A poor prognosis for autonomy: self-regulated cosmetic surgery in the United Kingdom

Abstract

In recent years, cosmetic surgery in the United Kingdom, which is provided almost entirely by the private sector, has gained in popularity despite evidence of its potential risks to patients. Over 32,000 procedures were reported by one association of cosmetic surgeons alone in 2007, three times more than in 2003. This article examines the regulation of cosmetic surgery in the UK, in light of the need for informed consent and the importance of patient autonomy. Since 2000, the government has attempted through legislation covering all health care provision to regulate cosmetic surgeons' qualifications, patient rights to information, and the inspection and registration of premises. However, the risk to patients from unregistered and poorly qualified surgeons, and from private clinics with a poor quality of care, has still not been adequately addressed. Moreover, ensuring informed consent and the maintenance of standards has been left to professional self-regulation. An independent, government-funded umbrella organisation with lay representation and sufficient powers of registration and inspection of all relevant cosmetic surgery practitioners is needed to fully protect patients, and should have its roots in specific legislation governing cosmetic surgery.

Résumé

Ces dernières années, la chirurgie esthétique au Royaume-Uni, qui est pratiquée presque totalement dans le secteur privé, a gagné en popularité, malgré des informations faisant état de ses risques potentiels pour les patients. Plus de 32 000 procédures ont été notifiées rien que par une association de chirurgiens esthétiques en 2007, trois fois plus qu'en 2003. L'article examine la réglementation de la chirurgie esthétique au Royaume-Uni, compte tenu de la nécessité d'un consentement éclairé et de l'importance de l'autonomie du patient. Depuis 2000, l'État a tenté, par une législation couvrant tous les soins de santé, de réglementer les qualifications des chirurgiens esthétiques, le droit des patients à l'information ainsi que l'inspection et l'enregistrement des locaux. Néanmoins, le risque pour les patients soignés par des praticiens non agréés et peu qualifiés, dans des établissements privés dispensant des soins médiocres, n'a toujours pas été pris correctement en considération. De plus, le soin de garantir un consentement éclairé et de maintenir les normes requises a été laissé à l'autorégulation professionnelle. Une organisation indépendante, financée par l'État, où les non-professionnels seront représentés et qui disposera de pouvoirs suffisants d'agrément et d'inspection de tous les chirurgiens esthétiques, est nécessaire pour protéger totalement les patients. Elle devrait s'appuyer sur une législation spécifique régissant la chirurgie esthétique.

Resumen

En los últimos años, la cirugía cosmética en el Reino Unido, gran parte de la cual es ofrecida por el sector privado, se ha vuelto más popular a pesar de la evidencia de sus posibles riesgos a los pacientes. Más de 32,000 procedimientos fueron informados por una sola asociación de cirujanos cosméticos en 2007, tres veces más que en 2003. En este artículo se examina la regulación de la cirugía cosmética en el Reino Unido en vista de la necesidad de consentimiento informado y la importancia de autonomía del paciente. Desde 2000, el gobierno ha intentado, mediante legislación que cubre toda la prestación de servicios de salud, regular las calificaciones de los cirujanos cosméticos, los derechos del paciente a información y la inspección y el registro de locales. Sin embargo, aún no se ha eliminado el riesgo a los pacientes por cirujanos no inscritos y no calificados, y por clínicas privadas con calidad de atención deficiente. Más aún, la obtención del consentimiento informado y el mantenimiento de estándares se han dejado en manos de la autorregulación profesional. Se necesita una organización independiente, financiada por el gobierno, con representación de legos y suficientes poderes de registro e inspección de todos los practicantes pertinentes de cirugía cosmética, para proteger plenamente a los pacientes; ésta debe basarse en la legislación específica que gobierna la cirugía cosmética.

