Eleanore Robinson

NHS in crisis a pivotal moment for PMI?

The latest LaingBuisson Health Cover market report found strong demand pre-Covid for corporate PMI services, which account for 79% of subscribers/enrolees.

With the pandemic hitting already-stretched NHS resources hard, that has continued through into 2021, according to the report.

It continued: ‘When people in employment continued to rise, so too, according to industry sources, did private medical cover subscriber/enrolee numbers.’

With no end in sight to the difficulties in the NHS, is now the time for the PMI market to enjoy a significant growth spurt?

Executive chairman of the Association of Medical Insurers and Intermediaries (AMII) David Middleton said that from talking to its members, there has never been as much demand as there is currently from both individuals and corporates due to the issues with the NHS.

He said: ‘People do want to enquire about medical insurance which is great.’

AXA Health commercial director Fergus Craig added: ‘We are seeing significant uplifts in Google searches (22%). We are seeing a lot of activity in the individual

market. It is pretty competitive. At the moment the SME market is doing very strongly - genuinely, possibly the strongest I’ve ever seen it.’

Craig said this is being driven by people not being able to work until they’ve had surgery and a lot of companies getting squeezed to put through higher salary increases.

Benefits in kind such as PMI are ‘part of that equation’, he explained. Employers are asking ‘Is the benefit I’m providing perceived to be of more value to my staff member than it costs me?’, Craig added.

While demand remains strong, barriers to growth remain.

In the corporate market, the taxation system is deterring some people from taking out policies.

Middleton explained: ‘It is P11D - the benefit in kind. I wouldn’t see why you wouldn’t have 100% membership of a corporate scheme if nobody was taxed. People don’t join sometimes because of the quite onerous tax implications for them. So that is a barrier in the corporate world.’

However, he explained, that since it is an employee-led market, employers are reluctant to take PMI away altogether.

The remainder of the market (21%) is made up of individual lines.

According to LaingBuisson, the ‘cost of living crisis’, with CPI predicted to reach 10% by the end of the year, may ‘dampen’ demand in the sector.

Another barrier to growth in the individual market is people wanting to switch policies to a product that covers their pre-existing conditions. Middleton said: ‘That is a barrier at times as you can very rarely insure something that you know is going to happen.’

Affordability is also a factor in the corporate sector explained Aviva UK Health medical director Dr Doug Wright, as the PMI market has only ever been around 11% of the UK population.

He said that, despite the problems in the NHS, inflation and the pressures on everyone’s pockets, including corporate pockets, is holding back growth.

‘I think there is an even sharper focus on affordability for PMI,’ said Wright. ‘It feels like the two things are almost trading each other off at the moment. On the one hand you have people thinking it is a product we want, and we want to make it available to ourselves or our colleagues or employees, but also we will need to keep it affordable.’

One of the ways of tackling barriers to growth is bringing out value-added products to support clients.

It is one of the reasons Legal & General introduced its ‘Umbrella Benefits’ package, said its director of intermediary Julie Godley.

She said: ‘Private diagnostics is an example of the type of Umbrella Benefits we offer clients. It’s something they can tap into on an ongoing basis and as such, helps enhance customer engagement while also providing intermediaries with more discussion points with customers.

‘By moving towards bespoke approaches and away from the ‘one size fits all approach’ it gives clients greater flexibility and control over their healthcare.’

For AXA Health, it is existing products that are proving popular but also some aspects of new features that have come on board.

Craig said take up of AXA’s modular products, where the management get ‘the full fat’ PMI while other staff receive more limited benefits, has soared.

He explained: ‘For instance, our GP service is the most popular thing since sliced bread. We are clearing 10,000 consultations a week. It is just a massive sea-change in the level of engagement and used by customers on a regular basis compared with what existed in the PMI market before.

‘Mental health is a really top-button issue for employers and we are seeing that in the numbers. That is really making them see the value of what they are getting, I think. Mental health treatment isn’t the most expensive thing in the world but they see more customer contact and more customer benefit, and not a vast increase in cost as a result.’

Godley added that customer feedback had revealed value-added benefits that are free to consumers, such as wellbeing services, were very popular.

She said: ‘The idea is that all customers get extra value on an ongoing basis.

And the benefits can help immediate family too. For example, if your child was being bullied at school, our Wellbeing Support services could be used to help support them with counselling.

‘Obtaining data for such benefits is an industry-wide challenge but the above highlights how our wellbeing add-ons can add huge value, and feedback from customers confirms this.’

Wright agreed, saying it was not easy to prove a direct, tangible financial benefit from health and wellbeing services on PMI products.

He said: ‘The reason I say that is in the corporate world a lot of what we see in terms of claims is muscular-skeletal conditions and those aren’t the sorts of things you improve by a general wellbeing approach.

‘However, diabetes and heart conditions do have benefits from wellbeing
- but only over a long period of time and mainly in Aviva’s consumer book as the customer is a bit older.’

Wright said that data is going to be useful on the mental health and muscular-skeletal pathways, generating and using clinical scores pre and post-intervention which show the degree of improvement. ‘That sort of data is going to be really powerful as it builds and becomes richer over time’, he said.

