“All work and no play makes Jack a dull boy.” So, what happens when there is no work? We present viewpoints from various plastic surgeons faced with the implications of the COVID-19 pandemic. The members of the Cosmetic Surgery Forum represent their opinions and seek a constructive way forward by working together, and planning for the future. Additionally, we are delighted to include contributions from a legal and financial perspective. The implications for those who work in the public and private sectors will be of enormous magnitude.
Colleagues are having to deal with issues of redeployment, PPE, staffing and financial considerations; never before have international governments curtailed elective clinical activity to the extent that we have seen. This has had major implications for our patients and the services we can provide, for many it has exposed the fragility of the system and dependence on private hospital-based provisions. With hindsight it appears that the rapid building of additional capacity was not overwhelmed by the situation in the UK. Clinicians who work exclusively in the private sector and use private hospitals have had to deal with unilateral decisions regarding the services and access to clinics and theatres.
This has been a time of active reflection, considering how best to organise ourselves as a community of clinicians and consider where we will work and how to provide appropriate clinical services to all our patients. The views by some of our most experienced clinicians will be thought-provoking and hopefully bring all clinicians together to plan for the future and give us all 2020 hindsight.
Dalvi Humzah, Co-editor, The PMFA Journal.
From facelifts to frontline to facing the future: Accept, adapt, achieve
By Nora Nugent
The COVID-19 coronavirus pandemic has radically changed lives and society across the UK and the world. None of us would have predicted that the first half of 2020 would turn out to be so turbulent and destructive. Almost every sector of society has been affected in some way. The most devasting effects have undeniably been on those who have fallen critically ill with COVID-19 including the many lives lost and on their families. The entire country has suffered a healthcare crisis, an economic shut-down and a ‘stay home’ and social distancing directive all of which will have long reaching implications going forward. These measures are unprecedented in our times.
As plastic surgeons, we find ourselves affected to different degrees in many, if not all, of these ways. Some of us have contracted COVID-19 or have family members who have had COVID-19. Many of us work in the NHS and have been redeployed to help with the national effort to contain the spread and treat those affected in one way or another. Elective patients have had their appointments and procedures postponed in both the NHS and private sectors for safety reasons and to allow the private hospitals to support the NHS.
Those of us in private practice have also faced the economic implications of reduced or no income, while continuing to accrue business overheads and expenses. This has particularly and severely affected plastic surgeons in full-time private practice and those who own and run independent clinics. Business overheads and expenses such as rent, mortgages, medical indemnity, insurance, salaries, rates, utilities and supplier invoices continue to accumulate while practices and clinics are closed. Staff have needed to work remotely, have their hours reduced or been furloughed and we have all become very quickly immersed in virtual consultations and web-based meetings.
The BAAPS is primarily focused on education and patient safety in aesthetics. As the COVID-19 pandemic unfolded, it became clear in March that aesthetic procedures should be halted during the crisis time and NHS work prioritised. Our President, Mr Paul Harris, issued advice to that effect to our members at this time. Urgent and emergency patient care had to be the priority and the BAAPS fully supported this.
BAAPS Support is a sister organisation of the BAAPS which was set up in 2019 specifically to provide support and help to members and their practices. I took over as Chair in March 2020 from Mr Mike Tyler as he took on an expanding role within the NHS. It was very apparent that our previously planned workstream for 2020 would need to be put on hold and member support relevant to the unfolding situation became the priority. We set up a weekly webinar series which has been focusing on the practical changes and problems facing members such as medical indemnity, reducing expenditure, navigating the new government tax, employment and financial aid measures, virtual consultations and restarting practice. The aim of the webinar series was to provide support, advice and practical information to our members. We have also looked at areas where we could act as an advocate or voice for our members in helping with these issues such as medical indemnity.
This has also been a time where plastic surgeons have come together as a community and the different organisations representing us such as BAAPS, BAAPS Support, BAPRAS and UKAAPS have collaborated together and with the many other surgical and medical associations that we all interact with. The informal Cosmetic Surgery Forum group for plastic surgeons on WhatsApp set up by Mr TK Sanker has also come into its own as a source of support, communication, information and advice. This has been a positive effect of an otherwise difficult and troubling time and one that we hope to continue with in the future.