Key Words:

• cosmetic surgery
• health policy
• informed consent
• patient autonomy
• statutory vs. self-regulation
• United Kingdom

Cosmetic surgery is an increasingly popular medical procedure in the UK, as elsewhere. The British Association of Aesthetic Plastic Surgeons reported that its members carried out 10,738 procedures in 2003¹ and 32,453 in 2007.² The provision of cosmetic surgery mainly takes place in the private sector, as it is more often than not done in response to a patient's request for the aesthetic enhancement of their bodies rather than in response to disease or injury. Cosmetic surgery refers usually to face, neck or eyebrow lifts; liposuction; tummy tucks; nose (rhinoplasty) and ear re-shaping; and breast implants or reduction. It is unlikely to be carried out on clinical grounds and is therefore not widely available from a publicly funded National Health Service (NHS) with limited resources, in contrast to plastic surgery. In the United Kingdom (UK), most procedures are carried out on women, and the most requested invasive cosmetic procedure is for breast implants, with the number increasing rapidly year on year: approximately 3,700 breast enlargements were carried out by members of the British Association of Aesthetic Plastic Surgeons in 2004, 5,646 in 2005,³ and 8,349 in 2008.⁴

Although increasing numbers of men are taking up cosmetic surgery, female patients still outnumber male patients by a ratio of 9 to 1. In 2007, 91% of cosmetic surgery in the UK was carried out on women, although male surgery such as face lifts and rhinoplasty did increase by 17.5% between 2006 (2,452 procedures) and 2007 (2,881 procedures).⁵ Arguably women are also oppressed by the growing culture of cosmetic surgery to a greater extent than men, notwithstanding the fact that cultural pressures to conform to images of attractiveness or sexuality can affect both sexes. The regulation of cosmetic surgery as it affects women patients in England and Wales^* is therefore the focus here. Many of these treatments – breast implants or reduction, rhinoplasty, facelifts, and liposuction, for example – involve invasive surgery. Patients therefore run the risks associated with any surgery: blood loss, bruising, infection, deep vein thrombosis, wound healing problems, scarring, even death.⁶ There may be additional risks, however; breast implant patients in Sweden have been shown to be at a higher risk of depression and suicide,⁷ for example, although these women may have opted for these procedures because they were more emotionally vulnerable in the first place.^8†

Risks associated with cosmetic surgery in the UK are significantly affected by the fact that it is provided by private clinics and surgeons. In order to obtain cosmetic surgery on the National Health Service, a plastic surgeon and a psychiatrist or psychologist must determine whether there is enough social, psychological or physical benefit to the patient to justify surgery. They will only do so on exceptional grounds, such as where excessive eyelid skin needs to be surgically removed because it is obscuring a patient's vision, for example. Patients of cosmetic surgery are therefore invariably treated at private clinics. These clinics provide a particular context for treatment decisions. Initial consultations may be with a receptionist on the premises, or with a cold-calling member of a sales team over the phone. This contrasts with the advice that a qualified health professional should ideally give about the appropriateness to a patient of a particular treatment and its known clinical risks. Private sector advertising and marketing may also raise false expectations amongst patients. Since patients are unlikely to have been referred by their GP, self-referral risks non-disclosure to the surgeon of important contraindications. In private practice, there are almost never waiting lists for treatment. This leaves the patient with less time to reflect on the treatment, and in the case of invasive surgery on non-clinical grounds, to reconsider having the treatment altogether.⁹

Patients in the UK who have suffered from negative outcomes as a result of cosmetic surgery have claimed compensation from their surgeons. A report published in February 2003 by the Medical Defence Union, who supply indemnity and insurance to doctors in the UK, provided evidence that cosmetic surgery is resulting in disfigurement and injury. Forty per cent of successful claims were on grounds of dissatisfaction with the results of operations, with 24% of cases to do with scarring, and 12%, the next biggest cause, from infections.¹⁰ Over a 13-year period, £7 million was paid out to 264 patients. Reasons for claims included a failure to warn patients of the risk of complications.

