Healthcare Market 2005

Market Review 2005
Tenth Edition September 2005 Edited by Isla Gower ISBN 1-84168-846-0
Healthcare Market
Healthcare Market
Foreword
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Healthcare Market
Contents
Contents
Executive Summary 1. Market Overview 1 3
REPORT COVERAGE ....................................................................................................................... 3

Public Healthcare.............................................................................................................................. 3 The National Health Service.............................................................................................................3 Private Healthcare ............................................................................................................................4 Private Medical Insurance ................................................................................................................ 4 Other Healthcare Services ................................................................................................................ 4
REPORT BACKGROUND ................................................................................................................ 5

Devolution and Healthcare..............................................................................................................6
ECONOMIC TRENDS ....................................................................................................................... 6

Population......................................................................................................................................... 6 Table 1.1: UK Resident Population Estimates by Sex (000), Mid-Years 2000-2004 ......................7 Gross Domestic Product.................................................................................................................... 7 Table 1.2: UK Gross Domestic Product at Current and Annual Prices (m), 2000-2004 ..............7 Inflation............................................................................................................................................. 8 Table 1.3: UK Rate of Inflation (%), 2000-2004 .............................................................................8 Unemployment .................................................................................................................................9 Table 1.4: Actual Number of Unemployed Persons (million), 2000-2004 .....................................9 Household Disposable Income......................................................................................................... 9 Table 1.5: Household Disposable Income Per Capita (), 2000-2004 ............................................9
MARKET SIZE ................................................................................................................................10

The Total Market ............................................................................................................................10 Table 1.6: The Total UK Healthcare Market by Sector by Value (m,) 2001-2005 .....................10 Figure 1.1: The Total UK Healthcare Market by Value (m), 2001-2005 ....................................11 The National Health Service...........................................................................................................11 Table 1.7: Total UK Expenditure on the National Health Service by Sector by Value (m), 2001-2005 .............................................................................................11 Private Healthcare ..........................................................................................................................12 Table 1.8: The Total UK Private Healthcare Market (Including Private Medical Insurance) by Sector by Value (m), 2001-2005 ...........................................................................13
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Other Healthcare Services ..............................................................................................................13 Table 1.9: The Total UK Other Healthcare Services Market by Sector by Value (m), 2001-2005 .............................................................................................14
MARKET SEGMENTATION ..........................................................................................................14

The National Health Service...........................................................................................................14 Hospital and Community Health Services .....................................................................................15 Family Health Services ....................................................................................................................15 Private Healthcare ..........................................................................................................................15 Private Medical Insurance ..............................................................................................................16 Complementary and Alternative Medicine...................................................................................16 Palliative and Hospice Care............................................................................................................16
INDUSTRY STRUCTURE ................................................................................................................16

Employment....................................................................................................................................16 Table 1.10: Profile of NHS Employees in the UK, 1999-2003 ......................................................17 Distribution .....................................................................................................................................19
MARKET POSITION ......................................................................................................................20 KEY TRENDS ..................................................................................................................................20

Demographics .................................................................................................................................20 Population.......................................................................................................................................20 Table 1.11: UK Resident Population Estimates and Projections (000 and %), Mid-Years 1971-2026 ..............................................................................................20 Figure 1.2: UK Resident Population Estimates and Projections for Those Aged Under 18 and of Pensionable Age (000), Mid-Years 2001-2026 ..........................................................................................................21 Births ...............................................................................................................................................22 Table 1.12: Number of Births in the UK (000), 1970-2003 ...........................................................22 Legal Abortions ..............................................................................................................................22 Table 1.13: Actual Number of Legal Abortions in the UK (number and %), 1986-2003 .........................................................................................................23 Infant Mortality ..............................................................................................................................23 Table 1.14: Infant Mortality Per 1,000 Live Births in the UK, 1950-2002 ...................................23 Public Health...................................................................................................................................24 Cause of Death ...............................................................................................................................24 Table 1.15: Number of Deaths in the UK by Major Cause (number and %), 2002 and 2003 ..................................................................................................25 Infectious Disease ...........................................................................................................................25 Table 1.16: Notified Cases of Infectious Diseases in the UK (number and %), 2002 and 2003 ..................................................................................................26 Back Pain .........................................................................................................................................26
LEGISLATION .................................................................................................................................27
Scotland...........................................................................................................................................27
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KEY TRADE ASSOCIATIONS........................................................................................................28

The National Health Service...........................................................................................................28 The British Medical Association .....................................................................................................28 English Community Care Association ............................................................................................28 The Federation of Ophthalmic and Dispensing Opticians ...........................................................28 General Dental Council ..................................................................................................................28 General Medical Council ................................................................................................................28 General Optical Council .................................................................................................................29 National Pharmacy Association .....................................................................................................29 Royal College of Nursing................................................................................................................29 Royal Pharmaceutical Society of Great Britain .............................................................................29 Private Medical Insurance ..............................................................................................................29 Association of British Insurers........................................................................................................29 Complementary and Alternative Healthcare................................................................................29 Aromatherapy Consortium ............................................................................................................29 British Acupuncture Council ..........................................................................................................30 The British Herbal Medicines Association .....................................................................................30 Faculty of Homeopathy..................................................................................................................30 General Chiropractic Council .........................................................................................................30 General Osteopathic Council .........................................................................................................30 Palliative and Hospice Care............................................................................................................30 Association of Childrens Hospices ................................................................................................30 Help the Hospices ...........................................................................................................................31 The National Council for Palliative Care .......................................................................................31 Scottish Partnership for Palliative Care .........................................................................................31
2. PEST Analysis
33
POLITICAL FACTORS ....................................................................................................................33

Re-Election of the Labour Government ........................................................................................33 The NHS Plan...................................................................................................................................33 Key Targets .....................................................................................................................................33 Acute Trusts ...................................................................................................................................33 Primary Care Trusts ........................................................................................................................34 Ambulance Trusts ..........................................................................................................................34 Selected Others ..............................................................................................................................34 Restructuring of Primary Care .......................................................................................................35 Staff Shortages ...............................................................................................................................36 Waiting Lists....................................................................................................................................36 Reform of the Ambulance Service.................................................................................................36 Long-Term Care and the Elderly....................................................................................................36 Tougher Healthcare Targets ..........................................................................................................37
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ECONOMIC FACTORS ..................................................................................................................37

Funding Shortfalls and Budget Changes.......................................................................................37 NHS Funding ...................................................................................................................................38 Funding Crisis..................................................................................................................................38
SOCIAL FACTORS ..........................................................................................................................38

Demographic Trends ......................................................................................................................38 Care in the Community ..................................................................................................................38 Obesity ............................................................................................................................................38 Severe Acute Respiratory Syndrome, Bird Flu and the Risk of Travel .........................................39 Treatment of the Terminally Ill......................................................................................................39 Smoking Trends ..............................................................................................................................39 Tuberculosis ....................................................................................................................................40 Protection From Poor Doctors .......................................................................................................40
TECHNOLOGICAL FACTORS .......................................................................................................40

Technological Advances in Medical Treatment ............................................................................40 Digital Technology .........................................................................................................................40 Drug Resistance ..............................................................................................................................41 Measles, Mumps and Rubella ........................................................................................................41
3. Key Note Primary Research
43
INTRODUCTION ............................................................................................................................43 CONSUMER PROFILE....................................................................................................................43

Table 3.1: Summary of Consumer Profile (% of respondents), 2005 ..........................................45 Thinking About the Last 12 Months, Which, if Any, of These Statements Apply to You? .............................................................................................................46 Took Out/Renewed Private Medical Insurance.............................................................................46 Table 3.2: Penetration of Taking Out/Renewing Private Medical Insurance in the Last 12 Months (% of respondents), 2005 .........................................................................48 Had NHS Surgery ............................................................................................................................50 Table 3.3: Penetration of Having NHS Surgery in the Last 12 Months (% of respondents), 2005 ..............................................................................................................51 Had Cosmetic Surgery ....................................................................................................................53 Table 3.4: Penetration of Having Cosmetic Surgery in the Last 12 Months (% of respondents), 2005 ..............................................................................................................53 Consulted a General Practitioner ..................................................................................................55 Table 3.5: Penetration of Consulting a General Practitioner in the Last 12 Months (% of respondents), 2005 .........................................................................56 Called a General Practitioner Out of Hours ..................................................................................59 Table 3.6: Penetration of Calling a General Practitioner Out of Hours in the Last 12 Months (% of respondents), 2005 .........................................................................60
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Consulted NHS Direct .....................................................................................................................62 Table 3.7: Penetration of Consulting NHS Direct in the Last 12 Months (% of respondents), 2005 ..............................................................................................................63 Visited a Hospital Casualty Department .......................................................................................65 Table 3.8: Penetration of Visiting a Hospital Casualty Department in the Last 12 Months (% of respondents), 2005 .........................................................................66 Was Referred to a Specialist/Consultant .......................................................................................68 Table 3.9: Penetration of Being Referred to a Specialist/Consultant in the Last 12 Months (% of respondents), 2005 .........................................................................69 Used Over-the-Counter Medicines ................................................................................................ 71 Table 3.10: Penetration of Using Over-the-Counter Medicines in the Last 12 Months (% of respondents), 2005 .........................................................................72 Used Herbal/Alternative Remedies................................................................................................74 Table 3.11: Penetration of Using Herbal/Alternative Remedies in the Last 12 Months (% of respondents), 2005 .........................................................................75 Regularly Took Vitamins/Minerals/Supplements ..........................................................................77 Table 3.12: Penetration of Regularly Taking Vitamins/Minerals/Supplements in the Last 12 Months (% of respondents), 2005 .........................................................................78 Visited a Dentist..............................................................................................................................80 Table 3.13: Penetration of Visiting a Dentist in the Last 12 Months (% of respondents), 2005 ..............................................................................................................81 Had a Routine Eye Examination ....................................................................................................83 Table 3.14: Penetration of Having a Routine Eye Examination in the Last 12 Months (% of respondents), 2005 .........................................................................84 Consulted an Osteopath ................................................................................................................86 Table 3.15: Penetration of Consulting an Osteopath in the Last 12 Months (% of respondents), 2005 ..............................................................................................................87 Consulted a Chiropractor ...............................................................................................................89 Table 3.16: Penetration of Consulting a Chiropractor in the Last 12 Months (% of respondents), 2005 ..............................................................................................................90 Had Physiotherapy..........................................................................................................................92 Table 3.17: Penetration of Having Physiotherapy in the Last 12 Months (% of respondents), 2005 ..............................................................................................................93 None of the Above .........................................................................................................................95 Table 3.18: Penetration of None of the Above in the Last 12 Months (% of respondents), 2005 ..............................................................................................................95
CONSUMER ATTITUDES ..............................................................................................................98

Table 3.19: Summary of Consumer Attitudes Towards Healthcare (% of respondents), 2005 ..............................................................................................................99 Which Three of the Following Actions Do You Consider Most Necessary to Improve the Health Service? .................................................................................100 Recruiting More Healthcare Professionals ..................................................................................100 Table 3.20: Recruiting More Healthcare Professionals (% of respondents), 2005 ...................101 Monitoring Their Performance....................................................................................................103 Table 3.21: Monitoring Their (Healthcare Professionals) Performance (% of respondents), 2005 ............................................................................................................104
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Cutting NHS Waiting Lists ............................................................................................................106 Table 3.22: Cutting NHS Waiting Lists (% of respondents), 2005 .............................................107 Increasing NHS Funding ...............................................................................................................109 Table 3.23: Increasing NHS Funding (% of respondents), 2005 ................................................110 Monitoring Hospital Performance...............................................................................................112 Table 3.24: Monitoring Hospital Performance (% of respondents), 2005 ...............................113 Improving Hospital Cleanliness....................................................................................................115 Table 3.25: Improving Hospital Cleanliness (% of respondents), 2005 ....................................116 Improving General Practitioner Out-of-Hours Services..............................................................118 Table 3.26: Improving General Practitioner Out-of-Hours Services (% of respondents), 2005 ............................................................................................................119 Increasing the Range and Availability of Over-the-Counter Medicines....................................121 Table 3.27: Increasing the Range and Availability of Over-the Counter Medicines (% of respondents), 2005 ............................................................................................................122 Encouraging Private Healthcare ..................................................................................................124 Table 3.28: Encouraging Private Healthcare (% of respondents), 2005 ...................................125 Changing Government Policy ......................................................................................................127 Table 3.29: Changing Government Policy (% of respondents), 2005 .......................................128 Educating the Public on Health Issues.........................................................................................130 Table 3.30: Educating the Public on Health Issues (% of respondents), 2005 .........................131
4. Competitive Structure
133
THE MARKETPLACE ...................................................................................................................133 MARKET LEADERS......................................................................................................................133

Anchor Trust .................................................................................................................................133 AXA PPP healthcare Group PLC ...................................................................................................134 Barchester Healthcare Ltd............................................................................................................135 The British United Provident Association Ltd .............................................................................136 FirstAssist.......................................................................................................................................137 Four Seasons Health Care.............................................................................................................137 General Healthcare Group Ltd.....................................................................................................138 HSA Group Ltd ..............................................................................................................................139 Norwich Union Healthcare Ltd ....................................................................................................140 Nuffield Hospitals .........................................................................................................................140 Western Provident Association Ltd .............................................................................................141 Other Companies..........................................................................................................................141
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5. The National Health Service
143
DEFINITION ..................................................................................................................................143 KEY TRENDS ................................................................................................................................143

NHS Funding and Investment ......................................................................................................143 The NHS Plan.................................................................................................................................143 Staff Shortages .............................................................................................................................144 Waiting Lists..................................................................................................................................144 Day Surgery Inefficiency...............................................................................................................144 Performance Criteria and Foundation Trusts..............................................................................145 Antibiotic Resistance and Super Bugs .........................................................................................145 Litigation and Negligence............................................................................................................145 Healthcare Commission Report ...................................................................................................145 Demographic Pressures ................................................................................................................147 Chlamydia Screening Programme ...............................................................................................147 Private Finance Initiative..............................................................................................................147
MARKET SIZE ..............................................................................................................................148

Table 5.1: Total UK Expenditure on the National Health Service (m), 2001-2005 .................148 Figure 5.1: Total UK Expenditure on the National Health Service (m), 2001-2005 ...............148
SUPPLY STRUCTURE ...................................................................................................................149

Strategic Health Authorities ........................................................................................................149 Primary Care Trusts.......................................................................................................................149 NHS Trusts .....................................................................................................................................149 Monitoring of Standards of Care ................................................................................................150 The Private Finance Initiative.......................................................................................................150 Organisation of the NHS ..............................................................................................................150
FORECASTS ..................................................................................................................................151
Table 5.2: Forecast Total UK Expenditure on the National Health Service (m), 2006-2010 ...........................................................................................................................151 Figure 5.2: Forecast Total UK Expenditure on the National Health Service (m), 2006-2010 ...........................................................................................................................152
6. Hospital and Community Health Services
153

Budget Priorities ...........................................................................................................................153 Patient Trends...............................................................................................................................153 Waiting Lists..................................................................................................................................153 NHS Beds and Patient Turnover...................................................................................................154 Hospital Cleanliness and Antibiotic Resistance...........................................................................154 Changes to the Ambulance Service .............................................................................................154
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MARKET SIZE ..............................................................................................................................154

Table 6.1: The Total UK Hospital and Community Health Services Market by Value (m), 2001-2005 ............................................................................................................155 Figure 6.1: The Total UK Hospital and Community Health Services Market by Value (m), 2001-2005 ............................................................................................................155 Table 6.2: Profile of Hospital Activity for England by Number of Episodes and Admissions, 2003/2004 .....................................................................................156
SUPPLY STRUCTURE ...................................................................................................................156 BUYING BEHAVIOUR .................................................................................................................157

Table 6.3: Hospital Operations in England by Type (number, days, years and %), 2003/2004 ...................................................................................158 Table 6.4: Hospital Episodes in England by Primary Diagnostic Group (number, days, years and %), 2003/2004 ...................................................................................159
FORECASTS ..................................................................................................................................159
Table 6.5: The Forecast Total UK Hospital and Community Health Services Market by Value (m), 2006-2010 ............................................................................................................159 Figure 6.2: The Forecast Total UK Hospital and Community Health Services Market by Value (m), 2006-2010 ............................................................................................................160
7. Family Health Services
161

Improved Access ...........................................................................................................................161 NHS Walk-In Centres ....................................................................................................................161 Organisation .................................................................................................................................161 Restructuring of Primary Care .....................................................................................................162 NHS Local Improvement Finance Trust........................................................................................162
MARKET SIZE ..............................................................................................................................162

Table 7.1: The Total UK Family Health Services Market by Sector by Value (m), 2001-2005 ...........................................................................................162 Figure 7.1: The Total UK Family Health Services Market by Value (m), 2001-2005 ............................................................................................................163
FORECASTS ..................................................................................................................................164
Table 7.2: The Forecast Total UK Family Health Services Market by Sector by Value (m), 2006-2010 ...........................................................................................164 Figure 7.2: The Forecast Total UK Family Health Services Market by Sector by Value (m), 2006-2010 ...........................................................................................165
PHARMACEUTICAL SERVICES ..................................................................................................165

Definition ......................................................................................................................................165 Key Trends.....................................................................................................................................166 The NHS Plan and the Expanding Role of Pharmacists ..............................................................166 The Drugs Bill and Price Regulation ............................................................................................166
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Prescription Volume and Charges ...............................................................................................166 Increased Generic Prescribing ......................................................................................................166 Consolidation of Pharmacy Outlets.............................................................................................167 Proposed Changes to the Pharmacy Contract ............................................................................167 Market Size ...................................................................................................................................167 Table 7.3: The Total UK Pharmaceuticals Services Market by Value (m), 2001-2005 ............................................................................................................168 Table 7.4: Number and Type of Prescriptions Dispensed in England by Diagnostic Group (million and %), Year Ending December 2004 .......................................168 Supply Structure ...........................................................................................................................169 Table 7.5: Number of Pharmacies Contracted to Health Authorities in England and Wales, 1999/2000-2003/2004 ............................................................................170 Figure 7.3: Number of Pharmacies Contracted to Health Authorities in England and Wales, 1999/2000-2003/2004 ............................................................................170 Major Players ................................................................................................................................171 Pharmaceutical Companies ..........................................................................................................171 AstraZeneca .................................................................................................................................171 Eli Lilly and Company Ltd ............................................................................................................171 GlaxoSmithKline ..........................................................................................................................171 Pfizer Ltd ......................................................................................................................................171 Shire Pharmaceuticals ..................................................................................................................171 Pharmacy Chains...........................................................................................................................172 Boots the Chemist ........................................................................................................................172 Lloyds Pharmacy ..........................................................................................................................172 Moss Pharmacy ............................................................................................................................172 Buying Behaviour .........................................................................................................................172 Advertising and Promotion..........................................................................................................173 Forecasts........................................................................................................................................173 Table 7.6: The Forecast Total UK Pharmaceutical Services Market by Value (m), 2006-2010 ............................................................................................................174
GENERAL AND PERSONAL MEDICAL SERVICES....................................................................174

Definition ......................................................................................................................................174 Key Trends.....................................................................................................................................174 Access to General Practitioners....................................................................................................174 New General Practitioner Contracts............................................................................................175 Market Size ...................................................................................................................................175 Table 7.7: The Total UK General and Personal Medical Services Market by Value (m), 2001-2005 ............................................................................................................175 Supply Structure ...........................................................................................................................176 Table 7.8: Number of General Practitioners Contracted to the NHS in the UK, 2000-2004 ...................................................................................................................176 Figure 7.4: Number of General Practitioners Contracted to the NHS in the UK, 2000-2004 ...................................................................................................................176 Table 7.9: Average Number of Patients per General Practitioner in the UK by Country, 2002 .........................................................................................................177
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Figure 7.5: Average Number of Patients per General Practitioner in the UK by Country, 2002 .........................................................................................................177 Buying Behaviour .........................................................................................................................178 Forecasts........................................................................................................................................178 Table 7.10: The Forecast Total UK General and Personal Medical Services Market by Value (m), 2006-2010 ............................................................................................................178
DENTAL SERVICES ......................................................................................................................178

Definition ......................................................................................................................................178 Key Trends.....................................................................................................................................178 Preventative Dentistry..................................................................................................................178 Dental Care Plans and Healthcare Insurance ..............................................................................179 New Contract ................................................................................................................................179 Market Size ...................................................................................................................................179 Table 7.11: The Total UK Dental Services Market by Value (m), 2001-2005 ..........................179 Supply Structure ...........................................................................................................................179 Table 7.12: Number of Dentists in the UK by Country (% and number), 2002 .......................180 Figure 7.6: Dentists in the UK by Country (%), 2002 .................................................................180 Table 7.13: Number of Adult Courses of Dental Treatment in the UK (000), 2000-2004 ..........................................................................................................181 Table 7.14: Number of New Adult Dental Patients in England (000), 2000-2002 ...................181 Funding for Dental Services .........................................................................................................182 Buying Behaviour .........................................................................................................................182 Table 7.15: General Adult Dental Services in England by Type of Treatment (%), 2002/2003 .............................................................................................................................182 Figure 7.7: General Adult Dental Services in England by Type of Treatment (%), 2002/2003 .............................................................................................................................183 Forecasts........................................................................................................................................183 Table 7.16: The Forecast Total UK Dental Services Market by Value (m), 2006-2010 ............................................................................................................184
GENERAL OPHTHALMIC SERVICES..........................................................................................184

Definition ......................................................................................................................................184 Key Trends.....................................................................................................................................184 Market Size ...................................................................................................................................185 Table 7.17: The Total UK General Ophthalmic Services Market by Value (m), 2001-2005 ............................................................................................................185 Supply Structure ...........................................................................................................................185 Table 7.18: The Actual Number of Ophthalmic Practitioners in England and Wales by Type, 1999-2003 ...................................................................................................186 Sight Tests and Eye Examinations................................................................................................186 Table 7.19: Number of UK NHS Sight Tests and Spectacles Redeemed (000), 2000-2004 ..........................................................................................................................187 Table 7.20: NHS Sight Tests in England and Wales by Type of Practitioner (% of sight tests performed), April-September 2004 ................................................................188 Table 7.21: Health Authority-Contracted Opticians by Number of Premises in England and Wales, 1999-2003 ..............................................................................................188
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Major Players ................................................................................................................................189 Boots Opticians Ltd.......................................................................................................................189 Dollond & Aitchison Ltd ...............................................................................................................189 Specsavers Optical Group.............................................................................................................189 Vision Express................................................................................................................................189 Advertising and Promotion..........................................................................................................190 Main Media Advertising Expenditure .........................................................................................190 Table 7.22: Main Media Advertising Expenditure on Prescription Frames and Contact Lenses (000), Year Ending March 2005 ...............................................................190 Buying Behaviour .........................................................................................................................191 Table 7.23: NHS-Paid Sight Tests by Patient Eligibility in England and Wales (% of sight tests), April-September 2004 ...................................................................................192 Table 7.24: Percentage of Spectacles/Appliances for Which Vouchers Were Reimbursed by the NHS by Patient Eligibility (%), April-September 2004 ..............................193 Forecasts........................................................................................................................................193 Table 7.25: The Forecast Total UK General Ophthalmic Services Market by Value (m), 2006-2010 ............................................................................................................193
8. Private Healthcare
195
DEFINITION ..................................................................................................................................195 MARKET SIZE ..............................................................................................................................196

Table 8.1: The Total UK Private Healthcare Market by Sector by Value (m), 2001-2005 ......196 Figure 8.1: The Total UK Private Healthcare Market by Value (m), 2001-2005 .....................196
FORECASTS ..................................................................................................................................197
Table 8.2: The Forecast Total UK Private Healthcare Market by Sector by Value (m), 2006-2010 ...........................................................................................197 Figure 8.2: The Forecast Total UK Private Healthcare Market by Value (m), 2006-2010 ............................................................................................................197
LONG-TERM CARE......................................................................................................................198
Key Trends.....................................................................................................................................198 Funding and Compliance .............................................................................................................198 Market Polarisation ......................................................................................................................198 Demographic Trends ....................................................................................................................198 Social Trends .................................................................................................................................199 Increasing Investment in the Long-Term Care Market...............................................................199 Market Specialisation and Added Value.....................................................................................199 Market Size ...................................................................................................................................199 Table 8.3: The Total UK Private Long-Term Care Sector by Subsector by Value (m), 2001-2005 .....................................................................................200 Supply Structure ...........................................................................................................................200 Table 8.4: Number of Long-Term Care Places by Subsector, April 2004 ..................................201 Legislation and Funding of Long-Term Care ..............................................................................202 National Minimum Standards .....................................................................................................202
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Major Players ................................................................................................................................202 Anchor Trust .................................................................................................................................203 BUPA Care Homes.........................................................................................................................203 Craegmoor Group Ltd ..................................................................................................................203 Four Seasons Health Care.............................................................................................................203 Highfield Care...............................................................................................................................203 Southern Cross Healthcare...........................................................................................................204 Westminster Senior Living ...........................................................................................................204 Advertising and Promotion..........................................................................................................204 Buying Behaviour .........................................................................................................................204 Forecasts........................................................................................................................................205 Table 8.5: The Forecast Total UK Private Long-Term Care Sector by Subsector by Value (m), 2006-2010 .....................................................................................205
ACUTE CARE................................................................................................................................207
Definition ......................................................................................................................................207 Key Trends.....................................................................................................................................207 Consolidation in the Marketplace ...............................................................................................207 Cosmetic Surgery ..........................................................................................................................207 Fertility Treatment........................................................................................................................207 Market Size ...................................................................................................................................207 Table 8.6: The Total UK Private Acute Care Sector by Value (m), 2001-2005 ........................208 Supply Structure ...........................................................................................................................208 Table 8.7: The Total UK Private Acute Care Sector by Number of Hospitals and Beds, 1999-2004 ....................................................................................................................208 Table 8.8: Ownership Status of Private Acute Care Providers (% of total beds), 1998 and 2004 ...............................................................................................209 Major Players ................................................................................................................................209 BMI Healthcare .............................................................................................................................209 Nuffield Hospitals .........................................................................................................................209 BUPA Hospitals Ltd .......................................................................................................................209 Capio Healthcare ..........................................................................................................................210 HCA International Ltd ..................................................................................................................210 Table 8.9: Leading UK Private Acute Care Providers by Number of Hospitals and Beds, 2004 ....................................................................................210 Private Care in the NHS ................................................................................................................211 Advertising and Promotion..........................................................................................................211 Buying Behaviour .........................................................................................................................211 Forecasts........................................................................................................................................212 Table 8.10: The Forecast Total UK Private Acute Care Sector by Value (m), 2006-2010 .......212
PSYCHIATRIC CARE ....................................................................................................................212

Definition ......................................................................................................................................212 Key Trends.....................................................................................................................................213 Market Size ...................................................................................................................................213 Table 8.11: The Total UK Private Psychiatric Care Sector by Value (m), 2001-2005 ...............213
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Supply Structure ...........................................................................................................................214 Table 8.12: The Total UK Independent Acute Psychiatric Care Sector by Number of Beds (number and %), 2002 and 2004 ...............................................................214 Major Players ................................................................................................................................214 Table 8.13: Major Players in the UK Independent Acute Psychiatric Care Sector by Number of Hospitals and Beds, 2004 ....................................................................................215 Priory Healthcare Ltd....................................................................................................................215 Partnerships in Care Ltd ...............................................................................................................215 St Andrews Group of Hospitals...................................................................................................216 Care Principles...............................................................................................................................216 Cygnet Healthcare ........................................................................................................................216 Advertising and Promotion..........................................................................................................216 Buying Behaviour .........................................................................................................................216 Forecasts........................................................................................................................................217 Table 8.14: The Forecast Total UK Private Psychiatric Care Sector (m), 2006-2010 ...............217
PRIMARY CARE ...........................................................................................................................217

Definition ......................................................................................................................................217 Key Trends.....................................................................................................................................217 Market Size ...................................................................................................................................218 Table 8.15: The Total UK Private Primary Care Sector by Subsector by Value (m), 2001-2005 ............................................................................................................219 Figure 8.3: The Total UK Private Primary Care Sector by Subsector (%), 2005 ........................219 Supply Structure ...........................................................................................................................220 GP Services ....................................................................................................................................220 Occupational Health Services.......................................................................................................220 Major Players ................................................................................................................................221 GP Services and Walk-In Clinics....................................................................................................221 BMI Health Services ......................................................................................................................221 BUPA Occupational Health Ltd....................................................................................................221 BUPA Wellness ..............................................................................................................................222 Franbar Holdings Ltd....................................................................................................................222 General Medical Clinics PLC .........................................................................................................222 GP Plus...........................................................................................................................................222 Advertising and Promotion..........................................................................................................223 Buying Behaviour .........................................................................................................................223 Forecasts........................................................................................................................................224 Table 8.16: The Forecast Total UK Private Primary Care Sector by Subsector by Value (m), 2006-2010 .....................................................................................224
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9. Private Medical Insurance
225
DEFINITION ..................................................................................................................................225 KEY TRENDS ................................................................................................................................225 MARKET SIZE ..............................................................................................................................226

Table 9.1: The Total UK Private Medical Insurance Market by Subscription Income (m), 2001-2005 ...................................................................................226 Figure 9.1: The Total UK Private Medical Insurance Market by Subscription Income (m), 2001-2005 ...................................................................................227

Number of Subscribers .................................................................................................................229 Table 9.2: Total UK Private Healthcare Policies by Number of Subscribers to Private Medical Insurance and Medical Expenses Schemes (000), 2001-2005 .....................229 Cost of Claims ...............................................................................................................................229 Table 9.3: The Total UK Private Medical Insurance Market by Cost of Claims (m and %), 2001-2005 ..................................................................................230
MAJOR PLAYERS ........................................................................................................................230

Table 9.4: Leading Private Medical Insurers by Share of Subscription Income (%), 2003 ...............................................................................................232 Figure 9.2: Leading Private Medical Insurers by Share of Subscription Income (%), 2003 ...............................................................................................232 British United Provident Association Ltd ....................................................................................233 AXA PPP healthcare Group PLC ...................................................................................................233 Norwich Union Healthcare...........................................................................................................233 Standard Life Healthcare Ltd .......................................................................................................233 FirstAssist.......................................................................................................................................233
ADVERTISING AND PROMOTION ............................................................................................233 BUYING BEHAVIOUR .................................................................................................................234 FORECASTS ..................................................................................................................................234

Table 9.5: The Forecast Total UK Private Medical Insurance Market by Subscription Income (m), 2006-2010 ...................................................................................235 Figure 9.3: The Forecast Total UK Private Medical Insurance Market by Subscription Income (m), 2006-2010 ...................................................................................235
10. Complementary and Alternative Medicine
237
DEFINITION ..................................................................................................................................237 KEY TRENDS ................................................................................................................................238 MARKET SIZE ..............................................................................................................................239

Table 10.1: The Total UK Complementary and Alternative Medicine Market by Value (m), 2001-2005 ............................................................................................................239 Figure 10.1: The Total UK Complementary and Alternative Medicine Market by Value (m), 2001-2005 ............................................................................................................239
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Contents

Table 10.2: Number of Complementary and Alternative Medicine Practitioners in the UK, 2005 ............................................................................................................................242
MAJOR PLAYERS ........................................................................................................................243 ADVERTISING AND PROMOTION ............................................................................................243 BUYING BEHAVIOUR .................................................................................................................244 FORECASTS ..................................................................................................................................244
Table 10.3: The Forecast Total UK Complementary and Alternative Medicine Market by Value (m), 2006-2010 ..............................................................................................245 Figure 10.2: The Forecast Total UK Complementary and Alternative Medicine Market by Value (m), 2006-2010 ..............................................................................................245
11. Palliative and Hospice Care
247

Demographic Trends ....................................................................................................................249 Greater Integration ......................................................................................................................249 Availability ....................................................................................................................................249 NICE Guidance ..............................................................................................................................249 Childrens Palliative Care..............................................................................................................250 Palliative Care Funding ................................................................................................................250
MARKET SIZE ..............................................................................................................................251

Table 11.1: The Total UK Palliative and Hospice Care Market by Value (m), 2001-2005 ............................................................................................................251 Figure 11.1: The Total UK Palliative and Hospice Care Market by Value (m), 2001-2005 ............................................................................................................252

Table 11.2: Inpatient Palliative Care Provision in the UK by Number of Units and Beds, 2001-2005 ..................................................................................253 Table 11.3: Number of Palliative Care Support Services in the UK by Type, 2001-2005 .....................................................................................................255 Regional Variations ......................................................................................................................255 Table 11.4: Inpatient Adult Palliative Care Provision in the UK by Number of Units and Beds by Country (number and %), 2005 .............................................................................255 Table 11.5: Inpatient Child Palliative Care Provision in the UK by Number of Units and Beds by Country (number and %), 2005 .............................................................................256 Table 11.6: Palliative Care Support Services in the UK by Type by Country (% and number), 2005 ................................................................................................................256
MAJOR PLAYERS ........................................................................................................................257

MacMillan Cancer Relief ..............................................................................................................257 Marie Curie Cancer Care ..............................................................................................................258 The Sue Ryder Foundation...........................................................................................................258
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ADVERTISING AND PROMOTION ............................................................................................258 BUYING BEHAVIOUR .................................................................................................................259

Profile of Use ................................................................................................................................259 Table 11.7: Patient Usage of Palliative Care Facilities and Services (number of patients), 2003/2004 ................................................................................................259 Patient Profile ...............................................................................................................................260
FORECASTS ..................................................................................................................................260
Table 11.8: The Forecast Total UK Palliative and Hospice Care Market by Value (m), 2006-2010 ............................................................................................................261 Figure 11.2: The Forecast Total UK Palliative and Hospice Care Market by Value (m), 2006-2010 ............................................................................................................262
12. A Global Perspective
263
OVERVIEW ...................................................................................................................................263
Table 12.1: Total Healthcare Expenditure as a Percentage of Gross Domestic Product by Country (%), 2003 ......................................................................263
KEY OVERSEAS MARKETS ........................................................................................................264

France ............................................................................................................................................264 Germany........................................................................................................................................265 Italy................................................................................................................................................265 Spain..............................................................................................................................................265 The US ...........................................................................................................................................266 Japan .............................................................................................................................................266
13. The Future
269
INTRODUCTION ..........................................................................................................................269
The Economy.................................................................................................................................269 Table 13.1: Forecast UK Economic Trends (000, % and million), 2005-2009 ............................270 FORECASTS....................................................................................................................................270 Table 13.2: The Forecast Total UK Healthcare Market by Sector by Value (m), 2006-2010 ............................................................................................................271 Figure 13.1: The Forecast Total UK Healthcare Market by Value (m), 2006-2010 .................272
FUTURE TRENDS .........................................................................................................................272

Demographics ...............................................................................................................................272 Antibiotic-Resistant Strains of Bacteria.......................................................................................272 Staff Shortages .............................................................................................................................273 Technological Developments.......................................................................................................273
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14. Further Sources
275
Associations...................................................................................................................................275 General Sources ............................................................................................................................277 Government Publications.............................................................................................................277 Other Sources................................................................................................................................277 Bonnier Information Sources .......................................................................................................279
Key Note Research The Key Note Range of Reports
281 271
Key Note Ltd 2005
Contents
Healthcare Market
Key Note Ltd 2005
Healthcare Market
Executive Summary
Executive Summary
This Key Note Market Review analyses the healthcare market in the UK, which can be divided broadly into public healthcare (the NHS, which comprises hospital and community health services [HCHS] and family health services [FHS]), private healthcare (and private medical insurance [PMI]), and other healthcare services (covering complementary and alternative medicine [CAM] and palliative and hospice care). Key Note estimates that, in 2005, the total UK healthcare market will be worth 111.42bn, an increase of 8.9% on 2004. Since its inception in 1948, the UK healthcare market has been dominated by the significant, comprehensive NHS. When the NHS was established with the remit to provide healthcare based on need rather than the ability to pay, there was no conception of how much costs would rise as the boundaries of healthcare expanded, along with the increasing number of elderly people in the population. In spite of the problems in funding and delivery, the British public remain fiercely protective of the NHS and politicians are aware that any significant erosion of the central principles of the NHS will have a huge political cost. At the same time, governments have had to grapple with the key issues of limited resources, prioritisation of care and, most importantly, how best to deliver healthcare in the most cost-effective and efficient way without compromising the principles of the NHS. Key Note estimates that, in 2005, the NHS will account for 80.7% of total UK expenditure on healthcare services. The NHS is organised into two main service delivery organisations: HCHS, which are responsible for hospital-based services; and FHS, which are responsible for frontline community-based primary care. HCHS account for the bulk of NHS expenditure. Within FHS, the highest proportion of expenditure is on pharmaceutical services (PHS). In the UK, the private healthcare sector has evolved in the shadow of the significant public sector, largely through supplying solutions to the problems in the NHS. As a result, much of the private-sector provision is traditionally for routine elective procedures, which are likely to have longer waiting lists on the NHS. The private sector has also developed niche markets, such as cosmetic surgery, abortion services and fertility treatment, which are either limited or unavailable on the NHS. More recently, the private sector and the NHS have been working in partnership, supplying services to reduce waiting lists for the NHS or running services for the NHS directly, such as long-term care, certain psychiatric care services and specialist diagnostic services. Primary care services, particularly occupational health, are also a relatively small, but emerging, market in the private healthcare sector. In 2005, Key Note estimates that private healthcare services (excluding PMI) accounted for 15.3% of healthcare expenditure in the UK. By far the largest private sector market was that of long-term care. PMI remains the principal source of funding for the private healthcare sector, although the NHS has become a significant commissioner of private-sector services and many private patients are opting for self-pay fixed-price schemes.
Key Note Ltd 2005
Executive Summary
Healthcare Market
CAM comprises a significantly diverse range of therapies and treatments, of which some, such as chiropractic and osteopathy, have achieved statutory recognition and regulation. Others have little or no regulation outside the voluntary self-regulation of a large number of different trade organisations. A number of the more popular complementary therapies, including osteopathy, chiropractic, acupuncture, reflexology and aromatherapy, are becoming increasingly integrated into mainstream care. Homeopathy is available in a number of NHS hospitals, in spite of the scepticism of many healthcare professionals. Palliative and hospice care, although a comparatively small sector of the market in terms of expenditure, is also hugely influential. Largely run by charities and voluntary organisations, the palliative and hospice care sector has had funding problems, coupled with increasing demand for services. However, there has been increasing recognition from the public sector in terms of funding and the development of more integrated partnerships in care with, or actually within, the NHS. In particular, the palliative care sector has been developing more flexible community-based services, with the emphasis on home and respite care. Healthcare services in the UK are under increasing pressure from a demographically ageing population. In addition, medicine is a technology-driven market, with new treatments and procedures continually expanding the scope of care. The Government has been trying to contain costs and improve efficiency in the public sector through significant increases in funding, coupled with the use of increasingly tough targets. In addition, the Government has recently been introducing reforms aimed at the decentralisation of decision making, and the reduction of bureaucracy and administrative costs. The private sector has responded to funding pressures and the drive for cost efficiency by adding value to services, which broadens the scope of these services. The result has been a significant rise in acquisition and merger activities within the private sector, creating large companies that operate across the continuum of healthcare, with greater flexibility and economies of scale. At the other end of the spectrum, conditions have become increasingly difficult for small, independent operators. Although the problems facing healthcare in the UK are complex, intractable and significant, there is immense political and public will for great improvements in the delivery of healthcare in the UK. The stakes are particularly high for a government that has been pouring unprecedented amounts of funding into the health sector, and for a public that are still looking for significant signs of improvement.
Key Note Ltd 2005
Healthcare Market
1. Market Overview
1. Market Overview
REPORT COVERAGE
The UK healthcare market is a comprehensive, highly complex mixture of interconnecting primary, secondary and tertiary services. This Key Note Market Review provides an overview of public, private, charitable, complementary and alternative healthcare services in the UK, and examines the market structure and segmentation within the various sectors. The report also examines key market issues, including the effects of government policy and other social, economic and environmental factors, as well as the impact of demographic trends and European legislation.
Public Healthcare
The National Health Service
Public healthcare provision in the UK is provided by the NHS, which is a comprehensive network of services that dominate and define the UK healthcare market. The NHS is organised into two main service supply structures, as follows:
Hospital and community health services (HCHS), comprising of:

NHS trusts, which consist of acute care hospitals, psychiatric hospitals, long-term residential and nursing homes, rehabilitation facilities, specialist diagnostic services, ambulance services, blood transfusion services and other specialist services community-based services, including health visitors, district nurses, community midwives, community dental services (preventative dental services to those in the community who are unable to access practitioner dental services; the service performs dental epidemiological surveys and need assessments for children in schools and adults in long-term residential care, as well as providing dental health promotion and education programmes) and community vaccination services.
Family health services (FHS), which comprise:

pharmaceutical services (PHS), for the supply and dispensing of NHS prescription medicines general and personal medical services, which are responsible for core primary healthcare services, including general practitioners (GPs) and supporting practice staff dental services, which comprise independent dental practices contracted to the NHS general ophthalmic services (GOS), comprising a variety of different independent practitioners contracted to the NHS.
Key Note Ltd 2005
1. Market Overview
Healthcare Market
The NHS, HCHS and FHS are considered separately in Chapters 5, 6 and 7 of this report.
Private Healthcare
In the UK, private healthcare is supplied by a combination of commercial and charitable providers of a variety of services, including the following:
long-term care residential and nursing home care acute care hospitals and specialist diagnostic services psychiatric care both hospital and community-based services primary care private GP practices and occupational health services.
Private Medical Insurance

Most private healthcare in the UK is funded through private medical insurance (PMI), which is supplied by specialist commercial insurance companies or non-profitmaking provident associations. Other types of funding include self-pay and fixed-price schemes, as well as cash benefit and critical illness schemes. In Key Notes Private Healthcare Market Report, PMI is considered as part of the overall private healthcare market. However, in this Market Review, the markets for private healthcare and PMI are considered separately, in Chapters 8 and 9.
Other Healthcare Services

Other major healthcare services in the UK comprise the following:
Complementary and alternative medicine (CAM) this market covers a

broad and variable range of healthcare therapies and treatments outside mainstream healthcare. Although certain services are statutorily regulated, much of this sector is self-regulated and supplied by a variety of practitioners with varying degrees of training and qualifications.
Palliative and hospice care in the UK, palliative and hospice care is
provided by a combination of voluntary and public services. They are based either in charitable hospices and NHS hospitals, or they are community-based and supplied by teams of specialist healthcare professionals. This market also includes respite care and day care services, as well as home-based care. The markets for CAM and palliative and hospice care are considered separately in Chapters 10 and 11 of this report.
Key Note Ltd 2005
Healthcare Market
1. Market Overview
REPORT BACKGROUND
The UK healthcare system is highly complex in terms of the nature and type of services that it delivers. It is heavily influenced by trends and changes in the population that it serves. In addition, it is highly dependent on the state of the UK economy, as it relies on general taxation for the bulk of its funding. When the NHS was founded in 1948, at a time when the country was rebuilding in the post-war period, there was a general optimism that new treatments (particularly antibiotics), together with improvements in diet, sanitation and housing, would lead to improvements in the general health of the population, which would limit the costs of healthcare. Instead, an ageing population, along with rising levels of circulatory disease and cancer, as well as chronic conditions such as asthma, have resulted in significant increases in costs. Previous problems, such as malnutrition and infectious disease, have been replaced with rising levels of obesity and viral diseases such as acquired immune deficiency syndrome (AIDS). Increasing levels of antibiotic resistance have also begun to erode the advantages of antibiotics. Also adding to these costs are the advances in technologies that are expanding the scope and range of treatment possibilities. In an effort to contain and control costs, successive governments have introduced a variety of comprehensive reforms with the appropriate legislation. During 18 years in power, the previous Conservative Government introduced legislation that brought an internal market structure to the NHS, dividing it into service providers and service commissioners who bought services on behalf of consumers (patients). As part of the reforms, the Conservative Government introduced tendering of services to bidders inside and outside the NHS and, in an effort to obtain much-needed investment for the NHS infrastructure, it extended the Private Finance Initiative (PFI) into the NHS. As part of its legacy, the previous government attempted to develop a culture of cost awareness and cost effectiveness although, ultimately, it was criticised for the expanding centralisation and bureaucracy of services. Under the reforms, the Conservatives introduced Care in the Community and closed many psychiatric institutions. At the same time, the NHS began to withdraw from long-term residential care, relying increasingly on the private sector, and costs continued to rise. When the current Labour Government came to power, it did so with a clear commitment to improving the NHS, and has proceeded to invest unprecedented sums of money into the service. Although it abolished the internal market as such, the current Government has retained something of the infrastructure, and has continued to foster private public partnerships and the PFI with a streamlined approval process. The publication of the NHS Plan in 2000 set out its goals for reform, with a new system of healthcare delivery and specific commitments for improvement in key areas, such as reducing waiting lists and improving access to care.
Key Note Ltd 2005
1. Market Overview
Healthcare Market
With a commitment to preventative medicine and greater co-ordination of services, the Government introduced the national frameworks to target specific areas of health concern, such as cancer, as well as investing in primary care services. Perhaps the most controversial reform introduced to date has been the creation of foundation hospitals from high-performing trusts, which will be given powers of autonomy to be run by community and trust stakeholders. In an effort to improve the quality and consistency of service provision, the Government introduced a system of standards and target setting, and has established organisations such as the National Institute of Clinical Excellence (NICE) to oversee, promote and rationalise care provision. However, the costs of care are continuing to rise and there are still many challenges yet to be resolved, including staff shortages, bed blocking, the rationalisation of service provision, rising problems of antibiotic-resistant infection, and the problems in long-term care funding and provision.
Devolution and Healthcare

Since devolution in 1998, the Scottish Parliament and, to a lesser extent, the Welsh and Northern Ireland Assemblies, became responsible for health policy and the NHS in their respective countries. Scotland, in particular, has diverged from English policy in a number of ways. Scotland has undergone a staged elimination of the internal market, with the abolition of trusts and the creation of 15 health boards. The country has also chosen to let healthcare professionals run the hospitals. There is some use of the PFI, although less so than in England. Since devolution, Wales has had a well-publicised series of problems. It now operates through 22 local health boards, similar to primary care trusts (PCTs). In 2004, a report from the University of Nottingham found that waiting lists had lengthened in Wales since the Welsh Assembly took over in 1999. In Northern Ireland, there was considerable delay before GP fund holding was abolished and replaced by commissioning by subcommittees of health boards that acted like PCTs.
ECONOMIC TRENDS
Population
Between 2000 and 2004, the UK population rose by an estimated 1.5% to 59.8 million people. More important is the ageing nature of the UK population, which has an effect on the healthcare market (see Key Trends section).
Key Note Ltd 2005
Healthcare Market
1. Market Overview
Table 1.1: UK Resident Population Estimates by Sex (000), Mid-Years 2000-2004

