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UK Acute Care Sector Market Update August 2019

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UK Acute Care Sector Market Update August 2019 Market Update August 2019 UK Acute Care Sector The acute care sector has shown some resilience compared to other multi-site clinical subsectors over the past 12 months. Lincoln’s acute care sector index is down 10.0% on an LTM basis, but valuations remain above the average over the last ten years The Lincoln International Healthcare Group has experience in the acute care sector, having acted recently on a UK mandate, and the broader healthcare services and multi-site clinical space We expect investor interest in the acute care sector to recover given strong macro drivers Select multi-site Valuation update on the acute sector - relative sector performance clinics deals LTM relative stock indices price performance 110% 10 5% 0.1% 100% (10.0%) 9 5% 90% (10.7%) 8 5% (12.0%) 80% 75% 70% IVF clinics 6 5% 60% Aug-18 Sep-18 Oct-18 Oct-18 No v-1 8 Dec-18 Jan-19 F eb -1 9 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 A cu te car e Dental IVF MSCI Europe Healthcare Current market valuations EV/Revenue EV/ EBITDA 1.6x 9.3x Acute care 0.8x 4.2x 6.5x 20.0x 3.2x 9.5x Dental 0.9x 4.6x 7.3x 17.7x 2.1x 9.7x IVF 1.6x 2.8x 6.1x 11.3x Acute care 1.6x 9.5x All 0.8x 4.6x 6.1x 20.0x Low/high Median Based on calendarised December CY19 data 10 year EV/EBITDA 20.0x 18.0x 16.0x 14.0x 12.0x Veterinary clinics 10.0x Median Median EV/EBITDA * 8 .0 x 6 .0 x 4.0x Dec 2008 Dec 2009 Dec 2010 Dec 2011 Dec 2012 Dec 2013 Dec 2014 Dec 2015 Dec 2016 Dec 2017 Dec 2018 A cu te car e Dental IVF Analysis of EV/EBITDA points (10 year period) All sectors Acute care Dental IVF (exc. Acute) All sectors Median 9.7x 14.4x 9.4x 11.5x 9.7x Acute care Mean 9.3x 13.7x 10.4x 10.7x 10.2x Low 7.1x 5.8x 6.3x 6.3x n/a * Managing Director when at High 12.8x 19.0x 14.7x 15.3x n/a previous advisory firm Acute Care Sector Market Update Q3 2019 | 2 Acute and other clinic-based share indices data % change Market Enterprise LTM EBITDA 2yr CAGR Enterprise Value / CY19 Company Name Share price LTM Cap (m) Value (m) Period Revenue (m) margin LTM Revenue EBITDA Acute care Athens Medical Center S.A. (GR) £1.90 57.3% £165 £283 31-Dec-18 £164 13.0% 4.5% n/a n/a Community Health Systems, Inc. (US) 1.82 (27.5%) 207 12,201 30-Jun-19 10,689 9.8% (11.8%) 1.1x 9.1x HCA Healthcare, Inc. (US) 103.71 (2.6%) 35,363 66,271 30-Jun-19 38,437 19.3% 7.5% 1.6x 8.3x IASO S.A. (GR) 1.30 71.4% 159 233 31-Dec-18 89 26.0% (7.7%) n/a n/a IHH Healthcare Berhad (MY) 1.13 (3.5%) 9,871 11,832 31-Mar-19 2,316 22.8% 9.7% 4.2x 20.0x Life Healthcare Group Holdings Ltd (ZA) 1.23 (7.7%) 1,788 2,712 31-Mar-19 1,321 22.5% 16.3% 2.0x 8.5x Mediclinic International plc (ZA) 3.17 (37.1%) 2,336 4,169 31-Mar-19 2,932 16.1% 3.3% 1.4x 8.4x Medicover AB (publ) (SE) 7.05 2.6% 940 1,241 30-Jun-19 673 8.7% 17.9% 1.6x 11.3x Netcare Limited (ZA) 0.89 (41.8%) 1,193 1,567 31-Mar-19 1,133 20.6% (13.0%) 1.3x 6.5x NMC Health Plc (GB) 20.00 (48.9%) 4,175 5,435 31-Dec-18 1,614 23.3% 29.8% 2.6x 9.8x Quorum Health Corporation (US) 1.45 (56.0%) 48 1,127 30-Jun-19 1,420 7.1% (7.7%) 0.8x 8.5x Rales Medical Group Ltd (SG) 0.59 (9.9%) 1,087 1,122 30-Jun-19 293 19.8% 3.2% 3.5x 19.2x Ramsay Générale de Santé SA (FR) 16.81 (9.9%) 1,855 4,033 31-Dec-18 2,260 10.7% 4.8% n/a n/a Ramsay Health Care Limited (AU) 38.19 24.6% 7,674 10,891 31-Dec-18 5,474 12.9% 5.9% 1.5x 11.9x RHÖN-KLINIKUM (DE) 22.17 n/a 1,484 1,364 30-Jun-19 1,311 9.0% 4.9% 1.2x 12.9x Spire Healthcare Group plc (GB) 0.96 (49.3%) 386 837 31-Dec-18 931 12.5% 0.3% 0.9x 6.7x Surgery Partners, Inc. (US) 5.40 (56.6%) 267 3,323 30-Jun-19 1,405 19.0% 25.4% 2.2x 15.5x Tenet Healthcare Corporation (US) 17.41 (34.7%) 1,801 16,590 30-Jun-19 14,332 15.1% (2.9%) 1.1x 7.5x Universal Health Services, Inc. (US) 120.19 17.2% 10,834 14,531 30-Jun-19 8,706 15.6% 4.6% 1.6x 9.5x Mean (Acute) (11.8%) 16.0% 5.0% 1.8x 10.8x Median (Acute) (9.9%) 15.6% 4.6% 1.6x 9.3x Dental 1300SMILES Limited (AU) £3.48 (9.6%) £82 £84 31-Dec-18 £22 31.6% 5.8% 3.2x 9.5x Abano Healthcare Group Limited (NZ) 1.99 (56.7%) 52 128 31-May-19 144 11.4% 13.4% 0.9x 7.3x LDC Dental Public Co Limited (TH) 0.03 (12.4%) 16 14 31-Mar-19 