JOURNAL TRANSCRIPT
FEATURE
From PIP to DC-CIK to the Sorcerer’s Apprentice: a medico-political minefield BY PROFESSOR ANDREW BURD
P
oly Implant Prothese (PIP) was a French company that manufactured silicone breast implants that were surgically implanted mainly for cosmetic breast augmentation. Of note, ‘cosmetic’ is used in the strict sense of the word meaning false and artificial and does not imply any medical need or health benefit. When silicone is implanted into the body a special medical grade silicone should be used. This requires a higher form of preparation and incurs greater costs in manufacture than non-medical grade silicones. It was a significant act of self-deception when the owners of the PIP company thought that they could save costs and increase profits by using an industrial grade silicone rather than the medical grade silicone in the manufacture of their breast prostheses. Who would know about the substitution? Ultimately it was the unacceptably high rupture rate of the PIP implants that led to the downfall of the company and a worldwide scare that induced a range of responses from different national governments and regulatory bodies. By 2011, the French government was recommending that 30,000 French women should have their implants removed. Who by, who pays, are they replaced, who by, who pays? A recommendation is easy to make but the logistics of implementation are very different. The subsequent fallout from the ‘PIP scandal’ is still playing out, but one of the outcomes is the Review of the Regulations of Cosmetic Interventions. This was the public face of the Department of Health demonstrating their concern about a massive industry that appears to be growing Hydra-like with seemingly little control or regulation. Prof Sir Bruce Keogh KBE, the National Medical Director for the NHS in England chaired a review committee that produced its report in April of 2013. Ms Judy Evans is commenting on this report in this issue (A Reaction to the ‘Keogh Report’ – page 22) and I will make no detailed
remarks about the report here apart from the fact that I think it is an example of an opportunity wasted. Surely the first part of any such report should be a definition of terms, but the report, supposedly on cosmetic interventions, jumps from surgical operations to medical procedures to non-medical and beauty treatments.The definition as stated in the glossary of the report is thus: ‘Cosmetic intervention: operations or other procedures that revise or change the appearance, colour, texture, structure, or position of bodily features, which most would consider otherwise within the broad range of ‘normal’ for that person.’ This is really so imprecise it relegates the recommendations within the report to mere political gestures, which have little moral, ethical or professional substance. The whole issue is further trivialised by bringing up the analogy with purchasing a ballpoint pen or toothbrush and then by this very strange figure of speech appearing at the bottom of page five of the report: ‘These recommendations are not about increasing bureaucracy but about putting everyone’s (sic) safety and wellbeing first.’ So, in my opinion the Review panel has put in a lot of work to deliver a marginal performance and must try to focus more in the future. The problem is that whilst there may be a common view about how the service should be delivered, there is no such common ground about recognising who should deliver the service. Unfortunately, the medical profession, or perhaps more correctly, a small number of specialists, appear to want to put their financial well being first and foremost when considering control and regulation. I am a little weary of the oft-repeated mantra of the less mature surgeons regarding the need to restrict interventions to only those for which the practitioner can manage all relevant complications. This is a spurious justification for surgeons who want to try and control the lucrative dermal filler market. But
it is fundamentally wrong. Mr Chris Munsch, a Consultant Cardiothoracic Surgeon and Past Chairman of the Joint Committee on Surgical Training for the Royal Colleges of Surgeons, was involved in compiling Appendix four: recommendations regarding training and
...whilst there may be a common view about how the service should be delivered, there is no such common ground about recognising who should deliver the service.
education in cosmetic surgery, and here is recommendation number one: Recommendation number 1: ‘The only person who should carry out cosmetic surgery is a doctor, fully trained in the technical, professional and cognitive aspects of the practice, and competent to handle any complications that may arise.’ It sounds reasonable until you consider the reality of medicine and in order to put an abrupt stop to a faulty line of reasoning we just have to ask how many of Mr Munsch’s interventional cardiology colleagues are competent in performing open heart surgery in the event of a complication with, for example, a coronary angioplasty that requires an emergency coronary artery bypass graft (