candesic healthcare

HealthInvestoressential reading for the healthcare businessSeptember 2011 vol 8•no 7

primary care • secondary care • social care • IT • infrastructure • markets • policy • dentistryISSN 1742-884X

DilnotWill care insurance catch on?

RegulationCould sector face caps on profi ts?

Private hospitalsNew UK markets to explore

In the hot seatStephen Collier on taking charge of UK’s biggest hospital group

finance

The Candesic team investigates how private hospitals can

regain their distinctiveness

analysisStanding out

finance

Candesic Regaining distinctivenessPrivate hospitals need to innovate again to regain their distinctiveness. Luckily, the NHS is undergoing a time of structural change and is likely to be constrained in new areas of capital expenditure and in developing new specialities.

Historically, the private sector has stepped in where the NHS has exited, or not kept up with demand. For example, the closure of the Victorian mental asylums over the last 20 years, coupled with the failure of the NHS to build new long-stay forensic capacity, gave an opportunity to the private sector to look after forensic mental health patients (Exhibit 1).

In the last issue (July-August 2011), we wrote on how UK private hospital groups were struggling to remain distinctive in the face of a

resurgent NHS. This month, we explore some ideas for how private hospitals can regain their advantage.

First, a recap of last month’s article: all private hospital revenue segments (private insurance, NHS and self-pay) are facing decline. Private insurance subscriber numbers have fallen 10% from 2008 to 2010 (Source: Laing & Buisson industry survey 2011).

Private hospitals have made up for this by accepting NHS funded referrals through the “Choose & Book” IT platform which allows patients to choose their hospital.

But this is now under threat. Since last year’s election, the growth in NHS referrals through Choose & Book has slowed as PCTs have quietly enacted barriers such as minimum waiting times and referral management centres. Plus, the Coalition government has dropped its target of 90% of GP referrals going through Choose & Book.

The distinctiveness of the private hospital proposition has also been diluted by NHS outsourcing to the private sector, and by new NHS construction during the last decade. The NHS estate has been renewed – 29% of NHS hospitals were built in the last 15 years compared to only 12% of private hospitals.

The push towards competition within the NHS may have even more dramatic consequences. New Private Patient Units and the removal of the Private Patient Cap may mean that more private patients will choose to be treated privately in NHS hospitals in the future. Their busy surgeons, mindful of the advantages of co-location, may well choose for them.

The NHS has had a decade of liberal spending. The waiting time for elective surgery has dropped to approximately 18 weeks from referral, reducing the incentive to “go private” to skip the queue. This year, 99% of patients referred urgently by the GP with a suspicion of cancer have been seen within two weeks (compared with 63% in 1997).

Missed last Month’s pRivate hospital analysis?download the fiRst paRt of the pRivate hospital

analysis seRies at:www.healthinvestoR.co.uk

fi nance

UK private hospital groups are struggling to remain relevant in an age of day surgery. Dr Victor Chua considers the challenges facing the sector and the rise of clinician partnerships

analysisPrivate concerns

Candesic

▶

EXHIBIT 1UK PRIVATE HOSPITAL BUILDINGS BY AGE

Old estatesThe private hospital estate is too old and increasingly decrepit. Only 12% of private hospitals were built since 1995 (exhibit 1) and their median age is 30 years. Their confi gurations were conceived in an age before minimally invasive surgery, so they have too many beds and not enough operating theatres, and the operating theatres are not aligned with day-case waiting areas.

Private equity ownership has acted as a brake on new investment. Half of the 200-odd private hospitals in the UK are owned by private equity groups which invested in them via leveraged buyouts. Private equity makes money by growing the profi tability (ebitda) of the business and they generally have a three to fi ve

20

4

9

41

31

6 6

0

5

10

15

20

25

30

35

40

45

year investment cycle. This model of fi nancing has limitations compared to having corporate owners, because there are strong disincentives to building new hospitals or renovating old ones. It takes two years to decommission a hospital and build a new one in its place, and another year for its revenues to bed down.

