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Spire Healthcare

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Spire Healthcare is one of the UK's largest private hospital company, with 39 hospitals, 11 clinics, a diagnostics centre, and a cancer care centre. The company was founded in 2007 and is a public company with shares traded in the UK. The company's revenue is from personal medical insurance patients, NHS patients and self-paying patients. In 2019, Spire received 29.1% of revenue or £285.7 million from the NHS. In 2020, Spire received millions from NHS England for staff and capacity to support the NHS during the Covid-19 pandemic.

Strategy

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.

The group employees 8,380 full-time staff including 3,900 plus consultants and had 775,000 patients in 2017.

In January 2017 Spire announced a move into the private GP market. The company has set up a network of GP clinics in its hospitals around the country. Spire is not the first private company to do this, HCA, Nuffield and BUPA all have private GP services within their clinics.

Spire Healthcare's revenue is derived from three major sectors: personal medical insurance (PMI); the NHS; and self-paying customers.

Work carried out for the NHS accounted for just over 29% of total revenue in 2018, the majority of this is from GP referrals rather than block contracts from local commissioning groups. Private medical insurance (PMI) made up just over 46% of revenue in 2018.

Spire had great hopes of gaining business as a result of the underfunding of the NHS. In an article in the Financial Times in August 2016, the company was reported to be investing £190m in new hospitals, wards, and operating theatres in the belief that the NHS funding squeeze would push more British patients into its private facilities. Although, it was noted that in the short-term the company's business from NHS referrals is likely to suffer as NHS budgets are constrained. Results for 2017 and 2018 showed however that cost-constraints in the NHS were reducing the work Spire carries out for the NHS. The company now sees the NHS market as one in which "overall, we seek to hold share" rather than a growth market. In 2018 NHS revenues fell by 7.2%, whilst the private medical insurance business was up 1.5% and self-pay was up 8.7%.

The company expects a major growth opportunity in those patients who self-pay. This the company believes will be fuelled by the increase in NHS waiting times and the increase in treatments that are unavailable within the NHS. The company reported in its 2018 annual report that progress in the private market was "pleasing".

Spire opened new hospitals in Manchester (costing £67m), Bushey (£23m) and Nottingham (£60m) in early 2017, as well as five additional operating theatres at existing facilities over the previous two years.

In early 2021 Ramsay Healthcare launched a bid to acquire Spire Healthcare. However, several of Spire's leading shareholders opposed the takeover, including Fidelity International and Toscafund Asset Management and in June 2021 urged other investors to reject Ramsay's offer of 240p per share, which valued the company at around £1 bn. The opposition forced Ramsay to increase its offer to 250p per share and £1.2 bn. The reason for the opposition to the original offer notes Toscafund was that "operating conditions in the private healthcare market [in the UK] are set to be strong for some years to come." Toscafund continued to oppose the increased offer for the same reasons - it undervalued the company. However, the board of Spire unanimously recommended it to shareholders and many supported it.

If the merger goes ahead, and this looks likely, Ramsay will become the largest private hospital company in the UK. The merger will also be looked at by the Competition and Mergers Commission and Ramsay is likely to have to sell some of its facilities.

Financials

Spire Healthcare was floated on the stock exchange in July 2014 valued at £850 million.

For 2020, Spire Healthcare reported revenue of £919.9 million down from £980.8 million in 2019, and a net loss of £20.7 million, down from a net profit of £7.2 million in 2019.

The company's income in 2020 came from PMI (personal medical insurance - 37.4%), self-pay revenue (15%), and the NHS (47.6%). This dramatic increase in funding from the NHS (up from 29.1% in 2019) is due to the Covid-19 pandemic and the contract with the UK government over the vast majority of 2020. The actual figure from the NHS was £437.9 million, according to the company's accounts.

In 2019, revenue was split as 50.1% from PMI, 18.2% from self-pay, and 29.1% (£285.7 million) from the NHS.

In 2020 net debt fell to £314.5 million, from £330 million in 2019.

In March 2021, Spire's principal investors were Mediclinic International PLC 29.90%, M&G Plc 8.72%, FIL Ltd 5.49%, and Melquart Opportunities Master Fund 5.01%.

In October 2017, Mediclinic International, a South African company, put in an offer to acquire Spire International for £1.3 billion in cash and shares. This offer was rejected by Spire in November 2017.

In May 2021, Ramsay Healthcare, an Australian company, put in an offer to acquire Spire for £1 billion.