12 (0.1%) 18.5% n/a n/a Odontoprev S.A. (BR) 3.36 20.9% 1,784 1,724 30-Jun-19 384 24.4% 7.8% 4.6x 17.7x Pacific Smiles Group Limited (AU) 0.69 (20.3%) 106 111 31-Dec-18 63 16.6% 14.2% 1.6x 8.4x Q & M Dental Group (SG) Limited (SG) 0.28 (9.6%) 222 270 31-Mar-19 69 12.4% (10.9%) 3.5x 14.7x Mean (Dental) (14.6%) 16.0% 8.1% 2.7x 11.5x Median (Dental) (11.0%) 14.5% 10.6% 3.2x 9.5x IVF MD Medical Group Investments Plc (CY) £4.24 (33.5%) £317 £356 31-Dec-18 £169 28.7% 10.7% 1.7x 6.1x Medicover AB (publ) (SE) 7.05 2.6% 940 1,241 30-Jun-19 673 8.7% 17.9% 1.6x 11.3x Monash IVF Group Limited (AU) 0.81 20.5% 190 239 31-Dec-18 83 24.4% (1.6%) 2.8x 10.8x NMC Health Plc (GB) 20.00 (48.9%) 4,175 5,435 31-Dec-18 1,614 23.3% 29.8% 2.6x 9.8x Singapore Medical Group Limited (SG) 0.22 (12.9%) 106 117 31-Mar-19 50 21.7% 38.0% 2.0x 9.6x Virtus Health Limited (AU) 2.92 (6.9%) 234 332 31-Dec-18 149 21.4% 1.6% 2.1x 8.9x Mean (IVF) (13.2%) 21.4% 16.1% 2.1x 9.4x Median (IVF) (9.9%) 22.5% 14.3% 2.1x 9.7x Total Mean (12.6%) 17.0% 7.8% 2.0x 10.6x Total Median (9.9%) 16.6% 5.8% 1.6x 9.5x Source: Capital IQ and company filings, as of market close on 7 August 2019 Note: All data in GBP (£); converted from local currency at current spot rate and annualised to 31 December for CY multiples Acute Care Sector Market Update Q3 2019 | 3 Macro drivers include: UK market analysis Ageing population: the Valuations in the global acute care sector have remained relatively robust in recent years, in line global population aged 60 with the sector’s historically defensive nature and growing patient demand. M&A has been stable across the acute care space with both Trade and PE competing for assets in 2018, while EBITDA years or over is expected multiples in traded groups have retreated slightly from their 2014 highs, settling at 9.3x CY19. to more than double between 2015 and 2050. Market size and growth: the UK acute care sector hospitals and 80 NHS private patient This will drive demand, services market is valued at £74.8 billion units totalling 9,872 beds particularly in relevant (including both independent and NHS This growth figure obscures uneven payor providers) as of 2019 and underpinned by a medical disciplines such as segment growth, with self-pay growing broad range of positive macro drivers. The orthopaedics at a CAGR of 8.1% between 2010A and growth, however, is modest at a CAGR of 1.5% 2017E, while PMI funded care has slowed Prevalence of chronic due to NHS pressures constraining wider significantly, growing at a CAGR of 1.2%. illnesses: the number of market growth While NHS outsourcing has increased unhealthy years over the The UK private-pay acute care services strongly (at a CAGR of 7.9%), recent market age of 65 has grown in market is valued at £5.2 billion and is evidence suggests that growth has been tandem with increased growing at a faster rate than the broader curtailed driven largely by funding and life expectancy in the market, at a CAGR of 4.3% between 2010A policy intervention (see NHS funding), UK, growing at a CAGR and 2017E though anecdotally some newer operators of 1.5% from 7.5 years in As of 2017, there were 197 independent are succeeding at the expense of the 2001 to 9.0 years in 2013, incumbents at a local level accelerating demand as the population ages UK hospital market £8 5.0 Shift to self-pay: factors 80.0 78.5 such as long waiting £80.0 76.9 74.8 75.6 73.6 lists for publicly-funded £75.0 73.2 surgery, rising prosperity £70.0 among older generations (£ in billions) and health tourism have £6 5.0 led to greater numbers of 2017 2018 2019 2020 2021 2022 2023 patients to seek treatment on a self-pay basis Independent acute care market 5.2 5.2 Outsourced volumes: £6 .0 4.6 4.8 5.0 3.9 4.1 4.3 UK legislation has led 0.9 1.0 1.1 £4.0 0.7 0.7 0.8 0.6 0.7 1.6 1.7 1.0 1.1 1.2 1.3 1.4 1.6 to greater private sector £2.0 involvement in the form 2.1 2.2 2.2 2.3 2.3 2.3 2.3 2.3 £- (£ in billions) of elective procedures 2010 2011 2012 2013 2014 2015 2016 2017 outsourced from the NHS CAGRs 1.2% 7.9% 8.1% 4.3% to the private sector; the PMI NHS Sel f-Pay Ove rseas number of NHS funded surgeries in the UK NHS capacity: the NHS is at the limit of its further behind its targets.
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