Middleton agreed saying: ‘Data is vital in everything we do. Without data how do you influence behaviour, how do you have a strategy? Particularly in the corporate sector, how do you demonstrate value? What is the medical plan for your employees? Does it demonstrate that you got somebody back to work for example? That kind of information is so important for me just for corporates to put a return on their investment.’

Wright believes the number of people who have PMI will grow.

‘I think there is a very long-term issue we have in the UK about the affordability of many of our publicly-funded services,’ he said.

‘If you look at dental services - 15 years ago that was very much a similar situation and now it is much more of a mix of public and private provision. I think we will see a much more obvious mixof healthcare provision than these two things called the NHS and private care that never touch on each other.’

Healthcare Markets UK: August/September 2022

Speed is of the essence

It is no secret that the UK has some of the worst cancer survival rates among OECD countries.

Add to that the impact of Covid-19, and it’s clear that the NHS is struggling to manage waiting lists and to direct patients along its cancer pathway as fast as other high-income nations.

The government’s Elective Recovery Plan highlighted the role that the independent sector can play in taking away some of this burden.

But is this actually going to happen on the ground or is a different approach needed?

It is not just the pandemic that is responsible for the current situation, according to Independent Health Provider Network chief executive David Hare, but long-term structural issues.

He said: ‘We have known for quite some time the UK has lagged behind comparable nations when it comes to cancer survival rates. The numbers are pretty stark.’

He said that breast cancer survival rates lag well behind and for colon cancer survival it is the lowest in the OECD.

Hare added: ‘There is a huge amount to do and that is not just a pandemic effect, it is a long-term structural issue with regards to cancer treatment in the UK driven in many cases by slower than average detection rates.’

The problem was a lot of cancers were only diagnosed after referral for something else which slows down accessing the right treatment.

Check4Cancer chief executive Professor Gordon Wishart said poor outcomes were due to inadequate early cancer detection, a lack of access to optimal treatment and a shortage of cancer treatment specialists.

Wishart also found in his own breast cancer research that after 65 treatment ‘fell off a cliff’ as well as ‘massive region- al differences’ in access to surgery for older patients.

He said that this just shows that ‘cancer services in the UK need to be reviewed and completely reorganised’.

‘I think until we have ringfenced resources and treatment, especially treatment, we are always going to be under pressure from whatever pandemic comes along next’, he said.

Furthermore, the UK’s diagnostics ca- pacity lags behind comparable nations.

Genesis Care chief medical officer Dr Eliot Sims said that, in some cases, ‘a reticence to adopt ‘novel’ diagnostic techniques and treatments has delayed realising improvements in treatment and perpetuated cost and efficiency challenges.

He said: ‘The UK has pioneered treatment in some areas, yet in others it continues to rely on well-established but increasingly outdated models of care that are unable to meet the growing demand.’

Hare argued that the development of Community Diagnostic Centres will help increase capacity, but it is currently unclear the extent to which that is adding additional capacity rather than redesignating existing diagnostic services.

It is expected that the majority of these centres will be NHS-led. ‘The capital that the independent sector could deploy into those centres is sitting on the shelf’, he added.

Professor Karol Sikora, one of the world’s leading authorities on cancer, agreed that the slow progress in diagnostics was ‘the key problem’.

He said there was a lot of private cancer equipment and private diagnostic equipment that could be deployed to support the NHS. ‘They are not over- used’, he said.

Sikora added that the independent sector could offer appointments outside of traditional hours. For example, for something like endoscopy, there is the capacity there to change ways of working.

‘In cancers there is huge spare capacity in the private sector. It is diagnostics that has the bottleneck,’ he said.

Wishart said that the private sector was already helping in areas like breast cancer diagnosis, particularly in London. Independent providers of radiotherapy

and chemotherapy will also have a key role to play when large numbers of people whose diagnosis has been delayed come through the system, he added.

Sims added: ‘We see some green shoots. The pandemic forced the health- care system to innovate and operate differently. We saw a willingness to collaborate across the public and private sectors. Clinicians were encouraged and liberated to design and accelerate the adoption of new protocols and ways of working.

‘We therefore believe we have a “moment-in-time” opportunity to reset and transform how cancer care is planned and delivered in the UK, based on the best of both current and emerging global practices.’

Despite the role of the private sector outlined in the elective recovery plan, Sikora said the issue is implementing the plan at a local level and ‘there isn’t much interest in that’.

Implementing the elective recovery plan on the ground is going to be key agreed Hare.

He said: ‘We have been very clear for 18 months now that there is capacity for a whole host of specialties, including the cancer pathway, that is not being picked up by the NHS and we are not really seeing that trend shift.

‘The overall policy environment for working with the independent sector is as positive as I can remember it.

‘The problem is it breaks at local level where protection of Trust balance sheets, focus on very long waiters, the move towards integrated care systems, seems to be stopping translated intent into measurable reality.’

However, IHPN is seeing more people accessing private oncology services and seeing growth in that market.

One of the routes they are using to do this is PMI.

For example, AXA Health has given all its members access to a remote GP service so they can speak to a doctor without placing additional volume and strain on the public services.

Director of medical policy John Burke said: ‘It also encourages our members to be proactive in engaging with us if they have a concern about a sign or symptom which may be cancer.