Contracts

Covid-19 contracts

In March 2020, Spire was part of the deal with the government for using all its premises and staff for NHS patients during the Covid-19 pandemic. NHS England block-booked almost the entirety of the private hospital sector’s services, facilities and nearly 20,000 clinical staff for the foreseeable future to help cope with the surge of covid-19 patients. The agreement only covered England and added around 8,000 hospital beds, nearly 1,200 more ventilators, more than 10,000 nurses, 700 doctors and 8,000 other clinical staff. This deal, which means the NHS is paying all operating costs for the hospitals, has been a lifeline for the company, as the lockdown meant that no private work was possible.

In June 2020, a £5 billion deal to extend the March deal to help the NHS clear the backlog of work was agreed by NHS England and the private hospital companies, however this was blocked by the Treasury.  The Treasury did not believe the deal represented good value for money and that the evidence was not substantial. The block-contract basis of contracts with private providers continued, however, as NHS England prepared a new four-year framework contract for increasing capacity. In December 2020, the leading private providers, including Spire, were reported to be in advanced talks with NHS England over a new three-month outsourcing contract, which aims to provide a ‘smooth transition’ to the four year framework contract, which began at the end of March 2021. Spire was reported to be signed up to the NHS Increasing Capacity Framework contract by June 2021, which is valued at £10 bn over four years.

In October 2020, the HSJ reported that Spire was the recipient of the second largest contract for staff and capacity from NHS England, according to a series of contract award notices, however the time period of 2020 this covered is unclear. The contract with Spire amounted to £345.9 million.

These block contracts have been criticised after leaks revealed that the capacity paid for by NHS England at companies such as Spire and Circle/BMI was very under-utilised. HSJ reported that two-thirds of the private sector capacity that was block-purchased by the NHS at a cost of an estimated £400 million a month went unused by the NHS over the summer, despite long waits for operations.

Pre-Covid-19 contracts

Spire Healthcare is part of the e-referral system (formerly Choose and Book) for NHS patients.

Concerns

Care Quality

In May 2018, a CQC report found that two in five private hospitals are failing to meet safety standards. The private hospital sector was warned by Jeremy Hunt, the then Health Secretary, to put its house in order if it wished to partner with the NHS. Of major concern is that some private hospitals currently avoid liability by saying a clinician is not an employee if something goes wrong. In addition, a clearer process is needed for managing a patient if their health deteriorates in private care and they have to be transferred to the NHS in an emergency.

The breast surgeon Ian Paterson, convicted in 2017 of of multiple charges of wounding with intent due to his botched operations, worked within several Spire hospitals. In 2017, Spire settled all current and known claims against the company relating to his practice at Spire. Spire paid £28.7 million in relation to this settlement, plus related costs, of which £26.1 million has been paid.

The report of the Independent Inquiry which was set up following the conviction and imprisonment of Ian Paterson, was published in February 2020. Spire Healthcare was criticised for not doing enough to follow up Paterson's patients. As a result of this criticism, in December 2020, Spire began a recall of 5,500 patients. Earlier in 2020, senior coroners in Birmingham launched new inquests into 23 of Paterson’s deceased patients at the request of West Midlands Police.

In the company's 2019 annual report, it noted that five of its hospitals are now rated ‘Outstanding’, up from three in 2017, and 85% are rated ‘Good’ or ‘Outstanding’ by the CQC or regional equivalents.

In February 2011 MP Ian Duncan Smith called for an inquiry into the death of a patient with bowel cancer at Spire’s Roding Hospital in Essex in 2009. The patient died of a heart attack and questions have been raised over the hospital’s resuscitation procedure. Furthermore, the patient’s death was recorded as carcinoma of the colon rather than heart attack, and it was only due to information from a nurse who had worked at the hospital that the true nature of the patient’s death came to light.

Financial Stability

Over the years the financial stability of Spire Healthcare has been questioned. The company has massive debts and as it leases several of its properties, it is subject to rent increases and disputes. In 2019, the company's debts were £420.8 million. However, this is considerably lower than the £1.3 billion worth of debt in 2013.

Price-fixing

In mid-2020, the Competition and Markets Authority (CMA) fined Spire Healthcare and six ophthalmologists a total of over £1.2m for illegal price fixing at the Regency Hospital in Macclesfield. Spire Healthcare Ltd and Spire Healthcare Group plc were fined £1.2m while the six consultants received fines of between £642 and £3,859after admitting they had agreed to fix self-pay fees for initial consultations at £200 over a two-year period.

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