In brief

• Following serious concerns raised about the regulation of the cosmetic surgery industry in Australia, the Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (Medical Board) announced the establishment of the Independent Review of the Regulation of Health Practitioners and Patient Safety Issues in Cosmetic Surgery (Independent Review) in November 2021. We wrote about the Independent Review in May 2022 – our article can be found here.

• In August 2022, AHPRA and the Medical Board reported the findings of the Independent Review which included the recommendation for cosmetic surgery to be endorsed as a speciality area of practice.

• Following a short consultation process, the Medical Board announced that the new accreditation standards for cosmetic surgery endorsement would take effect from 19 April 2023.

• Under the new accreditation standards, medical practitioners need to complete a program of study that has been approved by the Australian Medical Council (Medical Council) before they can apply to the Medical Board to have an endorsement for cosmetic surgery on their registration. If endorsed, the endorsement is published on the publicly available AHPRA register of health practitioners. The endorsement will not permit the relevant medical practitioner to use the title of ‘surgeon’, although the endorsement is for ‘cosmetic surgery’.

• The endorsement of cosmetic surgery has been heavily criticised by the Royal Australasian College of Surgeons (RACS) and other surgical speciality societies – those organisations believing that the standards “do more harm than good” because the benchmark in skills and capabilities required to perform cosmetic surgery will be lower than that required for other forms of surgery.

Results of the Independent Review

Prior to the introduction of the accreditation standards, medical practitioners who were not qualified as surgeons could perform cosmetic surgeries without necessarily having the skills and experience to undertake the procedure.

The Independent Review found that under the pre-April 2023 regulatory scheme:

• universal minimum standards for education, training and qualifications in cosmetic surgery were non-existent;
• it was the responsibility of each medical practitioner to ensure that they only practised cosmetic procedures and surgeries which were within their scope and level of skill, knowledge and competence; and
• an unacceptable level of pressure was placed on consumers to determine which practitioners were qualified and competent to undertake the relevant cosmetic procedure or surgery.

In response to these findings, the Independent Review made 16 recommendations to AHPRA and the Medical Board. These included a proposal to introduce an endorsement requirement for cosmetic surgery, requiring medical practitioners to complete an accredited cosmetic surgery program before they can claim to have an approved qualification to practice cosmetic surgery.

The accreditation standards

The accreditation scheme proposes to set a clear minimum standard of training for practitioners. It is intended to enhance the protection of consumers by making it easier to identify whether a practitioner is qualified to perform cosmetic surgery, as the endorsement will be listed on AHPRA’s public register of medical practitioners. For a program of study to receive accreditation from the Medical Council, the program needs to show that quality of care is delivered safely, ethically and in the best interests of patients.

The Medical Board only recognises one other endorsement of medical practitioners, being for acupuncture procedures. Cosmetic surgery is not considered a surgical specialty because the surgeries do not address a ‘burden of disease’; rather, the procedures are typically undertaken for aesthetic reasons. This is in contrast with plastic and reconstructive surgery, which is a recognised speciality requiring additional training and experience to become a Fellow of the Royal Australasian College of Surgeons (FRACS), whose members can undertake cosmetic surgery as well as medically necessary surgery.

Criticisms of the accreditation scheme

The draft accreditation standards were subject to a four week consultation phase. The Medical Council reported that they received 249 submissions from organisations, practitioners and consumers, and 595 responses to a consumer survey.

Differing opinions on the amount of training and experience required to competently and safely perform cosmetic procedures led to substantial debate around the accreditation standards. The key concern is the ability of medical practitioners to obtain an endorsement to perform cosmetic surgery without undertaking any formal training to make them a qualified surgeon.

In an open letter to the Medical Council, the RACS (together with other surgical specialty societies) expressed significant concern for the proposed endorsement approach and accreditation standards.^[1] The letter argued that:

• the accreditation scheme creates a set of standards that are lower and less rigorous than those that surgical specialities require, creating a significant risk to patient safety;

• the recognition of prior learning creates a risk that an accredited provider could grant qualifications easily, “which could result in the practical outsourcing of the power to ‘grandparent’ endorsement with the potential for conflicts of interest”; and

• the accreditation scheme creates confusion amongst the public about whether all medical practitioners who offer cosmetic procedures are also qualified as specialist surgeons (irrespective of the restriction of the title ‘surgeon’ to those practitioners who are registered in the surgical specialities).

While the RACS recommended that the Medical Board and AHPRA consider alternative models to the single endorsement model, they also made other recommendations to the single model including the requirement to make applications for accreditation of a program of study open to public consultation and tighter standards for the recognition of prior learning – specifically, a requirement for a detailed assessment of prior training as well as recency of practice against a range of technical and non-technical competencies. It does not seem that any of the RACS recommendations were adopted in the final standards, with the exception of an explanation for the difference in standards from other speciality standards.

Conversely, the Australasian College of Cosmetic Surgery and Medicine (which, in addition to other medical post-graduate training, requires three years of accredited surgical training and a further two years of advanced training in cosmetic surgery before awarding a surgical fellowship) is in favour of the endorsement model, arguing that plastic and reconstructive medical specialities do not accurately train practitioners for cosmetic surgery.

What's next?

The Medical Council is shortly expected to release procedures for the assessment and accreditation of education programs that lead to an endorsement of cosmetic surgery. Once released, education providers can seek accreditation.

AHPRA and the Medical Board have also announced the implementation of other recommendations made in the Independent Review to take effect on 1 July 2023, including:

• tougher new rules on advertising which require promotional communications to include information on a medical practitioner’s registration type and number and the risk of and expected recovery time from the procedure. Advertisements must also not include testimonials, offers of inappropriate incentives or inducements, negative body language or misleading images that may give the impression that the image represents the outcome of the surgery;

• new patient suitability assessments which require a person seeking cosmetic surgery to obtain a referral from a medical practitioner (e.g. their GP), and undergo an assessment of underlying psychological conditions such as body dysmorphic disorder; and

• new patient consultation requirements, including guidelines as to when consent can be obtained and the timing of surgery (e.g. use of cooling off periods between consultations, consent and booking the surgery).

It remains to be seen what effect the endorsement regime, together with the other new guidelines, will have on this controversial industry. In any event, further work may be required to improve the regulation of unregistered health practitioners performing other cosmetic treatments that traditionally fall outside the scope of ‘cosmetic surgery’, including laser skin treatments, dermabrasion and cryolipolysis (e.g. fat freezing).