PRECEDENTE EN EL NUEVO CÓDIGO DE PROCEDIMIENTO ADMINISTRATIVO Y DE LO CONTENCIOSO ADMINISTRATIVO
3.3 Extensión Ante el Consejo de Estado
through comparison with other information that has been made public by the relevant third
party, no fact has been omitted which would render the reproduced information inaccurate or
misleading.
Attendo’s markets
Attendo operates in the private market for publicly financed care in Sweden, Finland, Norway and Denmark. Attendo’s services comprise care for older people, care services for people with disabilities as well as individual
and family care. The Company’s business in Finland also comprises primary care, dental care, occupational health care as well as staffing where Attendo provides general practitioners, specialist doctors and dentists.
Figure 1: Attendo’s markets and distribution of net sales 2014
The group 54% 41% 3% 2%
Care for older people • Nursing home • Home care
Care
• People with disabilities • Social psychiatry • Individual and family care
Health care • Primary care and
occupational health care • Dental care • Combination contracts • Staffing Source: Attendo. 59% 18% 23% 39% 15% 0% 16% 3% 23% 3% 0% 0% 2% 0% 0%
The total size of the market where Attendo operates amounted to SEK 288bn in 2014, with a variable degree of private share. In two of Attendo’s largest markets – nurs- ing homes in Sweden and Finland – the private share amounted to 16 percent in Sweden and 43 percent in
Finland. The private market expanded with an annual increase of 8 percent in Sweden during 2010–2014, and an annual increase of 7 percent in Finland during 2009– 2013.6)
Figure 2: Attendo’s addressable markets’ size, growth and share of services conducted by private providers
Country Attendo’s addressable business areas Market size 2014
Market size private providers 2014 (SEKbn) Market share private providers 2014 (percent) Historical annual growth total (2010–2014) Historical annual growth private (2010–2014) Care for older
people
Nursing homes1) 76 12 16% 2% 8%
Home care2) 18 4 25% 1% 8%
Care
Care for people with disabili-
ties and social psychiatry3) 33 11 32% 5% 4%
Individual and family care4) 10 5 46% 6% 6%5)
Care for older
people Nursing homes6) 26 11 43% 4% 7%
Care Care for people with disabili-ties and social psychiatry7) 9 4 51% 10% 9%
Health care
Primary care, occupational
care and dental care8) 46 n.a. n.a. 2% n.a.
of which Dental care9) 9 5 59% 2% 4%
of which Outsourcing10) 2 2 100% 32% 32%
of which Staffing11) 1 1 100% 4% 4%
Care for older
people Nursing homes12) 34 4 11% 4% 4%
Care for older people
Nursing homes13) 23 4 17% 1% 3%
Home care14) 13 5 36% -3% 3%
Note: Exchange rates based on average of 2014.
1) Socialstyrelsen, Statistiska centralbyrån, Kommunernas finanser; 2) Socialstyrelsen, Statistiska centralbyrån, Roland Berger, Attendo analysis; 3) Statistiska centralbyrån, Socialstyrelsen, HVB-registret, Attendo analysis; 4) Socialstyrelsen, Statistiska centralbyrån, Kommunernas finanser. Market size for 2013, CAGR 2010–2013. Individual and family care comprise family homes and homes for care or residency (HVB); 5) The growth within the private market for individual and family care is estimated to be the same as for the total market for individual and family care in Sweden; 6) Statistikcentralen – ”Terveydenhuollon menot ja rahoitus”, Institutet för hälsa och välfärd, SOTKAnet, Kuusikko-rapporter, Attendo analysis. Market size for 2013, CAGR 2009–2013; 7) Institutet för hälsa och välfärd, SOTKAnet, Kuusikko-rapporter, Statistikcentralen, Roland Berger, Attendo analysis. Market size for 2013, CAGR 2009–2013; 8) Institutet för hälsa och välfärd, Statistikcentralen, Roland Berger, Attendo analysis. CAGR 2011–2014; 9) Institutet för hälsa och välfärd, Statistikcentralen, Roland Berger, Attendo analysis. CAGR 2011–2014, for the private market 2010–2014; 10) Institutet för hälsa och välfärd, Statistikcentralen, Roland Berger, Attendo analysis. CAGR 2011– 2014; 11) Institutet för hälsa och välfärd, Statistikcentralen, Roland Berger, Attendo analysis; 12) Statistisk sentralbyrå, Attendo analysis. Market size for, CAGR 2010–2013; 13) Danmarks statistik, Attendo analysis. CAGR 2011-2014; 14) Danmarks statistik, Attendo analysis. Market size for 2013, CAGR 2009–2013.
