On 2 September 2022, Australian federal, state and territory health ministers met to discuss their concerns regarding cosmetic surgery and potential risks to patients.1 This meeting followed an independent review of cosmetic surgery practices in Australia,2 as well as considerable media coverage of allegations of concerning practices within the cosmetic surgery industry, including programs such as Four Corners’ 'Cosmetic Cowboys' episode.3
This article was originally published in the Lexis Nexis Health Law Bulletin Volume 32 No 2.
On 2 September 2022, Australian federal, state and territory health ministers met to discuss their concerns regarding cosmetic surgery and potential risks to patients.1 This meeting followed an independent review of cosmetic surgery practices in Australia,2 as well as considerable media coverage of allegations of concerning practices within the cosmetic surgery industry, including programs such as Four Corners’ 'Cosmetic Cowboys' episode.3
During the meeting it was agreed that urgent action was required for the protection of the public. As a result, legislative amendment was proposed to protect the title of 'surgeon' in Australia, and the Australian Commission on Safety and Quality in the Health Care (the Commission) and the Medical Board of Australia (MBA) were tasked with implementing urgent changes to guidelines and standards across the industry.4
An examination of the reforms directed at health practitioners who perform cosmetic surgery including the protection of the title 'surgeon' and the changes to the MBA guidelines, is set out in a previous article of the Australian Health Law Bulletin.5 The latest chapter of reforms occurred in December 2023 when the Commission published the National Safety and Quality Cosmetic Surgery Standards6 (Cosmetic Surgery Standards) shifting focus from individual practitioners to healthcare facilities, or Services,7 where cosmetic surgery is performed (discussed further below).
This article reviews these latest reforms and considers the implications for healthcare facilities as well as the patient populations that they service.
The cosmetic surgery industry and previous reforms
Cosmetic surgery is a growing industry in Australia with thousands of procedures performed each year. It has been reported that Australians spend more than $1 billion on cosmetic procedures annually, with suggestions that cosmetic surgery is more popular per capita in Australia than in the US.8 Cosmetic surgery differs from all other surgical procedures because it is performed for the sole purpose of changing physical appearance rather than for medical purposes.
Concerns have been raised that a disproportionate number of consumers seeking cosmetic surgery have mental health conditions including body dysmorphia, anxiety or depression, making them significantly more vulnerable than the general population.9
The Cosmetic Surgery Standards follow and complement other recent reforms including:
- the Legislative amendment to the Health Practitioner Regulation National Law 2009 (Qld) (National Law) to protect the title of 'surgeon' and limit its use to practitioners who have undergone the requisite training,10
- stronger guidelines by the MBA for medical practitioners performing or advertising cosmetic surgery,11
- introduction by the MBA of a cosmetic surgery area of practice endorsement with a view to clarifying expected training to be undertaken by doctors performing cosmetic surgery, and
- the Commission’s National Licensing Framework for Cosmetic Surgery which was developed to guide nationally consistent licencing of private health facilities across the state and territories.12
The MBA guidelines introduced in July 2023 imposed a number of obligations on individual health practitioners who perform cosmetic surgery procedures, and the recent Cosmetic Surgery Standards are designed to support them by regulating the facilities in which the procedures are performed. The MBA guidelines require practitioners to perform cosmetic surgery in a facility accredited to the Commission’s Standards13 which from December 2023 will now include the Cosmetic Surgery Standards. In return, the Cosmetic Surgery Standards impose obligations on the facilities to assure themselves that medical practitioners conducting cosmetic surgery in the facility address critical safety and quality risks to patients.
Application of the Cosmetic Surgery Standards
According to the Cosmetic Surgery Standards, 'cosmetic surgery':14
- employs invasive surgical procedures that involve cutting beneath the skin for the purpose of achieving what a person perceives to be a more desirable appearance,
- is not used to prevent, diagnose or treat medical diseases or conditions,
- may include procedures such as breast augmentation, abdominoplasty, rhinoplasty, blepharoplasty (eyelid surgery), surgical facelifts, cosmetic genital surgery, liposuction and fat transfer, and
- in this context, does not include non-surgical cosmetic procedures such as injectables.
