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Westminster Hall

Wednesday 10 May 2000

[Mr. Michael J. Martin in the Chair]

Cosmetic Surgery

Motion made, and Question proposed, That the sitting be now adjourned.--[Mrs. McGuire.]

9.30 am

Ann Clwyd (Cynon Valley): I am grateful to have secured this debate, because it is a subject on which I have campaigned for a long time. I first introduced a ten-minute Bill on the regulation of cosmetic surgery in 1994. My interest started because one of my constituents had had silicon implants that had gone wrong, and as a result she had to have a double mastectomy, which left her feeling shattered. That ten-minute Bill generated considerable publicity. I was invited to appear on many programmes and to campaign with consumer organisations, such as Which?, and with the BBC programme "Watchdog", among others, which by then had had letters and telephone calls from innumerable people, mainly women, who had had problems with cosmetic surgery that had gone wrong.

Many of us have at some time in our lives wanted to change something about ourselves, perhaps the nose, the bags under the eyes or the spare tyre, because something about our bodies has not pleased us. I do not believe that anyone in this Chamber could say that they would not like to change something about themselves. For some people it becomes almost an obsession. Pressure is put on women in particular, but increasingly on men, too, to change their appearances, suggesting that they will have a better sex life, be more attractive to the opposite sex or simply feel better about themselves if they have some kind of cosmetic surgery.

In 1994, about 60,000 people had private cosmetic surgery. It is difficult to say exactly what the figure will be for 2000, but I suspect that more than 100,000 people a year request private cosmetic surgery, most of which is carried out in private clinics. I was tempted to bring the drawers of material in my filing cabinets to show how many people have written to me over the years on some aspect of cosmetic surgery.

My interest in cosmetic surgery began with silicon implants. I was contacted by many people who suspected that silicon had somehow leaked into their bodies. Having had silicon implants in their lips, faces, breasts or buttocks, they believed that the silicon had started to make them ill. I took various deputations to the Department of Health to try to persuade it to investigate silicon implants, but those pleas fell on deaf ears. It was not until July 1998, under the present Government, that the independent review body on silicon breast implants presented its recommendations to Parliament, a move which I welcomed. Previously, people did not even know how many silicon implants had been carried out in this country. There was no register or follow-up, and that work desperately needed to be done. As a result of that work, the Royal College of Surgeons agreed to develop multi-disciplinary clinical

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standards for breast implant surgery. The Department of Health accepted the recommendations of that review group on the compulsory registration of details of each breast implant and removal with the national breast implant registry. That was an important step forward.

The other aspect of cosmetic surgery on which I am still campaigning is laser surgery, which is offered almost exclusively by the private sector. There are no regulations for the training of doctors who work in private clinics, and no regulations to prevent a doctor in private practice who does not have specific experience from offering treatment. Some eye surgeons in Harley street and at Moorfields eye hospital contacted me about a year ago to say that they were concerned that there was nothing to prevent someone from setting up a business without a medical background, and that problems were often glossed over. Although many thousands of laser treatments on eyes are performed with few long-term complications, a small but significant number result in permanent damage to eyesight. That must concern us all.

Private sector clinics offer many procedures and people spend millions of pounds on cosmetic surgery. Although plastic surgery in the national health service is generally safe, the NHS has no time to perform cosmetic surgery. It spends its time for such surgery on people with medical needs, such as burns victims, cancer patients and those with limb deformities.

I remember a press conference that Sir Norman Browse, a former president of the Royal College of Surgeons, and I gave in the House of Commons a few years ago. It is not often that the president of that body emerges to give such a conference with a politician, but he said that he was concerned that too many people could set up shop as cosmetic surgeons with no qualifications. Unless they specifically claim to be doctors or surgeons, they do not even commit an offence. As soon as the so-called surgeons have the patient's consent, they can legally operate without any expertise whatever.

Horrifying though it may sound, Ministers could perform liposculpture in a private clinic, so long as they did not tell lies about their qualifications. That would be legal. Sir Norman Browse said at the press conference that animals were better protected in Britain than people because one had to be a qualified veterinary surgeon to operate on an animal. To do so without that qualification is to break the law. But a veterinary surgeon could operate on someone in a private cosmetic clinic without being taken to task.

Far too many butchers practise in some clinics. Repair of botched surgery can be time consuming, expensive and embarrassing to the person involved. It sometimes has to be done on the NHS and can cost as much as £10,000. There may be a long wait for surgery, especially as the disfigurements, though nasty to look at, are not life threatening.

Many of the clinics get a lot of business from advertising in national newspapers and women's magazines, in which they often use misleading images. I have had correspondence with the Advertising Standards Authority, which has tightened up the regulations a little, but not enough. The advertisements make claims such as "Walk in, walk out", "Gentle

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surgery", "Looks you always desired", or suggest that to change one's whole outlook on life one should have a particular type of cosmetic surgery.

