the licensed procedures should be restricted to those above the age of 18, unless approved by a doctor and carried out by a healthcare professional. Only 1% thought that none of the procedures should be age-restricted.

Support was similar between members of the public and professional respondents. Aesthetic practitioners (78%) and healthcare practitioners working in cosmetics (83%) demonstrated a similar level of support. Healthcare practitioners working outside cosmetics were most supportive of age restriction (88%). Views were consistent across the UK.

Respondents were given an open text box to explain their answer. We used the same technique as before to identify any procedures named in this section.

Of the 884 respondents who mentioned at least one procedure that we were able to categorise, the procedures most commonly discussed were (references to):

• acne
• dermal filler
• Botox
• chemical peel
• laser (all)
• laser hair removal
• microneedling

We received 2,700 responses to the open text portion of this question. In our analysis, we have separated these into the most important respondent groups.

Aesthetic practitioners

A significant number of responses stated that all procedures should only be carried out from age 18 or an age higher than 18. Some of these responses raised that restrictions are important for protecting children and that individuals under the age of 18 do not need cosmetic procedures. Several responses stated that the age limit should be raised to 21 or higher. Some responses highlighted that Botox and dermal fillers are already legally restricted to over 18s only.

A few respondents raised the negative impact of social media and peer pressure on people under the age of 18. Some responses indicated that under 18s are not able to provide informed consent and that under 18s could regret the long-term consequences of changing their appearance at a young age.

Many responses raised that not all procedures need to be restricted to people over the age of 18. Many responses stated that some procedures in the green category could be carried out on under 18s. These responses highlighted that some procedures on the green list could be used to treat the following:

• acne
• blemishes on the skin
• excess facial hair
• skin tags

Procedures that respondents stated could be carried out on under 18s included:

• microneedling
• lasers
• LED light therapy
• chemical peels

Several respondents noted that under 18s should still need to have parental or legal guardian consent.

Many responses stated that if a cosmetic procedure was needed for medical purposes then only a doctor should be able to approve the procedure.

Several responses raised that other procedures should also be age-restricted, including piercings, lash lifting, hair colouring and nail treatments.

Regulated healthcare professionals working in cosmetics

A large number of responses stated that all procedures should not be carried out on individuals under the age of 18. Some responses raised that under 18s are easily influenced, may make impulsive decisions, and may regret decisions that they make as a child. A few responses raised that the age limit should be raised to 21 or above, or that young adults should be required to have an additional assessment before a cosmetic procedure is carried out:

No one under 18 unless related to a medical condition should receive treatment and even at the age of 18 screening should be done so that the practitioner can justify the need for cosmetic procedures on a young adult

Some responses stated that some or all of the green procedures could be carried out on under 18s as they do not significantly impact on an individual’s appearance:

Some of the procedures in the green category are for rejeuvenation and skin enhancing purposes. These procedures do not alter structure or change physical appearance

A number of responses stated that some procedures could be carried out on 16 year olds with the consent of parents or legal guardians. Many of these responses highlighted the positive impact of some procedures on reducing acne and/or acne scarring. A few responses noted that under 18s may benefit from hair removal procedures if suffering from polycystic ovary syndrome (PCOS) or hirsutism. Most of these responses listed the following procedures as potentially being suitable for under 18s:

• chemical peels
• lasers
• LED lights
• microneedling

Many responses stated that if a cosmetic procedure was needed for medical purposes that only a doctor should be able to approve the procedure. Some responses stated that any regulated healthcare professional should be able to approve the procedure.

Regulated healthcare professionals not in cosmetics

Most respondents in this group agreed that procedures should be restricted to over 18s only. A few responses stated that the age should be higher, with a small number of responses stating the age should be raised to 25.

Several responses cited concerns that young people are susceptible to being influenced by social media and are vulnerable to being insecure about their body image, causing them to seek to undergo aesthetic procedures. Several respondents stated that they do not feel that under 18s have the capacity to be able to give informed consent or to fully appreciate the risks and potential consequences of undergoing aesthetic procedures.

Some responses highlighted the benefits of treatments for acne and acne scarring and excessive facial or body hair, and said that young people should be able to access these treatments where necessary:

Many children have appearance concerns. Consider girls with facial hair with polycystic ovary syndrome. It seems entirely appropriate that they should request laser hair ablation under 18 years of age.

Members of the public not working in cosmetics

Many of the responses in this group agreed that procedures should not be carried out on individuals aged under 18. Some responses stated that the age should be lifted to 21 or higher. A number of responses stated that under 18s have not fully developed and that children are more likely to be negatively influenced by social media. A few responses stated that procedures carried out in childhood could impact on an individual’s mental and physical health later in life.