‘In addition, we have developed an easy route through to diagnostics by developing pathways with private facilities to connect individuals quickly – and without the need for them to engage with their NHS GP first.

‘This approach also helps ensure that, upon diagnosis, there’s a seamless transition for the member to onward care, if required.

‘By way of example, in the first quarter of 2022, 99% of our members with a breast concern accessed a diagnostic appointment within ten days of contacting AXA Health.’

Wishart added that if another 5‒10% of the population were to have PMI, that ‘would take a huge pressure off the NHS’. It would also protect the core services, he said.

More urgently, however, he said a dedicated cancer recovery plan, with a minister responsible for cancer treatment to produce a new strategy, was essential if targets were to be achieved.

Hare argued that a dedicated cancer plan with clear commitments around how the independent sector can be brought in at the point of diagnosis and the point of treatment would be appropriate.

He added: ‘The elastic has rather snapped back despite the recovery phase, arguably for cancer patients, is more daunting than the pandemic response.’

‘A fully formed long-term partnership, leveraging investment, improving co-ordination between providers and focusing in on early diagnosis could over the medium to long term make a real impact’, he said.

Hare, however, cautioned that the independent sector is not a silver bullet, and its inclusion needs to be accompanied by wider reforms.

Sims agreed: ‘A focus only on NHS-funded care risks ignoring those who choose to access privately-funded healthcare.

‘There is undoubtedly a role that the independent sector can play but a focus on traditional “outsourcing” models is unlikely in our view to fundamentally change the dial.’

Healthcare Markets UK: July 2022

The doctor will see you now

Covid-19 and difficulties accessing NHS doctor services has led to a surge in demand for private GPs in the past few years.

Much of that demand has been for online GP services, driven by the accessibility and immediacy of appointments.

For example, online GP service Doctor Care Anywhere has reported growth of north of 100% for two or three years in a row.

It is now conducting 50,000 consulta- tions a month, compared to 5,000 two years ago.

Co-founder and chief executive Bayju Thakar said: ‘We have seen significant scale and now have about somewhere north of 350 GPs on our panel.

‘What Covid did is to force people to do things differently and think this is much easier and much simpler.’

Digital provider HealthHero also reported that demand had grown ‘exponentially’ across all its channels, including NHS 111.

Vice president and chief of staff Kayleigh Hartigan said that, while the company did see an interest in uptake prior to Covid, the pandemic accelerated what was already growing.

She said barriers such as patient expectation and experience and regulation ‘just disappeared’ due to the pandemic.

‘They were no longer something you had to think about’, she said. ‘From a patient perspective if you wanted to talk to a GP it was either through a video conference or telephone call.

‘In the UK we have seen for the first time this huge and exciting shift of NHS purchasing of digital health.’

This shift looks set to continue.

‘Between 2020 and 2021 there was an 86% increase in use in our GP services and even more shocking is that it is con- tinuing’, explained Emma Elstead, head of clinical services at Simply Health. ‘Between December and February 2021 and the same time period this year, we have had an 89% increase, so it is not dropping.’

‘The pandemic gave people permission to try these services, which then gave them the trust in using them.

‘People realised these services were good, they were effective, and they can provide a lot of support.’

Thakar agreed that the pandemic had brought up confidence levels in online services and also highlighted what more could be done.

He said: ‘Covid unlocked that “can I trust this”, “can I do things in this way” and I think it did that for clinicians too.’

‘Quite a lot of the push is coming from GPs themselves.’

For GPs, it is a manageable source of income explained LaingBuisson consultant Liz Heath. She said: ‘You book in for a session and wait for things to happen.

‘That is one of the reasons there has been a proliferation of providers, particularly in the digital space.’

Heath added that people wanting an immediate consultation, just to put their minds at rest and not wanting to take the time up of NHS GPs were also driving demand.

She said: ‘They are more likely to use the whole 15-minute slot with a private GP and be able to talk about multiple issues.

‘That opportunity to talk and have a valuable consultation is one of the drivers.’

In addition, Heath said that these consultations were ‘very much a gateway for other private healthcare services’. This could be through referrals for issues such as back pain, which could lead to more diagnostics.

She said: ‘If you talk to providers, certainly in the last year or so, outpatients in diagnostics has been one of the areas of growth.’

At Nuffield Health, services across its whole operation are at pre-pandemic levels.

Head of primary care Marc Holl said: ‘We are trading really well and the majority of that reason is that diagnostics and routine procedures in hospitals has got a significant waiting list.

‘One of the ways of accessing private healthcare is by private GP. We are seeing multiple referrals coming off each appointment.

‘We are seeing an increase in demand for primary and secondary care services that GPs are gatekeeping.’

Holl added that Nuffield Health had seen growth in self-funding GP services post-pandemic from people who don’t have PMI but don’t want to wait for services on the NHS. ‘The referrals for ongoing services have definitely increased’, he said.

There has also been a rise in demand for onsite GPs among the big corporates in major cities. Holl explained: ‘What they are wanting is that hybrid of virtual and face to face.’

Nuffield Health provides virtual services via Doctor Care Anywhere while its GPs carry out face-to-face appointments.