2000
Female Male
2001
2002 30,359 28,963 59,322 0.4
2003 30,446 29,108 59,554 0.4
2004
30,196 28,690 58,886 -
30,281 28,832 59,113 0.4
30,542 29,245 59,787 0.4
Total
% change year-on-year
census year
taken from Projections Database
Source: Monthly Digest, May 2005, National Statistics website/ Projections Database, Government Actuarys Department Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)
Gross Domestic Product

At current prices, UK gross domestic product (GDP) has shown steady growth over the past 5 years, rising year on year at rates ranging between 4.6% and 5.5%. GDP increased from 950.56bn in 2000 to 1,160.34bn in 2004 at current prices, an increase of 22.1%. Annual chain-linked GDP has also shown steady annual rates of growth, varying from 1.8% in 2002 to 3.1% in 2004. The UK spends 7.7% of its GDP on healthcare, ranking it 19th in the world (see Chapter 12 A Global Perspective).
Table 1.2: UK Gross Domestic Product at Current and Annual Prices (m), 2000-2004
2000
Current prices % change year-on-year
2001
2002
2003
2004
950,561 -
994,309 1,044,145 4.6 5.0
1,101,144 1,160,339 5.5 5.4
Table continues...
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1. Market Overview
Healthcare Market
Table 1.2: UK Gross Domestic Product at Current and Annual Prices (m), 2000-2004
...table continued 2000
Annual chain-linked GDP % change year-on-year
GDP gross domestic product
2001
2002
2003
2004
971,937 -
994,309 1,011,892 2.3 1.8
1,034,097 1,066,542 2.2 3.1
Source: National Accounts, Main Aggregates 1948-2004, National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)
Inflation
In 2000, the UK rate of inflation was 2.9%, before dropping to 1.8% in 2001 and a low of 1.6% in 2002. Since then, inflation has risen to reach 2.9% in 2003 and 3% in 2004. Higher levels of inflation give rise to higher wage bills and prices, both of which add to the burgeoning costs of healthcare.
Table 1.3: UK Rate of Inflation (%), 2000-2004

2000
Inflation (%) Percentage point change year-on-year
2001 1.8 -1.1
2002 1.6 -0.2
2003 2.9 1.3
2004 3.0 0.1
2.9 -
Note: inflation is at retail price index (RPI).
Source: Monthly Digest, May 2005, National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)
Key Note Ltd 2005
Healthcare Market
1. Market Overview
Unemployment
The actual number of unemployed persons (claimants) in the UK fell steadily from 1.1 million in 2000 to 850,000 in 2004.
Table 1.4: Actual Number of Unemployed Persons (million), 2000-2004

2000
Actual number of claimants (million) % change year-on-year
2001 0.97 -11.0
2002 0.95 -2.1
2003 0.93 -2.1
2004 0.85 -8.6
1.09 -
Source: Monthly Digest, May 2005, National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)
UK healthcare services are major employers in the UK, with the NHS employing around 1.4 million people directly, and many more in the various supply industries. However, the lack of suitably qualified healthcare professionals has resulted in a significant number of unfilled vacancies and the NHS has been actively recruiting abroad (see Key Trends in Chapter 5 The National Health Service).
Household Disposable Income

Between 2000 and 2004, household disposable income per capita increased by 18.3% to 13,210. According to Family Spending A Report on the 2003-2004 Expenditure and Food Survey from National Statistics, average weekly household expenditure on health was 5, which included an average weekly spend of 3.30 on medicine, prescriptions and healthcare products.
Table 1.5: Household Disposable Income Per Capita (), 2000-2004

2000
Household disposable income () % change year-on-year
2001 11,880 6.4
2002 12,195 2.7
2003 12,720 4.3
2004 13,210 3.9
11,162 -
Source: Economic Trends, June 2005, National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)
Key Note Ltd 2005
1. Market Overview
Healthcare Market
MARKET SIZE
Since the last edition of this report was published (February 2003), market size figures and source data have been subject to a number of revisions and, as a result, may differ from previous reports. Similarly, Key Note estimates from the last report have been revised into actual figures.
The Total Market

Key Note estimates that, in 2005, the total UK market for healthcare services will be worth 111.42bn, a rise of 8.9% on 2004. Since 2001, the market has grown by an estimated 40%. The healthcare market in the UK is dominated by the NHS; Key Note estimates that, in 2005, total expenditure on the NHS will be 89.89bn, accounting for 80.7% of the total healthcare market. Private healthcare services account for an estimated 15.3% of the total market in 2005, at 17bn, having grown by 25.9% since 2001. Between 2001 and 2005, PMI has increased by an estimated 22.6% to 3.26bn. Over the same 5-year period, the market for CAM has risen by 32.9%, and the palliative and hospice care market has increased by 43.4%.
Table 1.6: The Total UK Healthcare Market by Sector by Value (m,) 2001-2005
2001
NHS Private healthcare Private medical insurance Complementary and alternative medicine Palliative and hospice care
2002 67,159 14,243 2,863 624 376
2003 74,592 15,287 2,980 671 412
e2004
e2005
62,509 13,499 2,662 583 348
81,935 16,054 3,114 721 453
89,890 16,993 3,263 775 499
Total
e Key Note estimates
79,601 85,265 7.1
93,942 102,277 111,420 10.2 8.9 8.9
Source: Annual Abstract of Statistics, National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)/Annex A2, Department of Health Annual Report 2005 Crown copyright/Laings Healthcare Market Review 2004-2005/trade sources/Key Note
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Key Note Ltd 2005
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1. Market Overview
Figure 1.1: The Total UK Healthcare Market by Value (m), 2001-2005
120,000 110,000 100,000 90,000 80,000 70,000 60,000 50,000 2001 2002 2003 2004 2005
Note: figures for 2004 and 2005 are Key Note estimates.
Source: Annual Abstract of Statistics, National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)/Annex A2, Department of Health Annual Report 2005 Crown copyright/Laings Healthcare Market Review 2004-2005/trade sources/Key Note

In 2005, HCHS account for an estimated 77.6% of all NHS expenditure, at 69.73bn. In the FHS arm of the NHS, PHS account for the largest proportion of expenditure (56.1%), followed by general and personal medical services, at 30.5%.
Table 1.7: Total UK Expenditure on the National Health Service by Sector by Value (m), 2001-2005
2001
Hospital and community health services
2002
2003
e2004
e2005
48,236
51,641
57,438
e63,280
e69,728
Table continues...
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1. Market Overview
Healthcare Market
Table 1.7: Total UK Expenditure on the National Health Service by Sector by Value (m), 2001-2005
...table continued 2001 Family Health Services
Pharmaceutical services General and personal medical services Dental services General ophthalmic services
2002 8,230 4,873 2,045 370
2003 9,176 5,470 2,115 393
e2004
e2005
7,293 4,656 1,962 362
10,249 5,798 2,200 408 18,655 81,935 9.8
11,304 6,146 2,288 424 20,162 89,890 9.7
Total family health services Total

e Key Note estimates e Department of Health estimates
14,273 15,518 17,154 62,509 67,159 74,592 7.4 11.1
Source: Annual Abstract of Statistics, National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)/Annex A2, Department of Health Annual Report 2005 Crown copyright/Key Note
Private Healthcare
In the private healthcare market, long-term care is the largest market sector, worth an estimated 10.8bn in 2005, accounting for 63.5% of the private healthcare market. Acute care constitutes the second-largest sector, at an estimated 5.33bn in 2005.
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1. Market Overview
Table 1.8: The Total UK Private Healthcare Market (Including Private Medical Insurance) by Sector by Value (m), 2001-2005
2001 Private Healthcare
Long-term care Acute care Psychiatric care Primary care
2002 9,582 3,989 384 288
2003 10,153 4,406 424 304 15,287 2,980 18,267 6.8
e2004
e2005
9,300 3,581 344 274
10,416 4,847 469 322
10,796 5,332 523 342
Total private healthcare

Private medical insurance
13,499 14,243 2,662 2,863
16,054 16,993 3,114 3,263
Total
16,161 17,106 5.8
19,168 20,256 4.9 5.7
Source: Laings Healthcare Market Review 2004-2005/Key Note
Other Healthcare Services

Palliative and hospice care was the fastest-growing sector of the other healthcare services market, increasing by an estimated 43.4% between 2001 and 2005.
Key Note Ltd 2005
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1. Market Overview
Healthcare Market
Table 1.9: The Total UK Other Healthcare Services Market by Sector by Value (m), 2001-2005
2001
Complementary and alternative healthcare Palliative and hospice care
2002
2003
e2004
e2005
583 348 931 -
624 376 1,000 7.4
671 412 1,083 8.3
721 453 1,174 8.4
775 499 1,274 8.5
Total
Source: Trade sources/Key Note

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MARKET SEGMENTATION
The NHS was founded in the post-war period in 1948 with the remit to provide comprehensive healthcare services to all UK citizens as a service based on need rather than the ability to pay. It is funded, uniquely in the world, from general taxation and the NHS element of National Insurance (NI) contributions. The service was founded at an optimistic time, when it was generally believed that demand for care would naturally fall as public health improved and various diseases were eliminated. However, since then, the ageing population and diseases such as cancer and heart disease, together with the emergence of antibiotic resistance, asthma, allergies and other chronic intractable conditions, have increased demand significantly. At the same time, technology has expanded the opportunities for care and the demand for increasing amounts of care. As such, there has been a significant increase in healthcare expenditure, with demand outstripping the ability to provide. Since the 1970s, the NHS has been subjected to a significant amount of reorganisation and reform by successive governments. These reforms include the creation of an internal market of providers and purchasers introduced by the previous Conservative Government, and the introduction of the PFI and private partnerships and tendering mechanisms.
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1. Market Overview
Although the current Labour Government abolished the internal market, it has maintained many elements of the previous reforms, including providers (NHS trusts) and commissioners (PCTs) of care, as well as private public partnerships and tendering processes. In addition, the current Government has added elements of its own, including foundation hospitals and a target-driven culture. Service provision in the NHS is divided into two major organisational arms, as follows:
Hospital and Community Health Services

HCHS provide hospital-based secondary and tertiary care services with certain diagnostic, screening and specialist services, together with certain community-based services. Key Note estimates that, in 2005, expenditure on HCHS will be 69.73bn.
Family Health Services

FHS, which comprise four main service sectors, is the arm of the NHS responsible for primary care services and acts as the gateway to secondary care services in the UK. In 2005, expenditure is estimated to be 20.16bn.
PHS this sector is responsible for the controlled supply of prescription

medicines in the primary care sector, consisting of registered pharmacists operating from licensed premises to dispense pharmaceuticals prescribed by GPs.
General and personal medical services this sector supplies the core
primary care provision in the NHS via community-based GPs. General and personal medical services are the primary point of access to the NHS (both public and private).
Dental services service provision of dental services is through qualified

dentists operating as independent practitioners under contract to the NHS.
GOS these are provided by a variety of independent professionals

operating under contract to the NHS, including sight testing, and the prescription and dispensing of spectacles and contact lenses.
Private Healthcare
The private healthcare market comprises both commercial and voluntary providers, and the commercial sector has become increasingly dominant in recent years. Although comparatively small to the NHS, it has been growing through a combination of public private partnerships, the development of niche markets and capitalising on the waiting lists and service provision problems of the NHS. Key Note estimates that, in 2005, the private healthcare market will be worth an estimated 17bn.
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1. Market Overview
Healthcare Market
Long-term care long-term residential and nursing home care for the
elderly and disabled is dominated by the private sector, both commercial and charitable, as the public sector gradually withdraws from the provision of these services. The market has been significantly affected by funding issues and high barriers to entry for care providers. In 2005, long-term care is, by far, the largest sector in the private healthcare market.
Acute care there are around 206 private acute care hospitals in the UK
and commercial operators now dominate the marketplace. Most treatment in this sector is for routine elective surgery, but niche markets, such as cosmetic surgery and fertility treatment, are growing rapidly.
Psychiatric care private psychiatric care is a niche market of public

private partnerships in which the NHS is the main commissioner of services. It provides a wide range of specialist residential and clinic-based services.
Primary care this is an emerging market comprising occupational health

services and a small number of private GP services, although a number of acute care private hospitals are introducing them in situ.

Most private healthcare in the UK is paid for by PMI policies supplied by provident associations or commercial insurance companies. Policies are either purchased individually or through corporate schemes and there are no taxation incentives to encourage use. The market is dominated by BUPA.
Complementary and Alternative Medicine

CAM is used to describe a wide and diverse range of therapies and treatments outside mainstream medicine. Apart from osteopathy and chiropractic, the market is self-regulated, although a number of therapies are increasingly being integrated into mainstream medical care.
Palliative and Hospice Care

Palliative care is provided to patients with incurable and progressive diseases, and incorporates the needs of the family and carers. In the UK, it is organised by the hospice movement and is increasingly operating in partnership with the NHS to provide flexible residential and home-based care for patients and their families. Hospice services have traditionally been funded by charities and voluntary groups, but are increasingly attracting funding from the NHS.
INDUSTRY STRUCTURE
Employment
The UK healthcare market is dominated by the public health service provider, the NHS, which is the largest employer in the UK. In 2003, the NHS employed 1.4 million people, compared with 1.2 million in 1999.
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Table 1.10: Profile of NHS Employees in the UK, 1999-2003

1999 HCHS Medical Staff 2000 2001 2002 2003
Consultants Other medical staff

Total medical staff
24,250 44,839
69,089
25,067 45,872
70,939
26,106 47,100
73,206
27,951 50,073
78,024
29,566 52,728
82,294
Hospital Dental Staff
Consultants Other dental staff

Total hospital dental staff
581 1,235
1,816
580 1,201
1,781
578 1,238
1,816
610 1,334
1,944
664 1,317
1,981
Nursing and Midwifery Staff
Qualified nursing staff Other nursing staff

Total nursing and midwifery staff 415,786 423,737 437,417 455,361 474,263
303,644 112,142
309,682 114,055
320,685 116,732
335,313 120,048
349,701 124,562
Table continues...
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...table continued
1999 HCHS Non-Medical/Nursing Staff 2000 2001 2002 2003
Administrative and clerical staff Professional and technical staff Healthcare assistants Ambulance staff Other non-medical/ nursing staff
Total non-medical/ nursing staff Total HCHS FHS 455,135 941,826 466,545 963,002 490,414 1,002,853 519,029 1,054,358 548,574 1,107,112
190,421 128,116 22,746 18,562 95,290
197,327 131,943 24,919 19,209 93,147
209,004 138,348 30,047 19,888 93,127
224,490 146,804 33,301 20,864 93,570
241,634 155,507 36,027 21,449 93,957
Personal social services staff GPs Dental practitioners Optometrists Ophthalmic medical practitioners
Total FHS Total
221,700 37,125 20,840 8,423
217,200 37,572 21,316 8,742
212,000 38,162 21,929 8,650
208,300 38,649 22,194 8,761
212,000 40,013 22,891 9,123
827
288,915 1,230,741
819
285,649 1,248,651
754
281,495 1,284,348
686
278,590 1,332,948
674
284,701 1,391,813
Table continues...
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...table continued
HCHS hospital and community health services FHS family health services includes residential care staff, home helps, day care staff and field social service GPs general practitioners
Source: Annual Abstract of Statistics 2005 (Tables 9.4 and 9.5), National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland) The decentralised and diverse nature of the private sector make it difficult to determine the number of people employed but, according to the Department of Health (DoH), there are around 9,000 full-time equivalent qualified nurses working in the private sector, with around 41,000 qualified nurses working in private residential nursing homes. Since there is a significant shortage of qualified nurses, the NHS has been recruiting from abroad for some years, with foreign recruits accounting for around a third of all new registrations. Most of these recruits are from the Philippines. In terms of private medical staff, most consultants (more than 85%) working in the private sector also have contracts with the NHS, and very few are exclusively private.
Distribution
The NHS was established with the remit to provide comprehensive care, free at the point of need and, as such, has a network of facilities throughout every part of the UK. GPs are the frontline for primary care services, which act as a conduit from the community to secondary care services based mostly in hospitals, and the corresponding tertiary care services. The private sector in the UK is comparatively small and is far less comprehensive in nature than the NHS. Services are provided in greatest concentration in large urban areas, in London in particular. Palliative and hospice care operate both within the NHS and in voluntary hospices and community-based services, whereas complementary care is provided mostly by private community-based therapists.
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MARKET POSITION
According to the Organisation for Economic Co-operation and Development (OECD), in terms of total healthcare expenditure as a percentage of GDP, the UK was ranked 19th in the world, at 7.7% in 2003 (see Chapter 12 A Global Perspective).
KEY TRENDS
Demographics
Population
The UK population has increased by 6.9% since 1971 and is projected to reach 60.3 million by 2006. Population growth is projected to reach 64.9 million by 2026, an increase of 8.6% on 2004 (see Table 1.1). The UK population has been ageing steadily since 1971, with the proportion of those aged 18 years and under falling from 28.2% in 1971 to a projected 21.7% in 2006. In addition, the proportion of this age group is forecast to fall further and account for a projected 19.5% of the population by 2026. In contrast, the proportion of elderly people of pensionable age rose from 16.3% in 1971 to a projected 18.9% in 2006, and is forecast to reach 21.4% by 2026. The ageing population, with the accompanying health problems associated with getting older, is increasing pressure on NHS services.
Table 1.11: UK Resident Population Estimates and Projections (000 and %), Mid-Years 1971-2026
% Population Population
1971 1981 1991 2001 2002 2006 2011
% Population of Pensionable Age 16.3 17.8 18.4 18.3 18.4 18.9 19.8
Under 18 Years 28.2 25.7 22.8 22.6 22.4 21.7 20.5
55,928 56,357 57,439 59,114 59,322 60,254 61,401
Table continues...
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Table 1.11: UK Resident Population Estimates and Projections (000 and %), Mid-Years 1971-2026
...table continued % Population Under 18 Years 19.9 19.7 19.5 % Population of Pensionable Age 19.8 19.9 21.4
Population
2016 2021 2026
62,618 63,835 64,902
does not match the figure given in Table 1.1 due to rounding by source
Source: Annual Abstract of Statistics 2005 (Table 5.3), National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)
Figure 1.2: UK Resident Population Estimates and Projections for Those Aged Under 18 and of Pensionable Age (000), Mid-Years 2001-2026
14,500 14,000 13,500 13,000 12,500 12,000 11,500 11,000 10,500 10,000 2001 2002 2003 2006 2011 2016 2021 2026
Under 18 Pensionable age
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According to the English Community Care Association (ECCA), 20% of all people aged over 85 years were admitted to care homes in England in 2003. The ECCA forecasts that 29% more beds will be required over the next 12 years to meet increasing demand.
Births
The birth rate has fallen steadily from 880,000 in 1970-1972, to a low of 672,000 in 2000-2002. In 2003, the latest figures available indicate a rise in the number of births to 696,000, an increase of 3.6% on 2000-2002. In 2003, the general fertility rate was 56.2. However, the still-birth rate rose from a low of 4.6 still births (born dead after 24 weeks) per 1,000 women in 1990-1992, to 5.7 still births per 1,000 women in 2003.
Table 1.12: Number of Births in the UK (000), 1970-2003

Live Births (000)
1970-1972 1980-1982 1990-1992 2000-2002 2003
rate per 1,000 population rate per 1,000 women aged 15 to 44 years
Crude General
Birth Rate Fertility Rate 15.8 13.0 13.8 11.4 11.7 82.5 62.5 63.7 54.7 56.2
StillBirth Rate 12.7 6.8 4.6 5.4 5.7
880 735 790 672 696
Legal Abortions
Since 1986, the number of legal abortions rose from 147,619 to a peak of 177,871 in 1998, before falling to a low of 173,701 in 1999. Since then, the number of legal abortions has risen slightly and, in 2003, there were 181,582. The proportion of abortions performed on girls aged 15 years or under was at its highest in 1986, at 2.6%, before falling to 1.9% in 1992. Since then, it has remained at a steady 2.1% of all abortions until 2003, when it increased slightly to 2.2%. In contrast, the proportion of abortions by the over-45s has remained steady, at 0.3%. The greatest fluctuation was observed among 16 to 19 year-olds, ranging from 22.9% in 1986 to 17.2% in 1992. By 2003, the proportion of abortions in this age group was 18.9% of the total.
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Table 1.13: Actual Number of Legal Abortions in the UK (number and %), 1986-2003
% of Total All Ages
1986 1992 1998 1999 2000 2001 2002 2003
% of Total Aged 16-19 Years 22.9 17.2 18.7 18.9 18.9 19.0 18.7 18.9
% of Total Over 45 Years 0.3 0.3 0.3 0.3 0.3 0.3 0.3 0.3
Aged 15 Years and Under 2.6 1.9 2.1 2.1 2.1 2.1 2.1 2.2
147,619 160,501 177,871 173,701 175,542 176,364 175,932 181,582
Infant Mortality
Since the 1950s, infant mortality has fallen quite dramatically each decade. In 1950-1952, the mortality rate was 30 for every 1,000 live births, compared with 5 per 1,000 live births in 2000-2002. This is a strong indication of the successful development of antenatal and postnatal maternity services, combined with general improvements in public health.
Table 1.14: Infant Mortality Per 1,000 Live Births in the UK, 1950-2002
1950-1952 1960-1962 1970-1972 Table continues... 30 22 18
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Table 1.14: Infant Mortality Per 1,000 Live Births in the UK, 1950-2002
...table continued 1980-1982 1990-1992 2000-2002
under 1 year
12 7 5
Public Health
Cause of Death
Heart and circulatory disease is the main cause of death in the UK and was responsible for 38.1% of all deaths in 2003. Cancer is the second major cause of death in the UK, constituting 26% of all deaths in 2003. However, between 2002 and 2003, the number of deaths caused by cancer decreased by 0.4%. Together, these two conditions were responsible for 64.1% of all deaths in the UK in 2003. The highest level of growth was observed for respiratory disease, with an increase of 7.7% between 2002 and 2003, although there were also significant increases during this period in genito-urinary disease (7.2%), and diseases of the central nervous system (CNS) and sense organs (5.6%).
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Table 1.15: Number of Deaths in the UK by Major Cause (number and %), 2002 and 2003
% Change 2002 Deaths From Natural Causes
Heart and circulatory disease Cancer Respiratory disease Digestive system disease Mental and behavioral disorders Diseases of CNS and sense organs Genito-urinary disease Endocrine, nutritional and metabolic diseases Other deaths from natural causes
2003 233,058 158,654 84,674 28,750 17,824 17,577 10,503 9,220 29,110 589,370 21,818 611,188
20022003 -2.0 -0.4 7.7 3.2 3.0 5.6 7.2 2.6 2.0 0.8 2.4 0.8
237,850 159,331 78,589 27,858 17,301 16,644 9,797 8,986 28,544 584,900 21,316 606,216
Total deaths from natural causes

Other deaths
Total
CNS central nervous system
Infectious Disease
In 2003, there was a 95.7% rise in the number of reported cases of mumps, compared with a 25.8% fall in notified cases of measles. Rubella cases also decreased by 23.8%. Following a rise in the incidence of measles in 2002, there has been a significant rise of mumps in 2003. These rises could have been facilitated by safety fears over the measles, mumps and rubella (MMR) vaccine, which has led to many parents failing to have their infants vaccinated and creating a potential pool for infection in the population. Reported cases of typhoid and paratyphoid fevers rose by 51.4% during this period, although whooping cough decreased by 51.6%.
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There was also a rise in the reported number of cases of scarlet fever (18.3%) and hepatitis (3.3%), although there were decreases in reported cases of malaria (5.3%), tuberculosis (5.2%), food poisoning (3.1%) and dysentery (2%).
Table 1.16: Notified Cases of Infectious Diseases in the UK (number and %), 2002 and 2003
% Change 2002-2003 -3.1 -5.2 3.3 95.7 18.3 -25.8 -23.8 -2.0 -5.3 -51.6 51.4
2002
Food poisoning Tuberculosis Hepatitis Mumps Scarlet fever Measles Rubella Dysentery Malaria Whooping cough Typhoid and paratyphoid fevers
2003 79,073 6,863 5,203 4,565 3,252 2,726 1,525 1,144 820 509 277
81,562 7,239 5,035 2,333 2,749 3,675 2,002 1,167 866 1,051 183
Back Pain
Back pain has been identified by the DoH as being the leading cause of disability in the UK, affecting over 1.1 million people. The incidence of back pain has risen more rapidly than any other common disability. According to the DoH, around half of the UK adult population (49%) reported having suffered from lower back pain for at least 24 hours during 2000. Another series of surveys carried out for the DoH estimated that four out of five people will experience significant back pain at some stage in their life. In another survey, it was estimated that more than half of those with back pain had pain lasting for more than 4 weeks and that 2.5 million people had pain lasting throughout the year. There was little difference between men and women, but young people were more likely to have shorter acute episodes of pain and older people were prone to more chronic problems. Back pain has profound economic implications, with one in eight unemployed people claiming that back pain is the reason for their unemployment. At any one time, around 430,000 people are claiming social security payments as a result of this.
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LEGISLATION
NHS reforms in recent years have been underpinned by a large number of Acts and Bills, and by statutory instruments. Some of the most recent major reforms are as follows:
Mental Capacity Act 2005 which provided a statutory framework to

protect vulnerable people, carers and professionals
NHS Improvement Plan 2004 which sets out priorities for the NHS
until 2008
Health Protection Agency Bill 2004 this bill established the Health
Protection Agency as a UK-wide public body to tackle the problems of infectious disease, radiation and other hazards
Health and Social Care (Community Health and Standards) Act 2003
legislative machinery for the NHS Plan which includes reforms in the complaints procedure and the creation of foundation trusts
NHS Reform and Health Care Professions Act 2002 which created the
Strategic Health Authorities and other organisational and structural change
The NHS Plan 2000 outlining the reforms to the NHS and setting out
priorities for improvement and reform
Care Standards Act 2000 which established a major regulatory

framework for social care
Carers and Disabled Children Act 2000 setting out the rights and services
for carers
Health Act 1999 amending the law regarding the NHS involving
arrangements and payments between NHS service providers and local authorities
Community Care (Direct Payments) Act 1996 which determines

circumstances when cash payments can be offered as an alternative to social services care
The Community Care Act 1990 which is aimed at helping people live in
the community wherever possible and imposed a duty of care on local authorities.
Scotland
NHS Reform Bill (Scotland) 2003 which covers the reform of the structure
of the NHS in Scotland, the abolition of NHS trusts and establishment Community Health Partnerships (CHPs)
Health Act 1999, Part II, The National Health Service, Scotland outlining
reform for the NHS in Scotland and the abolition of the internal market
Designed to Care (White Paper) December 1997.
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KEY TRADE ASSOCIATIONS

The British Medical Association
The British Medical Association (BMA) is the representative body for doctors from all branches of medicine in the UK. It is a voluntary professional association and trade union representing the interests of doctors in the UK and abroad. The BMA operates as a limited company funded by its members. It has a membership of around 130,000 doctors, including more than 3,000 overseas members and more than 16,000 medical students.
English Community Care Association

The ECCA is the largest representative body for community care in England, representing both small and large care providers. It was formed from the amalgamation of the Independent Healthcare Association (IHA) and English Care (the largest representative body in long-term care) in January 2004. English Care had a membership representing more than 300,000 care beds in England.
The Federation of Ophthalmic and Dispensing Opticians

The Federation of Ophthalmic and Dispensing Opticians (FODO) represents the interests of dispensing opticians in the UK, including individual practitioners, small companies and large national organisations. FODO represents around 174 companies employing around 3,201 practitioners.
General Dental Council

The General Dental Council (GDC) is the statutory body responsible for the regulation and registration of dentists, dental hygienists and dental therapists in the UK, all of whom must be registered to practise in the UK. The GDC currently represents the interests of around 37,000 registered practitioners.
General Medical Council

The General Medical Council (GMC) was formed in 1858 as the statutory body responsible for the registration of doctors and the maintenance of professional standards through its role as the regulator of the medical profession. The GMC is currently engaged in a comprehensive reform of medical regulation, including a smaller council with 40% lay members, changes in the registration procedure and a new streamlined complaints process. The GMC currently has around 200,000 doctors registered in the UK and, in the future, it is introducing a requirement that doctors must revalidate their fitness to practise in order to remain registered.
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General Optical Council

The General Optical Council (GOC) is the statutory body regulating dispensing opticians and optometrists in the UK.
National Pharmacy Association

The National Pharmacy Association (NPA) was formed in 1921 and is the national organisation representing the interests of community pharmacies. The NPA also provides information and advice regarding pharmacy services to the general public, government and healthcare professionals. The NPA provides a wide range of support services, including training and educational services for pharmacy assistants, to community pharmacy members.
Royal College of Nursing

The Royal College of Nursing (RCN) is the professional organisation that represents the interests of nurses both nationally and internationally. The RCN represents more than 370,000 nurses, healthcare assistants and nursing students in the public and private sectors.
Royal Pharmaceutical Society of Great Britain

The Royal Pharmaceutical Society of Great Britain (RPSGB) is the organisation with statutory powers that is responsible for the registration of pharmacists and their premises in the UK. It represents the interests of around 43,000 pharmacists in the UK and abroad. As well as controlling the registration process in the UK, the organisation can also review and withdraw registration if pharmacists are deemed unfit.

Association of British Insurers
The Association of British Insurers (ABI) is the trade association representing the UK insurance industry. It has around 400 members, including PMI companies.
Complementary and Alternative Healthcare

Aromatherapy Consortium
The Aromatherapy Consortium (AC) is an umbrella body that comprises a number of member associations representing aromatherapists. It is effectively an interim body to facilitate consultation with aromatherapy professionals. Aromatherapists are invited to register voluntarily with the AC.
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British Acupuncture Council

The British Acupuncture Council (BAcC) is the main regulatory body in the UK for the practice of acupuncture, representing more than 2,500 trained acupuncturists. Although there is no legislation governing the practice of acupuncture in the UK, the BAcC acts to maintain standards of practice, training and education.
The British Herbal Medicines Association

The British Herbal Medicines Association (BHMA) was formed in 1964 to promote the practice of herbal medicine in the UK and to ensure its continued statutory recognition in the country. Members include herbalists, pharmacists and herbal medicine manufacturers.
Faculty of Homeopathy
The Faculty of Homeopathy has more than 1,400 members worldwide and promotes the academic and scientific development of homeopathy. The association works to promote high standards of practice and provides training and education in homeopathy. The Faculty was incorporated by an Act of Parliament in 1950.
General Chiropractic Council

Formed in 1994, the General Chiropractic Council is the statutory body responsible for the registration and regulation of chiropractors in the UK. It also determines and maintains standards of practice, and represents the interests of registered chiropractors.
General Osteopathic Council

The General Osteopathic Council was formed in 1993 as the statutory body responsible for the registration and regulation of osteopaths in the UK. There are currently 3,627 osteopaths registered with the council, of whom 18.8% are based in London and 73% in other parts of England.
Palliative and Hospice Care

Association of Childrens Hospices
The Association of Childrens Hospices (ACH) is the national body representing the interests of childrens hospice and palliative care services in the UK. It is committed to raising both public and professional awareness of childrens hospice services in the UK.
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Help the Hospices

Help the Hospices is the official national charity for the hospice movement. It supports hospices in the UK through fundraising, information services, education and training, advice, and various grants and bursaries. Help the Hospices acts as a lobbying group for independent hospices through the Independent Hospice Representative Committee. It is also developing a UK network of organisations and professionals supporting services abroad via the UK Forum for Hospice and Palliative Care Worldwide. In a joint venture with St Christophers Hospice, it offers Hospice Information, a comprehensive information service and website on UK palliative care.
The National Council for Palliative Care

The National Council for Palliative Care (NCPC) is the umbrella organisation for all those who are involved in providing, commissioning and using hospice and palliative care services in England, Wales and Northern Ireland. It promotes the extension and improvement of palliative care services regardless of diagnosis in all health and social care settings and across all sectors to government, national and local policy makers.
Scottish Partnership for Palliative Care

The Scottish Partnership for Palliative Care (SPPC) is the national umbrella organisation for palliative care in Scotland.
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POLITICAL FACTORS
Re-Election of the Labour Government
On 5th May 2005, a General Election re-elected the Labour Government with a substantial, although much-reduced, majority. Following a reshuffle, a new Health Secretary, Patricia Hewitt, was appointed. Since then, a raft of policy announcements have been made. However, the reduced Government majority may make it difficult for the government to push through some of its more radical and controversial plans in the face of back-bench opposition.
The NHS Plan

Since it originally took office, the Labour Government has channelled significant amounts of funds into the NHS. The essence of the 10-year plan is to create a patient-focused health service, modernise services and end regional inequalities. The Government has established a number of key performance targets that are assessed and upgraded on a regular basis, including the following:
Key Targets
Acute Trusts
12-hour waits for emergency admission from accident and emergency (A&E)
departments after the decision to admit waits of more than 12 hours were considered unacceptable.
All cancers a maximum wait of 1 month from diagnosis to treatment by

December 2005, and a maximum waiting time of 2 months for urgent referral to treatment by December 2005. There should be a maximum of 2 weeks from urgent general practitioner (GP) referral to first outpatient appointment.
Hospital cleanliness improvements required following concerns over

methicillin-resistant Staphylococcus aureus (MRSA) using the PEAT cleanliness assessment score with year-on-year reductions in infection rates.
Outpatients and inpatients waiting longer than the standard the NHS
Plan target is that, by December 2005, the maximum wait for inpatient treatment should be 6 months, with urgent cases treated according to clinical need. By 2008, average waits should be 9 weeks from referral to treatment. This is also a target for primary care trusts (PCTs).
Total time in A&E, less than 4 hours the NHS target requires that, from
March 2005, patients should spend a maximum of 4 hours in A&E from arrival to admission, transfer or discharge. This is also a target for PCTs and ambulance trusts.
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Outpatient and elective procedures bookings by the end of 2005, every

hospital appointment should be booked for the convenience of the patient, with a guaranteed maximum waiting time and a choice of at least four to five different healthcare providers for planned hospital care, paid for by the NHS.
Financial management to attain financial stability for NHS bodies. Improving working lives using modern employment practices to improve
the recruitment and retention of staff.
Primary Care Trusts
Access to a GP or primary care professional the Plan requires guaranteed

access to a primary care professional within 24 hours, and 48 hours for a GP, by March 2005.
Treatment for drug misusers reducing drug misuse is a key priority and
PCTs have a key role. PCTs have been asked to increase participation of drug users in treatment programmes by 100% by 2008.
Quit smoking a target for 800,000 people to quit smoking at the 4-week
stage by 2006.
Outpatient and inpatients waiting longer than the standard the NHS
Plan target is that, by December 2005, the maximum wait for inpatient treatment should be 6 months, with urgent cases treated according to clinical need. By 2008, average waits should be 9 weeks from referral to treatment. This is also a target for NHS trusts.
Ambulance Trusts
All ambulance trusts are required to respond to 75% of Category A calls

within 8 minutes by March 2005.
All ambulance trusts are required to respond to 95% of Category B calls

within 14 minutes (urban) or 19 minutes (rural).
Selected Others
Increase life expectancy at birth to 78.6 years for men and 82.5 years for
women by 2010.
A 20% reduction in death rates from cancer among people under the age
of 75 years by 2010.
A 40% reduction in death rates from circulatory disease among people

under the age of 75 years by 2010.
To improve the health outcomes for people with chronic, long-term

conditions by providing a personalised care plan for vulnerable people and to reduce emergency bed days by 5% by 2008 through improved primary care and care in community settings.
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Diabetic retinopathy screening a minimum of 80% of diabetics to be

offered early detection and treatment for diabetic retinopathy by 2006, rising to 100% by 2007.
Improve life outcomes for adults and children with mental health problems
by ensuring access to crisis services by 2005, and a comprehensive Child and Adolescent Mental Health Service by 2006.
Influenza vaccinations the target uptake among those aged over 65 years
is 70%.
Health equity reduce health inequalities by 10% by 2010, as measured by

infant mortality and life expectancy after birth.
Halting the rise in obesity among children under 11 years by 2010. Immunisation to increase uptake and reduce fears over safety of the
measles, mumps and rubella (MMR) vaccine.
Infant health to deliver an increase of 2 percentage points per year in

breastfeeding initiation rates, and a reduction of 1% per year in the proportion of women smoking in pregnancy.
Suicide audit reduce mortality from suicide and undetermined injury by

20% by 2010.
Teenage pregnancies reduce the under 18 conception rate by 50% by

2010.
Restructuring of Primary Care

On 29th July 2005, a far-reaching and comprehensive shake-up of primary care services was announced just 5 years after the last reforms were introduced. In the restructuring, many of the 303 PCTs in England will face a merger and will no longer have the responsibility for employing district nurses, school nurses, therapists and other frontline healthcare personnel. Instead, they will be employed by a combination of charities, private healthcare providers or a range of public bodies, including social services and foundation hospitals. The Kings Fund has warned that this might adversely affect the Governments stated plans to improve patient choice.
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Staff Shortages
Shortages of qualified healthcare professionals are threatening to derail improvements in the health service. In addition, according to the Royal College of Nursing (RCN), a significant proportion of nurses are nearing retirement age or planning to take early retirement. According to the Department of Health (DoH), as of March 2004, there were 7,520 vacancies (of more than 3 months) for qualified nurses, midwives and health visitors, compared with 1,670 medical and dental staff. In addition, there were vacancies for 1,260 consultants. The Government has expanded the number of medical school places, with around 5,300 new doctors emerging each year. However, other problems have arisen, with recent reports highlighting the shortage of training places for newly qualified doctors, leaving at least 2,000 of them without a post at a time when there are significant staff shortages. These training posts are necessary for doctors to take further specialist training to become consultants or GPs. There are currently around 49,000 junior doctors in the UK, as well as 5,300 first-year house officers, around 24,500 senior house officers and 19,200 registrars. Generally, house officers work under 6-month contracts.
Waiting Lists
The Government remains committed to reducing waiting lists in the NHS. Although the latest figures indicate that waiting lists are falling, opposition leaders claim that authorities are massaging the statistics. As at the end of May 2005, the number of patients in England waiting for more than 6 months for admission into NHS hospitals was 49,600, an increase of 9.3% on April 2005, but a fall of 42.2% on the same period in 2004. There were only 17 patients waiting for over 9 months at the end of May 2005, and no patients waiting over 12 months.
Reform of the Ambulance Service

The Government announced major reforms to the ambulance service in England over the next 5 years. Ambulance staff will carry out diagnostic tests and other basic procedures in the patients home. In future, they will be empowered to refer patients to social services, admit patients to specialist units and prescribe a wider array of medicines. They will also make routine assessments of long-term patients in their homes in partnership with GPs and nurses.
Long-Term Care and the Elderly

Funding remains the key limiting factor for long-term care in the UK. A coalition of charities the Social Policy Ageing Information Network (SPAIN) claims that, although the elderly constitute 62% of social services clients, they are allocated only 47% of local authority care budgets, with funding being diverted to younger adults. The report What Price Care in Old Age? found that the number of households that receive home care services had fallen by 25% since the Labour Government took office in 1997.
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Tougher Healthcare Targets

In the 2004/2005 financial year, all hospital trusts met the targets set for A&E services, which required that 90% of patients should wait for less than 4 hours. This target has increased to 100% for the current fiscal year and, so far, 62 of the 159 trusts with A&E departments have failed to meet this. In England, around 42% of 173 acute care and specialist trusts achieved 3-star status (indicative of high performance) between March 2004 and March 2005, a fall of 44% on the previous year. Around one in 20 trusts achieved no star ratings at all. Five of the 25 foundation trusts achieved 2 rather than 3 stars, and three of them were reported to have underachieved on their financial management. Problems were particularly acute in the south east of England; around 21 trusts, including five 3-star trusts, had poor results in the control of MRSA.
ECONOMIC FACTORS
Funding Shortfalls and Budget Changes
The Labour Government committed itself to the decentralisation of public services during its third term in office. It has been claimed that the DoH is already implementing this by advancing a programme to reduce head office staff by 38%. The NHSs Chief Executive, Sir Nigel Crisp, has stated that, within the next 5 years, the majority (80%) of targets would be set locally and 20% nationally. Currently, around 80% of targets are set nationally. Recently, Sir Nigel Crisp contacted chief executives of NHS organisations and demanded 15% cuts in administration and management costs, with the aim of saving at least 250m a year. The Government has received criticisms that much of the extra funding allocated to the NHS is being swallowed up by increasing administration costs and expenditure on non-frontline staff. It has been reported that at least 25% of all trusts are failing to spend within budget constraints. The end result of the new reforms will mean a smaller number of PCTs and a reduction in the number of strategic health authorities, of which there are 18 at present. By the end of 2006, GPs will be able to commission services directly under budgets set up by trusts. In addition, it is anticipated that charities will play a much greater role in the new system. According to the National Institute of Economic and Social Researchs (NIESRs) National Institute Economic Review (July 2005, number 193), in order to balance public finances, the Chancellor will have to raise taxes by an extra 10bn a year. A deficit of 8bn is forecast in the current fiscal year, which will rise to 12bn by 2007/2008. The think-tank has called on the Chancellor to exercise fiscal prudence, and criticised the Chancellor for basing his so-called golden rule on a cycle that can be frequently defined. The golden rule states that the Government will only borrow to invest over the course of the economic cycle. In June 2005, government borrowing rose to 5.9bn, which is the highest June figure since records began. (The full version of the Review is available from www.niesr.ac.uk.)
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NHS Funding
Unlike any other healthcare system, healthcare in the UK is funded from general taxation and, as such, is strongly linked to the performance of the economy.
Funding Crisis
According to the Health Inspectorate, around a third of trusts failed to balance their books in 2004 and nearly a quarter of primary care bodies showed large deficits in spite of significant increases in public spending.
SOCIAL FACTORS
Demographic Trends
The UK population is continuing to age demographically, with those of pensionable age projected to rise to 21.4% of the population by 2026, compared with 18.4% in 2002 (see Table 1.11 in Chapter 1 Market Overview). This will have far-reaching consequences for the health service and social services, as demand for treatment and support rises.
Care in the Community

Traditionally, women have been the carers in society and the majority of carers for elderly relatives are women. However, as a growing number of women continue to work while raising a family and, as family members continue to move further afield for employment purposes, these traditional roles are beginning to be eroded, with significant consequences for the social care of the elderly in the community. In addition, as many people live to greater ages, many children themselves become too infirm to care for their parents.
Obesity
According to the Health Survey for England, childhood obesity has risen significantly between 1995 and 2003 the prevalence of obesity among children aged between 2 and 10 years rose from 9.9% to 13.7%, while the proportion of children who were overweight rose from 22.7% to 27.7%. Levels of obesity were significantly higher in lower-income households and areas of deprivation. These findings have serious implications for the future health of the population, as obesity has been linked to many health problems, including diabetes and circulatory disease. Many obese children face a lifetime of ill health and a premature death.
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Severe Acute Respiratory Syndrome, Bird Flu and the Risk of Travel
The recent outbreaks of severe acute respiratory syndrome (SARS) and Asian bird flu have demonstrated the speed that epidemics can move around the world, facilitated by social mobility and modern air travel. The World Health Organization (WHO) has reported that the world is long overdue for a major flu pandemic, following the pandemic in 1918, which killed more than 18 million people worldwide. There is concern that the Asian flu could easily mutate, giving rise to human-to-human transmission. With a reported mortality rate of 70%, a pandemic could be devastating. There has been widespread concern that the UK Government has been complacent about this possibility compared with other countries, which have laid in stocks of vaccine and anti-flu treatments. To date, the UK has only stockpiled treatments for use by key personnel.
Treatment of the Terminally Ill

In July 2005, the Appeal Court overturned a landmark ruling that General Medical Council (GMC) guidelines for the treatment of the terminally ill were unlawful. The original judgement was made as the result of a case brought by a terminally ill patient, who was concerned that doctors might end his life prematurely by withdrawing food and water when he had reached a state that he could no longer communicate with them. This ruling was hailed as a landmark by disability rights campaigners, patient interest groups and right-to-life organisations. The Appeal Court ruled that although the GMC guidelines were not clearly worded, they were not unlawful. It ruled that the patient was sufficiently protected by ordinary law, which would rule that any doctor withdrawing treatment from a mentally competent patient would be guilty of murder.
Smoking Trends
The Government has claimed success for its initiatives after a rise in the number of people quitting smoking in 2004/2005 was announced DoH figures claim that 300,000 people (56%) were not smoking 4 weeks after announcing the decision to stop, compared with only 205,000 in the previous year, representing a 45% rise. Many of these had used nicotine-replacement therapies. The Government is currently trying to introduce a ban on smoking in public places, with the exception of public houses not serving food, which is receiving varying amounts of hostility from a number of interest groups.
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Tuberculosis
According to the WHO, cases of tuberculosis (TB) in England have risen by 25% since 1994, prompting fears of its emergence within the general population. However, between 2002 and 2003, the number of reported cases of TB fell by 5.2% (see Table 1.16 in Chapter 1 Market Overview). Antibiotic resistance is also making TB far more difficult to treat effectively.
Protection From Poor Doctors

The GMC has announced that NHS managers should do more to protect patients from the actions of rogue doctors, following a number of high-profile scandals and enquiries. The GMC has been stung by criticism that its system of self-regulation is protecting doctors at the expense of patients. The GMC has countered these claims by stating that it has streamlined procedures to remedy failures in the system. However, the Government has ordered a comprehensive review of the system of self-regulation.
TECHNOLOGICAL FACTORS
Technological Advances in Medical Treatment
The healthcare market is a technology-driven one, with new treatments and procedures continually pushing forward the possibilities and boundaries of care. However, these new opportunities often come at an increased cost, applying further pressure on stretched health budgets. Conversely, certain technologies might actually reduce costs, with technologies such as keyhole surgery reducing patient recovery times and allowing for increased throughput of patients. Others can create ethical dilemmas, with significant controversy surrounding cloning technologies and stem-cell research.
Digital Technology
In spite of the digital revolution in technology, around 75% of hospital radiology departments still use X-ray equipment with 19th century photographic technology. The DoH has set a deadline for electronic X-rays to become available in all units, but many healthcare professionals have been resisting the call to move to digital technology. Costs could be significantly reduced, as the NHS has negotiated special deals for bulk provision of pictures archiving and communications systems (PACs) technology as part of the national programme for IT. However, only three hospitals have installed the new technology so far. Hospitals are reluctant to pay out the initial 5m startup costs, even though savings of 1m a year could be made. Clinicians are reluctant to remove technology that they are comfortable with.
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Drug Resistance
Health watchdogs have voiced concern that viruses are now becoming resistant to drugs in a similar way to bacteria. Research has shown that 27% of patients with human immunodeficiency virus (HIV) become resistant to at least one or the triple cocktail of drugs that they receive within 5 years. Similarly, up to 20% of patients with hepatitis B are becoming resistant to standard treatments. The WHO is also monitoring anti-flu treatments, although resistance is reported to be under 1%.
Measles, Mumps and Rubella