A few respondents disagreed with procedures being age-restricted. These responses stated that individuals of any age should be able to make decisions about their own bodies. Some responses stated that any procedure that had a limited impact on a person’s appearance could be carried out on under 18s.

Several responses highlighted that procedures could be beneficial for under 18s suffering from medical conditions, particularly acne. These responses listed procedures including LED lights and lasers. A few responses highlighted that any procedures under the age of 18 should be signed off by doctors but carried out by a licensed individual (not just regulated professionals).

Training provider or business owner

A large number of respondents in this group agreed that procedures should not be carried out on individuals under the age of 18. A few respondents said the age should be 21 or higher. Many responses highlighted that children are influenced by social media and may not have the capacity to fully consent to procedures that could significantly alter their appearance.

Some respondents stated that under 18s should be able to access green procedures. Most of these responses stated that parents or legal guardians should still need to provide consent. Many respondents highlighted the beneficial impact of certain procedures on acne and facial scarring. A few respondents mentioned other conditions such as eczema and/or skin complaints such as skin tags and warts. A few responses noted that the NHS and GPs do not have the capacity to approve or carry out cosmetic procedures. These responses noted that under 18s should, therefore, be able to access procedures including:

• chemical peels
• lasers
• microneedling
• cryotherapy
• cryocautery

Some responses stated that only doctors should be permitted to approve procedures on under 18s for medical purposes. A few responses included that some procedures could be approved by a doctor to help an individual’s mental health.

A few responses raised that other procedures should be age-restricted including certain types of body piercings (nipple, genital, tongue, micro or macrodermals, and surface piercings).

Licensing professionals

Several respondents agreed with the proposal that 18 was a suitable age for restricting procedures to, citing that under 18s are unable to understand the potential impact of undergoing a procedure:

some of these procedures can have lasting or devastating effects on the body. Children under the age of 18 should be protected from making a decision that was made whilst they were immature and did not appreciate the long term consequences of their decision

Several respondents commented that they agreed that any treatments for people under the age of 18 must be approved by a doctor and some also clarified their support for procedures to only be administered by regulated healthcare professionals.

Some responses suggested that some procedures currently registerable with local authorities should be included within the licensing scheme and should be made available to under 18s, particularly piercing.

Several responses highlighted how they believe young people are particularly vulnerable to pressure from social media and their peers to access these procedures without being able to fully comprehend the potential consequences of doing so.

As with the comment above, a few respondents suggested either that 18 was too young for all or some of the procedures in question, or that some less invasive procedures should be made available to under 18s:

I feel this needs far more investigation before a blanket age restriction is brought in. 18 is far too low for some treatments but fine for others.

Organisation responses

Many responses highlighted that introducing an age restriction of 18 would be a proportionate measure to safeguard children and young people from the risks posed by the procedures proposed for inclusion in the scheme. Many responses cited how under 18s are still developing physically and emotionally and that they were unable to appreciate what the longer-term consequences of undergoing a non-surgical cosmetic procedure might be. Several responses highlighted that young people are more susceptible to pressure from peers, the media and social media and may seek to undergo procedures as a result. Many responses said that the introduction of an age restriction of 18 would align the licensing scheme with existing legislation such as the age restrictions imposed by the Botulinum Toxin and Cosmetic Fillers (Children) Act 2021 and restrictions on accessing sunbeds and undergoing tattooing.

Some respondents advocated for more invasive treatments such as Botox and filler injections and treatments to breast, buttock and intimate areas to be restricted to over 21s.

A few respondents suggested that healthcare professionals other than doctors also had the necessary skills to assess and approve procedures for under 18s, and it was also suggested that the person administering the treatment did not necessarily have to be a registered healthcare professional provided that the required qualification standards had been met and appropriate safeguarding measures were in place. It was suggested that requiring procedures to be approved by doctors and performed by registered healthcare professionals could lead to increased waiting times for young people to be able to access procedures and potentially increased costs.

Several respondents suggested that if the scope of the licensing scheme were to be widened to incorporate those activities registrable under the Local Government (Miscellaneous Provisions) Act 1982, piercing should be exempt from the proposed age restriction. Piercing of the ear in particular was highlighted as a procedure which could be performed on under 18s, with some respondents further clarifying that this should be performed on under 18s only with parental or guardian consent.

