Ethics

Ethical aesthetics

Dr Harry Singh looks beyond the clinical aspects of facial aesthetic treatment, exploring the related ethical and medico-legal issues.

Dr Harry Singh BChD MFGDP has been carrying out facial aesthetics since 2002 and has treated over 3,000 cases. In his last dental practice (focused on aesthetics) he ended up performing more facial aesthetic treatments than dental treatments. Due to the very high profit margins associated with facial aesthetics, he decided to concentrate on facial aesthetics and currently has over 700 facial aesthetic patients. He has published numerous articles on the clinical and non-clinical aspects of facial aesthetics, and spoken at dental and facial aesthetics conferences on these topics. Harry was shortlisted at the Private Dentistry Awards in 2012 and 2013 in the Best Facial Aesthetics Clinic category and was a finalist in 2012 at the MyFaceMyBody awards for the Best Aesthetics Clinic.
For further information on Harry’s courses and to download a video ‘Getting Started in Facial Aesthetics’ free of charge, please visit http://www.botulinumtoxinclub.co.uk/

With facial aesthetics gaining in popularity, greater numbers of dentists are being asked by their patients to offer treatment beyond the usual dental fare. Of course, this kind of treatment requires clinical training, but also an understanding of the associated medico-legal requirements and ethical issues.

Medico-legal requirements

Currently, there is no regulatory body or any formal process of regulation regarding the administration of non-surgical facial aesthetics. However, this will be changing. With the completion of the Keogh Review and the Government’s response to this, together with the European Aesthetics Surgery regulatory standards gaining CEN (European Committee for Standardisation) approval, it will be wise to be prepared and ready for any imminent regulation.

Since there are no formal regulations in place directly related to non-surgical facial aesthetics, in theory anyone can perform such procedures. However, indemnity providers will only insure certain medically-trained professionals such as dentists, medical doctors and medical nurses.

There are various options regarding indemnity (which is mandatory) that allow you to be covered when performing these procedures. To give you some idea of what is available, below is a snap-shot of what some indemnity providers offer. (NB – this information is correct at the time of writing, but terms and conditions may change so it is advisable to check with your indemnity provider.)

With the Medical Protection Society (MPS) you may be able acquire coverage for facial aesthetics, as long as certain requirements are met, such as, but not limited to a, cap on earnings per year from aesthetics, areas to be treated (mainly neck and above), and registration with the ‘Treatments you can trust’/IHAS scheme.

For those with the Dental Defence Union (DDU), you may be able to have such treatment included in your dental indemnity, as long as you have evidence of training and competence in the areas you will be treating.

I personally use Hamilton Fraser Insurance Services (HFIS). There is no limit on your earnings and which areas are covered (as long as you can prove you have been adequately trained).

Other specialist indemnity providers include Cosmetic Insure and HISCOX.

As briefly touched upon earlier in the article, you will need to attend an approved training programme (as decided by your indemnity provider) and provide evidence of a certain level of competence before you will be allowed to carry out these procedures.

Another important point to note is that Botulinum toxin is a POM (prescription only medicine). Therefore, only prescribers can order it, and it can only be obtained from a pharmacy. You will need to set up a pharmacy account before you order the toxin. Currently, dermal fillers are not classified as prescription only medicines, so you can order either from a pharmacy (to save on the VAT) or directly from filler suppliers.

Care Quality Commission regulations (CQC) may also be relevant when it comes to facial aesthetics. You will require suitable premises in which to provide these treatments. If you are providing aesthetics within your dental practice, then it will come under the CQC’s remit. However, if you are providing these services away from your premises, then – for now – CQC requirements are not relevant in most cases. On this issue, a word of warning is important here. If you are treating hyperhidrosis (excessive underarm sweating), irrespective of the premises the CQC may feel it comes under their remit because this condition is classed as a disorder that must be diagnosed before it can be treated. It is further defined as such by the NHS. This makes it a ‘regulated activity’ within the realms of the CQC in England (with similar requirements in Wales, Scotland and Northern Ireland).

Ethical issues

Non-surgical facial aesthetic services are elective and therefore no patient ‘needs’ them. It’s a ‘wants’-driven business. This is advantageous for the business, as patients will seek these services, will be willing to pay for such treatment, and will be appreciative of the results. However, it can be a double edged sword in that we need to base our treatments and recommendations on a sound evidence base that is supported by long-term studies, alongside an assessment of whether we can improve upon the patient’s current situation.

I look like to follow the 4 Ps in terms of providing ethical solutions to my patients’ problems:

• Person – are you the right person to see and treat this patient?
• Patient – are you happy to see and treat this patient?
• Product – are you using the right product?
• Place – are you injecting in the right plane?

Marketing and advertising are often considered by practitioners offering non-surgical facial aesthetics. In this regard, it is important to note that, since Botulinum toxin is a POM, you cannot advertise this to the general public. The word ‘Botulinum Toxin’ cannot appear in any print media, posters, flyers, etc. that is exposed to the general public. Regarding websites, at the moment you cannot have the word ‘Botulinum Toxin’ on the homepage of your website and Google will not allow any PPC (pay-per-click) campaigns on this medicine.

As a result of the PIP breast implant scandal and the Keogh report, regulatory bodies such as the ASA (Advertising Standards Agency) and the GDC are clamping down on adverts that include any of the following:

• Time-limited deals
• Financial inducements
• Package deals, such as ‘buy one get one free’
• Offering cosmetic procedures as competition prizes.

The GDC has certain requirements regarding advertising, as stated in section 1.3.3 of its Guidance on advertising document: ‘You must make sure that any advertising, promotional material or other information that you produce is accurate and not misleading, and complies with the GDC’s guidance on ethical advertising. All information or publicity material regarding dental services should be legal, decent, honest and truthful.’

Managing expectations is also, of course, an important aspect of providing ethical treatment. Never treat anyone if you cannot improve their look. Any patient seeking this kind of care will be mainly concerned with their appearance and it is vital that you can confidently improve upon this; it’s all about the adage of under-promise and over-deliver.

As for consent, the GDC has 3 essential elements in its document Principles of patient consent:

• Informed consent – the patient has enough information to make a decision
• Voluntary decision-making – the patient has made the decision
• Ability – the patient has the ability to make an informed decision.

Notes should be made contemporaneously to include, but not limited to, details regarding: the patient’s initial concerns; options discussed; patient input; explanation of procedures; what to expect; duration of results; potential complications; and aftercare and post-op instructions.

In addition, take before and after photographs of every treatment you perform. This is vital to track and show patients the improvements.

You cannot stop patients from suing you, but you can stop them from suing you successfully!

Handle with care

The rewards from aesthetic treatments can be dramatic in terms of improving patients’ confidence, as well as offering the practitioner a financial boost. However, it is imperative clinicians interested in incorporating facial aesthetics into their practice fully understand the medico-legal requirements and are able offer all treatments in a safe and ethical manner.

Call 07711 731173 or email [email protected] for more information on why you should choose BTC to help you achieve a successful aesthetic business.