2014 Business Opportunities for US Firms in the new NHS

Market Opportunities for US
Health Providers
In the New UK NHS
Prepared By
Navigate Consulting
For: Client XXX
September 2014

i
Executive Summary
Background to the New NHS
The NHS is a much loved British institution, however strained public finances mean it has become
virtually impossible to preserve the NHS as it is without seriously damaging other important public
services or raising taxes significantly. The NHS in England has to find up to £30 billion (US$50 Billion)
in efficiency savings by 2020, to cope with the gap between essentially flat funding and rising demand
and costs. Aware of this the incoming Conservative Government set about developing a radical reform
process, which was legislated in the Health and Social Care Act of 2012.
There are five pillars to this act, but the most important to independent service/private healthcare
providers if the fifth, which aims to allow increased healthcare market competition for a majority of NHS
healthcare services. So far 77 categories of service have been opened to bidding from Any Qualified
Provider (ACP), British or international. Procurement is managed on a regional and local basis by the
211 Clinical Commissioning Groups (CCGs) across the UK. CCG’s are GP-led commissioning consortia
which replaced the prior Primary Care Trusts under the 2012 Health and Social Care Act. In 2012/13
CCGs accounted for 91% of all NHS spend or £93.7 Billion (US$155.5 Billion)1
.
The Potential Market for Independent Service Providers (ISPs)2
LaingBussion Healthcare Analysts estimated the UK independent healthcare market to be valued at
£40.5 Billion ($US 67 Billion) in 2012/13. This estimation though only captures the first 6 months of the
new system and thus the 2013/14 value of the independent sector is likely to have grown considerably
as the process of tendering gathers pace. For example in the period June 2013 to June 2014 £13.5
Billion (US$21.5 Billion) of contracts were awarded, which was a 304% increase on the prior year. 70%
of these were won by private providers.
Service sectors representing key opportunities for international ISPs
Having analysed in depth the segment size, growth rates, ISP share and projected future share of each
health service segment; the areas TSAG see as those of greatest mid-long term opportunity for
international providers include the following;
Acute Care
The private acute sector encompasses healthcare provided by the independent sector (both private and
voluntary), medical/surgical and mental health hospitals and clinics, as well as healthcare provided to
private patients in NHS hospitals in the UK.
In the acute care sector, around 71% of private acute care services are distributed through independent
hospitals and clinics. According to Laing & Buisson, there were 454 independent acute medical/surgical
hospitals in the UK. Major providers of private acute care services include Netcare’s General
Healthcare Group, Spire Healthcare, HCA, Nuffield Health and Ramsay HealthCare UK.
Between them, the five largest hospital operator groups own 210 acute medical/surgical hospitals
withman overnight bed capacity of 7,354, or an estimated 79% of the UK independent acute sector bed
total. The total value of the acute care segment grew at a CAGR of 5.5% between 2008 and 2013.
1
Note all US to GBP conversion rates are based on the wholesale interbank rates of August 28th
, 2014. Whereby 1
GBP = US1.66
2
Note – Throughout this document the acronym ISP refers to Independent Services Providers or private providers

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Behavioral Health/Mental Health
Outpatient mental health services are predominately provided by community health and this appears
to be one of the areas of greatest opportunities for ISPs.
Allocation of spending on community and mental health services to ISPs has continued to rise year on
year. The independent sector has become a more important provider of NHS community and mental
health services and in 2012/13 was worth £1.57 Billion (US$2.6 Billion). ISP’s share of the mental health
services market increased from 12% to 17.5% in just one year to 2012/13 If current trends continue
is likely to dominate the lion’s share of expenditure by 2025.
Inpatient mental health services are provided both by the NHS and ISPs.
The four largest inpatient and outpatient mental health service providers are Partnerships in Care,
Priory Healthcare, St Andrews Group and Cygnet HealthCare. Together they operate around 43%
of independent mental health hospital beds and generate around 53% of sector revenue.
Other providers include Care Principles, Castlebeck Group, Huntercombe Hospitals, Alpha
Hospitals, Cambian Healthcare and St Luke’s Group.
Community Health Services
Community Health Centers in the UK are clinics staffed by a group of general practitioners and nurses.
Typical services covered are family practice and dental care, but some clinics have expanded greatly
and can include internal medicine, pediatric, women’s care, family planning, pharmacy, optometry, lab,
and more.
In 2012/13 20% of all expenditure on community health services was spend on care provided by ISPs;
an increase of 34% on the prior year. The proportion (by value) of community health services provided
by the independent sector increased from 12% in 2010/11 to 18% in 2012/13
Residential and Non-Residential Home Care
With the aging British population residential care homes and end-of-life care services represent a clear
growth opportunity for ISPs.
The combined value of the care market for older people alone (Local Authority funded, voluntary and
private expenditure), is estimated to be worth £22.2 billion (US$ 36.8 Billion) and is growing at 4% per
annum, of which £13.4 billion (US$ 22.2 Billion) is attributable to residential care and £8.8 billion
(US$14.6 Billion) to non-residential care.
Around 92% of care home places are provided by the independent sector across the UK. About 89% of
home care hours purchased by councils in England are provided by the independent sector. The
remaining 11% are provided in house by Local Authorities.
The companies with the largest portfolios of homes for older and physically disabled people include
Southern Cross Healthcare, BUPA Care Services, Four Seasons Health Care and Barchester
Healthcare. As of July 2012, these companies owned or leased 106,000 registered care home beds
between them, accounting for 28% of the UK’s for-profit capacity for older and younger physically
disabled people

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Telecare and Telehealth
The UK Government in 2012, established a clear objective that by 2017 “significant progress will be
made towards the 3 million people with long-term conditions being able to benefit from telehealth and
telecare”.
Clinicians and patients, however, have been less enthusiastic. Many have concerns about the perceived
lack of robust evidence on cost-effectiveness of telehealth, which indicates the telehealth industry will
need to develop new networks, relationships and metrics to demonstrate the benefits of the wider
adoption of the technology.
Indeed, a January 2014 survey of Clinical Commissioning Groups (CCGs) suggested that delays and
lack of interest from clinicians and patients have undermined progress on rolling out telehealth and that
some CCGs were withdrawing their investment.
Nonetheless even if adoption is slower than providers hope for, telehealth services will represent a
significant mid-long term market opportunity for ISPs. Clearly the margins and value of telehealth
services to providers are far greater than telecare. Additionally it is likely the competitive space at
present is less crowded than telecare, which would potentially provide first mover advantage to secure
significant market share.
Figure 1: UK Healthcare Segments-Growth/Share Matrix

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Penetrating the UK NHS Healthcare Market
International providers must be prepared to commit to the market for the long haul. As discussed each
contract procurement process takes on average a year to complete. The market is already competitive
with many well established UK providers (as shown in detail in Appendix E).
Nonetheless the UK is at the very beginning of the most substantial reform of the NHS in its history,
value opportunities for Independent Service Providers (ISPs) is only likely to grow year on year and
international firms entering in the next two to three years will still be considered early movers, with all
the attendant advantages of such.
Standard Due-Diligence Procedures Apply to UK Healthcare Market Entry Strategies
This document details much of the first of the key processes in determining both the attractiveness and
viability of the UK Healthcare market for international ISPs. As with any market entry strategy careful
consideration must also be given to customer analysis, the firm’s potential position and its business
capabilities. The key processes of which are detailed in figure 1 below.
Figure 2: Key Stages in Assessing the UK Market Attractiveness

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Any international provider aiming to compete for CCG contracts must establish an on-the ground
presence in the UK. A practical early entry strategy would be to recruit UK staff experienced with the
new CCG procurement system, in addition to experience in the service field the firms wishes to compete
in.
Figure 3: International ISPs also need to consider a range of commercial and operational issues that will
affect their go-to-market approach in the UK

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Table of Contents
EXECUTIVE SUMMARY......................................................................................... I
TABLE OF CONTENTS ..................................................................................................I
1. INTRODUCTION ..........................................................................................2
1.1 CONTEXT ....................................................................................................... 2
1.2 OVERVIEW OF THE HEALTH AND SOCIAL CARE ACT 2012................................................ 2
1.3 PURPOSE OF THE REPORT..................................................................................... 3
1.4 HOW THE NEW NHS IS STRUCTURED....................................................................... 4
1.5 DEVELOPING THE CLINICAL COMMISSIONING GROUPS (CCGS) ......................................... 4
1.6 THE CCG PROCUREMENT PROCESS ......................................................................... 5
1.7 MARKET DEVELOPMENT, SIZE AND SCOPE.................................................................. 6
1.7.1 WHICH NHS SERVICES ARE GOING TO MARKET?................................................ 8
1.7.2 POTENTIAL INDEPENDENT SECTOR/PRIVATE MARKET SIZE AND SCOPE ....................... 8
1.8 SEGMENTS OF INTEREST TO INTERNATIONAL PROVIDERS ............................................... 11
1.8.1 BEHAVIORAL HEALTH/MENTAL HEALTH ......................................................... 11
1.8.2 COMMUNITY HEALTH SERVICES.................................................................. 12
1.8.3 CHRONIC DISEASE MANAGEMENT ............................................................... 13
1.8.4 DIAGNOSTICS...................................................................................... 13
1.8.5 ELDERLY AND END-OF LIFE CARE................................................................ 14
1.8.6 HOME HEALTHCARE ............................................................................... 14
1.8.7 INTEGRATED HEALTHCARE SERVICES ........................................................... 15
1.8.8 PRIMARY CARE..................................................................................... 15
1.8.9 MUSCOLOSKETAL SERVICES (MSK) ............................................................ 16
1.8.10 TELECARE/TELEHEALTH ........................................................................... 17
1.8.11 PREVENTATIVE HEALTH ........................................................................... 18
1.9 THE COMPETITIVE LANDSCAPE – A SELECTION OF PRIVATE PROVIDERS BY SERVICE SECTOR ........ 19
APPENDIX A: DETAILS OF KEY PROCUREMENT STAGES ....................................21
APPENDIX B: PROCUREMENT DECISION TREE ..................................................24
APPENDIX C: LIST OF ALL UK CCG’S .................................................................25
APPENDIX D: PREVENTATIVE HEALTH RECOMMENDED ACTIVITIES .................31
APPENDIX E: IN-DEPTH PRIVATE PROVIDER PROFILES ...................................32

