HealthInvestor

September 2011 vol 8 no 7

essential reading for the healthcare business

In the hot seat

Stephen Collier on taking charge of UKs biggest hospital group

Dilnot Will care insurance catch on? Private hospitals New UK markets to explore Regulation Could sector face caps on prots? primary care secondary care social care IT infrastructure markets policy dentistry
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NHS 20

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analysis

Candesic

The Candesic team investigates how private hospitals can regain their distinctiveness

Standing out

text

Missed last Months pRivate hospital analysis?

45 40 35 30 25 41 31

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essential reading for the healthcare business

has a management contract with BMI). Clinician partnerships have opened five more which we will discuss later. Decline in private medical insurance during the recession Private medical insurance is the main revenue source for private hospitals, accounting for 60% of revenue in 2009. However the recession has taken its toll on both subscribers and persons covered (exhibit 2). In both 2009 and 2010 the number of subscribers fell by 5% year on year. In our interviews with major insurers, it is clear that the more lucrative segment of customer self payers has taken the major hit while the corporatepaid segment has been less affected. Hospitals have made up for the falling private demand by increasing the amount of work they do under contract to the NHS (exhibit 3). In volume, this has more than made up for the decreases in the number of private cases. However, early indications are that 2011 will be a flatter year for NHS procedures, as data from a recent Freedom of Information request shows (exhibit 4).

Exhibit 3

EXHIBIT 3 PRIVATE HOSPITAL* VOLUME EVOLUTION THROUGH THE RECESSION Cases, 000s
CAGR 4.97%
975 888 NHS Self-pay and other 942

CAGR %

56 177

149 156

212

98.1 -11.8

25 20 15 10 5 0 2 0 4

(1,000s)

5,000 4,000 3,000 6 2,000 1,000 0 1989 1994 1999 2004 2009

20 15 10 5 0

137

PMI

656

638 625

-2.2

2007

2008

2009

* Excludes day only hospitals, ISTCs, and termination of pregnancy clinics Source: Laing & Buisson 2010-11; Acute Market Monitoring Initiative

Why private sector is taking clinician partnerships seriously

Hospitals Circle float surprises market Policy Health Bill retreat threatens competition Southern Cross The never ending story primary care secondary care social care IT infrastructure markets policy dentistry
ISSN 1742-884X

Doctor doctor

Competition from foundation trusts Much of the current political debate on the NHS reforms has centred on outsourcing elective procedures to the private sector, and the danger that this presents to NHS acute trusts. This is misconceived. Our view is that, far from the NHS trusts having to fear the private sector taking their NHS business, private hospitals need to worry about NHS trusts taking private hospitals core business of private patients. After all, in both volume and value, private hospitals are dwarfed by NHS hospitals NHS acute hospitals are more than 10 times bigger. Under the coalition government, caps on private income under Labour were removed and we are aware of at least 10 foundation trusts planning to expand their private patient units (PPUs). This is a threat to private hospitals, because co-located private patient units can use the infrastructure of the NHS acute hospital including intensive care units, which are very rare in the private sector. Consultants also like the convenience of having all their patients on one site. For example, Guys & St Thomass,
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EXHIBIT 4 NHS OUTSOURCING TO INDEPENDENT SECTOR AND REVENUE Volumes and value outsourced under Extended Choice NHS OUTSOURCING TO INDEPENDENT SECTOR VOLUMES AND REVENUE Network under Choose and Book VOLUMES Exhibit 4
Volumes and value outsourced under Extended Choice Network under Choose and Book General election 000 25,000