Consequently, only one hospital has been built by private equity in the last few years – Spire Shawfair Park in Edinburgh, which opened in 2010. By contrast, non-private equity owned groups have opened fi ve hospitals in the same period: Circle in Bath, two Nuffi eld hospitals in Cardiff and Guildford, a Ramsay cosmetic surgery hospital in Birmingham, and a hospital in Weymouth Street in London (which

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

Source: Laing & Buisson 2010-11; Healthcare Market News, Vol. 15 Issue 5, June 2011; Candesic Industry interviews April – May 2011;ONS online; Candesic analysis

20

4

9

41

31

6 6

0

5

10

15

20

25

30

35

40

45

0

5

10

15

20

25

30

35

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

1989 1994 1999 2004 2009

Persons covered

SubscribersEmployed population (millions)

(1,0

00

’s)

(mill

ions

)

* 1993: Decrease in persons insured is an artefact of re-estimation of Bupa’s multiplier which converts subscribers to persons coveredIncludes third party administrators (self-insurance by big companies ) Before 1992, no fi gures for self-insured available; fi gures above assume none 2010 Market report update due July 2011

fi nance

After big increases in coverage in the 1970s and 80s, the penetration of private medical insurance has levelled o� with about 11% of the UK population covered

2009-10 saw decreases following a time lag after 2008 recession. Much of the decrease has been in the self-pay segment

Industry expectations for the next fi ve to 10 years are that 2010 saw the market bottom out and recovery will be slow but steady from 2011-12; no dramatic change is expected without an unlikely policy change such as tax relief on PMI

20

4

9

41

31

6 6

0

5

10

15

20

25

30

35

40

45

0

5

10

15

20

25

30

35

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

1989 1994 1999 2004 2009

Persons covered

SubscribersEmployed population (millions)

(1,0

00

’s)

(mill

ions

)

60 HealthInvestor • July/August 2011 HealthInvestor • July/August 2011 61

has a management contract with BMI). Clinician partnerships have opened fi ve more – which we will discuss later.

Decline in private medical insurance during the recessionPrivate medical insurance is the main revenue source for private hospitals, accounting for 60% of revenue in 2009. However the recession has taken its toll on both subscribers and persons covered (exhibit 2). In both 2009 and 2010 the number of subscribers fell by 5% year on year. In our interviews with major insurers, it is clear that the more lucrative segment of customer – self payers – has taken the major hit while the corporate-paid segment has been less affected.

Hospitals have made up for the falling private demand by increasing the amount of work they do under contract to the NHS (exhibit 3). In volume, this has more than made up for the decreases in the number of private cases. However, early indications are that 2011 will be a fl atter year for NHS procedures, as data from a recent Freedom of Information request shows (exhibit 4).

Competition from foundation trustsMuch of the current political debate on the NHS reforms has centred on outsourcing elective procedures to the private sector, and the danger that this presents to NHS acute trusts. This is misconceived. Our view is that, far from the NHS trusts having to fear the private sector taking their NHS business, private hospitals need to worry about NHS trusts taking private hospitals’ core business of private patients. After all, in both volume and value, private hospitals are dwarfed by NHS hospitals – NHS acute hospitals are more than 10 times bigger.

Under the coalition government, caps on private income under Labour were removed and we are aware of at least 10 foundation trusts planning to expand their private patient units (PPUs).

This is a threat to private hospitals, because co-located private patient units can use the infrastructure of the NHS acute hospital – including intensive care units, which are very rare in the private sector. Consultants also like the convenience of having all their patients on one site.

For example, Guy’s & St Thomas’s,

fi nance fi nance

▶EXHIBIT 3PRIVATE HOSPITAL* VOLUME EVOLUTION THROUGH THE RECESSIONCases, 000’s

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

656 638625

177156 137

56 149 212

2007 2008 2009

PMI

Exhibit 3

Self-pay and other

NHS

888

975 942

CAGR%

98.1

-11.8

-2.2

CAGR4.97%

EXHIBIT 4NHS OUTSOURCING TO INDEPENDENT SECTOR – VOLUMES AND REVENUEVolumes and value outsourced under ‘Extended Choice Network’ under ‘Choose and Book’

Exhibit 4

NHS OUTSOURCING TO INDEPENDENT SECTOR – VOLUMES AND REVENUE

0

5,000

10,000

15,000

20,000

25,000

0

5,000

10,000

15,000

20,000

25,000

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

£ ‘000 No.

Monthly spend

£ million

Monthly procedures

Volumes and value outsourced under “Extended Choice Network” under “Choose and Book”

General election

Source: DH Freedom of Information request; Candesic analysis

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

Maintaining their value propositionOne of the reasons for the decline in the more lucrative private revenue stream for private hospitals is the distinctiveness of their proposition has been diluted. People ‘go private’ for a combination of reasons: the choice of physician or surgeon, the assurance that one’s doctor has reached consultant status, to beat NHS waiting lists, and to have their own room and greater general amenity.

