12 January 2021

Consultation on the placement and scheduling of cosmetic interventions advertising

Response from Transform Hospital Group

This document sets out Transform Hospital Group’s response to the Committee of Advertising Practice (CAP) and Broadcast Committee of Advertising Practice’s (BCAP) proposal for new regulations governing the placement and scheduling of cosmetic interventions advertising.

The document first provides background on Transform Hospital Group and its relevant clinical, operational and marketing activities, before addressing in turn each area under consultation by CAP and BCAP.

About Transform Hospital Group: what we do and the values that define us

Transform Hospital Group is a wellbeing and healthcare services organisation and the UK’s leading provider of cosmetic interventions – both surgical and non-surgical – and weight-loss solutions. The company operates two state-of-the-art hospitals – Burcot Hall in Birmingham and The Pines in Manchester – in addition to a nationwide network of 25 clinics which cover most major towns and cities across the UK.

An absolute commitment to patient safety, clinical excellence and corporate responsibility underpins everything we do and is core to our identity as a healthcare services provider. Indeed, as a healthcare organisation, Transform Hospital Group has been proud to support the NHS during the COVID-19 pandemic, supporting the delivery of elective care for NHS patients during the initial peak of infections. In so doing, we made our hospitals in Birmingham and Manchester available to local NHS trusts, playing our part in supporting the nation’s health at a critical time for public health services and our local communities.

Transform Hospital Group believes that this consultation comes at a timely moment for the cosmetic interventions industry and welcomes its proposals in the context of a rapidly evolving, globalised and technology-led consumer culture. It is this culture that defines the cosmetic interventions sector to the same extent as the beauty, fashion and cosmetics industries more generally, meaning that there is an ever-increasing and pertinent need for regulatory change.

Transform Hospital Group functions with a clear-minded awareness of the responsibilities of cosmetic interventions providers at a time when questions and debates surrounding body image, mental health, gender normativity and identity are high on the public agenda. As a market leader in the sector, we recognise our responsibility to adopt an extremely thoughtful, considered and nuanced approach to the way in which we engage patients – through our marketing activity, our patient interaction, the surgeon and nurse-led consultation processes and in the delivery of aftercare. We recognise and embrace the imperative to remain forensically aware of the external dynamics that may condition the motivations of our patients, and thus adopt a holistic and compassionate approach to patient safety and wellbeing throughout the patient journey.

This outlook, and the values that underpin our perspective on what we do and why we do it, defines Transform Hospital Group, our culture and our people.

Ensuring effective and patient-focused regulation of the cosmetic interventions sector

Transform Hospital Group is a healthcare provider first and foremost, committed to clinical best practice, governance and serving as a prominent advocate for patient safety and wellbeing. We work closely with regulators, industry bodies, government and parliamentarians to ensure that the regulatory environment that structures the cosmetic interventions sector is wholly aligned to that of the wider healthcare sector. We are recognised as a thought leader in this domain and are frequently called upon by policymakers to provide insight, expertise and input to the development of regulation and industry guidelines.

In line with our progressive and robust approach to advocating for an appropriate regulatory framework for the sector, Transform Hospital Group fully supports and is compliant with all regulations pertaining to the delivery of cosmetic interventions procedures on children (up to the age of 16) and young people (those aged between 16 and 17). In fact, the company adopts stricter age-restriction measures than it is required to by law, and does not offer non-surgical cosmetic interventions to anyone below the age of 18 unless there is a condition-led clinical reason to do so and only in consultation with the patient’s GP and with the authority of the patient’s legal guardian.

To this end, Transform Hospital Group has directly advised the All-Party Parliamentary Group on Beauty, Aesthetics and Wellbeing on the regulatory issues surrounding non-surgical cosmetic procedures, calling for legislation to be implemented which would make it illegal for providers and practitioners to deliver non-surgical cosmetic interventions to under-18s. The company also supports the passage of the Botulinum Toxin and Cosmetic Fillers (Children) Bill[1] – which at the time of writing is currently being debated in the Houses of Parliament, and seeks to ban the provision of botulinum toxin and cosmetic fillers for people under the age of 18.