Many respondents felt that some treatments should be made available to under 18s. For example, it was suggested that several of the treatments proposed for being subject to licensing can be used to treat conditions such as acne and associated scarring, excessive body hair and excessive sweating. Responses highlighted the mental health benefits that under 18s can gain from being able to access these treatments. Some respondents qualified their responses by saying that accessibility of treatments for under 18s should be dependent on parental consent being given, or an assessment of the young person’s capacity to understand the procedure and give informed consent.

Any other comments

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

We received 2,461 responses to the open text portion of this question. In our analysis, we have separated these into the most important respondent groups.

Aesthetic practitioners

Many responses highlighted how the current lack of standardisation of training in the sector and the proliferation of short courses available are the source of many of the issues in the sector, and should be the main focus of the licensing scheme:

Look into training providers. It is too easy to get qualified or to train in something you know hardly anything about. This is where I believe the problem lies in this industry. Please don’t penalise professional businesses like mine who carry out treatments to a high standard.

Many responses stressed that the standards the licensing scheme will introduce will need to apply to all practitioners regardless of professional background, with some highlighting that being a healthcare professional does not automatically make someone a better practitioner. Several aesthetic practitioners used this question to emphasise that they are well qualified, perform procedures to a high standard and have invested significant money in their businesses.

Several aesthetic practitioners cited concerns about how the proposed scheme might impact on their businesses, such as through limiting the procedures they are able to perform or through having to pay to undertake new training to meet the new qualification requirements the scheme will introduce. Some respondents felt that the proposed scheme is biased towards regulated healthcare professionals.

Some respondents reiterated their concerns about how proposals for the scheme might impact on the NHS, with comments saying that introducing requirements for supervision or restricting certain procedures to regulated healthcare professionals only could create shortages of staff in the NHS or encourage people to undertake healthcare professional training courses with the sole intention of practising in aesthetics on qualification.

Regulated healthcare professionals working in cosmetics

Many regulated healthcare professionals working in cosmetics advocated the view that aesthetic procedures, particularly those proposed for inclusion in the amber and red categories, should only be carried out by regulated healthcare professionals. Professions proposed for inclusion in this category included:

• doctors
• pharmacists
• nurses (including nurse prescribers)
• midwives
• dentists

There was however some disagreement with this notion, with the knowledge and experience of many aesthetic practitioners being noted:

The best work in my opinion comes from beauty therapists and skin specialists with superior knowledge of the face.

Concerns around current training standards and the need to regulate training were also commonly mentioned.

Some responses also raised concerns about the products being used in the industry and highlighted the need for action in this area:

Review of the unlicensed products circulating in the UK needs to happen. Criminalisation for practitioners utilising products that are not bought from reputable sources. Unlicensed Products are offered regularly to all practitioners via social media sources.

A few respondents also highlighted concerns that safeguarding concerns were being overlooked in the consultation process:

Nowhere in the DHSC proposals document is patient safeguarding mentioned. This is a huge error and oversight on your part, but given recent past history is utterly unsurprising. At no point has this (or previous) government(s) shown any interest in protecting aesthetic medicine patients from rogue elements. As it currently stands any person in the UK (irrespective of training, background, insurance, criminal record, ability and morality) can inject unsuspecting patients with the world’s most dangerous neurotoxin and class III medical devices unencumbered by the need to provide any level of safeguarding to the public. This preposterous situation cannot be allowed to continue.

Regulated healthcare professionals not in cosmetics

Many responses highlighted concerns about the current lack of regulation in the sector:

This is a long time coming. I see so many dangerous practices from aesthetic practitioners with no medical training who simply don’t understand the pharmacology, physiology and anatomy of what they are doing. I recently saw a lady who had local anaesthetic toxicity and almost died because the injector did not understand the nature of local anaesthetic within the filler and gave far too much of it. Action is needed NOW!

There was strong support expressed for procedures included within the scheme, or procedures proposed for inclusion in the amber and red categories, to be restricted to healthcare professionals:

I do not believe that what has been suggested is far reaching enough to protect the public. I am really concerned that the proposal of licenced aesthetitions delivering treatments on the amber list is dangerous. It just creates confusion and blurring. I believe that allowing anyone other than registered healthcare professionals to provide the amber listed treatments will effectively change nothing. There needs to be a clear distinction between beauty and clinical treatment. The idea of an amber list is a farce. This should all be regulated by the healthcare regulators and not local councils. They do not understand the medical professions.

However, there was also some acknowledgement of the quality of the work performed by non-healthcare professionals:

There are some very dangerous practitioners in the UK and the industry should be regulated for certain. However the majority of practitioners working from.clinics and salons are running safe businesses with good SOPs. Being a doctor doesn’t qualify one person over another for cosmetic procedures. Over regulating by discounting safe practice will push the worst underground and still causing issues and will put the best out of a job that they worked and trained hard for.

