COVID-19 Pluto’s Practical Guide for Dentists

May 5, 2020

Pluto Partners would like to start this guide by thanking those frontline workers, both NHS and carers, for their unbelievable bravery in the face of such tragedy. The team would also like to extend our heartfelt condolences to anyone reading this who has suffered a personal loss from the virus.

Please refer to https://bda.org and https://www.england.nhs.uk/participation/why/nhse/ for the latest guidance

 

Latest Political Update

As Foreign Secretary Dominic Raab announced an extension of three or more weeks to the lockdown, the uncertainty and fear levels continue to rise. There is still very little information in terms of when the lockdown will end but what we do know is that the evidence from the period so far has been mixed and inconsistent and in some settings infections are still increasing.

On Thursday evening, 16th of April, the Foreign Secretary admitted “we still don’t have infection rates down as much as we need to” but that he wanted to be “up front with British people” about the UK’s potential exit plan and considerations. He referenced the time frame of three months, previously stated by Prime Minister, Boris Johnson. https://www.gov.uk/coronavirus

So, before you can return to your dental practice and start seeing patients again here are some of the crucial aspects the government are watching closely.

Making sure the NHS can continue to cope and is not inundated

Clear evidence showing a sustained and consistent fall in daily death rates 

Dependable data showing the rate of infection is decreasing to manageable levels

Being confident in the variety of operational challenges - ensuring testing and the right amount of PPE

Being confident any adjustments will not risk a second peak

On the first of those objectives it seems like we are already there to a degree but on the second, a consistent fall in daily death rates, will by most expert opinions take more than a couple weeks.

Current Business Advice

No dental practice - big or small, private,public or corporate, is untouched as business plans and forecasts become basically meaning less as companies try to adapt with the government’s lockdown and therestrictions these places on trading.

The Sunday Times has recently revealed the results of a poll carried out by the British Dental Association stating that 70% of dental practices say that they can only maintain financial viability for a maximum of three months, with a hugely worrying 20% saying that they may only be able to survive for one more month. JP Morgan has revealed that the average SME’s cash buffer is a mere 27 days, so the impact of a prolonged lockdown makes the protection of working capital paramount.

In circumstances that are changing, sometimes rapidly each day, management teams are having to make decisions about the best way to protect their customers, their staff and their business.

To protect your practice, be realistic about the circumstances, and we would d suggest considering the worst-case scenarios. This requires a true understanding of the business’s financial position by: 

  • Ensuring cashflow forecasts are up-to-date and reviewed daily (download our free cash-flow P&L calculator)
  • Reviewing all fixed costs, identifying non-essential overheads and other discretionary expenses
  • Chasing all overdue invoices 
  • Reviewing which aspects of business interruption are covered in insurance policies. The Government has indicated that disruption caused by Covid-19 could include policies for both pandemic and government ordered closures. As a practice owner you may also need to check with your insurers about the property being left vacant for weeks and the implications.

You also need to know of any operational issues that may affect the business’s cashflow. This means: 

  • Knowing the impacts of absences and working from home practices. Could adapting, or temporarily revising your business, maximising online efforts etc lead to a small revenue stream
  • Being aware of supplier-related business continuity challenges, you may have, or can foresee, so that interruptions can be planned for.
  • Informing customers of your situation and any production or service delivery problems. Be sure you have communicated the steps being taken to minimise Covid-19’s impact
  • Reviewing supplier and customer contracts to ensure obligations are understood should unexpected situations arise, so any breach can be mitigated

To buy or sell a Dental practice:

https://plutopartners.co.uk/buying

https://plutopartners.co.uk/selling

Other Aspects You Should Consider

  1. Rent – if you rent, you should consider asking your landlord for a break or reduction as a result of this situation.
  2. Furlough – all salaried staff who carry out private work can be furloughed. The Government will then pay 80% of their salaryup to £2,500 per month, currently until the end of May but this may possibly be extended beyond. Please note the employee must have been on the payroll submission sent to HMRC for the month ending 19th March2020 – if they were not, then no government support can be claimed for this individual. Though if an employee left you on for example on the 10th of March 2020 for another job and this job has now been withdrawn (due to the implications on their business from COVID-19) it is permissible and within the spirit of the scheme for you tore-employ this individual and furlough them even if you offer them just thegovernment refunded contribution. If you are a director of a Limited Company and you are employed by the Company then you can furlough yourself provided you only perform statutory duties during the period.
  3. Further Training – whilst on furlough you or your employees can and should continue to develop your skills and training which will have long term career benefits eg. training for a qualification or online CPD.
  4. Insurance - it is unlikely your practice has pandemic cover but you should still contact your insurers to find out your position. It is obviously a long shot but some insurance policies willcover where the business has to close due to an unforeseen reason -such as a Force Majeure or pandemic. Call and ask, if you are indeed covered it will probably be a substantial amount of money. Absolutely no point in paying for the insurance if you never claim on it when you possibly can.
  5. Grants - £10,000 cash grants from local authorities have been made to some small businesses, and dental practices with business rates under £15,000 are eligible for these grants. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878807/business_support_grants-local_authorities_guidance.pdf 
  6. Loans - Government-backed loans of £330 billion have been made open to all businesses, including dental practices. You should contact your bank for further information.
  7. The BDA Benevolent Fund - the charity provides financial aid to dental students, dentists and their families in need, whether they are in training, in practice, have left the profession or are retired. Ifthis might be of interest you can find out more by following the link https://www.bdabenevolentfund.org.uk/

Your Staff

During the most uncertain period of not just your career but also your entire teams, it is crucial to maintain regular, clear and honest communication with all your staff.

It’s extremely likely that your staff will undergo a degree of stress and anxiety relating to the change in routine and concern over the future.

Offer them support and reassurance wherever you can and let them know you are always just a phone call away; no question is too small or silly to reach out. You need to encourage staff who can operate parts of their roles (and are not furloughed) from home to establish a set routine and to take regular breaks throughout the day, including a lunch break. Finishing working and turning off their devices at a reasonable time is also highly recommended to improve mental health and create a clear separation between the working and then living environments.

The closure of schools will undoubtedly be the cause of anxiety amongst your employees with younger children when it comes to organising their day and their work. It’s vital to speak to those affected to agree a flexible working approach, which may include changing working hours to allow for childcare.

You have to remember that when this crisis is over, you will rely on your staff to get your business operating as if not more effectively and efficiently than before. By taking care of them in these desperate times, they will have your back later on when this is over.

Yourself

We’ve seen in the headlines the effects on mental health quarantine can have.

Right now, we know you have an incredible amount of pressure on your shoulders. You cannot afford to forget to take time to work on your own personal growth, it’ll help your relationships with your family,friends, staff and clients.

When we talk about personal growth, we are referring to various techniques for improving one’s habits, behaviour, actions and reactions. The enforcer of such growth stems from having the right mindset. 

Our mindset is a set of attitudes we hold and often reflects how we view ourselves and the world around us. But unfortunately,it can also create self-imposed restrictions within our own belief systems.

Sometimes we need to be reminded that we control our mindset and our future. In incredibly tense times like we are experiencing today, when we wake up in lockdown and listen to the news with record deaths from Covid-19, it’s more important than ever before to stay mentally healthy. To improve our mindset, we need to become aware of the process, know what it is, and take the right steps to grow yourself.

At Pluto we have a 15-minute start of day morning routine, so the day always starts well. We want to share our five-step process with you, so that your day also feels more purposeful and productive!

1. Breathe (three minutes)

When we wake up in the morning the first thing many of us do is reach for our mobiles. We immediately open messages and start checking the news. Instead we should try to spend the first three minutes on wakening just breathing from deep in our belly. It’s that simple. Studies show by starting our day with a few deep breaths, we can open our brains and make it available for our most exciting and innovative ideas whilst immediately reducing stress levels.

2. Think about your thoughts (three minutes)

Have you ever woken up and looked out the window to see the rain pouring from stormy grey clouds and just thought to yourself, jeez this is going to be a bad day? I’ve been guilty of this. It sets our day off on the worst start imaginable. Our thoughts are beyond powerful as they generate feelings. Spend three minutes when you wake up thinking positive thoughts,this will have a knock-on effect and set your mindset on the right path. 