No. 25,000

20,000

20,000

15,000

10,000

Monthly spend million Monthly procedures

15,000

Maintaining their value proposition One of the reasons for the decline in the more lucrative private revenue stream for private hospitals is the distinctiveness of their proposition has been diluted. People go private for a combination of reasons: the choice of physician or surgeon, the assurance that ones doctor has reached consultant status, to beat NHS waiting lists, and to have their own room and greater general amenity. NHS hospitals have spruced up under 10 years of Labour largesse just look at the ever-expanding Addenbrookes Hospital campus in Cambridge, which has doubled in size since I was a medical student there in the early nineties. In contrast, the majority of private hospitals no longer have the newness and wow factor that they did in their heyday. Many private hospitals, particularly the Ramsay hospitals, are now full of NHS patients, further diluting their distinctiveness. Lastly, with waiting lists for elective procedures down to 18 weeks, the NHS has got better no longer must a patient wait a year for a cataract operation or a knee arthroscopy. No wonder so many people are opting to be treated under the NHS, and dropping their private medical insurance. Relationships with insurance companies Its not all doom and gloom for private hospitals, however. In the last few years, it seems insurance companies have lost power in negotiations with hospital groups: the biggest operators (BMI Hospitals and Spire Healthcare) have become larger by acquisition, improving their negotiating power. We estimate that large groups such as BMI and Spire
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analysis Private concerns

UK private hospital groups are struggling to remain relevant in an age of day surgery. Dr Victor Chua considers the challenges facing the sector and the rise of clinician partnerships
Old estates The private hospital estate is too old and increasingly decrepit. Only 12% of private hospitals were built since 1995 (exhibit 1) and their median age is 30 years. Their congurations were conceived in an age before minimally invasive surgery, so they have too many beds and not enough operating theatres, and the operating theatres are not aligned with day-case waiting areas. Private equity ownership has acted as a brake on new investment. Half of the 200-odd private hospitals in the UK are owned by private equity groups which invested in them via leveraged buyouts. Private equity makes money by growing the protability (ebitda) of the business and they generally have a three to ve
60

8,000 7,000 6,000

35 30 25 20

Persons covered

(millions)

Subscribers Employed population (millions)

(1,000s)

5,000 4,000 3,000 2,000 1,000

(millions)

which has probably the most businesslike mindset of the London teaching hospitals, has tendered for the fitout and management of a new 6,000 square-metre PPU due for handover in 2015, on a 25-year lease. There is some consolation in that the management of many of the PPUs are to be privately managed, but in a flat market it is clear that the private hospital sector as a whole will lose out, as private patients are spread more thinly across more units. This is a concern to what are essentially fixed-cost businesses.

EXHIBIT 2 PRIVATE MEDICAL INSURANCE COVERAGE*, UK 2000-2009

8,000
45 40 35 30 41 31

35 30 25

Persons covered

7,000 6,000

Subscribers Employed population (millions)

Candesic

After big increases in coverage in the 1970s and 80s, the

15 penetration of private medical insurance has levelled o with about 11% of the UK population covered 10

2009-10 saw decreases following a time lag after 2008

5 recession. Much of the decrease has been in the self-pay segment

Industry expectations for the next ve to 10 years are that 2009

EXHIBIT 1 UK PRIVATE HOSPITAL BUILDINGS BY AGE

45 40 35 30 25 20 15 10 5 0 2 0 4 9 41 31

0 year investment cycle. This model of

nancing has limitations compared2004 to 1989 1994 1999 having corporate owners, because there are strong disincentives to building new hospitals or renovating old ones. It takes two years to decommission a hospital and build a new one in its place, and another year for its revenues to bed down. Consequently, only one hospital has been built by private equity in the last few years Spire Shawfair Park in Edinburgh, which opened in 2010. By contrast, non-private equity owned groups have opened ve hospitals in the same period: Circle in Bath, two Nufeld hospitals in Cardiff and Guildford, a Ramsay cosmetic surgery hospital in Birmingham, and a hospital in Weymouth Street in London (which
HealthInvestor July/August 2011

2010 saw the market bottom out and recovery will be slow but steady from 2011-12; no dramatic change is expected without an unlikely policy change such as tax relief on PMI

10,000

5,000

5,000

* 1993: Decrease in persons insured is an artefact of re-estimation of Bupas multiplier which converts subscribers to persons covered Includes third party administrators (self-insurance by big companies ) Before 1992, no gures for self-insured available; gures above assume none 2010 Market report update due July 2011 Source: Laing & Buisson 2010-11; Healthcare Market News, Vol. 15 Issue 5, June 2011; Candesic Industry interviews April May 2011;ONS online; Candesic analysis

