Complications from medical cosmetic tourism result in costs to the NHS

My Post (15)While many patients venture outside of the UK for cosmetic surgery, due to the significant cost of private care in the UK, there is also a lucrative business for non-invasive aesthetic treatments abroad. In the UK, botulinum toxin injections or dermal fillers cost about £150–£350 per session, depending on the amount of product used (NHS Choices, 2016a). Chemical peels cost about £60–£100 for mild peels, with deeper treatments often costing over £500 (NHS Choices, 2016a). The cost of cosmetic micropigmentation varies from £75 for a beauty spot to £500 for lip liner (NHS Choices, 2016a). Microdermabrasion costs £40–80 for a single session (NHS Choices, 2016a).

By contrast, costs for treatments abroad can be substantially cheaper. For example, prices for botulinum toxin can be as low as £40 in Thailand, £50 in the United Arab Emirates and £60 in the Czech Republic (MEDIGO, 2017a). Chemical peels start from £22 in Thailand, £44 in Turkey and £45 in Malaysia (MEDIGO, 2017b).

Complications of non-surgical cosmetic treatment

Complications arising from non-invasive cosmetic treatments are less common and often less severe than those from surgical procedures. However, there is still a notable element of risk involved.

The most common complications from botulinum toxin and soft-tissue filler injections are bruising, erythema and pain (Levy and Emer, 2012). Erythema is also not uncommon following chemical peels, as well as irritation and burning (Levy and Emer, 2012). These side effects are generally temporary and easy to treat. More serious complications include muscle paralysis from botulinum toxin, granuloma formation from soft-tissue filler placement, and scarring from chemical peels (Levy and Emer, 2017).

Issues regarding regulation

In 2013, Sir Bruce Keogh was asked to undertake a review into the regulation of cosmetic interventions in the UK. It revealed that non-surgical interventions were almost entirely unregulated, with no restrictions on who may perform procedures (Department of Health (DH), 2013). This poses a significant risk to patients, as without accredited training, practitioners are unlikely to recognise complications of the procedures, or be able to treat them. The review committee therefore recommended approved training schemes were introduced, as well as accredited qualifications, and associated registers for both surgical and non-surgical cosmetic procedures.

The DH (2014) provided a response to this review, largely accepting many of the recommendations, but did not believe a new regulated profession for those performing cosmetic procedures should be introduced, as many practitioners were already members of professional registers and so subject to regulation. In 2015, Health Education England (HEE) unveiled new qualifications to improve the safety of non-surgical cosmetic procedures (HEE, 2015), but again did not go as far as to establish legal requirements for the administration of non-surgical cosmetic interventions.

Issues concerning regulation for non-surgical cosmetic interventions also exist in other countries. Due to differences in standards and qualifications, it can be difficult to establish the suitability of a practitioner to carry out an intervention. In Europe, dermal fillers are regarded as medical devices requiring only Conformité Européenne certification (Hachach- Haram et al, 2013). It is only in the US that dermal fillers are seen as medicines and are therefore required to be approved by the US Food and Drug Administration (Hachach- Haram et al, 2013).

Whose responsibility is follow-up care?

Follow-up care is an important part of treatment, particularly in the case of cosmetic surgery. The NHS advises that when making enquiries about treatment abroad, it is important to know how complications would be handled, what would happen if revision surgery was needed after the original procedure, and how much it might cost (NHS Choices, 2016b). Unfortunately, all too often the expectation in the UK is that if something goes wrong, the NHS will sort it.

It is believed the cost to the NHS of fixing botched botulinum toxin injections could be as much as £1 million a year (Savage, 2016). However, because of a lack of data, it is difficult to accurately gauge the cost to the NHS of fixing cosmetic complications, or to establish the numbers of complications attributable to UK private care, treatment abroad or self-administration.

It has been questioned whether cases should be considered individually, whether guidelines and standards of treatment need to be outlined, or whether treatment by the NHS should be strictly limited to acute cases only (Hachach-Haram et al, 2013).

Additionally, there is limited knowledge of public attitudes towards the regulation and safety of treatment. People considering this type of treatment need to be aware of the risks and thoroughly research the practitioners who will be carrying out their treatment. Many websites offer holiday packages of treatment, travel and accommodation, but can be misleading in what it is they are providing.