I looked at some of the ads in some current magazines last night, and there are pages of them. One states:

Cindy Jackson is an example of the extravagant claims made in those advertisements. I remember her because she sat in the audience at some of our press conferences. She is described as

The adverts go on and on. "Specialist in figure re-shaping", one of them says. It is accompanied by various sketches of before and after, showing soft liposculpture. One says:

I mentioned Cindy Jackson and liposculpture for a particular reason. Today, I spoke to Toni Rust who, in a letter to me last year, said:

I asked Toni Rust whether I could quote her letter today. She said that I could, because there were hundreds of women with the same concerns as herself. She said:

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I looked up two cuttings, one of which, dated 20 April from The Guardian, is headed "Model wins £93,000 for ruined looks." The article states:

Another cutting, which appeared in The Daily Telegraph on 28 January, was written by that paper's medical correspondent. It states:

Christine Doyle, the medical correspondent, continues:

Another case that I drew to the attention of Which? was that of a woman called Joyce. She had seen a lot of adverts for liposculpture, and was so impressed with their claims that she felt sure it would give her the figure that she dreamt of. She contacted a private clinic, whose promotional leaflet said that liposculpture was a straightforward and minor operation. She agreed to pay

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£2,500 to have liposculpture to her knees, thighs and hips in two stages. She was awake throughout the two-hour operation. She believed that the local anaesthetic must have worn off after 45 minutes, as the pain was intense. She went home the same day, her legs in blood-stained bandages. She got little advice after the operation and ended up having to take two weeks off work. She was supposed to have follow-up appointments but they did not occur. Her left knee still has a large flap of overhanging fat and is a completely different shape from her right knee. She had many lumps, bumps and pits on her legs. Needless to say, she was extremely disappointed with the results.

Such incidents are common. I heard from someone who was given liposculpture in a ground floor office in Harley street. She said:

The level of complaints, unless victims write to Members of Parliament, and so on, or talk to magazine and newspaper journalists, is low, because people are often acutely embarrassed. Filing a complaint is the last thing on their minds. One victim told me that when her surgery went wrong,

Some of the clinics and adverts are, as it were, selling body parts by mail order. The clinic surgeons often work on a commission, so the more operations they perform, the more money they pocket. One woman said:

Newspaper and other reporters have gone to cosmetic clinics to investigate them; they are usually aged about 21 and in most people's eyes look perfect, with nothing wrong with their appearance. They go to those clinics, and the hard sell begins. One reporter told me it was incredible--it was as though they were totting up on a calculator, as fast as they could, what they could do.

I shall quote further from the letters that I have received. One woman spoke of

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A Minister with responsibility for health in the previous Government repeatedly told me that he was not convinced that a case had been made to show that the existing controls were insufficient. Clearly, that is nonsense. A couple of months ago, I said in the Chamber that, unless some action was taken against a particular surgeon, I would name him in the House. I shall do so now, although he has now since been named on television. David Charles Herbert is a cosmetic surgeon, who works in the private cosmetic surgery industry. He has earned the nickname of the flying doctor for the speed at which he carries out his surgery and the brief time that he spends with patients, especially post-operative patients. Apparently, he performs 35 surgical procedures a week and carries out a face lift in only 40 minutes, which other surgeons say should take between two and four hours. He has operated from clinics in Huntingdon, Preston and Nottingham.

Over the years, David Herbert's work has generated a huge number of complaints, mainly from women. Allegedly, one woman nearly died after a bowel infection following a tummy tuck; one woman was left with a gaping hole in her stomach after a tummy tuck; and several women have had to have corrective surgery after David Herbert performed breast surgery. He performed a face lift without using enough anaesthetic. The list of allegations goes on. I could spend the entire morning repeating the list of complaints against him.

In 1986, Mr. Herbert was apparently asked to leave one hospital in Nottingham after the operating theatre staff refused to work with him. As far back as 1988, he was the subject of a BBC "Watchdog" expose, which involved four alleged victims of his surgery. He did not sue the programme makers, but instead went to ground for a period. It has been alleged that Mr. Herbert often settles with patients out of court to avoid the bad publicity that would come with a court case. Several surgeons have also made serious observations about his work, describing it as verging on the psychopathic and crude, and describing him as a psychopath, saying that anyone with an ounce of moral integrity would not go around causing permanent disfigurement; that that is not how doctors act. It has also been said that he is careless and carries out bad, rushed surgery. It is rare for a doctor's colleagues to make such observations.

Mr. Herbert is still operating and my dossier of evidence about him is as gruesome as it is long. The BBC's Sally Chidzoy first raised the allegations with the General Medical Council in November 1999. In January this year, she contacted me with a dossier from Mr. Herbert's patients and I then wrote to Finlay Scott, the chief executive of the GMC. On 2 February, I raised the matter in the House and I also forwarded the evidence to the Secretary of State for Health. In April, I received further witness statements from the BBC. Some 70

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complaints have now been made as a result of the programme about the surgeon. The slow progress made by the GMC and the fact that he is still continuing to operate prompted me to chase up both the Department and the GMC. The Government's chief medical officer, Professor Liam Donaldson, has sent all the evidence to the GMC asking for an urgent update on its investigations into Mr. Herbert.

I then contacted the GMC again and spoke to Isabel Nisbet, director of its fitness to practise directorate, for an update on progress. On 27 April she confirmed that the GMC would not try for a misconduct charge against Mr. Herbert because it would be too easy for him to get away with it, as he could bring witnesses- former patients--who could testify to his excellent surgery, skills, conduct and so on.