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1. Introduction
1.1 Context
The NHS is the name given the four publicly funded healthcare systems in the countries of
the United Kingdom. It was formed in 1948 following legislation passed in 1947. Each
system operates independently, and is politically accountable to the relevant government:
the Scottish Government, Welsh Government, the Northern Ireland Executive, and the UK
Government which is responsible for England's NHS.
The NHS is now 66, but strained public finances mean it has become virtually impossible
to preserve the NHS as it is without seriously damaging other important public services or
raising taxes significantly. The NHS in England has to find up to £20 billion (US$33.2Bn)
of efficiency savings over the next four years, to cope with the gap between essentially flat
funding and rising demand and costs. Aware of this the incoming Conservative Government
set about developing a radical reform process, which was legislated in the Health and Social
Care Act of 2012.
1.2 Overview of the Health and Social Care Act 2012
The Health and Social Care Act 2012 introduced radical changes to the way that the NHS
in England is organised. The legislative changes from the Act came into being on 1 April
2013 and include five key reforms:
A. A move to clinically led commissioning. Planning and purchasing healthcare
services for local populations had previously been performed by England's 152 primary
care trusts (PCTs). The Act replaced the PCTs with 211 clinical commissioning groups
(CCGs), led by clinicians. CCGs now control the majority of the NHS budget.
B. An increase in patient involvement in the NHS. The Act established independent
consumer champion organisations locally (Healthwatch) and nationally (Healthwatch
England) to drive patient and public involvement across health and social care in
England.
C. A renewed focus on the importance of public health. The Act provided the
legislation to create Public Health England (PHE), an executive agency of the
Department of Health. PHE's aim is to protect and improve the nation’s health and to
address health inequalities.
D. A streamlining of 'arms-length' bodies. The Act conferred additional responsibility
on the National Institute for Health and Care Excellence (NICE – formerly the National
Institute for Clinical Excellence) to develop guidance and set quality standards for social
care. The Health and Social Care Information Centre (HSCIC) was also tasked with
responsibility for collecting, analysing and presenting national health and social care
data.
E. Allowing healthcare market competition in the best interest of patients. The
Act aimed to allow fair competition for NHS funding to independent, charity and third-
sector healthcare providers, in order to give greater choice and control to patients in
choosing their care. To protect the interests of patients under these new arrangements,
Monitor was established as the sector regulator for health services in England. Monitor
issues licences to NHS-funded providers, has responsibility for national pricing and
tariff (in conjunction with NHS England) and helps commissioners ensure that local
services continue if a provider is unable to continue providing services.
Implication - Clearly to independent sector/private providers the final of these five key
reforms represents the market opportunity. It is estimated that in the year July 2013 to
June 2014, £13.5Bn (US$22.4Bn3
) worth of contracts across all sectors were advertised.
This compares to £3Bn (US$5Bn) in the previous year, a 347% increase year on year.4
3
Note all US to GBP conversion rates are based on the wholesale interbank rates of August 28th
, 2014.
Whereby 1 GBP = US1.66
4
*The 2013-2014 figure includes all contracts advertised through the Official Journal of the European
Union and the Supply2Health website

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1.3 Purpose of the Report
The extensive reforms being undertaken at the NHS following the passing of the Health
and Social Care Act of 2012 have opened previously unavailable opportunities for
international healthcare providers to market their products and services to the NHS.
The purpose of this report is to provide international providers with a preliminary overview
of potential opportunities that the new NHS structure presents for their firms. A particular
focus of this report is the operations and commissioning structures of the 211 CCGs that
will commission a wide range of healthcare services and products for their populations. We
will outline in detail the procurement process that is relatively standardized across the
CGGs. We will also assess (as far as is possible with the information available) the size of
the market;
 Nationally across healthcare groups and services
 By specific healthcare service/products that offer significant opportunities to
international providers. These include
o Diagnostics
o Community health
o Residential homes, elderly and end-of-life care
o Home healthcare
o Integrated health services
o Musculoskeletal health
o Behavioral health (Mental Health)
o Telecare and Telehealth
o Chronic disease management
o Preventative health

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1.4 How the New NHS is Structured
Figure 4: The New NHS Structure
1.5 Developing the Clinical Commissioning Groups (CCGs)
Clinical commissioning groups (CCGs) are one of the main components of the government’s
reforms to the health and social care system. In April 2013, these newly established,
clinically led organizations replaced primary care trusts as the commissioners of most
services funded by the National Health Service (NHS) in England, and now control around
two-thirds of the NHS budget. There are 211 CCGs in England as of 2014.
In simple terms Clinical Commissioning Groups are groups of General Practices that work
together to plan and design local health services in England. They do this by
'commissioning' or buying health and care services including:
 Secondary care
 Community services
 Mental health services
 Rehabilitation services
All general practices in England are now legally obliged to be a member of a CCG. The
intention is to encourage clinicians to play a greater role in deciding how funds are spent
in order to shape services to meet local needs. CCGs are responsible for commissioning
primary, secondary and community care services for their local populations. Figure 5,
below illustrates the CCGs footprint across Metropolitan London;

5
Figure 5: Clinical Commissioning Group Footprints - Example London
Source: NHS.co.uk
1.6 The CCG Procurement Process
The process of procurement can be complex and time-consuming and a number of
organisations have been set up to help with the process. CCGs and trusts can gain support
for the procurement process from the Commissioning Support Units specifically set up to
support the CCGs, or from a number of other organisations, including what are known as
regional procurement hubs and the central organisation NHS Shared Business Services.
If a CCG or a hospital trust wishes to procure a service it now has a number of options: it
can enlist the help of its local Clinical Commissioning Unit (CSU) or it could approach a
regional procurement hub, HealthTrust Europe or NHS Shared Business Services to
organise a competitive tendering process.
However there is also another option - the use of a framework agreement or pre-tendered
contract. Framework agreements are negotiated by the hubs or other public procurement
organisations, such as NHS Shared Business Services, HealthTrust Europe, NHS England
and Monitor. A competitive tender process is carried out and depending on the amount of
business under the framework, several companies are chosen to be on the framework.
CCGs and trusts can then choose from the contracts available from the approved
companies. For example, in November 2013 NHS Shared Business Services advertised for
providers for a framework agreement for patient transport. The value of the work offered
under the Framework agreement is £515 million (US$855 million), which is likely to be
split between many different companies successful in the tendering process. Once a
framework agreement is in place, theoretically providers can be chosen by CCGs or Trusts
without the need for any further tendering process and out of public scrutiny.

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Figure 6: Outline of the Typical CCG Procurement Process
Source: 2014 NHS Procurement Guidelines for CCGS
In Appendix A, a more detailed description of the procurement process at each of the
stages illustrated above is outlined, while in Appendix B a procurement decision tree
framework used by the Barnsley CCG but common to most CCGs is illustrated. The decision
tree guides procurement managers as to under what circumstances services should be put
to competitive tender.
1.7 Market Development, Size and Scope
The figures provided in figure 5 below are from the Department of Health 2012/13 Annual
Report. As indicated CCG commissioned services accounted for £93.7 Billion ($US155.5
Billion) in 2012/13. This constitutes 91% of all NHS spend in England (Note: this does not
include NHS Scotland, Northern Ireland and Wales)

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Figure 7: The Flow of Money under the New Structure

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1.7.1 Which NHS Services are going to market?
In 2012 the government asked Primary Care Trusts (which in 2013 became Clinical
Commissioning Groups) to select areas where it could license alternative providers to help
create competition and extend patient choice. Known by the name Any Qualified Provider
or AQP this scheme allowed competition around a list of 53 treatments and types of
community based care. This has since been extended and there are currently 77 types of
care listed on the supply to health website where competition for patients is taking place.
These are shown in figure 8 below
Figure 8: Services Which Any Qualified Provider May Bid For Include The Following
1.7.2 Potential Independent Sector/private Market Size and Scope
the 2012-2013 edition of Laing’s healthcare Market Review calculates that revenues
generated by a wide range of independent providers delivering services such as elderly
care homes, homecare and private hospitals stood at £40.5Bn (US $67.2Bn) in
2012/13 (the last period that figures are available for). The ISP market value by each
major sub-sector is shown in figure 9 below
This however is prior to the reforms of 2013 and with the greatly expanded list of services
(now 77) available for tender to Any Qualified Provider (AQP) the current and future market
will be considerably larger.

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Figure 9: UK Independent Healthcare Market Value by sub-sector
As a brief updated synthesis of the performance of the independent sector in the new
regime, this sections begins with the key findings of an audit of contracts awarded by CCG’s
to providers over the period July 2013 to June 2014. By reviewing contract value
summaries and recording submissions and awards on the official websites Tenders
Electronic Daily-Supplement to the Official Journal of the European Union and Supply to
Health we have been able to develop a picture of what services have been tendered, who
is winning them and how much money is involved.
Key Findings;
 £13.5 billion (US$ 21.5 Billion) worth of contracts to run or manage clinically related
NHS services were been advertised in the 12 months to June 2014. This is more than
three times the value of the previous year.
 70% of the contracts awarded (98) since June 2013 have gone to private providers.
 The types of care most involved in tendering and the Any Qualified Provider scheme
are Diagnostics (93 contracts), Mental Health (37 contracts), Pharmacy (33), Home
Care (30), GP services and Out-of-Hours (25), Musculoskeletal Services (21), and
Community Health (17).
 Contracts to provide community healthcare (which often includes Mental Health)
typically cover the widest range of care – often catering for the complex health needs
of older patients. A number of CCGs have chosen to bundle these services into a single
super tender. One such contract to provide community health services in
Cambridgeshire and Peterborough is the most wide ranging yet and is worth (£800m-
£1bn+).
In our sample from TED and Supply to Health, mental health and GP services were those
most frequently involved in competition and outsourcing in the period June to December
2013. These are also areas where private sector involvement has been longer established.
However there is now a far wide range of treatment and care that alternative providers to
the NHS are now able to bid to run or manage.

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Figure 10: Services Most Frequently Procured Through the Market (June to Dec 2013)
Source – Tenders Online Daily, Supply to Health
The ten CCGs with the largest spend on non-NHS providers in the year June 13 to July 14
are shown in figure 11 below.
Figure 11: July 2013 – June 2014: CCGs with the Highest Spend on Non-NHS Providers. GBP
Million

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1.8 Segments of Interest to International Providers
1.8.1 Behavioral Health/Mental Health
Outpatient mental health services are predominately provided by community health and
this appears to be one of the areas of greatest opportunities for ISPs/private providers.
Mental Health services were the second most commonly outsourced services in the six
months to December 2013. It should be noted that many mental health contracts are being
bundled with integrated community health service contracts that encompass a range of
services. This often necessitates ISPs to form consortiums with other services providers to
bid for the bundled community services contracts.
Allocation of spending on mental health services to ISPs has continued to rise year on year.
Funding for independent sector mental health service providers increased by 15 per cent
in real terms between 2011/12 and 2012/13 alone while funding for NHS provided mental
health service decreased by five per cent. ISP’s share of the mental health services market
increased from 12% to 17.5% in just one year to 2012/13.
Figure 12: Expenditure on mental healthcare by service providers, 2010/11 to 2012/13
(£billion)
Recent Community Health Contracts Awarded to ISPs
 In February 2014, Cumbria CCG awarded an £13.8 million ($US 23 million) one year
mental health contract to the Priory Group
 June 2014, Birmingham Children’s Hospital Foundation Trust selected a consortium of
public, private and voluntary organizations to deliver mental health services for young
people in Birmingham. The five year contract is worth £100 million (US$166 million). The
consortium comprises the public organizations Birmingham Children’s Hospital,
Worcestershire Health and Care Trust and Birmingham Metropolitan College. They are
joined by two private companies – the Priory Healthcare Group and mental health
consultancy Beacon UK – and by The Children’s Society, a charity.