NHS hospitals have spruced up under 10 years of Labour largesse – just look at the ever-expanding Addenbrookes Hospital campus in Cambridge, which has doubled in size since I was a medical student there in the early nineties. In contrast, the majority of private hospitals no longer have the newness and ‘wow’ factor that they did in their heyday. Many private hospitals, particularly the Ramsay hospitals, are now full of NHS patients, further diluting their distinctiveness.

Lastly, with waiting lists for elective procedures down to 18 weeks, the NHS has got better – no longer must a patient wait a year for a cataract operation or a knee arthroscopy. No wonder so many people are opting to be treated under the NHS, and dropping their private medical insurance.

Relationships with insurance companiesIt’s not all doom and gloom for private hospitals, however. In the last few years, it seems insurance companies have lost power in negotiations with hospital groups: the biggest operators (BMI Hospitals and Spire Healthcare) have become larger by acquisition, improving their negotiating power. We estimate that large groups such as BMI and Spire ▶

62� HealthInvestor�•�July/August�2011 HealthInvestor�•�July/August�2011� 63

HealthInvestoressential reading for the healthcare businessJuly/August 2011 vol 8•no 6

primary care • secondary care • social care • IT • infrastructure • markets • policy • dentistryISSN 1742-884X

Doctor doctor

Why private sector is taking clinician partnerships seriously

HospitalsCircle float surprises market

PolicyHealth Bill retreat threatens competition

Southern CrossThe never ending story

texttext n

text

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

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

1989 White Paper Caring for People : established purchaser/provider split and social services were encouraged to purchase from independent providers

2005: Partnerships in Care acquired by Cinven for historic 14xEDITDA

2011: Advent International buys Priory for £925m. 2010 EDITDA close to £100m

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

0

Exhibit 1

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

Source: Laing & Buisson 2010-11; MIND

MENTAL HEALTH BEDS, NHS AND PRIVATEEngland, n

Private beds

NHS beds

No

. of

bed

s

NHS 20

Private80


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exhibit 2souRces of funding foR ivf, uk

exhibit 1Mental health Beds, nhs and pRivateEngland, n

%

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

1989 White Paper Caring for People : established purchaser/provider split and social services were encouraged to purchase from independent providers

2005: Partnerships in Care acquired by Cinven for historic 14xEDITDA

2011: Advent International buys Priory for £925m. 2010 EDITDA close to £100m

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

0

Exhibit 1


Source: Laing & Buisson 2010-11; MIND

MENTAL HEALTH BEDS, NHS AND PRIVATEEngland, n

Private beds

NHS beds

NHS 20

Private80

▶Source: Human Fertilisation and Embryology Authority (HFEA)

HealthInvestor • September 2011 5352 HealthInvestor • September 2011

finance finance

▶

▶

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

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

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

exhibit 3dRug licensing in the nhs

Specialists (particularly lead investigators in clinical trials) often know or suspect years in advance that new therapeutics are working. But patients outside the trials cannot benefit in the UK.

We feel that private hospitals have suffered from a lack of focus on oncology. Private hospitals sometimes offer drugs and diagnostics not given in the NHS, and private insurers are happy to pay for them. But no UK private hospital has a reputation for cancer in the same way that the Marsden Hospital in London, or the Mayo Clinic in Minnesota, or the MD Anderson Cancer Center in Houston, does. (The closest is CancerPartnersUK, funded by Apposite Capital, which is focused on radiotherapy.)

Building a great clinical reputation takes a great deal of effort. Good clinicians wish to work in a successful organisation, which cannot be built overnight. But a focus on cancer therapeutics is capex light and we believe that a hospital group which embraces a cancer strategy can reap rich rewards.

exhibit 4 (cont.)availaBility of BReast canceR diagnostics

1 dRug and diagnostics access

England (NHS)

France

Spain

Germany

Referral to NICE Approval by NICE

Transparency committee and

pricing committee

InterministerialCommission

and Ministry of Health

Market authorisation

0 12 24 36

In European Union countries, the European Medicines Evaluation Agency (EMEA) surveys clinical trial data. If a drug is approved, the EMEA advises the EU to provide market authorisation*

8 months

10 months

7 months 14 months

NICE approval before prescribing a drug.

48

Licensing procedures

Availability to patient

The drug approval procedure within the NHS produces a significant delay between market authorisation and availability to patients.