That seems a strange defence for an accused person. Supposing somebody being tried for murder brought 100 witnesses to the court to testify that, because he had not murdered them, he must be innocent of the one murder of which he was accused. The fact that Mr. Herbert may have performed some operations--perhaps many operations--satisfactorily is irrelevant. It is the cases and the evidence that we have, which allege that he performed badly, that matter.

What is more, the GMC says that, under the present law, it cannot suspend Mr. Herbert pending the outcome of the investigation. Therefore, the GMC has decided on the professional assessment option because it offers a better chance of a successful outcome in terms of making the charges stick and has apparently informed all the complainants of that fact.

The GMC wrote to Mr. Herbert on 25 April to say that it is minded to invite him for a professional assessment before two plastic surgeons and a lay person. He has until the end of May to reply with his comments. After that, provided that he does not appeal against an assessment, he will be assessed and, if he fails, he will be suspended for a period or have conditions set on his work or his employment. The danger with that option is that Mr. Herbert could have a good day and pass the assessment with flying colours, in which case he would be free to carry on, in many cases, unfortunately, disfiguring patients for life. To judge by his past record, the likelihood is that he will avoid a showdown with the GMC and go into retirement.

In view of what my right hon. Friend the Secretary of State said earlier this year in the Chamber about the GMC's performance, that is a totally inadequate response to the information supplied to it, nor is it new information. Apparently, it had previously received complaints about Mr. Herbert. In the meantime, he has been allowed to carry on regardless.

This morning, I heard from Toni Rust, whose letter I read earlier, that a friend of hers phoned the GMC as recently as January this year to ask for advice on which cosmetic surgeon to choose. She asked specifically about Mr. Herbert and was told that he was all right. No official register of cosmetic surgeons is kept by the GMC, but it can apparently supply information about the area of surgery in which a certain surgeon has trained. It is incredible that the situation has been allowed to go on for so long.

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In answers to me, the Government have pointed to the safeguards that exist. The Registered Homes Act 1984 provides for the registration and inspection of private cosmetic surgery clinics by health authorities. I do not know how often such inspections are carried out, how vigorous they are, or what the results are.

I gave evidence to the Select Committee on Health, which published its report last year, giving it some of the information that I have collected since 1994. That Committee made all kinds of recommendations. A couple of months ago, the Under-Secretary of State for Health, my hon. Friend the Member for Birmingham, Edgbaston (Ms Stuart), said:

A number of measures need to be implemented as soon as possible. The complaints procedure for patients must be improved. Patients need improved mechanisms for obtaining redress for their complaints. The position of the GMC should be reviewed. The medical profession regulates itself through the GMC, but it might be better for patients and the medical profession if an independent body were to be responsible for investigating complaints and disciplining doctors and surgeons. An independent disciplinary body must be given effective teeth. Pending a decision, people who are being investigated must be suspended; they must not be allowed to practise in the meantime. It is incredible that Mr. Herbert should continue to operate, given the seriousness of the complaints against him. I cannot think of any other profession that would allow that.

Can the NHS offer more cosmetic surgery? That is currently lacking. I understand that rationing is necessary, but it means that people are forced into the private sector. When the NHS has to correct the negligence or malpractice of private cosmetic surgeons, it should be able to reclaim the costs of that treatment from the private sector. In order to raise standards, everyone in the private sector who carries out plastic surgery should be made financially responsible for the outcome. If a patient has to have corrective surgery, those who carried out the original botched surgery should pay.

Patients must be better informed; they should not have to rely on advertisements. Sometimes even asking one's GP is not entirely satisfactory. There must be other methods of telling patients where they can get the best possible treatment in the private sector.

There should be a review of the training of cosmetic surgeons, with a view to establishing recognised specialist training and regular professional assessments. No doctor, surgeon, or any other person should be allowed to practise cosmetic surgery without formal training or accreditation in that specialty.

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A mandatory peer review audit process should be introduced into the private sector. Regular scrutiny of surgeons' competence is undertaken by other doctors or surgeons. The surgeons who made the complaints against Mr. Herbert found it very difficult to make them formally to the GMC. We have those complaints on record, with the names attached.

I do not ask for all those matters to be dealt with immediately. However, if some of them could be addressed, it would give recognition to genuine competence and experience, while rooting out incompetence.

Someone suggested to me that for a patient to have complicated surgery practised on them by someone who is not experienced in cosmetic surgery is equivalent to boarding a jumbo jet and finding that the pilot has been trained only on a crop-spraying plane. I do not know whether that analogy is correct, but it gives an idea of the frustration and concern felt by many of the people who have written to me who have suffered physical damage.

I received a letter from a teacher--these letters are not from stupid women who do not think about what they are doing--who told me that, after reconstructive surgery on her nose, she cannot wear her glasses for more than half an hour because the side of her nose collapses. She has had two operations to try to rectify the problem, but it is still not right. Some women cannot close their eyes properly; some look as though they have been in a car crash; others have large indentations in their bodies. All these women have been promised many things by the advertisements. The Government have a responsibility to introduce the kind of regulation for cosmetic surgery that is long overdue.

10.11 am

Dr. Peter Brand (Isle of Wight): I congratulate the hon. Member for Cynon Valley (Ann Clwyd) on raising the issue and pointing out the need for the debate. The case histories that she has given clearly demonstrate that this is an important issue.