Contract models
Own operations
Own operations means that the private provider is responsible for the operations as well as ultimately legally responsible. Own operations require permit. The private provider is also responsible for operating and managing the premises in which the care is provided.
The public procurer purchases the services from the pri- vate provider through framework agreements which have been procured under the public procurement legislation in
the respective countries. The public procurer chooses the provider or providers which best meet the requirements specified in the tender concerning for example quality and/ or have the lowest price. Framework agreements usually comprise several private providers. In own operations under a system of choice, clients and patients have the possibility to choose their provider themselves.
The contract period of a framework agreement is usu- ally between 2 and 4 years. Following the contract period there is usually a possibility to extend the agreement.
Figure 3: Market size and share of own operations within nursing homes and care homes for people with disabilities in Sweden 2014 and Finland 2013 8 12 10 11 2 4 7 2 (69%) (31%) (21%) (79%) Outsourcing operations Own operations
Note: Exchange rates based on average of 2014. Excluding social psychiatry Source: Statistiska centralbyrån, Socialstyrelsen, Kommunernas finanser, Statistikcentralen, Institutet för hälsa och välfärd, SOTKAnet, Kuusikko- rapporter, Roland Berger, Attendo analysis.
1) The figure presents data for care for people with intellectual disabilities,
since this is Attendo’s primary area of operations.
Disabilities 1) Nursing homes Disabilities (LSS) Nursing homes SEKbn Outsourcing operations
Outsourcing means that the public procurer through pro- curement delegates the execution of a certain operation to a private provider through an outsourcing contract. The public procurer maintains ultimate legal responsibility, while the private provider is responsible for providing the care. The care is provided in the public procurer’s premises and the private provider is not responsible for these prem- ises.
The public procurer chooses the provider that best meets the requirements that are specified in the tender concerning for example quality and/or have the lowest price. Outsourcing agreements comprise only one private provider.
The contract period of an outsourcing agreement is usu- ally between 3 and 5 years. Following the contact period there is usually a possibility to extend the agreement. Staffing
Staffing means that the private provider provides health care professionals. The public provider is ultimately legally responsible and is responsible for providing the health care. The health care is provided in the public pro- curer’s premises and the private provider is not responsi- ble for these premises.
The public provider purchases staffing services from the private provider through agreements which are procured according to the public procurement legislation in Fin- land or through direct procurement. The public procurer chooses the staffing supplier or suppliers which best meet the requirements specified in the tender concerning for example quality and/or have the lowest price. The agree- ment usually includes one or more private providers.
The contract period is usually up to 4 years.
Competitor overview
Several of Attendo’s markets are fragmented with a sig- nificant proportion of smaller operators. Few providers have extensive operations in several Nordic countries. Attendo, Ambea and Aleris are present in this group. The larger Finnish providers are primarily national, including Mehiläinen, Mainio Vire, Esperi and Pihlajalinna.
Figure 4: Competitor overview
Sweden Finland Denmark Norway
Company older peopleCare for Care older peopleCare for Care Health care older peopleCare for Care older peopleCare for Care
✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔Presence
Figure 5: Population growth for people older than 85 years within selected European countries, 2014–2030 France Belgium Spain Italy Austria Switzerland Germany United Kingdom Norway Sweden Finland Denmark 2014 2030P 113201 134226 256 401 114 152 1,503 2,717 2,166 3,645 2,881 2,435 1,864 1,247 1,705 1,887 309 194 209325 278 359 Thousands
Source: Eurostat, Office for National Statistics, INSEE, Statistiska centralbyrån, ISTAT: Demo-Geodemo, Instituto Nacional de Estadística (National Statistics Instituto 2002–2015 – Eurostat 2016–2030 (ESP)), Statistisk sentralbyrå, Statistikcentralen, Danmarks Statistik.
+78 % +69 % +56 % +33 % +59 % +56 % +29 %
+55 % +68 %
+81 % +37 % +29 %
Trends in Attendo’s markets
An aging population increases the demand for care and health care The demographic development with an increasing num- ber of older people in the population and a longer life expectancy entails that the demand and need for care and health care services in society will increase, especially the demand for nursing homes and home care. In Attendo’s largest markets, Sweden and Finland, the number of peo- ple older than 85 years is expected to increase with 56 and 69 percent, respectively, by 2030, as is illustrated in figure 5. The same trend is to be seen in many parts of Europe, where for example the United Kingdom, Denmark and Germany are expected to have a significant increase in the group 85+ years old.
