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1. The Royal College of Surgeons of England, led by a Cosmetic Surgery Interspecialty Committee, has developed a certification process that aims to provide accreditation of competences (including professional behaviours, clinical skills, knowledge and experience) in defined areas of cosmetic surgery.
The review into the regulation of cosmetic interventions in 2013, led by the Department of Health, recommended a more robust regulatory framework that provides protection against the potential risks from cosmetic procedures.
2. The certification process outlined in this document is an important step in this direction by recognising those surgeons who have the appropriate training, qualifications and experience in the area of cosmetic surgery in which they practise, by supporting patient choice and by promoting confidence in the quality of training and practice in cosmetic surgery.
Please see guidelines on the principles underpinning certification in cosmetic surgery, including:
• eligibility and criteria
• application and assessment process
• maintaining certification
B. Scope of certification
3. Cosmetic surgery is where a person chooses to undergo an operation, or invasive medical procedure, to alter their physical appearance for aesthetic rather than medical reasons. It is rarely available through the NHS, primarily taking place in the private sector. There must be overriding physical or psychological reasons for it to be considered as a treatment option on the NHS.
The scope of certification extends to invasive surgical cosmetic procedures and does not include non-surgical procedures such as Botox®, dermal fillers and chemical peels. Invasive cosmetic procedures have been defined in the RCS Professional Standards for Cosmetic Practice (RCS, 2013) as: ‘Operations and all other invasive medical procedures where the primary aim is the change, the restoration, normalisation or improvement of the appearance, the function and well-being at the request of an individual.’
Invasive treatments are categorised as follows:
Medium-high risk; may require general anaesthetic; may require overnight stay.
Low-medium risk; usually only require local anaesthetic; performed as an outpatient.
For non-surgical cosmetic interventions that do not fall under the above definitions (including hair restoration), Health Education England (HEE) has developed a set of qualification requirements, which is available through the HEE website.
4. Certification is open to all surgeons who are on the GMC specialist register in a surgical specialty that provides training and experience related to the area of cosmetic surgery in which they practise. There are nine available areas of certification, based on a categorisation of cosmetic surgical procedures into groups of closely related operations. These procedures are grouped anatomically and the operations within the groups have overlapping requirements of skills and training. The available areas of certification and the corresponding GMC registration/specialty training are:
Area of certification* GMC Specialist Registration
Cosmetic breast surgery • Plastic surgery
• General surgery (with a declared interest in breast surgery)
Cosmetic nasal surgery • Plastic surgery
• Oral and maxillofacial surgery
Cosmetic surgery of the periorbital region • Plastic surgery
• Ophthalmology (with a declared interest in oculoplastic surgery)
• Oral and maxillofacial surgery
Cosmetic surgery of the ear • Plastic surgery
• Oral and maxillofacial surgery
Cosmetic facial contouring surgery • Otolaryngology
• Oral and maxillofacial surgery
• Plastic surgery
Cosmetic surgery of the face • Plastic surgery
• Oral and maxillofacial surgery
Cosmetic surgery of the face/nose/periorbital region/ears • Plastic surgery
• Oral and maxillofacial surgery
*Full information on the scope of each certification area and the specific cosmetic procedures it encompasses is provided in Appendix II.
5. Surgeons are able to obtain certification in more than one area within the scope of their specialty training.
6. Surgeons who practise predominantly overseas are also eligible to apply for certification provided they are on the GMC specialist register in the corresponding specialty. Surgeons who have not completed an approved training programme in the UK can still enter the GMC specialist register in the required specialty by applying for the GMC’s Certificate of Eligibility for Specialist Registration (CESR). More information on the CESR route to the GMC specialist register is available through GMC website at http://www.gmc-uk.org/doctors/24630.asp
7. In addition to entry on the GMC register and the corresponding specialty training, certification is based on a series of criteria and evidence that demonstrate competence in:
a. professional behaviours
b. clinical skills and experience
8. A summary of the criteria for certification is as follows:
• Knowledge and acceptance of the professional responsibilities set out in the GMC’s Guidance for All Doctors Who Offer Cosmetic Interventions (GMC, 2016) and RCS’ Professional Standards for Cosmetic Surgery (RCS, 2016).