I should like to address the matter under three headings. The first is consumer protection. Someone who goes out into the marketplace to buy a service should be protected from incompetence, shady practice and over-promotion of a product. The second heading is medical competence. We have had illustrations to show that that is not always satisfactory. The third is medical ethics, which raises the question of whether it is appropriate to offer some of the surgery available.

The Health Committee has addressed the issue of private cosmetic surgery in two reports: one on the control of private medicine, the other on the unexpected and often disastrous outcomes of medical intervention. It is interesting that cosmetic surgery has provided the best examples of areas that lack regulation and consumer protection. I am glad that the Government have taken notice of those reports. When I questioned the previous Secretary of State on the matter, he said that it was a matter for the private sector, not for a Secretary of State for Health who was solely concerned with standards in the national health service. I am glad that there has been a change of mind on that matter, because the hon. Member for Cynon Valley has highlighted some important issues.

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Consumers become quite confused about cosmetic surgery. We have been given illustrations of the hyped claims made for surgery outcomes: one will be more economically prosperous; one will get a better job and have a better sex life; one will be more interesting. In my experience, rather than becoming more interesting, people who have had a great deal of cosmetic surgery tend to become extraordinarily boring because their only topic of conversation is their surgery. It is frightening to read advertisements that present an idealised picture of the perfect human being that can be created. Those are not the kind of aspirations that should be encouraged. I am sorry to say that the Advertising Standards Authority has proved itself to be completely toothless. It receives many complaints and it has guidance on these matters, but it ignores that guidance more frequently than it adheres to it.

One of the main problems, from the consumer's point of view, involves the balance of accountability between the organisation that employs a surgeon and the surgeon himself. Discussions with a patient and those involved with advertising are conducted through the organisation or clinic. The person who is considering having cosmetic surgery has an appointment with a consultant, who is often a handsome lady in a white coat who probably trained on the Clinique counter in Boots rather than as a consultant in cosmetic surgery. There is no protection against the misleading use of the phrase "cosmetic consultant" in the circumstances that I describe.

Things may go right-if people pay their money and like the outcome, that is fine--but if things go wrong and a complaint is made against the clinic that took the cheque for the service that was provided, the clinic's usual response is to say that responsibility lies not with it but with the operating surgeon, who is contracted but not employed by it. Claims have to be made against the surgeon, not the clinic. That situation cannot be acceptable. People often do not realise that that is the case, and, not infrequently, they do not meet the surgeon before they pay their money. I shall discuss the Select Committee's recommendation in that regard later.

It is important for people to realise that no surgery is without risk. The basic issue in relation to cosmetic surgery is that there is no such thing as minor surgery, although there are minor surgeons. The General Medical Council has a specialist register, but it does not specify the specialism that the people on the register have. The GMC also resisted setting up a specialist register for cosmetic or plastic surgery--it relies on trade organisations and professional bodies to provide that service. That is confusing to the consumer because most people believe that the GMC's role is to maintain the standards of doctors who offer their services to the public.

I have a surgical qualification and I am a member of the Royal College of Surgeons, which probably qualifies me to remove a wart or an appendix, but that is about the extent of my surgical expertise. Having a surgical qualification and being a fellow of the Royal College of Surgeons demonstrates surgical expertise in a general field, but it does not demonstrate that someone has specialist training in a particular area. We have already established this morning that the results can be disastrous.

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Concerns have been expressed about silicone implants. I was concerned to have read during the weekend that much cadaveric material is now used in implants. People have dead donor tissue rather than silicone injected into their lips to make them more pouting. The situation is obscene: people donate their organs to save lives, but some of their bits are used for breast enhancements or for what I believe is called facial sculpting.

The Select Committee highlighted concerns about laser surgery, which can be extremely helpful. We should not fail to recognise that plastic and cosmetic surgery have an important role to play in the treatment of patients. It is totally justifiable to try to remove obscene tattoos inflicted on someone at the age of 16 who was drunk. It would improve his prospects for employment as, for example, a waiter, if he can have obscene language removed from his hands. I am pleased that laser treatment has something to offer and, if expertly done, can be effective and not very expensive. I echo the comments made by the hon. Member for Cynon Valley: the NHS should have a greater role, and we should not abandon people to the private sector.

The second issue relates to medical competence. The General Medical Council must get off the fence. It is essential that registers showing the specialism of the people listed be maintained. Ordinary members of the public should be able to go to the public library, look up the interests and expertise of the people on the list and see how competent and well trained they are in their particular field.

The third issue is one of medical ethics. Someone who is operating incompetently is behaving unethically. It is bizarre that, in the illustration used this morning, the General Medical Council has not taken a more active role, if only to protect the name of the surgeon concerned if he is innocent of what has been alleged. It seems extraordinary that such allegations can be made, without any action being taken. That is in no one's interests.

There are a number of outstanding issues. The Government have done a great deal to protect the users of medical services, setting up the Commission for Health Improvement and the National Institute for Clinical Excellence and establishing clinical governance. They are all positive steps. Unfortunately, the Government have, for what I believe to be dogmatic reasons, left the private sector outside the framework. That is disappointing. Clinical governance is just as important in the private sector as in the NHS. The creation of a special body parallel to the NHS will not feed good practice from one sector of health care delivery to another. Without doubt, the NHS can learn from the innovations introduced in responsible private practice, especially in this field. The more reputable clinics have a great deal of experience that could be of benefit to the NHS. Indeed, the NHS could occasionally contract to the private sector desirable and essential plastic surgery, if a private clinic were better geared up to carrying it out.