0
Dec-07 Jun-08 Dec-08 Jun-09 Dec-09 Jun-10

0
Dec-10

Source: DH Freedom of Information request; Candesic analysis

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download the fiRst paRt of the pRivate hospital analysis seRies at: www.healthinvestoR.co.uk
HealthInvestor September 2011

n the last issue (July-August 2011), we wrote on how UK private hospital groups were struggling to remain distinctive in the face of a resurgent NHS. This month, we explore some ideas for how private hospitals can regain their advantage. First, a recap of last months article: all private hospital revenue segments (private insurance, NHS and self-pay) are facing decline. Private insurance subscriber numbers have fallen 10% from 2008 to 2010 (Source: Laing & Buisson industry survey 2011). Private hospitals have made up for this by accepting NHS funded referrals through the Choose & Book IT platform which allows patients to choose their hospital. But this is now under threat. Since last years election, the growth in NHS referrals through Choose & Book has slowed as PCTs have quietly enacted barriers such as minimum waiting times and referral management centres. Plus, the Coalition government has dropped its target of 90% of GP referrals going through Choose & Book. The distinctiveness of the private hospital proposition has also been diluted by NHS outsourcing to the private sector, and by new NHS construction during the last decade. The NHS estate has been renewed 29% of NHS hospitals were built in the last 15 years compared to only 12% of private hospitals. The push towards competition within the NHS may have even more dramatic consequences. New Private Patient Units and the removal of the Private Patient Cap may mean that more private patients will choose to be treated privately in NHS hospitals in the future. Their busy surgeons, mindful of the advantages of co-location, may well choose for them. The NHS has had a decade of liberal spending. The waiting time for elective surgery has dropped to approximately 18 weeks from referral, reducing the incentive to go private to skip the queue. This year, 99% of patients referred urgently by the GP with a suspicion of cancer have been seen within two weeks (compared with 63% in 1997).
HealthInvestor September 2011

Regaining distinctiveness

80 Private hospitals need to innovate again to regain their distinctiveness. Luckily, the NHS is undergoing a time of structural change and is likely to be constrained in new areas of capital expenditure and in developing new specialities. Historically, the private sector has stepped in where the NHS has exited, or not kept up with demand. For example, the closure of the Victorian mental asylums over the last 20 years, coupled with the failure of the NHS to build new long-stay forensic capacity, gave an opportunity to the private sector to look after forensic mental health patients (Exhibit 1). Exhibit 1

Private

MENTAL HEALTH BEDS, NHS AND PRIVATE exhibit 1 England, n Mental health Beds, nhs and pRivate

England, n
Private beds 9,000 8,000 7,000 6,000 No. of beds 5,000 4,000 3,000 2,000 1,000 0 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
1989 White Paper Caring for People : established purchaser/provider split and social services were encouraged to purchase from independent providers 2005: Partnerships in Care acquired by Cinven for historic 14xEDITDA 2011: Advent International buys Priory for 925m. 2010 EDITDA close to 100m

NHS beds

Until 2003, Laing & Buisson defined the sector to include acute psychiatric and medium secure hospitals only. From 2003, the regulatory system and medium secure hospitals only. From under the Care Standards Act. L&B changed its sector definition to include any drew a clearer distinction between MH hospitals and care homes2003, the regulatory system drew establishment registered as a MH hospital by the Healthcare Commission, including acute, medium secure, low secure and non-secure a clearer distinction between MH hospitals and care homes under the Care establishments, also some independent hospitals providing secure treatment for learning disabled people. Standards Act. L&B changed its sector definition to include any establishment 0 Source: Laing & Buisson 2010-11; MIND

Note:

Note: Until 2003, Laing & Buisson defined the sector to include acute psychiatric

registered as a MH hospital by the Healthcare Commission, including acute, medium secure, low secure and non-secure establishments, also some independent hospitals providing secure treatment for learning disabled people.