• Attendance at an RCS-accredited masterclass on professional behaviours for cosmetic surgery.
• Professional indemnity insurance that covers cosmetic practice in the UK.
• Successful revalidation that has taken cosmetic practice into account.
• CPD activities relevant to cosmetic practice.
• Four complex case reviews.
• Multi-source feedback exercise with reflection on results.
• Exposure to a minimum number of procedures relevant to the area of certification.
• Clinical outcomes in line with the requirements of the Competition and Markets Authority, with reflection on results.
• Two references.
• A full description of the criteria and associated evidence, including any variations for surgeons in training or those who practise predominantly overseas, is provided in Appendices I and II.
E. Application and assessment
9. Candidates can apply for certification by registering on the online Cosmetic Surgery Certification Portal at the following weblink: https://certify.rcs.eng.ac.uk
The Portal is a secure, web-based system that will guide you step-by-step through the application process and will allow you to upload and store all required evidence for certification. You can access professional guidance and information relevant to certification through the Portal, including tools and templates for specific categories of evidence. You will also be able to track the status of your application and contact the certification support team with any questions.
10. As part of the online application process you will be asked to pay an application fee of £2,000. This includes your attendance at the professional behaviours masterclass course (which is a mandatory component of certification), as well as your application fee for certification. You can apply for more than one certificate in different certificate areas at the same time for no additional application fee. Payment is made at the point when you book onto a masterclass course session.
11. Your application will be assessed by a surgeon who has received dedicated training for assessing applications. There is a team of evaluators with representation from each of the recognised surgical specialties. An evaluator will be assigned to each application and will review elements of the submitted evidence and make a decision about awarding certification. Where this is required, specialty-specific elements of the evidence will be reviewed by an evaluator who practises specifically in the certification area. An evaluator may ask for further evidence from an applicant if the information is unclear or missing.
12. Once a complete application has been submitted, a decision will normally be made within 28 days. This time- frame might be longer if any of the required information is missing or if further clarification is required. A hard copy of your certificate(s) will be sent to the address you provided on the Portal. Additional hard copies of a certificate can be requested for a small administrative fee.
F. Maintaining certification
13. Certification, along with the required portfolio of evidence, builds on the revalidation process and lasts for approximately five years in alignment with the revalidation cycle. To maintain certification, applicants will have to apply for renewal every five years at the point of revalidation. The date of the first renewal will be set at the point of successful certification.
14. Applicants will not have to repeat the original certification process or re-submit the same portfolio of evidence to maintain certification. They will be required to confirm that their details have not changed and that they continue to comply with the order of the Competition and Markets Authority for collection and publication of clinical outcomes data (see also paragraph 28 of this document). They will also be required to confirm that they have been contributing evidence about their cosmetic practice to their annual appraisal discussion as part of the existing requirement for whole practice appraisal for the purposes of revalidation. This includes relevant CPD activities about clinical and professional aspects of their practice, multi-source feedback and a regular audit of outcomes data as described in paragraph 28 of this document.
15. Renewal of certification will take place through the online Portal, for which there will be a fee.
Appendix I – Evidence requirements
16. The information and categories of evidence described in this section are a requirement for all areas of certification and are in principle the same for all applicants. Where there are variations for surgeons who practise predominantly overseas, or for surgeons who have recently completed their training, this is specifically indicated.
All evidence should be submitted on the Portal, where applicants will be guided to provide information and upload relevant documentation as part of the application process.
17. Registration on the GMC specialist register in a surgical specialty that corresponds to the certification area
(see section C of this document)
Applicants are asked to provide their GMC number and confirm the surgical specialty in which they are listed on the GMC register. General surgeons should also confirm that they have a special interest/specialisation in breast surgery, and ophthalmologists in oculoplastic surgery.