Following concerns over the safety of the MMR vaccine, there has been a fall in its uptake, with only four out of five children having the vaccination before the age of 2. Although the research that casts doubts on the safety of the vaccine has been largely discredited, many parents remain concerned over its safety. Uptake in London has been particularly low, at under 60% in some areas. The WHO recommends uptake of 95% to prevent outbreaks of the disease and there have already been reports of mumps outbreaks in schools in 2005.
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INTRODUCTION
In order to understand public attitudes towards healthcare issues, Key Note commissioned exclusive consumer research for this report. The research was conducted by BMRB Access between 28th April and 4th May 2005 among 1,010 adults aged 15 and over.
CONSUMER PROFILE
Respondents were asked the following question: Thinking about the last 12 months, which, if any, of these statements apply to you?
took out/renewed private medical insurance (PMI) had NHS surgery had cosmetic surgery consulted a general practitioner (GP) (once/more than once) called a GP out of hours (once/more than once) consulted NHS Direct (once/more than once) visited a hospital casualty department was referred to a specialist/consultant used over-the-counter (OTC) medicines used herbal/alternative medicines regularly took vitamins/minerals/supplements visited a dentist had a routine eye examination consulted an osteopath consulted a chiropractor had physiotherapy none of the above.
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Healthcare Market
In terms of usage and access to healthcare services, 75% of respondents said that they consulted a GP at least once in the previous 12 months, indicating that the GP remains firmly in the front line and is a gateway to healthcare services. Significantly more women (81%) than men (69%) accessed GP services in the last 12 months, and they were also more likely (52%) than men (38%) to have consulted a GP more than once. The second most frequently used service was that of dentistry, with over half (53%) of respondents having visited a dentist in the last 12 months (this is interesting in light of the well-publicised problems in finding/accessing NHS dentists). Again, significantly more women (58%) than men (47%) visited a dentist in this period. Just over a third (34%) of respondents used OTC medicines in the last 12 months again, more women (38%) than men (29%) did so indicating that self-medication is a vital part of healthcare in the UK today. However, the frequency of GP visits would seem to indicate that OTC medicines complement GP-based care rather than replace it. Another third (33%) of respondents had a routine eye examination in the previous 12 months. In contrast to the 34% of respondents who used OTC medicines, 14% of respondents used herbal or alternative medicines, with women (at 19%) more than twice as likely as men (at 9%) to have used them. In terms of accessing secondary (hospital-based) care services, 10% of respondents had NHS surgery in the previous year, while 20% visited a hospital casualty department. Just over a fifth (22%) of respondents were referred to a consultant or specialist within the last 12 months. There was very little enthusiasm among respondents for cosmetic surgery, with only 1% of respondents intriguingly all men admitting to having had any procedures in the previous 12 months. Only 8% of respondents took out or renewed PMI. In terms of remedial care, most patients (8%) were referred to physiotherapists, with comparatively few consulting an osteopath or chiropractor (both 2%). This might be due partly to the comparatively wide availability of physiotherapy services that are also well integrated into the NHS, whereas osteopathy and chiropractic services are mostly based in the private sector. When examining the summary data, it is evident that women are more likely than men to use healthcare services, particularly in consulting GPs, having NHS surgery and in their use of OTC medicines, alternative/herbal medicines and in regularly taking vitamins, minerals and supplements. Women were also more likely than men to visit dentists and have eye examinations, consult NHS Direct, visit a casualty department and call a GP out of hours. This builds up the strong picture that women are significantly more active in promoting their own health, using self-medication and seeking medical attention for themselves as well as for their families.
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Table 3.1: Summary of Consumer Profile (% of respondents), 2005

Thinking about the last 12 months, which, if any, of these statements apply to you?
All
Took out/renewed private medical insurance Had NHS surgery Had cosmetic surgery
Male 8 9 1
Female 8 12 0
8 10 1
Consulted a GP
Once More than once Once or more
30 45 75
31 38 69
29 52 81
Called a GP out of hours

Once More than once Once or more
7 2 9
5 2 7
9 2 11
Consulted NHS Direct

Once More than once Once or more Visited a hospital casualty department Was referred to a specialist/consultant Used OTC medicines Used herbal/alternative medicines Regularly took vitamins/minerals/ supplements Visited a dentist Had a routine eye examination
11 4 15 20 22 34 14 21 53 33
9 2 11 19 21 29 9 14 47 30
13 6 19 21 22 38 19 26 58 36
Table continues...
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Table 3.1: Summary of Consumer Profile (% of respondents), 2005

...table continued
Thinking about the last 12 months, which, if any, of these statements apply to you?
All
Consulted an osteopath Consulted a chiropractor Had physiotherapy None of the above
OTC over-the-counter Weighted sample: 1,010
Male 1 1 7 10
Female 2 2 8 4
2 2 8 7
Base: All adults aged 15+
Source: BMRB Access April/May 2005
Thinking About the Last 12 Months, Which, if Any, of These Statements Apply to You?
Took Out/Renewed Private Medical Insurance
8% of all respondents took out or renewed PMI in the previous 12 months. Although there were no gender differences, there were marked variations between the different age groups. The lowest rates of uptake of PMI were seen in the younger age groups, particularly among 15 to 24 year-olds, at only 3%. Many people in this age group are still dependants of their parents, so are covered by any family policies. In addition, many younger people are still in full-time education or starting out on their career pathways. In any case, health concerns tend to be low in these age groups and among lower earners than those who are established in their careers and are less likely to have dependants. Uptake of PMI rose with the age of respondents, charting their changing priorities as they get older, becoming more established in their careers and increasing commitments with families. As people enter the middle age groups, uptake will increase as the pressures and costs of young families and new mortgages begin to ease. In addition, as people age, their concerns over their health and healthcare increase. The largest proportion of respondents (12%) took out or renewed PMI in the 55 to 64 year-old age group, before dropping slightly among the 65 and over age group to 10%. This might be because of the financial constraints of pensioners and the rising costs of medical insurance premiums in the elderly.
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There were very marked differences between the different social grades, with by far the highest uptake (17%) seen in the higher-earning ABs, dropping to 7% and 6% among C1s and C2s, respectively, and being the lowest in the lower-earning Ds and Es, at 2%. Apart from the higher earnings in the ABs, these types of professionals tend to work for companies/organisations that are more likely to include PMI as a perk of employment and to have this benefit as part of their employment conditions. There were also regional differences in the uptake and renewal of PMI in the last 12 months, which might reflect the nature of employment in particular regions and possibly also the degree of concern or satisfaction over the quality and availability of healthcare services in those regions. The highest levels of uptake (12%) were seen in East Anglia and the North West, closely followed by Wales (at 11%). The lowest level of uptake/renewals in the last 12 months (at 1%) was observed in the North, which perhaps reflects the industrial nature of the area, levels of unemployment and the relative salary sizes in the region. There were also slight differences depending on the working status of respondents, with retired people having the highest levels of uptake of PMI, at 11%. This might reflect the older ages of this group of respondents and the likelihood that they have less in the way of commitments (e.g. mortgages and children). Lowest levels were seen among those not working (5%), possibly reflecting lower incomes (i.e. unemployed). The survey also indicated higher levels of uptake in two- or one-person households, at 10% and 9%, respectively. This might reflect higher levels of income in single- or two-earner households without dependants. Similarly, widowed respondents recorded a slightly higher level of uptake (at 11%), reflecting their older age profile and lack of dependants. In addition, separated respondents recorded a high level of uptake/renewals (also at 11%), perhaps partly reflecting the unresolved nature of this groups financial situation and commitments. Uptake/renewal of PMI in the last 12 months was also slightly higher in households without children (9%) with corresponding higher levels of disposable income and among respondents who are house owners (8% and 11%), who are more likely to have higher salaries. At 1%, uptake/renewal was lowest among respondents living in council properties.
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Table 3.2: Penetration of Taking Out/Renewing Private Medical Insurance in the Last 12 Months (% of respondents), 2005
All adults Sex Male Female Age 15-24 25-34 35-44 45-54 55-64 65+ Social Grade AB C1 C2 D E Region London South East South West Wales East Anglia East Midlands West Midlands Yorkshire and Humberside North West North Scotland Working Status Full time Part time Not working Retired Table continues... 8 8 5 11 7 9 4 11 12 9 9 5 12 1 6 17 7 6 2 2 3 5 7 9 12 10 8 8 8
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Table 3.2: Penetration of Taking Out/Renewing Private Medical Insurance in the Last 12 Months (% of respondents), 2005
...table continued Size of Household 1 2 3 4 5+ Marital Status Married Single Divorced Widowed Separated Presence of Children Aged 0-4 Aged 5-9 Aged 10-15 Any aged 0-15 None Tenure Owned with a mortgage/loan Owned outright Rented from the council Rented from someone else Rent-free from the council Rent-free from someone else
Weighted sample: 1,010
9 10 8 5 4 9 4 2 11 11 4 4 6 5 9 8 11 1 5 Base: All adults aged 15+
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Had NHS Surgery

10% of respondents claimed to have had NHS surgery in the previous 12 months and there were some gender differences, with 12% of women having had NHS surgery, compared with 9% of men. The reasons for this are complex, but can be partly explained by womens greater willingness to seek medical assistance for problems and the fact that there are a greater number of elderly women than elderly men. In addition, there are large number of gynaecological problems that may require surgery, which men are not subject to. There are significant age differences among respondents who have had NHS surgery in the last 12 months, with the highest levels of surgery seen in the oldest group 65 and over at 15%. This is mainly the result of conditions associated with the ageing process. At 12%, the second-highest penetration levels were recorded in the youngest age group 15 to 24 year-olds possibly reflecting their more active lifestyles (e.g. sporting activities, etc.). There were also some very marked regional differences, with the highest levels seen in East Anglia (17%) and Wales (16%), and the lowest levels in London and Scotland (both 6%), possibly reflecting the nature of employment in those regions: hard manual work in industry or agriculture is far more likely to generate injury and wear and tear than office-based work. Environmental and dietary factors could also play a part in the varying rates of surgery in different regions. Retired workers and respondents not working recorded higher levels of NHS surgery in the last 12 months compared with full-time workers. This is likely to reflect the elderly profile of respondents in the retired group and the higher levels of ill health in the not working group, which may contain respondents not working for health reasons, or the unemployed with associated health issues. At 11%, levels of NHS surgery in the last 12 months were only slightly lower in part-time workers, who are traditionally more likely to be women with their higher levels of surgery and also people working on a part-time basis for health reasons. At 13%, widowed respondents also recorded higher levels of surgery than other marital status groups, which is likely to reflect the elderly profile of this particular group. Respondents renting council properties also had high levels of NHS surgery in the last 12 months (at 14%), potentially reflecting the physical nature of their employment and, possibly, some of the health problems associated with poverty caused by environmental, social and dietary factors.
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Table 3.3: Penetration of Having NHS Surgery in the Last 12 Months (% of respondents), 2005
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Table 3.3: Penetration of Having NHS Surgery in the Last 12 Months (% of respondents), 2005
...table continued Size of Household 1 2 3 4 5+ Marital Status Married Single Divorced Widowed Separated Presence of Children Aged 0-4 Aged 5-9 Aged 10-15 Any aged 0-15 None Tenure Owned with mortgage/loan Owned outright Rented from the council Rented from someone else Rent-free from the council Rent-free from someone else
11 11 12 10 7 10 11 6 13 8 12 9 10 11 10 9 10 14 12 11 Base: All adults aged 15+
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Had Cosmetic Surgery

Only 1% of respondents admitted to having had cosmetic surgery in the previous 12 months and these were all men. Very little of any significance can be deduced from such a low response rate, but the majority of respondents that admitted to having had cosmetic surgery in the last 12 months were clustered in East Anglia (5%) and Wales (3%).
Table 3.4: Penetration of Having Cosmetic Surgery in the Last 12 Months (% of respondents), 2005
All adults Sex Male Female Age 15-24 25-34 35-44 45-54 55-64 65+ Social Grade AB C1 C2 D E Region London South East South West Wales East Anglia East Midlands West Midlands Yorkshire and Humberside North West North Scotland Table continues... 0 0 3 5 1 1 1 1 1 0 1 1 1 0 1 0 1
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Table 3.4: Penetration of Having Cosmetic Surgery in the Last 12 Months (% of respondents), 2005
...table continued Working Status Full time Part time Not working Retired Size of Household 1 2 3 4 5+ Marital Status Married Single Divorced Widowed Separated Presence of Children Aged 0-4 Aged 5-9 Aged 10-15 Any aged 0-15 None Tenure Owned with mortgage/loan Owned outright Rented from the council Rented from someone else Rent-free from the council Rent-free from someone else
1 1 0 0 1 1 2 0 1 1 2 1 0 1 0 1 Base: All adults aged 15+
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Consulted a General Practitioner

According to the survey, the majority of respondents (75%) consulted a GP at least once in the last 12 months. Just under a third (30%) of all respondents consulted a GP once in the previous 12 months, compared with 45% who consulted a GP more than once. There were marked gender differences, with 81% of women consulting a GP, compared with only 69% of men. More than half (52%) of women consulted a GP more than once, compared with 38% of men. There were also marked differences between the age groups, particularly with respondents who consulted a GP more than once. As might be expected, the older age groups were most likely to have consulted a GP in the previous 12 months, ranging from 85% of respondents in the 65 and older age group to 88% of respondents in the 55 to 64 year-old group. This compares with 60% of 15 to 24 year-olds. In addition, 57% of respondents aged over 55 had consulted a GP more than once, compared with only 33% of 15 to 24 year-olds. This demonstrates the extra pressures put on the health service as a result of the demographically ageing population, caused by chronic diseases and conditions associated with the ageing process. The patterns observed between the different social grades are also interesting. The comparatively affluent ABs (at 35%) were most likely to have consulted a GP once over the last 12 months, whereas respondents in social grade E were the least likely (19%). However, the Es were the group most likely to have consulted a GP more than once (64%), followed by the ABs (46%). This would seem to indicate a significantly different pattern of use between those groups. If it was simply a question of greater ill health resulting in a greater need to consult a GP, then one might expect the more prosperous ABs to have the lowest overall levels of consulting a GP, rather than being second highest at 81%. Possibly, ABs are more assertive and proactive in seeking medical help than the other groups, which could also explain them having the highest levels for consulting a GP once. The fact that Es are far more likely to consult a GP more than once could indicate a greater likelihood of chronic conditions and ill health in this group associated with poverty, poor diet and bad housing. However, it is not possible to establish these facts without further detailed research. There were also significant regional variations. In particular, respondents in the North were least likely to have consulted a GP once in the previous 12 months (at only 10%) but, in contrast, 52% were likely to have consulted a GP more than once, lower only than the South West (54%) and Yorkshire and Humberside (53%). Yorkshire and Humberside had the highest overall levels at 85%. London had the lowest levels both overall (63%) and for consulting a GP more than once (30%). The reasons for these variations are not clear, but are likely to be the result of a complex mix of environmental and social factors, including the nature of employment and the availability and accessibility of GP services.
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In terms of working status, the highest levels of response were seen among retired respondents, of whom 88% had consulted a GP at least once in the last 12 months and 56% had consulted a GP more than once. This is consistent with the elderly profile of this group. Part-time workers and those not working (excluding retired) gave higher results than those working full time. Full-time workers are most likely to be younger and in good general health. Many part-time workers are women, who are more likely to consult a GP, and those not working may not be doing so for reasons of health or may suffer health, mental and social problems as the result of unemployment. In terms of household size, one-person households were most likely to have consulted a GP at least once in the last 12 months (86%) and more than once (56%). This group is likely to contain a significant number of elderly people. Similarly, widowed respondents were also most likely to have consulted a GP, at 87%, and 64% of these had consulted a GP more than once. Respondents who owned their houses outright (who are likely to be elderly, having paid off a mortgage) were also more likely to have consulted a GP (at 82%) and half (50%) had consulted a GP more than once. Similarly, respondents living rent-free (not from the council) were most likely to have consulted a GP (84%) and 53% did so more than once.
Table 3.5: Penetration of Consulting a General Practitioner in the Last 12 Months (% of respondents), 2005
Not Consulted a GP 25 31 19 40 28 28 27 12 15
Once
All adults
More Than Once 45 38 52 33 44 38 42 57 57
At Least Once 75 69 81 60 72 72 73 88 85
30 31 29 27 28 34 31 31 28
Sex
Male Female
Age
15-24 25-34 35-44 45-54 55-64 65+
Table continues...
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...table continued Not Consulted a GP
Once Social Grade

AB C1 C2 D E
More Than Once
At Least Once
35 33 29 26 19 33 32 23 38 24 25 31 32 35 10 34 31 33 25 32 30 32 29 32 23
46 44 41 40 64 30 48 54 42 52 45 47 53 36 52 48 35 45 53 56 56 48 43 38 37
81 77 70 66 83 63 80 77 80 76 70 78 85 71 62 82 66 78 78 88 86 80 72 70 60
19 23 30 34 17 37 20 23 20 24 30 22 15 29 38 18 34 22 22 12 14 20 28 30 40
Region
London South East South West Wales East Anglia East Midlands West Midlands Yorkshire and Humberside North West North Scotland
Working Status
Full time Part time Not working Retired
Size of Household
1 2 3 4 5+
Table continues...
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...table continued Not Consulted a GP
Once Marital Status

Married Single Divorced Widowed Separated
More Than Once
At Least Once
32 30 27 23 22 32 30 24 29 31
46 36 46 64 41 45 49 44 44 46
78 66 73 87 63 77 79 68 73 77
22 34 27 13 37 23 21 32 27 23
Presence of Children
Aged 0-4 Aged 5-9 Aged 10-15 Any aged 0-15 None
Tenure
Owned with mortgage/loan Owned outright Rented from the council Rented from someone else Rent-free from the council Rent-free from someone else
30 32 26 31 31
43 50 47 40 46 53
73 82 73 71 46 84
27 18 27 29 56 16
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Called a General Practitioner Out of Hours

According to the survey, 9% of respondents called a GP out of hours at least once in the last 12 months. Of the respondents, 7% called a GP once, while 2% called a GP more than once. Women (11%) were more likely than men (7%) to have called a GP out of hours at least once in the last 12 months, but only 2% of either men or women had done so more than once. There were some marked differences between the age groups, with the older age groups being less likely to have called a GP out of hours. The reasons for this are not clear; possibly the younger age groups are more likely to be working full time so are less able to seek help during the day. Alternatively, there could be cultural factors, with older people perhaps less willing to cause inconvenience. Another strong factor contributing to the younger age groups calling GPs out of hours more frequently is the likely presence of young children. This is borne out by the high levels of call-outs in households with children, particularly those with children aged between 0 and 4 years (15%) and 5 to 9 years (13%). In contrast, households without children had a call-out rate of only 8%. The presence of children made no significant difference to the likelihood of calling a GP out of hours more than once in the last 12 months. There were marked regional differences, with the highest rates of call-out observed in Wales (19%), followed by East Anglia and the South West (both 14%). The lowest levels were recorded in London, the West Midlands and the North West (all 5%). In terms of calling a GP out of hours more than once, there was far less difference between the regions. The reasons for these regional differences are not clear and a number of factors are likely to be involved. It may depend on the varying availability of services in towns and rural areas, the nature of employment in different regions, and the levels of service available (whether GP practices are oversubscribed, making it difficult to get a timely appointment, or whether there are hospital casualty departments nearby). Divorced respondents were also more likely to have called a GP out of hours in the last 12 months, perhaps reflecting the effects of the stresses of divorce on families. There also appeared to be marked differences between respondents in terms of tenure. In general, those renting (particularly from the council) appeared to be more likely to call a GP out of hours in the last 12 months. A number of factors might be involved in this, including the effects of poverty on poor health, the availability of services and possibly the fact that many people on council estates, particularly women and the elderly, are nervous about going out at night. Respondents living rent-free in council property appeared most likely to call out a GP more than once, possibly reflecting the high numbers of ill or disabled people living on benefits with chronic health problems in this group.
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Table 3.6: Penetration of Calling a General Practitioner Out of Hours in the Last 12 Months (% of respondents), 2005
More Than Once All adults Sex Male Female Age 15-24 25-34 35-44 45-54 55-64 65+ Social Grade AB C1 C2 D E Region London South East South West Wales East Anglia East Midlands West Midlands Yorkshire and Humberside North West North Scotland Table continues... 4 7 13 14 9 5 5 8 5 8 4 1 1 1 5 5 4 5 5 5 8 14 19 14 9 5 13 5 8 9 6 6 9 7 5 1 2 1 3 5 7 8 10 10 10 6 11 8 4 5 7 4 1 3 1 3 1 10 12 11 5 8 8 5 9 2 2 7 11 7 Once 2 At Least Once 9
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Table 3.6: Penetration of Calling a General Practitioner Out of Hours in the Last 12 Months (% of respondents), 2005
...table continued More Than Once At Least Once
Once Working Status Full time Part time Not working Retired Size of Household 1 2 3 4 5+ Marital Status Married Single Divorced Widowed Separated Presence of Children
6 9 7 6 4 8 6 8 6 8 4 9 4 5 12 11 8 9 6 7 5 6 12 -
2 1 3 2 3 1 3 3 1 2 1 5 3 3 2 3 3 2 2 1 6 1 11 Base: All adults aged 15+
8 10 10 8 7 9 9 11 7 10 5 14 7 5 15 13 11 12 8 9 6 12 13 11 -
Tenure Owned with mortgage/loan Owned outright Rented from the council Rented from someone else Rent-free from the council Rent-free from someone else
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Consulted NHS Direct

According to the survey, 15% of respondents consulted NHS Direct at least once in the last 12 months, while only 4% consulted NHS Direct more than once. There were gender differences, with 19% of women consulting NHS Direct at least once in the last 12 months, compared with 11% of men. As the major carers, women are more likely than men to consult NHS Direct on behalf of children or other dependants. There were also certain age differences, with the highest levels of consultation seen among 25 to 34 year-olds, with 24% of respondents in this group having consulted NHS Direct at least once in the last 12 months. This age group possibly contains comparatively high numbers of respondents with young children. Lowest levels of consultation were observed in the 65 and older age group, with 7% of respondents having consulted NHS Direct at least once over the previous 12 months. Variation according to social grade was not particularly significant, although the C1s appeared slightly more likely than other groups (at 19%) to have consulted NHS Direct at least once. Regional variations were also slight, with respondents living in the South West (22%) and the North (20%) slightly more likely to have consulted NHS Direct at least once in the last 12 months. Respondents in these regions were more likely to have consulted NHS Direct once in the last 12 months, rather than on multiple occasions. In terms of working status, part-time workers (25%) and those not working (19%) were the most likely to have consulted NHS Direct in the last 12 months, possibly because these groups contain a high proportion of women, mothers and carers. Retired respondents were least likely to have consulted NHS Direct, again possibly reflecting the older age profile of this group. Households containing one or two people were less likely to have consulted NHS Direct, as were widowed respondents. The latter is likely to reflect the older age profile of this group. Households with children were significantly more likely to have consulted NHS Direct at least once in the last 12 months (25%) compared with those with no children (11%). In particular, at 33%, those with infants under 4 years of age were most likely to have consulted NHS Direct in the last 12 months. These levels reflect the anxieties of parents with young children.
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Table 3.7: Penetration of Consulting NHS Direct in the Last 12 Months (% of respondents), 2005
More Than Once
All adults
At Least Once 15 11 19 17 24 19 13 15 7 14 19 14 14 13 14 16 22 15 15 13 16 11 17 20 13
Once 4 2 6 7 7 7 1 4 1 3 6 4 3 4 2 6 6 6 6 2 5 2 4 6 4
11 9 13 10 17 12 12 11 6 11 13 10 11 9 12 10 16 9 9 11 11 9 13 14 9
Sex
Male Female
Age
15-24 25-34 35-44 45-54 55-64 65+
Social Grade
AB C1 C2 D E
Region
London South East South West Wales East Anglia East Midlands West Midlands Yorkshire and Humberside North West North Scotland
Table continues...
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Table 3.7: Penetration of Consulting NHS Direct in the Last 12 Months (% of respondents), 2005
...table continued More Than Once At Least Once
Once Working Status

Full time Part time Not working Retired
9 18 14 7 6 9 14 16 13 14 6 15 4 12 22 19 15 17 8 13 9 13 10 11 17
4 7 5 2 2 3 7 4 6 5 3 3 11 8 4 8 3 4 2 5 9 -
13 25 19 9 8 12 21 20 19 19 9 18 4 12 33 27 19 25 11 17 11 18 19 11 17
Size of Household
1 2 3 4 5+
Marital Status
Married Single Divorced Widowed Separated
Presence of Children
Tenure
Owned with mortgage/loan Owned outright Rented from the council Rented from someone else Rent-free from the council Rent-free from someone else
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Visited a Hospital Casualty Department

20% of respondents visited a hospital casualty department in the last 12 months, with little difference between men (19%) and women (21%). However, there were significant differences between the age groups, with the highest levels of visits recorded in the younger age groups 15 to 24 year-olds (25%) and 25 to 34 year-olds (23%). This could possibly reflect the more active lifestyles of these groups, who would be more prone to injuries through their leisure pursuits. Young people are more likely to be out at night drinking and perhaps involved in incidents associated with this, such as fights. In addition, these age groups are more likely to be less settled in their lifestyles (through education and work) and perhaps less likely to have registered with a GP. In contrast, the lowest levels of visits to a hospital casualty unit were seen in the 65 and over age group, at 15%. This age group is likely to have more sedentary lifestyles and be under the care of a GP. There was little variation between the social grades, although the ABs were slightly less likely to visit casualty departments, perhaps because of the nature of their employment compared with other social groups who are likely to be involved in more physically active forms of work. There were also regional variations, with the lowest levels of visiting seen in the West Midlands (12%) and East Anglia (13%), and the highest in Wales (37%) and Scotland (28%). These variations could partly be explained by the types of employment in these regions, differing proportions of ethnic minorities, social factors and the availability and access to other forms of medical care in the region, such as GP services and clinics. Households with four people were also slightly more likely to have visited a hospital casualty department in the last 12 months. At 29%, respondents who were separated were also more likely to have visited a hospital casualty department, which is possibly explained by their unsettled transitional lifestyle. As might be expected, families with children, particularly infants aged 4 years and under (at 26%), were more likely than households without children (18%) to have visited a hospital casualty department in the last 12 months. In addition, home owners with mortgages/loans (at 25%) were more likely than respondents with other types of tenure particularly owning their home outright or rent-free from the council to have visited a casualty department. Households with mortgages are likely to represent a high proportion of households with young children, whereas homes that are owned outright are likely to represent high numbers of older people.
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Table 3.8: Penetration of Visiting a Hospital Casualty Department in the Last 12 Months (% of respondents), 2005
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Table 3.8: Penetration of Visiting a Hospital Casualty Department in the Last 12 Months (% of respondents), 2005
17 19 21 26 17 22 17 14 21 29 26 24 23 24 18 25 15 19 20 16 17
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Was Referred to a Specialist/Consultant

22% of all respondents were referred to a specialist or consultant in the last 12 months, with little difference between men (21%) and women (22%). There were, however, significant differences between the age groups, with the lowest levels of referral seen in the youngest age groups 18% among 15 to 24 year-olds and 14% among 25 to 34 year-olds who are less likely to have significant/chronic health problems. In contrast, the highest levels of referral were seen in the oldest age groups 55 to 64 year-olds and 65s and over (both 29%). This is consistent with the increased incidence of many medical disorders in older people, such as cancer, cardiovascular disease, central nervous system disease and musculoskeletal disorders. At 25%, the AB social grade was also more likely than the other social groups to have had referrals, perhaps indicating a greater assertiveness and awareness of their health problems or better access to primary care services. There were marked regional differences, with the highest levels of referral recorded in the South East (28%), compared with only 13% in London and 15% in the North West. There are many possible factors contributing to these regional differences, ranging from types of employment, access to primary care services, waiting lists and pressures on secondary care services, as well as the ethnic make-up of the regional population and the particular social and medical problems associated with these groups. Language barriers and cultural pressures might make it difficult for certain groups to access care services. In terms of working status, retired respondents (generally older) were more likely to have been referred (at 31%), compared with the other groups, particularly those working full time and those not working (both 17%). Part-time workers also had relatively high rates (27%); perhaps a proportion of these were older people winding down for retirement or those working limited hours for health reasons. Similarly, widowed respondents (at 28%), who are also more likely to be elderly, were likely to have higher levels of referral compared with single respondents (17%), who are more likely to be made up of the younger age groups. People living in properties that are owned outright (and also more likely to be in the older age groups) had higher levels of referral than respondents living in private rentals (who are more likely to be in the younger age groups).
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Table 3.9: Penetration of Being Referred to a Specialist/ Consultant in the Last 12 Months (% of respondents), 2005
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Table 3.9: Penetration of Being Referred to a Specialist/ Consultant in the Last 12 Months (% of respondents), 2005
23 26 21 20 11 23 17 18 28 22 16 16 21 18 23 21 25 23 14 19 15
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Used Over-the-Counter Medicines

According to the survey, over a third (34%) of respondents used OTC medicines in the last 12 months. There were significant gender differences, with 38% of women having used OTC medicines, compared with 29% of men. There were also significant differences between the various age groups, with the lowest levels of use recorded among 15 to 24 year-olds (15%) and the highest levels of use seen in the middle age groups (34% to 40%). A high proportion of the UK population are exempt from paying prescription charges and, as a result, are less likely to use OTC medicines that they will have to pay for. Exempt groups include pensioners, people with chronic disorders, children and young people in full-time education, who would be included in the 15 to 24 year-old age group. There were also differences between the various social grades, with ABs (at 42%) being far more likely than the other groups to use OTC medicines. The relative affluence of this group means that cost is less likely to be a consideration when weighed against convenience. In addition, ABs are more likely to be proactive in their own healthcare. In terms of working status, part-time workers (at 48%) were far more likely than others to have used OTC medicines. These high levels of use are consistent with the high proportion of women and older people in these particular groups, who are both far more likely to use OTC medicines than other groups. There were significant regional differences in the use of OTC medicines in the last 12 months, with the highest levels of use recorded in East Anglia where almost half (48%) of respondents had used them and the North (44%), followed by the East Midlands and the South West (both 43%). The lowest levels of use were in the North West (24%) and London (18%). Factors contributing to this difference include the proportion of the population exempt from prescription charges, access to primary care services and the proportion of ethnic minorities and their ability to access healthcare services. According to the survey, households with five or more people were less likely to use OTC medicines than other households, possibly because this group has high numbers of younger people or people who are exempt from paying prescription charges. In terms of marital status, divorced respondents were the highest users of OTC medicines in the last 12 months, while single respondents were the lowest users. Households without children also appeared slightly less likely than others to have used OTC medicines in the last 12 months. In terms of tenure, respondents living rent-free in private accommodation were least likely to have used OTC medicines (21%), possibly because of the high proportion of younger people in this group, followed by those living in rented council accommodation.
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Table 3.10: Penetration of Using Over-the-Counter Medicines in the Last 12 Months (% of respondents), 2005
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Table 3.10: Penetration of Using Over-the-Counter Medicines in the Last 12 Months (% of respondents), 2005
34 36 35 33 24 37 23 50 31 34 40 41 33 38 31 39 33 24 29 49 21
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Used Herbal/Alternative Remedies

Of all the respondents in the survey, 14% used herbal/alternative remedies in the last 12 months. There were marked gender differences in usage, with 19% of women having used these remedies in the last 12 months compared with only 9% of men. There were also some age-related differences, with the highest levels of use among 55 to 64 year-olds, at 21%, and lowest use among 15 to 24 year-olds, at 8%. This might partly be because of the fewer health problems seen in that age group generally and possibly because many respondents in that group would be exempt from paying prescription charges for conventional medicine. There were also marked differences between the social grades, with the highest levels of use seen in the AB social grade (at 23%), compared with 8% among C2s and 6% among Ds. Again, this reflects the relative affluence of the ABs and their relative greater use of OTC medicines in general. In contrast, the lower use in the other groups may be at least partly explained by sensitivity to costs and the exemption of significant numbers of respondents from prescription charges for conventional medicine. There were also significant regional differences, with the highest levels of use observed in the South West (25%) and Scotland (23%), and the lowest levels seen in the North (6%) and the East Midlands (5%). There might be a number of factors contributing to these differences, ranging from availability and accessibility, and the corresponding costs and availability of conventional medicines, together with cultural and social factors. At 21%, part-time workers were more likely to have used herbal/alternative remedies in the last 12 months, which is consistent with the high number of women who work part time. The lowest level of usage was recorded among respondents who work full time. Households with five or more people were far less likely (at 6%) than the other groups to have used these remedies, possibly for economic reasons. Similarly, respondents who were separated (5%) or single (7%) were far less likely than divorced respondents (at 25%) to have used herbal alternative remedies in the last 12 months. Higher levels of use were also seen in respondents who are outright owners of their houses (18%) and those with mortgages (16%), perhaps reflecting their relative affluence.
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Table 3.11: Penetration of Using Herbal/Alternative Remedies in the Last 12 Months (% of respondents), 2005
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Table 3.11: Penetration of Using Herbal/Alternative Remedies in the Last 12 Months (% of respondents), 2005
14 16 16 15 6 17 7 25 12 5 15 13 9 14 15 16 18 8 8 Base: All adults aged 15+
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Regularly Took Vitamins/Minerals/Supplements

21% of respondents regularly took vitamins, minerals or supplements in the last 12 months and there was a marked gender variation, with 26% of women being regular takers compared with only 14% of men. There was also a degree of variation between the age groups, with the lowest levels of use observed in the youngest age group, while usage increased with age to reach 25% among the 65s and over. There were also slight variations in the different social grades, with the highest usage in the more affluent and health-conscious ABs (25%) and the lowest levels in the less affluent C2s (13%) and Es (17%). There were also significant regional differences, with the highest levels of use in the South East (27%) and the South West (26%), and the lowest levels of use in Scotland (12%) and the North (10%). Cultural and social differences, as well as economic factors, are likely to play a role in these variations. Higher levels of use were also seen among retired respondents (25%), reflecting the age profile of this group, with older respondents more likely to regularly take vitamins, minerals and supplements. Lowest levels of usage were recorded among those not working (15%), which is likely to include respondents who are unemployed and less affluent with economic reasons not to take vitamins, minerals and supplements. The survey also indicated that one-person households were most likely to be regular takers (27%); this group is likely to contain older respondents and respondents with higher disposable income, groups that are both more likely to be regular users. In contrast, the lowest usage was seen in households with five or more people (10%), who are likely to have economic constraints. Over a third (36%) of divorced respondents were regular users of vitamins, minerals or supplements in the last 12 months, compared with only 13% of single respondents (who are likely to have a younger age profile). Slightly higher levels of usage were observed in respondents with houses that were owned outright (24%), a group that is likely to have significant numbers of older people who have paid off their mortgages, in contrast with only 8% of respondents living in private rented properties (who are likely to be young and single, often paying comparatively high rents).
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Table 3.12: Penetration of Regularly Taking Vitamins/Minerals/ Supplements in the Last 12 Months (% of respondents), 2005
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Table 3.12: Penetration of Regularly Taking Vitamins/Minerals/ Supplements in the Last 12 Months (% of respondents), 2005
27 23 21 17 10 21 13 36 25 23 16 15 19 19 21 21 24 15 16 22 8
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Visited a Dentist
Over half (53%) of respondents visited a dentist in the last 12 months. There were some gender differences, with 58% of women having visited a dentist compared with 47% of men. There were also differences between the age groups, with the highest levels in the middle age groups, ranging from 61% to 67%, and the lowest levels in the youngest age group (15 to 24 year-olds, at 39%) and the oldest (those aged 65 and above, at 43%). The costs of dentistry are likely to significantly prevent many people from visiting dentists. In addition, there can be great difficulty in finding an NHS dentist, and both of these factors are likely to deter people on limited incomes. In keeping with this, the highest levels of dental visits were seen among the relatively affluent ABs (65%) and the lowest levels were observed in the E social grade (37%). There were also regional differences, with the highest levels of dental visits seen in the South West (65%) and Scotland (61%), and the lowest levels of visits seen in London (37%). These levels are likely to be dependent on the ease and accessibility of dental services, and shortages of dentists are particularly marked in the London area. In terms of working status, the highest levels of dental visits in the last 12 months were seen among part-time workers (68%) with high numbers of women and middle-aged people and the lowest levels were recorded among older retired respondents (46%) and those not working (47%), who are likely to have financial constraints. Separated and single respondents were far less likely than other groups to have visited a dentist in the last 12 months, at 25% and 38%, respectively. Separated respondents are likely to have financial constraints, while single respondents are likely to be young and move jobs and houses as they continue their education and establish their careers, leading to financial constraints and difficulties in finding an NHS dentist. Similarly, only 27% of those living rent-free from the council have visited a dentist in the last 12 months, probably through a combination of financial constraints and poor access to a dentist. In contrast, higher levels of visits were observed in the more established and affluent home owners with a mortgage (62%) and outright owners (55%).
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Table 3.13: Penetration of Visiting a Dentist in the Last 12 Months (% of respondents), 2005
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Table 3.13: Penetration of Visiting a Dentist in the Last 12 Months (% of respondents), 2005
43 55 52 59 50 61 38 50 40 25 54 58 63 59 50 62 55 35 36 27 44
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Had a Routine Eye Examination

According to the survey, 33% of respondents had a routine eye examination in the last 12 months. There was some degree of gender variation, with 36% of women having had an eye examination in the last 12 months, compared with 30% of men. There were also variations between the different age groups, with levels of visits increasing with age to reach 44% among respondents aged 65 and above, compared with 22% among 15 to 34 year-olds. These levels are consistent with the increasing levels of eye problems associated with ageing, including short-sightedness and the need to screen for glaucoma and other potentially serious age-related problems. In addition, eye tests are free for those of pensionable age. This has resulted in a very different situation than is seen in dentistry, with much greater access to affordable screening and treatment. However, in spite of this, there are still higher levels of visits in the health-aware ABs (at 47%), compared with the other social grades C2s (at 26%) and Ds (at 25%). There were also significant regional differences, with the highest levels in the South West (44%) and the lowest levels in London (22%). Many factors could contribute to these variations, including the availability and accessibility of these services in the different regions, particularly to any ethnic minority populations, as well as the make-up of regional populations. In terms of working status, the highest levels of examinations were observed among the retired (48%) as might be expected compared with only 26% of full-time workers. Lower levels of examinations were seen in households of five or more people (22%) and there were higher levels in two-person households (41%). Higher levels of examinations were seen in divorced respondents (46%) and widowed respondents (45%), while the lowest levels were recorded among single respondents (21%). Slightly higher levels of examinations were seen in households without children (37%), which are likely to comprise older residents. In terms of tenure, higher levels of eye examinations were seen in households owned outright (44%), which are likely to belong to older people who have paid off their mortgages, and the lowest levels, just 8%, were found among those living rent-free in council accommodation. This is a very low level, which should give great concern to welfare and healthcare services.
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Table 3.14: Penetration of Having a Routine Eye Examination in the Last 12 Months (% of respondents), 2005
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Table 3.14: Penetration of Having a Routine Eye Examination in the Last 12 Months (% of respondents), 2005
35 41 30 28 22 36 21 46 45 23 25 27 23 26 37 30 44 28 22 8 41
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Consulted an Osteopath
Only 2% of respondents consulted an osteopath over the last 12 months, and little of significance can be established with such a low response rate in this particular group. In terms of gender differences, 2% of women consulted an osteopath in the last 12 months, compared with 1% of men. There was a small amount of difference between the age groups, with 3% of both 15 to 24 year-olds and 45 to 54 year-olds having consulted an osteopath. This would make sense when taken in context of the more active lifestyles of the young age groups and the greater likelihood of sports-related injuries. Among the 45 to 54 year-olds, wear and tear injuries, such as osteoarthritis, are becoming more evident. Although it is possible to be referred to an osteopath on the NHS, this low response rate, particularly when taken in context of the 8% of respondents who had physiotherapy in the last 12 months (see Table 3.17), would indicate that it is not a very common practice. There were some regional differences observed in the survey, with the highest consultation levels observed in the South West and East Midlands (both 4%), although the differences are probably too slight to be truly significant. Factors involved in regional differences will include availability of and access to osteopath services in conjunction with awareness of the possible benefits of osteopathy. Financial considerations are also a factor, although a number of private healthcare policies allow for limited use of osteopathy and other complementary therapies. Slight differences were also observed according to marital status, with widowers recording a slightly higher response rate (4%), which is in keeping with the older age profile of this group and the higher concentration of women.
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Table 3.15: Penetration of Consulting an Osteopath in the Last 12 Months (% of respondents), 2005
All adults Sex Male Female Age 15-24 25-34 35-44 45-54 55-64 65+ Social Grade AB C1 C2 D E Region London South East South West Wales East Anglia East Midlands West Midlands Yorkshire and Humberside North West North Scotland Working Status Full time Part time Not working Retired Table continues... 2 2 2 2 2 4 4 3 3 3 2 3 2 1 1 3 1 2 3 2 1 2 2
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Table 3.15: Penetration of Consulting an Osteopath in the Last 12 Months (% of respondents), 2005
2 2 3 2 2 1 4 1 2 2 2 2 2 3 1 Base: All adults aged 15+
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Consulted a Chiropractor
In a response very similar to that of osteopathy, only 2% of respondents had consulted a chiropractor in the last 12 months, including 2% of women and 1% of men. Slight (although probably not truly significant) differences can be observed in the age groups, with the lowest response seen among 15 to 24 year-olds and 35 to 44 year-olds (both 1%), and the highest among the 65s and over (3%). Similarly, there are slight regional variations, with the highest response rates seen in London, East Anglia, the West Midlands and the North West. Part-time workers were also slightly more likely to have consulted a chiropractor compared with other types of worker, possibly because of the higher number of female respondents in this particular working group. Widowed respondents were also slightly more likely to have consulted a chiropractor (3%), possibly because of the higher proportion of women and elderly people in this particular group. It is also of note that the largest group of respondents who had consulted chiropractors were those living rent-free in council accommodation (at 11%). This group contains a high proportion of people not working through disability. As they are unlikely to have paid for chiropractic services, it is likely they have been referred and paid for by the NHS. According to the Department of Health (DoH), the most common cause of disability from work is back injury and pain, with levels particularly high in those engaged in the more physical types of employment, such as manual labour.
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Table 3.16: Penetration of Consulting a Chiropractor in the Last 12 Months (% of respondents), 2005
All adults Sex Male Female Age 15-24 25-34 35-44 45-54 55-64 65+ Social Grade AB C1 C2 D E Region London South East South West Wales East Anglia East Midlands West Midlands Yorkshire and Humberside North West North Scotland Working Status Full time Part time Not working Retired Table continues... 2 3 1 2 3 2 2 3 1 3 1 3 2 2 2 2 1 2 1 2 1 2 2 3 1 2 2
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Table 3.16: Penetration of Consulting a Chiropractor in the Last 12 Months (% of respondents), 2005
2 2 3 2 2 1 3 1 1 2 1 2 2 2 0 0 11 0
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Had Physiotherapy
According to the survey, 8% of respondents had undergone physiotherapy in the previous 12 months. There was little gender difference, with 8% of women having undergone physiotherapy, compared with 7% of men. There were significant differences between the different age groups, with 15% of 55 to 64 year-olds having undergone physiotherapy in the last 12 months, compared with levels of 6% to 8% for the other age groups. Higher levels for 55 to 64 year-olds are likely to be due to the high levels of wear and tear injuries seen in this age group and associated musculoskeletal procedures such as hip replacements. Physiotherapy was also more common in the AB social grade (10%), compared with the other social groups, at 6% to 8%. This is possibly for lifestyle reasons (i.e. leisure activities such as sport, skiing, etc.), as well as their greater assertiveness over healthcare issues. In addition, ABs are likely to be more able to afford private physiotherapy than the other social grades. There were also some regional differences, with the highest use of physiotherapy recorded in Wales (12%) and East Anglia (11%), and the lowest in London (5%). This variation might be due to a combination of different factors, including access to and availability of NHS services, relative incomes, and cultural and social reasons, particularly among ethnic minorities. Higher penetration of having physiotherapy in the last 12 months was observed among non-working respondents (10%) and retired respondents (9%). Many non-working respondents may have disabilities or chronic health problems that require regular treatments, while the older retired respondents may have musculoskeletal problems associated with ageing. Households of five or more people appeared to have lower levels of physiotherapy (4%), compared with other households (ranging between 7% and 9%). This might be because they contain higher numbers of younger respondents or it might be due to economic reasons. At 11%, separated respondents were slightly more likely than other groups to have had physiotherapy in the last 12 months, while widowed respondents (at 5%) were the least likely. There were significant differences between the types of tenure, with the highest levels of physiotherapy (19%) recorded among those living rent-free in council accommodation. The lowest levels were seen among respondents renting from the council (4%) and renting from someone else (5%), which are groups with younger age profiles.
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Table 3.17: Penetration of Having Physiotherapy in the Last 12 Months (% of respondents), 2005
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Table 3.17: Penetration of Having Physiotherapy in the Last 12 Months (% of respondents), 2005
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None of the Above