Dangers for cosmetic surgery patients are also posed by “health care tourism”. It has been estimated that up to 30,000 UK citizens travel abroad annually for cosmetic surgery at reduced prices.¹¹ These patients are even less able to verify a surgeon's qualifications or obtain after-care, such as clinical supervision of wounds, bruising or scarring. The lack of after-care can potentially result in post-operative problems, such that they need to be remedied in NHS hospitals through reconstructive surgery. Indeed, it has been argued by NHS plastic surgeons that the scale of such reconstructive work being done is such that it might be cheaper for the NHS to offer cosmetic surgery in the first place.¹²

Regulation of the private cosmetic surgery sector has been part of a more general schema of reforms of the health care professions, namely the Care Standards Act 2000 and the Health and Social Care (Community Health and Standards) Act 2003. The cosmetic surgery sector is also affected by the National Health Service Act 2006, and the Health and Social Care Act 2008. These have in essence provided a system of registration and inspection of establishments and providers of cosmetic surgery in the private sector. Ultimately, however, the supervision of these regulations operates within a regime of self-regulation, and remains largely in the hands of private surgeons and clinics themselves.

This article offers a critique of the current scheme of regulation of cosmetic surgery in the UK in relation to the effect this has on the autonomy of women patients. Elsewhere I have analysed feminist debates on cosmetic surgery in more depth.¹³ Regulators have also been critical of the cosmetic surgery industry, but have focused on enhancing standards within a regime of self-regulation and advocated clinic inspection and the monitoring of professional qualifications. I argue here that this form of regulation does not sufficiently enhance women patients' autonomy.

Ethics and patient autonomy

Conventional ethical theories, such as utilitarianism, can offer useful insights into questions about the ethics of cosmetic surgery. The principle that patients should be autonomous is a central tenet of medical law and ethics. As Scott has argued, we might usefully see autonomy as a value to which certain interests may be related and from which certain rights are derived:

“Autonomy is a notable value in the medical treatment context; from it flow the interests in self-determination and bodily integrity, which in turn underpin the moral and legal right to consent to and refuse medical treatment.”¹⁴

Naturally, the autonomous cosmetic surgery patient shares this interest in self-determination and bodily integrity and thus, the moral and legal right to consent to and to refuse treatment.

Autonomy can be taken to refer to the ability of patients to make their own fully informed decisions about their treatment, necessitating information about choice of procedures, standards of treatment, risks and possible outcomes, and the ability of the health professional to carry the procedures out. A patient's physical integrity is respected in this way. Thus, the autonomous patient should be able to refuse or request a particular medical treatment and not be coerced into consenting to treatment by a private surgeon or clinic salesman who stands to profit from their treatment decisions.¹⁵

Feminist ethicists have concentrated particularly on the power relationship between patient and doctor and the effect of that on issues of autonomy and choice. The presence of this relationship in the medico-legal context has potentially serious consequences for the female patient. There might be varying views as to the amount of information a patient seeking cosmetic surgery would need, for example, on risks of surgery that are not clinical but cosmetic. Another possible risk is that the patient might fail to achieve her physical aspirations. Moreover, a patient may have psychological needs that are not investigated by the surgeon and which put her mental health at risk should such dissatisfaction arise or should the procedure result in the need for further corrective treatment. Ideally, counselling may be needed to fully explore the reasons for surgery and the expectations of the patient. Whether such thorough counselling is routinely available is open to question.

Feminists have generally been critical of cosmetic surgery practices. Some advocate change to a culture which encourages women to subject themselves to surgery in the name of beauty. Others seek to enable women to better negotiate that culture by placing a greater emphasis on constructive dialogue, counselling and fully informed consent. In the light of feminist critiques of cosmetic surgery, this kind of regulatory approach is limited. Rather, the provision of cosmetic surgery should ideally be informed by professional and institutional awareness of cultural and social pressures on women patients.¹³