Of course, the next task is the future! How will we move forward and when? What will the aesthetic landscape look like and when will it return to a semblance of what was normal up to March 2020? When is it reasonable and safe to recommence our aesthetic practices and how do we decide what is reasonable and safe? At the time of writing, these are all questions under discussion and not fully answered yet. What is clear is that 2020 will be a year to remember and will have far-reaching consequences for all of us.
Nora Nugent, Consultant Plastic Surgeon, Member of Council BAAPS & Chair of BAAPS Support.
Plan…don’t panic: Unified approach to fight COVID-19 crisis and beyond
By Shailesh Vadodaria
The WHO confirmed the global coronavirus pandemic in March 2020 and this has created an unprecedented economic and social crisis that involves all business sectors within the United Kingdom, but specifically in healthcare, where routine NHS work has stopped and private hospitals have been temporarily nationalised to make beds and facilities available for anticipated use by COVID-19 positive patients, and all independently owned clinics have by necessity closed.
Fortunately, it appears that these private facilities will not be required, but there are now serious logistical problems getting the NHS back into full flow. This may include the use of private hospital facilities for urgent and less urgent NHS cases in preference to non-urgent private cases, especially for aesthetic surgery. In addition, restrictions on the use of PPE and routine general anaesthetic drugs may be prioritised until supplies are rebuilt following reports of shortages.
The legal framework for social distancing, isolation and ‘working from home’ was set up by the Department of health, NHS England and the regulatory bodies in Scotland, Wales and Ireland, and by mid-March this was mandatory throughout the UK. Aesthetic medicine and surgery was halted by 22 March, 2020 and the aesthetic plastic surgery industry was completely paralysed by first week of April, with clinic owners immediately losing income stream but retaining expenses associated with staff, leasehold, business rates and ongoing facility costs including contracts. Private hospitals have been assured that they will remain cost neutral with central funding provided, but private clinic owners have no such agreement. As a consequence, staff have been working ‘reduced hours’ contracts or furloughed. Previously profitable clinics will go bankrupt unless a strategy for returning to working practice is devised.
Totally independent consultant plastic surgeons
We recognised that there are a significant number of consultant plastic surgeons who are in full-time private practice and own their own aesthetic surgery clinics. These plastic surgeons have had the biggest financial impact in the current crisis. They stopped generating revenue as the clinics were shut down and the overheads are considerable.
There is an urgent need to mitigate cash flow problems within these independently owned businesses and to seek solutions to optimise regular expenditures, e.g. clinic staff salaries, clinic and professional indemnity insurance, rent, lease, mortgage, business rate, utility bills, CQC registration fees, service charges, clinic cleaning, waste disposal monthly cost, website hosting / maintenance costs, etc. Plastic surgeons are not trained to face such unprecedented financial and management crises, yet each surgeon is an entrepreneur that sought to develop a business related to his expertise. In ordinary times the businesses generate revenue for the exchequer but now they need guidance and help.
Recognising the need to work together
This pandemic has taught us one thing and that is the importance of sticking together and supporting each other at a time of crisis with a view to overcoming all difficulties. With this in mind, a core group of plastic surgeons thought of organising a series of webinars to brainstorm solutions to these various challenges and, with the assistance of a senior barrister Mr Sailesh Mehta and an experienced chartered accountant Veronica Donnelly, there has been a fabulous response. The group of plastic surgeons have developed a better insight into identifying problems and providing various solutions to optimise some expenses and to plan a way forward getting out of financial crisis.
There is an exclusive but clear subgroup of aesthetic plastic surgeons that have built their own clinic facilities around their professional reputations. There is an urgent need to develop a consortium of such affected individuals to discuss and plan a road map to deliver a return to their previously successful businesses.
The fundamental aim of the WhatsApp interactive group and webinars was to bring independent clinic-owning plastic surgeons under one unified umbrella to assist each other. The webinar discussions made contributors aware of seen and unseen difficulties and this consortium strongly believes that the only way forward to fight the battle against this crisis is to remain united, be positive and innovative to plan and restart our practices safely and under regulatory control once the lockdown is released. This will require revision of patients’ care pathways, protocols, policies, procedures and specific consent to include COVID-19. The consortium is actively working on the collation of national and international evidence-based data, extended infection control training to staff, clinic working policies and patients’ perioperative information leaflets. We are in the process of organising additional seminars to finalise the new protocols to safeguard patients, their relatives and clinic staff. These protocols need to be approved by the CQC and relayed to the insurance companies. The consortium can also work together on any procurement issues and assist in negotiation on rates for provision of services including insurance and possibly NHS contracts. It is also likely that the corporate hospitals will be utilised for NHS work and hence, aesthetic surgery procedures are likely to be done in aesthetic surgery clinics and hospitals, as such clinics will be free from NHS overload. We are in the process of organising UK-based webinars for education and training in small groups.