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1.8.2 Community Health Services
The government has now opened up 69 community health services to competition. The
services include some child and adolescent mental health services, diagnostics and weight
management. Private companies and charities can now apply to join a list of approved
health providers alongside existing NHS services. The idea is that NHS patients are given
a choice of providers - with the help of their GP. Each provider, including existing NHS
services will be paid according to how many NHS patients choose their service. In 2012/13
20% of all expenditure on community health services was spend on care provided by ISPs;
an increase of 34% on the prior year.
Figure 13: Annual change in CCG spending on independent sector providers (ISPs) and NHS
providers of community health services
The proportion (by value) of community health services provided by the independent sector
increased from 12 per cent in 2010/11 to 18 per cent in 2012/13
Figure 14: Expenditure on community healthcare by service providers (£billion)

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Recent Community Health Contracts Awarded to ISPs
 In March 2013: Serco was awarded a three-year £140 million (US $232 million)
contract to provide community health services for NHS Suffolk. Serco will provide
community and specialist nursing, the management and operation of community
hospitals, speech and language therapy, specialist children’s services and equipment
services.
 October 2013 - Virgin Care won the £500m (US $830 million) Surrey community
services. It involves eight community hospitals in south west and north west Surrey,
as well as sexual health services and prison healthcare across the whole county.
 April 2014, The Calverdale CCG community health contract worth £1,055,000 (US
$1.75 Billion) per annum has been put to tender. It requires the development of a
multidisciplinary team built on primary care and supported by specialists including
geriatric medicine, community nursing, mental health and rehabilitation.
 April 2014, Bristol CCG has put its £250 million (US $415million)community health
services to tender, 17 providers has entered the process including 12 ISPs
1.8.3 Chronic Disease Management
The combined effect of a rising number of people with chronic conditions being admitted
to hospital, plus the growth and ageing of the population, will increase total pressure on
hospitals and other acute services in England by three per cent a year in real terms. As a
result the NHS is looking to move where feasible, patients with chronic conditions to a
home care service model.
Recent Chronic Disease Contracts Awarded to ISPs
 May 2014, South East Staffordshire awarded the 3 year Pulmonary Rehabilitation
Service contract for the management of Chronic Obstructive Pulmonary Disease
(COPD) for 450 eligible patients to BOC Health Ltd. The contract value is £350,000.
1.8.4 Diagnostics
Common diagnostic services include pathology, radiology services, endoscopy and
cystoscopy services (endoscopy procedures look inside the bowel and stomach and
cystoscopy procedures look inside the bladder) and laboratory services (tests on blood and
tissue samples).
A number of these services have been open to competition for several years and there are
many ISPs competing in the sector.
As of 2012 Pathology services in the UK are primarily delivered by the NHS, which accounts
for 70% of the market. It is estimated that the pathology service market is worth £2.5 bn
(US$ 4.15 Billion) per annum. Companies such as Spire Pathology Services, Quest
Diagnostics, Unilabs-IHS, GSTS and Integrated Pathology Partnerships operate in
this market.
Recent Diagnostics Contracts Awarded to ISPs
 In June 2014, Basildon and Thurrock University Hospitals Foundation Trust teamed with
the private laboratory Integrated Pathology Partnerships, to reconfigure and run
pathology services across south Essex; the contract is valued at £135 million over five
years.
 June 2014, 4Ways Healthcare Limited won a two year contract for medical imaging
services from the East of England Collaborative Procurement Hub at a value of £6.8
million ((US $11.3 million)

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1.8.5 Elderly and End-of Life Care
The number of residential care homes (without nursing care) was 12,848 at the end of
2012/13. The number of registered nursing homes was 4,664 homes. The number of
nursing home beds was 218,678 in 2012/13.
Residential care home provision, comprises 7,420 registered home care agencies. Other
community care services, such as supported living comprised 2,034 registrations at the
end of 2012/13.
The combined value of the care market for older people alone (Local Authority funded,
voluntary and private expenditure), is estimated to be worth £22.2 billion (US $ 37.2 Bn),
of which £13.4 billion is attributable to residential care and £8.8 billion to non-residential
care.
Around 92% of care home places are provided by the independent sector across the UK.
About 89% of home care hours purchased by councils in England are provided by the
independent sector. The remaining 11% are provided in house by Local Authorities.
Several ISPs have recently been investing in the high end sector of the care home market.
For example, Barchester, Sunrise Senior Living, and Maria Mallaband Care. The
Anchor Trust has also recently invested in a high priced care home in Surrey. In July 2013
Four Seasons announced its intention to invest in the market for self-funded residential
care.
Recent Elderly Care Contracts Awarded to ISPs
 September 2014: Virgin Care won a contract from Cambridgeshire and Peterborough
CCG to run services for older people, including end of life care. The contract is worth
£750 million to £1.1 billion.
 August 2014, Avery Healthcare Services won the contract to provide nursing
services to elderly residential homes on behalf of the Northhampton General Hospital
Trust at a value of £8 million over two years.
 May 2014, NHS Devon CCG awarded Bluebird Care and Support a Personal Care for
End of Life, a two contract valued at £4.5 million.
1.8.6 Home Healthcare
Moving patient care out of acute hospitals and into the community has been a UK-wide
priority for over a decade. The majority of people in receipt of homecare receive it through
local social services, which assesses need for help according to certain eligibility criteria.
Most councils contract out the supply of homecare services to the independent sector,
which now provides over four fifths of publicly funded homecare.
However the homecare market appears to offer limited value to international
providers, because with council budget cuts in recent years the independent
sector is finding that contract prices offered by local authorities often fail to keep
pace with inflation and other statutory burdens on employers and prioritize cost
over quality.
To illustrate in 2011-12 the average unit cost of “in house” local authority homecare had
risen to £35.50, while the average unit cost of homecare to authorities from using
independent providers was £14.70. Effectively the independent sector is operating at less
than half the cost of the statutory sector.
During 2011-12 an estimated total of 517,000 adults of all ages received homecare through
their local authority
Gross annual public expenditure on older people’s homecare in 2011-12 was an estimated
£3.2 billion (US $5.3Bn), and overall expenditure on day and domiciliary care across all
adult age groups totaled nearly £7.8 billion (US $ 13Bn).
The main purchasers of homecare are local authorities who are estimated to buy 80% of
the hours of care provided by the independent sector

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Recent Home Health Care Contracts Awarded to ISPs
 July 2014, BUPA Home Healthcare was awarded the home delivery parenteral
chemotherapy and parenteral biologics for the Derby CCG at a value of £8.5 million
over three years.
1.8.7 Integrated Healthcare Services
The healthcare services will include but not be limited to: Primary Care, GP and Nursing
services, Healthcare Administration, Mental Health Services, Sexual Health, Services,
Clinical Substance Misuse Services, Allied Healthcare Services (e.g. Chiropody/Podiatry,
Physiotherapy etc), Pharmaceutical Services, Dental Services, Radiology Services,
Continuity of Care and in some cases as shown in figure 15 below social services are
brought into a region’s integrated care framework.
Figure 15: Example north Norfolk Integrated Care Model
Recent Integrated Healthcare Contracts Awarded to ISPs
 June 2014, G4S won a 5 year integrated Healthcare Services contract for four
immigration removal centres valued at £55.4 million.
 April 2014, Virgin Care was awarded the Integrated Healthcare contract at HMPs
Norfolk and Waveney worth £54.5 million over three years.
1.8.8 Primary Care
Primary care includes GP services, dental, pharmaceutical services, prescribing costs,
ophthalmic services and range of other services. In 2012/13 NHS expenditure on primary
care was £21.4 Billion ($US 35.5 Billion). The costs and sector share of each primary care
service is shown in figure 16 below.

16
Figure 16: Primary & Secondary Care Expenditure and Share of Market, 2011/12 & 2012/13
Recent Primary Care Contracts Awarded to ISPs
 In May 2013, Virgin Care was awarded the contract to manage primary care at HMP
Bullingdon in Bicester.
 April 2013, Medacs Healthcare was awarded GP services contracts for Derbyshire
CGG values at £8.8million per annum.
1.8.9 Muscolosketal Services (MSK)
Muscolosketal services in 2010/11 MSK accounted for £5 Billion in expenditure. The NHS
intention is to move a majority of hospital outpatient services to a community setting;
including muscolosketal services.
The MSK services considered appropriate (on a case by case basis) for community care
include;
 Physiotherapy services
 Rheumatology services
 Trauma and Orthopaedic services
 MSK related Podiatry services
Recent Muscolosketal Services Contracts Awarded to ISPs
 In October 2012, Virgin Care took over the running of physiotherapy services at the
Conquest Hospital in Sussex.
 In August, 2014, Bedfordshire Clinical Commissioning Group awarded its’ five year
£120m contract for musculoskeletal integrated service to private provider Circle. The
contract will see Circle organise the service which was previously handled by more than
20 separate contracts.