A number of recommendations could be made. One is that the Advertising Standards Authority might as well be disbanded if it will not do its job properly. There

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should be an investigation into the effectiveness of the Advertising Standards Authority in all its work, but specifically in an area such as this, where vulnerable people with hyped-up expectations are not always the best judges of how to act as a consumer. The patient as consumer is a nice concept, but unless people are extremely well informed, they need a lot of information to make informed choices. One reason why I am critical of the Advertising Standards Authority is that its code of practice does not cover the information that a patient can expect--information such as the success rate for an operation, for the organisation offering it or for the surgeon carrying it out.

On the consumer side, there must be a clearer framework of accountability when things go wrong. In the national health service, it is now accepted that, through clinical governance, either the medical director or the chief executive of a trust is responsible for everything that happens in that trust, although liability may of course be passed to clinicians further down the line. In the private sector, there seems to be a tradition whereby the employing authority or contracting authority washes its hands and passes responsibility to the clinician carrying out the work. That is not acceptable.

The public are entitled to a specialist register that has meaning. Again, the Government should take action in that regard and instruct the General Medical Council. If they cannot do so under current regulations, the regulations should be changed to ensure that information is available to members of the public.

The medical profession has lacked application in respect of the important issue of medical ethics. Those who apply for surgery are vulnerable, and it is essential that they be protected as patients, as well as consumers. At times, the ethical approach is to say no to someone who requests a particular intervention. At the moment, there seems to be no framework for addressing that issue.

I endorse the recommendations made by the Health Committee in its fifth report on the regulation of private and other independent health care. Reference was made to a cooling-off period, and evidence clearly showed that people who paid in advance, before seeing the surgeon who was to carry out the work, could not recover that payment. Consumers of double glazing and life insurance seem to have greater protection than those who undergo major surgery. It was also recommended that it should be mandatory for information on outcomes to be available to those who contemplate surgery.

My final plea is that the Government should address the issue of the control mechanism and the complaints system. There should be a single route for complaints. Many people who work in the private sector also hold national health service contracts, and many of the things that go wrong in the private sector become the responsibility of the NHS. It is ridiculous to talk about setting up two complaints systems--one through the ombudsman and the other through a private sector-funded ombudsman. I would much prefer the people of this country to have the protection of a competent regulatory body and access to an efficient complaints investigation system, irrespective of whether complaints or mishaps occur within the national health service or the private sector.

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A useful contribution to the debate has been made this morning, and I hope that the Minister will be able to take these issues forward. Unlike the hon. Member for Cynon Valley, I do not think that her requests for Government action were unreasonable. Indeed, all of them should be implemented.

10.29 am

Mrs. Caroline Spelman (Meriden): I begin by congratulating the hon. Member for Cynon Valley (Ann Clwyd) on securing the debate. All hon. Members will have constituents who have had bad experiences that they could recount, and it was doubtless deemed that, because the subject is familiar to other hon. Members, it would make a good one-and-a-half-hour Adjournment debate. It is unfortunate that more hon. Members are not present to give those examples, but the hon. Lady raised many cases--almost horror stories--of what is happening in cosmetic surgery.

The debate is important against the background of the increasing popularity of cosmetic surgery. According to a recent survey by a women's magazine, there has been a 50 per cent. increase in cosmetic surgery in this country during the past five years. For all the bad examples that have been given, more and more people are undergoing such treatments. It is estimated that almost £160 million is spent on cosmetic surgery in this country. This is a good opportunity to raise specific cases, but we also want to speak on behalf of many people who have had adverse results and no satisfaction in trying to sort them out.

One of the underlying problems is how to define cosmetic surgery and I shall be interested to hear how the Minister does so. The more I looked into the matter, the more difficult it became to draw the line. Many procedures now are carried out on the margin of medical treatment. Can cosmetic surgery be defined as an invasive procedure that requires local or general anaesthesia? What about procedures such as dermabrasion which involves neither, but may cause damage? We need a definition of cosmetic surgery so that we can try to provide better protection for patients.

In February this year, the Secretary of State for Health referred to the key purpose of the General Medical Council and stated:

The examples that have been given reveal the sad fact that cosmetic surgery seems to attract some dubious practitioners. That is not confined to the United Kingdom and there are horror stories from around the world. There are clear anomalies in this country and it is

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the Government's responsibility to try to sort them out. For example, a doctor suspended from working in the NHS can continue to practise in the private sector. Surely that cannot be right.

Another issue concerns protection of title. It is clear that one problem with cosmetic surgery is that a patient may be seeing a consultant who is more a consultant in name than what we understand to be a medical consultant. The hard sell to which the hon. Member for Cynon Valley referred may come from someone without medical qualifications. There is an issue concerning the words "cosmetic surgeon".