Attendo’s assessment is that the public sector will have difficulties to, on its own, make the significant invest- ments required to meet this increasing demand. According
to the Health and Social Care Inspectorate, several Swed- ish local authorities have queues for nursing homes and the National Housing Board’s statistics show that the pro- portion of local authorities who reports a lack of beds in nursing homes is increasing from 27 percent in 2014 to 42 percent in 2015. It is not uncommon that clients ready for discharge are forced to remain in hospitals since there are no beds in nursing homes to move to.7) Simultaneously, the number of older people who, despite approved need assessments, are forced to remain in their homes awaiting an available bed in a nursing home, increases. The rapidly increasing demand is expected to present opportunities for private companies with investment capacity to expand their operations. Attendo anticipates that there will be a need to develop approximately 80,000 new nursing home beds in Sweden and Finland until 2030.
Figure 6: The market for nursing homes and share of private providers within selected European countries, 2014
Attendo's primary markets 248 94% 171 89% 61 73% 49 69% 61 68% 69 56% 168 51% 26 43% 26 42% 158 19% 23 17% 76 16% 34 11% SEKbn
Share of private providers
Norway 1) Sweden Denmark Nordics Austria 1) Finland 1) France Switzerland 1) Italy Belgium 1) Spain 1) United Kingdom 1) Germany 1)
Source: Gesundheitsberichterstattung des Bundes, Genesis Statistisches Bundesamt, Liang & Buisson, Xerfi, DREES, Federation Hospitaliere de France, annual accounts and companies' websites, Statistiska centralbyrån, Socialstyrelsen, Statistics Switzerland, ISTAT, Italienska finansministeriet, Network Non Autosufficienza, European Network of Economic Policy Research Institutes, AESTE, IMSERSO, INAMI, OECD, Statistisk sentralbyrå, Statistics Austria, GBE-bund, Frank Knight rapport, Institutet för hälsa och välfärd (SOTKAnet), Statistikcentralen, Danmarks Statistik.
An increased share of private providers of care and health care The private share of care and health care has historically been increasing. The trends described below, including increased focus on quality, an increasing demand for free- dom of choice and a need for productivity improvements, are contributing to the expectation that the share of pri- vate care and health care to continue to increase in the future. In most European countries, the private and for- profit providers have increased their market share com- pared with public and non-profit providers. This can be exemplified by private providers developing and producing approximately 45 percent of the total new nursing homes in Sweden and Finland the last couple of years,8) signifi- cantly more than the private provider’s market share. Also in for example Germany, the United Kingdom and Spain, an increasing share of new nursing homes are developed by private providers, while the share which is operated by public and non-profit providers has decreased.
The share care and health care conducted by private providers varies between countries. In several European countries, the share of nursing homes which is operated privately exceeds the corresponding share in the Nordic countries. During the period 2010–2014, the private pro- viders’ share has grown faster than the market as a whole in the Nordic countries, meaning that the private share of nursing homes has been increasing.
Increasing client requirements
As living standards are improving, the behaviour of cli- ents, patients and their relatives are changing. Today they are more active in their choices and evaluate more care options before making a decision. Primarily in larger cities more people are prepared to choose another nursing home than the one located closest or recommended by the local authority. The access to information has also become more available through the Internet. Because of this, relatives and clients can be more well-informed.
Furthermore, the legislation in several countries has been developed to ensure the client’s right to assistance – in Sweden for example through the Act concerning Sup- port and Service for Persons with Certain Functional Impairments (Sw. LSS), a civil rights legislation giving those who are comprised under this act the right to the necessary assistance to live a life as independent as pos- sible.
Ultimately, this leads to higher requirements on care and health care providers. Local authorities and other public procurers are already turning to private provid- ers to reach a higher level of innovation and new ways of thinking within care and health care.
Attendo anticipates that private providers will be favoured by the local authorities’ need to meet the increas- ing expectations and requirements from clients, patients and relatives.