Common law protection

Patients in England and Wales^* who choose to undergo cosmetic surgery are afforded some protection by judgments handed down from case law, also referred to as common law. Judgments made in relation to a particular branch of the law, tort law, thus protect patients from negligent or sub-standard treatment and enhance patient safety by requiring adequate disclosure of information and fully informed consent. Under English common law, physical contact is permissible only where the health care professional has the patient's consent. The requisite standard of care is provided by the Bolam¹⁶ and Bolitho¹⁷ tests, which means according to the standards adhered to by a responsible body of medical professionals, subject ultimately to the logical analysis and legal scrutiny of the court. With a private patient there is still a duty of care, as with NHS treatment. But this is a result of the contract between the patient and the cosmetic surgeon.¹³

Following the case of Sidaway¹⁸, the decision to consent to surgery can only be made if information is provided on the risks and benefits of treatment, and alternative methods of treatment. This was found to be as much as could be expected of a health professional, acting in accordance with a competent body of professional opinion, as per Bolam above. Although an enquiring patient should be given all the information they request, it was also decided that the test for disclosure was not subjective but objective – the doctor would decide this, not the patient.^*

In one recent case, Christine Williamson v. East London and the City Health Authority & Ors, ¹⁹ a patient was awarded damages for medical negligence after her surgeon performed a mastectomy rather than replacing her silicone breast implants. In another recent case, O'Keefe v. Harvey-Kemble, ²⁰ the Court of Appeal held that the surgeon had not informed the claimant of the risks associated with breast implants, most notably the very high risk of encapsulation which in fact ensued. Had she been so informed it was found to be more than probable that she would not have chosen to undergo the original operation. She would not then have had to undergo a further seven painful and distressing operations. The surgeon was also found not to have assessed the aspirations of the patient as to outcome or given proper written advice for her to study at a later date about risks. These cases highlight the importance of fully informed consent in the encounter between the cosmetic surgeon and his/her patient.

While it is significantly more likely that liability for negligent performance of cosmetic surgery would be pursued in tort law, the actions of all health professionals are also circumscribed by criminal law in England and Wales. Hence, any cosmetic surgeon who intentionally or recklessly causes injury will be liable to a criminal prosecution for assault or battery under the Offences Against the Person Act 1861, s.18 and s.20. Theoretically, a cosmetic surgeon could be prosecuted under this Act if consent to the surgery is invalid for any reason. Where a cosmetic surgeon is grossly negligent and the patient dies, then the surgeon may be tried for manslaughter.²¹ As cosmetic surgery is invariably carried out by private practitioners, contract law can also help to ensure fairness, responsibility, and value for money.^†

Statutory regulation

Despite the protection afforded to patients by the common law, it has been criticised as insufficient. The dangers for patients of cosmetic surgery in the UK and the need for specific and tighter regulation have both been highlighted in Parliamentary debates at Westminster. Part II of the Registered Homes Act 1984 Act, for example, covered the inspection of the facilities of independent acute hospitals by Local Health Authorities, but the Act was criticised by Members of Parliament (MPs) for not regulating clinical standards in cosmetic surgery, which were invariably low and inconsistent across the UK. Nor did it provide redress for patients.^22**

In June 1994, a ten-minute rule bill, the Regulation of Cosmetic Surgery Bill, was introduced by Ann Clwyd MP to establish registration procedures for cosmetic surgeons in order to set minimum standards of training and practice.²³ The Clwyd bill fell in 1994 and until the late 1990s the need for any regulation of the essentially private sector provision of cosmetic surgery was not accepted by government.

After 1997, the new Labour government began to respond to criticism. In relation to breast implants particularly, during these debates, the possible dangers of silicone leaking from the implant into the patient's body were raised by Ann Clwyd MP. The Medicine and Healthcare Products Regulatory Agency ensures the safety of medicines and reports to the UK government. As a result of Ann Clwyd's efforts to highlight the risks of silicone implants, the Chief Medical Officer and the Minister of Health asked the Agency in May 1999 to study the compounds in implants. Their report²⁴ led to the National Breast Implant Register, to enable the follow-up of patients and enhance their safety. This was closed in February 2006, as it was felt to be less useful than other forms of regulation, such as guidance for manufacturers and health professionals.²⁵ Despite this closure the publication of the Report and guidelines, and the establishment of the register, gave evidence of some concern by government for affected women.