A similar trend has been witnessed in IVF treatment. Despite NICEs guidelines to offer three NHS-funded cycles of stimulated IVF to eligible couples, funding has not been ring-fenced at PCT level and guidance is often ignored. The failure of the NHS to provide a sufficient supply to meet need has led to a market in which around 80% of IVF treatment cycles are arranged privately (Exhibit 2).

exhibit 2 souRces of funding foR ivf, uk

%

NHS 20

Private 80

Source: Human Fertilisation and Embryology Authority (HFEA)

Source:

2005-7: 64% of acute psychiatric inpatient NHS hospital wards were at 100% or higher occupancy

Laing & Buisson 2010-11; MIND

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52

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United Kingdom France Spain

Oncotype DX

Femtelle

MammaPrint

finance

We think there are three main ways that private hospitals can innovate to regain their distinctiveness. We have taken into account the degree to which private hospitals, many of which are owned within leveraged buyout financial structures, are capex constrained.

exhibit 4 (cont.) Germany availaBility of BReast canceR diagnostics

dRug and diagnostics access

Screens formalin-xed, para nembedded tissues for a panel of 21 genes using Q-RT-PCR Results spare low risk patients from additional cycles of chemotherapy Cost $4000 Performs ELISA analysis on fresh or frozen tumour tissue, to provide a quantitative determination of two tumour markers (uPA and PAI-1) Results give an indication of low or high risk recurrence, and may spare chemotherapy in low risk individuals Frequently used in Europe. Cost $250 An FDA-approved test which screens fresh or frozen tumour tissue using a 70-Gene DNA microarray in order to identify groups with good or poor prognosis Results spare low risk patients from additional cycles of chemotherapy Cost $4,200, or 2675 in Europe

There is a long time lag between market authorisation of a drug for use within Europe, and the availability to patients (Exhibit 3). English patients tend to be offered novel cancer drugs two years later than patients in France, Germany or Spain. This is because NICE looks at cost effectiveness rather than just efficacy, and it takes time for sufficient quality studies to be published to make a cost/benefit assessment. In France and Spain, regulatory bodies need only to approve pricing and reimbursement policies for a drug.

exhibit 3 dRug licensing in the nhs

Market authorisation

Licensing procedures Availability to patient

The drug approval procedure within the NHS produces a signicant delay between market authorisation and availability to patients. Within other European countries, the delay between market authorisation and availability to patient occurs as government committees seek to approve pricing and reimbursement policies for a drug. In contrast, NICE reviews health e ects, cost, and cost-e ectiveness of a drug. NICE guidelines are highly regarded in Europe and can inuence drug prescribing policy across the continent. However, it is a lengthy process, and denies patients access to newly authorised drugs. Similar to Germany, once market authorisation has been granted by the EMEA, it is legal to prescribe the drug within the UK. However, NHS hospitals will almost always wait for NICE approval before prescribing a drug.

Source: Candesic interviews August 2011; Corporate websites

Source: Candesic interviews August 2011; Corporate websites

England (NHS)

Referral to NICE 7 months In European Union countries, the European Medicines Evaluation Agency (EMEA) surveys clinical trial data. If a drug is approved, the EMEA advises the EU to provide market authorisation* Transparency committee and pricing committee 10 months Interministerial Commission and Ministry of Health 8 months

Approval by NICE 14 months

France

Spain

Specialists (particularly lead investigators in clinical trials) often know or suspect years in advance that new therapeutics are working. But patients outside the trials cannot benefit in the UK. We feel that private hospitals have suffered from a lack of focus on oncology. Private hospitals sometimes offer drugs and diagnostics not given in the NHS, and private insurers are happy to pay for them. But no UK private hospital has a reputation for cancer in the same way that the Marsden Hospital in London, or the Mayo Clinic in Minnesota, or the MD Anderson Cancer Center in Houston, does. (The closest is CancerPartnersUK, funded by Apposite Capital, which is focused on radiotherapy.) Building a great clinical reputation takes a great deal of effort. Good clinicians wish to work in a successful organisation, which cannot be built overnight. But a focus on cancer therapeutics is capex light and we believe that a hospital group which embraces a cancer strategy can reap rich rewards.

Germany

12

24

36

48

* The EMEA is a centralised body providing authorisation for all EU countries. It is possible for manufacturers to apply for licenses in individual countries through national regulatory authorities. Source: European Federation of Pharmaceutical Industries and Associations; European Competition Commission; International Society for Pharmacoeconomics and Outcomes Research

The same constraints are seen in the use of innovative diagnostic tests within the NHS. For example, MammaPrint, OncotypeDX and Femtelle are not supported by the NHS. However, they are used frequently on the continent and in the USA (Exhibit 4). These (expensive) tests spare low-risk patients from additional cycles of chemotherapy.
Exhibit 4 AVAILABILITY OF BREAST CANCER DIAGNOSTICS

exhibit 4 availaBility of BReast canceR diagnostics

Oncotype DX United Kingdom France Spain Germany Femtelle MammaPrint

NICE approval before prescribing a drug.