3. I’m grateful for… (three minutes)

OK, so you’ve now been awake just six minutes and you’re going to spend the next three on your grateful list. Some prefer to just do it in their head; others find it important to write it down -either way works. Think of three or more things that you’re grateful for. It links in to starting your day off on the right foot with a great attitude. 

4. Set your goals for the day (three minutes)

Be it getting an important work task completed, mowing the lawn, or washing the car, have a think before you get out of bed – what do you want to achieve today. It can be big or small, just make sure it’s achievable. The point is that when you get to the end of the day, you’ve got something to be proud of. 

5. Play that song (three minutes) 

Before you get into responding to all the messages and tasks that daily life demands, play one of your favourite songs whilst you get out of bed and start to organise your life. Music automatically makes me feel more awake and positive. By the end you’ll have gone 15 minutes without any negativity, and you’ll be on track!

Be aware of what is Offered

With 5.9 million SMEs in the UK employing close to 60% of the private sector workforce, the government is taking necessary action to aid them through the crisis by launching several schemes.

You most likely will have heard of them by now and may have already taken advantage of the government schemes available such as the Coronavirus Business Interruption Loan Scheme (CBILS), Coronavirus Job Retention Scheme, business rate relief, VAT deferral and HMRC Time to Pay.

Whilst these can help ease some worries right now, you still need to be aware of the standing commitments, such as loan and asset finance payments. We would encourage all practice owners to keep a daily eye on what the government’s latest support is and how it may apply to you.

Rise in Real Cyber Threats

When you are remote working, it’s critical to ensure that your IT network is sufficiently guarded and robust, and that staff understand how to access systems and applications from home. It also raises the real aspect of the resilience of your cyber security. You need to remind staff to maintain the same vigilance working from home as they do when in the office. There are several fake emails with hooks like “Order a Covid-19Test Kit Now” or “See how many infections there are in your area” going around the country trying to pray on the fears and vulnerability of the public. Make your staff aware of these dangers.  

Dental Practice Values

The planet’s media is gripped by COVID-19 (coronavirus). Currently, the global and national reactions we are seeing is causing more economic and mental health damage than mortality, with the repercussions moving from the global health sphere into business and politics.

As a company, we have replaced meetings with more video calls and phone calls with clients, in-depth desktop valuations utilising technology to present opportunities to buyers and investors. This is something that we started doing 18 months ago and it is now more relevant than ever.

We are encouraging our clients to contact us by phone, email, video calls and social media and we have set up dedicated WhatsApp groups with all our clients, with access 7 days per week.

We are monitoring the situation and will adapt to upcoming government advice regarding meetings and social contacts.

It is normal that there is some apprehension,but we must try not to panic, and we should plan for different scenarios. There is time now to learn social media platforms, photography, budget marketing and completing CQC.

So how will all this affect our economic corner where healthcare meets business?

NHS dental practice owners will be busily consulting about the force majeure clauses in their contracts which may deliver them full contract revenue without all the costs.

Private dental practices are a little more difficult to predict. There may just be silver linings to the current clouds, with all the economic giveaways that the Government have already announced and possibly more to come, such as; 

  • Increase in the NI employee allowance;
  • Coronavirus Job Retention Scheme
  • Rates holidays for certain size businesses;
  • Grants (with Dental practices hoping to get the same £25,000 grant as Retail/Restaurants

Please download our free cash-flow P&L calculator.

https://www.gov.uk/government/publications/guidance-to-employers-and-businesses-about-covid-19/covid-19-support-for-businesses

For both NHS and private dental practices, the clinical wage bill has always been scaleable to the work performed, leaving the waged support staff as their biggest issue to address.

Please refer to https://bda.org and https://www.england.nhs.uk/participation/why/nhse/ for the latest guidance

To buy or sell a Dental practice:

https://plutopartners.co.uk/buying

https://plutopartners.co.uk/selling

So how will all this affect dental practice values?

As usual 10 different people will give you 10 different answers, but the considered Pluto Partners view is this;

There is very strong appetite for NHS practice sand groups now, and buyers/investors have no intention of slowing down the market.