Doctor Care Anywhere now has 15,000 corporate partners, Thakar said with most companies seeing it as a “must have”.

He said: ‘With hybrid working, there isn’t much point in having a GP in the office and it is a service that can be offered to all employees, making it much fairer.’

Holl agreed that hybrid working is here to stay. ‘As a result of that, the healthcare system is going to have to accommodate people’s new ways of working’, he said.

However, some providers would differentiate themselves by offering 100% face- to-face services as people got fatigued with virtual services, Holl argued.

He said: ‘I do wonder in around five-plus years whether everyone will be a little bit fatigued by virtual and there could be an increased demand for that face to face again.’

Corporates are interested in providing access to tools and support in a way they weren’t before, Hartigan added.

She said: ‘Now there is a much more involved role of the corporate in healthcare.

‘There has been some big shifts in terms of services and the way you access services and what that looks like.

‘But there also has been the rise of new types of payer in healthcare.

‘Historically you would have the NHS and private health insurance.

‘Now it is a much more fragmented buyer’s market where you have the NHS, private health insurance, you have people paying out of pocket but we are also seeing this role for the corporate where people can’t get access to services they might have needed, so the corporate is stepping up and taking a greater role in supporting their workforce.’

And it is not just corporate companies using online services. Elstead said that pre-pandemic more virtual services were used within the corporate market than the consumer market, now it is 50/50.

She said: ‘It is going up in the corporate but we have seen the consumers take it on as well.’

Elstead added that these would continue to increase and there would be more text and live chat services.

She said: ‘Having that contact helps people manage their own healthcare. The pandemic has made people become more responsible for their own healthcare and lifestyle.’

Heath added that more consolidation in the market was likely in future.

She said: ‘It has attracted a lot of investors and I think there will inevitably be some consolidation as people try to grow their own space with different things.

‘Some will offer travel services and all sorts of other things that NHS primary care is stretched for now.’

However, there are limits to what online services can provide.

NHS England has said around 60- 70%% of GP consultations could be carried out online and Dr Thakar said this could rise to 70%-80% in the future.

He said: ‘The more data they have available, the more they assess trends and make judgements.

‘But there are certain things you can’t do. There are certain times when you want to hold the hand of a patient and be there in person.’

Healthcare Markets UK: May 2022

Taking the heat out of healthcare

As global leaders committed to reduce carbon emissions at COP26 in November, the Independent Healthcare Providers Network (IHPN) launched its own net zero pledge on behalf of its members.

The move mirrors the NHS’ target of reducing its ‘carbon footprint plus’ to net zero by 2045, including direct emissions and those caused by its supply chain.

Pressure to change is also coming in financial form. Private investors are demanding more action, while the NHS and Cabinet Office are including emission reduction as a requirement in their pro- curement process.

The IHPN also decided to go down this path in response to the ‘growing evidence’ of the impact climate change was having on people’s health, for example air pollution with links to conditions like lung cancer, out of hospital cardiac arrest and asthma, its head of policy Danielle Henry told HMUK.

Furthermore, as temperatures rise conditions such as Lyme disease and encephalitis are expected to become more prevalent.

Henry explained that IHPN members recognised that they had a role to play in changing this.

She said: ‘IHPN and our members acknowledge that we can make a real difference’.

They have agreed to scope 1, or direct emissions from their operations, to be net zero by 2035.

Scope 2, which relates to provider’s supply chain, sets a target of net zero by 2045.

This latter change is expected to be delivered through the procurement of supplies from companies who can demonstrate their products, equipment and services are carbon neutral.

Henry said the targets had been set to be ‘achievable and a challenge’.

She said: ‘Our members do not feel we should be playing it safe on this.’

However, the challenge in reducing emissions will vary between members. For example, for community nursing teams the focus will be on the vehicles they drive, while for a diagnostics provider it would be around the equipment used, and for hospitals efforts would need to concentrate on the buildings.

‘The hardest challenge is fear of the unknown when getting started,’ Henry said.

Leading the way are a handful of IHPN members that have already committed to becoming net zero by 2030.

Among them is Spire Healthcare. Group supply chain and procurement director Martin Alley, who leads on its environmental initiatives, told HMUK: ‘As a responsible corporate citizen, we are determined to do everything we can to reduce our impact on the planet.

‘For the past 12 months Spire has been implementing its decarbonisation strategy which is designed to achieve net zero carbon emissions by 31 December 2030.

‘To support this, we have ring-fenced some £16m of investment over the next ten years and this is already being deployed.

‘For example, Spire Cardiff has just completed the installation of 78 PV solar panels on the roof of its outpatients building. We are also now procuring 100% of electricity from renewable sources.’

Spire has signed a contract with Scottish Power for the latter to supply it with renewable electricity for the next few years.

Alley said its gas and power purchasing commitments had been made in accordance with Spire’s prevailing energy procurement strategy framework, which includes a commitment to only procure renewable electricity, and has been approved by the Board.

Procuring electricity from only renewable sources could make a real impact on energy intensive healthcare operations reducing their carbon emissions.

Director of future electricity systems at RenewableUK, a representative body for renewable energy generators, Barnaby Wharton said healthcare providers had a couple of options when making this transition.

