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Providing cosmetic procedures

GPs should be alert to the legal implications of offering an increasing range of cosmetic and aesthetic procedures to patients, says Dr Nicholas Norwell of the MDU

GPs should be alert to the legal implications of offering an increasing range of cosmetic and aesthetic procedures to patients, says Dr Nicholas Norwell of the MDU

GPs have long provided minor surgical services to patients, such as removing skin lesions. But some GPs are now offering the sort of cosmetic and aesthetic procedures that used to be the sole preserve of cosmetic surgeons. These include administering botulinum toxin and collagen fillers, thread vein treatment and tattoo removal.

Before offering these services, it is essential to be aware of the legal and ethical implications. Below we outline some common questions asked by MDU GP members about cosmetic procedures.

Can I provide cosmetic procedures to my patients?

GPs are free to offer cosmetic procedures to patients but may not accept a fee for carrying them out – except, of course, from private patients. The drugs concerned should be prescribed on a private prescription. To ensure you are properly indemnified, you should inform your medical defence organisation before providing such services.

You are expected to have had the appropriate training and experience in line with the GMC's guidance, which stresses that doctors must recognise and work within the limits of their competence and keep their knowledge and skills up to date (Good Medical Practice, paragraphs 3(a) and 12).

Some of the procedures can only be prescribed for cosmetic usage outside the product's licensed indications. GPs may prescribe so called 'off-licence' or 'off-label' but they must take responsibility for the prescription.The GMC gives specific guidance on off-label prescribing in paragraphs 20 and 21 of its guidance Good Practice in Prescribing Medicines (2006). It states that doctors should be satisfied that there is sufficient evidence for using the medicine and that an alternative medication would not better meet the patient's needs.

Doctors need to explain the reason for using the drug and must give sufficient information to allow patients to make an informed decision about the procedure including any known serious side-effects or adverse reactions. GPs also need to make a note of the reasons for their decision and the discussion with the patient, and to arrange appropriate monitoring and follow-up.

If I prescribe a drug such as botulinum toxin for a cosmetic procedure for a patient, can I delegate its administration to a nurse?

Yes, provided the nurse is competent to undertake the procedure. The GMC says doctors who delegate care or treatment are still responsible for the overall management of the patient and accountable for their decision. The GMC adds: 'When you del-egate care or treatment you must be satisfied that the person to whom you delegate has the qualifications, experience, knowledge and skills to provide the care or treatment involved.' (Good Medical Practice, paragraph 54.)

Do I need to register with the Healthcare Commission?

The Healthcare Commission currently does not regulate 'non-surgical' procedures such as the administration of botulinum toxin and cosmetic dermal fillers. A self-regulatory scheme is being set up by the Independent Healthcare Advisory Services (

However, the Healthcare Commission does regulate cosmetic surgery in the independent sector and providers need to be registered. You can check with the Healthcare Commission if you are in doubt. More information is available on the Healthcare Commission's website (

What are your tips on ensuring patient safety and minimising the risk of complaints and claims arising from cosmetic procedures?

•Work within the limits of your professional competence.
•Ensure you are appropriately trained, qualified and experienced to undertake the procedure.
•Seek informed consent from the patient and document this in the records.
•Make sure patients understand what alternatives are available (including doing nothing), what the procedure involves and whether there are any risks involved – for example, the possibility of scarring.
•Record these discussions in the notes.
•Provide patients with information about follow up arrangements and postoperative care, and who to contact if any complications arise. •Follow the recommended guidelines for procedures, and if you are using equipment, ensure it is regularly serviced and maintained according to the manufacturer's guidelines.
•Always personally check drugs you are going to administer.
•Check and record drug, dosage, route of administration, expiry date and batch number.
•If things go wrong, give patients a full explanation and where appropriate offer an apology.

What is the position regarding indemnity?

At the MDU we ask all members to inform us about the type of procedures they are planning to carry out to ensure they are paying the correct subscription. Some non-surgical cosmetic procedures may be included in the MDU's GP subscription, but you should check with your medical defence organisation about what the position is.

Are there any sources of information for my patients considering undergoing cosmetic procedures?

In addition to the Healthcare Commission's website, it may be useful to draw patient's attention to the Department of Health online advice before undergoing any cosmetic or aesthetic treatment (

Dr Nicholas Norwell is a medicolegal adviser with the MDU

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