Within other European countries, the delay between market authorisation and availability to patient occurs as government committees seek to approve pricing and reimbursement policies for a drug. In contrast, NICE reviews health e�ects, cost, and cost-e�ectiveness of a drug.

NICE guidelines are highly regarded in Europe and can influence drug prescribing policy across the continent. However, it is a lengthy process, and denies patients access to newly authorised drugs.

Similar to Germany, once market authorisation has been granted by the EMEA, it is legal to prescribe the drug within the UK. However, NHS hospitals will almost always wait for NICE approval before prescribing a drug.

Source: European Federation of Pharmaceutical Industries and Associations; European Competition Commission; International Society for Pharmacoeconomics and Outcomes Research

3

Exhibit 4

Source: Candesic interviews August 2011; Corporate websites

AVAILABILITY OF BREAST CANCER DIAGNOSTICS

Oncotype DX Femtelle MammaPrint

United Kingdom ✗ ✗ ✗

France ✗ ✔ ✔

Spain ✔ ✔ ✔

Germany ✗ ✔ ✔

• Screens formalin-fixed, para�n-embedded tissues for a panel of 21 genes using Q-RT-PCR

• Results spare low risk patients from additional cycles of chemotherapy

• Cost $4000

• An FDA-approved test which screens fresh or frozen tumour tissue using a 70-Gene DNA microarray in order to identify groups with good or poor prognosis


• Cost $4,200, or €2675 in Europe

• Performs ELISA analysis on fresh or frozen tumour tissue, to provide a quantitative determination of two tumour markers (uPA and PAI-1)

• Results give an indication of low or high risk recurrence, and may spare chemotherapy in low risk individuals

• Frequently used in Europe. Cost $250

exhibit 4availaBility of BReast canceR diagnostics

3

Exhibit 4


AVAILABILITY OF BREAST CANCER DIAGNOSTICS

Oncotype DX Femtelle MammaPrint

United Kingdom ✗ ✗ ✗

France ✗ ✔ ✔

Spain ✔ ✔ ✔

Germany ✗ ✔ ✔

• Screens formalin-fixed, para�n-embedded tissues for a panel of 21 genes using Q-RT-PCR


• Cost $4000

• An FDA-approved test which screens fresh or frozen tumour tissue using a 70-Gene DNA microarray in order to identify groups with good or poor prognosis


• Cost $4,200, or €2675 in Europe

• Performs ELISA analysis on fresh or frozen tumour tissue, to provide a quantitative determination of two tumour markers (uPA and PAI-1)

• Results give an indication of low or high risk recurrence, and may spare chemotherapy in low risk individuals

• Frequently used in Europe. Cost $250



* The EMEA is a centralised body providing authorisation for all EU countries. It is possible for manufacturers to apply for licenses in individual countries through national regulatory authorities.

Greater personalisation of medicine is also driven by the remarkable drop in the cost of sequencing the entire human genome (Exhibit 6). The announcement that the human genome had been sequenced around the turn of the century at the cost of $100 billion was rightly highlighted by the media as a milestone in the understanding of disease. Less well known, however, was another breakthrough which became apparent in 2008 – second-generation DNA sequencing, which is likely to cut the cost of sequencing to $1000 within the next two years.

At Candesic, we believe that there are a number of technologies which private hospitals can adopt with a minimum of effort. For example, pharmacogenomics can help predict patient responses to many commonly used drugs such as warfarin and tamoxifen. In cardiology, genetic mutations have been identified that affect patient responses to beta-blockers in long and short QT syndromes. In oncology, the potential for implementing patient-specific treatment plans is developing fast: The Sanger Institute in Cambridge is currently characterising the response of over 1,000 cancer-cell genotypes to a wide range of existing therapeutics.

Personalised medicine should prove attractive to private health care providers for three reasons: Firstly, there is widespread public knowledge of the human genome project, and the informed middle class expect their doctors to be making use of the information generated; Secondly, the genomic tests are outsourced, and therefore fit within the low capex requirements of today’s private hospital; Finally, personalised medicine and therefore early detection reduces cost of treatment and increases the likelihood of curing the disease (Exhibit 7) – all good selling points for treatment which could distinguish private care from NHS care.