The group believes that there are huge opportunities for a United Independent Consortium of Aesthetic Plastic Surgeon Clinic Owners (CAPSCO) working together within the framework of regulatory bodies including the CQC and the GMC.
Shailesh Vadadoria, Consultant Plastic Surgeon, President of UK Association of Aesthetic Plastic Surgeons (UKAAPS).
The question of professional indemnity payments
By Jeyaram Srinivasan
In this time of reduced activity – and income – many of us are looking at our finances more closely. For anyone in private practice, be it part-time, full-time or as a clinic owner, one of the big outgoings is professional indemnity premiums. Just because we are not operating, it does not mean that we can ‘stop’ the cover or the need to pay the premiums. Such a move, queried by some colleagues, will be counterproductive as, without such a ‘continuous cover’, if someone unfortunately lands with a claim, then the legal costs and the damages have to be borne by the individual and would be far more costlier and, in some cases, may bankrupt the individual.
Not all indemnity providers are the same. Organisations such as MDU, MPS and MDDUS are ‘Medical Defence Organisations (MDO)’ while many others such as CFC, Paragon, Incision are ‘Indemnity Providers’. This difference is not just in the groups but in the products offered – indemnity cover on the basis of ‘Claim Occurrence’ (MDOs) versus ‘Claims Made’ (indemnity providers). That distinction also influences how they calculate the premium cover – in addition to other factors such as projected or actual annual income, claim history, range of procedures offered. etc.
Professional indemnity cover is something like paying tax – we may not like it, but we all need to do it. In times like this, when incomes, for many, have plummeted drastically, any saving that we can make would be welcome. Professional associations like BAAPS and BAPRAS, and membership associations like PRASIS, have been busy behind the scenes to find out ways in which the individual could be supported from this burden.
During the course of many discussions, it has become clear that there is a perception and demand that indemnity providers be more helpful to their plastic surgery members, in this time of crisis. Many colleagues have been voicing their expectations of part refund of premium paid or reduction of premium for those about to renew in near future – based on a prolonged period of inactivity. Some indemnity providers have ‘offered’ some reductions and reassurances, but industry experts are advising ‘caution’ in this area. Many insurers are anticipating some increase in claims, as some solicitor firms have been actively encouraging such steps via social media outlets, in this time of lockdown. In such a scenario, many insurance providers would want to keep a ‘reserve’ for such potential claims and are looking at alternate ways to help the members, such as, by offering an extended period, up to 120 days, to pay off the premium.
Alongside this discussion, other debates are occurring as to how to manage the ‘recovery’ phase, as to when we can safely start our surgical / non-surgical aesthetic practices. The key factor in these discussions is, of course, how to maintain safety to patients, surgeons and healthcare workers. No one wants to see a colleague or a patient affected by COVID-19, in the process of an essentially elective, aesthetic procedure. Not only would this be potentially life-threatening to the affected individual but also hugely detrimental to the profession as a whole.
Probably, due to the organisational limitations and safety concerns, this ‘recovery’ may have to be slow and gradual. So, it is better to expect a prolonged period of reduction in activity, which is being used as the main point of discussion with many indemnity providers to provide tangible support for members. It will be advisable to have a direct conversation with your indemnity providers or insurance brokers as to what help they can offer to cover this difficult time.
Jeyaram Srinivasan, Consultant Plastic Aesthetic Surgeon, Preston Council Member (BAAPS), Board Member (PRASIS).
Surviving COVID-19: A lawyer’s perspective
By Sailesh Mehta
Professional bodies
You will be better protected if the leaders of your representative bodies are able to produce joint documents and protocols. By way of example: (a) a number of clinics closed well before the Government imposed ‘lockdown’ on 22 March 2020. You may be asked to justify why you closed your business before this date. A letter from leaders of your profession explaining why it was closure of non-essential businesses was necessary and good practice would be useful evidence; (b) when you re-open and your employees ask about the level of safety provided by your business, a joint protocol on the types of equipment necessary for particular procedures would be looked upon favourably by Courts when deciding upon an (inevitable) complaint from an employee.
