Examination of Witness (Questions 1 -
THURSDAY 22 MARCH 2001
1. Good morning and can I welcome you to this
session of the Committee. May I express my thanks on behalf of
the Committee to all the witnesses and those who have given us
written evidence. Professor Sturrock, we are very grateful that
you been able to come over today and I would ask you to briefly
introduce yourself to the Committee.
(Professor Sturrock) I am Professor Roger
Sturrock. I am the Professor of Rheumatology in the University
of Glasgow and Chairman of the Independent Review Group.
2. May I ask a little about your own personal
background in terms of medicine.
(Professor Sturrock) I am a physician specialist in
rheumatology. I do both rheumatology and general internal medicine
but my major sub-specialty is in the field of rheumatology which
covers all categories of rheumatic diseases with connective tissues
disorders at one end and problems like back pain, shoulder pain
and neck pain at the other, so it is a very broad spectrum of
3. May I begin by asking you, before we get
onto your report and the outcome, about your general thoughts
as to the pressures which lead women to undergo breast augmentation.
You may not have reflected on this in particular in the report
you conducted, but do you have any personal views of the background
as to why women are determined to undergo this surgery?
(Professor Sturrock) It is a very interesting question
and, before coming to chair the Review Group, I suppose I had
not really given it much thought. One of the things which, to
a certain extent, surprised me was that, in reading through the
relevant literature and listening to what people say, self-image
for women is obviously very important, as it is for men, and the
state of breast size is quite important, not just for cosmetic
reasons but also for women's self-worth, for their confidence
in society. So there are a whole range of complex reasons why
women may contemplate having breast augmentation and obviously
within the culture in which we live with the concept of the `body
beautiful' appearing in the media, I think there are all these
other subtle pressures which are put upon women which may make
them think that they are inadequate in whatever sense and may
lead them to consider breast augmentation.
4. Do you have any thoughts on the role of governments
in tackling the pressures on women from those seeking to market
(Professor Sturrock) One of the things we were concerned
about in the group was the pressure of advertising and we were
very concerned that, when adverts were put out, there should be
a rider which indicated that advice will be available to give
women all the aspects involved in breast implantation and augmentation
before they go forward with it, so we were very concerned about
the lack of control of the advertising aspects of this whole issue,
which of course is very, very considerable.
5. Of course, as a Committee, we took this up
as an issue when we looked at regulation of the private sector
and certainly we were concerned at some of the advertisements
that were appearing, not so much on this area but certainly in
terms of other forms of plastic surgery which was enticing people
to undergo various treatments. Your Committee made a number of
recommendations on the issue of providing information to women.
What progress do you feel has been made so far in implementing
(Professor Sturrock) I think there has been some progress.
I do not know whether you have actually seen this booklet
which was as a direct result of one of our recommendations?
6. Yes, we have had a copy of it.
(Professor Sturrock) It is now about to go into its
second edition as I gather it has been sold out, so it has obviously
attracted a great deal of interest and is very comprehensive in
the advice that it has given. I think the next step is to construct
a proper informed consent form that women would have to fill in
prior to breast implantation augmentation and there has been considerable
consultation with the Colleges of Surgeons and with the professional
bodies in plastic surgery to produce an informed consent form,
which is still not finally there yet but which I gather is in
preparation, so I do think progress is being made. It is never
as fast as we would like these things to be, but I was encouraged
when this booklet was printed as to how well received it had been.
7. Proportionately, of the operations currently
being undertaken in this country, in percentage terms, how many
are in the private sector compared to the NHS? Presumably an overwhelming
number would be in the private sector.
(Professor Sturrock) I could not give you a precise
percentage because the data just is not there.
8. Are you able to give me a guestimate that
we will not hold you down to?
(Professor Sturrock) One would imagine that approximately
80 per cent would be in the private sector.
9. Do you think, following the recommendations
that you made relating to information within your Review Group,
that as well as the response from women that you refer to, the
private sector have responded constructively to points that were
raised about the information issues that you pointed out?
(Professor Sturrock) I think there has been a response.
Whether it has gone as far as we would like I think is another
matter. We ourselves have not surveyed what is happening in the
private sector as a result of our recommendations and our report
but, from what we understand, certainly in the bigger private
clinics, our recommendations have been taken seriously and have
been considered in terms of providing better information, but
I think there is still a way to go there.
10. You mentioned a little while ago that your
Review Group has suggested putting health warnings on adverts.
It does appear from the ones we have seen that that might well
not be happening. Even if it were happening, what sort of effect
do you think those warnings might have and do information booklets
and health warnings have much impact in the face of the social
and advertising pressures that women are under?
(Professor Sturrock) I think that is a very good point.