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1.8.10 Telecare/Telehealth5
The use of telecare has evolved rapidly in the UK, telehealth is a more recent development,
but the use of telehealth in the UK is accelerating, putting the country at the forefront in
Europe. In England, the expansion has been driven by initiatives such as the Department
of Health's (Department's) Whole System Demonstrator Programme; the “3 Million Lives
campaign” and the Concordat between the Department and the telecare and telehealth
industry. There have also been national initiatives in Scotland, Northern Ireland and Wales.
Currently, the UK telecare market is most mature for first generation telecare (social
alarms), which are widely used compared to second-generation equipment like tracking
sensors, and third-generation equipment like ambient assisted living devices.
The UK is arguably a leading nation in this respect with a total estimated annual spend of
£106 (US$ 176 million) million in 2010 (compared to £154.8 million in Europe). Projected
spend in the UK by 2015 is £251 million (US$ 416 million) (a 12.5 percent compound
annual growth rate (CAGR), compared to £277 million in Europe.
The estimated spend on telehealth in Europe in 2010 was some £148 million, of which
£35.7 million (US$57.7 million) was spent in the UK. This spend is expected to increase to
£296 million and £70 million (US$116 million) respectively by 2015. The combined UK
telecare and telehealth market was £141.7 million (US$ 235 million) in 2010 and
is expected to reach £320 million (US$ 531 million) by 2015.
In the UK, the telecare and telehealth market is highly fragmented with over 80 players,
including over 25 players on the National Telehealth Framework. Tunstall is the dominant
player, providing telecare sensors, monitoring software and monitoring centres. Other
leading firms include Doboco, O2 Healthcare, Chubb Community Care, Just
Checking, Phillips Healthcare, Care Innovation, Bosch, Tynetec, Telesupport and
Invicta Telecare.
The telecare market in 2010 comprised 90 percent public and 10 percent private spending.
There were around 1.6 million users each spending on average around £66 (US$ 110) on
telecare (including alarm installation and response centres). The highest penetration of
telecare was within the over 65 age group. The Department of Health estimates that the
total income from telecare in the UK could rise to £7.15 billion (US$11.9 Billion) by 2020,
a growth rate of 19 percent from 2010. The market for private response centres could
exceed this growth rate as local authorities move to more outsourcing.
Figure 17: The Potential UK Telecare Market
5
2014 – Deloitte Life Sciences; Global Review of Telecare and Telehealth Markets

18
Preliminary research seems to indicate telehealth services to represent a significant mid-
long term market opportunity for private providers. Not only has the government made the
widespread adoption of telehealth a strategic priority, but clearly the margins and value of
telehealth services to providers are far greater than telecare. Additionally it is likely the
competitive space at present is less crowded than telecare, which would potentially provide
first mover advantage to secure significant market share.
1.8.11 Preventative Health
Objectives of the Service
 Provide comprehensive, integrated lifestyle services across priority areas
 Reduce health inequalities and decrease the life expectancy gap
 Provide services that meet individual needs including those of marginalised communities
 Offer interventions based on current evidence-based practice and develop innovative solutions
 Work with the CCGs to decrease the prevalence of smoking over the next five years.
Key NHS Service Provision
 Adult Weight Management
 Child Weight Management
 Smoking Cessation
 Consistent and accurate messaging
 Health Trainers
 Outreach NHS Health Checks
 Signposting
 Integration and Innovation
In Appendix D an illustration of the UK NHS recommended Preventative Health activity programmes
and stages is illustrated. Also the perceived role of the three entities, public sector, non-profit and
private sector in the preventative health programme going forward is outlined in Appendix D

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1.9 The competitive landscape – A selection of private providers
by service sector they have bid for
GP / COMMUNITY CARE
Virgin Care / Assura 24 networks of GP provider companies, each comprises several GP
surgeries, probably over 400 GP surgeries altogether. Also delivery of
community services, musculoskeletal, sexual health, integrated children’s
services. Rapidly expanding judging by press releases in 2012.
Care UK Day care and homes for elderly. GP services, diagnostics, CATS, treatment
centres, mental health services (eating disorder service), learning disability
services.
The Practice Provider of primary care services and delivers specialist clinical services to
GPs, the MoD and PCTs. Network of surgeries. Acquired United Health
Primary Care in 2011 from United Health UK – six practices. Recent
contract to provide ENT services in London, ophthalmology services in
Dorset, cataract services in Croydon.
United Health Wide range of services for NHS – Health Needs assessment, GP
Commissioning, clinical services redesign, performance & contract
management, Care solutions, Medicines management. No longer involved
with GP practices
Harmoni Large range of services, including out of hours, NHS 111, GP-led health
centres.
Serco Range of services, including out-of-hours, prisons, long-term condition
management e.g., contract to run all of Suffolk community health services
Nestor Primecare Home care, care homes, mental health services, children’s services, out-of-
hours, dentistry and primary care (as Primecare).
HOSPITALS
Circle Private hospitals: Circle Bath, Circle Reading; clinics: Windsor,
Nottingham; NHS hospitals: Hinchingbrooke
General Healthcare
(BMI, Netcare)
Owned by General Healthcare with over 70 facilities UK-wide. GHG also consists
of Care Fertility, a private specialist in fertility treatment, and Netcare, a
network of clinics set up in 2002 in the UK by South African company Netcare,
which undertakes work under contract to the NHS.
Spire / Classic Second largest private healthcare hospital group in the UK with 37 hospitals.
The major part of Spire’s business (61% in 2010) is from the private medical
insurance market, but NHS admissions accounted for 25% of its business in
2010, followed by 14% from self-paying customers.
HCA International HCA International is one of the smaller private hospital groups in the UK, with
a network of only six hospitals and four outpatient clinics, all in the London
area. Partnerships with leading NHS hospital trusts.
Ramsay (plus Capio) Ramsay Health UK has a network of 22 acute hospitals in the UK delivering
both private treatment and care under contract to the NHS.
MENTAL HEALTH
SERVICES
Partnerships in Care Largest independent provider of secure mental health facilities across the
UK.
Priory Group Provider of acute mental health care, secure and step down services,
specialist education, complex care and neuro-rehabilitation services,
fostering and care homes.

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DIAGNOSTICS
Alliance (Lodestone) Diagnostics for the NHS and independent sector.
InHealth Group Ltd InHealth provide diagnostics for NHS patients throughout the UK and
Ireland.
IT
Capita IT, patient engagement, HR, payroll, estates
CapGemini IT
McKesson IT
Atos Healthcare
Atos Healthcare is a business division of Atos Origin, a leading
International information technology (IT) services company,
providing Hi-Tech Transactional Services, Consulting, Systems
Integration and Managed Services for healthcare services
Residential Homes/Elderly &
End of Life Services
Care UK Ltd
Residential and nursing care homes (also primary and secondary
healthcare)
BUPA Care Services
BUPA Care Homes (CFG) PLC is a division of the medical insurer
British United Provident Association. The company has over 300 care
homes in the UK, offering expert residential, respite and nursing
care, and specialist homes in dementia and other conditions. 70%
of BUPA’s care home residents are state-funded.
Four Seasons Health Care
Four Seasons owns and operates over 400 care centres and nursing
homes, employing over 21,000 staff. Its Care Homes division
provides services include dementia care, short-term respite care and
end-of-life palliative care
Barchester Healthcare.
Barchester Healthcare Ltd is a UK leading care home provider which
Caters primarily for self-paying elderly residents. The company now
cares for more than 10,000 people at over 200 different locations
across the UK
Note – Appendix C contains detailed profiles of the major private providers active in
tendering for NHS contracts

21
Appendix A: Details of Key Procurement
Stages
Figure 18: Procurement Stages
The key stages of the procurement process for the CCG Services
 Pre-Qualification Stage – requirements and evaluation
 Invitation to Submit Outline Solution Stage
 Dialogue Stage
 Invitation to Submit Final Tender Stage
 Some early key Commercial Terms
 Timescales and next steps for Potential Bidders
Pre Qualification – The Market Engagement Event (Action 4 on the model above)
Purpose:
 Facilitate a fair, open and transparent procurement process
 Take feedback from the market on interest in the procurement
 Allow Bidders an opportunity to speak to the team and ask questions
 Help bidders and the CCG understand market barriers and deliverability
 Helpful for Providers that are not familiar with the process
 Provide an understanding of the process the CCG’s requirements
 Facilitate a better quality response to Pre-Qualification Questionnaire (PQQ) process
 Ensure bidders are clear on the rules of the procurem

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Pre-Qualification Questionnaire (PQQ) (Action 6)
This is the first stage of the selection process
 The PQQ seeks to test the Potential Bidders across three areas:
o Capacity and Capability (“technical ability”) (procurement and services)
o Economic and Financial Standing; and
o Eligibility to enter into a public services contract.
 Requirements will be appropriate to the scale / scope of services to be procured
 Outcome: a short-list of Bidders to take forward to Invitation to Submit an Outline Solution
 Taking forward between 3-5 Bidders to the Invitation to Submit Outline Solution
 Invitation to Submit Outline Solution (“ISOS”) and Invitation to Submit Final Tender
(“ISFT”) – About the Bid / solution
PQQ Evaluation Result
To pre-qualify a Potential Bidder must:
 Have no outstanding (or insolvable) “red-flags”;
 Score above a predetermined level (e.g. 2.00 on scale of 0-4) under the Capability & Capacity
Criteria
 Pass the Financial & Economic Standing criteria
 Be Eligible under the Public Contract Regulations
 Output is a “long-list” of pre-qualified Potential Bidders given and Invitation to Submit Outline
Solution (“ISOS”)
Invitation to Submit Outline Solution (“ISOS”) (Action 7)
 The CCG will provide detailed requirements for the delivery of services
 Bidders will be required to present their outline solutions to how they will meet the CCGs
requirements
 The outline solution is evaluated – but there is no ‘final-selection’ during this stage.
Dialogue with bidders (Action 8)
Following evaluation of Bidders’ outline solutions, dialogue meetings will be held with each Bidder
 The meetings will seek to establish:
 Further details behind the proposals put forward by Bidders
 Discussions on how the service specification can be updated to add extra value to
services and allow increased cost effectiveness
 Discussion on potential output measures that can be put in place
 Following the Dialogue stage – the CCG will work to finalise the specification for services –
which will then be subject to a final consultation
Invitation to Submit Final Tender (“ISFT”) (Action 10)
 A final specification is provided to Bidders
 Bidders are requested to put forward their final detailed proposals for
delivery of the requirement and the final Bid Price
 Evaluation of the final tender will result in [one] preferred bidder being selected to take forward
to contract award stage

23
The procurement process can be long, an example below from the Brent CCG for home
based Musculoskeletal Services essentially took 12 months, from announcement to service
commencement.
Figure 19: Procurement Timeline Example-Brent CCG MSK Services

24
Appendix B: Procurement Decision Tree
Figure 20: Barnsley CCG Procurement Decision Tree

25
Appendix C: List of All UK CCG’s
CCG Name Commissioning Board Region
NHS Airedale, Wharfedale and Craven CCG North
NHS Bradford City CCG North
NHS Bradford Districts CCG North
NHS Leeds North CCG North
NHS Leeds South and East CCG North
NHS Leeds West CCG North
NHS Coventry and Rugby CCG Midlands and East
NHS South Warwickshire CCG Midlands and East
NHS Warwickshire North CCG Midlands and East
NHS Bath and North East Somerset CCG South
NHS Wiltshire CCG South
NHS Bedfordshire CCG Midlands and East
NHS Luton CCG Midlands and East
NHS Bracknell and Ascot CCG South
NHS Newbury and District CCG South
NHS North & West Reading CCG South
NHS Slough CCG South
NHS South Reading CCG South
NHS Windsor, Ascot and Maidenhead CCG South
NHS Wokingham CCG South
NHS Birmingham CrossCity CCG Midlands and East
NHS Birmingham South and Central CCG Midlands and East
NHS Solihull CCG Midlands and East
NHS Dudley CCG Midlands and East
NHS Sandwell and West Birmingham CCG Midlands and East
NHS Walsall CCG Midlands and East
NHS Wolverhampton CCG Midlands and East
NHS Dorset CCG South
NHS Bristol CCG South
NHS North Somerset CCG South
NHS South Gloucestershire CCG South
NHS Calderdale CCG North
NHS Greater Huddersfield CCG North
NHS North Kirklees CCG North

