Aesthetics looks at the confusion surrounding standards and guidelines for hair restoration surgery, and examines how some practitioners may be putting themselves at risk
Last month, the British Association of Hair Restoration Surgery (BAHRS) announced it had contributed to the development of a Care Quality Commission (CQC) inspection guide on hair restoration surgery (HRS), with the aim of promoting patient safety in the HRS field. The guide – which is not available for public viewing – is said, by BAHRS President and hair transplant surgeon Dr Greg Williams, to provide CQC specialist advisors with clear guidance when inspecting clinics that provide HRS, to ensure they meet CQC standards. Aesthetics speaks to Dr Williams to ask why he believes the inspection guide was necessary and how patient safety is being put at risk.
By law, clinics offering surgical procedures must register with the CQC.1 Some time after registration, a CQC team, including specialist advisors, should inspect the clinic to ensure that it meets CQC standards. The new HRS guide aims to assist the specialist advisors, who are unlikely to have specific knowledge on professional areas such as HRS, to make a proper and valid assessment. According to Dr Williams, it will give the advisors a general description on the different types of hair restoration surgery procedures and the areas of patient care that need extra scrutiny.
“There has also been a lack of clarity as to whether or not hair transplantation is surgery"
Lack of clarity
Dr Williams explains that one of the main issues with CQC registration is the confusion that has existed with regards to HRS. “In the past, there have been some inconsistencies in the information that was given out by the CQC about whether or not HRS was in the CQC’s scope, and I think that this was partly to do with a lack of understanding of what HRS entails,” says Dr Williams. He explains the importance of understanding the definition of HRS, which is detailed in the guide, saying, “There are two types of HRS – the first is hair transplant surgery and the second is prosthetic hair fibre implantation. For the purposes of the CQC, it does not include hair-bearing flap surgery or non-surgical forms of hair restoration such as platelet rich plasma injections, mesotherapy or microneedling.”
He continues, “There has also been a lack of clarity as to whether or not hair transplantation is surgery; there are two techniques for harvesting donor hair to transplant – the first being strip follicular unit transplantation (FUT), which involves an incision in the skin and is clearly surgery, and the second being follicular unit extraction (FUE), which some practitioners claim isn’t surgery because it involves multiple small round punch incisions. However, as the total cross-sectional area of the round incisions is large, there is potential for significant bleeding, and there can be serious complications. The newly formed Cosmetic Practice Standards Authority (CPSA) has clearly acknowledged both techniques as Level 1b invasive surgical procedures.”
The CQC has now recently clarified that all hair restoration surgery procedures are indeed ‘in scope’, and therefore all clinics offering these procedures must be registered with the CQC
The uncertainty as to whether hair transplantation was deemed as ‘surgery’ also came up after the Keogh review. Following Keogh, the Royal College of Surgeons (RCS) took ownership of the cosmetic surgical treatment recommendations and Health Education England (HEE) did the same with non-surgical procedures. But, according to Dr Williams, there was a dilemma about where HRS should go, as he says the majority of HRS procedures are carried out by doctors who do not have a surgical qualification.
In Phase One of the HEE Final Report (2014), it is stated, “HRS is classed as a Level 1b invasive surgical procedure usually done under local anaesthetic and is delivered in the UK and internationally by doctors from a variety of medical backgrounds, not limited to those with formal surgical training. The Cosmetic Surgery Inter-speciality Committee (CSIC) has taken the view that hair restoration surgery would fit better with work on non-surgical cosmetic interventions (NSCIs) led by HEE, given the non-surgical background of the majority of practitioners who currently perform this procedure.”2
Although HRS now comes under the authority of the Joint Council for Cosmetic Practitioners (JCCP), Dr Williams explains that the CQC has now recently clarified that all hair restoration surgery procedures are indeed ‘in scope’, and therefore all clinics offering these procedures must be registered with the CQC.1
“I believe that there are a large number of clinics offering HRS that are not CQC registered"
Due to the lack of understanding over the years on whether HRS should be CQC registered, some practitioners may be putting themselves at risk of breaching the law by not being registered. “I believe that there are a large number of clinics offering HRS that are not CQC registered,” says Dr Williams. He explains, “Some practitioners may have misinterpreted the scope, some may have realised it was vague and therefore chosen to interpret it differently, and others may have been told they did not need to register.”
Dr Williams explains that the BAHRS will be reporting all clinics it is aware of, that are offering HRS but are not registered. Once reported, it is up to the CQC to take steps to stop clinics operating until they are registered.
Dr Williams further clarifies, “Any service provider offering hair transplant surgery or prosthetic hair fibre implantation must be registered with the CQC. A service provider can be an individual, a partnership or an organisation [such as companies, charities, NHS trusts and local authorities]. A service provider, which is a subsidiary of another company that is CQC registered must still, itself, be registered.”3
He adds that, “A service provider can use or rent an operating theatre of another service provider but both providers must be CQC registered. The location may not need to be registered but the provider must be.”4
Two new HRS standards are due to be released in early 2018 by the CPSA – one on hair transplant surgery and one on prosthetic hair fibre implantation.5 For practitioners who practice HRS, to be included on the JCCP register, they must meet the standards of the procedures they offer to patients.
“If you are operating on patients in a non-CQC registered hair transplant clinic then you are operating illegally”
Dr Williams, who has worked with the CPSA on these standards, explains, “We can certainly say at this stage, it is proposed that only GMC registered doctors should perform the surgical steps of hair transplantation procedures, which includes making FUE incisions to harvest donor hair, and that only GMC registered doctors who are also hair transplant surgeons should offer prosthetic hair fibre implantation.” The standards will also reiterate that both forms of HRS must be undertaken by CQC registered service providers.3
However, Dr Williams says patients need to be made more aware of the dangers, “I think there needs to be wider public awareness campaigns about HRS, who can offer it, and the type of facility where it should be performed. I also believe patients and practitioners should not hesitate to report any clinics to the CQC that offer HRS and are not registered.” Dr Williams concludes, “If you are operating on patients in a non-CQC registered hair transplant clinic then you are operating illegally.”
- CQC, Regulated activities, Care Quality Commission, <http://www.cqc.org.uk/guidance-providers/ registration/regulated-activities>
- HEE, Review of qualifications required for delivery of non-surgical cosmetic interventions, Phase 1, (2014) https://hee.nhs.uk/hee-your-area/north-west-london/our-work/attracting-developing-our-workforce/qualification-requirements-non-surgical-cosmetic-procedures
- CQC, Scope of registration, http://www.cqc.org.uk/sites/default/files/20150428_scope_of_ registration_independent_medical_practitioners_working_in_private_practice.pdf
- CQC, What is a location guidance, http://www.cqc.org.uk/sites/default/files/20160211_300900_ v6_00_what_is_a_location_guidance.pdf
- CPSA, Hair Restoration Surgery http://www.cosmeticstandards.org.uk/hair-restoration-surgery.html