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

exhibit 6the cost of genoMe seQuencing

exhibit 7peRsonalised Medicine and its Benefits

2 peRsonalised MedicinePersonalised medicine (care that often uses genetic information to optimalise an individual’s treatment) is no

longer science fiction, but everyday practice – just not in the UK. Sir John Bell, who is leading an inquiry into the future of NHS genetics that will report at the end of the year, said: “There has already been a lot of innovation, almost none of which has been adopted by the NHS. There’s now lots of evidence that the benefits we’ll get from this will be at least very large, and could be enormous.” (The Times, 3 August 2011).

The opportunity is large and enough to move the needle of the largest private hospital groups – if you scale US expenditure to the UK by population and also by spend on healthcare per capita, you arrive at a £1.5 billion opportunity, potentially growing at 14% per year (Exhibit 5).

exhibit 5peRsonalised Medicine: MaRket siZe, usa (and uk)

finance finance

$bn

Exhibit 5

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

PERSONALISED MEDICINE: MARKET SIZE, USA AND UK$bn

3 3

510

6

1113

21

2011 2015

Molecular Diagnostics

Esoteric Test Sales

Esoteric Lab Services

Targeted Therapeutics

27

45CAGR13.6%

Scaled for the UK by population size and total expenditure on health per capita, this gives a

UK market size of around £1.5bn in 2011

US market size for core personalised medicineS

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Note: Left axis scale is logarithmic

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

Advanced disease

Time

Current model

Future model

Diagnosis Treatment

Predisposition & risk management

Early molecular diagnosis Personalised treatment

Poor health / High cost

5

Note: Left axis scale is logarithmic

2002 20102004 2006 2008

$1,000

$10,000

$100,000

$1,000,000

$10,000,000

$100,000,000

February 2008 -second generation massively parallel DNA sequencing introduced to

replace the traditional Sanger

method and initiated a vast drop in time

and cost of genome sequencing

Publication of the first draft of the human

genome in February 2001

• Since 2008, the cost of sequencing an entire genome has fallen by almost 3 orders of magnitude

• Whilst barriers still exist, many have speculated that the $1000 genome could be achieved by 2013, making whole genome sequencing an achievable possibility for a large number of patients

• Realisation of the potential of the genome will require advances in information technology, and implementation of data management systems to inform clinician choices. Such programmes are being initiated in some hospitals in the USA, such as Vanderbilt University Medical Centre

Source: www.genome.gov

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s

Exhibit 7

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

PERSONALISED MEDICINE AND ITS BENEFITS

Genetic risk

Molecular signs

Early clinical signs

Early stage disease

Advanced disease

Baseline risk Preclinical progression Disease initiation and progression

Pat

ient

hea

lth

reve

rsib

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Genome screening can identify individuals genetically predisposed to developing a condition

Approaches using proteomics, metabolomics, and early clinical biomarkers can identify subclinical disease

Current model

Future model

Diagnosis Treatment

Predisposition & risk management

Early molecular diagnosis Personalised treatment

Good health / Low cost

Poor health / High cost

▶

▶


3 alleRgyLastly, we believe that private hospitals could take advantage of a big gap in NHS provision in the diagnosis and

treatment of allergies, which are increasing in prevalence in all Western countries (Exhibit 8).

exhibit 8pRevalence of childRen with peanut alleRgies

finance finance

exhibit 9clinical alleRgists peR 1M patients

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

* Andrew Thomas is an analyst, Sarah Downes is an associate consultant, and Dr Victor Chua a partner in Candesic’s London office. [email protected] 020 7096 7682

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is

Exhibit 8

Source: Scientific papers, Candesic analysis

PREVALENCE OF CHILDREN WITH PEANUT ALLERGIES

0

0.5

1

1.5

2

1994 1999 2004 2009

USA – clinical peanut allergy in under 18s. Cohort chosen at random using a nationwide, cross-sectional random telephone survey and questionnaire

UK – Clinical peanut allergy in children 3-4 on the Isle of Wight. Cohort of approx. 2000 children, all SPT, allergy diagnosed with open food challenge

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

Canada – Clinical peanut allergy in children aged 4-8. Children surveyed from a random cross section of schools, diagnosis made by SPT, peanut specific IgE, and oral peanut challenge

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Exhibit 9

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

CLINICAL ALLERGISTS PER 1M PATIENTS

63

57

29

27

23

23

23

20

16

15

11

9

5

5

2

1

1

Germany

Czech Republic

France*

Switzerland

Sweden

Italy

Spain

Hungary

Portugal

USA

Finland

Bulgaria

Greece

Romania

Serbia

Belgium

UK

* Data from UEMS

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

▶


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