I suppose it is analogous to cigarette advertising. To what extent
do the health warnings that appear on advertising boards and on
the cigarette packet affect the buying of cigarettes? I suppose
it is similar, in a sense, to putting health warnings on adverts
about breast implants, but I think it is important that the warnings
should be there because I think that it might make some people
think seriously, "Perhaps I do need to take a little more
information about this before I actually submit myself to it."
I think it is important that the warning is there but, to answer
your question precisely, I am really not sure what kind of effect
it has in percentage-wise terms in the general public taking heed
of these things if they really want to go ahead with something.
11. Given the pressure that women are under
once they perhaps want to go ahead with such an operation, is
it realistic to suppose that a surgeon, with a vested interest
in performing a particular cosmetic operation, will give objective
advice to often vulnerable young women contemplating this type
of operation? Who should be advising them? Is the doctor or the
surgeon the right person?
(Professor Sturrock) One of the things we were concerned
about was the lack of information provided to the general practitioner
in relation to women who might go into the private sector to see
a surgeon about a breast implant and often no letter is sent to
the general practitioner about that consultation. That was one
of the things we were very concerned about. Often of course it
is because the woman herself may not wish that to take place because
one of the things we realised was that many women go for this
kind of surgery and they do not even discuss it with their partner
or husband or any close members of the family. It is really kept
to themselves and many women may not wish their general practitioners
to be informed because then it might spill out into the wider
family situation, so that could be one possibility. Having said
that, we felt very strongly that there should be a proper communication
between the surgeon who has been consulted and the general practitioner
who, being alerted to what was being considered, might therefore
be able to raise a red flag as there may be some other problem
that the particular lady concerned might have which might militate
against her having an implant in the first place.
12. There is a great deal of concentration on
giving advice and booklets etc, but who is the best person to
give that advice? Is it the GP or the surgeon? Are surgeons renowned
for giving good practical advice to the women who are often feeling
(Professor Sturrock) I am not a surgeon, so I have
to be careful what I say. I think good clinical practice should
involve any doctor giving appropriate advice to a patient contemplating
any kind of procedure with the advantages and the risks involved
in that procedure and I suppose that is part of clinical standards,
which is another area that we were concerned to see improved,
especially within the private sector. So, there are big issues
here in terms of standards within the private sector, clinical
audit and clinical standards which I know that the surgical professional
bodies are very concerned to address and have been looking at
ways in which that can be improved.
13. Did I understand you correctly when you
said or implied that in a situation where a GP may refer to a
surgeonand this often may involve a patient crossing into
the private sector and frequently willit is common practice
for that GP to have no information back about what has happened
to that patient, even when they are consenting to that operation?
(Professor Sturrock) I am obviously only referring
to breast implantation, I cannot comment widely.
14. We are talking particularly about this area.
(Professor Sturrock) It certainly was a feature that
we were aware of that many general practitioners did not receive
information from the private clinic relating to the consultation
or what was being planned or even information that the surgery
had taken place.
15. So indeed the patient may go to the GP having
had this operation and the GP may have no knowledge whatsoever?
(Professor Sturrock) That is absolutely correct.
16. The patient may possibly present with something
symptomatic or relating to it and they have no information at
all. Can I come back to Siobhain's point which I thought was a
very important point regarding who is the most appropriate person
to give advice and counselling. Surely if a surgeon in the private
sector is seeing a patient referred by a GP, that surgeon has,
as Siobhain said, a vested interest in that surgery going ahead
because, to gain the reward from that work, the surgeon has to
undertake that intervention. Do we have a need to check on that
process somewhere, looking at what this Committee may recommend
and looking at the way forward? Is there not some way in which
we could perhaps look at a system that would ensure that taking
place? You talk about a checklist, but I am looking more at perhaps
detailed counselling by somebody who is independent and objective
who does not have a vested interest in seeing that surgery undertaken.
Have you looked at where that check might be built in?
(Professor Sturrock) No, we have not looked specifically
at that area. Of course, what is behind your question is really,
will the surgeon perform the operation because of the financial
incentive even if the clinical criteria for that surgery is not
strong? That of course is another big issue. Every good doctor,
regardless of financial incentive, should make an appropriate
clinical decision for that particular patient.
17. I am afraid we have found in our investigation
of the private sector that that did not necessarily happen.
(Professor Sturrock) I am sure that is the case. I
am just saying that is what should happen.
18. Some of the surgeons in the private sector
have a vested interest and produce the kind of advertising that
appears in our local and national newspapers day by day suggesting
to women that their life chances could be changed overnight by
that operation. They are part of that sales mechanism, are they
(Professor Sturrock) They could be part of that. This
is obviously approaching a territory which the Independent Review
Group were obviously not specifically concerned with.
19. We are taking you outside your remit and
I appreciate that.
(Professor Sturrock) Yes.