A Select Committee on Health was also established in 1999 by the government to review the regulation of private health care provision, including cosmetic surgery. Their recommendations led to the passing of the Care Standards Act 2000, in which the Clywd Bill of 1994 was incorporated at Clause 2(7). Arguably the Act improved the situation for patients undergoing cosmetic surgery, as it stipulated that they should be interviewed pre-operatively by the consultant surgeon and provided with written and verbal information about results and risks. They were also to be offered counselling and a two-week “reflection” period before treatment.

However, the Act was not specific, nor stringent. It alluded briefly to cosmetic surgery at various points in a long-winded and wide-ranging general statute, which set out to regulate the whole gamut of private and voluntary health and social care in one place. Its most notable parts were those that introduced national minimum standards for clinics, which were to be enforced by the National Care Standards Commission (NCSC) in England.^* The NCSC was to inspect registered clinics annually, and impromptu where necessary to ensure they continued to meet the standards required by the legislation in order to protect patient safety. All practitioners had to be appropriately recruited, trained and qualified clinicians. From 1 April 2004, the inspections of the NCSC were done instead by its replacement, the new Healthcare Commission.^†

The regulation of cosmetic surgery currently comes under the aegis of the Health and Social Care Act 2008, which continues the system of inspection of registered premises, and also creates a system of registration for providers and managers of health care, with the threat of sanctions such as penalty notices for non-compliance and the power to suspend registration. Powers of entry and inspection of premises have also been handed over to the new Care Quality Commission under ss. 62 and 63 of the 2008 Act. The Act has also extended inspection and registration to those providing laser treatments for cosmetic purposes (for eye surgery, hair removal or liposuction) and any cosmetic surgery or medicine which uses general or local anaesthetic.

Thus, each subsequent statute since 2000 – the Care Standards Act 2000, the Health and Social Care (Community Health and Standards) Act 2003, the National Health Service Act 2006, and the Health and Social Care Act 2008 – has offered an opportunity to ensure that standards are high enough to optimise patient safety and, accordingly, their autonomy. However, any improvements legislation may have made to informed consent to cosmetic surgery, and the maintenance and improvement of standards by surgeons and clinic managers, have been laid on a foundation of professional self-regulation, which the government has entrusted to cosmetic surgeons themselves. Self-improvement has been the order of the day.

Shortcomings of self-regulation

Unfortunately, this self-regulation has not provided sufficient improvements for patients at risk from cosmetic surgeons. Under the Care Standards Act 2000, for example, existing unqualified practitioners were not forced to adhere to new published standards, only those registering to work in private practice after 1 April 2002. Nightingale and Kay reported in 2002 that care of patients was less than adequate, including a lack of written guidance on clinic procedure, misleading advertisements about the potential success of treatments, informal and undocumented complaints procedures, lack of information about practitioners' qualifications, too few staff with knowledge of life support procedures, and inadequate medical records and clinical governance.²⁶

Successive reports, some even government-authored, have also highlighted serious shortcomings.²⁷ In June 2003, for example, a report by the National Care Standards Commission catalogued the extent to which cosmetic surgery clinics it inspected in Central London were not adhering even to the minimum standards set by the Care Standards Act 2000, and echoed all of Nightingale and Kay's criticisms.²⁸ In addition, establishments were not monitoring quality of care and adverse events were not being recorded. Following publication, however, the Commission only recommended new self-assessment tools for specific procedures, to assist clinics to monitor their own performance: the private hospital or clinic where cosmetic treatments were carried out was to be responsible itself for ensuring that surgeons were suitably qualified according to Department of Health Independent Healthcare National Minimum Standards.