18. Scope of work
Applicants are asked to provide information on the full scope of their work, including (but not limited to) their cosmetic practice. This should encompass all work undertaken in the NHS or in private or independent practice, and should include clinical commitments as well as managerial, educational, research and academic roles.
This information can be recorded directly on the Portal. Applicants are also asked to upload the job plan that was valid during their most recent appraisal.
19. Declaration of no suspensions or restrictions of practice
Applicants are asked to declare that they are not subject to any suspensions or restrictions on their practice at the time of application.
We are also asking applicants to let us know if at the time of application they are under investigation by the GMC. The nature of any investigation will be assessed by a clinical evaluator on a case-by-case basis and will not necessarily result in an unsuccessful application.
20. Declaration of knowledge and acceptance of professional responsibilities set by the GMC and the Royal College of Surgeons
All surgeons who practise cosmetic surgery are expected to have full knowledge and understanding of the GMC’s Guidance For Doctors Who Offer Cosmetic Interventions (GMC, 2016) and the RCS’ Professional Standards for Cosmetic Surgery (RCS, 2016). Applicants will be asked to declare that they accept the
professional responsibilities placed on them by the above two documents in relation to ethical bahaviours and practices when offering cosmetic interventions.
21. Masterclass on professional behaviours for cosmetic surgery
Applicants are required to attend and meet the requirements of a masterclass on professional behaviours as this is one of the most significant areas that impact on patient satisfaction, quality and safety in cosmetic surgery. The masterclass must be accredited by the Royal College of Surgeons for cosmetic surgery.
A list of accredited masterclasses will be provided through the Portal, where you will be guided to upload your certificate of successful completion of the masterclass.
Applicants are required to have professional indemnity insurance that specifically covers their cosmetic practice in the UK. They will be asked to confirm their indemnity arrangements and provide the name of their medical defence organisation or insurance provider as well as their membership number or insurance policy number.
Surgeons who practise predominantly overseas and whose insurance provider is not based in the UK must provide additional evidence to demonstrate that their insurance provider is aware of their practice in the UK and provides adequate cover for it. Examples of such additional evidence include a copy of their indemnity policy, their indemnity certificate or a letter by the insurance provider.
Applicants are asked to provide information about their revalidation to demonstrate that they are up to date in the areas in which they practise. This includes details of their designated body, the date of their most recent revalidation along with the GMC’s revalidation confirmation, and the date of their next revalidation.
Applicants should upload a summary of their appraisals as signed off by the applicant’s appraiser and the designated body. Applicants whose most recent revalidation took place during their training or at the point of CCT should upload an ARCP Outcome 6 form or a RITA G form. Where an applicant’s practice encompasses
work across multiple organisations, the applicant is required to provide information about any safety incidents, legal claims and patient complaints they have been involved in in each organisation during the last appraisal period, normally confirmed by the head of department or the chief of medical service in each organisation.
Applicants’ appraisals should include evidence from their whole practice, including their cosmetic practice. Surgeons who submit evidence for certification from the first cycle of revalidation are required to have undertaken at least one appraisal for the purposes of revalidation that has taken into account their cosmetic practice. They will also be asked to confirm that they will be including evidence of their cosmetic practice in all future appraisals.
24. Continuing professional development
Applicants should provide evidence of having undertaken continuing professional development (CPD) activities in the area of certification. Surgeons are normally expected to collect 50 credits of CPD activity per year, or 250 credits across the 5-year revalidation cycle, spread proportionately across all areas of their practice. Detailed guidance on CPD requirements for surgery is available through the College website on: https://www.rcseng.ac.uk/surgeons/surgical-standards/docs/cpd-summary-guide-for-surgery-2013
Applicants can record all relevant activities directly on the Portal and/or upload a CPD diary, eg one that is provided through their hospital or through the Surgeons Portfolio (https://www.surgeonsportfolio.org/). In addition, applicants will be asked to upload any supporting information of their CPD activities such as certificates of attendance, letters from event organisers, and minutes of meetings.