A few comments highlighted the lack of, and need for, consistent education standards and some responses highlighted the need for penalties and sanctions to be robust and enforceable to prevent a black market of practitioners forming.

Members of the public not working in cosmetics

Comments were received from members of the public not working in cosmetics on a variety of issues. Several responses highlighted how action in this area is needed:

There needs to be a major overhaul of the industry and regulations in the UK, this seems like a sorely needed consultation and I hope changes are enacted. The mind boggles at who can perform certain procedures in the UK, many of which can have long-term effect on people’s health.

Several responses advocated for the skills and training of non-healthcare practitioners and raised concerns that the licensing scheme would restrict their practice and adversely affect their businesses:

I believe that the regulating the cosmetic industry to prevent non medics from practicing is immoral and discriminatory. I have personally experienced far better service, knowledge and safety from non medics than medics. I have had botched jobs and awful service carried out by medics who hide behind the medic title and get away with it.

Conversely, some responses cited concerns about non-healthcare professionals being permitted to perform certain procedures.

Many responses emphasised the importance of ensuring training and qualification standards are enforced in the sector:

I do believe that all 2 day courses on what you call amber and red catagory treatments should be stopped! This includes medics advertising these courses. I do believe everyone should have an ‘across the board’ qualification and have to prove they are up to standard.

Training provider or business owner

While several responses advocated for the need for further regulation in the sector, many respondents felt that attention should be directed towards ensuring robust training requirements are implemented. Many respondents voiced concern that the consultation’s proposals would be detrimental to businesses:

I have real concerns that this new license will force qualified, competent and experienced practitioners out of business due the unnecessary need for medical oversight for certain treatments.

It was also expressed by some respondents that healthcare professionals are not automatically more experienced in performing aesthetic procedures.

Some respondents cited concerns that the government is not consulting with the sector when developing proposals for regulation:

This consultation is flawed. You have grouped too many procedures together inappropriately. It needs to be redesigned with more input from industry experts.

Concern was also raised that current standards required for obtaining insurance vary widely between insurance providers, leading to practitioners being able to become insured while not having adequate training.

Licensing professionals

Many responses from those working in licensing advocated for the new scheme to include those procedures currently subject to registration under the Local Government (Miscellaneous Provisions) Act 1982. Responses cited the lack of enforcement power the current registration scheme bestows, and how the existing legislation is outdated and unable to uphold public safety in this area. Respondents also cited concerns that local authorities operating registration and licensing simultaneously would be confusing, creating the requirement for some businesses to obtain both registration and a licence, depending on the types of procedures they offer.

Resourcing concerns were voiced by several respondents, stating that local authorities would struggle with their current staffing levels to add the operation of the licensing scheme to their list of obligations. Some responses highlighted the need for local authority staff to receive training and guidance in the procedures they would be licensing to enable them to fulfil the duties the scheme will place on them.

Organisation responses

Many organisations used the free text box for the final question to reiterate points they had made in their response to issues covered in previous questions, particularly regarding the need for robust training and qualification standards for the sector to be determined, and questions and concerns about how oversight might be defined and implemented. A few responses raised concerns that respondents’ assessment of which category procedures should be classed as or what restrictions might be appropriate would be based on a view of current standards of practice in the sector. They proposed that once robust qualification and training requirements had been established, standards would improve and it might be that opinions on suitable classifications and restrictions might change. Some respondents highlighted inaccuracies in the consultation document’s glossary of procedures, and difficulty in responding to the questions without being provided with definitions on the concepts the questions relate to, such as what will constitute ‘oversight’ or who will be included in the definition of a ‘regulated healthcare professional’.

In addition, respondents raised several other issues that they felt were pertinent to the development of the licensing scheme for DHSC to take into consideration as this work is progressed. Many responses, particularly those from local authorities, cited concerns about how local authority resourcing might cope with the increased demands which licensing would place on it, and also highlighted the need for additional training and guidance to equip local authorities with the knowledge needed to administer and enforce the scheme.

It was also frequently stated that licensing should incorporate activities currently subject to registration under the Local Government (Miscellaneous Provisions) Act 1982.

Several responses also raised the issue of fees. Respondents felt that these should be set at a standard to aid cost recovery but there was some difference of opinion as to whether these should be set at a national or local level. Some respondents cited concerns that when fees are set through legislation it is difficult for them to then be altered when needed.