Coronavirus Job Retention Scheme
The stated purpose of the Government’s Coronavirus Job Retention Scheme is to allow employers to claim for the cost of employment of furloughed employees. The scheme applies to all UK businesses and all PAYE employees who were on the business payroll on or before 19 March 2020. A condition (one of many) is that the employee does not do any work for the employer (even on a pro-bono basis) during the claimed period. Check the Government website for further details. I have advised businesses in other sectors who have opted to negotiate with individual staff members – but by doing so, they take themselves out of the furlough scheme.
Rates relief
Rates relief is available from the local authority, based on the rateable value of your businesses and how many premises you have. A number of local authorities have been flexible but this is not universal. Some local authority staff are not aware of the details of the scheme and you will need to quote chapter and verse to them. Look up the Government website or contact a rates expert.
Insurance claim
Many clinics will have a ‘loss of income’ clause in their insurance contract. Insurance companies are already gearing up to defend every claim on such contracts. Study your policy carefully. Put in a claim pursuant to the policy. If the insurance company rejects your claim, consider instructing a solicitor on a ‘no win no fee’ basis. It would be sensible if a group of potential litigants got together to negotiate favourable terms with a firm of solicitors.
Care Quality Commission
Check the CQC website to ensure you are up to date with their guidance. The CQC have been proactive in contacting those it regulates and has been accommodating in giving ‘holidays’ on payment and negotiating favourable terms.
End contracts
You are probably paying regularly for a number of services, some of which could be safely ended. Check your contracts and if you cannot lay your hands on any contract, contact the service provider and ask for a copy immediately. Check the contract clauses carefully – usually, there is a clause to allow you to end the contract (often with three months’ notice). Usually, your contractor will forgo the notice period if you negotiate forcefully, with the ‘carrot’ of re-employing their services as soon as lockdown is lifted. Examples of such contracts are cleaning services and clinical waste collection services.
Negotiate a payment holiday or mitigation of payment
There are many regular payments that you may be able to mitigate by negotiation.
Examples include:
Rent payment: you should contact your landlord and seek a rent holiday or a reduction in rent. Most landlords have ben understanding. Some have been tough and have threatened or started on first step of repossession proceedings. The Government and Courts have stepped in – possession proceedings have been suspended in all cases and the Government has made it temporarily impossible to take other rent-related action.
Service charges: again, negotiate a lower amount. In any event, put the landlord on notice that you expect them to negotiate with its suppliers to reduce the cost of service charges, particularly as the building is likely to be empty.
Sailesh Mehta, Barrister specialising in regulatory law.
Surviving COVID-19: An accountant’s perspective
By Veronica Donnelly
Without question we are in difficult times for businesses, particularly in the services industries. With aesthetic clinics being forced to shut down, business owners have had to immediately consider how to survive with little or no money coming in.
There are a number of different groups:
- All income derived from the business
- Businesses where the owners also work in the NHS, or provide training
- Businesses which sell products
All these businesses will survive or perish on the basis of finding an income source and managing costs. Clearly those with other income streams will be in a better place but costs still need to be managed carefully.
I have recently spoken as part of several webinars and the attendees seem to be taking advice from their accountants, specialists in employment law, insurance, marketing or each other. This is positive and encouraging. HMRC have uploaded information on the .gov website, which is proving useful, but the volume of information can be overwhelming. The trick is to have a plan and work through it methodically.
Most businesses have developed a 13-week cashflow plan. This is a first step only. It is advisable to do a cashflow model for six to nine months. We don’t know when we will all get back to normal or, indeed, what the new normal will look like, so you need to be robust financially. No matter how rough and ready your cashflow model is it will highlight monies coming in against bills due. This means that you assess what you can pay and more importantly what you can’t. Salaries are a key cost in all businesses and the aesthetic sector has been quick to take up the furlough opportunity. With the government portal for claiming now open, this is an effective way to deal with 80% of that cost. The next stage is to look at your supplier costs, rent, insurance, bank loans, etc.
The banks are aware of the current position (how could they not be!), and from what we have seen from our client feedback, they have been open to discussions about payment holidays, etc. If they want supporting information, your accountant can help you. It is recommended you also have a conversation with any of your suppliers if you are going to have difficulty paying; they are more likely to be helpful if you can arrange a payment plan rather than stopping all payments. That said, insurance is probably not one you want to stop paying.