They can take out corporate purchase power agreements directly with electricity generators under which they agree to by renewable energy for a specific number of years.

This is suitable for large companies with very high electricity demands,’ Wharton explained. They would also need a good credit rating so developers would be sure that they would be still operating at the same levels throughout the con- tract, he added.

Smaller companies can still be supplied with purchase power agreements by asking an energy company to supply them only with renewable energy.

He explained: ‘Because the supplier is buying loads of renewable energy, they can say across the year we have bought this amount of renewable energy and we can assign that to you. These supplier PPAs are much easier to do.’

However, there will be some periods were there isn’t enough renewable energy generated, so it is necessary to look at the source over the year.

‘It is very important for suppliers that they can correlate the power they have used with power they have bought’, Wharton said.

Healthcare providers can demonstrate that they are using energy from renewa- ble sources through Renewable Energy Guarantee of Origin (REGO) certificates.

The government has just closed a consultation to make this process more transparent.

‘What is really important is to make this a much more transparent process so you can be confident when you are buying renewables,’ Wharton added.

By ensuring the money goes back to renewable energy providers, it will allow the industry to expand and supply power at lower prices, he said.

Spire has also appointed a ‘carbon champion’ at each of its 39 hospitals, who are responsible for working with colleagues to identify, develop and promote initiatives at their site which will reduce carbon consumption and create a ‘carbon culture’.

Alley said: ‘Each Carbon Champion is provided training to understand the relationship between energy use and carbon emissions and is equipped to identify some simple energy savings opportunities as well as be able to recognise and act upon bad energy management practices.

‘Examples of initiatives which the champions have in train include reduction in hours of car park/street lighting as well as the identification of capital investment needs such as insulation upgrades.’

Progress towards its net zero targets will be monitored via regular updates to the Spire board, as well as regulatory reporting requirements.

In addition, Spire anticipates that its investment of £16m will be offset by the benefits to be derived through reduced energy consumption.

However, for many, smaller healthcare providers or those with more complex operations, the journey towards net zero may be more challenging.

A year ago, IHPN set up a climate change group to support members on their own journey. This centred around providing information, sharing best practice and ambitions to become net zero. Henry said that when you started to break the latter down into stages, IHPN members have found it becomes less challenging.

However, despite providers’ best efforts, there will always be carbon emissions that will be impossible to eliminate. Henry said that these will have to be off-set but the focus among IHPN members is very much reduction.

Also new, unforeseen challenges will emerge over time which could stall progress on reaching
the targets on time, or even hinder them being achieved at all, so plans need to be flexible.

But Henry said the will is there to make a difference with momentum growing from staff to implement carbon reduction measures. She said that healthcare providers’ green credentials are increasingly coming up during interviews with potential employees and that a rising number of patients are asking about environmental standards when choosing a provider.

‘Every provider I have spoken to said: ‘It was easier than I thought’, Henry revealed. ‘The costs weren’t as great as providers’ feared and the costs of not doing it is huge. They cannot afford to be not involved in this.’

Healthcare Markets UK: February 2022

Straight to the point

The restrictions resulting from the Covid-19 pandemic have meant most forms of interaction in the UK have been conducted online in the past 18 months.

As well as seeing the person we were talking too, most virtual meeting apps had a small box in the corner of the screen where we could see ourselves and all our perceived flaws.

Coupled with the pressure to post images featuring a ‘perfect smile’ on social media sites, this has led to a boom in orthodontic services.

The so-called ‘Zoom effect’ has led to a huge increase in teeth straightening services, both at the dentist and through online companies.

A recent survey for the British Orthodontic Society (BOS) found the more than 61% of dentists had experienced a larger than expected increase in demand for private treatment in the last 12 months.

Almost 90% of survey respondents said they had seen an increase in the growth in the popularity of aligners in the last five years.

But as the restrictions ease, will this boom last or is a bust in the so-called ‘smile clinic’ market, as witnessed in 2008, on the horizon?

The UK Orthodontics market is projected to grow from £82.6m in 2020 to £269.6m in 2027 at a CAGR of 18.4% between 2020‒2027, according to a Fortune Business Insights report published earlier this year.

The development of alternatives to traditional metal braces, such as clear aligners, ceramic braces and lingual braces has led to more people in the UK seeking orthodontic treatment ‘as these invisible devices are more comfortable and aesthetically pleasing as compared to the traditional products’, according to the report.

The BOS survey found that almost 85% of respondents had noticed an increase in adults seeking orthodontic treatment in the past five years.

Reasons given included rising patient expectations or social factors or being inspired by a celebrity blogger.

Patients were much more likely to be female than male and 26‒40 years old was the most common age bracket among private adult patients, according to the results.

BOS director for external relations Anjli Patel said she had seen ‘a massive increase’ both anecdotally and in her own practice.

Patel said: ‘We are definitely a more self-aware society.’

As many companies are now adopting a hybrid model, with most people going into the office part-time, Patel does not see this trend tailing off any time soon.

She said: ‘We will be using a lot more Teams, Zoom, Hang-outs. People have had a lot more time to get used to seeing themselves. They haven’t been able to spend their money on holidays, are not going out as much as before, so I think for the foreseeable future I can see it increasing.