A further report by the Department of Health's Expert Group on the Regulation of Cosmetic Surgery in January 2005 was also critical of the inadequate registration of cosmetic surgeons and the fact that only NHS consultants in plastic or cosmetic surgery would have completed higher surgical training and be on the Specialist Register of surgeons of the General Medical Council.²⁹ This was a problem for patients attempting to select an appropriate surgeon for their treatment. There was no evidence in the registers of which surgeon was specialist in which surgical area, if the surgeon was registered at all. They recommended that all cosmetic surgeons should undergo suitable training in plastic surgery in the NHS for a period of at least 5–6 years. They should also keep patient records. Those surgeons exempt from being on the Specialist Register under the 2000 Act, who worked in the private sector prior to 1 April 2002, were also asked to ensure that their individual professional appraisal and validation process included a strong demonstrable component of peer review of their clinical procedures. They would also have to adhere to the requirements of the National Minimum Standards of the Care Standards Act 2000. Despite this criticism, however, it was only recommended that those covered by the 2000 Act who began providing services after 1 April 2002, whether surgeons or other health professionals, should have to provide details themselves to their patients of their qualifications, registration, membership of professional organisations, medical training and education.

The government has ignored numerous calls by MPs and other critics for one umbrella body governing the cosmetic surgery profession.^30–32 Furthermore, there is evidence of a relationship between the UK government and cosmetic surgeons' organisations that is arguably too close and lacking in the independence that proper regulation requires. Organisations set up since 2000 by cosmetic surgeons themselves, for example, have been endorsed by the Department of Health and are now overseeing the reforms of the industry. The Cosmetic Surgery Inter-specialty Committee, for example, was formed by the Senate of Surgery of Great Britain and Ireland in 2001. A sub-group of this organisation was then formed as the Independent Healthcare Advisory Service, to look at the funding of cosmetic surgery training, as this was seen as a key area for the improvement of patient safety. Both organisations also published their own Good Medical Practice in Cosmetic Surgery Procedures in May 2006. These mirrored the General Medical Council's Good Medical Practice guidelines to doctors of May 2001. The Chief Medical Officer, Sir Liam Donaldson, responded by entrusting the task of developing training and accreditation for cosmetic surgeons practising in the UK to the Cosmetic Surgery Inter-specialty Committee itself.

This is all the more surprising when seen against the backdrop of extensive government criticism of self-regulation by the medical profession more generally in recent years. Various government reports into the conduct and practice of medical professionals and the General Medical Council were published between 2001 and 2005.³³³⁴ The government then set out to regulate practice and curb what had come to be seen as the ineffectiveness of professional organisations to prevent poor professional practice. From 1 January 2005, for example, medical practitioners have been required to possess a “licence to practice”, which they will receive on first registration.³⁵ In addition, doctors will be required to be revalidated every five years with the aim of ensuring that they are fit to practice and that they possess relevant current information regarding their speciality.

Recommendations

An independent umbrella organisation, as called for by Ann Clwyd MP and others, which registers all cosmetic surgeons and practitioners practising in the UK, is urgently needed. This would go a long way to protecting patients, who currently have nowhere to apply for information. However, there is no such body. On the other hand, as many as four separate organisations represent the interests of cosmetic surgeons in the UK. The British Association of Plastic, Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons are recognised by the Surgical Royal Colleges; members of each undergo six years training in plastic and cosmetic surgery and are eligible to take up Consultant Appointments in Plastic Surgery in the NHS. The British Association of Cosmetic Surgeons was formed in 1980; it has around 30 members, and does not provide comprehensive training, though it only accepts as members those who have experience of cosmetic surgery. A fourth organisation, the British Academy of Cosmetic Practice, was established by the Cosmetic Surgery Inter-specialty Committee in 2008. This organisation has also been set up by cosmetic surgeons themselves, and is currently setting out to be solely responsible for listing and appraising competent and qualified cosmetic surgeons, non-surgical practitioners, dentists and registered adult nurses by name and specialty. Their hope is that the General Medical Council will recognise these lists. Membership is entirely voluntary, however, and it is therefore difficult to say how many surgeons practising cosmetic surgery have actually joined. Despite this, they claim to be overarching, independent and academic.³⁶