26
NHS Wakefield CCG North
NHS Cambridgeshire and Peterborough CCG Midlands and East
NHS Eastern Cheshire CCG North
NHS South Cheshire CCG North
NHS Vale Royal CCG North
NHS Warrington CCG North
NHS West Cheshire CCG North
NHS Wirral CCG North
NHS Kernow CCG South
NHS Cumbria CCG North
NHS Erewash CCG Midlands and East
NHS Hardwick CCG Midlands and East
NHS North Derbyshire CCG Midlands and East
NHS Southern Derbyshire CCG Midlands and East
NHS North, East, West Devon CCG South
NHS South Devon and Torbay CCG South
NHS Gloucestershire CCG South
NHS Swindon CCG South
NHS Bolton CCG North
NHS Bury CCG North
NHS Central Manchester CCG North
NHS Heywood, Middleton & Rochdale CCG North
NHS North Manchester CCG North
NHS Oldham CCG North
NHS Salford CCG North
NHS South Manchester CCG North
NHS Stockport CCG North
NHS Tameside and Glossop CCG North
NHS Trafford CCG North
NHS Wigan Borough CCG North
NHS East and North Hertfordshire CCG Midlands and East
NHS Herts Valleys CCG Midlands and East
NHS East Riding of Yorkshire CCG North
NHS Hull CCG North
NHS North East Lincolnshire CCG North
NHS North Lincolnshire CCG North

27
NHS Ashford CCG South
NHS Canterbury and Coastal CCG South
NHS Dartford, Gravesham and Swanley CCG South
NHS Medway CCG South
NHS South Kent Coast CCG South
NHS Swale CCG South
NHS Thanet CCG South
NHS West Kent CCG South
NHS East Leicestershire and Rutland CCG Midlands and East
NHS Leicester City CCG Midlands and East
NHS West Leicestershire CCG Midlands and East
NHS Lincolnshire East CCG Midlands and East
NHS Lincolnshire West CCG Midlands and East
NHS South Lincolnshire CCG Midlands and East
NHS South West Lincolnshire CCG Midlands and East
NHS Halton CCG North
NHS Knowsley CCG North
NHS Liverpool CCG North
NHS South Sefton CCG North
NHS Southport and Formby CCG North
NHS St Helens CCG North
NHS Darlington CCG North
NHS Durham Dales, Easington and Sedgefield CCG North
NHS North Durham CCG North
NHS Great Yarmouth & Waveney CCG Midlands and East
NHS North Norfolk CCG Midlands and East
NHS Norwich CCG Midlands and East
NHS South Norfolk CCG Midlands and East
NHS West Norfolk CCG Midlands and East
NHS Barnet CCG London
NHS Camden CCG London
NHS Enfield CCG London
NHS Haringey CCG London
NHS Islington CCG London
NHS Barking & Dagenham CCG London
NHS City and Hackney CCG London

28
NHS Havering CCG London
NHS Newham CCG London
NHS Redbridge CCG London
NHS Tower Hamlets CCG London
NHS Waltham Forest CCG London
NHS Newcastle North and East CCG North
NHS Newcastle West CCG North
NHS North Tyneside CCG North
NHS Northumberland CCG North
NHS Brent CCG London
NHS Central London (Westminster) CCG London
NHS Ealing CCG London
NHS Hammersmith and Fulham CCG London
NHS Harrow CCG London
NHS Hillingdon CCG London
NHS Hounslow CCG London
NHS West London (K&C & QPP) CCG London
NHS Bexley CCG London
NHS Bromley CCG London
NHS Greenwich CCG London
NHS Lambeth CCG London
NHS Lewisham CCG London
NHS Southwark CCG London
NHS Gateshead CCG North
NHS South Tyneside CCG North
NHS Sunderland CCG North
NHS Croydon CCG London
NHS Kingston CCG London
NHS Merton CCG London
NHS Richmond CCG London
NHS Sutton CCG London
NHS Wandsworth CCG London
NHS Hartlepool and Stockton-on-Tees CCG North
NHS South Tees CCG North
NHS Mid Essex CCG Midlands and East
NHS North East Essex CCG Midlands and East

29
NHS West Essex CCG Midlands and East
NHS Hambleton, Richmondshire and Whitby CCG North
NHS Harrogate and Rural District CCG North
NHS Scarborough and Ryedale CCG North
NHS Vale of York CCG North
NHS Corby CCG Midlands and East
NHS Milton Keynes CCG Midlands and East
NHS Nene CCG Midlands and East
NHS Mansfield & Ashfield CCG Midlands and East
NHS Newark & Sherwood CCG Midlands and East
NHS Nottingham City CCG Midlands and East
NHS Nottingham North & East CCG Midlands and East
NHS Nottingham West CCG Midlands and East
NHS Rushcliffe CCG Midlands and East
NHS Aylesbury Vale CCG South
NHS Chiltern CCG South
NHS Oxfordshire CCG South
NHS Blackburn with Darwen CCG North
NHS Blackpool CCG North
NHS Chorley and South Ribble CCG North
NHS East Lancashire CCG North
NHS Fylde & Wyre CCG North
NHS Greater Preston CCG North
NHS Lancashire North CCG North
NHS West Lancashire CCG North
NHS Somerset CCG South
NHS Basildon and Brentwood CCG Midlands and East
NHS Castle Point, Rayleigh and Rochford CCG Midlands and East
NHS Southend CCG Midlands and East
NHS Thurrock CCG Midlands and East
NHS Barnsley CCG North
NHS Bassetlaw CCG North
NHS Doncaster CCG North
NHS Rotherham CCG North
NHS Sheffield CCG North
NHS Fareham and Gosport CCG South

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NHS Isle of Wight CCG South
NHS North East Hampshire and Farnham CCG South
NHS North Hampshire CCG South
NHS Portsmouth CCG South
NHS South Eastern Hampshire CCG South
NHS Southampton CCG South
NHS West Hampshire CCG South
NHS Cannock Chase CCG Midlands and East
NHS East Staffordshire CCG Midlands and East
NHS North Staffordshire CCG Midlands and East
NHS South East Staffs and Seisdon and Peninsular CCG Midlands and East
NHS Stafford and Surrounds CCG Midlands and East
NHS Stoke on Trent CCG Midlands and East
NHS Ipswich and East Suffolk CCG Midlands and East
NHS West Suffolk CCG Midlands and East
NHS East Surrey CCG South
NHS Guildford and Waverley CCG South
NHS North West Surrey CCG South
NHS Surrey Downs CCG South
NHS Surrey Heath CCG South
NHS Brighton & Hove CCG South
NHS Coastal West Sussex CCG South
NHS Crawley CCG South
NHS Eastbourne, Hailsham and Seaford CCG South
NHS Hastings & Rother CCG South
NHS High Weald Lewes Havens CCG South
NHS Horsham and Mid Sussex CCG South
NHS Herefordshire CCG Midlands and East
NHS Redditch and Bromsgrove CCG Midlands and East
NHS Shropshire CCG Midlands and East
NHS South Worcestershire CCG Midlands and East
NHS Telford & Wrekin CCG Midlands and East
NHS Wyre Forest CCG Midlands and East

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Appendix D: Preventative Health
Recommended Activities
Figure 21: UK Preventative Health Activity Guidelines
Figure 22: Perceived Role of Enties in Preventative Health

32
Appendix E: In-Depth Private Provider
Profiles
Virgin Care Ltd
Virgin Care Ltd was founded in March 2010 when Virgin acquired a majority stake in Assura Medical;
the renaming took place in March 2012. Assura began life in 2003 as a property investment
company, The Medical Property Investment Fund Limited (MPIF), which then became Assura Medical
in 2006. The property arm of Assura continues to trade as a separate company listed on the LSE as
Assura Group Ltd.
Primary care and community care. Virgin Care has two arms to its business: 24 GP-led provider
companies that provide NHS services through networks of GP surgeries; and community-based NHS
services
In October 2012 Virgin Care announced that it would be taking over all jointly owned GP-provider
companies, to give Virgin Group 100% ownership of Assura Medical. Over 300 GPs had to relinquish
stakes in the partnership. Previously, each GP provider company was owned 50% by the surgery
GPs and 50% by Virgin; each GP provider company was run by a board consisting of locally elected
GPs and one Virgin representative. Each GP-led provider company consists of a network of a number
of GP surgeries, some of only three surgeries whilst others contain over 20 surgeries. Altogether
358 surgeries were listed as being part of these provider companies in mid-2012.
Assura Medical, prior to its takeover by Virgin Care, also tendered for contracts with PCTs and won
a number of community-based services, including a musculoskeletal service in Hampshire, a
dermatology service in Reading and sexual health services in Teeside. Since Virgin’s takeover of
Assura Medical, the company has targeted much larger, more high profile contracts with the NHS.
The most recent financial data for Virgin Care are the accounts filed with the UK Companies House
for the year ending 31 March 2012; this was prior to acquisition of 100% of Virgin Care by the Virgin
Group. Virgin Care had revenue of £1.4 million in 2012 and a net loss of £9.9 million.
In March 2010 Richard Branson’s Virgin group bought a majority share of the medical division of
Assura Group setting up Assura Medical as a company in its own right. Although GPs still had a stake
in the GP provider companies, Virgin Care had the controlling stake in the company as a whole. With
the October 2012 announcement of an ending of the 50:50 GP-provider companies, the Virgin Group
will have complete ownership of the business.

33
Prior to the takeover by Virgin Care, Assura was extremely successful at winning contracts through
its GP partnership companies, with in 2009 around 68 NHS contracts and 12 contracts awarded for
GP-led health centres. In mid-2013 Virgin Care reported that it operates over 200 services including
community-based intermediate NHS services, GP-led walk-in and healthcare centres, urgent care
centres, out of hours, community diagnostics and GP practices. As Virgin Care alone the company
has gained some large contracts and is tendering for many more, including as follows:
September 2013: Virgin Care was among a shortlist of four ISPs/private providers for a contract
from Cambridgeshire and Peterborough CCG to run services for older people. The contract is worth
£750 million to £1.1 billion. The company or consortium that is awarded lead provider status will
both provide services for older people, including end-of-life care, and be responsible for coordinating
care for older people.
May 2013: Contract to manage primary care at HMP Bullingdon in Bicester.
July 2012: Virgin Care awarded preferred bidder status by NHS Devon and Devon County Council
for a contract to run a range of core NHS and social care services for children and young.
June 2012: Virgin Care and GPs provide a new sexual health service in Oldham.
June 2012: Virgin Care selected as preferred bidder by NHS Sussex for a contract to provide a new
community musculoskeletal service in Hastings and Rother.
March 2012: Virgin Care signed a contract with NHS Surrey to deliver community services across
much of the county from 2012 to 2017. The £500 million contract covers community health services
in South West and North West Surrey, as well as some provided county-wide such as prison
healthcare and sexual health services. The services will continue to be known as Surrey Community
Health providing NHS healthcare for Surrey patients.
December 2011: Virgin Care selected as preferred bidder by NHS Coventry to provide health
services at the Anchor Centre and Meridian Practice for the homeless, asylum seekers and refugee
patients in the city.
October 2011: Assura Medical chosen as preferred bidder to provide the urgent care service at
Croydon University Hospital.