HMRC have been quick to offer VAT and tax deferrals and payment plans for outstanding debts.
The next stage is to try to get money into the business. If you are already in receipt of rates relief then you should be able to get grants of £10,000 or £25,000 depending on the rateable value of your property. The rules are different across Scotland, England, Wales and Northern Ireland so you will need to check the local authority website for your area. Payments are already being released which are helping businesses enormously.
If all of this is not enough the next stage is to look at business loans. Specific loans called Coronavirus Business Interruption Loans (CBILS) are available for businesses with turnovers up to £45m and a separate CBIL for business with turnovers over £45m. Where you have a business manager you are likely to get a quicker response than online banking clients who are reporting delays of up to four weeks to get a response from their bank. So, the message is to get an application in as early as possible. You may need assistance from your accountant to produce formal cash flow models. There were some issues around the fact that the government is only offering an 80% guarantee on CBILS.
To deal with this a new loan called the Bounce Back Loan was introduced on 4 May offering loans up to £50k. These will have a 100% government guarantee and may offer a lower interest rate outside the 12 months’ interest-free period. If you have already signed up to a CBIL and the Bounce Back Loan looks better, you will have until 4 November 2020 to switch the CBIL to a Bounce Back Loan.
If your business is correctly funded and you are managing your costs you will then be in a position to look forward and connect with your customers, who after all are your most important asset in a successful business.
The key message is to take advice. Speak to your accountant to make sure you haven’t missed any grants or loans you may need or if you need assistance dealing with HMRC or your lenders. Yes, there may be a cost but if you get the help to keep your business strong in these difficult times then that at least is money well spent.
Veronica Donnelly, Chartered Tax Advisor & Partner, Campbell Dallas.
Cosmetic Surgery Governance Forum (UK): Support, share, learn & care
By Shanks T K Sankar
The Cosmetic Surgery Governance Forum (CSGF) was started in September 2014 after a brain storming session with my colleague Mr Nitin Vaingankar. We work at two different neighbouring NHS trusts but work together in the same private facilities.
Having started a small plastic surgery service in a district general hospital about 11 years ago, I found myself alone in my professional life which was challenging but manageable and I never shied away from seeking a second opinion whenever I was in doubt or difficulty.
In the private sector working closely with your colleagues is the best thing we can offer to our patients. But in spite of working together, sometimes challenges arise which need a wider consensus from experts in the vast field of cosmetic surgery.
The speciality has been under immense public and regulatory scrutiny after the Patterson’s scandal from the West Midlands. It took about eight years before the law caught up with Mr Patterson. Having seen this and being a Medical Advisory Committee chair for a private hospital group made me realise the importance of an inter-disciplinary forum to share support, educate and learn from each other for the benefit of our patient care, particularly in the complex issues. I realised such a peer support system is the most important part of patient management, particularly in this post Patterson era.
CSGF uses WhatsApp messenger as its platform due to the fact it is very easy to use, highly secure and instant. The forum currently has 108 consultant plastic surgeons as its members with two administrators.
Over the last five years we have discussed approximately 110 complex cases by our members and either advised satisfactorily or referred to an appropriate expert. We have shared 569 photographs, 53 videos, 476 links and 32 documents. The range of topics discussed include not just plastic surgery but also wider medical subjects such as COVID-19 issues. We had our first Governance Forum regular meeting two years ago in Birmingham which was attended by 30 consultant plastic surgeons.
Our members include amongst others; the President of BAPRAS, the President of BAAPS, the National Secretary for ISAPS and the President of UKAAPS. Our members work across the entire British Isles. There is a great community spirit in our forum. Irrespective of seniority, colleagues have come together to support, educate and help each other.
Our independent and informal organisation has an advisory board which consists of Ms Nora Nugent, Mr Norman Waterhouse, Mr Nitin Vaingankar, Mr Shailesh Vadodaria, Mr Jeyeram Srinivasan and myself.
This forum is open for UK consultant plastic surgeons but restricted to those who are on the GMC Specialist Register in Plastic Surgery with an aesthetic surgery practice within UK. It is free to join.
If this includes you and you would like to join the forum, please email:
Send details including mobile number and we will send you the T&C of the forum usage.
Mr Shanks T K Sankar, CSGF Founder.
COMMENTS ARE WELCOME