Private Equity works with leveraged Debt. That debt usually comes with set time scales around repayment on the basis that a certain sum of money is available to spend for a certain amount of time. For both Corporates and the individual buyer with record low rates and the huge liquidity boost of Government backed loan facilities coming on stream, now is the time to look to buy.

The borrowers generally look to spend their money as quickly and efficiently as possible, so that they can either crystallise their returns and possibly go back to increase their borrowings or exit the sector.

They will not want to delay or slow down purchasing.The current climate will absolutely affect dental practices financial performance but investors will probably discount the effect as exceptional and focus on pre-Covid performance.

Not all dental revenue will be lost forever, instead much of it will simply be deferred and buyers will take that into account when projecting forward.

A very recent Goldman Sachs analysis said‘ The consensus is that there is no systemic risk, no one is even talking about that. Governments are intervening in the market to stabilise them and the private banking sector is very well capitalised…It feels more like 9/11 than it does like 2008’.

Taking all this into account we see no imminent drop in dental practice financial values. We expect deal structuring on private practices to adapt, with higher proportion of the agreed price being deferred over a period of time, as a way to maintain and maximise practice value and minimise risk on investment.

Dental Corporates are still eager to view and make offers, we have only seen one or two of them delaying completions, so this could be an opportunity for the freshly financed independent dental buyers to step up and make the move from associate to principal.

In Conclusion

It is now more than likely that lockdown will continue in some shape or form for a period. Even when we can return to work, there will be an element of social distancing still in place, for the safety and general protection of the public.

Changes will be necessary, like all other industries,to the dental profession and there has already been discussions that measures will be put in place to maintain infection control. The general public have as a result of Covid-19, have become far more attuned to avoiding infection and illness where they can, than ever seen before. 

Some of the real possibilities include things like dentists being required to space patient appointments out greater than before, to lessen the risk of spread of infection and build up in waiting rooms.There will also be far more time needed to disinfect surgeries between patients. 

When this comes to fruition, this will have an impact on contract delivery. The questions every dentist globally will be asking in the current pandemic, and the evidence we should be searching for is:

  • Some dental procedures require lengthy appointments involving sustained aerosol exposure. How does that change the risk?
  • How does host sensitivity alter the risk and should dental healthcare professionals with co-morbidities resume aerosol-based dentistry?
  • How do oral aerosol viral titres change with contact time and infection state of the patient?
  • How does a mechanically-driven dental aerosol compare with ‘violent’ expiratory events like sneezing and coughing, or experimental nebuliser-driven aerosols in in-vitro modelling?
  • Are we seeing evidence of COVID-19 infections amongst dental personnel when approved PPE is used for aerosol generating procedures?
  • What does is required to inoculate dental teams and what is the infectious potential from the oral cavity in the asymptomaticor pre-symptomatic individual?
  • Are dental hand piece and PPE manufacturers reviewing droplet transport analysis and aerosol fluid dynamics in the context of COVID-19?
  • Are live bioaerosol exposure tests and sampling being carried out in the laboratory or dental surgery for COVID-19?
  • Can additional external evacuation or air filtering devices have sufficient impact on the transport and physics of aerosol movement?

Answers to these vital questions will no doubt come to the surface in time. On a wider overview of the UK market – the practice sales and acquisitions market will no doubt change once we return to a more normal environment. We believe those Associates and independent practitioners who can raise the finances required to acquire a practice will be in a good position.

This could present a great opportunity for some dentists looking to become Principals for the first time or who are keen to expand as well as corporates who have weathered the storm efficiently. Kevin Saunders, independent finance broker, reports to us that he is still helping dental buyers through this period, and he expects the finance application to bemore detailed in the near future and we share his view.

Whilst we understand we are going to an uncharted period of history, we encourage all to stay positive and to bear in mind this will come to an end. The Pluto team are just a phone call away, with WhatsApp groups set up for contact 7 seven days a week. We will get through this together and will only be smarter and stronger on the other side of thisadversity.

The entire Pluto Partners team are sending well wishes and support to all our clients, family and friends. We are committed as always to continue to offer the highest level of care to our clients and partners.

We work hard to achieve the best results.
The sky is never the limit.
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