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Care UK Ltd
Founded in 1982 as Anglia Secure Homes. In 1994 the company became Care UK plc and in 2010
Care UK Ltd. Founded by John Nash (Chairman 1992-2010), venture capitalist.
Primary and secondary healthcare, residential and nursing care homes, community care and support
for people with learning disabilities, mental health services and out-of-hours services.
Care’s product and service portfolio includes eight NHS treatment centres, 12 GP-led healthcare
centres, four GP out-of-hours services, four NHS Clinical Assessment & Treatment Services (CATS),
primary care services in 13 prisons, 90 nursing and/or residential care homes with more than 3,500
beds, 118,000 hours of homecare a week, 17 mental health homes and hospitals and learning
disabilities services for 550 individuals
Its acquisition of Harmoni in November 2012 added Out of Hours GP care covering approximately 8
million people, plus additional GP-led health centres, referral management centres, 111 telephone
services, offender healthcare, urgent care and IT services.
Care UK has grown through a process of acquisition and organic growth. Recent acquisitions include
in 2011, 27 homes from Southern Cross, following the companies collapse, adding around 1,550
beds and in July 2012 Whitwood Care Limited, a residential learning disabilities provider based in
Yorkshire. Care UK is also actively building new care homes.
A notable move in November 2012 was the acquisition of Harmoni for £48 million, significantly
expanding Care UK’s OOH business, including 12 NHS 111 contracts, and prison healthcare business.
Following the deal Care UK is reported to provide unscheduled care to approximately 15 million
people across England.
Harmoni has been active in the development of telehealth, most recently in May 2012, Harmoni, the
Qatar Science & Technology Park (QSTP), and Corinium Technologies signed an agreement to use
RASAD, an ICT telehealth platform developed and owned by Qatar Science & Technology Park (QSTP)
and ASPETAR (the Gulf region’s first orthopaedic and sports medicine hospital in Doha), as part of
the UK’s long term health care management programme. Harmoni will use RASAD to remotely
monitor patients with conditions that require regular medical observation, such as pulmonary
vascular disease.
For the financial year ending September 2012 Care UK reported total revenue of £490.3 million and
a net loss of £4.1 million. It is estimated that following the acquisition of Harmoni, Care UK will have
a turnover of £700 million.

35
In March 2010 Care UK was acquired by Bridgepoint in a deal worth £432 million and Care UK was
removed from the public markets. At the same time Care UK’s management and Bridgepoint noted
that they had identified a string of potential acquisition targets.
Care UK has a large number of contracts with PCTs and local councils. An example of recently won
contracts reported in late 2012 are to operate two GP practices in Newcastle and an out of hours
service across Hampshire. The future of Care UK's walk-in clinics is uncertain, however, due to the
transfer of NHS budgets to new clinical commissioning groups on 1 April 2013. As a result, Care UK
has had to close walk-in centres in Newcastle, London Victoria and Liverpool and others may follow.
Social Care
Residential Care
 Care homes (90 homes with approximately 5,400 beds), plus day care places
Community Services
 Care worker visits and live-in support for people in their own homes (around 150,000
care hours for approximately 14,000 people delivered per week)
Mental Health
 18 facilities including independent hospitals, mental health homes and specialist
facilities
Health Care Services
 10 specialist hospitals (ISTCs)
 5 specialist Clinical Assessment and Treatment Services (CATS)
 19 GP practices
 10 walk-in centres
 Health services in 16 prisons
 12 NHS 111 services
 OOH services covering approximately 8 million people
Other major contracts acquired with Harmoni are as follows:
 GP-led health centres in North East Essex (North Colchester) and Stoke (Hanley Health
and Wellbeing Centre).
 Suffolk Integrated Healthcare, a joint venture between Suffolk GPs and Harmoni
delivering sexual health services, a minor injuries unit, a community hospital contract
and out of hours services in Great Yarmouth and Waveney.
 Hillingdon Health, a joint venture between Hillingdon GPs and Harmoni delivering an
Urgent Care Centre.
 Gryphon Health, a joint venture between North Somerset GPs and Harmoni delivering
a GP led health center and admissions avoidance service.
 Bucks Urgent Care Alliance, delivering an out of hours service, a GP led health center
and a referral management service in Buckinghamshire.
 Harmoni for Health is the offender healthcare division of Harmoni and specializes in
both the provision and facilitation of integrated offender healthcare services in the UK.
 Hermes service in East Sussex - Harmoni provides a telephone triage service for GPs
and healthcare professionals, staffed by a call center team of nurses and coordinators.
It manages all unscheduled care (excluding mental health) and provides cover for
750,000 patients.

36
Serco
Serco began life in 1929 when Radio Corporation of America formed a UK subsidiary, RCA Services
Limited, to support the country's growing cinema industry. Following a management buyout in
1987, RCA Services Limited was renamed Serco Limited. In 1988, the company achieved a full
listing on the London Stock Exchange as Serco Group plc.
Serco is one of the world’s largest outsourcing companies, operating in numerous sectors, including
defence, education, local government, facilities management, health, leisure and transportation.
In health in the UK Serco operates in the areas of out-of-hours, custodial health services,
community care, facilities management, pathology services, occupational health, and forensic
medical services.
Serco’s major business is with public sector organisations worldwide; in 2012 this represented 90%
of its business. The company has followed a policy of expansion into every area of the public sector
worldwide. The UK provides around 60% of its business.
In 2011 Serco reported revenue of £4.6 billion and net profit of £175.2 million. Health revenue is
included in the sector Civil Government, which represented 26% of Serco’s total revenue in 2011
at £1,199 million in 2011, up 6% on 2010. In 2012 Serco reported a revenue of £4.9 billion and
pre-tax profits of £302 million, a 26.7% increase on the previous year.
Serco is a public company with shares traded on the London Stock Exchange.
April 2006: Five year contract to provide Out Of Hours service in Cornwall and Scilly Isles valued
at £6.1 million. In 2011 the contract was renewed for a further five years valued at £6.4 million.
2009: Formed GSTS Pathology a joint venture with Guy's and St Thomas' NHS Foundation Trust
providing pathology services. The 50:50 joint venture was under a ten-year contract valued at
around £250 million to Serco. In December 2009 GSTS won a contract to provide pathology
services to Bedford Hospitals NHS Trust
2011: Serco acquired the company that manages Braintree Community Hospital, Essex, which
delivers NHS care on behalf of Mid-Essex Primary Care Trust. The hospital provides a range of
clinical services, including day surgery, outpatients, imaging, physiotherapy, endoscopy, a rapid
assessment unit and a 24-bed inpatient ward.
March 2012: Serco was awarded £130 to £180 million contract at East Kent Hospital University
Foundation Trust for services including cleaning, catering, portering, security, waste management,
switchboard, pest control, staff accommodation, helpdesk and ward housekeeping.
March 2012: Serco was awarded a three-year £140 million contract to provide community health
services for NHS Suffolk. Serco will provide community and specialist nursing, the management

37
and operation of community hospitals, speech and language therapy, specialist children’s services
and equipment services.
September 2012: A partnership agreement with South Warwickshire Hospital Trust was signed.
The nature of this partnership is unclear. It is referred to as an “innovation partnership” that “will
seek to use the expertise and skills that both organisations have to improve the care delivered to
our patients, whilst delivering best value.”
September 2013: Serco is one of ten organisations to pass the pre-qualification stage in a bid to
win a contract from Cambridgeshire and Peterborough CCG to run services for older people. The
contract is worth £750 million to £1.1 billion. The company or consortium that is awarded lead
provider status will both provide services for older people, including end-of-life care, and be
responsible for coordinating care for older people.
In addition, Serco currently provide Hospital Facilities Management services at the following
hospitals:
 Forth Valley Royal Hospital, Larbert, Stirlingshire
 Leicester Royal Infirmary, Leicester
 Norfolk and Norwich University Hospital, Norwich
 Derriford Hospital, Plymouth
 Wishaw General Hospital, North Lanarkshire
Latest Developments
Serco has announced plans to withdraw from the clinical health services market in the UK after
making a multimillion pound loss on its NHS contracts.
The group has revised upwards the estimate of the costs of running the contracts to term, resulting
in an additional non-cash exceptional charge of £3.9m in the period (year ended 31 December 2013:
£17.6m).

38
Ramsay Health Care UK – a subsidiary of Ramsay Healthcare
(Australia)
Established 1964 in Australia by Paul J Ramsay
Private hospitals, orthopaedics, general surgery, cardiac surgery and eye surgery. Ramsay
Healthcare operates 116 hospitals in four countries, with 10,000 beds and 30,000 staff. The
company treats over one million patients per year. In the UK Ramsay Health has a network of 22
hospitals, nine treatment centres and four neurological units in the UK delivering both private
treatment and care under contract to the NHS.
Through a process of acquisition in its home market Ramsay Health has become Australia’s largest
private hospital operator. Acquisitions have included other private hospital groups, with the largest
being of Affinity Healthcare in 2005, which increased Ramsay’s hospitals from 35 to 69. Ramsay
also has a history in Australia of moving into the public hospital sector.
Ramsay Healthcare’s first foray outside Australia was to Indonesia where it now runs three private
hospitals; these were acquired with the acquisition of Affinity Health in 2005. Then in 2007 the
company acquired Capio, at the time the fourth largest operator of private hospitals in the UK. The
company’s focus for expansion switched to France in 2010, with the March 2010 acquisition of 57%
of the French hospital company Group Proclif SAS, now known as Ramsay Santé. Ramsay’s
expansion in France has continued, with the May 2011 acquisition of the Clinique Convert hospital,
which Ramsay notes is a first step in expanding the Ramsay Santé business, with plans for further
expansion. The company currently operates nine hospitals in France.
In a March 2011 briefing for the company’s investors in the UK market the company noted that the
NHS bill (at that time) was positive for the company and that a key priority for the company was
to influence national policy. In November 2012 Ramsay noted that in the UK it is planning to
“commence strategy of broadening our service delivery platform” and that “Health care reform is
expected to provide continuing opportunities for the private sector.”
In the UK Ramsay’s business is conducted through Ramsay Health Care UK Operations Ltd. The
most recent accounts available from Companies House are for the financial year ending 30 June
2011.
Full accounts are published by the Australian parent company, Ramsay Health Care. Accounts are
available for the financial year ending June 2012. Revenue was up 6.4% to A$3.9 billion and net
profit was A$245.9 million, up 23% on the previous year. The UK contributed 14% to operating
revenue and UK revenue rose 3.0% during the year to £363.8 million.