Certain groups of respondents were much more likely than others not to have used any of the services or products described above and, at 10%, there were more than twice as many men as women in this category. Other groups that were less likely to have used the services/products described in this chapter were, in general, groups with high proportions of younger respondents, such as the 15 to 24 year-olds (16%), single respondents (15%) and those living in private rented accommodation (13%). Income and access to services may also play a role, with high numbers of respondents living rent-free in council accommodation (20%) not having used or accessed any of the services or products, in spite of being more likely to be older and in poor health.
Table 3.18: Penetration of None of the Above in the Last 12 Months (% of respondents), 2005
All adults Sex Male Female Age 15-24 25-34 35-44 45-54 55-64 65+ Social Grade AB C1 C2 D E Table continues... 3 6 11 11 4 16 9 6 6 3 2 10 4 7
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...table continued Region London South East South West Wales East Anglia East Midlands West Midlands Yorkshire and Humberside North West North Scotland Working Status Full time Part time Not working Retired Size of Household 1 2 3 4 5+ Marital Status Married Single Divorced Widowed Separated Table continues... 4 15 4 5 6 4 5 8 6 15 10 5 6 2 13 3 6 6 9 10 7 5 8 5 4
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...table continued Presence of Children Aged 0-4 Aged 5-9 Aged 10-15 Any aged 0-15 None Tenure Owned with mortgage/loan Owned outright Rented from the council Rented from someone else Rent-free from the council Rent-free from someone else
3 6 5 5 8 7 4 7 13 20 9
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CONSUMER ATTITUDES
Respondents were also asked the following question: Which three of the following actions do you consider most necessary to improve the health service?
recruiting more healthcare professionals monitoring their performance cutting NHS waiting lists increasing NHS funding monitoring hospital performance improving hospital cleanliness improving GP out-of-hours services increasing the range and availability of OTC medicines encouraging private healthcare changing government policy educating the public on health issues.
The action that respondents felt was most necessary to improve the health service was improving hospital cleanliness, which was selected by 55% of respondents (61% of women). This would seem to indicate that recent publicity surrounding methicillin-resistant Staphylococcus aureus (MRSA) and other super bugs, and standards of hospital cleanliness have had a very significant impact on public perception. Cutting NHS waiting lists was the second most important action, selected by 48% of respondents and almost half (49%) of women. This was closely followed by increasing NHS funding (47%). These results, together with the lack of enthusiasm for encouraging private healthcare (selected by only 6% of respondents), seem to indicate that the public remain steadfastly loyal to the NHS and the principles behind it, and are prepared to see more funding made available to it. However, it remains to be seen whether they would be prepared to pay higher taxes as a result. In any case, these results would seem to indicate that significantly changing or limiting the scope of the NHS would be an extremely perilous step for any government to take.
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Only 13% of respondents selected the option for changing government policy, indicating that there does not seem to be any particular hostility to current government policies, although there is certainly no great enthusiasm for performance monitoring of healthcare professionals (6%) or hospitals (15%), or for expanding the range and availability of OTC medicines (5%). However, it must be taken into account that a significant proportion of the population are exempt from prescription charges and would therefore have little incentive to pay for medication that they could obtain free of charge from the NHS. Significant numbers of respondents felt that recruiting more healthcare professionals was important (33%) particularly men, at 36% and educating the public on healthcare issues (29%).
Table 3.19: Summary of Consumer Attitudes Towards Healthcare (% of respondents), 2005

Which three of the following actions do you consider most necessary to improve the health service?
All
Recruiting more healthcare professionals Monitoring their performance Cutting NHS waiting lists Increasing NHS funding Monitoring hospital performance Improving hospital cleanliness Improving GP out-of-hours services Increasing the range and availability of OTC medicines Encouraging private healthcare Changing government policy Educating the public on health issues
GP general practitioner OTC over-the-counter Weighted sample: 1,010
Male Female 36 7 46 45 15 48 16 4 9 17 31 30 6 49 49 14 61 23 5 3 10 28
33 6 48 47 15 55 20 5 6 13 29
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Which Three of the Following Actions Do You Consider Most Necessary to Improve the Health Service?
Recruiting More Healthcare Professionals
A third (33%) of respondents believed that recruiting more healthcare professionals was one of the three most important actions necessary to improve the health service. There were distinct gender differences, with more men (36%) than women (30%) selecting this action. There were also differences between the age groups, with the highest levels observed in the middle age groups, particularly among 35 to 44 year-olds (41%), and the lowest levels of response in the youngest age group 15 to 24 year-olds (25%) who may have a lower perception of health-service problems. There were also differences between the social grades, with the highest levels of response from ABs (42%) and the lowest from Es (24%). There could be a number of reasons for this, not least the greater awareness over healthcare issues generally, and the fact that the AB group contains many healthcare professionals. There were also regional differences, with the highest levels of response recorded in East Anglia (43%) and the lowest levels in the North (22%) and Wales (20%). Many factors could contribute to these differences, including local staff shortages, perceptions of problems in local healthcare services and media coverage highlighting particular problems, among others. At 25%, one-person households were least likely to select this action. There were also differences depending on marital status, with the highest levels among separated (38%) and married (37%) respondents and the lowest among widowers (24%), possibly because of the higher numbers of women in this last group (who were shown previously to be less likely to select this option) and the high numbers of pensioners. Respondents living in rented accommodation, both council and private, were less likely to have opted for this action, particularly respondents living in private rentals (26%), who are most likely to be younger, single people.
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Table 3.20: Recruiting More Healthcare Professionals (% of respondents), 2005

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Table 3.20: Recruiting More Healthcare Professionals (% of respondents), 2005

25 37 31 37 30 37 26 30 24 38 29 32 38 34 33 38 32 29 26 32 33
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Monitoring Their Performance

Only 6% of respondents selected monitoring the performance of healthcare professionals as one of their three most necessary actions to improve the health service, with no significant difference between men and women. This would seem to indicate that respondents are generally confident about the quality of NHS healthcare professionals and their abilities. The older and middle age groups were slightly more sceptical than younger groups about healthcare staff performance, with 8% of 45 to 64 year-olds considering that they should have their performance monitored. However, respondents aged 65 and over were the most trusting, with only 4% selecting this option as being necessary. Of the different social grades, C2s and Ds were most sceptical (both 9%) while, at 4%, C1s were the least likely to select this option. As with the option for recruiting more healthcare professionals, there was some regional variation for monitoring their performance, with the highest levels for selecting this option observed in Wales (12%) and the lowest in East Anglia and Scotland (both 3%). Again, this is likely to reflect local problems, such as staff shortages, problems in local services, and the publicity and media coverage that they receive. Part-time workers and one-person households were most likely to select this option (both 10%), as were divorced respondents (at 14%), reflecting the higher levels seen with the option of recruiting more healthcare professionals. Particularly significant was the 19% of respondents living in rent-free council accommodation who had selected this option. As this group contains mainly disabled and chronically ill people, this high figure could reflect their familiarity with healthcare services from frequent contact and the particular pressures on healthcare services in less affluent, deprived areas of the country.
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Table 3.21: Monitoring Their (Healthcare Professionals) Performance (% of respondents), 2005

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Table 3.21: Monitoring Their (Healthcare Professionals) Performance (% of respondents), 2005

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Cutting NHS Waiting Lists

Almost half (48%) of respondents selected this option as one of the three most important actions necessary to improve the health service, which is an indication of the importance of this particular option. There were slight gender differences, with 49% of women selecting this option, compared with 46% of men. There were also distinct differences between the different age groups, with the highest levels of selection being recorded in the youngest age groups 15 to 24 year-olds (60%) and 25 to 34 year-olds (51%) compared with 42% of 45 to 54 year-olds and 43% of those aged 65 and older. The reasons for this marked age-related response are unclear, but are perhaps related to perceptions from experiences using healthcare services directly by respondents or from anecdotal information from their peers. Younger people might have a lower tolerance or patience for delays in treatment when compared with the attitudes of older age groups. There were also variations between the different social grades, with ABs demonstrating the lowest levels of selection (34%), compared with the other groups, particularly C2s (57%) and Es (56%). This could reflect differences in the quality and availability of healthcare services in affluent areas (such as those for the ABs) compared with the pressures on healthcare in less affluent areas. The above factors could also partly explain regional variations, with the highest levels of selection observed in East Anglia and Yorkshire and Humberside (both 58%), and the lowest levels in the South East (39%). At 55%, single respondents were also the most likely to have selected this option, reflecting the relative youth of this group. There were also variations depending on tenure, with the highest levels of selection observed among respondents renting from the council (55%) and the lowest among those living rent-free in private accommodation (37%). Again, these results are likely to reflect the quality and pressures on local health services.
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Table 3.22: Cutting NHS Waiting Lists (% of respondents), 2005

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Table 3.22: Cutting NHS Waiting Lists (% of respondents), 2005

45 49 48 46 49 46 55 40 44 40 50 52 43 45 49 47 46 55 48 44 37
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Increasing NHS Funding

Just under half (47%) of respondents selected increasing NHS funding as one of the three most important actions necessary to improve the health service. There were some gender differences, with women (at 49%) more likely than men (at 45%) to select this option. There were also variations between the age groups, with the highest levels of selection recorded among 25 to 34 year-olds, at 58%, and 35 to 44 year-olds, at 52%. In contrast, the lowest levels of response were seen among respondents aged 65 and older, with 40%. In terms of social grade, ABs (at 42%) were slightly less likely than the other groups to select this option. The affluent ABs could possibly be concerned over taxes being raised to pay for any increases in healthcare funding. There were also some regional variations, with the highest levels of selection observed in Wales (57%) and the lowest levels in London (38%). These variations could be due to a combination of factors, including the relative affluence of different regions, the availability of local services, media attention and political affiliations in the region, among others. Three- and four-person households were also more likely to have selected this action (at 52% and 54%, respectively). At 60%, separated respondents were far more likely than others to have selected this option, as were families with children (ranging from 52% to 54%). There were marked differences in response depending on the respondents tenure, with the highest levels of selection observed in those living in council rented accommodation (54%) and so likely to have a younger age profile compared with the lowest levels among respondents living in rent-free accommodation from the council (at just 11%). This particular group has high levels of illness and disability, with a vested interest in obtaining quality healthcare. They are also far less likely to be employed, living on benefits and, as such, are unlikely to worry about paying increased taxes.
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Table 3.23: Increasing NHS Funding (% of respondents), 2005

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Table 3.23: Increasing NHS Funding (% of respondents), 2005

45 43 52 54 43 47 49 40 45 60 54 50 52 52 44 49 40 54 53 11 51
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Monitoring Hospital Performance

15% of respondents considered that monitoring hospital performance was one of the three most important actions needed to improve the health service, with little significant gender differences. With a 15% response rate for this option and only 6% for monitoring the performance of healthcare professionals, there appears to be very little enthusiasm for the Governments performance-assessment initiatives. However, there were some differences between the age groups, and almost twice the proportion of 55 to 64 year-olds opted for hospital monitoring (19%), compared with only 10% of 25 to 34 year-olds. There were also differences between the social grades, with only 10% of C1s selecting this option, compared with 20% of Es and 18% of Ds. There was also some degree of regional variation evident, with the highest levels of selection in the North (25%), followed by Wales and the West Midlands (both 19%), and the lowest level in the East Midlands, at only 8%. There could be a number of factors contributing to this variation in addition to perceptions of local healthcare problems and issues. Social and cultural factors, as well as the political climate of particular regions and the influence of local media, can colour and dictate perceptions. Working status appeared to make little difference in levels of selection, although, at 12%, retired respondents were slightly less likely than the others to select this option, perhaps reflecting traditional degrees of trust in healthcare services. At 17%, one-person households were slightly more likely to have selected this option, and the survey showed that households with older children (10 years and over) were less likely than others to have selected this option, at 9%. In contrast, respondents living rent-free from the council were significantly more likely to have selected this option, at 35%. This indicates a lack of trust in hospital services in a group that is likely to contain significant numbers of people that are disabled or in poor health and with significant first-hand experience of healthcare services. It may also reflect the extra pressures on healthcare in more deprived areas of the country.
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Table 3.24: Monitoring Hospital Performance (% of respondents), 2005

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Table 3.24: Monitoring Hospital Performance (% of respondents), 2005

17 13 16 14 14 14 16 14 13 16 15 11 9 13 15 14 13 20 14 35 21
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Improving Hospital Cleanliness

The survey indicated that over half (55%) of respondents selected this option as one of the three most important actions necessary to improve healthcare services, suggesting that the recent significant media attention to MRSA and other hospital super bugs has significantly raised public awareness. Women (at 61%) were significantly more likely than men (at 48%) to select this option, indicating a greater awareness of the issues surrounding cleanliness among women. There were marked age-related differences, with the youngest age group being the least likely to have selected this option (at 40%), with the likelihood of selection generally increasing with age to reach 66% in the 65 and over age group. This greater awareness and concern in the older age groups may be partly due to their more frequent use of healthcare facilities. There was some regional variation, with the highest levels of selection in the West Midlands (67%) and Yorkshire and Humberside (66%). There are a number of factors contributing to the levels of regional variation, including the levels of MRSA and other super bugs, and the amount of coverage that any perceived problems are given in the local media. The quality of care and cleanliness in local hospital and care facilities may also vary. In terms of working status, retired respondents were the most likely to select this option (at 64%), which is consistent with the higher levels of awareness and concern seen in the 65 and over age range. There were also some differences in respondents depending on the size of the household, with the highest levels of selection seen in two-person households (60%). In terms of marital status, higher levels of selection were observed among widowed respondents (63%), again consistent with the elderly profile of this group, and the lowest levels were recorded among separated respondents (38%). More variation was observed depending on respondent tenure, with the lowest levels of selection among respondents living in private rent-free properties (30%).
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Table 3.25: Improving Hospital Cleanliness (% of respondents), 2005

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Table 3.25: Improving Hospital Cleanliness (% of respondents), 2005

53 60 56 51 49 59 46 40 63 38 51 60 54 52 57 54 63 48 50 50 30
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Improving General Practitioner Out-of-Hours Services

Around a fifth (20%) of respondents selected this option as being one of the three most important actions necessary for improving the health service. There were some gender differences, with 23% of women selecting this action, compared with 16% of men. As the major carers for children and frequently the elderly, women might place greater importance than men on out-of-hours services. There were also slight differences between the various age groups, with the highest levels of selection observed in the oldest age group (the 65s and over, at 24%) and the youngest (the 15 to 24 year-olds, at 23%), with the lowest levels recorded among the 25 to 34 year-olds (15%). The reasons for this are not clear but, for elderly people, many of whom have chronic health problems, good around the clock healthcare is likely to be a priority. Comparatively, younger people, with their active lifestyles and social activities, may value flexible healthcare services. Slight differences were also evident between the social grades, with the highest levels of selection seen in the lower groups C2s (23%), Ds and Es (both at 22%). In contrast, only 15% of C1s chose this option. There was also a certain amount of regional variation, with the highest levels of selection observed in Scotland (27%), and Wales and Yorkshire and Humberside (both 26%), and the lowest levels in the North West (15%). Possibly, variation in the quality of local out-of hours services, together with the type of GP practice (i.e. rural or city-based), might contribute to these differences. Rural practices might have a greater need for good out-of-hours services. In terms of working status, retired respondents (at 25%) had a higher level of selection than the other groups, which is consistent with the elderly profile of this particular group. At 16%, the lowest levels of selection were seen among those not working, possibly reflecting their ability to attend appointments throughout the day, often at very short notice, resulting in lower requirements for out-of-hours services. There was little difference between household size but, in terms of marital status, separated respondents (at 4%) gave a significantly lower level of selection than the others. The reasons for this are not clear, but it may simply be that they selected other options as a greater priority than other groups, rather than having less need for out-of-hours services. There was little significant difference between respondents with children and those without, although respondents with children under the age of 4 years had slightly higher selection rates (22%), possibly reflecting the anxieties of parents with babies and very young children. However, there were very significant differences between respondents depending on their tenure, with by far the highest levels of selection observed in respondents living rent-free in council accommodation, at 54%. This high rate could be due to a number of factors associated with the high numbers of chronically ill, disabled and/or elderly people in these groups, who are on low incomes often in areas of deprivation. All these factors would make respondents more dependent on out-of-hours GP services.
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Table 3.26: Improving General Practitioner Out-of-Hours Services (% of respondents), 2005

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Table 3.26: Improving General Practitioner Out-of-Hours Services (% of respondents), 2005

20 21 21 19 16 21 16 25 22 4 22 17 17 19 20 16 22 19 26 54 11
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Increasing the Range and Availability of Over-the-Counter Medicines

Very few respondents (only 5%) considered that increasing the range and availability of OTC medicines was a priority and there were no significant differences between men (4%) and women (5%). The middle age groups gave slightly higher response rates for this option (between 6% and 8%), possibly because time constraints might make OTC medicines more convenient than visiting a GP and because people in these groups might be less likely to be exempt from paying prescription charges. However, even in these groups, the levels of selection were very low. There were also slight regional differences, with slightly higher levels of selection observed in Wales (9%) and the South East (7%), and the lowest in Scotland and the East Midlands (both 2%). Levels of poverty and unemployment in these areas could contribute to the results, as high levels of these, along with the accessibility of healthcare services, would result in greater numbers being exempt from prescription charges. Respondents who find it more difficult to access healthcare in a convenient and timely fashion might be more likely to want OTC products for convenience. The nature of employment in these areas could also play a part in accessibility to health services. Divorced respondents also gave a slightly higher response, at 10%, and this might reflect their level of use of OTC products, along with constraints on their free time to access healthcare services.
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Table 3.27: Increasing the Range and Availability of Over-the Counter Medicines (% of respondents), 2005
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Table 3.27: Increasing the Range and Availability of Over-the Counter Medicines (% of respondents), 2005
7 5 3 4 5 5 3 10 2 5 7 4 4 5 5 4 4 4 3
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Encouraging Private Healthcare

There was very little enthusiasm among respondents for encouraging private healthcare, with only 6% selecting this option as one of their three choices. This would seem to indicate that, in general, respondents remain loyal to the idea of the NHS in spite of its perceived problems. In addition, it suggests that they remain suspicious and unenthusiastic over measures to encourage, increase and integrate private healthcare in the UK. Part of the reason for this is the cost of private care and a general suspicion that private-care service providers would put profit before the needs of the patient, and that greater use of private services could erode the principles of the NHS. However, there were distinct gender differences, with three times as many men (9%) as women (3%) in favour of this option, a result possibly linked to the higher earning power of many men. Similarly, the more affluent ABs (at 10%) were far more likely than the other groups particularly Es, at 2% to select this option. There was also some regional variations, with respondents in the East Midlands (at 12%) being the most enthusiastic about private care, compared with respondents in East Anglia, and Yorkshire and Humberside who were least enthusiastic, at only 0% and 1%, respectively. The reasons for this variation may reflect levels of affluence in particular areas and also the nature of employment and the likelihood of private healthcare packages being offered as part of employment packages. It might also be based partly on local perceptions of NHS services in these areas and levels of dissatisfaction. In terms of working status, respondents who were part time or not working (excluding retired) both of which include high numbers of women were least enthusiastic about private healthcare (both 4%). Respondents from households with five or more people were more likely to be enthusiastic about private healthcare (at 13%), as were single respondents (probably with higher levels of disposable income), at 8%.
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Table 3.28: Encouraging Private Healthcare (% of respondents), 2005

All adults Sex Male Female Age 15-24 25-34 35-44 45-54 55-64 65+ Social Grade AB C1 C2 D E Region London South East South West Wales East Anglia East Midlands West Midlands Yorkshire and Humberside North West North Scotland Working Status Full time Part time Not working Retired Table continues... 8 4 4 7 5 7 7 9 12 5 1 9 2 6 10 5 5 4 2 6 6 6 5 7 6 9 3 6
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Table 3.28: Encouraging Private Healthcare (% of respondents), 2005

5 7 4 2 13 6 8 4 1 5 5 8 6 6 6 6 6 4 8 9
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Changing Government Policy

13% of respondents felt that changing government policy was necessary for improvements in healthcare, with more men (17%) than women (10%) believing this is the case. There was little variation between the different age groups, although 45 to 54 year-olds (at 16%) were slightly more likely to have selected this option. There was also some regional variation, with the highest levels of selection in the London area and in the South East (both at 17%) and the lowest in Scotland (8%). Since devolution, Scotland has had considerable autonomy over its healthcare service and the results would seem to reflect that the Scots are generally more satisfied with government policy, whereas those in London are least satisfied. Respondents not working (excluding retired) gave the lowest levels of selection (at 10%), indicating more satisfaction with government policy than the other groups. Larger households seem most dissatisfied with government policy (ranging between 16% and 18%), as were the widowed (at 17%) and separated respondents (20%). Overall, the highest levels of dissatisfaction were observed in those living rent-free in private accommodation, at 29%. These results may reflect the general levels of satisfaction that respondents feel in overall government policy and their respective political affiliations. Their attitudes would also be based on those aspects of health services that are most relevant to them on a personal level.
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Table 3.29: Changing Government Policy (% of respondents), 2005

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Table 3.29: Changing Government Policy (% of respondents), 2005

...table continued Size of Household 1 2 3 4 5 Marital status Married Single Divorced Widowed Separated Presence of children Aged 0-4 Aged 5-9 Aged 10-15 Any aged 0-15 None Tenure Owned with mortgage/loan Owned outright Rented from the council Rented from someone else Rent-free from the council Rent-free from someone else
14 11 10 16 18 13 12 10 17 20 11 14 15 14 13 13 13 15 11 16 29
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Educating the Public on Health Issues

29% of respondents felt that educating the public on health issues was important for improving healthcare services, with slightly more men (31%) than women (28%) selecting this option. The younger age groups were also more likely to select this option, particularly the 15 to 24 year-olds, at 35%. This perhaps reflects the fact that they are less well informed on healthcare issues than older age groups. There were also differences between the social grades, with the affluent ABs (at 36%) being more likely than the other groups to believe that education on healthcare issues would improve healthcare services. ABs are generally better informed and more assertive than the other groups over healthcare issues. There were also distinct regional differences, with respondents in the North (42%) being the most likely to select this option and those in Wales (18%) the least likely. These differences could partly be explained by differences in local initiatives to inform people about healthcare issues and how successfully they are implemented. In addition, there would be variations depending on the social make-up of certain regions, i.e. the number of ABs and levels of education. Respondents who work full time (31%) and part time (35%) were most likely to select this option, as were people in larger households (36%). Half (50%) of separated respondents selected this option, compared with only 22% of widowed respondents. Households with children (30% to 34%) were slightly more likely than those without (27%) to have selected this option, perhaps reflecting the greater anxieties of parents. Respondents living rent-free in private accommodation (45%) were also more likely than council tenants (24%) to have selected this option. All these differences might also be a reflection of the educational levels of various populations and the degree to which they want to take responsibility for their own health.
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Table 3.30: Educating the Public on Health Issues (% of respondents), 2005

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Table 3.30: Educating the Public on Health Issues (% of respondents), 2005

...table continued Size of Household 1 2 3 4 5 Marital Status Married Single Divorced Widowed Separated Presence of Children Aged 0-4 Aged 5-9 Aged 10-15 Any aged 0-15 None Tenure Owned with mortgage/loan Owned outright Rented from the council Rented from someone else Rent-free from the council Rent-free from someone else
21 28 27 36 36 29 29 33 22 50 33 30 30 34 27 32 27 24 27 30 45
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THE MARKETPLACE
The UK healthcare market encompasses a wide range of different services and supply markets, and the companies that operate within the marketplace reflect its diversity and broad-ranging nature. The market has become increasingly polarised, with significant levels of acquisition and merger activity over the past decade creating a relatively small number of leading players with increasingly diverse interests in the market. Healthcare has a complex supply structure and, with increasing pressures on funding, it has become extremely cost sensitive. In an effort to maximise profitability, the larger companies are increasingly developing their interests across the whole healthcare supply structure. As such, certain private medical insurers, such as BUPA, have also become major providers of care. Others are developing partnerships across the spectrum of care, tapping into healthcare supply networks. At the other end of the spectrum are a large number of small independent operators or practitioners, although they are finding it extremely difficult to compete cost-effectively with larger players. Some of them, most notably in the ophthalmic services industry, buy into franchised networks. These allow a degree of autonomy, but offer some protection against the economies of scale of the larger operators. In recent years, many small companies and niche market players have been swallowed up by larger players diversifying their interests and consolidating their market position.
MARKET LEADERS
Anchor Trust
Company Structure
The Anchor Trust, which is the largest non-profitmaking provider of housing support and care in England, is a registered charity. It provides a wide range of services for the elderly. Anchor was established in 1968 as Help the Aged (Oxford) Housing Association. Since then, it has grown to employ more than 10,000 people nationwide, providing housing and support services to around 50,000 people. Services include the following:
Anchor Homes provides residential and nursing care in a network of 104

registered care homes with 4,330 places, of which 685 are nursing home places. Some of the homes provide specialist services for people with mental health problems or physical disabilities.
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Anchor Care provides home care services and support to the elderly and
disabled in their own homes and operates as a registered charity. According to Anchors website, Anchor Care has 5,800 clients and provides 33,000 hours of care every week.
Anchor Retirement Housing which offers self-contained retirement

properties for rent with on-site managers and communal meeting rooms, as well as other facilities.
Guardian Management Services offering retirement housing for sale. Anchor Staying Put which provides retirement housing with extra
support services, including housing adaptions.
Anchor Integrated Care and Housing which is a range of retirement

housing with extra services available on-site 24 hours a day.
Anchor Call a telephone alarm system that is available 24 hours a day.
Financial Results
In the year ending 31st March 2004, Anchor Trusts turnover was 205.9m, a rise of 7.1% on 2003. The company made a pre-tax profit (surplus) of 43.3m in 2004, compared with a pre-tax loss (deficit) of 7.4m in 2003.
AXA PPP healthcare Group PLC

Company Structure
AXA PPP healthcare was originally founded in 1938 as a provident association, Private Patients Plan (PPP). Provident status was abandoned in 1996, following extensive restructuring, and the business became known as PPP healthcare. In 1998, it was acquired by the Guardian Royal Exchange Group. Then, in May 1999, the UK business of the AXA Group, Sun Life and Provincial Holdings (SLPH now called AXA UK) acquired the Guardian Royal Exchange Group and, in 2001, PPP healthcare was renamed AXA PPP healthcare. AXA PPP healthcare has four major business operations employing 1,738 people, including the following:
Private medical insurance (PMI) the company is the second-largest

provider of medical insurance in the UK, with cover for around 2 million subscribers. AXA PPP healthcare offers a wide range of insurance products for both individuals and companies, including specialist insurance for the over-55s, long-term care policies, budget plans and expatriate medical benefits, as well as cash plans.
Dental capitation which is conducted through its sister company,

Denplan. AXA has also introduced Dental Coastguard, a new low-cost insurance that provides cash reimbursement in the event of a dental accident or emergency.
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Health information services and consulting. Occupational health, health screening and employee assistance services,
which are conducted through its sister company, AXA PPP healthcare Occupational Health Services. AXA PPP has developed a national preferred provider network of selected private hospitals in order to cost-effectively treat policy holders.
Financial Results
AXA PPP healthcare pays out around 1.5m in claims on behalf of its customers every day. In the year ending 31st December 2003, AXA PPP healthcare Ltd recorded a turnover of 728.3m and a pre-tax profit of 71m, compared with a turnover of 692.5m and a pre-tax profit of 86m in 2002.
Barchester Healthcare Ltd

Company Structure
In 2004, Barchester Healthcare Ltd purchased Westminster Healthcare. The combined group serves more than 10,000 people at 163 care homes in the UK. In addition, the company employs more than 12,000 people nationwide. Barchester Healthcare provides specialist residential and home care services to the elderly and those with specialist needs. The companys services include:
Care homes 24-hour nursing care at over 160 care homes Memory Lane Communities specialist care for dementia patients Care Villages and Close Care assisted living apartments and sheltered
accommodation
Life Designs Communities specialist services for adults of all ages with
impaired abilities
Barchester Homecare home care services Intermediate Care convalescent care and post-operative care facilities Respite care services and holiday breaks for carers Specialist Health Services for patients with degenerative central nervous
system (CNS) diseases, strokes and brain injuries.
Financial Results
In the year ending 31st December 2003, turnover for Barchester Healthcare Ltd was 59.7m, an increase of 57.2% on 2002. Pre-tax profit rose by 68.9% to 6.6m in 2003.
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The British United Provident Association Ltd

Company Structure
The British United Provident Association (BUPA) is a global health and care organisation. The company is the largest private medical insurer in the UK, employing more than 34,046 people. It is based in three continents, with more than 7 million customers. BUPA is a non-profitmaking provident association and, apart from its core business of medical insurance, it has a wide range of other businesses and interests across the spectrum of healthcare. BUPA businesses and operations include the following:
BUPA Health Insurance BUPA is the largest provider of health insurance

in the UK and has a comprehensive range of products. More than 50% of leading UK companies are BUPA subscribers, and the company has more than 4 million members.
BUPA Hospitals the BUPA network of hospitals in the UK treat almost

250,000 people every year.
BUPA Care Homes these provide specialist care for the elderly, mentally
ill, those with degenerative CNS disorders and young people with learning or physical disabilities. BUPA has the largest network of homes in the UK, with more than 245 homes caring for around 15,000 residents.
BUPA Wellness BUPA has 42 Wellness centres throughout the country

providing health assessments, occupational health services, private general practitioner (GP) services, employee assistance programmes, counselling services, physiotherapy, vaccinations and dental services (in London).
BUPA Childcare BUPA has 44 Teddies nurseries for the care of more than
2,000 children aged between 3 months and 5 years, as well as employee childcare packages.
BUPA International this is the largest international expatriate health

insurer in the world, with more than 275,000 members in 190 countries.
Sanitas Sanitas is the Spanish BUPA business, with more than 1 million
subscribers who have access to 18,000 medical professionals and 450 medical centres.
Financial Results
In the year ending 31st December 2003, turnover for The British United Provident Association Ltd was 3.35bn, a rise of 19.5% on 2002. The company made a pre-tax profit (surplus) of 134.5m in 2003, compared with a pre-tax profit of 103.6m in 2002.
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FirstAssist
Company Structure
FirstAssist was established in 1998 through the combination of three companies. The Healthcare business was formed in 1997 under Royal & SunAlliance and it is now one of the market leaders in the provision of health and wellbeing products. The company employs more than 1,100 staff, including medical experts, counsellors and other services. It is owned by Barclays Private Equity. FirstAssist also has a long-term partnership with Munich Re. FirstAssist provides a variety of insurance services, including PMI and hospital cash plans. It also provides a range of rehabilitation services, sickness cover, absence management, counselling and physiotherapy.
Financial Results
At the time this report was published (September 2005), there were no financial results available for FirstAssist Group Ltd on the ICC Juniper database.
Four Seasons Health Care

Company Structure
Four Seasons Health Care operates approximately 300 care homes and a number of Specialised Care Centres in England, Scotland, Northern Ireland and the Isle of Man. It was founded in the 1980s and has expanded through acquisition and investment in facilities. The company employs more than 19,000 people nationwide and cares for more than 15,000 people. Four Seasons was subject to a 775m buy out by Allianz Capital Partners in September 2004. The company has two main operating divisions:
Care Homes Division this Division comprises approximately 190 homes

and provides a variety of care services for the elderly and infirm, as well as a range of services such as respite care, rehabilitation services, intermediate care, terminal and palliative care, and care for young people with chronic conditions.
Specialised Services Division which comprises four brain injury

rehabilitation centres, as well as four hospitals providing rehabilitation for young people with a variety of conditions, including eating disorders and acute psychiatric disease. In addition, the Division offers adult psychiatric services. Four Seasons also provides childrens nurseries, nursing services, and retirement villages and day-care centres for the elderly.
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Financial Results
At the time this report was published (September 2005), the most recent financial results relating to turnover available for Four Seasons Health Care Ltd on the ICC Juniper database were for 2002. In the year ending 31st August 2002, the companys turnover was 150.2m, an increase of 8.2% on 2001. Four Seasons recorded a pre-tax loss of 315,000 in the 70 weeks ending 21st December 2003, compared with a pre-tax profit of 1m in 2002.
General Healthcare Group Ltd

Company Structure
The General Healthcare Group (GHG) is a leading provider of independent healthcare services in the UK. It was founded in 1970 when the US provider AMI entered the UK market and, by 1983, it had grown to 13 hospitals. In 1990, it was acquired by Vivendi (then Generale des Eaux). In 1993, the hospital operating company changed its name to BMI Healthcare and GHG was selected as the new corporate group name. In 1997, the Group was acquired by Cinven Ltd and GHG was merged with Amicus Healthcare Group Ltd. On 1st September 2000, Cinven sold their shareholding to BC Partners, a leading European private equity company. In 2005, Partnerships in Care, the psychiatric services company, was sold to Cinven. GHG provides a range of services and, as at 11th July 2005, had the following major operating divisions and businesses:
BMI Healthcare this is the acute hospital division of the company, with 49
acute care hospitals throughout the country which treat over 250 inpatients and 750,000 outpatients a year. BMI hospitals are equipped for complex surgical and diagnostic procedures, and have intensive care or high-dependency units at each hospital. BMI also manages a number of private patient facilities (PPUs) for the NHS. In addition, BMI has developed the Patient Choice Programme with primary care trusts (PCTs), and has a number of small hospitals based on NHS sites. BMI has focused on the development of private/public partnerships with the NHS to reduce waiting times and provide complementary services. The division also provides cosmetic surgery, obesity treatment and fertility treatment services.
BMI Health Services this division is a major provider of preventative

healthcare services in the UK through screening and occupational health services. BMI Health Services has a network of screening centres throughout the UK. On 11th July 2005, GHG announced the sale of BMI Health Services to the Capita Group PLC to become part of Capita Health Solutions. Following a period of integration, BMI Health Services Ltd will be renamed Capita Health Solutions. BMI will retain personal health screening services, including wellness programmes and the Wimpole Street Centre.
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Financial Results
In the year ending 31st December 2003, turnover for General Healthcare Group Ltd was 666.3m, an increase of 5.8% on 2002. The company made a pre-tax loss of 13.5m in 2003, compared with a pre-tax loss of 17.7m in 2002.
HSA Group Ltd

Company Structure
The Hospital Savings Association (HSA) is the leading UK cash plan company, employing around 600 people. It was founded in 1922 with the remit to save hospitals from closure and to help people contribute to the cost of care. The companys main products include health cash plans, which allow subscribers to claim cash benefits to help cover the costs of care, and the company also offers a corporate plan. In addition, HSA produces Personal Medical Plans (PMPs) to facilitate consultation and diagnostic costs, along with cover for surgery, complementary healthcare, specific medical conditions and other combinations. The HSA Group also incorporates the Leeds-based health plan provider LHF and, in March 2005, the company announced the merger with the Manchester-based HealthSure. In addition, HSA merged with the Bristol and Contributory Welfare Association (BCWA), a medical insurance business, which it acquired in January 2005. The entire HSA group has 1.1 million policyholders providing cover for around 2 million people. The HSA and LHF have also formed charitable trusts, which have pledged 1% of gross turnover to health-related charities. In July 2005, the Group joined forces with the occupational health provider Adastral Health Ltd, as part of the Groups ongoing strategy to become a healthcare services specialist.
Financial Results
In the year ending 31st December 2003, HSA Group Ltds turnover decreased by 6.5% to 218.4m. The company made a pre-tax profit of 27.8m in 2003, compared with a pre-tax profit of 100,000 in 2002. Also in the year ending 31st December 2003, Bristol Contributory Welfare Association Ltd recorded a turnover of 64.5m, an increase of 2.1% on 2002. Pre-tax profit rose from 1.1m in 2002 to 2.7m in 2003. Following the merger with BCWA, the HSA Group has an anticipated turnover of 275m and will enter the top 40 of UK general insurers, holding around 3% of the PMI market.
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Norwich Union Healthcare Ltd

Company Structure
Norwich Union Healthcare Ltd is part of Aviva PLC, the fifth-largest insurance group in the world and the largest in the UK, employing 49,000 people worldwide with over 30 million customers. Aviva was formed through the merger of CGU and Norwich Union in 2000, and the Aviva brand name was introduced in July 2002. CGU was created through the merger of Commercial Union and General Accident in 1998. As well as providing a range of PMI policies, the company runs Global Care, providing healthcare insurance for expatriates. Norwich Unions PMI gives access to treatment at a network of 120 private hospitals in the UK. It also provides a 24-hour GP helpline for subscribers.
Financial Results
In the year ending 31st December 2003, Norwich Union Healthcare Ltds turnover was 82.8m, a decrease of 7.6% on 2002. The company made a pre-tax loss of 3.1m in 2003, compared with a pre-tax profit of 2.1m in 2002.
Nuffield Hospitals
Company Structure
Nuffield Hospitals which was called Nuffield Nursing Homes Trust until 1st September 2003 was established in 1957 and it is now the largest network of non-profitmaking independent acute care hospitals in the UK, with more than 43 hospitals in England and one in Scotland, employing more than 8,293 people. Nuffield is continuing to grow through acquisition and investment. As well as comprehensive acute care hospital facilities, Nuffield provides specialist diagnostic services, including imaging, computed tomography (CT), ultrasound, digital spot imaging and magnetic resonance imaging (MRI). Nuffield also has specialist pathology laboratory services and has a number of specialist outpatient clinics providing in vitro fertilisation (IVF), asthma treatments and diabetes services. In addition, the company provides specialist preventative screening services.
Financial Results
In the year ending 12th December 2004, Nuffield Hospitals recorded a turnover of 455.9m, a rise of 11.3% on 2003. The company made a pre-tax profit of 13.3m in 2004, compared with a pre-tax profit of 3m in 2003.
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Western Provident Association Ltd

Company Structure
The Western Provident Association (WPA) Ltd is a leading private medical insurer. It is a non-profitmaking provident association that was founded in 1901. Unlike most insurers, the company is not tied in to a preferred provider network of hospitals, instead claiming that its policies allow access to most UK private hospitals. The WPA has more than 500,000 customers and claims to have paid more than 750,000 in claims over the past 10 years. The company guarantees to settle claims within 7 working days and, in July 2005, won the British Insurance Award for Customer Care.
Financial Results
In the year ending 31st December 2004, Western Provident Association Ltds turnover was 101.1m, compared with 103.4m in 2003. Pre-tax profit (surplus) decreased by 8.7% to 15.1m in 2004.
Other Companies
There are a wide range of other companies that provide healthcare services, including the following:
Capio Healthcare UK Ltd The Capita Group PLC Care UK PLC Craegmoor Group Ltd Highfield Group Nestor Healthcare Group PLC.
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DEFINITION
The NHS was founded in 1948 from a dispersed post-war infrastructure of voluntary and local hospitals and services. Since its inception, the NHS has had the broad remit to provide comprehensive healthcare to all UK citizens as a free service based on need rather than the ability to pay. This continues to be the basic premise of the service, albeit with the introduction of various charges for certain services, including prescriptions, eye care, dental care and certain elements of long-term care, among others. The NHS is organised into two main service supply structures hospital and community health services (HCHS) and family health services (FHS) which are considered in Chapters 6 and 7, respectively. Funding for the NHS is obtained from general taxation and the NHS element of National Insurance (NI) contributions, together with revenues from prescription and other charges. The basic contributions are mandatory for all employed residents who are unable to opt out of NHS charges and direct them into private healthcare policies. The NHS dominates the UK healthcare services market, partly through its size and comprehensive provision of services throughout the country and partly because of the immense loyalty it has generated from the population at large. The result of this loyalty is that any government introducing change to the NHS has to evaluate the political consequences carefully.
KEY TRENDS
NHS Funding and Investment
According to the Department of Health (DoH), it is estimated that, for 2005/2006, 94.1% of NHS financing in England will be met from a combination of general taxation and NI contributions. An estimated 73.9% will come from the Consolidated Fund (general taxation) and 20.2% from the NHS element of NI. The remaining finance will be derived from income generation schemes, charges and receipts from the NHS.
The NHS Plan

The Labour Government has invested unprecedented amounts of funding in the NHS in order to develop a more patient-/consumer-centred health service. As part of the 10-year plan, which was published in 2000 to modernise services and end the so-called postcode lottery, the Government put into place a number of key performance targets, as follows:
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general practitioner (GP) appointments within 24 hours by 2004 a 6-month maximum waiting time for hospital inpatient treatment and
3 months for outpatients by 2005
a reduction in deaths as a result of cancer and heart disease by 2010.
Staff Shortages
According to the General Practitioner Recruitment, Retention and Vacancy Survey 2004, which was prepared by the Government Statistical Service, there were 3,240 GP vacancies between 2003 and 2004. The average time taken to successfully fill a vacancy was 4.5 months, compared with 3.5 months in 2003, although the average number of applicants for each vacancy rose to 3.7 from 3.3. Around 13% of respondents claimed that the recruitment process was easier in 2004, compared with 9% of respondents in 2003. According to the DoH, as at March 2004, there were 7,520 vacancies (over 3 months) for qualified nurses, midwives and health visitors, compared with 1,670 medical and dental staff. In addition, there were vacancies for 1,260 consultants.
Waiting Lists
As at the end of May 2005, the number of patients in England waiting for over 6 months for admission into NHS hospitals was 49,600, an increase of 9.3% on April, but a fall of 42.2% on the same period in 2004. The total number of patients waiting for admission into hospitals in England was 826,000 at the end of May 2005, a fall of 0.1% on the end of April 2005, and a decrease of 7.6% on the previous year. There were only 17 patients waiting for more than 9 months at the end of May 2005, and no patients were waiting over 12 months.
Day Surgery Inefficiency

According to the Healthcare Commissions Day Surgery report (July 2005, 2005 Commission for Healthcare Audit and Inspection): In some trusts, facilities for day surgery are not exclusively dedicated to that purpose, leading to inefficiency and less satisfactory care. But even where dedicated facilities do exist, they are often used inefficiently at present. For example, operating theatres in day surgery units are used for an average of only 16 hours a week. Cancelled or short running operating lists and gaps between patients together account for 45% of planned operating hours.
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Performance Criteria and Foundation Trusts

As part of the NHS plan to raise standards and meet performance targets, the Government introduced a star ratings system for NHS trusts and, in 2002, for primary care trusts (PCTs). The ratings include measurements for the patients quality of experience, efficient use of resources and the accessibility of services. The plan for establishing foundation trusts aimed to allow trusts meeting the required top performance criteria (3 stars) greater autonomy and freedom from control. Conversely, the worst-performing trusts faced the prospect of being taken over by the more successful trusts or by private and voluntary sector organisations.
Antibiotic Resistance and Super Bugs

Methicillin-resistant Staphylococcus aureus (MRSA) is the most common type of hospital-acquired infection, affecting around 100,000 people every year. Concern surrounding this rate of infection has resulted in a high, media-fuelled concern over hospital cleanliness and hygiene standards. According to government figures, the number of cases in England and Wales has increased by 600% over the past 10 years and is estimated to cost the NHS around 1bn a year. The public services union, Unison, mostly blamed the privatisation of hospital cleaning for the lowering of standards. Since privatisation, the number of cleaners has halved to 55,000 in 2003/2004. Other problem infections include Clostridium difficile, glycopeptide-resistant enterococci and acinetobacter.
Litigation and Negligence

According to the DoH, around 5% of the population report suffering from injury or illness every year, with expenditure of 446m in 2001/2002. In 2002/2003, the NHS Litigation Authority handled around 7,000 claims and the cost of litigation is recognised to amount to 0.04% of gross domestic product (GDP).
Healthcare Commission Report

The following information is taken from the Healthcare Commissions State of Healthcare report, which was published on 18th July 2005 ( 2005 Commission for Healthcare Audit and Inspection). In England, the overall satisfaction of patients with most NHS services is high. The focus on waiting times by the Government and healthcare services is beginning to pay off, in spite of growing demands on services. People are able to gain access to many services more quickly and easily than in the past, with many taking advantage of new ways to receive care and treatment; for example, through NHS Direct and walk-in centres.
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The number of people waiting more than 6 months for admission as an inpatient in England is down by 85% from March 2000 to March 2005. There has also been a significant drop in the number of people waiting more than 13 weeks for an appointment as an outpatient down by 92% over the same period. There have been improvements in outcomes of care and treatment for people who have coronary heart disease or cancer. Mortality rates for cancer have gradually decreased, even as the number of people being diagnosed with cancer has increased, and fewer people are dying from coronary heart disease. While recent figures from the Government show that performance in meeting the 48-hour target for booking appointments with GPs is being met, people in some areas are now finding it increasingly difficult to book appointments in advance or see a GP out of normal working hours. Many people also experience problems gaining access to NHS dentists, with 58% of dental practices not taking on new NHS patients (up 40% from 2001). In some areas, however, services still fall short of national standards, particularly in areas of healthcare which are not considered high priority or which are not subject to Government targets. In mental health, only two-thirds of community-based crisis resolution teams operate 24 hours a day and fewer than half of people who receive mental health services reported that they had access to crisis care. More than a quarter of people in urgent need of sexual health services wait more than 48 hours for an appointment, while a quarter of people with symptoms of sexual infection wait more than 2 weeks to be seen. The opening times of sexual health services was another cause for concern, with half of NHS clinics open for less than 21 hours a week. The Healthcare Commissions investigations have also uncovered significant problems in some maternity services, such as poor standards of cleanliness, overcrowding and inadequate support for women whose first language is not English. Although the majority of patients feel that they receive enough information about their care and treatment, there is worrying evidence on how they receive information, what information they receive and whether they are involved in decisions about their care. Around a third of patients said that they did not understand the results of their diagnostic tests and received conflicting information from different health professionals. Patients from some groups within the community are getting a worse deal from healthcare services than others. This was evident among seldom-heard groups, such as travellers, homeless people and people with learning difficulties, and people who live in poorer areas of the community. For example, more than a quarter of homeless people are not registered with a GP, compared with 3% of the population as a whole. The take-up and success of immunisation, screening and stop smoking services is also lower in poorer areas.
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This years State of Healthcare report highlights a number of lessons for providers of healthcare and regulatory bodies, such as the Healthcare Commission. In particular, the report identifies the need to:
improve how services are assessed provide better information about services involve patients in the design of services give people more control develop and spread good practice take action on wider inequalities of health.
Demographic Pressures
Between 1971 and 2004, the UK population increased by 6.9% and it is projected to reach 60.3 million by 2006 and 64.9 million by 2026. The population has also been ageing steadily, with those of pensionable age rising from 18.4% in 2002 to a projected 21.4% by 2026 (see Table 1.11 in Chapter 1 Market Overview). The increasing numbers of elderly people will add to the pressures on the NHS.
Chlamydia Screening Programme

To date, 26 regional screening programmes have been implemented for chlamydia screening, offering screening to asymptomatic men and women under the age of 25, covering more than 25% of PCTs in England. The aim of the programme is to control the soaring chlamydia infection rate through early detection and treatment. The Government has provided funding worth 342m.
Private Finance Initiative