The company has also advocated for a number of other measures aimed at improving patient safety, including calling for the introduction of regulation to ensure that non-surgical cosmetic interventions are effectively regulated at a clinical level and brought into line with the regulatory frameworks governing surgical cosmetic interventions, to the extent that the health, safety and wellbeing of patients is safeguarded effectively. In addition to this, Transform Hospital Group also recognises the need for the clarification and stricter introduction of regulations effecting the marketing procedures of cosmetic interventions providers, which must not act to unduly influence the perceptions of body image for children and young people. 

This progressive and proactive approach to regulation conditions our wider commitment to engaging all stakeholders in and around the sectors in which we operate; and we look forward to continuing dialogue with the Advertising Standards Authority (ASA), CAP and BCAP in the wider context of this consultation process.

Note on reference to The Hospital Group in Consultation Document

Transform Hospital Group notes the reference to The Hospital Group brand – and specifically its operating company at the time, The Hospital Group Healthcare Limited - on page 13 of CAP and BCAP’s consultation paper[2] with regards to an advertisement commissioned by the operating company in 2014.

In 2016, The Hospital Group Healthcare Limited was acquired by Aurelius, a private equity investor. As a result of Aurelius’ acquisition, The Hospital Group Limited’s former owners and management no longer retained any interest in, or responsibility for, the operations or running of The Hospital Group. Following its acquisition of The Hospital Group Limited, Aurelius changed the operating structure of the business and put in place a new management team – led by a new CEO, Tony Veverka, with over 30-years’ experience in running healthcare organisations – with the objective of overhauling the previous culture of the organisation and ensuring the highest standards of corporate governance and responsibility at all levels of the company.

In 2019, The Hospital Group brand was merged with its sister brand, Transform – another market leading cosmetic interventions and weight loss services provider – to form Transform Hospital Group Limited (“THGL”), t/a Transform Hospital Group. While both The Hospital Group and Transform brands remain active and patient-facing, the corporate entity – THGL – is responsible for all patient interaction and continuity of care, and is registered, accountable to and regulated by all relevant regulatory bodies, such as the Care Quality Commission and the ASA.

Therefore, while THGL continues to operate The Hospital Group brand, it must be noted that the 2014 advert referenced in the consultation document is not connected to THGL and does not in any way represent or reflect the marketing practices or values of the company under its current ownership and management.

Transform Hospital Group’s industry-leading approach to responsible marketing

As a regulated healthcare provider, Transform Hospital Group is committed to operating the highest standards of responsible marketing across all communications channels and in line with all current ASA guidance specific to cosmetic interventions providers.  

Transform Hospital Group has recently altered its approach to its marketing activity, such that the company has not engaged in broadcast advertising methods (television and radio) over the last twelve months. The dominant advertising channels therefore now exist online, where the company utilises social media channels and paid digital advertising (both on third party websites and social media platforms), in addition to the appropriate and responsible use of influencer marketing, which is carried out with substantial and robust levels of due diligence.

It should be noted that Transform Hospital Group is currently updating its internal guidelines to instruct the company’s use of online advertising, with particular reference to the use of social media influencers, so as to remain responsible and in line with our brand values. We believe this work is unique and sets us apart from our competitors and we would be happy to share our guidelines with the ASA once they have been finalised. Ahead of the publication of the guidelines, Transform Hospital Group will continue to carry out robust due diligence procedures, which take particular care in considering the age of the audience that our marketing is likely to engage and the impact it might have on body image and mental health for people of all ages.

With specific regards to the use of social media influencers, this process takes into account the background, follower base, tone and content of all influencers, ensuring they reflect the company’s values and its responsibility to protect young people. These procedures have already resulted in the company turning down influencers that have expressed interest in promoting our products based on the age demographic that is likely to view or engage with the posts. In addition, Transform Hospital Group operates its own websites and social media channels, which serve as clinically oriented information hubs for patients.

Transform Hospital Group’s marketing activities fully comply with guidance set out by the General Medical Council[3] (GMC), the Joint Council for Cosmetic Practitioners[4] (JCCP) and Save Face[5], all of which make clear that marketing should not be directed towards children or young people, through either content or placement. It should be noted that Transform Hospital Group has been a leading and active member of the JCCP since its inception and was the first major cosmetic interventions provider to join the organisation.