39
In 1997 Ramsay Health Care was floated on the Australian stock exchange and became a public
company. The five largest shareholders as of June 2012 are as follows (2):
 Paul Ramsay Holdings (36.2%)
 HSBC (11.98%)
 J P Morgan (9.91%)
 National Nominees Ltd (8.44%)
 BNP Paribas Nominees (2.32%)
In November 2012 Ramsay reported that NHS admissions had risen 11.3% compared to the
financial year 2011 and now comprise more than 65% of UK admissions. According to a Guardian
report Ramsay Health Care is the third biggest supplier to the NHS receiving £30 million in revenue
in 2010/2011.
Ramsay Healthcare runs NHS treatment centres (ISTC) and performs surgery at nearly all its
hospitals and clinics for the NHS.
In 2010 Ramsay Health was a bidder in the tender process for running Hinchingbrooke hospital;
Ramsay eventually withdrew from the process in August 2010.
In October 2012 Ramsay Healthcare was reported to be one of the bidders for the new contract to
run the Nottingham ISTC beginning in 2013; this is currently run by Circle Health.

40
The Practice plc
Founded in 2005 by Dr Ajit Kadirgamar and Dr Jeremy Rose, both GPs, plus Peter Watts, a
businessman.
Primary care, community care and secure health. The Practice Plc has a network of surgeries,
including walk-in centres, plus contracts to run community services in the area of ophthalmology,
dermatology, sexual health, and ear, nose and throat (ENT) services, and health services at four
prisons and an immigration removal centre. The business is an unlisted limited company with three
divisions covering surgeries, properties and services.
In the outset, The Practice’s strategy was to offer to take over the running of the infrastructure of
existing GP practices including the premises. It offered 100% purchase or a partial equity release
scheme for GP premises and then employed the GPs as medical staff with the possibility of share
options in The Practice plc. The company has targeted GPs selling their premises, down-sizing for
retirement or needing expansion funding. By mid-2010 The Practice had 16 contracts with GP
surgeries. In October 2011, The Practice provided GP services to around 180,000 patients at 60
surgeries, including eight walk-in centres, and more than 100 community-based outpatient NHS
clinics per week. The Practice also had 800 employees, including 220 clinicians.
The most recent accounts available for The Practice Plc at Companies House are for the 15 month
period to the end of March 2011. The company made a loss in this period of £2.5 million and as of
March 2011 had debt of £3.3 million. The company paid £88,300 in tax.
The Practice’s major investor is the venture capital fund MMC Ventures Ltd. The initial investment
of £865,000 was in 2006. This was followed by a further £1.4 million in October 2007 and £1.1
million in July 2007.
June 2013: Contract to provide a community ophthalmology service from Salford CCG
January 2012: Contract to provide a pilot service for cataract treatment in Croydon
July 2011: Primary care ophthalmology service in Weymouth and Bournemouth.
July 2011: Contract to provide an expansion of The Practice’s (ENT) services in London.
November 2010: Contract to provide community-based ophthalmology for Solihull NHS
August 2010: Contract to provide a community-based ophthalmology service for NHS
Worcestershire
May 2010: Contract with NHS Harrow to provide primary care ENT services in West London.
2009: Contracts to provide primary medical services for HMP Winchester and HMP Kingston

41
HCA International - the international arm of HCA [Hospital Corporation America]
1968 in Nashville, Tennessee, USA by Dr. Thomas Frist, Jr., Jack C. Massey and Dr. Thomas Frist,
Sr.
HCA is one of the USA’s leading provider of healthcare services, a company comprised of 163
hospitals and 110 freestanding surgery centres in 20 US states and the UK and employing
approximately 199,000 people. Approximately 4-5% of all inpatient care delivered in the USA is
provided by HCA facilities.
HCA International operates six hospitals in central London: The Harley Street Clinic, The Lister
Hospital, London Bridge Hospital, The Portland Hospital, The Princess Grace Hospital, and The
Wellington Hospital. HCA International also has a range of outpatient and diagnostic centres.
HCA has four joint ventures with NHS hospitals: a blood and bone cancer treatment centre with the
University College Hospital London; a young person's cancer unit, The London Gamma Knife Centre,
at St Bartholomew's Hospital in The City of London; Harley Street at Queen's, a private patient
cancer centre at the Queen's University Hospital in Romford; and with the Christie cancer hospital
in Manchester, The Christie Clinic, a private patient unit for cancer patients from across the North of
England.
HCA International’s primary source of income is the corporate market and international clients. HCA
has not sought contracts with CCGs, but its strategy with the NHS has been to set up joint ventures
through its HCA NHS Ventures business. The company has four partnerships at present. It is a
member of the Private Hospitals Alliance, who collectively share 80% of the UKs private hospitals, a
group formed to influence the Government’s healthcare policy.
The most recent accounts available from Companies House for HCA International are for the financial
year ending 31 December 2011.
In March 2011, HCA raised $3.8 billion in what was at the time the US’s largest private-equity backed
initial public offering (IPO). Following the IPO the three private equity companies and the Frist family
continued to own a majority share of HCA (62% in December 2011).
HCA International does not have contracts with CCGs, but works with the NHS on joint ventures
through its HCA NHS Ventures business.

42
Spire Healthcare
2007
Private hospitals. Spire Healthcare is the second largest private healthcare hospital group
in the UK with 38 hospitals (including the recently completed Montefiore Hospital,
Brighton.) Spire undertakes a wide variety of treatments, but major areas of business are
fertility, obesity treatment, cosmetic surgery and cancer treatment.
Spire was formed through the buy-out of 25 BUPA hospitals in 2007 by the UK private
equity firm Cinven. The hospitals were rebranded as Spire Healthcare and a further 11
hospitals were added in 2008.
For 2013 Spire reports that providing care for NHS patients’ accounts for nearly 25% of its
business revenue. Furthermore, Spire was reported to be the eighth largest provider of
healthcare services to the Department of Health in 2012, being paid approximately £27
million. Spire notes that NHS work is a supplement to its own private business and, as far
as can be ascertained, Spire’s NHS work to date comes from the use of the Choose and
Book system.
In 2012, Spire Healthcare reported revenue of £739 million, up 9.6% on 2011, and an
operating profit of £129.7 million, however the company reported a loss of £130.5 million
for the year. The loss was due to finance costs of £190.3 million (£183.3 million in 2011),
plus exceptional finance costs of £129.1 million.
The parent company of Spire Healthcare is Spire Healthcare Co-Invest Limited Partnership,
a limited partnership registered in Guernsey. Rozier (Guernsey) Limited, a subsidiary of
Cinven Limited, has a significant interest in the partnership. Cinven is keen to sell Spire
and in January 2013 completed a partial refinancing in order to reduce Spire's heavy debt
burden and make it more attractive to buyers. This saw 12 of the company's 38 hospitals
sold and then leased back. In 2014 Cinven indicated its desire to sell on Spire, with a
consortium fronted by CVC Capital Partners - a London based private equity firm - and also
backed by the Abu Dhabi Investment Authority (ADIA) in the running to purchase the
company.
Spire Healthcare is part of the Choose and Book system for NHS patients and in 2012 23%
of its income came from NHS work, up from 20% in 2011. In 2012 it was reported that
Spire was part of the bidding process to run the Nottingham Independent Treatment Centre
from 2013; this contract was eventually won by Circle, however. Furthermore the company
is reported to be cultivating its relationships with new Clinical Commissioning Groups.

43
General Healthcare Group (GHG)
1970 when the US company AMI acquired its first UK hospital, but since then the company
has undergone several name and ownership changes.
BMI Healthcare (private hospitals) and Netcare (clinics). BMI Healthcare operates acute
private hospitals, and is the largest provider of private healthcare facilities in the UK, with
61 hospitals UK-wide. Netcare is a network of clinics set up in 2002 in the UK by South
African company Netcare, which undertakes work under contract to the NHS.
GHG views NHS reforms as an opportunity to expand its business. The CEO in 2010, Adrian
Fawcett noted “We are entering a new, exciting era, driven by the forthcoming healthcare
reform that will ultimately change, to our benefit, the landscape in which we operate.”
Fawcett was replaced in early June 2011 by Stephen Collier, a barrister by training. In an
interview in August 2012, Collier noted that NHS work is “pretty critical” to GHG and that
the firm could “do very well” out of policies such as Any Qualified Provider.
GHG’s leading shareholder, South African company Netcare, made clear in 2006, when it
acquired GHG, that the UK provides an opportunity for expansion for Netcare as there is
little opportunity for expansion in its home market. The company's reasons for expansion
in the UK were described: "We have targeted the UK healthcare market for expansion, as
the long-term demographic trends and prospects for development of the private acute care
market as well as partnership with the NHS, offer significant future growth potential.”
When Netcare acquired a majority share in GHG in 2006, GHG was split into two operating
companies BMI OpCo, the healthcare operating company, and a property-owning
subsidiary containing the subgroups GHG Propco 1 and GHG Propco 2. GHG Propco 1 has
substantial debts (see Concerns – Financial Instability).
According to Netcare’s annual report for the financial year ending 30 September 2012,
GHG recorded a profit on continuing operations of £5.7 million. If exceptional items (the
£862.8 million) and discontinued operations are included GHG recorded a loss of £825.3
million.
GHG carries out a large amount of NHS work at its hospitals via the NHS Choose and Book
system.NHS services through Netcare UK include surgical centres and ophthalmic units
(specialising in cataract operations).