There will be an opportunity shortly during the debate on the Care Standards Bill, to define medical nursing and other titles as a vital protection for the public. Does the Minister agree that such an opportunity exists? I urge him to be cautious on the question of protection of title. I am sure that he knows that protection of title was sought for professions allied to medicine under the Health Act 1999. The consensus among some of those professions is that the provisions do not work well. In an effort to protect patients from so-called cosmetic surgeons, the incorrect use of that title should be avoided, but we need assurances that some of the mistakes learned from dealings with professions allied to medicine can be avoided.

There is no doubt that better regulation is required for cosmetic surgery. The hon. Member for Isle of Wight (Dr. Brand) referred to the Health Committee report, in which there are several good recommendations. I would be interested to hear the Government's opinion of some of them. I endorse the hon. Gentleman's view that a 14-day cooling-off period for cosmetic surgery would be wise before someone signs up for an operation, given that it would be a non-urgent procedure.

I also draw attention to the Health Committee's recommendation that health warnings should be given on cosmetic surgery advertisements. Perhaps that would be a way around the fact that the Advertising Standards Authority is proving ineffective on the subject. The British Medical Association supports that recommendation.

Another important recommendation was that warnings should be given to patients of the risk of being treated by a doctor who does not have access to their records. That is common in cosmetic surgery and applies to other health care issues. If followed, the recommendation might help to prevent disastrous examples such as those given by the hon. Member for Cynon Valley. I look forward to hearing the Minister's views on that and on how legislation could be toughened to deal with the misleading advertisements for cosmetic surgery.

The timing of the debate is useful in that the Care Standards Bill, which should provide an opportunity to improve regulation for cosmetic surgery, is returning from another place. Clause 2(7) of the amended Bill mentions cosmetic surgery, so it is beyond doubt that the Bill deals with such surgery. My reading of the Bill is that it creates an option to ensure that the same safeguards as protect patients in the public sector apply in the private sector. Does the Minister accept that there is reduced resistance in the Government to the idea that the private sector should be regulated on a level playing field? There is no resistance from the independent health

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care sector to that change of attitude. The chief executive of the Independent Healthcare Association said:

Does the Minister acknowledge that it is important that inspection standards for independent health care establishments are consistent with those applied to NHS hospitals? That is both important and practical. The inspectorate that will be set up following the Care Standards Bill will at some date result in a good level of expertise. After a couple of years of carrying out inspections of publicly owned establishments, the team of inspectors' level of expertise could be usefully applied to private sector inspections. I urge the Minister to ensure consistency across both types of establishment, as it would be beneficial.

In the debate in the House of Lords on the Care Standards Bill, Lord Laming pointed out that

As a result of the amendments made in the House of Lords, the new National Care Standards Commission will be able to contract with the Commission for Health Improvement to carry out on its behalf inspections of private and voluntary establishments. In practice, will experienced inspectors enter both types of establishment?

Having read clauses 2 and 21 of the amended Bill, I am slightly worried. The treatment of the lady who found herself in a dentist's chair rather than on a proper operating table and suffered accordingly took place in a ground-floor office. The establishments in which cosmetic surgery is carried out are diverse. Will the Bill cover such establishments? It is not beyond the wit of man to imagine that some cosmetic surgeons may work in a home setting. Will the Bill extend to cosmetic surgery treatments in a domiciliary setting? That may be another loophole that we must try to close if we are trying to prevent more accidents.

It has been important to have this debate. Clearly, many vulnerable people have had poor experiences, and we as politicians should try to see what could be done under existing law or proposed new law to tighten up and provide proper protection for patients who undergo cosmetic surgery. I realise that the Care Standards Bill is betwixt and between another place and this place, but I should be interested to hear what scope the Minister believes legislation offers in providing a level of protection that is currently lacking.

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10.42 am

The Minister of State, Department of Health (Mr. John Hutton ): Like other hon. Members, I congratulate my hon. Friend the Member for Cynon Valley (Ann Clwyd) on having chosen this subject for today's debate. She made the important point that tens of thousands of cosmetic procedures are performed in this country every year, so it is clearly big business. Parliament must ensure that it is properly regulated and that the public are properly protected. It is clear from what my hon. Friend has been saying for a long time that there is room for considerable improvement in both those areas, and I shall explain what the Government are doing.

As I am sure the House is aware, my hon. Friend has a long-established interest in this important subject, and has campaigned long and hard for better protection and higher standards. In 1994, she introduced a private Member's Bill to establish registration procedures for cosmetic surgeons in order to set minimum standards of training and practice. She followed that by bringing to the House's attention on several occasions her anxieties about doctors who work privately as cosmetic surgeons but do not necessarily have either the expertise or the experience to perform such operations. The House owes her thanks for ensuring that these matters are raised.

I assure my hon. Friend that the Government take the issues involved extremely seriously. We accept her view that the public need greater assurance on the safety and quality of such treatment. I am sure that she will be glad to know that we are therefore introducing, in the Care Standards Bill, improved regulation of independent health care services, including premises where cosmetic surgery, medical treatment under anaesthesia or sedation and certain laser treatment is provided.

The hon. Member for Meriden (Mrs. Spelman) asked whether the Bill would be sufficiently flexible to cover a variety of circumstances and places where private cosmetic surgery is performed. It will be. The Bill has been constructed to ensure that many of the detailed powers can be dealt with through regulation, which will allow us to respond as and when situations arise. We do not want to repeat some of the mistakes of the past, when the regulatory framework was too inflexible, and did not take account of people's desire to find a way around, and through, the regulatory net.