‘Even teenagers are looking for orthodontics a lot more than before. It is a lot more accepted. It is almost like a rite of passage for them.’

‘The appetite for teeth straightening is very strong and has grown rapidly in recent years’, said Nick Marston, director of private & specialist at {my}dentist.

He said: ‘Like virtually every other developed market, teeth straightening and in particular clear aligner therapy has seen exponential growth in recent years.

‘Some of this demand has been stimulated by the new direct to consumer market entrants. We feel that a clinically led model offering choice and value to patients is well placed to meet the unmet demand in the market.

‘Short term orthodontics, particularly clear aligners, are most in demand and are offered across almost all of our practices nationwide.’

He said that patients do discuss being on both social and work-based video calls as a factor which has led them to enquire about improving the aesthetic appearance of their teeth.

Marston said: ‘There may be some short term drop off as people adjust their priorities to the changing work landscape, however we don’t feel this will be significant.’

Research conducted by {my}dentist in August 2021 suggested that more than one in four (28%) of young adults (aged 18-44) in the UK are currently interested in teeth straightening.

But it is not just patient demand for treatments that is driving growth, but also clinician appetite to upskill to provide the treatments.

Marston said {my}dentist worked with Straumann Group for its ClearCorrect product and Invisalign.

This meant it was able to support clinicians with access to training opportunities at a reduced cost.

It is also investing in digital marketing campaigns for these treatments to drive leads direct to practices and further sup- port its clinicians’ development.

Market growth, however, has not been limited to the dentist surgery.

US-based teledentistry platform for teeth straightening SmileDirectClub entered the UK market in 2019.

Aiming to make teeth straightening services more accessible, customers can schedule a free 3D scan of their teeth at one of its SmileShops or book an appointment on its travelling SmileBus.

They can also order an impression kit delivered to their front door in one box, to create both standard and night-time aligners.

SmileDirectClub vice president for the UK, Ireland & Iberia David Cran said: ‘Sales of our dentist-prescribed, at-home impressions kit grew during the pandemic.

‘Teledentistry is a relatively new concept and so there’s huge growth potential in the sector.’

The operator recently commissioned a piece of research that found nearly 40% of British consumers felt lockdown was a good time to enhance their appearance while out of the office, with one in five (19%) of respondents saying the pandemic made them focus more on taking care of themselves with the hope it would improve their physical appearance on screen.

Other research shows that nearly half of the UK population (48%) agree that having a straight set of teeth is the most important feature in creating a smile they would love, Cran said.

He added: ‘SmileDirectClub’s goal is to provide access to safe and affordable care for all customers across the globe and will continue to innovate and grow in the sector to allow this to happen.’

The safety of teeth straightening services is a key concern of BOS, which has launched Safe Smiles campaign.

Patel said: ‘Our main mission is to educate people, so they know who their clinician is, and they’ve had a clinical exam.’

She said that there needed to be a guarantee that the moulds are accurate, and the aligners are going to do what the algorithm tells them it’s going to do.

Another issue is monitoring the market as, while the CQC regulates dentists in the UK, not all online services fall into this classification.

This gap will become more of a problem if, as expected, the market continues on its current growth trajectory.

While so-called smile clinics suffered in the wake of the 2008 financial crisis, those in the market do not see history repeating itself.

Marston said: ‘All the market data and analysis suggests that demand for teeth straightening will remain strong for the next decade.

‘If you layer on the fact that there is an overall shortage of dentists in the UK to meet patient demand; it’s very likely in our opinion that this will continue to be a buoyant market.’

Patel agreed, saying orthodontics had been around for years so would still be around in the future.

She said: ‘I think demand will continue to increase. We follow the US. They have adverts in the US saying, ‘Save for your car, save for your health and save for your orthodontics’. I think we are heading that way.’

Healthcare Markets UK: November 2021

A difficult diagnosis

Covid-19 has left the NHS with a significant diagnostics backlog, with many hospitals still not operating at pre-pandemic capacity levels.

In response, it has launched Community Diagnostics Hubs to increase capacity outside hospitals for routine scans or things like minor fractures, releasing a £10bn framework procurement contract this summer. The successful bidders will have the ability to award contracts or sub-contracts for a range of clinical services to be provided at the hubs. 

But with an ongoing recruitment short- age, enhanced infection control measures due to Covid and a ‘hidden waiting list’ of patients not yet ready to visit their GP, could they be the answer? Or are more radical solutions needed?

At the end of May 2021 there were 1,333,900 patients waiting for a key diagnostic test, up from 354,300 in 2021, up from 1,016,500 at the same time last year. 

In addition, NHS England guidance issued in May 2021 states that waiting lists should be reviewed and prioritised according to clinical need rather than waiting time in areas where more than half of patients have been waiting for more than six weeks. 

Medica chief executive Stuart Quin told HMUK that the NHS was back to between 85‒100% of pre-Covid levels in terms of scanning but the bottleneck is the ability to get patients through the scanners.

He said: ‘I think that has been the backlog to date, the fact that they’ve had to disinfect these scanners in between each patient. That has really reduced the capacity.’ 