The Cosmetic Surgery Standards apply to every Service in Australia performing cosmetic surgery procedures. The term 'Service' is broadly defined as the physical setting where cosmetic surgery is performed.15 Services may vary in size and complexity from a single practitioner day clinic to a large and complex organisation compromising multiple clinicians, management and overarching governing body.
The majority of hospitals and day procedure hospitals across Australia are already required to be accredited to the National Safety and Quality Health Service Standards16 (NSQHS standards) which were first introduced by the Commission in 2011. The Cosmetic Surgery Standards are aligned in structure and intent to the NSQHS standards and are intended to apply alongside the NSQHS standards to provide additional assessment requirements during the one accreditation assessment process.17 For these facilities, it seems the additional compliance burden is likely to be minimal.
For smaller Services, such as single practitioner clinics, where accreditation to NSQHS standards has not previously been required, the burden will be more substantial. Independent assessment and accreditation will now be required, where no such obligation existed previously.
The Commission states that it is working with state and territory Governments to incorporate the Cosmetic Surgery Standards into the jurisdictional licensing schemes.18
The Cosmetic Surgery Standards
Like the NSQHS standards, the Cosmetic Surgery Standards19 comprise 7 individual standards, although these can be considered within 2 groups.
Firstly, the Clinical Governance Standard and the Partnering with Consumers Standard (Standards 1 and 2) set the overarching framework for the implementation of the other standards.
Secondly, the remaining standards (Standards 3 to 7) deal with the following specific areas of risk as they relate to cosmetic surgical procedures:
- Preventing and controlling infections,
- Medication safety,
- Comprehensive care,
- Communicating for safety, and
- Recognising and responding to acute deterioration.
This structure mirrors the structure of the NSQHS standards, and much of the content is duplicated.
Independent assessment of a Service against the Cosmetic Surgery Standards and the issuing of accreditation against these standards is intended to provide confidence to the community that the Service has safety and quality systems and processes in place. Each standard includes actions which describe what is required to meet the standard.
Clinical Governance and Partnering with Consumer Standards
The Clinical Governance Standard requires Services to have a robust governance framework in place to promote continuous improvement in safety and quality of the clinical care. This includes appropriate policies and procedures, open disclosure and complaints management processes, as well as defined roles and responsibilities within the organisation. Matters like training, credentialing and scope of clinical practice and document management are also addressed.20
Whilst these requirements can be readily applied to larger facilities and hospitals, the implementation would look different in a single practitioner clinic. There is some recognition in the Cosmetic Surgery Standards of this fact,21 although what this means in practice for accreditation remains to be seen.
The Partnering with Consumers Standard addresses requirements for informed consent processes, including information about any medical devices planned for use, as well as communication and advertising.22
Specific Standards 3 to 7
Standards 3 to 7 address specific areas of risk which are relevant to cosmetic surgery procedures. Services must have in place evidence-based processes for infection prevention and control,23 as well as robust medication management processes.24
The Comprehensive Care Standard25 includes screening and assessment obligations, requiring Services to assure themselves that practitioners performing cosmetic surgery assess a patient’s suitability, including with reference to independent psychological assessments. Services must also have processes to ensure patients are provided with post-operative monitoring and follow up health care as necessary.
The Communicating for Safety Standard imposes obligations on Services in respect of clinical handovers and documentation, as well as patient and procedure identification processes.26
Finally, Standard 7 requires Services to have systems for recognising and responding to patient deterioration, including processes for monitoring vital signs and escalating clinical care as appropriate. This includes an obligation on the Service to ensure rapid access at all times to at least one clinician, either on site or close by, who can deliver advanced life support.27
Analysis
The Cosmetic Surgery Standards provide an additional layer of protection for cosmetic surgery patients by applying accreditation standards to all facilities where cosmetic surgery is performed, in particular, individual practitioners.
Whilst it remains a matter for state and territory licensing authorities to implement and enforce the processes, the interaction with the MBA guidelines of July 2023 means that in practice, cosmetic surgery will only be able to be performed in a facility accredited to the Cosmetic Surgery Standards. The Commission estimates that most Services will be accredited to the new standards by 2025.