During 2004, five private finance initiative (PFI) schemes with a total capital value of more than 90m became operational. As at June 2005, there are now 50 operational hospital schemes, of which 42 were delivered under the PFI as part of the NHS Plan target of over 100 hospital schemes by 2010. A further 15 schemes were given approval to proceed during 2004. In 2005, seven more hospital schemes are expected to become operational. In July 2005, the Government announced plans to spend 2.5bn over the next 5 years in contracts with the private sector to perform fast-track day surgery on NHS patients.
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MARKET SIZE
Key Note estimates that, in 2005, total UK expenditure on the NHS will reach 89.89bn, a rise of 9.7% on 2004. Between 2001 and 2005, expenditure increased by an estimated 43.8%.
Table 5.1: Total UK Expenditure on the National Health Service (m), 2001-2005
2001
Value (m)
e Key Note estimates Note: these figures apply to services only and do not contain government central administration costs. They may also contain elements not in the overall government budget.
2002 67,159 7.4
2003 74,592 11.1
e2004
e2005
62,509 -
81,935 9.8
89,890 9.7
Source: Annual Abstract of Statistics, National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)/Department of Health Annual Report 2005 Crown copyright/Key Note
Figure 5.1: Total UK Expenditure on the National Health Service (m), 2001-2005
90,000 85,000 80,000 75,000 70,000 65,000 60,000 55,000 50,000 2001 2002 2003 2004 2005
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SUPPLY STRUCTURE
Since its inception, the NHS has evolved considerably and successive governments have introduced a wide and often conflicting range of reforms. Perhaps the furthest-reaching reform was the attempt by the then Conservative Government to create an internal free market within the NHS by dividing it into purchasers (local authorities, national health boards and fundholder GPs) and providers (NHS trusts). The aim of creating the internal market was to introduce choice using market competition, with the aim of improving efficiency and reducing costs. The private sector was to add another dimension to this market by competing for NHS tenders and contracts. Involvement of the private sector was extended through the introduction of the PFI, which was intended to generate capital investment for much-needed new healthcare facilities to replace the ageing post-war infrastructure. When the current Labour Government took office in 1997, it immediately abolished all GP fundholders, as well as the internal market, although it retained many of the elements that formed it. The NHS was still organised along divisions in the commissioning of care and the provision of care, albeit in altered forms. Devolution in July 1999 created National Assemblies for Scotland, Wales and Northern Ireland, all of which had varying degrees of autonomy in the setting, distribution and prioritisation of their NHS budgets.
Strategic Health Authorities

28 strategic health authorities (SHAs) were established in 2002/2003 to act as the local headquarters of the NHS, including the performance management of both NHS trusts and PCTs. SHAs have a statutory obligation to contain revenue and resource spending. In 2003/2004, all SHAs achieved their statutory financial duties and the financial balance performance measure.
Primary Care Trusts

PCTs comprise local interest groups, NHS trusts and local authorities. These determine and agree the priorities for their local health services and the health of local communities, and have the responsibility for the commissioning of care. Certain PCTs are also responsible for the provision of community services to their local population. PCTs are responsible to SHAs and there are 303 of them in England.
NHS Trusts
NHS trusts (and health and social services trusts [HSSTs] in Northern Ireland) are autonomous bodies responsible for the provision of hospital and community services. (In Scotland, this role is taken by the Scottish health boards.) With the exception of Northern Ireland, these bodies can also commission research and professional education and training programmes. NHS trusts derive most of their income from PCTs. In England, there were 269 operational NHS trusts in 2004.
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Monitoring of Standards of Care

Successive governments have introduced a wide range of measures to monitor standards of care and improve accountability. There has been a move away from the system driven mainly by national targets towards one with more scope for addressing local priorities, with incentives for improvement involving all local services. The standards-driven system comprises:
core standards setting out minimum requirements for existing services developmental standards providing a framework for improvement standards for better health key performance requirements of all
healthcare organisations, which are designed to improve standards by identifying areas for improvement. The guidance of the national service frameworks (NSFs) and National Institute for Clinical Excellence (NICE) is an integral part of the standards-based system, and although the emphasis is on local targets, national targets will still be set as necessary. The national priorities for 2005/2006 and 2007/2008 are as follows:
health and wellbeing of the population preventative healthcare and

health promotion
patient/consumer experience promotion of choice, provision of

information and consumer-focused service provision
access to services fair and equitable access to timely healthcare long-term conditions promotion of better self-care and communitybased care.
The Private Finance Initiative

The PFI for healthcare was introduced in 1992 in order to generate finance and capital investment in the NHS infrastructure, particularly hospital facilities. Although the process has been streamlined and simplified, it remains a complex and frequently slow process. The process is overseen by the NHS Capital Prioritisation Advisory Group, which aims to ensure that the main focus of projects is to meet the needs of the NHS.
Organisation of the NHS

The NHS is organised into two principal service supply structures:
HCHS these are the so-called secondary and tertiary healthcare services.
They are run by NHS trusts and comprise the NHS network of hospitals and outpatient services, as well as specialist services, including diagnostic and screening services and blood donations. (See Chapter 6 Hospital and Community Health Services.)
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FHS these are responsible for the provision of primary healthcare

services, including pharmaceutical services (PHS), general and personal medical services, dental services and general ophthalmic services (GOS). (See Chapter 7 Family Health Services.)
FORECASTS
The Government is continuing to invest heavily in healthcare, as it has done since taking office. As a result of this, and the various plans and initiatives that the Government has introduced, expenditure on NHS services is forecast to rise from 99.72bn in 2006 to an estimated 138.7bn by 2010, an increase of 39.1%.
Table 5.2: Forecast Total UK Expenditure on the National Health Service (m), 2006-2010
2006
Value (m)
2007 108,156 8.5
2008
2009
2010
99,718 10.9
117,483 127,647 138,704 8.6 8.7 8.7
Source: Key Note

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Figure 5.2: Forecast Total UK Expenditure on the National Health Service (m), 2006-2010
150,000 140,000 130,000 120,000 110,000 100,000 90,000 80,000 2006 2007 2008 2009 2010
Source: Key Note

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DEFINITION
Hospital and community health services (HCHS) are responsible for the provision of outpatient services, screening and diagnostic services, blood donor services and certain community-based services.
KEY TRENDS
Budget Priorities
Acute services take up around 55% of the HCHS budget, which reflects the demand for emergency treatment and the current focus on reducing waiting lists and times. Mental health services account for 13% of the budget, followed by community services, at 9%.
Patient Trends
In 2002/2003, people aged 65 years and older (although constituting only 16% of the population) accounted for around 47% of total HCHS expenditure. According to the Department of Health (DoH), this is primarily because high levels of acute care expenditure and significant levels of mental health expenditure were used on patients aged 65 years or older.
Waiting Lists
As at the end of May 2005, the number of patients in England waiting for over 6 months for admission into NHS hospitals was 49,600, an increase of 9.3% on April, but a fall of 42.2% on the same period in 2004. The total number of patients waiting for admission into hospitals in England was 826,000 at the end of May 2005, a fall of 0.1% from the end of April 2005 and a decrease of 7.6% on the same period in 2004. There were only 17 patients who were waiting for more than 9 months at the end of May 2005 and no patients were waiting for more than 12 months.
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NHS Beds and Patient Turnover

NHS bed numbers have been declining since the 1990s, partly because of the widespread move to community-based care for those with mental disabilities, and partly because new technology has improved the throughput of patients through reduced recovery times. There has, however, been widespread recognition that more beds are needed. According to the Kings Fund, the government targets for 2,100 more acute beds, 300 critical care beds and 5,000 intermediate beds have largely been met, apart from a slight shortfall in intermediate beds.
Hospital Cleanliness and Antibiotic Resistance

Under the methicillin-resistant Staphylococcus aureus (MRSA) surveillance system, there were 7,212 MRSA cases in 2004/2005, compared with 7,684 cases in 2003/2004. There has been considerable publicity surrounding antibiotic resistance, and public concern and awareness of the problem has been rising.
Changes to the Ambulance Service

At the end of June 2005, the Government announced sweeping changes to the ambulance service in England to be made over the next 5 years. As part of the reforms to improve efficiency and streamline responses, ambulance staff will be trained and equipped to perform diagnostic tests and undertake basic procedures in the home. In addition, they will be able to refer patients to social services and directly admit patients to specialist units, as well as prescribe a broader range of medicines. It is anticipated that these changes will particularly benefit rural communities and more patients with urgent, although not dangerous, conditions could be treated at home rather than being taken to hospital. The DoH estimates that at least 1 million people taken to an accident and emergency (A&E) department each year could be treated at the scene. Ambulance staff will also make routine assessments of long-term patients in their homes in partnership with general practitioners (GPs) and nurses. In addition, improved technology and reorganisation will be aimed at improving response times to ensure that the most urgent cases are reached first. Alongside this, non-urgent calls to emergency services will be offered more advice. Response times for the most urgent calls will be measured from the call connection to minimise differences in measurement of response times. In order to fully implement the reforms, the number of emergency care practitioners will be significantly increased from the current 600 working in England.
MARKET SIZE
According to the DoH, expenditure on HCHS has been rising since 2001, fuelled by the unprecedented amounts of money injected into the health service. Expenditure is estimated to have risen from 48.24bn in 2001 to 69.73bn in 2005, an increase of 44.6%. Annual growth in 2005 is an estimated 10.2%.
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Table 6.1: The Total UK Hospital and Community Health Services Market by Value (m), 2001-2005
2001
Value (m)
e estimates
2002 51,641 7.1
2003 57,438 11.2
e2004
e2005
48,236 -
63,280 10.2
69,728 10.2
Source: Annex A2, Department of Health Annual Report 2005 Crown copyright
Figure 6.1: The Total UK Hospital and Community Health Services Market by Value (m), 2001-2005
75,000 70,000 65,000 60,000 55,000 50,000 45,000 40,000 2001 2002 2003 2004 2005
Note: figures for 2004 and 2005 are estimates.
Annex A2, Department of Health Annual Report 2005 Crown copyright
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In 2003/2004, there were 13.2 million finished consultant episodes, of which 51% had associated surgery. An episode refers to the average length of a patients treatment course, either surgical or medical. There were 9.4 million ordinary admissions between 2003 and 2004, of which 35.9% were associated with surgery. The number of day cases reached 3.8 million accounting for 28.5% of all finished consultant episodes of which the majority (88.6%) had an operation. 4.2 million admission episodes (35.5%) were emergency admissions. In the same period, 113,124 private patients were treated in NHS hospitals. In addition, there were 574,545 maternity deliveries and 266,330 deaths in NHS hospitals.
Table 6.2: Profile of Hospital Activity for England by Number of Episodes and Admissions, 2003/2004
Finished consultant episodes Ordinary admissions Day cases Private patients treated in NHS hospitals Deliveries (births) Total admissions Emergency admissions Discharges Deaths Waiting list (including booked) 13,174,480 9,417,004 3,757,476 113,124 574,545 11,699,163 4,158,734 11,757,022 266,330 4,227,180
Source: Hospital Episode Statistics 2003-2004, Department of Health Crown copyright
SUPPLY STRUCTURE
HCHS are provided in a nationwide network of NHS hospitals, clinics and day centres. In recent years, many small cottage hospitals have closed, as care has devolved to larger centres of excellence.
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In addition to acute care services, HCHS are responsible for a number of community-based services, including the following:
district nurses health visitors community midwives school nurses physiotherapy chiropody family planning clinics occupational and speech therapies community dental services day care services.
There is a degree of overlap with family health services (FHS) and, where this occurs, the services are organised and managed by working groups of relevant staff.
BUYING BEHAVIOUR
In 2003/2004, the most commonly performed operations were those on the upper digestive tract, at 513,087. 68% of these procedures were dealt with as day surgery cases. Cataract operations were the second most commonly performed surgical procedure, but the vast majority of these (92%) were day surgery cases and the average waiting time for such an operation was relatively long, at 148 days. There were 64,228 heart operations performed over the same period, with only 3% of percutaneous transluminal operations on coronary arteries (PTCAs) carried out as day surgery cases. Waiting times for heart operations ranged from 93 to 108 days. There were 81,437 hip replacements performed in 2003/2004 and these had, by far, the longest waiting times of any surgical procedure, at an average of 221 days. There were 1,480 kidney transplants carried out in the same period and these had the shortest waiting times of an average of 23 days. In addition, the majority of surgery was performed on older patients, with the exception of kidney transplants, which had an average patient age of 42 years.
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Table 6.3: Hospital Operations in England by Type (number, days, years and %), 2003/2004
Average Average Finished Episodes Operation Type
Upper digestive tract Cataract Hip replacement Heart (PTCA) Heart (CABG) Kidney transplant
Waiting Time (days) 53 148 221 93 108 23
Length of Stay (days) 12.7 1.5 13.3 3.5 12.6 14.6
Mean Age (years) 59 75 73 63 66 42
% of Day Cases 68 92 0 3 0 0
513,087 298,404 81,437 41,267 22,961 1,480
PTCA percutaneous transluminal operations on coronary artery CABG coronary artery bypass graft
Source: Hospital Episode Statistics, 2003-2004, Department of Health Crown copyright
In terms of the major diagnostic groups, the largest single group of patients were those suffering from cancer, which contained more than twice as many as the next largest primary diagnostic group, comprising respiratory diseases such as pneumonia and influenza. 14% of ischaemic heart disease was dealt with as day cases. The youngest patients were those being treated for head injuries, with an average age of 37 years.
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Table 6.4: Hospital Episodes in England by Primary Diagnostic Group (number, days, years and %), 2003/2004
Average Average Finished Episodes Primary Diagnostic Group
Cancer Influenza, pneumonia, etc. Ischaemic heart disease Hernia Head injuries
Waiting Time (days)
Length Mean % of of Stay Age Day (days) (years) Cases
1,390,107 672,939 425,452 162,998 133,855
44 144 100 127 19
8.4 7.5 7.2 3.3 3.7
60 55 68 55 37
56 4 14 48 7
Source: Hospital Episode Statistics, 2003-2004, Department of Health Crown copyright
FORECASTS
In 2006, expenditure on HCHS is forecast to grow by 11.7% to 77.89bn. Between 2006 and 2010, expenditure is expected to rise by 40.8% to 109.67bn. Growth will be fostered by a combination of increasing funds, the expanding scope of the marketplace and demographic trends.
Table 6.5: The Forecast Total UK Hospital and Community Health Services Market by Value (m), 2006-2010
2006
Value (m)
f Key Note forecasts
2007 84,688 8.7
f2008
f2009
f2010
77,892 11.7
92,310 9.0
100,618 109,674 9.0 9.0
Source: Annex 2, Department of Health Annual Report 2005 Crown copyright/Key Note
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Figure 6.2: The Forecast Total UK Hospital and Community Health Services Market by Value (m), 2006-2010
120,000 110,000 100,000 90,000 80,000 70,000 60,000 50,000 40,000 2006 2007 2008 2009 2010
Note: figures for 2008 to 2010 are Key Note forecasts.
Source: Annex 2, Department of Health Annual Report 2005 Crown copyright/Key Note
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DEFINITION
Family health services (FHS) are the arm of the NHS responsible for primary care services in the UK. Service provision is comprehensive and encompasses the following:
pharmaceutical services (PHS) general and personal medical services dental services general ophthalmic services (GOS).
Many of the providers of these services are effectively independent professionals who contract their services out to the NHS.
KEY TRENDS
Improved Access
Many of the Governments NHS reforms are aimed at primary care, which is perceived as being crucial to implement government targets in improving public health and reducing levels of ill health and disease through proactive and preventative medicine. Many reforms have been designed to improve overall access to primary care services through improvements in service delivery.
NHS Walk-In Centres

In 2005, there were 64 NHS walk-in centres that are designed to improve access to services and complement general practitioner (GP) and accident and emergency (A&E) services. Since their introduction in 2000, the centres have seen around 6 million people, and each centre sees an average of 115 patients per day. The Department of Health (DoH) is planning to open seven more walk-in centres to cater for commuters, giving them access to primary care near the workplace.
Organisation
From October 2002, primary care trusts (PCTs) assumed responsibility for ophthalmic matters and performed a review of the practitioners and services.
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Restructuring of Primary Care

In July 2005, the government announced plans for the comprehensive restructuring of primary care services. In the latest plans, many of the current 303 PCTs in England will merge and cease to have responsibility for the employment of district nurses, community care nurses, various therapists and other frontline healthcare workers. Instead, responsibility for these services will be taken over by a combination of charities, private healthcare organisations and various public bodies, including social services and Foundation Trusts. Concern has been voiced by the Kings Fund and other organisations about the impact that these reforms will have on patient choice.
NHS Local Improvement Finance Trust

The NHS Local Improvement Finance Trust (LIFT) initiative is driving the development of new primary care facilities. LIFT projects are being established as limited companies, together with PCTs, the private sector and Partnerships for Health (PfH), the joint-venture company formed by the DoH and Partnerships UK. PfH supplies procurement support to NHS LIFT projects together with equity investment. Priority is being given to inner city and rural schemes deemed to be the areas of greatest need. There are now 51 LIFT projects attracting over 490m of capital investment.
MARKET SIZE
Key Note estimates that total expenditure on the FHS market rose from 18.66bn in 2004 to 20.16bn in 2005, an increase of 8.1%. The highest levels of expenditure are in the PHS market, which accounts for an estimated 56.1% of all FHS expenditure in 2005.
Table 7.1: The Total UK Family Health Services Market by Sector by Value (m), 2001-2005
2001
Pharmaceutical services General personal and medical services Dental services
2002 8,230 4,873 2,045
2003 9,176 5,470 2,115
e2004
e2005
7,293 4,656 1,962
10,249 5,798 2,200
11,304 6,146 2,288
Table continues...
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Table 7.1: The Total UK Family Health Services Market by Sector by Value (m), 2001-2005
...table continued 2001
General ophthalmic services
2002 370 15,518 8.7
2003 393 17,154 10.5
e2004
e2005
362 14,273 -
408 18,655 8.8
424 20,162 8.1
Total % change year-on-year

Figure 7.1: The Total UK Family Health Services Market by Value (m), 2001-2005
25,000 20,000 15,000 10,000 5,000 0 2001 2002 2003 2004 2005
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FORECASTS
Key Note forecasts that, between 2006 and 2010, the total UK FHS market will grow by 33% to 29.03bn (see Table 7.2).
Table 7.2: The Forecast Total UK Family Health Services Market by Sector by Value (m), 2006-2010
2006
Pharmaceutical services General and personal medical services Dental services General ophthalmic services
2007 13,614 6,906 2,487 461
2008 14,839 7,251 2,599 484
2009 16,174 7,614 2,730 511
2010 17,629 7,995 2,867 539
12,490 6,515 2,380 441
Total
21,826 23,468 8.3 7.5
25,173 27,029 29,030 7.3 7.4 7.4
Source: Key Note

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Figure 7.2: The Forecast Total UK Family Health Services Market by Sector by Value (m), 2006-2010
30,000 28,000 26,000 24,000 22,000 20,000 18,000 2006 2007 2008 2009 2010
Source: Key Note

PHARMACEUTICAL SERVICES
Definition
PHS are responsible for the provision and delivery of prescription medicines as prescribed by general medical services through the NHS. Delivery is carried out by registered pharmacists operating from licensed premises, who dispense medicines as prescribed by GPs. Licensed premises range from small independent community pharmacies and community pharmacy chains to large high-street retail chemists. Pharmacies also sell pharmacy-only, over-the-counter (OTC) medicines, as well as the more widely available general sales list medicines. In addition, these pharmacies sell a wide range of health and beauty products, toiletries, alternative medicines, vitamins, minerals and supplements, and certain nutritionals.
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Key Trends
The NHS Plan and the Expanding Role of Pharmacists
Integral to the NHS plan is the utilisation and expansion of the role of pharmacists in acting as key information providers to the public and the managers of prescription services. The Government is also committed to the promotion of electronic prescribing and has proposed the expansion of supplementary prescribing powers still further to include other groups of healthcare professionals, such as pharmacists, optometrists, chiropodists, radiographers and physiotherapists.
The Drugs Bill and Price Regulation

Pharmaceutical supplies are the largest single cost to FHS and the drugs bill is continuing to rise significantly, in spite of government initiatives to control and curb costs. These measures include increasing prescription charges, the pharmaceutical price regulation scheme (PPRS) and promoting the use of cheaper generic products. The Government has agreed two schemes for the reimbursement of generic medicines to replace the Maximum Price Scheme that was introduced in August 2005. The DoH estimates that the agreements will generate savings of around 300m each year and the schemes will be in operation over the next 5 years. Around 80% of prescriptions are now written generically. A new voluntary 5-year agreement following negotiations with the Association of the British Pharmaceutical Industry (ABPI) replaced the 1999 PPRS. It is estimated that the new agreement will save the NHS 1.8bn over the next 5 years.
Prescription Volume and Charges

From 1st April 2005, the prescription charge in England rose by 10 pence to 6.50 per prescription item, making it the seventh consecutive year that the prescription charge has risen by this amount. The DoH has projected that this rise will contribute 452m to the NHS. The volume of prescriptions and the average number of prescriptions dispensed by pharmacies are also continuing to rise. The percentage of prescriptions that are subject to a prescription charge has remained relatively constant, between 13.7% and 14.9% over the past 5 years. The gross cost of a prescription increased by 0.4% in 2003/2004.
Increased Generic Prescribing

Around 80% of prescriptions are now written generically and the DoH remains committed to promoting generic prescribing where appropriate as part of its programme of measures to contain costs.
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Consolidation of Pharmacy Outlets

Retail pharmacy outlets are continuing to consolidate, with the percentage of pharmacies belonging to a chain of five or more pharmacies reaching 53% in 2003/2004, compared with 52% in the previous year. The overall number of pharmacies has stabilised since 2001.
Proposed Changes to the Pharmacy Contract

In August 2004, the Government announced proposals to change the pharmacy contract regulations. As well as updating and amending the assessment process for pharmacy contract applications, NHS pharmacy contracts will be granted to:
any party willing to open for over 100 hours per week those in large shopping centres (more than 15,000 square metres) distant
from town centres
pharmacies established by consortia as part of a package to provide a

comprehensive range of one-stop primary healthcare services to a population of at least 18,000 patients
Internet and mail-order pharmacies that provide a full range of services.

From April 2005, pharmacists are rewarded for the range and scope of the services they provide, rather than just the volume of medicines dispensed. The new contract also includes repeat prescribing as an essential service.
Market Size
Prescription pharmaceuticals are the single largest cost to FHS and these are continuing to rise. This increase in costs is driven by growing demand, partly due to demographic pressures and partly as a result of technology, driven by new developments in the pharmaceutical industry. Between 2001 and 2005, the total UK PHS market increased by 55% to an estimated 11.3bn. Annual growth peaked at 12.8% in 2002, before slowing slightly to 10.3% in 2005.
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Table 7.3: The Total UK Pharmaceuticals Services Market by Value (m), 2001-2005
2001
Value (m)
2002 8,230 12.8
2003 9,176 11.5
e2004
e2005
7,293 -
10,249 11.7
11,304 10.3
Source: Annual Abstract of Statistics, National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)/Key Note
In the year ending December 2004, 675.6 million prescription items were dispensed in England and Wales, a rise of 5.6% on 2003. According to the Prescription Pricing Authority (PPA), cardiovascular prescriptions were the largest single group, with 200.3 million prescription items. This group also had the highest levels of growth in 2004, at 11.5%. Central nervous system (CNS) drugs constituted the second-largest therapeutic group of prescription items, at 119 million, but recorded a comparatively low growth in 2004 of 3.4%.
Table 7.4: Number and Type of Prescriptions Dispensed in England by Diagnostic Group (million and %), Year Ending December 2004
Number of Items (million) Diagnostic Group
Cardiovascular Central nervous system Endocrine system Gastrointestinal Respiratory
% Change 2003-2004 11.5 3.4 7.4 4.8 1.2
200.3 119.0 54.0 50.9 50.7
Table continues...
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Table 7.4: Number and Type of Prescriptions Dispensed in England by Diagnostic Group (million and %), Year Ending December 2004
...table continued Number of Items (million) Diagnostic Group
Infections Others
% Change 2003-2004 -2.4 3.6 5.6
37.3 163.5
675.6
Total
does not sum due to rounding
Source: Key Note, adapted from data from the Prescription Pricing Authority/NHS Health & Social Care Information Centre
Supply Structure
According to the DoH, there were 10,462 community pharmacies contracted to PCTs in England and Wales, with an increase of ten pharmacies on 2003. In terms of ownership, 53% of pharmacies were owned by large pharmacy chains, an increase of 1% on the previous year. Certain supermarket chains, such as Tesco or Sainsburys, have in-store pharmacies. According to the Office of Fair Trading (OFT), there were around 12,250 community pharmacies throughout the UK in 2003/2004, with an estimated 5,000 people for every pharmacy in England, compared with 4,400 in Scotland, 4,100 in Wales and 3,300 in Northern Ireland. The position and placing of community pharmacies is highly regulated in order to ensure local access to populations, with local trusts or boards considering applications for contracts on the basis of need. According to the OFT, 79% of the population have a community pharmacy within 1 kilometre of their home, and 75% within 300 metres. Of these pharmacies, around 244 will have received payments under the essential small pharmacy scheme. (The report is available free from the OFT www.oft.gov.uk.)
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Table 7.5: Number of Pharmacies Contracted to Health Authorities in England and Wales, 1999/2000-2003/2004
1999/2000 2000/2001 2001/2002 2002/2003 2003/2004 10,474 10,471 10,463 10,452 10,462
Source: General Pharmaceutical Services for England and Wales, 1999/2000- 2003/2004, Department of Health Crown copyright
Figure 7.3: Number of Pharmacies Contracted to Health Authorities in England and Wales, 1999/2000-2003/2004
10,480 10,475 10,470 10,465 10,460 10,455 10,450 10,445 10,440 1999/2000 2000/2001 2001/2002 2002/2003 2003/2004
Source: General Pharmaceutical Services for England and Wales, 1999/2000- 2003/2004, Department of Health Crown copyright
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Major Players
Pharmaceutical Companies
AstraZeneca
AstraZeneca is a major international healthcare business engaged in the research, development, manufacture and marketing of prescription pharmaceuticals and the supply of healthcare services. It is one of the worlds leading pharmaceutical companies, with healthcare sales of more than $21.4bn and leading positions in sales of gastrointestinal, cardiovascular, respiratory, oncology and neuroscience products. AstraZeneca is listed in the Dow Jones Sustainability Index (Global) as well as the FTSE4Good Index.
Eli Lilly and Company Ltd

Eli Lilly is a US-based company with a major UK presence, employing over 3,000 people in the UK and 43,000 worldwide. It has four major blockbuster drugs, including the CNS drug Zyprexa.
GlaxoSmithKline
GlaxoSmithKline (GSK) is the second-largest pharmaceutical company in the world. It was formed through the merger of GlaxoWellcome and SmithKline Beecham in 2000, although it had to divest a significant number of drugs to gain regulatory approval. The company produces a huge range of more than 1,400 pharmaceutical brands and is a market leader in anti-infectives, CNS disorders, and respiratory and gastrointestinal/metabolic disease. GSKs top-selling product is the respiratory drug Seretide, with sales of almost 2.5bn in 2004. In 2004, GSK had sales of 20.3bn, of which 17bn were for prescription pharmaceuticals.
Pfizer Ltd
Following its acquisition of Pharmacia in 2003, Pfizer Ltd now claims to be the largest pharmaceutical company in the UK and the largest supplier of medicines to the NHS through Pfizer Global Pharmaceuticals. The company is US based, employing over 122,000 people worldwide, and has the blockbuster drug Lipitor.
Shire Pharmaceuticals
Shire Pharmaceuticals is a UK-based pharmaceutical company employing over 2,000 people, of whom 200 are UK based. The company develops drugs mainly for CNS disease, metabolic disease, cancer and gastroenterology. It has a number of major prescription pharmaceutical products, including Reminyl for Alzheimers disease.
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Pharmacy Chains
Retail and community pharmacy outlets in the UK are dominated by three major pharmacy chains: Boots the Chemist, Lloyds Pharmacy and Moss Pharmacy.
Boots the Chemist

Boots is the largest high-street pharmacy chain in the UK, with over 1,400 stores, almost all of which have pharmacists. In 2004, the core pharmacy business dispensed 94 million prescription items. In 2004, the company opened 80 new pharmacies and more than a quarter of its prescription customer base are signed up to their prescription collection service. During April 2005, the Boots Company PLC put Boots Healthcare International, its OTC medicines business, up for sale. Boots Healthcare International manufactures several major brands, including Nurofen, Strepsils and Clearasil.
Lloyds Pharmacy
Lloyds Pharmacy owns 1,390 community pharmacies throughout the UK and is the largest community pharmacy operator in the UK. It is a wholly owned subsidiary of Celesio AG (previously GEHE), which is the largest pharmaceutical wholesaler in Europe. The company has expanded through multiple acquisition.
Moss Pharmacy
Moss is the UK retail pharmacy division of the major pharmaceutical wholesaler Alliance Unichem. The company recently announced that its Moss Pharmacy chain would be rebranded as Alliance Pharmacy, with newly branded stores with upgraded services opening from mid-March 2005. As of December 2004, the company had 878 pharmacy outlets in the UK.
Buying Behaviour
Prescription pharmaceuticals can only be obtained via an authorised prescription from a GP and then from a licensed pharmacy dispensed by a registered pharmacist. These pharmacies operate as small local community pharmacies, larger retail pharmacies situated in high streets or through hospital pharmacies and, under the terms of the new pharmacy contract, eventually Internet or mail-order pharmacies. Unless the patient is exempt, a prescription charge of 6.50 per item is levied. However, there are a number of patient groups and prescriptions exempt from charges, including the following:
individuals under 16 years old students in full-time education under the age of 19 years individuals aged 60 years or over expectant and nursing mothers
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those with certain chronic listed medical conditions, such as diabetes or

physical disabilities
NHS inpatients war-disabled people individuals (and their dependants) on income support, family credit or
disability working allowance
those with NHS charges certificates for full help bulk prescriptions for schools diagnostic test procedures contraceptives.
Although contraceptives are exempt, hormone replacement therapy (HRT) is not and, moreover, has a double charge applied, since it technically has two active ingredients, oestrogen and progesterone.
Advertising and Promotion

Under the ABPI code of practice, promotional activities are strictly controlled for prescription pharmaceuticals. They cannot be advertised to the general public and there are also strict controls on promotional activities to healthcare professionals. Pharmaceutical companies can spend up to 9% of their turnover on promotional activities and must comply with the Medicines Act. The majority of advertising is carried out in professional publications or directly to healthcare professionals via dedicated sales representatives.
Forecasts
The need for PHS and pharmaceuticals is intrinsic and expanding as a result of increasing levels of ill health associated with an ageing population. In addition, the range and scope of treatments is continually expanding as a result of new drug development. Key Note estimates that the PHS market will grow significantly over the next 5 years (to 2010), with annual growth reaching 10.5% in 2006 before settling to 9% year on year until 2010, when the market is forecast to reach 17.63bn.
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Table 7.6: The Forecast Total UK Pharmaceutical Services Market by Value (m), 2006-2010
2006
Value (m)
2007 13,614 9.0
2008 14,839 9.0
2009 16,174 9.0
2010 17,629 9.0
12,490 10.5
Source: Key Note

GENERAL AND PERSONAL MEDICAL SERVICES

Definition
General medical services are the frontline of healthcare in the UK, acting as the gateway to the secondary, tertiary and specialist services of NHS healthcare. These services comprise qualified GPs, operating from practices contracted to the NHS. GP practices are also associated with a variety of nursing professionals.
Key Trends
There are over 300 million GP consultations in England each year.
Access to General Practitioners

The NHS target was set for guaranteed access to a primary care professional within 24 hours and a GP within 48 hours to be achieved nationally by 2004. According to the DoH, the primary care access survey carried out in January 2005 indicated that 99.9% of patients were offered appointments within 2 working days and the same percentage of patients were offered an appointment with a primary care professional within 1 working day. Improving access to primary care services is integral to the new general medical services (GMS) contract, requiring PCTs to offer practices incentive payments for improving access.
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New General Practitioner Contracts

Following a review, the new GP contract was implemented in 2003, resulting in the transformation of out-of-hours GP services provision. The new contract allows for GPs to opt out of out-of-hours provision, with PCTs taking responsibility from 2005. The cost of opting out is 6% of practice income, or 6,000 per GP. PCTs are able to organise provision as required from NHS Direct, NHS walk-in clinics, GP co-operatives or practices, community nursing teams and commercial providers, among others. Although extra government funding was available for PCTs to fund their out-of-hours provision, major problems have arisen, with most GPs opting out of provision, but then able to hire out their services for out-of-hours work at high rates. There have been reports of GPs being brought in from the continent, most notably Germany, to provide weekend cover.
Market Size
General medical services expenditure increased from 4.66bn in 2000 to an estimated 6.15bn in 2005, a rise of 32%. There was a particularly high jump in funding available in 2003, as government funding was made available for the new GP contracts and out-of-hours provision.
Table 7.7: The Total UK General and Personal Medical Services Market by Value (m), 2001-2005
2001
Value (m)
2002 4,873 4.7
2003 5,470 12.3
e2004
e2005
4,656 -
5,798 6.0
6,146 6.0
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Supply Structure
GPs are the core of primary care provision, operating as independent practitioners under contract to the NHS. GPs are the frontline of healthcare in the UK through the provision of diagnosis, treatment and referral of patients to specialist secondary and tertiary services. They work in partnership with teams of practice nurses, health visitors, district nurses and personal social services. In 2004, there were an estimated 39,777 GPs contracted to the NHS in the UK.
Table 7.8: Number of General Practitioners Contracted to the NHS in the UK, 2000-2004
2000
Number of general practitioners
2001
2002
e2003
e2004
37,572 -
38,162 38,649 1.6 1.3
39,228 1.5
39,777 1.4
Figure 7.4: Number of General Practitioners Contracted to the NHS in the UK, 2000-2004
40,000 39,500 39,000 38,500 38,000 37,500 37,000 36,500 36,000 2000 2001 2002 2003 2004
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In 2002, England had the highest doctor-to-patient ratio, with an average of 1,838 patients per GP. In the same period, Scotland had the lowest ratio, with 1,392 patients per GP. The number of patients per GP has fallen steadily since the early 1990s.
Table 7.9: Average Number of Patients per General Practitioner in the UK by Country, 2002
England Wales Northern Ireland Scotland 1,838 1,704 1,632 1,392
Source: Annual Abstract of Statistics, National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)
Figure 7.5: Average Number of Patients per General Practitioner in the UK by Country, 2002
1,900 1,800 1,700 1,600 1,500 1,400 1,300 1,200 1,100 1,000
England Wales Northern Ireland Scotland
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Buying Behaviour
Every resident in the UK is entitled to register with an NHS GP to receive free primary medical care and to obtain prescriptions subject to prescription charges for prescribed medicines. According to the survey that was conducted by BMRB Access in April and May 2005 for this report (see Chapter 3 Key Note Primary Research), 75% of respondents consulted a GP at least once in the last 12 months. More women (81%) than men (69%) accessed GP services, and women were also more likely than men to have consulted a GP more than once.
Forecasts
Expenditure on general and personal medical services is forecast to grow by 6% in 2006 and 2007 to reach 6.91bn, with growth then settling down to a steady 5% per annum to reach an estimated 8bn by 2010.
Table 7.10: The Forecast Total UK General and Personal Medical Services Market by Value (m), 2006-2010
2006
Value (m)
2007 6,906 6.0
2008 7,251 5.0
2009 7,614 5.0
2010 7,995 5.0
6,515 6.0
Source: Key Note

DENTAL SERVICES
Definition
Dental services in the UK are supplied by a network of independent professionals working under contract to the NHS. Some dentists are exclusively NHS or private, whereas others provide both NHS and private treatments.
Key Trends
Preventative Dentistry
Dentists are focusing increasingly on preventative dentistry. Many now have a dental hygienist operating from their practices, who specialise in plaque removal and dental hygiene.
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Dental Care Plans and Healthcare Insurance

Dental care plans are continuing to gain in popularity and certain private medical insurance policies now include certain types of dental treatment as part of the range of procedures that they provide cover for.
New Contract
The maximum price for a course of NHS dental treatment will be reduced by half to 183 under new government reforms that were announced in July 2005. A 6-month check-up, which currently costs around 6 per visit for the basic check, will no longer be recommended. People with healthy teeth will be advised to have check-ups every 18 months to 2 years, and will pay around 15 for complete preventative dentistry services. Simple fillings or extractions will cost 41. More complex treatments will cost up to 183. This simplified system will replace the current complex banding system, which contains 400 different charges. The Government is also recruiting 1,000 more NHS dentists and the budget is being increased by 269m.
Market Size
Between 2000 and 2005, the total UK dental services market grew by an estimated 16.6%, to 2.29bn.
Table 7.11: The Total UK Dental Services Market by Value (m), 2001-2005
2001
Value (m)
2002 2,045 4.2
2003 2,115 3.4
e2004
e2005
1,962 -
2,200 4.0
2,288 4.0
Supply Structure
As might be expected, England had the majority of dentists in the UK in 2002, at 82.4%, followed by Scotland, with 9.5%. In 2002, the total number of dentists in the UK was 22,194.
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Table 7.12: Number of Dentists in the UK by Country (% and number), 2002

Clinical Dental Staff England Scotland Wales Northern Ireland Total Total number 82.4 9.5 4.6 3.5 100.0 22,194
Source: Key Note, adapted from Annual Abstract of Statistics, National Statistics website
Figure 7.6: Dentists in the UK by Country (%), 2002
Wales 4.6% Scotland 9.5%
Northern Ireland 3.5%
England 82.4%
Source: Key Note, adapted from Annual Abstract of Statistics, National Statistics website
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According to the DoH, the number of adult courses of dental treatment in the UK has been falling gradually since 2001, to reach an estimated 29.8 million in 2004.
Table 7.13: Number of Adult Courses of Dental Treatment in the UK (000), 2000-2004
2000
Number of adult courses
e Key Note estimate
2001 32,401 -0.1
2002 30,558 -5.7
2003 29,947 -2.0
e2004
32,425 -
29,797 -0.5
The number of dental patients has continued to fall slightly since 2000, with 16.7 million new adult NHS patients and 6.7 million children accepted into capitation in 2002.
Table 7.14: Number of New Adult Dental Patients in England (000), 2000-2002
2000
New adult patients
2001 16,793 -0.1 6,784 -0.9
2002 16,739 -0.3 6,733 -0.8
16,813 6,845 -
Children accepted into capitation

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Funding for Dental Services

Funds for general dental services are channelled from both FHS, and hospital and community health services (HCHS), with FHS responsible for dental primary care services. The following groups qualify for free NHS dental care:
children under 18 years of age students under 19 years old in full-time education pregnant women or women with a baby under 1 year-old recipients or partners of people on income support or family credit.
People who are not in any of the above groups are obliged to pay for 80% of charges up to 325.
Buying Behaviour
It is becoming increasingly difficult for new patients to find an NHS dentist who is willing to take them on, particularly in London and the South East. In addition, many dentists are leaving the NHS, disillusioned with the funding available for service provision. In 2002/2003, the highest proportion of costs in adult dental services in England was for fillings (at 18.3%), followed by periodontal treatment (17.2%) and inlays and crowns (15.8%). According to the DoH, the number of examinations and reports has remained relatively constant since 1998/1999. Any changes in types of treatment on the NHS might be reflected in the types of treatment people are now having privately.
Table 7.15: General Adult Dental Services in England by Type of Treatment (%), 2002/2003
Fillings Periodontal treatment Inlays and crowns Examinations and reports Dentures and repairs Root fillings Bridges Other Total 18.3 17.2 15.8 14.5 11.0 4.9 4.4 13.9 100.0
Source: Key Note, adapted from Table B2, Department of Health Performance Tables Crown copyright
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Figure 7.7: General Adult Dental Services in England by Type of Treatment (%), 2002/2003
B rid g es 4.4% R o o t fillin g s 4.9%
O th er 13.9%
F illin g s 18.3%
Perid o n tal treatm en t 17.2%
Den tu res an d rep airs 11.0% Ex am in atio n s an d rep o rts 14.5%
In lays an d cro wn s 15.8%
Source: Key Note, adapted from Table B2, Department of Health Performance Tables Crown copyright
In the exclusive consumer survey that Key Note commissioned for this report, which was conducted by BMRB Access in April and May 2005 (see Chapter 3 Key Note Primary Research), more than half (53%) of respondents had visited a dentist in the last 12 months, despite the well-documented difficulties in accessing an NHS dentist. According to the survey, more women (58%) than men (47%) visited a dentist in the last 12 months.
Forecasts
Key Note forecasts that, between 2006 and 2010, the total UK dental care market will increase by 20.5% to 2.87bn.
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Table 7.16: The Forecast Total UK Dental Services Market by Value (m), 2006-2010
2006
Value (m)
2007 2,487 4.5
2008 2,599 4.5
2009 2,730 5.0
2010 2,867 5.0
2,380 4.0
Source: Key Note

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GENERAL OPHTHALMIC SERVICES

Definition
GOS from the NHS include eye testing services and the dispensing of prescribed spectacles and contact lenses. This sector does not include commercially retailed spectacles and contact lenses, or sunglasses.
Key Trends
The following trends are evident in the GOS market:
As the population ages demographically, the incidence of age-associated

eye conditions is increasing. The number of eye tests performed is also increasing, aided by the restoration of free eye tests to those of pensionable age.
The retail market for spectacle frames and contact lenses is highly
competitive and designer frames are increasingly popular. Although retailers are continuing to differentiate and add value to their products, the market is becoming increasingly price sensitive.
The availability of Internet-based services is also continuing to rise and

many have interactive computerised frame-fitting services.
In England and Wales, the total number of practitioners rose by 2.9% in

2003, with the number of optometrists rising by 3.7% and ophthalmic medical practitioners falling by 6.2% (according to the DoH). Over half of all practitioners have contracts with more than one PCT.
Following extensive consultations, the NHS sight test fee rose to 17.82
from 4th April 2004.
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Market Size
The total UK market for GOS has shown variable levels of annual growth in the past 5 years (to 2005), ranging from a low of 2.2% in 2002 to a high of 6.2% in 2003. Since 2001, the market for GOS has increased by 17.1% to an estimated 424m in 2005.
Table 7.17: The Total UK General Ophthalmic Services Market by Value (m), 2001-2005
2001
Value (m)
2002 370 2.2
2003 393 6.2
e2004
e2005
362 -
408 3.8
424 3.9
Supply Structure
In the UK, ophthalmic services are supplied by a number of independent registered practitioners operating under contract to the NHS. Professionals must be registered with the General Optical Council (GOC), which is the designated regulatory body in the UK. There are four main types of ophthalmic professionals:
Ophthalmologists/ophthalmic medical practitioners these are

medically qualified practitioners in community-based practices. Ophthalmologists are medical specialists in eye diseases and eye surgery based in hospital eye departments. In contrast to the UK, in the majority of European countries, ophthalmologists are responsible for most of the sight testing and eye examinations performed.
Optometrists these are qualified to perform eye tests; prescribe, fit and
dispense spectacles, contact lenses and low-vision aids; and recognise eye abnormalities and refer them appropriately. Optometrists provide community eye care services and operate as independent practitioners contracted to the NHS.
Dispensing opticians these are authorised to dispense and supply

spectacles, but are not authorised to prescribe. Some can also dispense low-vision aids.
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Orthoptists these treat disorders of binocular vision, working in eye

departments of hospitals under guidance from ophthalmologists. They might also carry out community-based visual screening of children. The number of optometrists contracted to the NHS in England and Wales has been rising steadily over the 5 years to 2003. Between 1999 and 2003, the number of optometrists rose by 13.5% to 8,140. In contrast, the number of ophthalmic medical practitioners fell from a peak of 742 in 2000 to 622 in 2003, a decrease of 16.2%.
Table 7.18: The Actual Number of Ophthalmic Practitioners in England and Wales by Type, 1999-2003
1999
Optometrists Ophthalmic medical practitioners
2000 7,490 742 8,232
2001 7,781 731 8,512
2002 7,850 663 8,513
2003 8,140 622 8,762
7,170 737 7,907
Total
Sight Tests and Eye Examinations

Sight tests have the same basic format, which are aimed at establishing the quality of an individuals eyesight and any deterioration or abnormalities of vision. In addition, they take into account age and any relevant health problems and medications. Sight tests follow a basic procedure, as follows:
Patient details and any specific concerns that have led to the request of an
eye test are taken. In addition, the history of any relevant symptoms and relevant personal details are taken in conjunction with establishing the visual needs of the patient.
Ocular status is established for each eye, with the testing of vision
(aided and unaided), as well as ocular motility, assessment of binocular vision and pupil reflexes.
Testing for the presence of gross visual defects is conducted. Objective refractive and subjective refraction findings are recorded. Intra-ocular pressure is measured. The visual field is assessed. Other relevant vision tests, e.g. for colour blindness, etc., are conducted.
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Once the test has been completed, the patient is advised of any relevant findings and given a prescription as necessary, along with documentation of the test results. If abnormalities have been found, an optometrist might refer the patient to an ophthalmologist, or arrange to further monitor the situation. From 2000, ophthalmologists have been granted permission to use clinical judgement in referring their patients. Protocols for referring are determined by Local Optometric Committees (LOCs) and primary care services. The number of NHS sight tests performed showed a general (although variable) increase since 2000, rising by an estimated 7.1% to 12.2 million in 2004 (based on 6-monthly figures for that year). The annual increase since 2003 was an estimated 4.2%, the highest rise since 2000. The number of spectacles paid for under the NHS voucher scheme dipped in 2001 and 2002, before rising by 1.7% in 2003. In 2004, the number of spectacles redeemed increased by 5.1% to 4.7 million, which was the highest growth level over the 5-year period.
Table 7.19: Number of UK NHS Sight Tests and Spectacles Redeemed (000), 2000-2004
2000
NHS sight tests
2001 11,650 2.4
2002 11,508 -1.2
2003 11,704 1.7
e2004
11,381 -
12,192 4.2
Number of spectacles redeemed

4,502 -
4,485 -0.4
4,355 -2.9
4,428 1.7
4,654 5.1
e estimates based on half-yearly figures
Source: Annual Abstract of Statistics, National Statistics website Crown copyright material is reproduced with the permission of the Controller of HMSO (and the Queens Printer for Scotland)/General Ophthalmic Services: Activity Statistics for England and Wales, Department of Health, 2005 Crown copyright
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Between April and September 2004, the vast majority (97.1%) of sight tests in England and Wales were performed by optometrists, which is a strong indication of the central importance of optometrists in the delivery of frontline ophthalmology services in the NHS. Ophthalmic medical practitioners were responsible for only 2.9% of tests over the same period. This is a strong contrast to the manner of service delivery in Europe, which is generally carried out by medically qualified ophthalmologists and ophthalmic medical practitioners.
Table 7.20: NHS Sight Tests in England and Wales by Type of Practitioner (% of sight tests performed), April-September 2004
Optometrists Ophthalmic medical practitioners Total 97.1 2.9 100.0
Source: General Ophthalmic Services: Activity Statistics for England and Wales, Department of Health, 2005 Crown copyright
In terms of the number of premises, the number of NHS-contracted opticians (optometrists and ophthalmic medical practitioners) fell by 6.2% between 1999 and 2003 to 6,552.
Table 7.21: Health Authority-Contracted Opticians by Number of Premises in England and Wales, 1999-2003
1999 2000 2001 2002 2003 6,984 6,868 6,878 6,544 6,552
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Major Players
Although the GOS market still has a large number of small independent operators, large multiple chains dominate the high street in a highly competitive environment. There are four major companies in the UK Boots Opticians Ltd, Dollond & Aitchison Ltd, Specsavers Optical Group and Vision Express.
Boots Opticians Ltd