It is clear that tighter rules regarding regulation are needed globally, along with clear outlines of practitioners’ aftercare responsibilities and improved education around the possible risks for prospective patients. Without this regulation, it is evident the NHS will continue to pick up the bill when things go wrong.

References

Department of Health. Review of the regulation of cosmetic interventions: final report. 2013. https://tinyurl.com/b8qq6ek (accessed 11 January 2018)

Department of Health. Government response to the review of the regulation of cosmetic interventions. 2014. https://tinyurl.com/nnjvlym (accessed 11 January 2018)

Hachach-Haram N, Gregori M, Kirkpatrick N, Young R, Collier J. Complications of facial fillers: resource implications for NHS hospitals. BMJ Case Rep. 2013; pii: bcr-2012-007141. https://doi.org/10.1136/bcr-2012-007141

Health Education England. Qualification requirements for delivery of cosmetic procedures: non-surgical cosmetic interventions and hair restoration surgery. 2015. https://tinyurl.com/z43cs8s (accessed 11 January 2018)

Levy LL, Emer JJ. Complications of minimally invasive cosmetic procedures: prevention and management. J Cutan Aesthet Surg. 2012;5(2):121– 132. https://doi.org/10.4103/0974-2077.99451

MEDIGO. Botox injections and wrinkle treatment at clinics and hospitals worldwide. 2017a. https://tinyurl.com/yd3xzu34 (accessed 11 January 2018)

MEDIGO. Chemical peel at clinics and hospitals worldwide. 2017b. https://tinyurl.com/ycwe3y72 (accessed 11 January 2018)

NHS Choices. Your guide to cosmetic procedures. 2016a. https://tinyurl.com/yae8sdyt (accessed 11 January 2018)

NHS Choices. Your guide to cosmetic procedures: Cosmetic surgery abroad. London: NHS Choices; 2016b. https://tinyurl.com/ydckt79p (accessed 18 January 2018)

Savage M. Up to £1m a year spent fixing bad Botox. 2016. https://tinyurl.com/y7dfn9jh (accessed 11 January 2018)

Taken from Journal of Aesthetic Nursing, published February 2018.

Advertisements

Whole system change needed in gender identity services

My Post (5)Gender identity services in the NHS are failing to meet the needs of patients. Huge delays in treatment are forcing many to go private or abroad, while a lack of funding and suitably trained staff means patients are not receiving adequate care.

Gender dysphoria is a condition whereby a person experiences discomfort or distress because there is a mismatch between their biological sex and their gender identity (NHS Choices, 2016). Figures estimate there are 650 000 people in the UK living with gender dysphoria, which is equal to 1% of the population (Women and Equalities Committee, 2016). This is expected to rise as society’s increasing tolerance and acceptance of transgenderism has encouraged more people to come forward and seek medical help.

In the UK, transgender people’s health needs regarding gender dysphoria are being met at specialised NHS gender identity clinics or through private care. At present, all GPs in England, Northern Ireland and Scotland may refer their patients directly to a gender identity clinic, and do not need to refer them to a mental health service for assessment beforehand. In Wales, however, GPs have to refer first to a local psychiatrist, who assesses the patient and can recommend they are referred for assessment and treatment at a gender identity clinic (General Medical Council (GMC), 2017).

Unacceptable waiting times

Waiting times for people with gender dysphoria before their first appointment at an NHS gender identity clinic are unacceptable, as are the times for subsequent gender reassignment surgery, should it be wanted. This, in turn, has a massive impact on the health and wellbeing of trans patients. According to the GMC, the risk of self-harm and suicide for trans people is much greater than in the general population, and any delays in accessing medical care can substantially increase these risks (GMC, 2017).

Under the NHS Constitution, patients are legally entitled to have their first appointment at a specialist service within 18 weeks of referral (Department of Health, 2015). However, due to increased demand, some transgender patients have found themselves waiting up to 4 years for an appointment (Lyons, 2016). Remarkably, it was only in January 2015 that the NHS accepted that the 18-week principle applies to gender identity services too (Women and Equalities Committee, 2016).

It is because of these long waiting times that many trans people are turning to private care—but this does not come cheap. Initial appointments can cost between £220 and £280, and tend to cover assessment, diagnosis and recommendations. It is generally after two appointments that hormone therapy is started.