By setting minimum standards for infection control, consenting processes and pre- and post-operative management at Services, the Cosmetic Surgery Standards are designed to complement the existing professional obligations of medical practitioners who perform cosmetic surgery, and support higher standards across the industry. However, operators of smaller private clinics, where accreditation to the NSQHS standards was not previously required, can expect to face a significantly greater regulatory burden in the future, with the costs of this likely to be passed on to consumers.
There are also some that suggest the reforms have gone too far. Concerns have been raised by plastic surgeons, for example, about the impact of the Cosmetic Surgery Standards on their ability to perform minor cosmetic procedures, such as simple scar revisions in their rooms, rather than requiring admission to a separate facility, given the broad definition of cosmetic surgery.28
From a legal perspective, it is interesting to note the imposition of responsibility on facilities for matters that have historically been the role of the medical practitioner. For example, in private hospitals and clinics, consenting and pre-operative workup have traditionally been the domain of the visiting consultant surgeon rather than the hospital. The requirements in the Cosmetic Surgery Standards relevant to consenting and pre-operative general and mental health assessments highlight the responsibility of facilities also, with potential implications for the applicable standard of care in civil litigation.
That said, there has been considerable support within the medical community generally for the reforms,29 noting the need for public confidence to be restored in the cosmetic surgery industry and the medical practitioners who perform these procedures. Work by the Australian Health Practitioner Regulation Agency is already underway in relation to non-surgical cosmetic procedures,30 and we will be continuing to watch this space with interest.
1 Department of Health and Aged Care Health Ministers Meeting (HMM): Statement (2022) www.health.gov.au/sites/defaul... .
2 Australian Health Practitioner Regulation Agency (AHPRA) Independent review of the regulation of medical practitioners who perform cosmetic surgery Final Report (2022) www.ahpra.gov.au/resources/cos... .
3 Australian Broadcasting Commission 'Cosmetic Cowboys' Four Corners 7 October 2021 www.abc.net.au/news/2021-10-26... .
4 Above n 1.
5 S Pillay and R Crozier 'The cosmetic surgery industry’s facelift: a before and after comparison of the new laws and guidelines' (2023) 31(5&6) HLB 99.
6 Australian Commission on Safety and Quality in Health Care (ACSQHC) National Safety and Quality Cosmetic Surgery Standards (2023) www.safetyandquality.gov.au/si... .
7 This term is defined above, at 5.
8 Australasian College of Cosmetic Surgery and Medicine 'More than a third of Australians considering cosmetic surgery' press release (18 June 2023) www.accsm.org.au/download/?id=...# .
9 G Sharp 'What’s the connection between cosmetic procedures and mental health?' Monash University 18 January 2023 https://lens.monash.edu/@medic... .
10 Health Practitioner Regulation National Law (Surgeons) Amendment Act 2023 (Qld).
11 AHPRA Guidelines for Registered Medical Practitioners Who Perform Cosmetic Surgery and Procedures (2023) www.medicalboard.gov.au/Codes-... .
12 See ACSQHC website: www.safetyandquality.gov.au/st... .
13 Above n 11, at [12.2].
14 Above n 6, at 4.
15 Above n 6, at 5.
16 ACSQHC National Safety and Quality Health Service Standards (2011) www.safetyandquality.gov.au/st... . Accreditation to the first edition started in 2013.
17 Above n 6, at 4.
18 Above.
19 Above n 6.
20 Above n 6, Standard 1.
21 Above n 6, at 5.
22 Above n 6, Standard 2.
23 Above n 6, Standard 3.
24 Above n 6, Standard 4.
25 Above n 6, Standard 5.
26 Above n 6, Standard 6.
27 Above n 6, Standard 7.
28 E Worthington and M Lloyd 'Extra protection for patients with new national standards for cosmetic surgery operators' ABCNews 13 Dec 2023 (quoting Brigid Corrigan from the Australian Society of Plastic Surgeons) www.abc.net.au/news/2023-12-14... .
29 Royal Australian College of Surgeons 'Draft National Licensing Framework for Cosmetic Surgery' media release (15 May 2023) www.surgeons.org/en/News/Advoc... .
30 AHPRA, Consultation begins on new guidelines for non-surgical cosmetic procedures, including dental, November 2023, accessed 8 March 2024 www.ahpra.gov.au/News/2023-11-... .