We do not often have the opportunity to correct such problems, but the Care Standards Bill provides it. The Government--and, I am sure, my hon. Friend the Member for Cynon Valley--want to make sure that the legislation is comprehensive and flexible, and can adapt to changing medical practice in the future or a desire on the part of some practitioners to find a way through the system. I hope that the Bill will address my hon. Friend's concerns. If she has further concerns, they can be addressed by tabling amendments in Standing Committee, which will provide an opportunity for more detailed discussion.

In addition to the legislation, the Government are working closely with the GMC to improve, strengthen and modernise the regulation of medical practitioners, whether in the public or private sectors. My hon. Friend will be aware that the vast majority of cosmetic surgery is carried out in the private sector. Arrangements for regulating private sector health care are long-standing,

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and are based on the Registered Homes Act 1984. We recognise the weaknesses in those arrangements, as she has done. For instance, they concentrate on facilities and equipment, do not address health care quality issues adequately and do not provide satisfactory access to redress for patients who are dissatisfied with the health care that they have received. We aim to achieve more effective regulation to ensure quality of private cosmetic surgery, adequacy of information for patients and would-be patients-all hon. Members who have spoken have addressed their concerns in that regard--safety of technology and equipment used, including laser treatment equipment, and effectiveness of complaints procedures when, sadly, things go wrong.

The Care Standards Bill will establish a new regulatory body for care homes and independent health care--the National Care Standards Commission. The commission will have the powers to inspect and, if necessary, shut down cosmetic surgery clinics that do not meet the rigorous standards that will be put in place. The starting point for the new regulatory system for independent health care is that those who operate private hospitals and clinics should be accountable for all aspects of care--clinical and non-clinical services--undertaken inside them. For hospitals, that includes the work of doctors to whom they grant admitting rights. The hon. Member for Isle of Wight (Dr. Brand) referred to that concern, which is perfectly valid, as did my hon. Friend the Member for Cynon Valley.

It is not acceptable for private clinics, hospital owners and managers to seek to wash their hands of their responsibilities on the ground that consultants are not employed by them, but have a private contract with their patients. The hon. Member for Isle of Wight will be aware that one of the most effective ways to address that issue is to make sure that private hospitals have proper complaints procedures in place. Ultimately, the operation of those complaints procedures will be tied to registration. Therefore, if clear evidence exists of poor practice within a private clinic, action can be taken to shut the place down, even if privately or self-employed consultants conducted the procedures. We must not have a system in which people shuffle off their responsibilities, pass the buck and blame others, while continuing to provide a poor service. That will not happen under the new arrangements for which we intend to legislate.

We shall also set up tough national minimum standards for private hospitals and clinics. That work will be developed through wide-ranging consultation, which will include the independent health care sector. Clearly, standards will need to be sensitive to the type of care that is being provided--they will differ between, for example, hospitals providing acute surgical care and those treating people with mental health problems. Our guiding light throughout the exercise will be patient safety.

We will therefore require all private hospitals and clinics to have proper arrangements in place to assure quality. Those will include proper treatment protocols, arrangements for clinical audit, proper maintenance of clinical records, systems for clinical risk management, arrangements for reporting untoward incidents to hospital management, and so on. All health professionals working in a hospital should participate in those arrangements. Private hospitals will need to put

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proper arrangements in place to oversee those systems, for example by using medical advisory committees. However, the hospital manager and owners will have the ultimate responsibility of ensuring that the hospital provides high-quality clinical care.

We will develop standards for independent health care by involving the relevant experts in the field. Our consultation on the development of standards for cosmetic surgery will also involve the Medical Devices Agency. Its views, expertise and professional contacts on, for example, the use of lasers, silicone breast implants--which concern my hon. Friend the Member for Cynon Valley--and devices used for liposuction will be essential in producing effective standards. We will also require private hospitals and clinics to have proper procedures in place to check the qualifications of the staff whom they employ and to ensure that they employ only state-registered staff in relevant posts, for example as physiotherapists.

However, the process does not end there. As part of our minimum standards, we want to ensure that staff have the appropriate skills and qualifications for the work that they undertake; for example, the employment of paediatric nursing staff to look after children will be a vital requirement in ensuring that there is proper 24-hour medical cover in place where hospitals carry out major surgery.

Standards will also cover the qualifications of all health care professionals involved in cosmetic surgery. Clinics where cosmetic surgery is performed will have to satisfy the National Care Standards Commission that surgeons who operate in them have the relevant qualifications and have reached consultant status. That will help to ensure that patients have increased protection from surgeons who are not adequately experienced or skilled in cosmetic surgery. We are also determined to put a stop to the practice of doctors continuing to work in the private sector when they have been suspended from their NHS work because they pose a risk to patients. All hon. Members who spoke in the debate have expressed their concerns about that. The current alert letter system has not always worked as effectively as we had hoped and we will work with the GMC and other bodies to establish better arrangements.