Increased prevalence of mental illness and neuro-psychiatric diagnoses
The number of people in Sweden being diagnosed with mental illness and neuro-psychiatric diagnoses is increas- ing. For example, the number of people being diagnosed with Autism Spectrum Disorder (ASD) has increased in the last few years. In 2011, there were almost 7,000 children with confirmed ASD in Stockholm County alone, corresponding to an increase of 75 percent compared with
the year 2007. The reason behind the increase has not been established, but an increase in attention for autism and knowledge thereof as well as increased resources for neuro-psychiatric investigations are probably of large impact.9)
Between 5 and 10 percent of the population in Sweden are estimated to be diagnosed with a condition requiring psychological treatment. The most frequently occurring conditions are various types of depression and anxiety as well as schizophrenia. Significantly more old people are affected by mental illness, disabilities and diseases than what is commonly known. Improved diagnostics within for example schizophrenia lead to an increase in the number of people being diagnosed with these disabilities.10) Over- all, the increasing number of people with mental illness and neuro-psychiatric diagnoses entails an increasing demand for care.
Private providers have historically played an important role within care for people with mental illness and neuro- psychiatric diagnoses, since private providers often have been able to contribute with specialised operations with a high level of expertise within specific diagnoses.
Attendo anticipates that private providers will have an important function to fulfil within this area also in the future.
Care is transferred from hospitals and institutions to home care and modern nursing homes
There is an increasing understanding regarding hospitals and similar environments as institutional care not being a good environment for high quality care. In reality clients often receive care for several years. This is best conducted in the clients’ home or in housing similar to the home. Fur- thermore, limited public financing is increasing the need for care and health care to be organised as efficiently as possible, and a hospital bed is more costly than a bed at a specialised care home.
In order to meet these needs, it has been, and still is, a political objective in several European countries to shift care from hospitals and larger institutions to the own home or to smaller, local and more specialised units and housing. This applies both to health care, with a shift of care from larger hospitals to primary care and smaller clinics, and to care for older people and for people with disabilities, where the operations have been shifted from large and old institutional homes to modern and effective housing and home care.
In 2008 the Finnish government issued a recommen- dation to reduce the share of older people living in insti- tutional care units while simultaneously increasing the share of older people living in modern nursing homes. Finland has since then made efforts to further reduce the number of institutional care units as a form of housing. In the beginning of 2015, a new legislation entered into force that declares that institutional care can only be offered in case of medical reasons.11) Furthermore, the governments in countries like Sweden and Finland have often contrib- uted to the development of modern nursing homes with various types of financing support and subsidies.
For a company like Attendo, that operates homelike nursing and care homes, this shift from institutions to smaller units entails an increasing demand for the Company’s services.
8) Attendo analysis.
9) ”Autismspektrumtillstånd bland barn och unga i Stockholms län”, Centrum för epidemiologi och samhällsmedicin – Faktablad 2014:2.
10) ”Utvecklingen inom valda områden – Vård vid psykisk ohälsa och sjukdom”, Socialstyrelsen – Hälso- och sjukvårdsrapport 2009. 11) The Act on Supporting the Elderly Population’s Functional Capacity and on Care and health care Services for Older People (28.12.2013/980).
Increased interest in freedom of choice
Private providers and freedom of choice is a natural part of care for older people in several European countries. When care for older people was developed in the Nordics, freedom of choice was limited. The older people were usu- ally referred to the option that was most closely located geographically. The interest in being able to make a choice yourself has, however, increased among older people in all Nordic countries. 90 percent of Swedish citizens consider it important to have a freedom of choice in terms of choosing their own nursing home, and correspondingly 81 percent for home care.12)
In 2009, the Act on System of Choice (Sw. LOV) was enacted in Sweden. The legislation established a frame- work for procurement of public services where the client or patient independently may choose their provider among those that the procurer (local authority or county) has procured. Presently, 176 out of 290 Swedish local authori- ties have introduced the Act on System of Choice in one or more areas of care. In recent years an increasing number of local authorities in the Nordics have chosen to introduce some form of system of choice, similar to the Act on System of Choice, within care and health care, which has enabled new possibilities for private providers.
In Finland, tenders for framework agreements have become more and more common in order to ensure that all suppliers are treated equally. In Denmark a system of choice for home care was enacted in 2003, through which private providers that meet certain quality requirements have a right to free establishment. In 2012, the require- ments for local authorities in Denmark to increase the share of alternative home care providers were raised, resulting in an increasing volume of new tenders in recent years. Norway has no clear rules or incentives for an increased private presence within care. Some procurement take place, primarily in the Oslo region, but only a smaller portion of the care for older people has a system of choice.
The increased freedom of choice applies not only to