25. Case reviews
Applicants are required to use the dedicated space provided on the Portal to record reviews of four complex cases in which they participated and the learning they achieved.
Cases can be complex because of technical challenges posed by the condition, unexpected complications, breakdown of the patient–doctor relationship, systems failure or other reasons. For certification, applicants should provide evidence of participation in consultation/post-consultation debrief sessions from any of the following groups:
• Planning of technically challenging cases, eg revision/salvage aesthetic surgery.
• Patient/surgeon challenges, eg failure to a meet patient’s expectations, or breakdown in communication.
• Managing complications following cosmetic surgery.
• Provision of a second opinion and/or transfer of care following breakdown of a patient–doctor relationship.
• Medicolegal assessment.
The purpose of case reviews is to demonstrate that cosmetic surgeons are engaging in discussion to maintain and enhance the quality of their professional work. The discussion can be with a peer, another specialist, within a multidisciplinary team or, for surgeons in training, with a supervisor. The emphasis of learning from such a meeting/discussion should be the management of the patient’s concerns, fears and expectations, rather than the specifics of the treatment.
For the breast surgery region, up to two of these case discussions may take place within applicants’ reconstructive practice. In all other areas, the complex cases should be wholly from the surgeon’s cosmetic practice. (Please see Appendix II for the time period within which cases have to be performed.)
26. Multi-source feedback
Applicants are asked to upload the results of one multi-source feedback (MSF) exercise that took place during their last revalidation cycle and included the collection of colleagues' and patients’ opinions on the applicant’s clinical performance and professional behaviour.
The selection of colleagues and patients should encompass applicants’ whole practice, including their cosmetic practice. Applicants who, at the time of their application for certification, had already completed an MSF exercise as part of the first revalidation cycle in the NHS between 2013–2017 and that exercise did not include cosmetic patients, can use their existing MSF results along with relevant reflection points. Any subsequent MSF exercises should include colleague and patient feedback from their cosmetic practice.
For surgeons whose multi-source feedback exercise took place during their training (and therefore did not include patient feedback), the results included as part of their ARCP evidence along with accompanying reflection will be sufficient for the purposes of certification.
Applicants should use the dedicated space provided on the Portal to record their reflection on the results of this exercise and of their performance, along with key learning and action points.
27. Evidence of operative exposure in the procedures identified for the respective areas of certification.
Applicants are required to confirm their operative experience in specific procedures relevant to their areas of practice and certification. Appendix II of this document sets out the system of credits for demonstrating appropriate experience.
Applicants can record their operative experience in the relevant section of the Portal, which will automatically calculate the corresponding number of credits. Applicants who have separate activity reports generated by their provider, or through a logbook which meet the criteria set out in Appendix II, can upload copies of these reports and do not have to use the Portal calculator.
Applicants should also provide a list of all hospitals and time periods where the procedures have taken place to allow assessors to sample and evaluate this information. These hospitals should meet fundamental standards of quality and safety in line with those set by the Care Quality Commission (https://www.cqc.org.uk/), Healthcare Inspectorate Wales (http://www.hiw.org.uk/) or equivalent.
Credits should normally be collected within a period of six years prior to the point of applying for certification, with periods of up to eight years to be considered on a case-by-case basis. For surgeons who are in less than full-time training, this period will be extended on a pro rata basis.
Applicants are asked to provide evidence that they comply with the order of the Competition and Markets Authority (CMA) for collection and publication of clinical outcomes data at provider and consultant level (the full order is available online at: https://assets.digital.cabinet- office.gov.uk/media/542c1543e5274a1314000c56/Non-Divestment_Order_amended.pdf). Such evidence can consist of uploading a letter from their provider confirming that the applicant has complied with the CMA requirements and that the outcome results fulfil all relevant internal governance structures.