Boots Opticians Ltd, which is part of the Boots Company PLC, is one of the leading chains in the UK. The company claims to sell over 1 million spectacles each year in the UK and carry out more than 30,000 eye examinations each week. Boots Opticians Ltd recorded a turnover of 206.2m in 2004.
Dollond & Aitchison Ltd

Dollond & Aitchison Ltd was founded over 252 years ago and is the oldest high-street retail chain in the UK. It was acquired in 1999 by the Italian eyewear company De Rigo and is organised into a number of operations, including the following:
Dollond & Aitchison Professional Services Ltd (for customer services) Dollond & Aitchison Eyewear Ltd Dollond & Aitchison Contact Lenses Ltd.
The company owns almost 400 stores in the UK, including franchises, employing around 3,000 people. This figure includes 600 qualified opticians, 250 dispensing opticians and more than 350 optometrists. In 2001, the company sold its manufacturing business to BBGR.
Specsavers Optical Group

Specsavers Optical Group is based on a joint-venture franchise structure with Specsavers, providing practitioners with support services. The company has more than 16 million registered customers and over 500 stores in the UK.
Vision Express
Vision Express is part of the Grand Vision Group, which is a major optical photography business. The company has almost 200 stores in the UK, employing more than 3,500 people. The company has introduced its new store concept, the Optical Lab, which was developed by Sir Terence Conrans CD partnership.
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Main Media Advertising Expenditure
In the year ending March 2005, main media advertising expenditure on prescription frames and contact lenses was 8.7m. Johnson & Johnson recorded the highest main media advertising expenditure of 3.6m. Transitions Comfort Lenses also recorded a high level of expenditure in the year ending March 2005, at 2.2m. In total, main media advertising expenditure on contact lens brands accounted for 81.4% of total expenditure in the sector. In terms of main media advertising expenditure on spectacles, Boots had the highest amount in the year ending March 2005 with 440,000.
Table 7.22: Main Media Advertising Expenditure on Prescription Frames and Contact Lenses (000), Year Ending March 2005
Johnson & Johnson Acuvue Advance Acuvue lenses 1 day Acuvue Total Johnson & Johnson Transitions Comfort Lenses Boots Opticians Prescription sunglasses Spectacles range Total Boots Opticians Freshlook colour contact lenses Essilor Lenses range Varilux lenses Total Essilor Table continues... 207 93 300 172 440 612 543 2,328 1,008 265 3,601 2,207
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Table 7.22: Main Media Advertising Expenditure on Prescription Frames and Contact Lenses (000), Year Ending March 2005
...table continued Chanel glasses Ciba Vision Focus Dailies Contact Lenses Varilux varifocal lenses Other brands Total
Note: total does not sum due to rounding by source.
265 247 197 746 8,719
Source: Nielsen Media Research
Buying Behaviour
By far, the largest number of sight tests (43%) in England and Wales were performed on older patients, aged 60 years or older. Many disorders of vision of the eye are age-related, such as short-sightedness, glaucoma, cataracts and age-related macular degeneration. Many of them are also successfully treatable if caught at an early stage. With the population of the UK continuing to age demographically, pressures on these services are likely to increase, along with costs. The next largest group undergoing NHS-funded sight tests in England and Wales was children aged between 0 and 15 years, at 21.6%, underlining the importance of catching many eye disorders, including conditions such as lazy eye and squinting or vision problems that can lead to educational problems, early on so that they can be successfully treated. Adults on income support are also a significant group undergoing NHS-funded eye tests, possibly because of the high proportion of elderly people on income support. One very important group of people undergoing eye tests are glaucoma sufferers and their relatives who are deemed to have some potential risk. Untreated glaucoma can result in irreversible blindness, although if it is caught early it can be treated before significant damage is done. Similarly, diabetics are at a high risk of developing eye problems and need to be carefully monitored.
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Table 7.23: NHS-Paid Sight Tests by Patient Eligibility in England and Wales (% of sight tests), April-September 2004
Adults aged 60 years and older Children aged 0-15 years Adults on income support Diabetics/glaucoma sufferers Adults receiving tax credits Close relatives of glaucoma sufferers aged 40 and over Students aged 16-18 years Adults receiving job seekers allowance Low income certificate holders (HC2) Patients who need complex lenses Registered blind/partially blind Total
Note: total does not sum due to rounding.
43.0 21.6 10.4 5.6 5.5 5.1 4.5 1.9 1.6 0.7 0.2 100.0
In terms of the uptake of spectacles and appliances reimbursed on the NHS, the largest single group in 2004 comprised adults on income support (at 44%), followed by children aged between 0 and 15 years (26.9%). At 6.4%, students aged between 16 and 18 years also represented a significant group.
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Table 7.24: Percentage of Spectacles/Appliances for Which Vouchers Were Reimbursed by the NHS by Patient Eligibility (%), April-September 2004
Full Vouchers Adults receiving income support Children aged 0-15 years Adults receiving tax credits Students aged 16-18 years HC2 vouchers (full remission) Adults receiving job seekers allowance HC3 partial payment of vouchers Total full vouchers Complex appliance payment only HC3 complex appliance payment Total 44.0 26.9 12.3 6.4 4.5 3.5 1.4 99.0 1.0 0.0 100.0
Forecasts
As the UK population continues to age and the incidence of age-related eye disorders continues to rise accordingly, there is added pressure on eye care services. The Government and the DoH are continuing to channel funding into primary care services and cost-effective preventative medicine. Key Note forecasts that, between 2006 and 2010, the total UK market for GOS will increase by 22.2% to 539m.
Table 7.25: The Forecast Total UK General Ophthalmic Services Market by Value (m), 2006-2010
2006
Value (m)
2007 461 4.5
2008 484 5.0
2009 511 5.6
2010 539 5.5
441 4.0
Source: Key Note

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DEFINITION
Private healthcare in the UK has emerged and developed in the shadow of a significant and comprehensive NHS. Traditionally, rather than competing with the NHS, the private sector has evolved to complement it and provide niche market services, such as cosmetic surgery and fertility treatments, or to provide routine elective surgery for those wishing to avoid NHS waiting lists. More recently, the private sector has been developing specialist markets, frequently in partnership with the NHS and fostered by the Private Finance Initiative (PFI), along with its more traditional markets. The private sector is a key provider of psychiatric services, counselling, substance dependency clinics and, increasingly, specialist diagnostics such as drug screening. Unlike many other European countries, there is no statutory requirement for healthcare insurance and the NHS is funded directly from general taxation. These factors have effectively limited the private sector to individuals opting for private medical insurance (PMI) in addition to the NHS or to those willing and able to pay directly. The private healthcare market consists of the following major market sectors:
Long-term care most long-term residential and nursing home care in

the UK is provided by private operators. Standard residential care homes are required to have a qualified nurse available on call. In contrast, nursing homes that care for those with greater medical needs must have qualified nursing care available around the clock and are accordingly considerably more costly. Many long-term care facilities now have dual registration to allow for the most cost-effective flexibility of care to cater for a residents changing medical needs.
Acute care the vast majority of acute care services in the private sector
are for routine elective surgery, particularly for procedures that are likely to have significant waiting lists on the NHS. The private acute care sector has also focused on an increasing range of niche markets that are poorly (or not) catered for by the NHS, including fertility and abortion services, LASIK and the expanding market for cosmetic surgery. Increasingly, the private sector is providing services such as diagnostic imaging, intensive care and trauma care.
Psychiatric care this includes specialist services and clinics for

rehabilitation, special needs education, behaviour modification, substance dependency and home-based care and monitoring services. The private sector also runs a number of medium-security psychiatric treatment units.
Primary care this is very much an emerging and evolving market. Apart
from a small number of private general practitioner (GP) practices or primary care facilities associated with private hospitals, much of this sector is involved in occupational health services.
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MARKET SIZE
Key Note estimates that, in 2005, the total UK private healthcare market will be worth almost 17bn, a rise of 5.8% on 2004. Long-term care accounts for the majority of the market, at an estimated 63.5% in 2005.
Table 8.1: The Total UK Private Healthcare Market by Sector by Value (m), 2001-2005
2001
2002 9,582 3,989 384 288 14,243 5.5
2003 10,153 4,406 424 304 15,287 7.3
e2004
e2005
9,300 3,581 344 274 13,499 -
10,416 4,847 469 322 16,054 5.0
10,796 5,332 523 342 16,993 5.8
Total
Figure 8.1: The Total UK Private Healthcare Market by Value (m), 2001-2005
18,000 17,000 16,000 15,000 14,000 13,000 12,000 2001 2002 2003 2004 2005
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FORECASTS
Key Note forecasts that, between 2006 and 2010, the total UK private healthcare market will grow by 34.9% to 24.41bn.
Table 8.2: The Forecast Total UK Private Healthcare Market by Sector by Value (m), 2006-2010
2006
2007 11,718 6,540 656 395 19,309 6.8
2008 12,314 7,325 738 424 20,801 7.7
2009 12,948 8,241 830 455 22,474 8.0
2010 13,634 9,354 930 490 24,408 8.6
11,242 5,892 586 367 18,087 6.4
Total
Source: Key Note

Figure 8.2: The Forecast Total UK Private Healthcare Market by Value (m), 2006-2010
26,000 24,000 22,000 20,000 18,000 16,000 14,000 12,000 10,000 2006 2007 2008 2009 2010
Source: Key Note

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LONG-TERM CARE
Key Trends
Funding and Compliance
There is chronic under-funding of long-term care by local authorities throughout the UK. Although the introduction of care-home standards through the Care Standards Act is being implemented and seen as necessary by many, compliance with and the monitoring of these standards have significantly added costs and bureaucracy to an already extremely costsensitive marketplace. In the government spending review in July 2004, the Chancellor of the Exchequer announced that, as part of government plans for healthcare, health and social care would work in close co-operation to enable old people to live in their communities whenever possible with suitable support, preventing bed blocking and reducing the need for expensive institutionalised care. However, although the Government has pledged billions in healthcare funding and local authorities have increased their fees to care-home operators, there are still significant shortfalls in funding and inequalities of long-term care provision throughout the UK. The lack of funding remains a key factor in limiting the scope, range and potential of the marketplace.
Market Polarisation
The long-term care market is increasingly dominated by large operators at the expense of small independent operators. Small operators are finding it increasingly difficult to compete with the economies of scale of the large providers or to provide a competitively comprehensive range of flexible services based on changing patient requirements. The introduction of the National Minimum Care Standards has hit small independent operators particularly hard.
Demographic Trends
The population of the UK is continuing to age demographically, with the number of very elderly people (85 years and older) expanding particularly significantly. These trends are continuing to increase the pressures on healthcare services through increased demand, and will inevitably boost demand for services associated with caring for the elderly. In 2001, the proportion of over-85s within institutionalised care was 21%, compared with 1% of 65 to 74 year-olds, according to Laing & Buisson.
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Social Trends
Traditionally, women have formed the backbone of carers within society. However, since the 1980s, a growing number of women are remaining in the workforce, even after having children, and this trend is being encouraged by a variety of government childcare initiatives. In addition, rising divorce rates, smaller family sizes and greater mobility as people move further afield and even overseas for jobs mean that traditional patterns of care are increasingly being eroded.
Increasing Investment in the Long-Term Care Market

According to analysts Matthews & Goodman, there have been signs of increasing investment in the care-home sector, particularly in London and the South East. Other market commentators have reported price rises in the sales of care homes throughout 2004, with prices up to a quarter higher than the previous year. These rises have been driven by the increased merger and acquisition activity in the marketplace, together with a perception of long-term market growth as a result of demographic trends.
Market Specialisation and Added Value

In an increasingly competitive marketplace, many care providers are enhancing existing facilities and extending their range of services in order to gain market advantage. A number of different market sectors are emerging, as providers tailor their facilities and services in order to focus more competitively on particular patient needs. As a result, the market is differentiating into a number of sectors. Some providers are focusing on assisted living and domiciliary care schemes, while others are targeting the high-end market for those who can afford it. In response, potential customers, carers and their families are becoming more selective and informed about their options.
Market Size
Although demand for long-term care has risen over the past 5 years (since 2001), fuelled by demographic trends and medical advances, the lack of funding is significantly inhibiting market growth. This is in spite of the partial adoption of the recommendations of the 2002 Royal Commission. According to industry consultants Laing & Buisson, the commercial subsector has shown a steady, if slightly erratic, growth, peaking at 8.1% in 2001. Following this, growth in the subsector ranged between 5% and 7% per annum to reach 7.3bn in 2004 and an estimated 7.7bn in 2005, accounting for 71.7% of the long-term care sector. Between 2001 and 2005, the commercial sector increased by an estimated 25.2%.
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In contrast to the commercial subsector, the public subsector has shown a gradual, if slowing, decline since 2001 and fell by 6.2% over the 5-year period to an estimated 1.7bn in 2005, accounting for 16% of the total sector. The voluntary/non-profitmaking subsector initially demonstrated significant growth, rising by 14.1% between 2001 and 2003, before decreasing by an estimated 8.8% to 1.3bn in 2005. This subsector accounted for an estimated 12.3% of the total sector in 2005.
Table 8.3: The Total UK Private Long-Term Care Sector by Subsector by Value (m), 2001-2005
2001
Commercial
2002 6,494 5.0 1,785 -3.1 1,303 2.5 9,582 3.0
2003 6,947 7.0 1,756 -1.6 1,450 11.3
e2004
e2005
6,187 1,842 1,271 9,300 -
7,307 5.2 1,745 -0.6 1,364 -5.9
7,745 6.0 1,728 -1.0 1,323 -3.0 10,796 3.6
Public
Voluntary/non-profitmaking
Total
10,153 10,416 5.6 2.6
Supply Structure
In 2004, there were 486,000 long-term care places in the UK, a fall of 1.9% on 2003. In terms of the number of places, the commercial subsector was by far the largest, with 346,700 places, of which just under half (47.4%) were nursing home places. The number of commercial places has risen by 0.2% since 2003. In the voluntary subsector, there were 64,700 places in 2004, a fall of 10% on 2003. Over the same period, the number of public sector places fell by 3.9% to 74,600 places.
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Table 8.4: Number of Long-Term Care Places by Subsector, April 2004

Commercial Residential care Nursing home care Total commercial care Public Local authority residential care NHS elderly residential NHS elderly mentally ill NHS younger physically disabled Total Public care Voluntary/Non-Profitmaking Residential care Nursing home care Total voluntary/non-profitmaking Total 49,700 15,000 64,700 486,000 44,200 19,500 9,700 1,200 74,600 182,400 164,300 346,700
Source: Key Note, adapted from Laings Healthcare Market Review 2004-2005
In 2004, the commercial subsector accounted for 71.3% of the long-term care sector in terms of the number of care places, compared with 69.8% in 2003, clearly demonstrating the continuing expansion of the commercial private subsector. In contrast, the voluntary/non-profitmaking sector declined from 14.5% of the market in terms of residential places to 13.3%. Similarly, the public sector fell from 15.7% to 15.3% over the same period.
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Legislation and Funding of Long-Term Care

Legislation relevant to the long-term care sector includes the following:
Care Standards Act 2000 The Regulation of Care Act 2001 (Scotland) The Care Home Regulations 2001 Regulation of Care (Requirements as to Care Services), Scotland,
Regulations 2002
National Minimum Standards for Care Homes 2002.

Funding of long-term care is a key element of the market. A comprehensive report, the Royal Commission Report on Long Term Care, which was published in March 2002, recommended that all costs for people in nursing homes should be fully funded. The government response was published in the NHS Plan 2000, confirming that nursing care would be funded for nursing homes among other initiatives. However, there are still significant shortfalls in funding, with hotel costs (all costs of residential care apart from the nursing and medical care, e.g. food, towels and sheets) being exempt from the funding for the first 3 months. After that, means testing would be applied. Scotland, in contrast to England, decided to fully fund long-term care.
National Minimum Standards

National Minimum Standards were introduced in April 2002 and their implementation has had major cost implications, particularly for small operators. These standards set out the basis for the physical environment of residents in long-term care, including room sizes, ensuite facilities and sharing ratios. Initially, a period of grace until 2007 was given for compliance, but following concerns relating to the effects on provision, particularly for small operators, the Government revised its policy, declaring that the standards would be aspirational for existing care homes, although standards would be applied to new care homes. A revised edition was published in 2003. These revisions did not apply to Scotland which, nevertheless, relaxed the stipulated conditions in a number of ways.
Major Players
There is increasing polarisation in the marketplace, as large companies continue to expand their presence and range of services through the acquisition of smaller groups and single operators. As a result, the market is increasingly dominated by a smaller number of larger players. Part of the impetus for this is the need to develop economies of scale in a highly cost-sensitive market subject to significant funding problems in a time of rising need. There is also a need to add value to existing services in a highly competitive marketplace.
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In between the two extremes in the market, there are a rising number of middle-sized operators (of up to 12 care homes), which are providing a volatile part of the marketplace through their own acquisition and merger activities, or through being acquired themselves.
Anchor Trust
The Anchor Trust is the leading non-profitmaking provider of care, sheltered housing and support services for elderly people in England. Anchor Homes care services include 104 registered care homes and 4,330 residential care places, of which 685 are nursing home places. Anchor employs more than 10,000 people, supporting 50,000 customers each week.
BUPA Care Homes

BUPA is the largest provider of care homes in the UK, with more than 245 homes throughout the country caring for more than 15,000 residents. It is a division of The British United Provident Association (BUPA) Ltd, the leading private medical insurer and private healthcare provider in the UK. BUPA also owns Goldsborough Estates, which provides specialist retirement housing. The company provides a range of services, including dementia care, young physically disabled care, stroke care, palliative care and specialist care for Huntingdons and Parkinsons disease sufferers, as well as residential and nursing-home care.
Craegmoor Group Ltd

Craegmoor Group Ltd is a leading long-term care provider, with more than 277 homes and establishments, providing a range of care services, including dementia care, brain injury care, mental health services and childrens services, as well as nursing home and residential care, for around 5,000 residents. The company was acquired by Legal & General Ventures in July 2001.
Four Seasons Health Care

Four Seasons Health Care is a leading provider of long-term care for the elderly in the UK, with approximately 300 care homes and a number of specialised care centres. Four Seasons cares for around 15,000 people and employs more than 19,000. The company also provides a range of services for brain injury rehabilitation, mental health services, behavioural disorders support and eating disorders services, as well as learning and physical disabilities support services.
Highfield Care
Highfield Care has more than 200 homes throughout the UK, of which 37 are in Scotland and Northern Ireland. The company provides care ranging from residential and nursing home care, to dementia care and care for the physically disabled.
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Southern Cross Healthcare

In March 2002, the nursing and residential care facilities (including 26 homes) of Trinity Care were acquired by Southern Cross Healthcare. The company is now one of the largest providers of care homes in the UK, running over 350 care homes with more than 17,000 beds, employing more than 25,000 people. The company has grown rapidly through a series of acquisitions, including Ultima in 2001, which brought in 35 care homes. Southern Cross Healthcare provides a range of services, including senior living, rehabilitation services, intermediate care, and support for people with physical and learning disabilities.
Westminster Senior Living

Westminster Senior Living is a division of Westminster Healthcare Ltd. The company is one of the major providers in the UK, with over 87 residential and nursing care homes, and a wide range of support services for the elderly, including community home care, assisted living, retirement and sheltered homes, respite care, intermediate care, and specialist care for dementia, brain injury and stroke rehabilitation.

Advertising and promotion for long-term care providers tends to be very specific, naturally focusing on the older sections of the population, which comprise potential clients and their middle-aged relatives and carers. National newspapers are sometimes used, while local newspapers and lifestyle magazines, which appeal to the target age groups and their carers, are other options. Similarly, GPs and healthcare professionals are targeted in professional journals and even through sales representatives visiting local GP surgeries.
Buying Behaviour
According to the most recent Government Actuarys Report (2002), the proportion of very elderly people is projected to increase for the foreseeable future. The number of very elderly the over-85s in particular is projected to rise to almost 1.2 million in 2002 and is forecast to increase to 3.3 million by 2056. Social changes are also playing a part in this, with people having smaller families. In addition, modern work patterns and mobility mean that families are more likely to be dispersed. Women, who traditionally acted as carers, are also more likely to be working. These factors are putting pressure on long-term care facilities, as well as on other healthcare companies. Care in the Community is still at the heart of government policy. It is perceived as being ideal to have patients being cared for and living in the community as far as possible, with increasing co-ordination of the various support services. The public sector is continuing to slowly withdraw from long-term care provision.
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According to Laing & Buisson, around 33% of payers in care homes were selfpayers, with around 6% of all residents being funded by the NHS; this figure rises to over 13% in nursing homes. In nursing homes, 34% of patients were self-payers. There were considerable regional variations in self-pay, with the Department of Healths (DoHs) 2002 census showing rates varying from 17% to 50% in Sussex and Surrey.
Forecasts
Over the next 5 years (to 2010), the highest growth is forecast for the commercial subsector, with continuing investment in the subsector and expansion through mergers and acquisition, fuelled by demographic changes. Growth in the commercial subsector is forecast to rise by 7% year on year from 2008 and continue at this level to 2010, the value of the subsector reaching 10.66bn. Limited growth is forecast for the voluntary/non-profitmaking subsector, which is expected to rise from 0.5% growth per annum in 2006 to 1.5% in 2010, with a market value of 1.39bn. Growth in this subsector will generally be offset by the refocusing of services into home-based care and other community-based support initiatives. In contrast to the other sectors, the public sector will continue to shrink gradually, as provision moves increasingly outside the NHS and initiatives to reduce bed-blocking and institutional care begin to take effect. The decline in the market is forecast to reach 2% in 2009 and the value of the subsector is expected to be 1.58bn in 2010. The overall market for long-term care in the UK is forecast to increase year on year to reach 13.63bn in 2010. The majority of this rise will be driven by demographics, although government proposals for extra funding could make a significant difference if they are fully implemented.
Table 8.5: The Forecast Total UK Private Long-Term Care Sector by Subsector by Value (m), 2006-2010
2006
Commercial
2007 8,703 6.0 1,676 -1.5
2008 9,313 7.0 1,650 -1.6
2009 9,965 7.0 1,617 -2.0
2010 10,663 7.0 1,584 -2.0
8,210 6.0 1,702 -1.5
Public
% change year-on-year Table continues...
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Table 8.5: The Forecast Total UK Private Long-Term Care Sector by Subsector by Value (m), 2006-2010
...table continued
2006
Voluntary/non-profitmaking
2007 1,339 0.7 11,718 4.2
2008 1,351 0.9
2009 1,366 1.1
2010 1,387 1.5
1,330 0.5 11,242 4.1
Total
12,314 12,948 13,634 5.1 5.1 5.3
Source: Key Note

The marketplace is expanding from its traditional residential and nursing home sectors and will increasingly provide ranges of services that are more tailored towards individual patient needs. A variety of different market sectors will continue to emerge, ranging from round-the-clock care for the very infirm to a variety of assisted living and home-care schemes. However, adequate funding will be the crucible that determines the growth and extent of market expansion. Although there is widespread recognition of the problem and the need for action, there has not yet been any clear attempt to tackle the problem systematically, with successive governments wary about the enormous costs involved in residential care. Technological and medical care advances could have a highly significant effect on the residential long-term care market. At one end, advances in telemedicine and other monitoring will increasingly facilitate the long-range monitoring of patients and enable them to live a more independent lifestyle, confident of prompt and timely support. At the other end, advances in medical care may result in prolonging the life of many infirm patients, increasing the overall need for care. However, certain advances, such as effective treatments for Alzheimers disease and other neurological and nervous system disorders, could dramatically lower the need for residential care. Equally, effective rehabilitation treatments for trauma injuries, strokes, musculoskeletal diseases and other disorders could also significantly reduce the need for assisted care and enhance independent living. In addition, technological advances in diagnostics and rehabilitation equipment could improve the effectiveness and cost-effectiveness of care.
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ACUTE CARE
Definition
The private acute care market encompasses routine and emergency surgical procedures, including niche markets such as cosmetic surgery, pregnancy terminations, fertility treatment and laser eye surgery, among others.
Key Trends
Consolidation in the Marketplace
The large hospital groups have continued to expand through mergers and acquisitions, which has led to consolidation in facilities and the number of overall beds. The continuing development of these large hospital networks, with their economies of scale and their superior purchasing power, has inevitably hit smaller networks and small independent providers very hard, resulting in a number of hospital closures with a reduction in overall bed capacity.
Cosmetic Surgery
The cosmetic surgery market has been growing rapidly. Cosmetic surgery is also gaining popularity among men, although women still form the largest demographic, with breast enhancement being the most popular surgical procedure. Non-surgical treatments such as botox are also becoming increasingly available and popular.
Fertility Treatment
According to Laing & Buisson, the private fertility treatment market was worth around 49m in 2003.
Market Size
In terms of hospital and bed numbers, there has been considerable consolidation in the private acute care market but, in value terms, the market has shown significant growth. Demand has been fuelled by demographic trends, increasing partnership with the NHS and technological advances that have increased the efficiency of care, resulting in shorter recovery times and more rapid patient turnover. Between 2001 and 2005, the UK market for private acute care grew by an estimated 48.9% to 5.33bn.
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Table 8.6: The Total UK Private Acute Care Sector by Value (m), 2001-2005
2001
Value (m)
2002 3,989 11.4
2003 4,406 10.5
e2004
e2005
3,581 -
4,847 10.0
5,332 10.0
Supply Structure
Between 1999 and 2004, hospital numbers fell by 9.6%, from 228 to 206. Over the same period, bed numbers fell by 13.1% to 9,176. These trends show the continuing consolidation in the marketplace by the major hospital groups through acquisitions, resulting in a reduction in bed overcapacity. In addition, they reflect changing medical practices, with increasing levels of day surgery. In 2004, there were also 43 acute-care day surgery hospitals with no overnight beds, of which 18 specialised in pregnancy terminations.
Table 8.7: The Total UK Private Acute Care Sector by Number of Hospitals and Beds, 1999-2004
Number of Hospitals
1999 2000 2001 2002 2003 2004
Number of Beds 10,565 9,980 9,834 9,463 9,533 9,176
228 225 222 218 216 206
excluding acute-care day surgery hospitals with no overnight beds
Source: Laings Healthcare Market Review 2004-2005
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In spite of the considerable consolidation in the marketplace through merger and acquisition activity, and as the market generally continues to reduce overcapacity of beds, the commercial subsector is continuing to expand market share in terms of bed numbers, rising from 65.9% of the market in 1998 to reach 68% in 2004, an increase of 2.1 percentage points. The charitable subsector declined by the same amount, from 34.1% in 1998 to 32% in 2004.
Table 8.8: Ownership Status of Private Acute Care Providers (% of total beds), 1998 and 2004
1998
Commercial Charitable
2004 68.0 32.0
65.9 34.1
Source: Laings Healthcare Market Review 1998-1999 and 2004-2005
Major Players
There are five major players in the private acute care sector and, together, they account for almost 78% of all private acute care beds.
BMI Healthcare
The largest private acute care operator is BMI Healthcare the private acute care division of the General Healthcare Group which has 2,267 beds, accounting for 24.7% of all private acute care beds.
Nuffield Hospitals
The second-largest operator in terms of bed numbers is Nuffield Hospitals, which is the UKs largest non-profitmaking independent hospital group. As well as expansion through acquisition, Nuffield has been building new hospitals to replace outdated facilities, and a new hospital in York opened at the end of 2004. In 2004, Nuffield won a 40m contract to provide NHS services.
BUPA Hospitals Ltd

BUPA Hospitals Ltd, the acute care division of BUPA, is the third-largest private acute care provider in the UK. The company is currently undergoing a degree of refocusing and consolidation, with the disposal of assets outside the companys main areas of focus.
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Capio Healthcare
Capio Healthcare, which is the fourth-largest provider of private acute care services, is a subsidiary of the Swedish healthcare company, Capio AB. It is a relative newcomer in the UK marketplace and became a major market force in private acute care through the acquisition of the Community Hospitals Group in May 2001. The company is continuing to expand in the market following the award of a number of large NHS contracts, particularly the 210m 5-year Independent Sector Treatment Centre (ISTC) contract for around 95,000 orthopaedic and general surgical procedures.
HCA International Ltd

HCA International was the fifth-largest provider of private acute care services. In 2004, the company had six hospitals (accounting for 2.4% of the total) and 730 beds (8%).
Table 8.9: Leading UK Private Acute Care Providers by Number of Hospitals and Beds, 2004
Number of Hospitals
General Healthcare Group (BMI) Nuffield Hospitals BUPA Hospitals Ltd Capio Healthcare Ltd HCA International Ltd
Number of Beds 2,267 1,689 1,590 868 730 7,144 9,176
45 43 35 23 6 152 249
Total Total private acute care beds
including two private patient units (PPUs) owned by BMI Healthcare, and excluding two hospitals managed by BMI Healthcare including one diagnostic centre with no overnight beds including one PPU owned by Capio Healthcare and one eye hospital with no overnight beds, and excluding one NHS PPU managed by Capio Healthcare
Source Laings Healthcare Market Review 2004-2005
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Private Care in the NHS

Private care is available in NHS facilities in a number of different ways. It is estimated that there are around 3,000 paying beds in the NHS, of which around 53% are situated within NHS wards. However, exact figures are difficult to establish, since rather than designating specific beds as pay beds, the NHS authorises consultants to set aside a number of patient bed-days for use by private patients. It is estimated that these designated beds have occupancy rates of around 10%. However, the majority of private patient activity in the NHS occurs in dedicated private patient units (PPUs). These dedicated units often (but not always) have dedicated staff and facilities, such as surgical theatres, and although most are managed and run within the NHS, some facilities have been contracted out to private operators. Traditional PPUs generally contain between 10 and 20 beds. In general, these beds are single units with ensuite facilities. In 2004, there were 79 PPUs in the NHS with around 1,275 beds, of which 22 units were situated in Greater London. According to Laing & Buisson, NHS private income constituted 12.5% of all private hospital, clinic and NHS private facility revenues combined in 2003/2004.

There is a degree of variety in the advertising of private acute care services and facilities. In general, advertising of particular services is targeted towards specific customers. For example, cosmetic surgery advertising targets womens magazines and newspapers with a high female audience, such as the Daily Mail. Private hospitals and facilities are promoted to relevant healthcare professionals in trade publications or directly through representatives. The large hospital networks and providers, particularly BUPA, have used extensive television campaigns to promote their financing packages and services.
Buying Behaviour
Most patients in the private sector are undergoing routine elective surgery, and going private enables them to avoid potential NHS waiting lists and to have their surgery at a time that is convenient to them. Patients also tend to use the private sector for provision that is unavailable on the NHS or available only in a limited way, including fertility treatments, cosmetic surgery and abortions. There is also a growing trend towards specialist surgery, such as endoscopy procedures and heart surgery. The majority of private acute care is financed through PMI although, according to Laing & Buisson, around 20% of patients are self-paying, a trend that is encouraged by the advent of fixed-price agreements with private providers, which are particularly promoted by the large hospital networks. Around 20% of self-payers are undergoing cosmetic surgery. These self-pay packages have expanded and evolved in recent years to encompass savings plans, deferred payment schemes, pay-as-you-go options and other flexible schemes, as well as long-term payment options. In recent years, self-pay brokers have emerged to assist patients in selecting the optimal self-pay schemes for their benefit.
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The vast majority of patients in the UK are UK based, with only 4.5% coming from overseas. However, these foreign patients typically have more complex and expensive treatments than the average patient, usually seeking treatment that is unavailable in their home country. Although data are hard to come by, an increasing amount of revenue in the private acute care sector is derived from NHS contracts; Laing & Buisson has estimated that it constituted around 9% of private acute care revenues in 2003.
Forecasts
The market for private acute care is forecast to grow steadily over the next 5 years to 2010, fuelled by the increasing healthcare demands of an ageing population, and increasing partnership and co-operation with the NHS, as well as the effects of advances in medical research and technology, expanding the range and nature of the healthcare market as a whole. Between 2006 and 2010, the market for private acute care is forecast to grow by 58.8% to 9.35bn. The annual rate of increase is forecast to reach 13.5% in 2010, as NHS partnerships begin to pay dividends.
Table 8.10: The Forecast Total UK Private Acute Care Sector by Value (m), 2006-2010
2006
Value (m)
2007 6,540 11.0
2008 7,325 12.0
2009 8,241 12.5
2010 9,354 13.5
5,892 10.5
Source: Key Note

PSYCHIATRIC CARE
Definition
Psychiatric care is a major specialist sector of the private healthcare market, encompassing acute psychiatric care and rehabilitation. It excludes long-term residential care, which is covered under long-term care.
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Key Trends
There is increasing demand for mental healthcare services and for an increasing range and scope of services. As the public become increasingly aware and educated about mental health issues, this is driving the demand for support and care. Rising levels of substance abuse are also fuelling demand for rehabilitation services. In the UK, the NHS is the major client to the sector for private psychiatric care. According to industry analysts Laing & Buisson, the public sector accounts for just over two-thirds of independent psychiatric hospital revenues and almost all medium-secure and mental rehabilitation services. As the traditional NHS psychiatric institutions were closed and Care in the Community was increasingly adopted, psychiatric services became increasingly outsourced under the then Conservative Governments NHS internal market. Even after the following Labour Government abolished much of the reform, outsourcing of psychiatric services continued. Care in the Community has been coming under sustained criticism following a number of high-profile failures, in which people suffering from mental illness have harmed or killed friends and family or even complete strangers. The DoH remains committed to community-based approaches where possible and these remain their top priority for resourcing.
Market Size
The UK private psychiatric care sector has been growing steadily since 2001, with an annual rise of between 10.4% and 11.6%. Between 2001 and 2005, the sector rose by an estimated 52% to 523m in 2005. Growth has been fuelled by increasing demand for psychiatric services, particularly for specialist markets such as substance abuse, eating disorders, behavioural disorders, specialist education services and counselling services.
Table 8.11: The Total UK Private Psychiatric Care Sector by Value (m), 2001-2005
2001
Value (m)
2002 384 11.6
2003 424 10.4
e2004
e2005
344 -
469 10.6
523 11.5
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Supply Structure
According to Laing & Buisson, there were 6,365 beds in the UK independent acute psychiatric sector in 2004, an increase of 2,451 beds (62.6%) on 2002. This increase is an indication of the rate of expansion in this market. In 2002, 70% of beds belonged to commercial operators, compared with 76.1% in 2004. Over the same period, the number of charitable beds rose from 1,174 to 1,524, an increase of 29.8%.
Table 8.12: The Total UK Independent Acute Psychiatric Care Sector by Number of Beds (number and %), 2002 and 2004
2002 Number of Beds
Commercial Charitable
2004 % of Total 70.0 30.0 100.0 Number of Beds 4,841 1,524 6,365 % of Total 76.1 23.9 100.0
2,740 1,174 3,914
Total
Source: Key Note, adapted from Laings Healthcare Market Reviews 2002-2003 and 2004-2005
Major Players
The independent acute psychiatric care market is dominated by five major players, of which the largest is Priory Healthcare, with 21 psychiatric care facilities and hospitals and 936 beds, accounting for 14.7% of all beds in the sector. The second-largest operator is Partnerships in Care, with 16 psychiatric hospitals and care facilities and 843 beds (accounting for 13.2% of all beds). In comparison, St Andrews Group of Hospitals has only four hospitals, but these provide a total of 642 beds, which account for 10.1% of the total number of beds.
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Table 8.13: Major Players in the UK Independent Acute Psychiatric Care Sector by Number of Hospitals and Beds, 2004
Number of Hospitals/Facilities
Priory Healthcare Partnerships in Care St Andrews Group of Hospitals Care Principles Cygnet Healthcare
Total leading five
Number of Beds 936 843 642 292 248 2,961 3,404 6,365
21 16 4 5 6 52 123 175
Other providers
Total
Note: some organisations may have other hospitals and facilities outside this sector.
Source: Key Note, adapted from Laings Healthcare Market Review 2004-2005/company literature and annual reports
Priory Healthcare Ltd

Priory Healthcare was originally founded by the US group Community Psychiatric Centres. The company was acquired in 2000 by Westminster Health Care for 94m and was then subject to a management buyout (MBO) in May 2002 following a separate MBO of Westminster Health Care. Priory is the only truly national network of independent psychiatric hospitals and, in April 2004, 15 of Priorys hospitals were included in the AXA PPP network of psychiatric facilities. As well as acute psychiatric facilities, Priory also provides specialist services for children and adolescents, as well as brain injury rehabilitation, and drug and alcohol addiction services.
Partnerships in Care Ltd

Partnerships in Care Ltd is the psychiatric services arm of the privately owned General Healthcare Group and is the second-largest independent provider of these services in the UK. With 16 hospitals and 843 beds, the company provides a wide range of services, including brain injury rehabilitation, behavioural treatment services and learning disability services. The company also has a number of residential homes for those with behavioural problems. In addition, Partnerships in Care has a range of employee support programmes involving counselling and stress reduction services.
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St Andrews Group of Hospitals

This is the largest non-profitmaking provider of private acute psychiatric services in the UK. The company has a flagship 506-bed hospital in Northampton, which has a wide range of services, including acute psychiatric care, behaviour rehabilitation and long-term care. It also has a 57-bed hospital and a 26-bed hospital based in Harrow, which are operated in a joint venture with Cygnet Healthcare, as well as a 53-bed hospital in Basildon, Essex.
Care Principles
Care Principles was founded in 1997 and provides a range of specialist medium-secure assessment and treatment services for adult learning disabilities and behavioural problems. Only patients referred and funded by the NHS are accepted.
Cygnet Healthcare
Cygnet has six acute psychiatric hospitals with 248 beds, as well as the joint-venture hospitals with St Andrews Group, and the company claims to have a major share of the London outsourced acute NHS psychiatric market. It also operates two nursing homes for the elderly. The company underwent an 82m MBO in November 2002 and, in June 2004, Barchester Healthcare acquired a 25% share in Cygnet for 30m. The company is continuing to expand, with at least two new hospitals in the pipeline.

As a highly specialised and fragmented market comprising a range of different services and disciplines, promotion and advertising in this sector is highly focused to mostly target specific healthcare and social services professionals. As such, the majority of advertising uses specialist professional publications and direct marketing and communications using trained representatives to directly communicate with GPs and consultants. In a break from this, Priory Healthcare has advertised for potential clients through national newspaper campaigns.
Buying Behaviour
Psychiatric and behavioural disorders are reported to be rising and there has been an increase in alcohol and drug abuse, as well as eating disorders. Society as a whole has become increasingly aware of the effects of stress and trauma, with counselling becoming more routine. Levels of stress are perceived to be rising, fuelled by the pressures of modern living, and the UK reportedly has the longest working hours in Europe. Many more people are combining work with raising a family and, at the same time, many traditional support networks are eroding, with rising levels of divorce and greater mobility resulting in the dispersal of family units.
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Employers are becoming increasingly aware of the effects of stress on employee health and productivity and, as such, are becoming increasingly willing to provide certain levels of stress counselling and other similar supports.
Forecasts
The UK market for psychiatric care is forecast to continue to expand steadily for the foreseeable future on the back of an expanding range of specialist care, rehabilitation, educational and counselling services, and increasing involvement with the NHS in the form of partnerships with a growing trend towards longer-term agreements. Between 2006 and 2010, the sector is forecast to increase by 58.7% to 930m.
Table 8.14: The Forecast Total UK Private Psychiatric Care Sector (m), 2006-2010
2006
Value (m)
2007 656 11.9
2008 738 12.5
2009 830 12.5
2010 930 12.0
586 12.0
Source: Key Note

PRIMARY CARE
Definition
In the private sector, primary care encompasses both GP services and occupational health services. It does not include dental or ophthalmic services, or health screening and diagnostics.
Key Trends
The private primary care market sector is still emerging, with the General Household Survey indicating that only 3% of all GP consultations are private. Unlike consultants in hospitals, GPs in the UK are not permitted to treat their registered NHS patients privately. If they treat a patient privately, they are not permitted to provide them with an NHS prescription.
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In the UK, most private healthcare is paid for through PMI policies and, until quite recently, there was little provision in these policies for private primary healthcare. In general, the market for occupational health has been driven by health and safety legislation, as well as increasing awareness among organisations and employers, and increasing nervousness of potential litigation. In general, employers are providing these services as an employee benefit, as well as part of a drive to reduce absence due to illness and improve productivity. In October 2000, a comprehensive independent review of GP out-of-hours services was published on behalf of the NHS, which made a number of recommendations aimed at eliminating regional variations in out-of-hours provision and integrating it with NHS Direct. In addition, it recommended transferring management to primary care trusts (PCTs), ensuring that all out-of-hours service providers would be subject to the same checks and standards, the so-called Carson Standards set out by the review. The costs of meeting these standards were significant, particularly to GP co-operatives and the small commercial operators. Individual GP practices are exempt from the need for Carson-standard accreditation. Following the review and the introduction of the new GP contract in 2003, there was a radical transformation in out-of-hours GP service provision. The contract allows GPs to opt out of providing out-of-hours provision, with PCTs becoming responsible for organising the out-of-hours provision in their regions from 2005. The cost of opting out (6,000 per year per GP) is 6% of practice income. PCTs are able to choose between a number of options, including NHS Direct, NHS walk-in clinics, GP co-operatives or practices, community nursing teams and commercial providers, among others. Although the Government has made extra funding available for PCTs to fund their out of-hours provision, there appear to be major problems, with most GPs opting out of provision, but then hiring out their services at high rates. There has been such a shortage of provision for out-of-hours GP services in some instances that PCTs have used GPs from the continent, most notably Germany, to provide weekend cover. This is resulting in far higher costs than anticipated.
Market Size
The market for private GP services has grown by just over 5% year on year since 2001, rising to an estimated 6.5% increase in 2005. In 2005, the market for private GP services was worth an estimated 213m. The increase in the market is the expansion of private GP services in various market niches, including walk-in clinics and out-of-hours services. The estimated increase in 2005 is the result of more out-of hours GP cover being contracted out to the private sector. Key Note estimates that, in 2005, the total private primary care sector in the UK will be worth 342m, a rise of 6.2% on 2004.
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Table 8.15: The Total UK Private Primary Care Sector by Subsector by Value (m), 2001-2005
2001
General practitioner services
2002 179 5.3 109 4.8 288 5.1
2003 189 5.6 115 5.5 304 5.6
e2004
e2005
170 104 274 -
200 5.8 122 6.1 322 5.9
213 6.5 129 5.7 342 6.2
Occupational health services

Total
Private GP services is the largest subsector in the private primary care sector. In 2000, this subsector accounted for 61.9% of the private primary care sector, and this increased to an estimated 62.3% in 2005.
Figure 8.3: The Total UK Private Primary Care Sector by Subsector (%), 2005
Occupational health services 37.7%
GP services 62.3%
Source: Key Note

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Supply Structure
GP Services
In the UK, the acute primary care sector is dominated by the significant public sector. Although GPs are not permitted to treat their registered NHS patients privately, they can refer their patients to consultants in the private sector. Although many NHS patients have to pay a prescription charge for any treatments provided, NHS GPs are widely available and there is little delay for consultation. As a result, private GP services are comparatively limited and often specialised. The types of private services include:
private GP practices there are between 200 and 300 exclusively private
GP practices in the UK, mostly in London and particularly in Harley Street
private GP practices in private hospital sites private walk-in medical centres private capitation schemes associated with existing NHS general practices
these were piloted by AXA PPP for 5 years but, in March 2004, the pilots finished and AXA announced that it would not be carried forward
out-of-hours/24-hour visiting doctor services company-paid GP services for employees telephone helplines and online help these are run by many private
medical insurers, providing advice and access to GP or nurse consultations.
Occupational Health Services

Occupational health services assess and manage health and safety risks in the workplace. They may provide medical services in the workplace and are involved in pre-employment and employment health assessments and medicals. They involve monitoring surveillance and management of workplace health, and health issues such as absenteeism. The Faculty of Occupational Medicine has around 1,660 registered physician members and around 70% of physicians involved in occupational health in the UK are operating outside the NHS. According to the Royal College of Nursing (RCN), there are over 3,700 nurses in the UK qualified in occupational health and many more are thought to work in the field.
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Major Players
GP Services and Walk-In Clinics
The market for walk-in medical clinics has had a very chequered history, with a number of companies in the marketplace closing or selling out, unable to attract the custom necessary for viability. The concept of walk-in medical centres was originally pioneered by Sinclair Montrose Healthcare, which aimed to cater for time-poor young professionals wanting a more convenient option than the traditional GP surgery and NHS primary care services, or for employers paying for services for their employees. However, the concept largely failed, mainly because they could not compete with traditional NHS GP services; people simply did not find that NHS GPs were inconvenient, as most people manage to see their GP within a timeframe that generally suits them. NHS GPs also provide their services free of charge and people were unwilling to pay privately for the slight gains in convenience. In addition, people were reluctant to pay the additional costs of private prescriptions rather than the fixed NHS prescription charge. In addition, although NHS GPs can refer patients to private specialists, private GPs cannot refer patients to the NHS. More recently, private centres are also having to compete with nurse-run, NHS walk-in clinics, which offer much of the convenience without the charges. Since their inception, private walk-in centres have evolved to provide services for wealthy corporate clients in the financial institutions of the City of London, where there is little in the way of NHS primary care services or, increasingly, as walk-in centres attached to private hospitals. Certain private hospital groups now provide primary care as part of their range of services, including eight BUPA hospitals and six hospitals in the BMI group. A number of individual private hospitals also offer these services, including the Cromwell hospital and PPUs at some NHS hospitals. There is a small market for privately run company-based primary care services, rather than PMI. These are generally based in financial institutions in the City. Providers of these services include BUPA, General Medical Clinics, Medicentres and GP Plus, among others.
BMI Health Services

On 11th July 2005, General Healthcare Group (GHG) announced the sale of BMI Health Services to the Capita Group PLC. BMI Health Services Ltd will be renamed Capita Health Solutions. BMI Health Services provides occupational health services, health screening and audiology. It is one of the largest providers of private occupational health services in the UK.
BUPA Occupational Health Ltd