The cost of gender reassignment surgery varies considerably and prices range from £10 000 to £20 000. In desperation, many are turning to far-flung destinations, such as Thailand, to have this surgery.

Things need to change

In an attempt to meet the increased demand on gender identity services, NHS England invested an additional £6.5 million in this area this year. It is hoped this will go some way to reducing waiting times. However, despite increased funding, there is no detracting from the stark truth that the NHS is letting transgender people down. Notably, according to a Government report on transgender equality, the NHS is ‘failing in its legal duty under the Equality Act’ (Women and Equalities Committee, 2016).

A lack of knowledge and understanding among many clinicians and staff within the NHS has meant transgender people all too often encounter significant problems, whether through prejudice or the provision of inappropriate care. Additionally, other commonly cited concerns include too much variation in clinical protocols, confusion about what is available in the NHS, and inequitable access arrangements (Women and Equalities Committee, 2016).

Following this report, NHS England asked its Clinical Reference Group for Gender Identity to make recommendations on new service specifications for these specialist clinics. This led to a 12-week public consultation on proposals for new service specifications that, if adopted, will describe how specialised gender identity services for adults will be commissioned and delivered in the future within England. The final decisions will be made at the end of autumn 2017.

Relationship between public and private services

Among the changes set out in the consultation include a proposal that only designated specialist gender identity clinics will be able to refer individuals for reassignment surgery in the NHS. This would mean other NHS professionals or private clinics would not be able to make the referrals. The decision was made because it is felt the multidisciplinary teams of gender identity clinics are best placed to consider an individual’s suitability for surgery in the context of the relevant medical, psychological, emotional and social issues (NHS England, 2017). They are also able to accurately gauge the likely range of risks in each case.

Unfortunately this means patients would be unable to begin down the private pathway of care for an initial assessment and diagnosis, before moving to the NHS for gender reassignment surgery. Though this would go some way to diverting pressures on NHS services, it could be argued that boundaries of care between private and public could be blurred, making it difficulty to ensure safety and quality of care. Equally, referrals to an NHS gender clinic would have to come through an NHS pathway.

A gender identity specialism is needed

The lack of suitably trained staff to take on specialist roles being created in nursing, medicine, psychology and other professions is one of the key reasons for unprecedented demand on gender identity services. There are under a dozen people in the UK working both privately and in the NHS who can carry out vaginoplasty or phalloplasty operations (Parkins, 2016).

With the above in mind, there have been discussions with Health Education England, the GMC and the Royal College of Physicians about the development of a gender identity specialism, supported by appropriate curricula and recognition. It is evident that this is sorely needed; however, even at a grassroots level, training for GPs is insufficient, consisting of two online educational modules on gender variance on the Royal College of General Practitioners’ website. Without a proper understanding of this patient population, health services cannot begin to address their needs.

Conclusion

While momentum for change is gathering and the Government is beginning to listen, anything short of a whole system change in gender identity services would be insufficient. Waiting times are the most pressing concern that need to be addressed, with demand and capacity out of balance. Quality indicators are needed to assess quality and benchmark providers; a better interface with primary care services is essential; and increased understanding and knowledge across all health services is paramount. Transgender people have just as much right to care as anyone else, and health services and professionals cannot let them down.

References

Department of Health. NHS Constitution for England. 2015. http://tinyurl.com/d7sa3wq (accessed 23 October 2017)

General Medical Council. Good medical practice. Trans healthcare. Treatment pathways. 2017. http://tinyurl.com/grugw8z (accessed 19 October 2017)

Lyons K. Gender identity clinic services under strain as referral rates soar. 2016. http://tinyurl.com/hcb9uzz (accessed 19 October 2017)

NHS Choices. Gender dysphoria. 2016. http://tinyurl.com/ybt7rbj7 (accessed 19 October 2017)

NHS England. Guide to consultation: specialised gender identity services for adults. 2017. http://tinyurl.com/ydg3pfmh (accessed 19 October 2017)

Parkins K. Meet the gender reassignment surgeons: ‘Demand is going through the roof’. 2016. http://tinyurl.com/hdblcpg (accessed 19 October 2017)

Women and Equalities Committee. Transgender equality: first report of session 2015–16. 2016. http://tinyurl.com/y8sftc2h (accessed 19 October 2017)

Taken from Journal of Aesthetic Nursing, published November 2017.