Applicants should also use the dedicated space on the Portal to reflect on their outcome results and should confirm that they will bring their outcomes for discussion at appraisal.
NB The first publication of the CMA-mandated data will take place in April 2017, whereas providers will only begin collecting such data from autumn 2015. Once the CMA requirements have been in operation for at least a year (ie approximately from April 2018 onwards) applicants will also be required to carry out an audit of their outcomes in line with College guidance (available on www.rcseng.ac.uk/cosmeticsurgerystandards) and subject the results to peer discussion and review.
Applicants are asked to provide the details of two referees, one of whom should be your clinical director and the other a senior colleague/consultant practising either in the same area of cosmetic surgery or at your main provider. For applicants who have recently completed their training, one of the references can be provided by their assigned educational supervisor or their clinical supervisor. Referees will be asked to submit their reference on the online portal. References have to be aligned with the GMC guidance Writing References (GMC, 2012) and referees will be asked to include information on:
• The applicant’s professional competence (the referee should be prepared to provide evidence to support this where appropriate and upon request by the certification evaluator).
• The applicant’s conduct, including matters that might affect a patient’s trust in the individual.
• Any other issues that may put patients at risk, including information on unresolved, outstanding or past complaints about the applicant’s competence, performance or conduct where those are relevant to the applicant’s suitability for certification.
Applicants are advised to check that they have the correct email address for their referee and that their referee is willing and able to provide a reference for them before they submit their application form and payment. An application will remain open until both referees have submitted their references on the portal.
Appendix II – Areas of certification, associated procedures and credits
A clear set of standards for cosmetic surgery are needed that easily enable a prospective patient to be confident that their surgeon has the appropriate training, qualifications and experience to perform their chosen procedure.
Through the Cosmetic Surgery Interspecialty Committee (CSIC), we have developed a system that allows surgeons to demonstrate high professional and clinical standards. Patients and hospitals will be able to search for a certified surgeon on the RCS website. The Care Quality Commission (CQC) will take account of our standards when inspecting and rating services. This new system of certification will make the cosmetic surgery industry safer for patients and enhance the reputation of the profession.
Surgeons will be able to obtain certification in one or more groups of closely related procedures, as long as they are on the GMC specialist register in a specialty that demonstrates training and experience in the chosen area of practice and can demonstrate that they meet the certification requirements. To facilitate this we have categorised cosmetic surgical procedures into groups of closely related operations. The procedures are grouped anatomically and the operations within the groups have overlapping requirements of skills and training.
One of the requirements of certification is to provide evidence of operative exposure in the area of certification. This involves carrying out a requisite minimum number of procedures for that area, as set out below. You can read further information about certification on our website (www.rcseng.ac.uk/cosmetic).
The RCS have devised a system of credits to demonstrate appropriate experience. This is explained as follows:
• Credits may be obtained from the cases described in each section
• 1 credit is obtained from a procedure performed or performed with assistance
• 0.75 of a credit is obtained from assistance during a procedure
• 0.5 of a credit is obtained from observation of a procedure
• Crossover skills/reconstructive credit rate is 50 per cent of the credit rate for cosmetic procedures
• The number of crossover skills/reconstructive credits that can count towards the total is specified for each certificate
To qualify for the credit in procedures observed, the surgeon must:
• be present for whole case
• discuss the case with the surgeon undertaking the procedure
• confirm that the observed cases have been approved by the supervising surgeon as appropriate teaching cases.
A maximum of 30% of credits in any area of certification can be obtained from observation.
Time period for obtaining the minimum number of procedures
Normally, procedures performed/observed within the preceding six years from the point of applying for certification can be used. Periods of up to eight years will be considered on a case-by-case basis. Periods for the collection of credits for less than full-time pre-CCT trainees will be extended on a pro rata basis.
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