BUPA is one of the two leading players in the occupational health market and has been developing a national network of services through a series of acquisitions over the past few years, including Occupational Healthcare (Railways) Ltd in 1997, Barbican Healthcare in 1999, City Healthcare Ltd in 2000, Company Health in December 2000 and the Personal Effectiveness Centre (PEC) in May 2003.
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BUPA Wellness
Following its acquisition of Barbican Healthcare in 1999, BUPA entered the private primary care market. Barbican was a provider of private primary care services in the City. BUPA Wellness now operates in more than 40 health centres throughout the country, providing health screening and assessments, as well as a number of other primary care services, including dentistry.
Franbar Holdings Ltd

The Guernsey-based company Franbar acquired Medicentres UK Ltd, which owned five London-based walk-in clinics (Medicentres) from Match Group PLC in 2001. Match Group PLC had originally acquired these Medicentres from Sinclair Montrose Healthcare PLC in an MBO. Since then, Franbar has invested in these clinics, opening a further Medicentre in 2002. These clinics provide a range of primary care services, including GP consultations
General Medical Clinics PLC

Apart from Franbar, General Medical Clinics PLC is the other major provider of private walk-in clinics. The company owns three clinics in the City of London and 70% of revenues come from employees, with the remaining 30% from self-paying walk-in patients.
GP Plus
GP Plus, which is a provider of private GP services in Edinburgh and Glasgow, has been expanding rapidly as a provider for corporate clients and publicsector organisations. As well as GP services, the company provides occupational health services and programmes, health assessments, physiotherapy, specialist sports injury services and vaccinations. Other private occupational health providers include the following:
Atos Origin AON Occupational Health AXA PPP healthcare Occupational Health Services Grosvenor Health MTL Medical Services (Swiss Life) Medigold Nestor Healthcare Cheviot Artus.
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As with other sectors of the private healthcare market, promotion and advertising is carefully targeted towards specialist professional magazines. Companies offering occupational health services target potential clients in a number of ways, including direct marketing, advertising in business publications and the mass media, as well as government organisations. The Internet is also a powerful tool for promotion and communication.
Buying Behaviour
The traditional image of private GP services is that of the prosperous Harley Street practitioner with a clientele of wealthy and privileged patients. Private practice in the UK is operating in the shadow of the huge comprehensive public sector. Access to medical treatment in the UK is channelled through the GP. Although there are well-documented shortages of GPs in some areas, and although there are problems with out-of-hours services, registered patients can obtain a relatively timely and convenient appointment. NHS GPs can also refer their patients privately, whereas private GPs cannot refer patients to the NHS. These factors limit the attractiveness of private GPs. A patient visiting an NHS GP has the option of taking either the public or private route, and any medications will be free except the statutory prescription charge, unless they are exempt even from that. Patients attending a private GP are locked into the private sector. In recent years, in an effort to rationalise services and improve access, the NHS has extended prescribing powers to other healthcare professionals, including nurses (in March 2001) and, in due course, pharmacists. The NHS has also introduced walk-in clinics and there is a 24-hour helpline and website with access to professional advice through NHS Direct. In spite of these factors, the market for private primary care services is growing, with initiatives by the major private healthcare providers setting up private clinics in order to channel patients into their private healthcare services in a more focused way. Occupational health services are increasingly being used by companies and organisations to monitor and oversee health problems and issues in their workforces, partly for health and safety reasons, as well as legislation. According to the most recent Health and Safety Executive (HSE) survey in 2002, around 44% of large organisations and 2% of small organisations had comprehensive occupational health services. A further 15% of organisations had limited occupational health services.
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Forecasts
The future for private primary care is very much dependent on the effects of various government policies and initiatives and how they are applied. The Government is committed to walk-in centres, NHS Direct and the overall expansion of GP services, and it is far from clear what role private partnerships and provision will play in their development. Much of the growth in the market is due to expansion in GP out-of-hours services. Between 2006 and 2010, the market for GP services is forecast to grow by 40.7% to 325m. Demand for occupational health services is also increasing, as employers and organisations respond to health and safety requirements, and initiatives to improve productivity and reduce absenteeism. In the longer term, ageing population demographics and, in the future, possibly delayed retirement ages with older, ageing workforces could increase the need for occupational health services still further. In the near future, the market for private occupational health services is forecast to grow more slowly than private GP services. Between 2006 and 2010, occupational health services are forecast to rise by 21.3% to 165m. Over the same 5-year period, the total market for private primary care services is expected to grow by 33.5% to 490m.
Table 8.16: The Forecast Total UK Private Primary Care Sector by Subsector by Value (m), 2006-2010
2006
General practitioner services
2007 252 9.1 143 5.1 395 7.6
2008 274 8.7 150 4.9 424 7.3
2009 298 8.8 157 4.7 455 7.3
2010 325 9.1 165 5.1 490 7.7
231 8.5 136 5.4 367 7.3
Occupational health services

Total
Source: Key Note

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DEFINITION
The national healthcare system in the UK is unique in that it is funded directly through general taxation and there is no mechanism for taxpayers to opt out into the private sector. In addition, there are no taxation concessions for private medical insurance (PMI) and the insurance premiums are taxed at the rate of 5%. In March 1999, the Government extended the National Insurance (NI) contributions of employers to cover benefits in kind, including PMI. Taxation relief for the over-60s was abolished in 1997. The main sources of funding for private healthcare include the following:
PMI self-pay either by individuals or companies; this is particularly popular for

cosmetic surgery, and fixed-price schemes for acute care are becoming increasingly popular
NHS there are increasing levels of public/private partnerships, particularly

in areas such as psychiatric services, screening services and specialist imaging services. Traditionally, the majority of private healthcare in the UK has been funded through PMI and, as such, the purchasing power of these policies has dictated and shaped the nature of private healthcare in the country. However, in recent years, major funding through NHS commissioning of care and through the increasing popularity of self-pay and fixed-priced surgery has added new dimensions to the nature of private healthcare in the UK.
KEY TRENDS
Although the NHS has been receiving unprecedented amounts of extra funding, services remain stretched and care is even being limited in certain areas. Waiting lists remain high in certain locations and although there is public loyalty towards the NHS, confidence in its ability to provide a good standard of care has been significantly dented. The vast majority of the population are not covered by PMI. According to exclusive consumer research conducted for this report by BMRB Access in April and May 2005 (see Chapter 3 Key Note Primary Research), only 8% of respondents had or intended to take out PMI in the last 12 months. In 2003, Laing & Buisson found that 11.2% of the population were covered by PMI, including dependants. There was also little enthusiasm in the BMRB Access survey for encouraging more private healthcare, with only 6% of respondents agreeing that this was an action most necessary to improve the health service.
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Market growth in terms of subscriber numbers has been relatively static since 2003; prior to that, the number of subscribers declined by up to 1% per annum. Growth in the corporate sector has been relatively stable in recent years, rising gradually in 2004 and 2005, with much of any decline occurring in the individual PMI market. Growth in the corporate sector has been driven by initiatives in the insurance sector, such as flexible policies and the increasing awareness of the effects of employee illness on profitability. Costs of claims incurred have been growing more slowly than subscription income, partly reflecting the increasing cost efficiency of medical treatments as a result of technological advances and changing medical practices, such as a drift away from inpatient and day surgery towards outpatient treatments. As well as reducing recovery times and increasing patient turnaround, hospital prices have remained relatively static in recent years as a result of increasing competition and the emergence of hospital networks. According to industry analysts Laing & Buisson, the incidence and complexity of claims have been rising in recent years.
MARKET SIZE
In terms of subscription income, growth has slowed significantly from 2001 as a result of a combination of factors, including lower premium rises as well as slowing growth in demand from both corporate and individual subscribers. The rate of growth fell from 8.4% in 2001 to 4.1% in 2003, before rising slightly in 2004 and 2005. In 2005, subscription income was estimated to be worth 3.26bn, a rise of 4.8% on 2004.
Table 9.1: The Total UK Private Medical Insurance Market by Subscription Income (m), 2001-2005
2001
Value (m)
2002 2,863 7.6
2003 2,980 4.1
e2004
e2005
2,662 -
3,114 4.5
3,263 4.8
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Figure 9.1: The Total UK Private Medical Insurance Market by Subscription Income (m), 2001-2005
3,400 3,200 3,000 2,800 2,600 2,400 2,200 2,000 2001 2002 2003 2004 2005
SUPPLY STRUCTURE
In the UK, subscription to PMI is taken out either by private individuals or by employers on behalf of their employees. There are a variety of different types of policies and healthcare cover available on the market, including the following:
Budget low-cost policies these policies typically have some form of

excess payment or higher levels of excess payment compared to standard policies. They also have greater limitations in the amount and type of treatment provision and frequently restrict provision to lower-cost network private hospitals. More recent innovations include treatment restrictions to a limited number of non-urgent medical conditions. Other policies limit cover to diagnostic services, with the option of critical illness cover. Certain others provide a form of progressive cover, with a variety of options for treatment. Some of these policies provide cover for alternative therapy, specific conditions such as cancer or heart disease, outpatient cover or other combinations.
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Premium enhanced benefit plans these are top-of-the-range

policies that provide benefits over and above the standard policy, including extras such as travel insurance, cash benefits for critical illness or disability, rehabilitation, fertility treatments, health screening and alternative medicine. There are also policies that offer round-the-clock access to doctors and other healthcare professionals. Other policies guarantee treatment in premium-priced hospitals, many of which are based in central London.
Standard PMI policies these provide funding for hospital treatment,

and outpatient, diagnostic and specialist services within fixed limits. The policies might have excess charges and might limit treatments to specific hospitals or hospital networks.
Flexible corporate schemes these are corporate policies that provide

choices to individual employee subscribers. They usually have a basic core cover, with options for benefits over and above this level. Other policies provide cover for employees in terms of conditions preventing them from working.
Specialist targeted plans these are designed to target specific groups

of subscribers by offering extra benefits tailored specifically for those groups. Extra benefits can include maternity cover, fertility care and benefits for people with active lifestyles, such as skiers.
Long-term care insurance there are now a number of these policies

available, including those from AXA PPP and BUPA. Long-term care insurance policies are designed to fund long-term residential or nursing home care.
Fixed-price policies these guarantee no change in premiums over a

fixed time period, usually for 5 or 10 years.
Individually underwritten policies these are personalised policies

with risk assessment on an individuals health and lifestyle. Subscribers with healthy lifestyles should benefit from lower premiums.
Combined health insurance (CHI) these combine ranges of insurance

products, with the cost of the combination significantly less than the sum costs of the individual policies and plans.
Medical expenses plans these are not insurance policies, but the plan
pays out specific amounts of money for certain medical events and procedures. Some large companies have established these schemes for employees, paying medical expenses as needed. According to Laing & Buisson, around 70% of these schemes are administered by PMI companies, with the remainder administered by third-party authorities (TPAs).
Critical illness cover these policies pay out lump sums in the event of
serious illness or injury. They are frequently linked with other policies, such as life assurance or mortgage protection.
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Number of Subscribers
In terms of the number of subscribers, the market for PMI has been relatively static, with subscriber numbers showing a slight decline in 2002 and 2003, mirroring general market conditions, before stabilising and recovering slightly to reach an estimated growth of 0.9% in 2005 to reach 3.7 million subscribers. In contrast, the number of subscribers to non-insured medical expenses schemes demonstrated strong growth, particularly in 2001 and 2002, before stabilising at around 7% per annum to an estimated 553,000 subscribers in 2005.
Table 9.2: Total UK Private Healthcare Policies by Number of Subscribers to Private Medical Insurance and Medical Expenses Schemes (000), 2001-2005
2001
Number of private medical insurance subscribers
% change-year-on-year
2002 3,709 -0.3
2003 3,671 -1.0
e2004
e2005
3,722 -
3,690 0.5
3,724 0.9
Non-insured medical expenses schemes

401 4,123 -
456 13.7 4,165 1.0
484 6.1 4,155 -0.2
517 6.8 4,207 1.3
553 7.0 4,277 1.7
Total
% change year-on year
Cost of Claims
The cost of claims incurred has grown more slowly than subscription income. Between 2001 and 2005, costs of claims rose by an estimated 18.3% to 2.45bn. The cost of claims as a percentage of subscriptions fell from 78% in 2001 to 75% in 2005.
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Table 9.3: The Total UK Private Medical Insurance Market by Cost of Claims (m and %), 2001-2005
2001
Cost of claims (m)
2002 2,195 6.1
2003 2,277 3.7
e2004
e2005
2,068 -
2,367 4.0
2,447 3.4
Cost of claims as a % of subscription income

e estimates
78
77
76
76
75
MAJOR PLAYERS
According to industry analysts Laing & Buisson, as at July 2004, there has been little in the way of consolidation in the PMI market, with ten provident organisations and around 24 commercial companies actively engaged in selling PMI. In addition, there were 18 commercial underwriters. A number of new companies have entered the marketplace: Private Health Partnership (Skipton Group), HSBC, Sainsburys Bank, Freedom Healthnet, Goodhealth and the Prudential. In July 2004, the provident associations were as follows:
Bristol Contributory Welfare Association (BCWA) BUPA CS Healthcare Exeter Friendly Society Foresters Friendly Society HAS Simplyhealth Medicash Health Benefits National Deposit Friendly Society Provincial Hospital Services Association Western Provident Association.
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Commercial companies active in the marketplace were:
AIG Europe (UK) AXA PPP healthcare Cigna Healthcare & Group Clinicare Compass Underwriting Discovery FirstAssist GE Frankona Re General and Medical Great Lakes Reinsurance (UK) Groupama Insurance Group Hamilton Insurance Company Legal & General Healthcare Life Norwich Union Healthcare OBE International Insurance Standard Life Healthcare The St Paul at Lloyds United Life & Health Insurance Company.
BUPA was the clear market leader in 2003, with 39.9% of the market in terms of subscription income. The company appears to have consolidated its leading position in the face of strong competition from commercial insurers. The second-largest player was AXA PPP healthcare, with 22.5% of the market and, together with BUPA, these two players commanded 62.5% of the total market in terms of subscription income.
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Table 9.4: Leading Private Medical Insurers by Share of Subscription Income (%), 2003
BUPA AXA PPP healthcare Norwich Union Healthcare Standard Life Healthcare FirstAssist Others Total Source: Laings Healthcare Market Review 2004-2005/Key Note 39.9 22.5 9.0 6.5 4.0 18.0 100.0
Figure 9.2: Leading Private Medical Insurers by Share of Subscription Income (%), 2003
FirstAssist 4.0%
Others 18.0%
BUPA 39.9%
Standard Life Healthcare 6.5%
Norwich Union Healthcare 9.0%
AXA PPP healthcare 22.5%
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British United Provident Association Ltd

British United Provident Association Ltd (BUPA) is the leading independent health and care organisation in the UK, and is also a leading global player. As a non-profitmaking provident association, it was created in 1947 through the amalgamation of 17 separate British provident associations. The company is both a purchaser and provider of private healthcare services and is the leading private medical insurer in the UK.
AXA PPP healthcare Group PLC

AXA PPP healthcare is part of AXA, the France-based global insurance group. It was founded in 1938 as a provident association, but abandoned this status in 1996. The company is the second-largest PMI provider in the UK.
Norwich Union Healthcare

Norwich Union Healthcare was established in 1990 by the leading insurance group, Norwich Union. It has expanded to become the third-largest private medical insurer in the UK by susbscription income and one of the leading providers of income protection and medical insurance in the country.
Standard Life Healthcare Ltd

Standard Life Healthcare Ltd is the fourth-largest provider of PMI in the UK. It is part of the Standard Life Assurance Company, which is the largest mutual insurance company in Europe
FirstAssist
The healthcare business of FirstAssist, which was formed in 1997 under Royal & SunAlliance, is now one of the leading providers of health and wellbeing products. It is owned by Barclays Private Equity. FirstAssist also has a long-term partnership with Munich Re. The company provides a range of insurance services, including PMI and hospital cash plans, and offers a range of rehabilitation services, sickness cover, absence management, counselling and physiotherapy.
ADVERTISING AND PROMOTION

The market for PMI is highly competitive, which is reflected in the high expenditure on advertising. BUPA has spent significant amounts on television advertising and most leading players advertise regularly in national newspapers and magazines.
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BUYING BEHAVIOUR
According to Laing & Buisson, the highest levels of cover, as might be expected, were found in middle-aged professionals, employers and managers. The exclusive consumer survey that was commissioned for this report and conducted by BMRB Access in April and May 2005 (see Chapter 3 Key Note Primary Research) confirmed this, with 17% of respondents in social grade AB and 12% of those in the 55 to 64 year-old age group claiming to have taken out or renewed PMI in the last 12 months. The survey also found that 10% of respondents aged 65 years and older had either renewed or taken out PMI in the last 12 months, compared with 8% of all respondents. In addition, the survey revealed clear regional differences, with the highest levels of insurance cover in East Anglia and the North West (both 12%) and Wales (11%), compared with only 1% of respondents in the North. A significant number of people also avoid PMI and choose instead to self-pay. This option has become particularly popular for cosmetic surgery, which is not covered under PMI, and the use of self-pay has become increasingly common.
FORECASTS
Future growth in PMI will be largely dependent on the status of the NHS and the amount of expenditure on healthcare in general. Long waiting lists and increasing limitations on the type of care in a poorly funded healthcare system, together with concerns relating to the quality of NHS care, will only foster interest in PMI cover. Another factor for future growth in the PMI market will be the ability of insurers to contain the costs of claims. They are likely to be aided by the increasing awareness of healthcare providers for cost-effectiveness and cost benefits of care procedures. Key Note forecasts that, in 2006, income from subscriptions will grow by 5.4% to 3.44bn. In 2010, subscription income is expected to reach 4.41bn, as a result of slowly increasing subscriber numbers and rather more rapidly increasing subscription income.
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Table 9.5: The Forecast Total UK Private Medical Insurance Market by Subscription Income (m), 2006-2010
2006
Value (m)
2007 3,644 6.0
2008 3,865 6.1
2009 4,116 6.5
2010 4,407 7.1
3,439 5.4
Source: Key Note

Figure 9.3: The Forecast Total UK Private Medical Insurance Market by Subscription Income (m), 2006-2010
4,500 4,000 3,500 3,000 2,500 2,000 2006 2007 2008 2009 2010
Source: Key Note

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DEFINITION
Complementary and alternative medicine (CAM) is used to describe a highly diverse and wide spectrum of different disciplines and treatments, some of which have traditions going back thousands of years, and others that are relatively new. The most commonly used complementary therapies in the UK are as follows:
acupuncture Alexander technique aromatherapy ayurvedic medicine Chinese traditional medicine chiropractic herbal medicine homeopathy iridology massage therapies naturopathy osteopathy psychotherapy (including hypnotherapy, counselling, biofeedback) spiritualism.
As a result of the decentralised and self-regulatory nature of most complementary therapies, accurate data are difficult to obtain. Apart from services provided by practitioners, there is also a very large retail market for supplements and alternative remedies. Only those medicines that are supplied by qualified practitioners are covered in this report. In this report, CAM is defined as those services and products supplied by CAM practitioners and therapists, and any products and equipment supplied and used by them. This includes essential oils, herbal medicines and homeopathic remedies. The definition also covers gross fees and costs of services. CAM in this report excludes herbal and natural supplements, aromatherapy oils and homeopathic remedies sold in retail outlets and not directly supplied by practitioners.
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KEY TRENDS
Until recently, the Government did not require manufacturers of vitamins,
minerals, supplements, herbal medicines or other remedies to rigorously test product claims as required by pharmaceutical companies for pharmaceuticals. However, new EU legislation will limit dosages of certain active ingredients, or in the case of some herbal preparations, will prevent their sale altogether.
Demand for CAM continues to increase, with growth particularly evident in

population groups that have not traditionally been open to the use of CAMs.
Despite the increasing integration of complementary medicine into the

NHS, the majority of complementary therapies are provided by private practitioners. The most commonly used complementary therapies are homeopathy, osteopathy, chiropractic, acupuncture, aromatherapy and reflexology.
Although available in some instances through the NHS, the provision of

complementary medicine is highly variable geographically, depending on the purchasing policies of primary care trusts (PCTs). The majority of the time, CAMs are paid for by the patient.
Many private health insurance plans offer some sort of cover for
complementary therapy, although around 90% of complementary medicine is purchased privately.
Although herbal medicines might be effective, many are gathered in the

wild in developing countries, making quality control of the product almost impossible. There have been cases of illness caused by medicines with ingredients sourced from India and China, as a result of heavy metal contamination or the inadvertent addition of poisonous plants. In other cases, the herbs themselves may have side effects.
For CAM practitioners, statutory regulation is leading to enhanced

professional status and the opportunity to enforce standards for education and training. There are, however, registration costs to be submitted. On 26th August 2005, it was reported that a Swiss-UK review of 110 trials found no convincing evidence that homeopathic treatment worked any better than a placebo. However, the row over homeopathy has continued for many years, and advocates of the treatment maintain that the therapy, which works on the principle of treating like with like, does work. A spokeswoman from the Society of Homeopaths claimed that many previous studies have demonstrated that homeopathy has an effect over and above placebo.
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MARKET SIZE
The market for CAM services has been growing steadily since 2001, as complementary therapies have become increasingly integrated with conventional medicine. Between 2001 and 2005, the total UK market for CAMs increased by an estimated 32.9% to 775m.
Table 10.1: The Total UK Complementary and Alternative Medicine Market by Value (m), 2001-2005
2001
Value (m)
e Key Note estimate
2002 624 7.0
2003 671 7.5
e2004
e2005
583 -
721 7.5
775 7.5

Figure 10.1: The Total UK Complementary and Alternative Medicine Market by Value (m), 2001-2005
800 750 700 650 600 550 500 2001 2002 2003 2004 2005

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SUPPLY STRUCTURE
Most practitioners operate as sole traders or small partnership businesses. They tend to operate either as freelance practitioners or are based in a dedicated complementary medicine clinic, or within an NHS or integrative practice. Some practitioners provide services directly to businesses or operate out of health clubs, hotels and spas. Complementary and alternative practitioners are subject to a range of statutory controls and regulations, including the Health and Safety at Work Act 1974, the Consumer Protection Act 1987 and the Food Safety Act 1990. Many CAM practitioners are also free to operate under Common Law, provided that they do not falsely claim to be a member of a regulated profession (e.g. osteopath or chiropractor), in which activities are tolerated unless expressly prohibited. In the UK, osteopaths and chiropractors are the only CAM practitioners that are regulated via specific regulation. The General Chiropractic Council and General Osteopathic Council were created through two acts of Parliament Osteopaths Act 1993 and Chiropractors Act 1994 making it a criminal offence to practice as an osteopath or chiropractor unless registered with the appropriate Council, both of which have statutory self-regulatory status. Only the practitioners rather than the modalities are regulated, i.e. other therapists may provide chiropractic and osteopathy, provided that they do not claim to be an osteopath or chiropractor. There are a number of professional organisations for herbalists, which are members of the umbrella body the British Herbal Practitioners Association, including the National Institute of Medicinal Herbalists (NIMH), the General Council and Register of Consultant Herbalists and the Register of Chinese Herbal Medicine. Although these self-regulatory organisations exist, many herbal remedies are available in retail outlets. Homeopathy, alone among complementary therapies, was recognised in the National Health Act of 1950 and there are around five hospitals in the UK with homeopathic services. However, the title of homeopath is not protected by statute and, in practice, anyone could set up as a homeopath regardless of training. Medical practitioners who provide homeopathic services can be members of the Faculty of Homeopathy, whereas for non-medically qualified homeopaths, the principal professional organisation is the Society of Homeopaths, which itself is a member of the European Council for Classical Homeopathy. In 2000, the House of Lords Select Committee on Science and Technology recommended that acupuncture and herbal medicine should have statutory regulation and suggested that non-medically qualified homeopaths should benefit from regulation. In the early part of 2002, the European Commission formally proposed a directive on the safety, efficacy and quality of over-the-counter (OTC) herbal remedies following serious safety concerns about some herbal remedies.
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Any products containing the Chinese herbal medicine aristolochia were banned from July 1999, following cases of serious kidney failure. In October 2002, the Committee for Safety of Medicines, alarmed by around 70 reported cases of liver damage as a result of taking the herbal supplement kava kava, banned its import into the UK from January 2003. The highly popular herbal Prozac, St Johns wort, has been shown to affect immunosuppressants in heart transplant operations, as well as oral contraceptives. Under the new Traditional Medicinal Products Directive, herbal remedies will only be licensed when safety criteria are met under the same regulatory procedures as for pharmaceuticals. There are a number of routes for obtaining CAM provision either on the NHS or privately, including the following:
Hospitals or clinics provision is either through dedicated independent

facilities, such as the Royal London Homeopathic Hospital, or as integrated hospital-based care, such as that often found in palliative care, which often provides a variety of therapies. There are currently five NHS homeopathic hospitals and a number of private hospitals that offer CAM as a benefit to patients.
Provision by general practitioners (GPs) who are trained in CAM therapies. Referral to an independent complementary health clinic or practitioner,
either NHS-funded or paid for by the patient.
Privately organised consultations with CAM practitioners or CAM clinics,

organised and paid for by the patient themselves, bypassing any NHS involvement.
Self-treatment the patient or carer learns and applies CAM directly.

There is a significant variety of OTC CAMs available from retail pharmacy outlets and health food shops, but these are not covered in this report. Funding for CAM comes from a variety of sources, including the following:
NHS, particularly PCTs registered charities and charitable trusts self-pay by patient private medical insurance (PMI).
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The largest single group of CAM practitioners are reflexologists, with an estimated 13,000 practitioners. However, there are likely to be many more part-time therapists who have not joined any trade association. Reflexology is used in a very wide spectrum of settings, ranging from private practices, hospitals, long-term care homes, hotels, spas and leisure facilities, and is used to treat a wide range of conditions. There are around 8,500 full-time and fully trained aromatherapists in the UK and there are also likely to be many more part-time practitioners with varying levels of training and experience. Aromatherapy is highly popular, not just in the healthcare setting, but also in the leisure and beauty treatment industries. It is enjoyed for its own sake by many people without health problems. Acupuncture is an ancient, traditional form of Chinese healing and is still widely practised and respected in China where training is highly rigorous. There are around 8,000 acupuncturists in the UK, many of whom are also qualified medical practitioners. Herbal medicine, particularly Chinese herbal medicine, has become increasingly popular in recent years and there is concern over the number of high-street Chinese herbal clinics opening up with practitioners of varying levels of expertise and training. Chiropractic and osteopathy might be considered as some of the most established types of CAM in the UK, with their statutory regulations and protections. Homeopathy is also well established in the NHS, with five practising hospitals and significant numbers of practitioners with medical qualifications. There are a wide range of other CAM practitioners, many of whom have undergone significant training.
Table 10.2: Number of Complementary and Alternative Medicine Practitioners in the UK, 2005
Reflexologists Aromatherapists Acupuncturists Herbalists (including Chinese) Homeopaths Osteopaths Chiropractors Alexander technique teachers Other practitioners Total 13,000 8,500 8,000 5,000 4,000 3,300 1,545 1,130 35,000 79,475
Source: Key Note, compiled from trade and industry organisations

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MAJOR PLAYERS
In the UK, CAM is provided by a number of means, including the following:
Qualified physicians according to surveys, around 13% to 38% of GPs in

the UK are involved in the provision of CAM, most commonly chiropractic, acupuncture and homeopathy through self-practice, and as many as 90% refer patients to practitioners.
Other healthcare professionals (nurses, pharmacists, etc.) various surveys

have found high levels of CAM practice in nurses (up to 18%), midwives (34%) and also some physiotherapists, with the most commonly provided services being aromatherapy and acupuncture.
Registered CAM practitioners (non-medical). Non-registered CAM practitioners who may work on a paid or voluntary
basis.
Retail outlets most commonly pharmacies and health-food shops. Mail order and the Internet. Self-care many people study and use these therapies for themselves and
their families and friends. Most therapy providers tend to be highly specialised in a particular CAM, rather than providing a range of different therapies. However, some may operate from specialist clinics that provide a range of complementary therapies.

As a result of the highly fragmented nature of services, the majority of promotion for CAMs is strictly local in nature, i.e. through local newspapers. Some practitioners may also advertise in specialist magazines and in magazines that cater for women. Promotion on the Internet is very popular, as are the frequent health and beauty fairs that take place throughout the year.
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BUYING BEHAVIOUR
Many studies have been carried out to examine the use of CAM in the UK and results have varied considerably, although there appears to be a consensus that CAM is significantly more popular among women than men. This is at least partly due to respondents perceptions of what constitutes CAM. Therapies such as osteopathy and chiropractic are so integrated into the NHS that some people do not regard them as CAMs, but as part of mainstream medicine. Others, such as aromatherapy, have become increasingly associated with the health and beauty market and are frequently provided in spas and leisure facilities. Reflexology comes somewhere in between. Surveys have indicated that most people using complementary medicine do so in conjunction with conventional medicine and most are seeking alleviation of chronic health problems rather than using it for ideological reasons. Often, they have had limited or unsatisfactory results from conventional medicine or have suffered adverse side effects of conventional treatments which they are seeking to alleviate. Certainly, according to Vos and Brennan, research has indicated that people with chronic debilitating conditions are more than twice as likely to use complementary medicine than those with short-term conditions. Various surveys also seem to indicate that even if the patients medical condition is not relieved by complementary medicine, most customers remain satisfied with its performance. Most complementary therapists provide a holistic patient-centred approach, with the average treatment time (usually between 30 and 60 minutes) being far longer than that provided by orthodox practitioners in the NHS, who are often rushed and have strictly limited time with their individual patients (the average length of time for a GP with a patient is limited to 7 minutes). Complementary therapists also tend to operate from comparatively luxurious accommodation, compared with NHS practitioners. Certain herbal medicines and supplements interact with other drugs, e.g. St Johns wort reduces the efficacy of the contraceptive pill.
FORECASTS
The market for CAM services in the UK is forecast to continue growing steadily, with increasing acceptance and integration into mainstream healthcare for a number of therapies. Between 2006 and 2010, the total UK CAM market is forecast to increase by 34.6% to 1.21bn.
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Table 10.3: The Forecast Total UK Complementary and Alternative Medicine Market by Value (m), 2006-2010
2006
Value (m)
2007 895 7.4
2008 962 7.5
2009 1,038 7.9
2010 1,121 8.0
833 7.5
Source: Key Note

Figure 10.2: The Forecast Total UK Complementary and Alternative Medicine Market by Value (m), 2006-2010
1200 1100 1000 900 800 700 600 500 400 2006 2007 2008 2009 2010
Source: Key Note

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DEFINITION
In 1990, the World Health Organization (WHO) defined palliative care as: the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of the best possible quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness, in conjunction with anti-cancer treatment. Palliative and hospice care is holistic in nature, taking into account the overall welfare of the patient, including emotional, spiritual and social needs, as well as any medical needs, encompassing the patients family. Hospices have pioneered patient-centred care for those suffering from incurable or terminal illness. The medical aspects of hospice care focus on symptom relief, particularly pain relief. In 1843, the first hospice was opened in France by Madame Jeanne Garnier specifically for the care of the dying. It was followed by Our Ladys Hospice in Dublin, St Lukes Hospital and St Josephs Hospice in Hackney, all with a firm Christian basis. The modern hospice movement was established with the founding of St Christophers Hospice in 1967 by Dr Cicely Saunders, who established the modern principles of palliative care, particularly with respect to pain relief. Although hospices form a centre core for palliative care, it has now moved outside the hospice into community-based care and respite care, using home-care teams and providing day-care facilities, increasingly in partnership with the NHS. The Department of Health (DoH) has officially recognised the key role that palliative care has for both patients and their carers, and that it should be provided along with any other disease treatments and therapies.
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The primary aims of palliative care are to:
provide pain and symptom relief integrate both the psychological and spiritual aspects of patient care provide a support system for both patients and their families to assist
patients in leading as full a life as possible and to help their family cope with the illness and bereavement
to apply palliative care throughout the course of the illness, along with
other therapies for the prolongation of life and conduct investigations to determine, understand and control any unpleasant symptoms and complications. Palliative care is patient-centred and is increasingly flexible and integrated with provision, often in partnership with voluntary organisations or the NHS. Services are based in hospices, hospitals, day-care centres and, increasingly, in the home. Palliative care teams are multidisciplinary, comprising specifically trained medical professionals and volunteers. The range of services include:
Pain and symptom relief using medication regimes, physiotherapy, and

alternative and complementary therapies, including acupuncture, aromatherapy, chiropractic, osteopathy, reflexology and others.
Counselling, psychotherapy and emotional support for patients and their

families. Alternative therapies and relaxation techniques are often provided.
Bereavement services counselling and less formal support for patients

and their families, including self-help groups, befriending, etc. These services are often provided by the voluntary sector.
Social services these include a wide range of advice services and practical
help, including advocacy and legal advice, group help, family support services and community care provision.
Alternative and complementary therapies. Spiritual care this is central to the tenets of palliative care. Spiritual,
cultural and religious needs for patients and their families are assessed and addressed, including for those who have no faith.
Art therapy to provide an outlet for emotions and anxieties. Other including music therapy, beauty therapy, and creative and social
activities that enhance wellbeing.
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KEY TRENDS
Demographic Trends
As the population continues to age and the number of ageing people with chronic incurable illnesses rises, there is an increasing need for palliative care services and support services for patients and their carers.
Greater Integration
The principles and practices of palliative care are becoming increasingly integrated into mainstream practices, as hospices and their services work in increasing partnership with the NHS. Growing numbers of healthcare professionals have been educated and trained in palliative care. As well as an increasing network of support in the UK, there are increasing links and information exchanges with overseas hospice networks.
Availability
The vast majority of palliative care services are provided to cancer patients. Increasingly, there is a recognised need to provide palliative care services to all who need it, including other terminal/incurable illnesses. The House of Commons Health Committee Enquiry, which was published in July 2004, established that there was a need to ensure equal access and availability of palliative care services regardless of region. It addition, it recognised that services should be available to people with other incurable illnesses as well as cancer. Currently, around 95% of palliative care patients are cancer sufferers and the National Council has stated that palliative care should be available to up to 25% of non-cancer patients, including those with end-stage heart failure and other circulatory disorders, neurological disorders, acquired immuno deficiency syndrome (AIDS) and others.
NICE Guidance
In March 2004, the National Institute for Clinical Excellence (NICE) published guidance on palliative care for England and Wales, Improving Supportive and Palliative Care for Adults with Cancer. The guidance stipulated that all regions should be covered by a multidisciplinary team comprising, at a minimum, a consultant in palliative care medicine and a nurse, as well as input from other relevant professionals. It also stated that palliative care should be available in hospital-based, specialist inpatient units, as well as in patients homes. The guidance recognised that there was a need for co-ordination between the various services for health and social care in both the public and voluntary sectors, with the promotion of communication between patients, professionals and carers. Cancer networks are required to establish networks for the co-ordination and management of palliative and supportive services.
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The guidance also proposed the need for day care services to be reviewed when more research has been performed. In addition, the NICE guidance outlined which services should be available to adult cancer patients and established a basis for national commissioning procedures for palliative care.
Childrens Palliative Care

There is growing recognition of the need for palliative care services developed specifically for children, as the palliative care needs of children have significant differences to those of adults. In 2004, a Quality Assurance Package was established as a self-assessment tool with the purpose of developing and promoting consistent care standards in hospices for children. At the basis of this package is the recognition that standards and practices should be developed specifically for children rather than being based on adult services. Specific childrens hospice services are continuing to develop and grow, with over 3,000 children and their families under the care of hospices each year. The National Service Framework (NSF) for Children, Young People and Maternity Services 2004 from the Department of Health (DoH) stated that palliative care services should be available to all children and young people in need. It also stipulated the range and type of services that were needed and the agencies that should be responsible for them. The NSF emphasised the need for integration of the various services and agencies involved in order to provide care services effectively. The emphasis was on family focused provision and choice, with respite care availability.
Palliative Care Funding

Demand is increasing for palliative care services, which are heavily reliant on voluntary contributions. Competition for funds in the voluntary sector is increasing, leading to funding pressures. Pay costs are also rising. Following a Treasury report in 2002 The Role of the Voluntary and Community Sector in Service Delivery: A Cross Cutting Review it was stipulated that voluntary groups should be paid the full costs of providing public services by 2006. In addition, as part of a move to support and promote home-based services, an extra 12m was allocated in England at the end of 2003 to support a number of initiatives, including the Liverpool Care Pathway, the MacMillan Gold Standards Framework and the Preferred Place of Care Initiative. Another 10m was allocated by the Welsh Assembly to support the Strategic Direction for Palliative Care in Wales to all hospices in Wales. In April 2003, following comprehensive consultation, the Scottish Executive Health Department announced the intention to fund 50% of the annual running costs of voluntary hospices by 2006 to 2007 at the latest.
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MARKET SIZE
According to Hospice Information, the majority (around 80%) of hospice care is provided by local, community-based charities, with funding obtained through fundraising activities. In England, around 35% of the running costs for adult hospices are derived from government funding, compared with 5% for childrens hospices. In Scotland, 37% of the running costs for adult hospices are provided by government funding. There is no doubt that, with the twin pressures of an ageing population and rising salary costs, the palliative care market has been rising steadily over the past 5 years. Between 2001 and 2004, the palliative and hospice care market grew by 30.2% to 453m. Key Note estimates that, in 2005, the market will increase by a further 10.2% to 499m.
Table 11.1: The Total UK Palliative and Hospice Care Market by Value (m), 2001-2005
2001
Value (m)
e estimates
2002 376 8.0
2003 412 9.6
e2004
e2005
348 -
453 10.0
499 10.2
Source: Key Note

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Figure 11.1: The Total UK Palliative and Hospice Care Market by Value (m), 2001-2005
500 450 400 350 300 250 2001 2002 2003 2004 2005
Note: figures for 2004 and 2005 are estimates.
Source: Key Note

SUPPLY STRUCTURE
In the UK, palliative care is provided in both the community and in specialised units. Specialised services include the following:
Independent hospices which are funded by charity. NHS palliative care units. Hospital support services/teams these comprise advisory palliative care
services and are based in hospitals and clinics. Hospital support services/teams monitor patients through the course of their disease.
Community-based services the first home care team was established by

St Christophers Hospice. Many teams have been established by MacMillan Cancer Relief, which funds the first 3 years, before the patient is taken over by the NHS or a voluntary/independent hospice. These teams and services provide specialist advice and support, working in partnership with general practitioners (GPs) and district nurses.
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Hospice at home increasing numbers of service providers are extending

their palliative care services to provide a broader range of specialist nursing, social and emotional support together with medical services in the home environment. This broad range of home services is termed hospice at home.
Day care day care is an increasingly important component of palliative

care services. It enables patients to remain based in their homes, but provides access to other hospice and palliative care services as well as a variety of social activities. In January 2005, 61.7% of palliative care units in the UK were provided by the voluntary sector, which accounted for 73% of all hospice beds. The number of voluntary units and beds has remained relatively stable over the past 5 years, having risen by 2.6% and 0.4%, respectively, between 2001 and 2005. Voluntary palliative care is funded through independently managed charities raising funds through community-based fundraising activities and initiatives, as well as through legacies and donations, frequently from patients families and friends. The number of NHS units accounted for 25.3% of all palliative care units and 19.6% of beds in the UK in January 2005. Since 2001, the number of NHS units has risen by 12.3%, while the number of beds has increased by 9.9%. Childrens hospice services grew significantly from 22 units in 2001 to 33 units in 2005, an increase of 50%. The number of beds rose by 45.7% over the same period to 255. As a result of the relative growth in these sectors, the overall number of hospices/palliative care units in the UK has increased by 9.5% since 2001, while the overall number of hospice/palliative care beds has risen by 4.6%. These figures include three specialist hospice units comprising 50 beds specifically for AIDS patients.
Table 11.2: Inpatient Palliative Care Provision in the UK by Number of Units and Beds, 2001-2005
2001 Adult Voluntary
Units Beds
2002
2003
2004
2005
152 2,480
152 2,433
152 2,433
153 2,522
156 2,489
Table continues...
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Table 11.2: Inpatient Palliative Care Provision in the UK by Number of Units and Beds, 2001-2005
...table continued 2001 Adult NHS
Units Beds
2002
2003
2004
2005
57 607 209 3,087
56 596 208 3,029
64 663 216 3,096
64 673 217 3,195
64 667 220 3,156
Total adult units Total adult beds Children

Units Beds
22 175
25 186
26 196
30 229
33 255
Total Units Beds 231 3,262 233 3,215 242 3,292 247 3,424 253 3,411
Source: Hospice and Palliative Care Facts and Figures 2005, Hospice Information Between 2001 and 2005, the number of community palliative care teams rose by 23 teams (6.9%) to 358. Over the same period, hospice-at-home services grew more rapidly by 46.5% to 104. Day care services increased by 8.7% to 263, while hospital support teams grew by 11.4% to 361 between 2001 and 2005.
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Table 11.3: Number of Palliative Care Support Services in the UK by Type, 2001-2005
2001
Community palliative services Hospice-at-home Day care Hospital-based support
2002 334 78 243 321
2003 332 93 247 335
2004 356 94 258 353
2005 358 104 263 361
335 71 242 324
including MacMillan nurses comprising hospital support nurses and teams
Source: Hospice and Palliative Care Facts and Figures 2005, Hospice Information
Regional Variations
In January 2005, England accounted for the majority (82.3%) of all adult palliative care beds in the UK, followed by Scotland, with 11.1%. Wales had 4.5% of palliative bed provision, while Northern Ireland had the lowest number of beds, at 2.2%.
Table 11.4: Inpatient Adult Palliative Care Provision in the UK by Number of Units and Beds by Country (number and %), 2005
Northern Ireland 5 68 2.2
England
Hospices/units Beds % of total adult beds
Scotland 25 349 11.1
Wales 16 141 4.5
174 2,598 82.3
Source: Key Note, adapted from Hospice and Palliative Care Facts and Figures 2005, Hospice Information
In terms of regional care for children, in January 2005, England accounted for 87.1% of total palliative bed provision, followed by Wales at 5.9%. Northern Ireland had 3.9% of palliative bed provision and, in contrast to its provision for adult palliative care, Scotland had the lowest levels of provision for children at 3.1%.
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Table 11.5: Inpatient Child Palliative Care Provision in the UK by Number of Units and Beds by Country (number and %), 2005
Northern Ireland 1 10 3.9
England
Hospices/units Beds % of total beds
Scotland 1 8 3.1
Wales 2 15 5.9
29 222 87.1
In January 2005, England accounted for the majority (73.5%) of home care services, followed by Scotland at 14.8%. Wales had 9.2% of home care services and Northern Ireland accounted for 2.5%. For the more comprehensive hospice-at-home services, England had an even higher proportion at almost 81.7%, followed by Wales at 10.6%. Scotland accounted for only 4.8% of services, with Northern Ireland at 2.9%. Again, the majority (81%) of day care services are situated in England, compared with 9.5% in Scotland and 7.6% in Wales. Northern Ireland had the lowest proportion of day-care provision at 1.9%. England also accounted for 76.5% of hospital support nurses and almost 77.8% of hospital support teams. Scotland had the second-largest levels of provision, with 16.2% of hospital support nurses and 10.9% of hospital support teams. Northern Ireland accounted for the lowest levels, with only 1.5% of hospital support nurses and 4.1% of hospital support teams.
Table 11.6: Palliative Care Support Services in the UK by Type by Country (% and number), 2005
Northern Number of Ireland Services 2.5 2.9 1.9 358 104 263
England Scotland
Home care Hospice-at-home Day care
Wales 9.2 10.6 7.6
73.5 81.7 81.0
14.8 4.8 9.5
Table continues...
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Table 11.6: Palliative Care Support Services in the UK by Type by Country (% and number), 2005
...table continued Northern Number of Ireland Services
England Scotland
Hospital support nurses Hospital support teams
Wales
76.5 77.8
16.2 10.9
5.9 7.2
1.5 4.1
68 293
MAJOR PLAYERS
MacMillan Cancer Relief
MacMillan Cancer Relief is a UK-based registered charity that was initially established as the Society for the Prevention and Relief of Cancer. The main aim of the charity is to help and support cancer patients and their families, as well as facilitate access to information and effective treatment. The charity is best known for its 2,500 MacMillan nurses, who specialise in cancer and palliative care, as well as providing information and support to patients and their families from the point of diagnosis throughout the course of the disease. They provide home-based services and are registered nurses with a minimum of 5 years experience, including at least 2 years in cancer or palliative care. For each patient, the charity funds these nurses for the initial 3 years, with the NHS then taking over the costs. In addition, MacMillan has ten primary care nurses in the UK working in GP practices. In addition to the nurses, there are over 300 MacMillan doctors operating via the NHS to provide specialist cancer care services, as well as advice and support to other healthcare professionals. MacMillan also funds a range of social and health professionals, such as dieticians, physiotherapists, speech and language therapists, geneticists, pharmacists, psychologists, benefit advisors and ethnic liaison officers, among others. As well as providing and training healthcare professionals, MacMillan has built over 100 specialist cancer care centres for the NHS and voluntary sector, usually in partnership with local primary care trusts. They also provide financial support in certain instances and, in 2004, gave 5.3m to help cancer patients facing financial difficulties. In 2003, the charitys total income was 89m.
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Marie Curie Cancer Care

This charity was established in 1948 and provides care to around 25,000 cancer patients each year in the UK, free of charge. The charity provides specialised home-nursing services to almost half of all cancer patients who choose to die at home. The charity has been strongly lobbying on behalf of patients to give them the choice of being able to die at home if that is their wish and, as such, has placed a strong emphasis on developing home care services and support to promote that choice. The charity also runs ten specialist hospices throughout the UK, with around 236 beds, and funds the Marie Curie Research Institute to carry out cutting-edge cancer research. Marie Curie Cancer Care provides comprehensive educational and training programmes in cancer care, as well as an information service for professionals, the public, patients and their families.
The Sue Ryder Foundation

The Sue Ryder Foundation was founded in 1953 and has evolved into an organisation that operates on an international basis. Sue Ryder Care provides support to people with a wide range of neurological disorders and terminal illnesses, both in the UK and overseas. Sue Ryder Care Centres are designed to provide the care that is most needed in a community. The centres are funded partly by social services and health authorities, as well as through fundraising in the community, legacies, donations and the revenue from more than 430 charity shops. The range of services offered varies from long-term and residential respite care in the charitys six UK hospices, with some 111 beds, to a number of day care centres and home care services ranging from physical care to activity programmes, transport, and leisure and community activities to improve the quality of life.