As a socially engaged and responsible provider, Transform Hospital Group is keenly aware that young people are often disproportionately influenced by societal and cultural norms relating to body image. We are also aware that the increasing prominence of cosmetic interventions within consumer culture at large may result in some under-18s perceiving that such procedures are necessary to achieve a form of beauty ideal, with resulting impact on their self-esteem and mental health.    

As such, Transform Hospital Group ensures that the procedures we provide are marketed thoughtfully, responsibly and targeted at an adult-only audience whilst emphasising a clinically led approach. While we believe it right to celebrate the authentic and empowered decisions that our patients make prior to undergoing a procedure, at no point does our marketing activity glamorise a cosmetic intervention, nor do we trivialise the importance of arriving at the decision to undergo a cosmetic intervention following education and full consideration of the risks and spectrum of outcomes of an intervention; whether it be surgical or non-surgical.[6]

Transform Hospital Group therefore agrees with the underlying principle that advertising for cosmetic surgery procedures should not be directed towards or targeted at young people and we therefore welcome the proposals set out by CAP and BCAP, which stand to protect children and young people from irresponsible operators. If measures are introduced to this effect, they will ensure more effective compliance with responsible marketing guidelines than the present system, which too often relies on operators acting in good faith and according to voluntary codes of conduct.

The following sections respond to each element of the consultation as outlined on page 18 of the consultation paper.

CAP consultation

  1. Whether the introduction of an age-specific placement restriction on non-broadcast advertising for cosmetic interventions in the CAP Code is necessary and proportionate? Please provide your rationale and any relevant evidence in support of your answer.

While Transform Hospital Group’s marketing is focused solely on engaging adult audiences – and therefore the company undertakes due diligence to ensure that it does not target children or young people with its marketing activity – the company acknowledges that audiences under the age of 18 could be exposed to marketing activity by providers of cosmetic interventions indirectly in non-broadcast advertising, particularly through digital and social media platforms.

As such, Transform Hospital Group believes that search engine platforms, social media platforms and cosmetic interventions providers carry a collective responsibility to review age restriction regulations in order to ensure effective levels of safeguarding are in place for under-18s, where possible. The onus is not only on cosmetic interventions providers in this regard and we would welcome an ASA-convened forum that would promote collaboration between relevant stakeholders to achieve this objective.

As with other sectors subject to age restricted advertising regulations, there will of course be practical limits to providers’ ability to guarantee categorically that any non-broadcast advertising activity does not reach children and young people – including but not limited to the fact that some under-18s may have inaccurately reported their birth date on digital platforms in order to gain access to adult content.  We believe, however, that industry operators should seek to ensure, where possible, that they support their choice of demographic data with behavioural data that similarly biases the target audience.

One area of particular sensitivity applies to influencer marketing on social media platforms, where the highly dynamic nature of an influencer’s follower-base is such that any content partnerships that the provider in question engages in with the influencer may indirectly reach under-18 audiences, in spite of the provider’s best efforts and intentions.

As such, an additional measure that should be placed under consideration by CAP in order to further protect children and young people from undue exposure to cosmetic interventions advertising is introducing clear age-restriction messages that are visibly evident in influencer marketing posts. 

It would be excessively punitive if cosmetic interventions companies were prevented from making use of social media influencers outright on the basis that the influencer’s audience included even a small proportion of under-18s, as this is out of the company’s control, may be subject to frequent change and relies on technology being put in place by social media platforms to effectively filter content.

We would however be supportive of measures that would, for example, put in place reasonable policies to guide the interaction between a cosmetic interventions provider and a social media influencer, such that providers are not restricted from working with influencers, but that checks and balances are put in place. This would ensure that the nature of the content is appropriate to the influencer’s follower-base, and that guidelines are put in place that require providers to take reasonable steps to determine whether an influencer’s audience is likely to include a disproportionate number of under-18s. This would require the collaboration of social media platforms to make user data openly available to providers, without which such guidelines or requirements would be unworkable in practice and subject to unhelpfully broad interpretation. We would welcome the opportunity to participate in further discussions on this topic.