54
Screens formalin-xed, para n Performs ELISA analysis on fresh or

HealthInvestor September 2011

An FDA-approved test which screens

HealthInvestor September 2011

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Future model

management

diagnosis Time

Personalised treatment

finance

finance

Source: Personalized Medicine: Progress and Promise Annual Review of Genomics and Human Genetics

Personalised medicine (care that often uses genetic information to optimalise an individuals treatment) is no longer science fiction, but everyday practice just not in the UK. Sir John Bell, who is leading an inquiry into the future of NHS genetics that will report at the end of the year, said: There has already been a lot of innovation, almost none of which has been adopted by the NHS. Theres now lots of evidence that the benefits well get from this will be at least very large, and could be enormous. (The Times, 3 August 2011). The opportunity is large and enough to move the needle of the largest private hospital groups if you scale US expenditure to the UK by population and also by spend on healthcare per capita, you arrive at a 1.5 billion opportunity, potentially growing at 14% per year (Exhibit 5).

peRsonalised Medicine

exhibit 6 the cost of genoMe seQuencing

$bn
Note: Left axis scale is logarithmic
$100,000,000 Publication of the first draft of the human genome in February 2001 February 2008 second generation massively parallel DNA sequencing introduced to replace the traditional Sanger method and initiated a vast drop in time and cost of genome sequencing

$10,000,000

Since 2008, the cost of sequencing an entire genome has fallen by almost 3 orders of magnitude Whilst barriers still exist, many have speculated that the $1000 genome could be achieved by 2013, making whole genome sequencing an achievable possibility for a large number of patients Realisation of the potential of the genome will require advances in information technology, and implementation of data management systems to inform clinician choices. Such programmes are being initiated in some hospitals in the USA, such as Vanderbilt University Medical Centre

exhibit 5 Exhibit 5 peRsonalised Medicine: MaRket siZe, usa (and uk) PERSONALISED MEDICINE: MARKET SIZE, USA AND UK $bn
$bn
Scaled for the UK by population size and total expenditure on health per capita, this gives a UK market size of around 1.5bn in 2011

$1,000,000

CAGR 13.6%

Source: PricewaterhouseCoopers The Impact of Personalized Medicine Today; WHO; World Bank; US Census Bureau

45

$10,000

$1,000 2002 2004 2006 2008 2010

21
27

Targeted Therapeutics Esoteric Lab Services Esoteric Test Sales Molecular Diagnostics

13

11

6 5 3 2011 10 3 2015

In the USA, personalised medicine is closely associated with improving hospital information technology infrastructure. While Source: www.genome.gov 5 the expenditure required may be beyond the reach of UK private hospital groups now, we believe that the medicine of the future will require substantial investment in IT in order to process the vast amounts of data which genomics and proteomics (the study of the various proteins in cells) are likely to generate. Hospitals which grasp the nettle first will have a clinical and reputational advantage. Exhibit 7

Note:

Left axis scale is logarithmic

PERSONALISED MEDICINE AND ITS BENEFITS

exhibit 7 peRsonalised Medicine and its Benefits

Baseline risk Good health / Low cost Preclinical progression Disease initiation and progression

US market size for core personalised medicine

Early clinical signs

Early stage disease

Advanced disease Poor health / High cost Current model Diagnosis Treatment

Future model

Predisposition & risk

management

Early molecular diagnosis Time

Personalised treatment

Source: Personalized Medicine: Progress and Promise Annual Review of Genomics and Human Genetics