44
InHealth
2004
InHealth provides diagnostics and imaging services to the NHS and private hospitals and
clinics, including MRI, CT, X-Ray, DXA, Nuclear Medicine, Mammography, Ultrasound,
Interventional Cardiology, Audiology, ENT, Endoscopy and Physiological Measurement. The
company employs about 1000 people, including clinical specialists and patient referral
teams. Its servicesare provided from over 280 locations in the UK and Ireland and they
work with a significant majority of NHS Trusts in the UK covering over 200 hospitals and
over 80 community health clinics. The company saw over 500,000 patients in 2011.
InHealth is a Choose and Book provider, fully integrated with the NHS Image Exchange
Portal (IEP). InHealth’s Preventicum subsidiary conducts private health check-ups,
including full MRI scan.
InHealth’s business strategy has included acquiring existing diagnostic companies such as
Preventicum and Vista Diagnostics. Some subsidiaries of the InHealth Group include,
Molecular Imaging Solutions Ltd, Euroclinics UK Ltd, Preventicum UK Ltd, e-Locum Services
Ltd and Vista Diagnostics Ltd. Most recently in February 2012 InHealth acquired 76% of
Prima Diagnostics.
In the company’s 2012 annual accounts, director and CEO Richard Bradford states “we
believe that the market opportunities within the diagnostics sector continue to be
significant albeit the market is currently fragmenting as services are being reconfigured
between primary and secondary care. We believe the advent of AQP procurement for GP
Direct Access Services will allow us to expand our strong position in the South East to other
parts of the UK.”
InHealth’s accounts for the financial year end September 2011, the most recent available,
give the company revenue of £63.2 million with profit of £2.4 million. In 2010/11 InHealth
received over £10 million from the Department of Health for work carried out on behalf of
the NHS
InHealth is a private company owned by The Damask Trust, the trustees of which are Ivan
Bradbury and the Embleton Trust Corporation Ltd.
During 2010/2011 InHealth provided over 400,000 diagnostic tests of which over 80%
were for NHS patients. Contracts reported by InHealth include the following:
NHS PET/CT South – Delivers 10,000 scans per year from 18 locations on behalf of the
Department of Health.
London NHS Diagnostic Service – Delivers a range of 10 diagnostic tests from over 60
locations

45
NHS Leicestershire and Rutland – Provided Echocardiography and BNO services to GP's
within this PCT for over 4 years.
Southampton ENT – Provides audiology and ENT service to Southampton City patients.
Also provides MRI, X-Ray, Ultrasound and Audiology as part of the local AQP.
York DXA (AQP) – Offers patients in York and surrounding areas DXA scans as an
alternative to nearby hospitals.
Derby/Peterborough (AQP) – Provides patients with access to audiology, assessment,
hearing aid fitting and on-going repairs/maintenance.

46
Alliance Boots
Boots the Chemist was founded in 1849 in Nottingham and has long been an icon of the
British high street. In 2006, Boots merged with European pharmacy wholesaler Alliance
Unichem Plc to form Alliance Boots (AB). One year later, the company went private in a
£12 billion leveraged buyout, led by executive chairman Stefano Pessina and US private
equity firm Kohlberg Kravis Roberts (KKR). In 2012, US pharmacy chain Walgreen’s bought
a 45% stake in Alliance Boots, with an option to buy the remaining 55% in 2015.
Pharmacy retail, wholesale and clinical homecare business. Boots is the largest community
pharmacy chain in the UK, with nearly 2,400 pharmacies trading under the Boots banner.
It is the largest single employer of pharmacists and pharmacy technicians outside the NHS,
with 6,700 pharmacists and at least 2,500 technicians.
Alliance Boots’ subsidiary Alcura focuses on clinical homecare, which is funded through the
NHS, and also provides clinical trial support.
Outside of the UK, Alliance Boots is primarily a pharmacy wholesaler—the biggest in
Europe, in fact—although it hopes to expand its retail footprint and other healthcare
services in Europe as well.
Alliance Boots also has major wholesale investments in Turkey and China.
Alliance Boots is seeking opportunities to develop new services through the Any Qualified
Provider contract model. In its pharmacies, the company has begun offering tests for
diabetes and treatment for asthma sufferers along with its prescription services. AB says
it is seeks to provide more healthcare services such as medicine check-ups, weight
management programmes, smoking cessation advice and flu vaccinations in the retail
pharmacy setting. The company expects its partnership with US pharmacy chain Walgreens
to “further enhance our capability to deliver such services, many of which are at a more
developed stage in the US.”
In the UK, the company has at least 16 GP surgeries in its stores and has announced plans
to open up to 100 over the next 2-3 years. The company also has a dentist surgery in in
Manchester and plans to open more.
Through its subsidiary Alcura, Alliance Boots has branched into an area of community
healthcare known as ‘clinical homecare’ and participates in contracts that reach into
millions of pounds. Clinical homecare includes medicine administration, delivery and
support within the home for patients.
For example, Alcura is a provider of intravenous nutrition to patients in their homes as part
of a £37.9 million contract with the Commercial Medicines Unit of the Department of Health.
The clinical homecare industry estimates sales of £1.5bn in 2012, with growth of nearly a
quarter on the previous year.
Alliance Boots’ global results for the year ending 31 March 2013 record revenues of £22.4bn
and trading profit before tax of £1.265m. The company makes a significant portion of its
revenues off public health care systems. Approximately 40% of Alliance Boots’ UK revenue
comes from services that are mainly paid for by the NHS. This includes revenues from
dispensing prescription drugs, which came to £2.2 billion for the year ending 31 March
2013.
Additionally, Alliance Boots UK wholesale division generated an estimated £1.82 billion in
revenue from independent pharmacies, which includes funds coming indirectly from the
NHS. Alliance Boots subsidiary Alcura UK Ltd. reported nearly £100 million in sales for the
year ended March 31 2012, a portion of which comes from NHS contracts.

47
The company has pharmacy contracts with the following NHS trusts:
 Surrey and Sussex NHS Trust (East Surrey Hospital)
 Sheffield Teaching Hospitals
 Derby Hospitals NHS Trust
 Birmingham Heartlands Hospital
 The Christie NHS Foundation Trust, Manchester
 Great Western Hospitals NHS Trusts (Swindon)
Alliance Boots holds the following contracts to provide regular monitoring for patients
requiring blood thinner medications to avoid dangerous clotting:
 South Tyneside NHS Trust
 Brighton and Hove NHS Trust
Alcura participates in NHS contracts worth over £80 million, often together with other
companies in multiple-award contracts. The company already has at least 16 GP surgeries
in its stores and has plans to expand in this area.
Boots has a 49% stake in David Ormerod Hearingcare Ltd which operates 340 Boots
hearingcare centres. David Ormerod also has AQP status with the following trusts under its
trading name Community Hearing Care Services:
 Gateshead PCT
 South Tyneside NHS Trust
 Sunderland Teaching Hospital NHS Trust
Lifeways Group
Established in 1998 initially under the ownership of Japanese investment bank Nomura
and then in 2007 when August Equity backed a buyout for an undisclosed sum.
With offices throughout Britain, over 5,000 employees and contracts with more than 100
local authorities and primary care trusts, Lifeways is a provider of supported living,
community based and residential services for people with learning disabilities, mental
health and forensic needs, physical disabilities and people needing ongoing social care
support
Organically growth has been achieved through successful tender wins backed by tighter
management systems rolled out as part of a £1m internal investment programme. The
company has also acquired ten smaller businesses in the past four years and continues to
pursue its buy and build strategy by seeking further acquisitions.
EBITDA has grown by 77% a year, from an annualised £2.2m in 2008 to over £10.9m in
2011 based on turnover rising from £36m to over £72.5m. Turnover for 2011/12 was
£115m, with EBITDA at over £22m.

48
Barchester Healthcare
Established in 1998 initially under the ownership of Japanese investment bank Nomura and then in
2007 when August Equity backed a buyout for an undisclosed sum.
With offices throughout Britain, over 5,000 employees and contracts with more than 100 local
authorities and primary care trusts, Lifeways is a provider of supported living, community based and
residential services for people with learning disabilities, mental health and forensic needs, physical
disabilities and people needing ongoing social care support
Organically growth has been achieved through successful tender wins backed by tighter
management systems rolled out as part of a £1m internal investment programme. The company has
also acquired ten smaller businesses in the past four years and continues to pursue its buy and build
strategy by seeking further acquisitions.
EBITDA has grown by 77% a year, from an annualised £2.2m in 2008 to over £10.9m in 2011 based
on turnover rising from £36m to over £72.5m. Turnover for 2011/12 was £115m, with EBITDA at
over £22m.
Circle (healthcare partnership)
Circle is an employee co-owned healthcare company based in Britain, co-founded in 2004 by social
entrepreneur Ali Parsa and Consultant Ophthalmologist Massoud Fouladi.
It has independent hospitals in Bath and Reading, and an NHS Treatment Centre in Nottingham.
In November 2011, it was awarded a contract to run the first National Health Service(NHS) hospital
franchised to an independent provider, and began the contract in February 2012.]
Circle's
independent hospitals, CircleReading and CircleBath, also provide NHS care under the NHS Choose
and Book scheme.
Circle is a partnership, in which clinicians and healthcare professionals are given the power to run
their own services. The flattened organizational structure is said to allow quality and efficiency to
remain high, through the creation of ‘clinical units’

49
BUPA Healthcare
BUPA is a highly diversified global healthcare provider. In the UK its two largest business units are
BUPA Care Homes and BUPA Health insurance which are profiled below.
BUPA Care Homes (CFG) PLC
Company Structure
BUPA Care Homes (CFG) PLC is a division of the medical insurer British United Provident
Association. The company has over 300 care homes in the UK, offering expert residential, respite
and nursing care, and specialist homes in dementia and other conditions. 70% of BUPA’s care
home residents are state-funded. The company also operates care homes in Spain, Australia and
New Zealand.
Financial Results
In the year ending 31st December 2012, turnover at BUPA Care Homes (CFG) PLC grew by 1.3%,
to £549.6m. Its pre-tax profit, however, fell from £56.3m to £50.5m over the same period.
BUPA Insurance Ltd
Company Structure
BUPA Insurance Ltd leads the UK market for private medical insurance, with an estimated share of
around 41% according to Laing & Buisson. The company is also present in other parts of the world,
having recently assumed market leadership in Australia by acquiring the local health provider MBF,
while its partnership with Max India means it now competes in one of the world’ fastest-growing
economies. However, the company also exited from the Irish market in 2008 in the wake of
regulatory changes.
In the UK, the company’s private medical insurance (PMI) is known as BUPA Heartbeat, and covers
inpatient and outpatient treatment by company-approved practitioners. BUPA’s insurance arm also
includes BUPA Wellness, which is an occupational health and wellbeing services and assessments
division. On a worldwide basis, the company has approximately 400,000 customers located
throughout 19 countries.
Current and Future Developments
In October 2010, BUPA sold its UK business, BUPA Health Assurance Ltd, to Resolution Ltd — a
financial services group that owns Friends Provident and AXA Life. The decision reflects BUPA’s
intention to focus on its healthcare businesses, including its health insurance products and services
in the UK that offer private medical, health cash and international private medical insurances.
BUPA launched a new multi-million pound advertising campaign in March 2011 to promote products
and services that it offers beyond its health insurance offering. The Helping You Find Health
campaign features a TV advertisement with ’real-life’ BUPA customers. The cast ranges from a
physiotherapy patient to a care home resident in order to show the range of products that are
available from BUPA, depending on peoples’ requirements. The company also announced plans to
improve the quality of its cancer cover by no longer selling corporate health insurance schemes
which feature overall cost or time limits for cancer treatment.
Financial Results
In the year ending 31st December 2010, turnover at BUPA Insurance Ltd decreased marginally by
0.1%, to £2.18bn. Meanwhile, its pre-tax profit fell by 16.4% from £120.6m to £100.8m.

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