Palliative care charities have to raise funds to finance their activities. As part of this, significant amounts are spent on advertising and promotion. Various fundraising activities are organised, such as sponsored walks, runs and other types of activities. Many of the hospices and voluntary groups raise funds from charity shops, benefiting from preferential business rates to operate in high streets and selling donated goods. Many raise funds through taxation-favourable donation schemes from employees and businesses, as well as from legacies.
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BUYING BEHAVIOUR
Profile of Use
Between 2003 and 2004, 41,000 new patients were admitted to inpatient units, with a total of 58,000 admissions every year for inpatient units and 30,000 inpatient deaths. Around 20,000 new patients attend day care each year, and there were 8,600 attendances at 263 day care centres each week in 2003/2004. Community care palliative nursing teams cared for 155,000 patients each year in home settings, with 110,000 new patients. Around 31,000 of these patients died at home in 2003/2004.
Table 11.7: Patient Usage of Palliative Care Facilities and Services (number of patients), 2003/2004
Number of Patients Inpatient Care Admissions New patients Deaths Community Care Services Total patients New patients Deaths (home) Day Care Average places per service per day Total places per week Attendances per week
excluding Scotland
58,000 41,000 30,000
155,000 110,000 31,000
15
13,700 8,600
Source: The National Council for Palliative Care
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Patient Profile
In 2004, around 95% of all palliative care inpatients were suffering from cancer and 0.6% from AIDS. The majority (68%) of patients were aged 65 years or over, while around 9% of patients were very elderly (aged 85 years or older). There were few ethnic minorities among hospice patients, with 96% of patients being white. According to Hospice Information, the annual prevalence rate for children (aged between 0 and 19 years) with life-threatening conditions is a minimum of 12 per 10,000 people, and figures indicate that 60% of these do not have cancer. There are estimated to be around 18,000 children in the UK requiring palliative care.
FORECASTS
In its election manifesto, the Labour Government promised that in order to increase choices for patients with cancer, we will double the investment going into palliative care services, giving more people the choice to be treated at home. Assuming that the Government keeps its pledge to at least significantly increase NHS expenditure on palliative care, this should greatly expand the market for palliative care services. However, there are a number of other factors that will contribute to market expansion in the near future, as follows:
Demographic pressures the UK, along with other developed countries, is

continuing to age demographically. The number of elderly, and particularly the very elderly, is continuing to rise, which adds pressure on healthcare services.
Staffing costs and salaries in the UK, there is a critical shortage of

healthcare professionals, particularly nurses and physicians (namely GPs). Staff turnover is high in all areas and there are chronic shortages in spite of recruitment drives abroad. It would seem inevitable that salaries will rise significantly in order to attract and retain suitably qualified professionals.
Community palliative care there is increasing recognition that improving

choice for patients in palliative care by providing home care services is cost effective, as well as being preferred by certain patients and their families. Increasingly, services are being established that are geared towards home-based services and supporting respite and day care services.
Increasing partnership and integration with the NHS the favourable

climate from the Government regarding developing partnerships between the NHS and the private sector can only facilitate expansion of palliative care services in the NHS.
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Expanding palliative care services currently, the vast majority of palliative

care services are for cancer patients. There is increasing recognition that other patients also have palliative care needs and proposals have been made to develop services accordingly. In addition, more work has to be done in developing specific provision for children, particularly in Scotland, Wales and Northern Ireland. This will lead to specific expansion in childrens palliative care services. Taking the above trends into consideration, Key Note forecasts significant expansion in the palliative and hospice care market over the next 5 years to 2010. In 2006, the market is forecast to grow by 12.6% to 562m. Following this, a year-on-year rise of between 15% and 15.5% is expected, with the market being worth an estimated 990m in 2010.
Table 11.8: The Forecast Total UK Palliative and Hospice Care Market by Value (m), 2006-2010
2006
Value (m)
2007 647 15.1
2008 745 15.1
2009 857 15.0
2010 990 15.5
562 12.6
Source: Key Note

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Figure 11.2: The Forecast Total UK Palliative and Hospice Care Market by Value (m), 2006-2010
1100 1000 900 800 700 600 500 400 2006 2007 2008 2009 2010
Source: Key Note

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OVERVIEW
According to the Organisation for Economic Co-operation and Development (OECD), in terms of total healthcare expenditure as a percentage of gross domestic product (GDP), the UK was ranked 19th in the world, at 7.7% in 2003. The US had, by far, the highest percentage, at 15%, followed by Switzerland, at 11.5%. This was closely followed by Germany, at 11.1%, which has increased expenditure on healthcare significantly over the past decade as the country upgraded healthcare services in the former East Germany. Iceland and Norway also had high levels of expenditure, at 10.5% and 10.3%, respectively. France had expenditure levels of 10.1%, closely followed by Canada and Greece (both at 9.9%), the Netherlands (9.8%), and Portugal and Belgium (both at 9.6%). Lowest levels of healthcare expenditure as a percentage of GDP were observed in Korea, at 5.6%, and the Slovak Republic, at 5.9%.
Table 12.1: Total Healthcare Expenditure as a Percentage of Gross Domestic Product by Country (%), 2003
US Switzerland Germany Iceland Norway France Canada Greece Netherlands Portugal Belgium Australia Sweden Denmark Italy New Zealand Japan Hungary Table continues... 15.0 11.5 11.1 10.5 10.3 10.1 9.9 9.9 9.8 9.6 9.6 9.3 9.2 9.0 8.4 8.1 7.9 7.8
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Table 12.1: Total Healthcare Expenditure as a Percentage of Gross Domestic Product by Country (%), 2003
...table continued UK Spain Austria Czech Republic Finland Republic of Ireland Turkey Mexico Luxembourg Poland Slovak Republic Korea Source: OECD Health Data 2005, Copyright OECD, June 2005 7.7 7.7 7.6 7.5 7.4 7.3 6.6 6.2 6.1 6.0 5.9 5.6
KEY OVERSEAS MARKETS

France
The French healthcare system is funded primarily through taxation revenues and health insurance contributions from employers and employees. Healthcare is funded through a combination of health insurance schemes and the government, and healthcare is provided by private, self-employed practitioners and non-profitmaking public hospitals and private commercial hospitals. All citizens are covered by public health insurance without any facility for opting out. There are three main health insurance schemes in France, which cover 96% of the population. Residents of the country are automatically affiliated to a scheme depending on where they live and their employment status. Around 90% of the population also have additional voluntary health insurance and the nature and quality of this is variable depending on the contracts involved. Most general practitioners (GPs) and healthcare professionals in ambulatory care are paid on a fee-for-service basis, while healthcare professionals in public hospitals are paid salaries. Patients in France are free to choose their physicians and hospitals.
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Germany
Healthcare in Germany is shaped by the federal nature of the government. Responsibility for healthcare is divided between the federal government, the Lander and the various representative organisations of healthcare providers, professionals and insurers. Healthcare is mostly funded through social health insurance contributions, with around 88% of the population covered by statutory health insurance and a further 9% covered by private health insurance. Around 2% of the population (mostly policemen, soldiers and those on welfare) are covered by free government health insurance, leaving less than 0.2% uninsured. Taxation only contributes around 8.4% of total expenditure on healthcare. In Germany, ambulatory care and hospitals have traditionally been separated, with almost no outpatient care provided in hospitals. Ambulatory care is provided by private office-based physicians, both GPs and specialists, who are paid on a fee-for-service basis. Hospital care is provided by a combination of public and private providers, and the public sector is significantly larger than the private sector.
Italy
Italy is a parliamentary republic and the Italian healthcare system has undergone some significant changes since the NHS model of care was established in 1978. Since then, the system has been progressively devolved to both the regions, and to lower-level purchaser and provider organisations. Public expenditure on health is around 68%, which is one of the lowest percentages in Europe.
Spain
The Spanish healthcare system has evolved dramatically since the new constitution was approved in 1978. Prior to this, the system was means tested and centralised, and was centred in a social security scheme. The new constitution gave all Spaniards the right to health protection and the system was reorganised into a regionally based one, as well as the creation of a National Health Institute (INSALUD) and the formation in 1981 of a separate organisation for healthcare within the social security system. Healthcare has effectively evolved from a social security system to a national health system, which is publicly financed via taxes. In addition, the provision of care is largely public. The system has been progressively decentralised into 17 regions, although only seven of these have full powers of control, covering 62% of the population. The INSALUD manages most services in other regions.
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The healthcare system in Spain is financed through general taxation and 94.6% of the population have obligatory affiliation to the social security system. 4.6% of the remaining population, who are mostly civil servants and their dependants, are covered by mutual funds. There is also a means-tested non-contributory scheme for the disadvantaged. Around 0.6% of the population, the most affluent, are not covered by the national health system. There are three types of private insurance in Spain: voluntary; civil servants mutual funds; and employer-purchased insurance schemes, which cover up to 19% of the population. Private insurance accounts for between 14% and 34% of total private healthcare expenditure. The primary care sector of the Spanish healthcare market is run by the public sector, although priority is given in Spain to the secondary care system. Most hospitals in the country are publicly owned. Since the 1990s, contracted programmes with private hospitals have increasingly been used in an effort to reduce waiting lists.
The US
According to Access to Healthcare, apart from South Africa, the US is the only country in the developed world that does not provide healthcare for all of its citizens. It is also the most expensive healthcare system in the world, partly because of its fragmented multiple payer system and partly because of the significantly high administration costs. Rather than a unified healthcare system, it has been described by some commentators as a mixture of competing systems and subsystems. The US healthcare market is dominated by the private sector, with 20% of the market belonging to the low-cost budget Health Maintenance Organisations (HMOs) and 50% to managed care options. The public provision is most generally carried out by Medicaid, which provides insurance for the poor and disabled, and Medicare, which provides cover for government insurance for the impoverished elderly. Although the US system of healthcare is based on private insurance, according to the Kaiser Foundation, around 44 million Americans (around 15.8% of the population) have no form of insurance at all. Around 60% of all healthcare comes from private sources. As with the UK, physicians act as gatekeepers and are usually reimbursed by a system of fees for services.
Japan
The Japanese universal healthcare system was established in 1958 and is financed by a number of insurance systems. The employees Health Insurance System is funded by compulsory contributions from employees (around 8% of wages), with the costs shared equally between employers and employees, and cover being provided to employees and their dependants. The National Insurance System provides for the self-employed, pensioners and healthcare employees, as well as their dependants. The system is administered by local government, which effectively acts as an insurer. Insurance premiums are calculated on the basis of individual income, assets and the number of dependants, and constitute 57% of health expenditure. Another 24% of expenditure is contributed by the federal government and another 9% by local government.
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In Japan, around 80% of hospitals and the majority (94%) of clinics are private. Patients are free to select their ambulatory care physicians and they are directly paid fees for services. These fees are regularly negotiated and uniformly applied, with the GPs income largely derived from their prescription revenues. In contrast, hospital physicians are paid fixed salaries.
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13. The Future
13. The Future

INTRODUCTION
The Economy
More than most healthcare systems, healthcare in the UK is dependent on the state of the economy, since it is funded from general taxation. However, healthcare systems throughout the world are under increasing pressure from demographically ageing populations and the rising costs of care as new technologies and treatments increase the scope and range of healthcare. These are both ongoing and long-term trends. According to the Treasury, UK gross domestic product (GDP) growth is forecast to remain virtually unchanged until at least 2009, with a 0.1% decrease predicted in 2006 (to 2.5%), followed by a rise of 0.1% in 2007 (to 2.6%). In 2008, GDP growth is forecast to remain virtually unchanged before falling by 0.1 percentage points to 2.5% in 2009. The Government is determined to control expenditure on healthcare, particularly on pharmaceuticals, and, with the new pricing agreements for the NHS, expenditure is unlikely to rise much beyond the current 7.7% of GDP (see Chapter 12 A Global Perspective). The rate of inflation is forecast to fall by 0.6% in 2005 to 2.4%, before rising by 0.1% in 2006. Inflation is then forecast to remain steady until 2008, when a rise of 0.1% (to 2.6%) is predicted, before stabilising in 2009. In a highly globalised industry such as pharmaceuticals, low inflation is essential for containing the already considerable costs of developing and marketing drugs and competing in a highly competitive world market. The pharmaceutical industry will continue to be subject to controls and regulation. Pharmaceutical prices that have already been kept low are likely to be squeezed further as a result of generic competition, parallel trading and initiatives by the Government and health services to contain costs in a health service that is under rising pressures. Official unemployment figures are forecast to be 860,000 in 2005, rising by 2.3% to reach 880,000 in 2006. Thereafter, unemployment is projected to increase by 1.1% per annum until 2009, when it is forecast to rise by 4.4% to 940,000. In the pharmaceutical industry, continuing consolidation in the industry through mergers and acquisitions will result in staff reductions in a number of areas. According to the Association of the British Pharmaceutical Industry (ABPI), the value added per employee is rising each year, and this trend is likely to continue.
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Table 13.1: Forecast UK Economic Trends (000, % and million), 2005-2009

2005 UK resident population (000)
2006 60,254 0.4 2.5 -0.1 2.5 0.1
2007 60,481 0.4 2.6 0.1 2.5 0.0
2008 60,707 0.4 2.6 0.0 2.6 0.1
2009 60,934 0.4 2.5 -0.1 2.6 0.0
60,024 0.4 2.6 2.4 -0.6
GDP growth (%)

Percentage point change year-on-year
Inflation (%)
Percentage point change year-on-year
Unemployment/actual number of claimants (million)

GDP gross domestic product Note: inflation is at retail price index (RPI).
0.86 1.2
0.88 2.3
0.89 1.1
0.90 1.1
0.94 4.4
Source: Projections Database, Government Actuarys Department/Forecasts for the UK Economy, May 2005, Treasury Independent Average Crown copyright
FORECASTS
Fuelled by growth in all market sectors, the total UK market for healthcare is forecast to grow by 10.1% in 2006, to 122.64bn. Between 2006 and 2010, the market is forecast to rise by 38.3% to 169.63bn.
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Table 13.2: The Forecast Total UK Healthcare Market by Sector by Value (m), 2006-2010
2006 NHS
Private healthcare Private medical insurance Complementary and alternative medicine Palliative and hospice care
2007 108,156 19,309 3,644 895 647
2008 117,483 20,801 3,865 962 745
2009 127,647 22,474 4,116 1,038 857
2010 138,704 24,408 4,407 1,121 990
99,718 18,087 3,439 833 562
Total
122,639 132,651 143,856 156,132 169,630 10.1 8.2 8.4 8.5 8.6
Source: Key Note

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Figure 13.1: The Forecast Total UK Healthcare Market by Value (m), 2006-2010
180,000 170,000 160,000 150,000 140,000 130,000 120,000 110,000 100,000 2006 2007 2008 2009 2010
Source: Key Note

FUTURE TRENDS
Demographics
The UK population has increased by 6% since 1971 and is projected to carry on growing to reach over 61 million in 2011, creating more overall demand for healthcare services. In particular, growth has been fuelled by the increasing migrant populations of the UK. In demographic terms, the population will also continue to age significantly, with the proportion of elderly people of pensionable age forecast to constitute 21.6% of the population by 2026, compared with only 18.4% in 2002. The increasing number of elderly people will significantly add to strains on the UK healthcare system.
Antibiotic-Resistant Strains of Bacteria

Antibiotic-resistant strains of bacteria will continue to add pressure on the healthcare system, with increased morbidity of infections, as well as increasing mortality. These add significantly to the costs of healthcare, particularly if litigation is used against the hospital by patients and their families.
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Staff Shortages
There are staff shortages in all areas of healthcare, particularly in nursing posts, although there are also significant shortages of medical professionals, particularly general practitioners (GPs). The NHS has tried a number of initiatives to recruit staff and has established recruitment programmes overseas to encourage medical professionals to work in the UK. The Government has come under significant criticism for poaching much-needed healthcare professionals from developing countries. In the future, it may be the case that the Government will attempt to increase the participation of the private sector in the training of professionals or at least contribute to the costs of training.
Technological Developments
Healthcare is a technology-driven marketplace. The development of new or improved techniques with faster recovery times will significantly cut care costs, as patients recuperate more rapidly. At the same time, new developments are also expanding the boundaries of care available, offering wider scope for treatments.
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14. Further Sources
14. Further Sources

Associations
Association of British Insurers 51 Gresham Street London, EC2V 7HQ Telephone: 020-7600 3333 Fax: 020-7696 8999 E-mail: info@abi.org.uk http://www.abi.org.uk Association of Childrens Hospices Kings House 14 Orchard Street Bristol, BS1 5EH Email: info@childhospice.org.uk http://www.childhospice.org.uk Aromatherapy Consortium PO Box 6,522 Desborough Kettering Northamptonshire, NN14 2YX Telephone: 0870-774 3477 E-mail: info@ aromatherapy-regulation.org.uk http://www. aromatherapy-regulation.org.uk British Acupuncture Council 63 Jeddo Road London, W12 9HQ Telephone: 020-8735 0400 Fax: 020-8735 0404 E-mail: info@acupuncture.org.uk http://www.acupuncture.org.uk The British Herbal Medicines Association PO Box 304 Bournemouth Dorset, BH7 6JZ Telephone: 01202-433 691 Fax: 01202-417 079 http://www. ex.ac.uk/phytonet/bhma.html The British Medical Association BMA House Tavistock Square London, WC1H 9JP Fax: 020-7383 6400 http://www.bma.org.uk The British Complementary Medicine Association PO Box 5,122 Bournemouth, BH8 0WG Telephone: 0845-345 5977 E-mail: info@bcma.co.uk http://www.bcma.co.uk English Community Care Association 145 Cannon Street London, EC4N 5BQ Telephone: 020-7220 9595 Fax: 020-7220 9596 E-mail: info@ecca.org.uk http://www.ecca.org.uk Faculty of Homeopathy Hahnemann House 29 Park Street West Luton, LU1 3BE Telephone: 0870-444 3950 Fax: 0870-444 3960 http://www.trusthomeopathy.org The Federation of Ophthalmic and Dispensing Opticians 199 Gloucester Terrace London, W2 6LD Telephone: 020-7298 5151 Fax: 020-7298 5111 E-mail: info@fodo.com http://www.fodo.com General Chiropractic Council 44 Wicklow Street London, WC1X 9HL Telephone: 020-7713 5155 Fax: 020-7713 5844 E-mail: enquiries@gcc-uk.org http://www.gcc-uk.org
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Healthcare Market
General Dental Council 37 Wimpole Street London, W1G 8DQ Telephone: 020-7887 3800 Fax: 020-7224 3294 E-mail: information@gdc-uk.org http://www.gdc-uk.org General Medical Council Regents Place 350 Euston Road London, NW1 3JN Telephone: 0845-357 8001 E-mail: gmc@gmc-uk.org http://www.gmc-uk.org General Optical Council 41 Harley Street London, W1G 8DJ Telephone: 020-7580 3898 Fax: 020-7436 3525 E-mail: goc@optical.org http://www.optical.org General Osteopathic Council 176 Tower Bridge Road London, SE1 3LU Telephone: 020-7357 6655 Fax: 020-7357 0011 E-mail: info@osteopathy.org.uk http://www.osteopathy.org.uk Help the Hospices Hospice House 34-44 Britannia Street London, WC1X 9JG Telephone: 020-7520 8200 Fax: 020-7278 1021 http://www.helpthehospices.org.uk The National Council for Palliative Care The Fitzpatrick Building 188-194 York Way London, N7 9AS Telephone: 020-7697 1520 Fax: 020-7697 1530 E-mail: enquiries@ncpc.org.uk http://www.ncpc.org.uk
The data supplied by The National Council for Palliative Care (NCPC) can be found in its MDS full report for the year 2003/2004, which contains vital statistics from services across the UK. This is the ninth report from the NCPC since the introduction of the Minimum Data Sets Project in 1995. The report can be accessed by logging on to www.ncpc.org.uk and downloaded for free. National Pharmacy Association Mallinson House 38-42 St Peters Street St Albans Hertfordshire, AL1 3NP Telephone: 01727-832 161 Fax: 01727-840 858 Email: npa@npa.co.uk http://www.npa.co.uk Royal College of Nursing Copse Walk Cardiff Gate Business Park Cardiff, CF23 8XG Telephone: 0845-772 6100 http://www.rcn.org.uk Royal Pharmaceutical Society of Great Britain 1 Lambeth High Street London, SE1 7JN Telephone: 020-7735 9141 Fax: 020-7735 7629 E-mail: enquiries@rpsgb.org http://www.rpsgb.org.uk Scottish Partnership for Palliative Care 1A Cambridge Street Edinburgh, EH1 2DY Telephone: 0131-229 0538 Fax: 0131-228 2967 E-mail: office@ palliativecarescotland.org.uk http://www. palliativecarescotland.org.uk
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14. Further Sources
General Sources
BMRB International Hadley House 79-81 Uxbridge Road Ealing, W5 5SU Telephone: 020-8566 5000 Fax: 020-8579 9809 E-mail: mailbox@bmrb.co.uk http://www.bmrb.co.uk Nielsen Media Research 1st Floor Atrium Court Bracknell Berkshire, RG12 1BZ Telephone: 01344-469 100 Fax: 01344-469 102 E-mail: nmrcommunication@ nielsen.co.uk http://www.nielsenmedia.co.uk
Government Publications
National Statistics 1 Drummond Gate London, SW1V 2QQ Telephone: 020-7533 5888 Fax: 01633-812599 http://www.statistics.gov.uk Department of Health Richmond House 79 Whitehall London, SW1A 2NL Telephone: 020-7210 4850 E-mail: dhmail@dh.gsi.gov.uk http://www.dh.gov.uk
Annual Abstract of Statistics
Department of Health Annual Department of Health Performance

Tables General Ophthalmic Services: Activity Statistics for England and Wales General Pharmaceutical Services for England and Wales Health Survey for England Hospital Episode Statistics 2003-2004 Report 2005
Other Sources
AstraZeneca PO Box 141 Mereside Alderley Park Cheshire, SK10 4TG Telephone: 01625-582 828 Fax: 01625-516 235 http://www.astra-zenica.com Eli Lilly Erl Wood Manor Sunninghill Road Windlesham Surrey, GU20 6PH Telephone: 01276-483 000 Fax: 01276-484 921 http://www.lilly.com
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GlaxoSmithKline 980 Great West Road Brentford Middlesex, TW8 9GS Telephone: 020-8047 5000 http://www.gsk.com Healthcare Commission Finsbury Tower 103-105 Bunhill Row London, EC1Y 8TG Telephone: 020-7448 9200 E-mail: feedback@ healthcarecommission.org.uk http://www. healthcarecommission.org.uk Hospice Information Help the Hospices Hospice House 34-44 Britannia Street London, WC1X 9JG Telephone: 0870-903 3 903 http://www.hospiceinformation.info
National Institute of Economic and Social Research 2 Dean Trench Street Smith Square London, SW1P 3HE Telephone: 020-7222 7665 Fax: 020-7654 1900 E-mail: enquiries@niesr.ac.uk http://www.niesr.ac.uk National Institute Economic Review July 2005, number 193 (the full version is available from www.niesr.ac.uk) Office of Fair Trading Fleetbank House 2-6 Salisbury Square London, EC4Y 8JX Telephone: 020-7211 8000 Fax: 020-7211 8800 E-mail: enquiries@oft.gsi.gov.uk http://www.oft.gov.uk Organisation for Economic Co-operation and Development 2 rue Andr Pascal F-75775 Paris Cedex 16 France Telephone: 00-331 4524 8200 Fax: 00-331 4524 8500 E-mail: webmaster@oecd.org http://www.oecd.org
Hospice and Palliative Care Facts

and Figures 2005 Kaiser Foundation 1177 West Hastings Street Suite 2210 Vancouver, BC V6E 2K3 Canada Telephone: 00-604 681 1888 Fax: 00-604 685 9046 E-mail: info@kaiserfoundation.ca http://www.kaiserfoundation.ca Laing & Buisson 29 Angel Gate City Road London, EC1V 2PT Telephone: 020-7833 9123 Fax: 020-7833 9129 E-mail: info@laingbuisson.co.uk http://www.laingbuisson.co.uk
OECD Health Data 2005

Pfizer Ltd Walton Oaks Dorking Road Tadworth Surrey, KT20 7NS Telephone: 01304-616 161 http://www.pfizer.co.uk Prescription Pricing Authority Bridge House 152 Pilgrim Street Newcastle Upon Tyne, NE1 6SN Telephone: 0191-232 5371 Fax: 0191-232 2480 http://www.ppa.org.uk
Laings Healthcare Market Review

2004-2005
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14. Further Sources
Bonnier Information Sources

Bonnier PLC Field House 72 Oldfield Road Hampton Middlesex, TW12 2HQ ICC Credit Telephone: 020-8481 8800 Fax: 020-8941 6014 E-mail: creditmarketing@icc.co.uk http://www.icc-credit.co.uk ICC Credit delivers services geared towards maximising the effectiveness of your credit management process. These range from reporting through decision and investigation services to integration and data management services. ICC Information Ltd Telephone: 020-8481 8800 Fax: 020-8941 6014 msn: ICC_FRMMGR@msn.com Internet: webmaster@icc.co.uk ICC can provide information via: Databases available via Juniper, Plum, Blueberry and Damson include:
Directory information on all live Analysed financial information of

every trading British company Database of all 4.9 million directorships Images of the latest directors reports and accounts Full text annual reports and accounts of UK quoted PLCs Stockbroker research Shareholders information IRN Research Telephone: 020-8481 8831 Fax: 020-8783 3691 E-mail: info@irn-research.com http://www.irn-research.com IRN offers a range of research solutions to management, information and marketing professionals on an ad hoc, continuous, contract or outsourced basis. and dissolved companies
Juniper (WindowsTM online service),

updated daily Plum (Internet), updated daily Blueberry (CD-ROM Credit Index, Company Index and Broker 50), updated monthly Damson (Bulk Data Supply via EDD, EDI, ISDN, magnetic tape and DAT)
Bespoke market research and Information consultancy Information management services Content/report production
IRN Research is the exclusive compiler of raw data to the entire Key Note report range and can provide customised analysis of data used in many tables in this report. For more information and prices, please e-mail: info@irn-research.com consulting
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14. Further Sources
Healthcare Market
Key Note Ltd Telephone: 020-8481 8750 Fax: 020-8783 0049 E-mail: sales@keynote.co.uk http://www.keynote.co.uk Market Reports Contraception Cosmetic Surgery Equipment for the Disabled Laboratory Equipment Medical Equipment Medical & Health Insurance Natural Products Ophthalmic Goods & Services OTC Pharmaceuticals Private Healthcare Retail Chemists & Drugstores 399 each Market Reviews Pharmaceutical Industry 649 Market Assessment Reports Alternative Healthcare Opticians and Optical Goods Vitamins and Supplements 799 each New Products Business Ratio Reports The Medical Equipment Industry Pharmaceutical Manufacturers and Developers Retail and Wholesale Chemists Book 295 PDF 310 + VAT
Financial Survey Reports The Pharmaceutical Industry Book 265 CSV File 445 + VAT Based on analysed company financial accounts, Business Ratio Reports and Financial Surveys focus on key players within 120+ specific industry areas in the UK. Prospect Swetenhams Ltd Telephone: 020-8481 8730 Fax: 020-8783 1940 E-mail: info@ prospectswetenhams.com http://www. prospectswetenhams.com Prospect Swetenhams offers list broking, list management, owned data and data processing services, publishing more than 300 business reports.
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Key Note Research
Key Note Research

Key Note is a leading supplier of market information, publishing an extensive range of consumer, industrial, business-to-business and services titles. With over 25 years experience, Key Note represents clear, concise, quality market information. For all reports, Key Note undertakes various types of research: Online searching is carried out by product code or free search method, and covers the period from the last edition of the report to the current day. The internal ICC Juniper database is used to select company information relevant to the particular report. The financial information extracted may then be backed up by further online searching on particular companies. Trade sources, such as trade associations, trade journals and specific company contacts, are invaluable to the Key Note research process. Secondary data are provided by BMRB International (TGI) and Nielsen Media Research for consumer/demographic information and advertising expenditure respectively. In addition, various official publications published by National Statistics, etc. are used for essential background data and market trends. Interviews are undertaken by Key Note for various reports, either face-to-face or by telephone. This provides qualitative data (industry comment) to enhance the statistics in reports; questionnaires may also be used. Field research is commissioned for various consumer reports and market reviews, and is carried out by either BMRB International (BMRB Access) or NOP Solutions (National Opinion Polls). Key Note estimates are derived from statistical analysis and trade research carried out by experienced research analysts. Up-to-date figures are inserted where possible, although there will be some instances where: a realistic estimate cannot be made (e.g. the number of disabled people in the UK); or external sources request that we do not update their figures. Key Note Editorial Manager, 2005
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The Key Note Range of Reports

Key Note publishes over 180 titles each year, across both the Key Note and Market Assessment product ranges. The total range covers consumer, lifestyle, financial services and industrial sectors.
Title Edition Published Title Edition Published
Market Reports and Reports Plus

A
Childrenswear Chilled Foods China & Earthenware Cigarettes & Tobacco Cinemas & Theatres Clothing Manufacturing Clothing Retailing Commercial Radio Commercial Vehicles Computer Hardware Computer Services Computer Software Confectionery Consumer Internet Usage Consumer Magazines Contraception Contract Catering & Foodservice Management Contract Cleaning Cooking Sauces & Food Seasonings Corporate Hospitality Cosmetics & Fragrances Cosmetic Surgery Courier & Express Services Credit & Other Finance Cards
D
5 12 22 19 9 12 5 8 12 6 7 6 23 4 13 2 17 18 1 4 18 4 13 12 3 13 3 9 3 2 16 4 10 13 5
2004 2004 2005 2004 2001 2000 2004 2004 2005 2005 2004 2005 2005 2000 2005 2002 2004 2004 2003 2004 2005 2004 2003 1999 2004 1999 2004 2002 2000 2003 2005 2003 2002 2003 2005
Access Control Accountancy Aerospace Agrochemicals & Fertilisers Air Freight Airlines Airports Animal Feedstuffs Arts & Media Sponsorship Automatic Vending Automotive Services Autoparts
B
7 9 12 3 2 15 9 11 1 19 3 16 12 1 17 12 17 12 20 12 24 13 2 14 8 11 12 7 10 3 13 14 15 8 7 2 10
2005 2005 2003 2002 2005 2004 2005 2001 2005 2005 2002 2002 2005 2001 2004 2005 2005 2004 2005 2004 2005 2001 2005 2004 2005 2003 2004 2003 2004 1999 2002 2005 2002 2005 2004 1999 2005
Baths & Sanitaryware Bearings Betting & Gaming Biscuits & Cakes Book Publishing Bookselling Bread & Bakery Products Breakfast Cereals Breweries & the Beer Market Bricks & Tiles Bridalwear Builders Merchants Building Contracting Building Materials Business Press Bus & Coach Operators
C
Dark Spirits & Liqueurs Debt Management & Factoring Debt Management (Commercial & Consumer) Defence Equipment Design Consultancies Digital TV Direct Marketing Discount Retailing Disposable Paper Products Domestic Heating Dry Cleaning & Laundry Services
E
Cable & Satellite TV Cameras & Camcorders Camping & Caravanning Canned Foods Carpets & Floorcoverings Catering Equipment CCTV CDs & Tapes The Chemical Industry
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Title
Edition
Published
Title
Edition
Published
Electrical Contracting Electrical Wholesale The Electricity Industry Electronic Component Distribution Electronic Component Manufacturing Electronic Games Employment Agencies (see Recruitment Agencies) Equipment for the Disabled Equipment Leasing Estate Agents Ethnic Foods Exhibitions & Conferences
F
7 3 4 12 11 4 14 3 12 15 12 7
2002 2004 2004 2002 2002 2003 1999 2001 2003 2005 2005 2004
Heating, Ventilating & Air Conditioning Home Furnishings Home Shopping Horticultural Retailing Hotels Housebuilding Household Appliances (Brown Goods) Household Appliances (White Goods) Household Furniture Household Detergents & Cleaners
I
9 15 10 15 19 16 10 15 17 14 10 8 5 8 11 8 7 10 20 5 9 14 6 10 1 17 15 4 19 6 3
2002 2002 2003 2002 2004 2003 2004 2004 2004 2004 2005 2001 2000 2001 2004 2005 2005 2005 2004 2004 2001 2002 2004 2003 2005 2005 2003 2004 2005 2005 1999
Ice Creams & Frozen Desserts Industrial Fasteners Industrial Pumps Industrial Valves Insurance Companies Internet Usage in Business IT Security IT Training
J
Factoring & Invoice Discounting Fast Food & Home Delivery Outlets The Film Industry Finance Houses Fire Protection Equipment Fish & Fish Products Fitted Kitchens Food Seasonings Football Clubs & Finance Footwear Franchising Free-To-Air TV Freight Forwarding Frozen Foods Fruit Juices & Health Drinks Fruit & Vegetables Further & Higher Education
G
2 21 4 11 7 12 10 1 3 14 9 8 14 20 10 18 5 11 3 14 12 21
2003 2005 2002 2000 2004 2004 2002 1999 2005 2004 2005 2004 2004 2004 2004 2004 2005 2004 2004 2005 2004 2005
Jewellery & Watches

K
Kitchenware
L
Laboratory Equipment Lighting Equipment Lingerie

M
Management Consultants Market Forecasts Meat & Meat Products Medical Equipment Metal Recycling Milk & Dairy Products Mobile Phones Mortgage Finance
N
Garden Equipment The Gas Industry Giftware Glassware Greetings Cards

H
Natural Products New Media Marketing Newspapers
1 3 15 2
2005 2002 2001 1999
Hand Luggage & Leather Goods Health Clubs & Leisure Centres Health Foods
12 6 22
2005 2004 2003
Nursing Care
O
Office Furniture
19
2004
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The Offshore Oil & Gas Industry Ophthalmic Goods & Services OTC Pharmaceuticals Own Brands
P
Sports Clothing & Footwear 3 14 11 10 12 12 13 14 14 2 11 14 12 10 2 4 6 10 17 5 21 6 8 5 5 1 20 13 19 8 1 9 12 4 8 10 16 15 2004 2004 2004 2003 2003 2003 2002 2003 2002 1998 2000 2005 2001 2003 2005 2005 2004 2005 2004 2004 2005 2005 2005 2005 2004 2003 2005 2003 2005 1999 1999 2005 2004 2001 2000 2005 2005 2004 Sports Equipment Sports Sponsorship Stationery (Personal & Office)
T
10 13 4 21 15 19 17 18 1 5 20 13 17 2 1 16 7 3 8
2005 2004 2005 2005 2004 2004 2003 2005 2005 2001 2005 2004 2004 2005
The Take Home Trade Telecommunications Timber & Joinery Toiletries Top Markets Tourist Attractions Toys & Games Training Travel Agents & Overseas Tour Operators The Tyre Industry
U
Packaging (Glass) Packaging (Metals & Aerosols) Packaging (Paper & Board) Packaging (Plastics) Paper & Board Manufacturing Pensions Personal Banking Photocopiers & Fax Machines Plant Hire Plastics Processing Poultry Power Tools Premium Lagers, Beers & Ciders Printing Private Healthcare Protective Clothing & Equipment Public Houses
R
The Under-16s Market

V
1998 1998 2005 2003 2005
Vehicle Leasing & Hire Vehicle Security Videoconferencing Video & DVD Retail & Hire
W
Wallcoverings & Ceramic Tiles Waste Management Water Industry Water Utilities Windows & Doors Wine Winter Holidays White Spirits
16 7 3 3 18 16 1 1
2004 2003 2004 1999 2003 2004 1999 2005
Rail Travel Ready Meals Recruitment Agencies (Permanent) Recruitment Agencies (Temporary & Contract) Renewable Energy Restaurants Retail Chemists Road Haulage Rubber Manufacturing & Processing Rugby Clubs & Finance
S
Market Reviews
Business Information in the UK Catering Market Clothing & Footwear Industry UK Computer Market UK Construction Industry Contracted-Out Services Defence Industry Distribution Industry DIY & Home Improvements Industry Drinks Market The Energy Industry 2 17 10 11 8 2 7 8 10 16 6 1998 2004 2005 2004 2001 2004 2003 2004 2005 2005 2005
Sauces & Spreads Shopfitting Short Break Holidays Slimming Market Small Domestic Electrical Appliances Snack Foods Soft Drinks (Carbonates & Concentrates)
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Title
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Title
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Published
The Food Industry Healthcare Market Insurance Industry Leisure & Recreation Market Mechanical Handling Motor Industry The Office Equipment Market Packaging (Food & Drink) Industry Passenger Travel in the UK Pharmaceutical Industry Process Plant Industry The Publishing Industry Retailing in the UK The Security Industry Sports Market Travel & Tourism Market
16 10 8 14 1 10 7 1 4 5 1 10 7 10 1 11
2004 2005 2005 2004 2001 2005 2004 2003 2004 2005 2000 2004 1998 2004 2004 2004
Chilled and Frozen Desserts Clothing Retailers Coffee and Sandwich Shops Commercial Dynamics in Financial Services Commercial Insurance for Small Businesses Condiments and Sauces Confectionery Consumer Credit and Debt Contraception Cooking and Eating Cross-Border Shopping Customer Loyalty in Financial Services Customer Magazines & Contract Publishing Customer Relationship Management Customer Services in Financial Organisations The C2DE Consumer D
1998 2000 2004 2005 2002 2004 1999 2005 2002 2004 2000 2000 2004 2003 2003 2002 2004 2004 2004 2003 1999 2000 2005 1999 1999 1999 2004 2004 2000 1998 2003 2005 2002 2004 2002 2004 2005 2003 2005
Market Assessment Reports

A The ABC1 Consumer Activity Holidays Advertising Agencies Airports and Airlines Alternative Healthcare Audio-Visual Retailing All-Inclusive Holidays B Baby Foods Baby Products Baths and Showers Beds, Bedrooms and Upholstered Furniture Betting and Gaming Book Retailing on the Internet Bottled Water Bridalwear Broadcast Media Building Materials Business Postal Services in the UK The Business Travel Market C Cable and Satellite Services Call Centres Canned Foods Charity Funding Childcare Childrens Publishing 2002 2004 1999 2005 2003 2005 2004 2001 2000 2000 2002 2004 2003 2002 1999 1998 2002 2005 2004 2003 2005 1999 2005 2000 2000
Diet Foods The DINKY Market Direct Insurance Direct Mortgages Distance Learning The Quiet Revolution Domestic Lighting and Electrical Products Domestic Telecommunications Duty-Free Retailing E Eastern European Lifestyles Eastern European Travel E-Commerce: The Internet Grocery Market E-Commerce: The Internet Leisure & Entertainment Market Electronic Banking Empty Nesters EMU The Impact on the UK Financial Services Industry E-Recruitment E-Shopping Estate Agents and Services Ethnic Foods The European Electricity Industry The European Gas Industry European Long-Term Insurance The European Oil and Gas Industry
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Title
Edition
Published
Title
Edition
Published
European Pharmaceuticals Market The European Renewable Energy Industry European Short Breaks European Telecommunications European Tourist Attractions The European Water Industry Extended Financial Families F Financial Services Marketing to ABs Financial Services Marketing to ABC1s Financial Services Marketing to C1C2DEs Financial Services Marketing to Over 60s Financial Services Marketing to Start-Up Businesses and the Self-Employed Financial Services Marketing to the Retired and Elderly Financial Services on the Internet Financial Services Organisations on the Internet The Fish Industry Forecourt Retailing Fresh and Frozen Foods Functional Foods Funding in Higher Education G Garden Leisure and Equipment General Insurance Global Waste Management Green and Ethical Consumer The Grey Consumer H Haircare Healthy Eating Holiday Purchasing Patterns Home Entertainment Home Gym Equipment Hot Beverages Hotels I Ice Cream In-Car Entertainment Independent Financial Advisers Individual Savings Accounts Insurance Prospects Internet Advertising Internet Service Providers
1999 2005 2001 2002 2000 2005 2005 2004 2000 2004 2004
Issues and Challenges in the UK Life Assurance Market IT Recruitment L Lifestyle and Specialist Magazines Low-Fat & Low-Sugar Foods The Luggage Market M Marketing in the Digital Age Marketing to Children 4-11 Medical & Health Insurance Men and Womens Buying Habits Mens Toiletries & Fragrances Millennium Youth Motor Finance N Nutraceuticals
2002 2005 2004 2003 2000 2003 2003 2004 2004 2005 2002 2005 2005 2003 1999 1999 2002 2004 1999 2004 2003 2000 1999 2005 2004 2002 2004 2003 1999 2003 2003 2005 1998 2001 1999 2005 2001 1999 2005 2001
2003 2003 1998 2005 2001 2005 1999 2004 2002 1999 2005 2004 2005 2004 1999 2004 2004 2002 1998 2004 1998 1998 2000 2003 1999 2002 2004 2005
The Newspaper Industry Newspapers and Magazines Niche Marketing in the Financial Services Industry Non-Food Sales in Supermarkets O Off-Trade Spirits Off-Trade Wines Opticians and Optical Goods Organic Food OTC Pharmaceuticals Out-of-Town Shopping Over-40s Consumer P Pay TV Pension Extenders Pensions Personal Banking Personal Communications Personal Lines Insurance Personal Loans The Pet Market The Pink Pound Plastic Cards in Europe Plastic Cards Time to Get Smart Plus-Size Fashion Private Sector Opportunities in Education Promotions and Incentives The Public Relations Industry Public Transport
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Title
Edition
Published
Title
Edition
Published
R The Railway Industry Ready Meals Recycling and the Environment Restaurants Retail Credit Retail Development S Savings and Investments Saving Trends in the Eurozone Singles Market The Slimming Market Shopping Centres Short Breaks Small Businesses & Banks Small Business Finance Small Kitchen Appliances Small Office Home Office Consumer Small Office Home Office Products The Soup Market Sponsorship Sports Footwear and Clothing Supermarket Own Labels Supermarket Services Sweet & Salty Snacks T Technology in Retail Distribution Teenage Fashionwear 1998 2000 2004 2002 2003 2002 2003 2004 2002 1999 1998 2001 2001 2001 2000 1999 2003 2003 2005 2004 2001 2000 1999 2000 2001
Teenage Magazines Telefinancial Services Teleworking Travel Foods Trends in Dry Cleaning Trends in Food Shopping Trends in Leisure Activities Tweenagers U UK Banking UK Beer Market The UK Heating Market The UK Overseas Package Holiday Market UK Tourism Urban Regeneration Utilities V Vegetarian Foods Vehicle Breakdown Services Vitamins and Supplements W Western European Lifestyles White Goods Women Over 45 Working Women
2005 1998 2003 1998 1998 2003 2003 2005 1999 1999 1998 1999 1999 1999 2004 2004 2003 2005 1999 2000 2003 2003
Key Note Ltd 2005

All rights reserved. No part of this publication may be reproduced, copied, stored in an electronic retrieval system or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988. Published by Key Note Ltd, Field House, 72 Oldfield Road, Hampton, Middlesex TW12 2HQ, Telephone: 020-8481 8750 Stringent efforts have been made by Key Note to ensure accuracy. However, due principally to the fact that data cannot always be verified, it is possible that some errors or omissions may occur; Key Note cannot accept responsibility for such errors or omissions. Details supplied by Key Note should only be used as an aid, to assist the making of business decisions, not as the sole basis for taking such decisions. Under the new Privacy and Electronic Communications Regulations 2004, it is unlawful for a business to make an unsolicited sales & marketing call to a corporate subscriber if it is either registered with CTPS or has requested NOT to receive such calls. Key Note Ltd holds and regularly updates (every 28 days) its data in accordance with the regulations and ensures that its data are compliant, as of the date created. It is the responsibility of the caller to ensure that these data are up to date; Key Note Ltd does not hold itself liable for any subsequent legalities. If you have any queries regarding the CTPS legislation you may find the following websites useful: www.informationcommissioner.gov.uk or www.prospectswetenhams.com
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Market Review 2005

Tenth Edition September 2005 Edited by Isla Gower ISBN 1-84168-846-0

James Donovan Managing Director Key Note Limited

Key Note Ltd 2005

REPORT COVERAGE ....................................................................................................................... 3

REPORT BACKGROUND ................................................................................................................ 5

ECONOMIC TRENDS ....................................................................................................................... 6

MARKET SIZE ................................................................................................................................10

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MARKET SEGMENTATION ..........................................................................................................14

INDUSTRY STRUCTURE ................................................................................................................16

MARKET POSITION ......................................................................................................................20 KEY TRENDS ..................................................................................................................................20

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KEY TRADE ASSOCIATIONS........................................................................................................28

POLITICAL FACTORS ....................................................................................................................33

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ECONOMIC FACTORS ..................................................................................................................37

SOCIAL FACTORS ..........................................................................................................................38

TECHNOLOGICAL FACTORS .......................................................................................................40

3. Key Note Primary Research

INTRODUCTION ............................................................................................................................43 CONSUMER PROFILE....................................................................................................................43

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CONSUMER ATTITUDES ..............................................................................................................98

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THE MARKETPLACE ...................................................................................................................133 MARKET LEADERS......................................................................................................................133

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5. The National Health Service

DEFINITION ..................................................................................................................................143 KEY TRENDS ................................................................................................................................143

MARKET SIZE ..............................................................................................................................148

SUPPLY STRUCTURE ...................................................................................................................149

6. Hospital and Community Health Services

DEFINITION ..................................................................................................................................153 KEY TRENDS ................................................................................................................................153

Key Note Ltd 2005

MARKET SIZE ..............................................................................................................................154

SUPPLY STRUCTURE ...................................................................................................................156 BUYING BEHAVIOUR .................................................................................................................157

7. Family Health Services

DEFINITION ..................................................................................................................................161 KEY TRENDS ................................................................................................................................161

MARKET SIZE ..............................................................................................................................162

PHARMACEUTICAL SERVICES ..................................................................................................165

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GENERAL AND PERSONAL MEDICAL SERVICES....................................................................174

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DENTAL SERVICES ......................................................................................................................178

GENERAL OPHTHALMIC SERVICES..........................................................................................184

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DEFINITION ..................................................................................................................................195 MARKET SIZE ..............................................................................................................................196

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PSYCHIATRIC CARE ....................................................................................................................212

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PRIMARY CARE ...........................................................................................................................217

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9. Private Medical Insurance

SUPPLY STRUCTURE ...................................................................................................................227

MAJOR PLAYERS ........................................................................................................................230

10. Complementary and Alternative Medicine

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SUPPLY STRUCTURE ...................................................................................................................240

11. Palliative and Hospice Care

DEFINITION ..................................................................................................................................247 KEY TRENDS ................................................................................................................................249

MARKET SIZE ..............................................................................................................................251

SUPPLY STRUCTURE ...................................................................................................................252

MAJOR PLAYERS ........................................................................................................................257

Key Note Ltd 2005