Greater personalisation of medicine is also driven by the remarkable drop in the cost of sequencing the entire human genome (Exhibit 6). The announcement that the human genome had been sequenced around the turn of the century at the cost of $100 billion was rightly highlighted by the media as a milestone in the understanding of disease. Less well known, however, was another breakthrough which became apparent in 2008 second-generation DNA sequencing, which is likely to cut the cost of sequencing to $1000 within the next two years. At Candesic, we believe that there are a number of technologies which private hospitals can adopt with a minimum of effort. For example, pharmacogenomics can help predict patient responses to many commonly used drugs such as warfarin and tamoxifen. In cardiology, genetic mutations have been identified that affect patient responses to betablockers in long and short QT syndromes. In oncology, the potential for implementing patient-specific treatment plans is developing fast: The Sanger Institute in Cambridge is currently characterising the response of over 1,000 cancer-cell genotypes to a wide range of existing therapeutics. Personalised medicine should prove attractive to private health care providers for three reasons: Firstly, there is widespread public knowledge of the human genome project, and the informed middle class expect their doctors to be making use of the information generated; Secondly, the genomic tests are outsourced, and therefore fit within the low capex requirements of todays private hospital; Finally, personalised medicine and therefore early detection reduces cost of treatment and increases the likelihood of curing the disease (Exhibit 7) all good selling points for treatment which could distinguish private care from NHS care.

Source: PricewaterhouseCoopers The Impact of Personalized Medicine Today; WHO; World Bank; US Census Bureau

Genetic risk Genome screening can identify individuals genetically predisposed to developing a condition Molecular signs Approaches using proteomics, metabolomics, and early clinical biomarkers can identify subclinical disease

Patient health reversibility 1/Cost

Source:

www.genome.gov

$100,000

57

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HealthInvestor September 2011

Source: Personalized Medicine: Progress and Promise Annual Review of Genomics and Human Genetics

HealthInvestor September 2011

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finance

Lastly, we believe that private hospitals could take advantage of a big gap in NHS provision in the diagnosis and treatment of allergies, which are increasing in prevalence in all Western countries (Exhibit 8). Exhibit 8

3
2

alleRgy

exhibit 8 PREVALENCE OF CHILDREN WITH PEANUT ALLERGIES

pRevalence of childRen with peanut alleRgies

1.5

UK Clinical peanut allergy in children 3-4 on the Isle of Wight. Cohort of approx. 2000 children, all SPT, allergy diagnosed with open food challenge USA clinical peanut allergy in under 18s. Cohort chosen at random using a nationwide, crosssectional random telephone survey and questionnaire Canada Clinical peanut allergy in children aged 4-8. Children surveyed from a random cross section of schools, diagnosis made by SPT, peanut specic IgE, and oral peanut challenge 1994 1999 2004 2009

0.5

The UK has long lagged behind the rest of the developed world in the training of clinical allergists (Exhibit 9), with treatment being offered by respiratory physicians (for asthma), dermatologists (for contact dermatitis) and general physicians (for anaphylactic shock) despite the fact that the underlying disease process is similar. An opportunity for Exhibit 9hospitals to fund the development of centres of excellence in allergy, filling a gaping hole in NHS provision, is private there for the taking. CLINICAL ALLERGISTS PER 1M PATIENTS

exhibit 9 clinical alleRgists peR 1M patients

Source: Scientific papers, Candesic analysis
Czech Republic France* Switzerland Sweden Italy Spain Hungary Portugal USA Finland Bulgaria Greece Romania Serbia Belgium UK 2 1 5 5 11 9 29 27 23 23 23 20 16 15 57
* Data from UEMS Source: World Allergy Organization; European Union of Medical Specialists (UEMS); RCP Report Allergy: Still Not Meeting the Unmet Need, July 2010

Germany

63

Allergies are an area which have been traditionally under-represented by NHS sta , despite the increasing prevalence of allergies within the population. In 2003 the Royal College of Physicians (RCP) published an analysis of the shortcomings of NHS allergy care entitled Allergy: The Unmet Need. The Department of Health responded by publishing guidelines on the provision of allergy services. However, this has not lead to signicant alterations in the provision of care. In July 2010, the RCP published a second paper, Allergy: Still Not Meeting the Unmet Need.

Source: Scientific papers, Candesic analysis

Australia Peanut allergy in Australia Capital Territory in children up to 72 months. Diagnosis involved skin prick test and history of acute, systemic allergic reaction within 2hrs

* Andrew Thomas is an analyst, Sarah Downes is an associate consultant, and Dr Victor Chua a partner in Candesics London office. vchua@candesic.com 020 7096 7682

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* Data from UEMS

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Source: World Allergy Organization; European Union of Medical Specialists (UEMS); RCP Report Allergy: Still Not Meeting the Unmet Need, July 2010