  1. If your answer to Question 1 is ‘Yes’, do you agree with CAP’s proposed wording for a new rule in Section 12 Medicines, medical devices, health-related products and beauty products of the CAP Code? Please explain your reasons in your response.
    1. Marketing communications for cosmetic interventions must not be directed at those aged below 18 years through the selection of media or context in which they appear.

Cosmetic interventions mean any intervention, procedure or treatment carried out with the primary objective of changing an aspect of a patient’s physical appearance. This includes surgical and non-surgical interventions, both invasive and non-invasive. This does not include cosmetic products as defined in Regulation (EC) No 1223/2009. See Advertising Guidance: Cosmetic Interventions.

Transform Hospital Group agrees with the proposed wording for a new rule in Section 12 of the CAP Code, on the basis that it would bring the marketing regulations for cosmetic interventions into line with operational industry regulations – some of which are likely to be imminently implemented – meaning that no children or young people should be exposed to cosmetic interventions advertising – whether that be for non-surgical or surgical procedures.

Of note in the proposed wording is the emphasis on the imperative for providers to ensure that their advertising is not “directed” at under-18s via the “selection of media or contexts in which they appear”. This phrasing rightly emphasises that the intentionality of marketing activity should not be focused (strategically or tactically) at an under-18 audience, such that this guides media buying activity, for example.

BCAP consultation

  1. Whether the introduction of an age-specific scheduling restriction broadcast advertising for cosmetic interventions in the BCAP Code is necessary and proportionate? Please provide your rationale and any relevant evidence in support of your answer.

Although broadcast advertising is not currently part of Transform Hospital Group’s marketing strategy, the company agrees that as with non-broadcast advertising, there should be age-specific scheduling restrictions for broadcast advertising for cosmetic interventions. Therefore, no cosmetic interventions advertising should be broadcast in or adjacent to programmes commissioned for or principally directed at audiences below the age of 18.

  1. If your answer to Question 3 is ‘Yes’, do you agree with BCAP’s proposed wording for a new rule in Section 32 Scheduling of the BCAP Code. Please explain your reasons in your response?

These may not be advertised in or adjacent to programmes commissioned for, principally directed at or likely to appeal particularly to audiences below the age of 18.

Cosmetic interventions, procedures or treatments carried out with the primary objective of changing an aspect of a patient’s physical appearance. This includes surgical and non-surgical interventions, both invasive and non-invasive. This does not include cosmetic products as defined in Regulation (EC) No 1223/2009. See Advertising Guidance: Cosmetic Interventions.

Transform Hospital Group agrees with BCAP’s proposed wording preventing industry operators from “advertising in” or “adjacent to” programmes “commissioned for and principally directed at” audiences below the age of 18. While judgments can of course be made independently and in good faith by marketeers, we would welcome the ASA’s guidance on measures that can be put in place to ensure absolute clarity on whether a programme has been “commissioned for and principally directed at” this audience, to guide marketing activity accordingly.

Transform Hospital Group however holds concerns relating to the qualification that cosmetic interventions advertising be banned from airing around programmes that are “likely to appeal particularly” to audiences under 18. We are concerned that this is a highly subjective turn of phrase that does not provide a substantive definition and is potentially open to wide interpretation from regulators, external observers and cosmetic interventions providers.

The question of whether or not a programme is “likely to appeal” to a specific age group, particularly under-18s, is subject to cultural forces beyond the control or perhaps even the predictability of regulators or marketeers; whether a programme “appeals” to an under-18 audience may change series-to-series, for example, and is conditional on broader, unpredictable media consumption trends, to the extent that marketing activity may not be reasonably planned. We would therefore welcome further discussion on this point particularly before providing our support for the proposed wording in its entirety.


[1] Botulinum Toxin and Cosmetic Fillers (Children) Bill

[2] Consultation on the placement and scheduling of cosmetic interventions advertising

[3] Guidance for doctors who offer cosmetic interventions

[4] JCCP Policies & Procedures

[5] Save Face Standards

[6] We evidenced this position when contesting the January 2018 ASA decision against a Transform broadcast advert, which focused on a patient’s personal journey to undergo breast surgery after the birth of her daughter. We would be happy to revisit this matter and provide further perspectives within the context of further discussions with the ASA, following submission of this consultation response.