Quin added that some NHS Trusts are now looking at longer opening hours or using the private sector to do scanning, which he said would make a difference. 

Medica was taking on the overflow reporting as well as any subspecialist reporting. It has also been doing out of hours work which Quin said, ‘has come back very quickly as lockdown has eased’. He said: ‘That part of the business has been growing as we come out of lock- down.’ 

InHealth chief executive Geoff Searle said that, while the official waiting lists of six weeks or more were more than seven times higher than pre-Covid levels, what nobody knows is the size of the ‘hidden waits’ of people needing tests but who have yet to go to their GP. 

He said: ‘When that washes through the system, what has become a challenging situation will become even more difficult. 

‘We are definitely seeing lots and lots of demand for diagnostic services, particularly for more flexible solutions like mobiles.’ 

Furthermore, Searle said that, while Community Diagnostics Hubs could increase capacity, it is unknown the degree to which the NHS would want to work with the independent sector on offering it. 

He said: ‘I would anticipate some parts of the NHS would want to establish that capacity as pure NHS capacity while others would want to work in whole or in part with an independent sector provider to support them.’ 

Searle added that ICSs are currently just forming plans about how much capacity they think they need, what kind of services and where they want it to be, so it would be a while before the commissioning of services started. 

Finding enough workers to staff these hubs will be a major hurdle for the NHS. 

LaingBuisson’s Diagnostics market report (published prior to the pandemic), claimed that UK radiologist vacancies have been running at around 10% for the past five years, while there is a 12.1% vacancy rate among histopathologists. 

Report author and chief executive of Latchmore Associates Hugh Risebrow said: ‘There are massive shortages of radiologists, pathologists and increasingly people like microbiologists, biomedical scientists and radiographers as well. 

‘Creating physical capacity doesn’t solve the workforce problem and the workforce problem is a bigger problem than the physical capacity problem.’ 

Furthermore, Risebrow said that anaesthetists have been overworked during the Covid-19 pandemic so many are not inclined to do extra work, leading to a bottleneck on the diagnostics pathway. 

Quin agreed saying recruitment was still a massive issue, not just in radiology, but ‘across the whole piece’. 

He said on the radiology side they are predicting a shortfall of around 4,000 staff, around 44% of the current work- force. ‘It is a huge shortfall’, he said. 

Medica is sourcing radiologists from Australia and New Zealand through its joint venture with Integral Diagnostics. 

It is also trying to be very efficient on using radiologists time and they audit the work. 

Quin said: ‘We don’t conjure up lots of additional radiologists, we use the radiologists in the NHS but we can use them better with more efficient systems. 

However, this is proving to be an uphill task with the number of scans per patient increasing at a much higher rate than the rate of radiologists. ‘Now we have had 18 months of chaos which has turned the whole system into a really difficult position’, Quin said. 

He added that while Community Diagnostics Hubs will increase the number of scanners available, they will also put more pressure on the reporting side, which could lead to longer backlogs unless a solution is found. 

InHealth is also trying to think creatively about recruitment but does not recruit outside of the NHS. 

Searle said there was an industry-wide responsibility to train more clinical staff, with a flow of graduates now coming into the sector each year and apprenticeship schemes available. 

InHealth is ensuring that all its workers are operating to the top of their licences ‘ensuring the workforce that is available is optimized’, Searle said. 

He added: ‘Retention is key and that gives rise to a series of questions for all employers about what we offer all our employees, not just in the sense of financial renumeration but in the wider package of benefits to ensure as many people in the sector are retained as possible.’ 

Technologies such as AI could have a role to play too. Medica is looking at how these systems could make its reporting more efficient. 

Quin said that AI is not there yet to re- port in place of a radiologists but can help with workflow prioritisation. 

Searle said the Government’s Health and Social Care Bill would impact diagnostics in a more positive way. 

He said: ‘If you look at the scale of the challenge with backlogs and the totality of diagnostic capacity across the NHS and independent sector, there is a substantial amount of capacity that isn’t fully utilised, mostly in the independent sector. 

‘My hope is that through this reconfig uration of how the NHS is structured by this legislation and taking a more system/regional view, there will be opportunities for more joined up working between the independent sector and the NHS to ensure that all available capacity is deployed to support the clearing of the backlogs.’ 

He said a good example of this was the national contract for mobile CT, which has seen InHealth scan more than 150,000 patients during the pandemic. 

Quin agreed saying: ‘In order to tackle this backlog, you are going to need all parts of the system providing a solution’. 

He said providers like InHealth and Alliance Medical can provide both the services and the capital for diagnostics, which will become more important in the long term. 

‘I think there is a massively important role for the independent sector in that’, he added. 

Healthcare Markets UK - August/September 2021

HIGH STREETS: THE NEW HEALTHCARE HUBS?

One of the side-effects of the Covid-19 pandemic has been the transformation of high street retail properties into sites providing temporary medical services.

Furthermore, the planning reform white paper published last August places medical centres in the more flexible Class E category, allowing for a mix of use to reflect changing retail requirements.

With these planning system reforms, great public transport links and a dearth of vacant retail properties owned by landlords desperate for new tenants, will the high street now become a permanent hub for primary healthcare delivery?