Recent government reports on health care have emphasised the importance of increased patient choice, and a stronger patient voice.³⁷³⁸ The Health and Social Care Act 2008, for example, sought to amend the remit of the various regulatory bodies, in order ostensibly to provide protection for patients. Overall, however, continuing government endorsement of self-regulation falls far short of the demands and expectations of critics of cosmetic surgery provision in the UK. Even cosmetic surgeons themselves remain critical of UK regulation. In a recent special issue of Clinical Risk, Nigel Mercer, consultant plastic surgeon and President of the British Association of Aesthetic Plastic Surgeons, expressed his concerns:

“In no other area of medicine is there such an unregulated mess. What is worse is that national governments would not allow it to happen in other areas of medicine. Imagine a ‘2-for-1’ advert for general surgery? That way lies madness!”³⁹

I would suggest that it is not just madness that might lie ahead, but more concretely a lack of protection for patients at risk from cosmetic surgeons and other practitioners, and consequently a real lack of autonomy for patients ostensibly protected by the law.

Conclusion

Certainly, the government has attempted to bolster the autonomy of cosmetic surgery patients, particularly in the Care Standards Act 2000, by regulating cosmetic surgeons' qualifications; patient rights to information; and the inspection and registration of premises. In the main, however, I would argue that the risk to cosmetic surgery patients from unregistered or poorly qualified surgeons, and from private establishments with low clinical standards, has still not been adequately addressed, and that this represents an obstacle to the realisation of safety and autonomy for patients. Moreover, ensuring informed consent and the maintenance of standards has been left to professional self-regulation. Organisations set up by cosmetic surgeons themselves since 2000 have been endorsed by the Department of Health and are now overseeing the reforms of the industry. It is true that self-regulation has been tightened up in recent years. However, a truly independent and government-funded umbrella organisation with lay representation and sufficient powers of registration and inspection of all relevant cosmetic surgery practitioners is needed to protect patients in this country. This organisation should have its roots in specific legislation governing cosmetic surgery. With the rapid increase in cosmetic surgery patient numbers, a genuine and growing need exists for the health and autonomy of cosmetic patients to be far better protected in this way.

Notes

* The data are collected for the whole of the UK, though regulation of health care differs for England and Wales from that of Scotland and Northern Ireland.

† Independent data on such complications are not available.

* Statutes regulate health care practice in the whole of the UK. However, statutes will outline the separate regulatory schemes governing their implementation in Wales, Scotland and Northern Ireland, often through secondary legislation. England and Wales share a common law system, but this is separate from those of Scotland and Northern Ireland.

* This judicial support for doctors was followed in Gold v. Haringey Health Authority [1987] 2 All England Law Reports p.888 and Blyth v. Bloomsbury Health Authority [1993] Medical Law Review p.151, whether the treatment was therapeutic or non-therapeutic (as with contraceptive treatment in Gold, and thus with cosmetic surgery) or whether or not the patients asked particular questions.

† These are central tenets in all the most relevant UK statutes and EU regulations, namely Supply of Goods and Services Act 1982; Sale and Supply of Goods Act 1994 s.1; Consumer Protection Act 1987; Directive 03/12/EC; Medical Devices (Amendment) Regulation 2003; Unfair Contract Terms Act 1977 s.2; Unfair Terms in Consumer Contracts Regulations 1999.

** The Registered Homes Act 1984 was repealed and replaced by the Care Standards Act 2000.

* And in Wales by the National Assembly for Wales.

† The Healthcare Commission has different functions in Wales to those in England. The Healthcare Inspectorate Wales, based within the Welsh Assembly, is responsible for local inspection and investigation of Welsh NHS bodies. The private health care sector in Wales is regulated by the Care Standards Inspectorate for Wales.