The need for clarity on how licensing will integrate with existing systems of oversight and regulation was raised. Many organisations questioned how licensing might interact with registration and local licensing schemes currently in operation, particularly for those businesses whose activities might include both registrable and licensable activities, and highlighted the need for a single unified system to aid local authorities and businesses. A handful of respondents also referenced the accredited registers currently in operation, citing how they provide an important safeguard for public protection and questioning how the licensing scheme might interact with them or acknowledge practitioners’ listing on them. The need for clarity on the interaction between the roles of local authorities and CQC in licensing was also highlighted.  

Several responses were received from statutory professional healthcare regulators, who questioned how licensing will integrate with the oversight they already provide to their registrants, including established fitness to practise processes. In particular, it was highlighted that there is a need for clarity on where responsibility will lie for investigating and taking action when a practitioner who is a registrant of a statutory professional regulatory body is found to have fallen short of the expected standard of practice or breached the terms of their licence to perform aesthetic procedures. Similarly, this raises the issue of how and when licensing authorities will need to be notified if a practitioner is subject to an investigation or has concerns raised about them in the course of performing the role for which they are registered with a statutory healthcare regulator. The need for clear channels of communication and delineation of responsibilities between licensing authorities, professional regulators and CQC was highlighted, so that concerns about practitioners or businesses are brought to the attention of all necessary bodies and there is a clear route through which such concerns are dealt with.

The related issues of supervision and oversight were also raised. Some organisations queried the extent to which those healthcare professionals acting as supervisors for cosmetic procedures would be deemed to be responsible for the practice of those they were supervising, and where the responsibility for identifying and tackling poor practice would lie. It was stressed that further work would be needed with the statutory professional healthcare regulators to understand how proposals for supervision of aesthetic procedures would accord with current practices and guidelines around supervision and delegation, which are already existing features of many facets of healthcare practice.

Building on comments around concerns of current prescribing practices outlined in the overview of responses to previous questions, some organisations highlighted how current prescribing legislation prevents independent nurse prescribers from being able to hold stocks of prescription medications. Respondents were concerned that this prevents timely access to medications needed to respond to emergencies or complications, such as adrenaline in the event of anaphylaxis or hyaluronidase to dissolve dermal fillers to prevent medical issues such as vascular occlusion and necrosis. Respondents therefore highlighted that amending medicines legislation to enable independent nurse prescribers to hold stock of such medication would be a crucial step to improving safety in the aesthetics sector.

Some organisations advocated for the need for a national register, citing how this would benefit the public by enabling them to search for suitable practitioners for the procedure they wish to undergo, and assist local authorities with information sharing. Several organisations said that monitoring and reporting through establishing information sharing channels would enable authorities to share concerns, verify information, track trends in procedures and products and provide the public with a forum through which to raise concerns or make complaints.

Linked to this is the issue of public awareness raising. Several respondents advocated for the need for a directed programme of communications to inform the public of what the licensing scheme entails, including its constituent categorisation of procedures and any restrictions on which practitioners are permitted to perform certain procedures, and how this will support them to make safe choices about any procedures they choose to undergo. Additionally, it was suggested that the department should work with the Advertising Standards Agency to ensure that information provided by businesses as to how they comply with the requirements for licensing is accurate.

As well as reiterating the need for robust education and training standards to be established, a few responses identified a need for requirements for continuing professional development to be put in place to ensure practitioners’ skills remain up to date post-qualification.

Safeguarding was identified by several respondents as being a central component of the scheme’s purpose of upholding public safety, who cited concern at the lack of focus this had been given in the consultation. Attention was drawn to the current lack of scrutiny given to the background or suitability of many of those operating in the sector, particularly those practitioners who have not undergone screening processes such as Disclosure and Barring Service checks as part of registration with a statutory regulatory body. Further concern was highlighted that practitioners have regular contact with vulnerable adults and young people. Given that the sector regularly interacts with and serves people who are vulnerable, several respondents identified a need for psychological assessment of clients to be a central part of the pre-procedure consultation process.

Some organisations gave views on how the introduction of licensing might impact on equality and diversity, advocating for assessments to be conducted on this to mitigate the risk that any patient groups might be disproportionately affected by the introduction of licensing and ensure equal accessibility and safety of procedures and effectiveness of outcomes for all who wish to undergo a non-surgical cosmetic procedure.

Many responses stressed the importance of futureproofing the scheme, saying that, given the range of procedures the sector encompasses and the speed with which new products and techniques are developed, the scheme must be designed in such a way to be able to quickly evaluate and include these treatments as deemed necessary. Additionally, it was felt to be important that treatments included in it are kept under review so that any emerging evidence which might impact on the scheme’s determination of these existing treatments’ safety is considered, and licensing and any associated restrictions around which practitioners are able to perform these treatments remains proportionate.