According to the latest figures from the British Retail Consortium, in the fourth quarter of 2020, 13.7% of retail premises in Great Britain were vacant, rising to 17.1% in shopping centres.

REIT Assura is currently backing Haven Health properties in converting a former Miss Selfridge unit next to the Cascades shopping centre in Portsmouth into a GP surgery.

Chief executive Jonathan Murphy said: ‘It is something we have been looking at for a long time.

‘When looking at a new development, a large out-of-town centre can be quite controversial because people want to be able to walk to their health centre. It has always been a very local service.’

He said any empty space in town with good transport links is ‘definitely an opportunity’.

However, Murphy did stress that it very much depended on what the local requirements are.

For example, the Cascades development has been driven by the need for the local CCG to have somewhere to provide primary care services for students in the city.

Portsmouth University’s GP practice will be the tenant, with a 21,000-strong patient list, comprising 75% of students, it is expected to be up and running by the end of the year.

Murphy said the council has really pushed for the development to go through and wanted healthcare to lead.

He said: ‘It is not always that easy because clinical requirements are quite different to retail. So, this one is costing us slightly more to convert a retail unit than it would to build a brand-new green- field site on the outskirts of town.’

However, Murphy stressed that being part of a regeneration project came with its own rewards.

National Regional Property Group received planning approval to convert a former Debenhams site in Southsea, Portsmouth in January.

Known as Handley’s Corner, the development will feature a GP surgery alongside residential apartments.

Chief executive Shaun Adams told local media: ‘We’re keen to deliver the homes, jobs, shops and new ‘health hub’ which will help regenerate the centre of Southsea.’

Rebecca Roffe, partner in the planning department at law firm CMS, said securing change of use approval certainly got easier once the Class E changes came in.

She said: ‘We have seen some clients come to us to use some of their more vacant units at the end of their leases.

‘We have found that even in big schemes that are being developed now, where before the developer would have been required to pay a big fee for a doctors’ surgery that would then get constructed to benefit the whole community, there has been a realisation that being smaller, easier to access and having more of them is more beneficial.’

However, she cautioned that, apart from planning, there might be other reasons healthcare providers are prevented from converting retail space, for example, restrictions on the property’s title.

There also might be some historic planning conditions for the site which excludes it from Class E restrictions.

In addition, some units have insufficient space, light and other facilities that makes conversion unviable.

Roffe added: ‘It won’t be the planning flexibility that drives the actual change. There would need to be a lot more done to enable that flexibility to be used.’

For example, she said that one property developer was looking at converting an old House of Fraser building for medical use but decided the light was not right and ceilings too low.

Murphy agreed saying: ‘At the moment the guidelines from the NHS are quite restrictive so if you’re delivering primary care services, it is a very precise con- figuration in terms of what you need to provide in terms of room size.

‘So, the fact that you have got empty space in itself is not the panacea. It is not as simple as putting a few consulting rooms in an empty retail unit.

‘It is not a silver bullet for all requirements.

‘Healthcare is not going to solve a major retail challenge. It will have a role to play but it is not going to fill a shopping centre. The requirements are not that large.’

Mixing healthcare and retail services is not new. Pharmacies have been offering services in adjoining consulting rooms for years and drop-in GP services have been popping up in heavy-traffic areas such as railway stations.

During the pandemic, the NHS was offered lots of real estate with no rent

Retail-to-healthcare conversation plans in Portsmouth from Haven Health Properties Limited from landlords. However, the NHS didn’t want to end up with lots of liabilities when they vacated, so law firm CMS created an industry-standard licence to minimise risk on both sides.

Real estate partner at CMS Candice Blackwood said: ‘I think there has been some activity over the last 12 months to fulfil some shorter-term needs for the NHS.’

She said more medical services such as pharmacies and dentists and ancillary services like physios would be suited to retail units, but it would be harder with the traditional GP model.

This is because Assura and Primary Health Properties account for 20% of the primary care market, 30% is owned by NHS Lift. The remainder is owned by GPs themselves, she said, and younger GPs don’t want the property responsibilities.

‘So, the NHS is having to relook at the whole GP property owning model and I think that’s where we might see shorter-term premises in the high street that are currently vacant that can be taken with cheaper rents on a short-term, five- year lease arrangement’, she said.

Looking forward, could primary care on the high street become the norm?

Blackwood said that primary care real estate needs upgrading – 50% is still run from converted Victorian houses – and the NHS is very keen to see future invest- ment going into polyclinics.

She said: ‘There is no other reason why they wouldn’t be prevalent in the high street going forwards.
‘I think with the way the government is changing and putting more public sector money into the recovery model from the pandemic, they will be encouraging active uses of shops that would encour- age trade and people going shopping around.’

Of the 16 schemes Assura is on-site with at the moment, only one is a retail conversion with no others in the pipeline.

Murphy said: ‘I do think it will have a long-term role to play. Could I see it becoming two, three or four? Absolutely. Could I see it 16 out of 16? No.

‘It is very much flavour of the month. People are seeing healthcare as a big part of the potential solution.

‘But the actual physical space requirement is such that it’s not going to be the only answer. It’s got to be part of a much wider review of the high street.’

HEALTHCARE MARKETS: MAY 2021