We recognise the difficulties that patients sometimes face when cosmetic surgery, or indeed any private health care treatment, goes wrong, and they try to seek redress. Patients can be faced with the surgeon and the hospital passing the buck, with neither accepting responsibility. That is simply not good enough. Under the new regulatory system, each hospital and clinic will be required to have a formal complaints procedure; that is not at present a formal or legal requirement. Patients will be able to make a complaint about their treatment and have it fully investigated. If they are not satisfied with the response that they receive, they will be able to raise the matter directly with the National Care Standards Commission, which will have considerable powers at its disposal. It will be able to ensure that all staff who work at the hospital or the clinic co-operate in those complaints investigations. If necessary, it will report poor or unethical practice directly to the GMC, under the fitness-to-practise procedures, where matters can be further investigated. If standards are persistently

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poor, the clinic can be closed down and will not be allowed to open in the next town, as can sometimes occur under the present arrangements.

Compared with the current system, in which 100 different health authority inspection units are involved, the position of the National Care Standards Commission as a single regulator will give it the necessary overview and co-ordination to apply that type of sanction effectively. Those who pose a risk to the public must not be allowed to slip through the regulatory net. In tackling those issues through the Care Standards Bill, we are confident that the measures we will introduce will provide the enhanced safeguards and assurance of standards in independent health care, including cosmetic surgery, that the public fully deserve.

The hon. Member for Isle of Wight raised concerns about the difference, as he saw it, between the arrangements that we are putting in place for the private health care sector and the national health service. I believe that he was wrong in several respects; I do not want to pick him up too much on that, but I will make two points. He was concerned about clinical governance arrangements. In relation to NHS patients being treated in the private sector, the same safeguards and procedures will apply. The Commission for Health Improvement will be able to follow the progress of those patients and the standard of care that they received. We expect medical practitioners in the private health care sector, when treating NHS patients, to apply exactly the same standards of clinical governance as they would apply to patients when treating them under the national health service. The hon. Gentleman may have inadvertently misunderstood the arrangements in those two respects.

Dr. Brand : Surely the Minister has just illustrated my point. It would be more sensible to have a common framework for clinical governance, whether for a private patient within an NHS hospital, an NHS patient in a private hospital or a private patient in a private hospital.

Mr. Hutton : The hon. Gentleman was saying that we were abandoning NHS patients in the private sector and exposing them to no effective safeguards. That is not the case. There is a logical argument for separating the role of the Commission for Health Improvement from the role of the National Care Standards Commission. The Commission for Health Improvement will not be a registration body; it will be an inspection body. The National Care Standards Commission will have both functions in relation to the private sector, which is a reasonable place at which to draw the line. The problem with legislation is where to draw the lines, define functions and separate one organisation's responsibilities from those of another. That is an inescapable part of the whole process of providing an effective regulatory framework.

The system will be flexible and, when we have amended the Care Standards Bill, the National Care Standards Commission will be able to use the expertise of the Commission for Health Improvement in carrying out certain inspection functions in relation to the private, acute health care sector. There is every

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possibility that we can ensure that the two separate organisations work closely together and advance the interests of patients in the way that we have always intended.

I have outlined the many improvements that will drive up the standards of private health care to a much higher standard. It is important to be aware that that work does not stand alone. The potential of the National Care Standards Commission cannot be met unless the regulation of the professions is thoroughly modernised. My hon. Friend the Member for Cynon Valley expressed her serious concerns about such issues. To that end, the Government are currently working closely with the GMC to bring about the necessary changes that she and others have long called for.

As my hon. Friend will be aware, the GMC has, by law, several specific functions such as keeping up-to-date registers of all qualified doctors, fostering good medical practice, promoting high standards of medical education and dealing with doctors whose fitness to practise is in doubt. The tragic events surrounding the Shipman case have most recently brought that last area into focus. The case highlighted beyond any reasonable doubt that the powers currently available to the GMC to impose interim suspension or place interim conditions on a doctor while cases are being investigated are inadequate under the current procedures. There is common consent about that. It is important to understand that that relates to all practising doctors, not only those who specialise in plastic surgery.

Currently, the preliminary proceedings committee of the GMC can impose interim suspension on a doctor's registration, but only after it has decided to refer the case to the professional conduct committee. The process, which is set out in regulations, requires a doctor to be given a minimum of 28 days' notice in which to respond--to which my hon. Friend referred. In reality, the delay may be eight weeks or more. Such a delay is not acceptable. Those various gaps and loopholes mean that doctors who may be a danger to patients can continue to practice. That is clearly unacceptable. It is certainly not in the public interest, which is why we have decided to take action.

We are giving the GMC additional powers to impose interim suspensions. We also intend to give practical meaning to the presumption that, when a doctor is struck off, it is for life--save in the most exceptional circumstances. Speed is vital to those powers. We shall use them to impose interim suspension or conditions quickly in any circumstance, including cases of performance and health. Importantly, the new power could be used at any point in the fitness-to-practise procedure. It would give the GMC similar flexibility to the United Kingdom Central Council for Nursing, Midwifery and Health Visiting in the timing of the imposition of interim conditions.

There are many other issues that I would have liked to discuss but, sadly, I have run out of time. There is no argument about what we want to achieve. We want private hospitals and other independent health care facilities to work to proper modern standards of health care. We want those hospitals to be accountable to their customers for the services that they provide, and to be subjected to the most rigorous and demanding checks to ensure that they meet the necessary requirements. That will be the case in future.

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