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1、UK&European Care Homes 2022SPOTLIGHTSavills ResearchThe Countercyclical Asset Class?Savills Operational Capital MarketsWebsiteSocialKey pointsIn common with many countries around the world,much of Europe has an increasingly ageing population.The private sector makes up 40%,equivalent to 46bn.The res
2、t is in public ownership through governments and local councils.The UK has by far the largest private care home market.The next highest is Germany at 40%.Belgium has by far the most consolidated European market,with a few very big players.Investment in European care homes has seen sustained growth o
3、ver the last five years.45%115bn 82%5bn 25%Old age dependency ratio in Germany by 2032Value of Care Home stock in 2022 Of stock in the UK is held by private ownersInvested in Germany since 2020Of private stock owned by five largest investors in Belgium Key pointsIntroductionCare Homes have proven to
4、 be a countercyclical real estate asset class,performing strongly in economic downturns.Underpinned by compelling supply/demand fundamentals and an ageing population,the European Care Home sector nevertheless has many nuances,and a close understanding of each markets regulation,spending and cultural
5、 approach to care,is key for investors looking to access and achieve success in this sector.Although many elderly care home operators and investors have grown their market share in recent years,European care home markets remain highly fragmented.Consolidation rates-the proportion of the market made
6、up by the top five operators in England,France,Spain and Germany,are between 11%and 13%.Belgium is the most consolidated market with 25%.This presents opportunities for pan-European aggregators.Introduction*refers to England Source Savills using Healthcare Business International,various company webs
7、itesFig 1:Key metrics across Europes seven largest care home markets GermanyFranceUKItalyBelgiumSpainNetherlandsCare Homes13,5007,40010,800*5,4008,3005,6004,900Beds900,000595,000414,000*321,000150,000385,000123,000Beds per 1,000 people aged 65+54484219664371Total market size(bn)35.80 26.20 21.80 14.
8、50 8.30 5.70 3.10Private market size(bn)14.30 6.00 17.80 3.50 2.70 1.40 0.50%of market that is private40%23%82%24%33%24%15%Market consolidation (top 5 operators)11%17%13%8%25%13%5%Across the seven largest markets in Europe the UK,Germany,France,Italy,Spain,Belgium and the Netherlands.3 million+Care
9、Home common with many countries around the world,much of Europe has an increasingly ageing population.That results in more people needing increasingly complex care,and for longer periods of time.This will underpin continued demand in the sector.The demographics are clear to see,and the problem is fo
10、recast to increase moving forward.Firstly,an ageing population means more people will have increasingly complex care needs,and for longer periods of time,as diseases such as dementia become more prevalent.Secondly,the old age dependency ratio,the number of people aged 65 compared to the number of wo
11、rking age people,is also increasing sharply there are more older people being supported by fewer working age people.That means countries will find it harder to pay for peoples care needs.The rate of these changes differs across Europe,however.The UK currently has the lowest old age dependency ratio
12、and will see the lowest rate of growth in people aged 65,according to data from Oxford Economics.The UKs old age dependency ratio will rise from 22%in 2022 to 25%in 2032.Meanwhile,Germanys will rise from 35%to 45%over the same period.Spain and the Netherlands will see the largest growth in their eld
13、erly populations,rising by around a quarter.Residents in need of care and national governments pay for social care in various ways.This ultimately means different approaches and outcomes for developers,investors and operators of social care real estate.The UK,Italy and Spain have taxation based syst
14、ems.All three combine funds raised through national taxation with regional/local taxation.A large proportion of long-term care funding in England is allocated to local councils by central government,however,the amount of these grants has been cut in recent years.In 2018,the IFS estimated the proport
15、ion of local taxes spent on adult social care will increase from 30%to over 50%by 2030.Governments across the world are grappling with the challenge of ageing populations,and the increased resources that will be needed.France,Germany,the Netherlands and Belgium all have an insurance based model.In G
16、ermany,the insurance is primarily collected as a 2.25%income tax with half paid by the employer,whilst in the Netherlands,every person living or working in the country is required to purchase a basic health insurance policy.Social care funded by insurance based systems can be vulnerable to the chang
17、ing state of the national environment,however.Lower than expected insurance contributions or higher than expected long-term care needs can leave funds facing financial problems,a problem which will only be exacerbated in challenging macroeconomic conditions,such as those were seeing currently.Europe
18、s demographic trends underpin future demandCare home markets have clear funding and regulatory differences Regulation and fundingDemographic trendsRegulatory and funding landscapeFig 3:The differences in funding models and service structures*GermanyFranceUK/EnglandItalyBelgiumSpainNetherlandsNationa
19、l vs DevolvedNationalNationalNationalDevolvedDevolvedDevolvedDevolvedFunding modelInsuranceInsuranceTaxationTaxationInsuranceTaxationInsuranceUniversal access?YesYesNoNoYesYesYesIn-kind vs cash benefitsIn-kindBothIn-kindCashBothCashBothInstitutional vs home careInstitutionalBothBothHome careBothHome
20、 careBoth%of GDP spend on LTCAverageAverageHighLowAverageLowHigh%spend via out of pocketHighLowHighAverageLowAverageLowSource Savills using Incisive Health,*reflects broad characteristics of each system/countrySource Oxford EconomicsFig 2:Europes ageing population40%35%30%25%20%15%Old age dependency
21、 ratio(2022)Estimated growth in population aged 65(2022 to 2032)15.0%17.5%20.0%22.5%25.0%27.5%Size of bubble refers to total population aged 65GermanyItalyUnited KingdomFranceBelgiumNetherlandsSpain Care home markets across Europe have clear funding and regulatory differences.England,Italy and Spain
22、 have taxation based systems,whereas France,Germany,the Netherlands and Belgium all have insurance based models.Social care funded by insurance based models can be vulnerable to the changing state of the national environment,in terms of demographics and economies.In predominantly means-tested system
23、s,such as England,risk is greater for the individual,with public support limited to the least wealthy.SUMMARY and fundingRegulation and funding Beds%of Total MarketMarket commentarySPAINCulturally,Spaniards have been hesitant about putting their elderly relatives in care homes,preferring to care for
24、 them at home.However,this appears to be changing in recent times with HBI reporting the fall in family size,which has made this more challenging,indicating a growing market opportunity in Spain,which has one of the fastest growing elderly populations in Europe.ITALYAccording to Healthcare Business
25、International(“HBI”),not-for-profit operators are largely church-owned and in poor financial shape,often run by monasteries.In Italy,the average age of a monk is 80,and as a result monasteries are not particularly well run,often selling out to for-profit operators.Many public operators are also leav
26、ing the market by selling out to for-profit operators,in part because the government no longer wants the responsibility for operating homes that often face safeguarding scandals.For-profit operators are expected to gain market share slowly over the next few years through consolidation of existing no
27、t-for-profit homes.BELGIUMThis market is strongly regulated and presents high barriers to entry.The number of beds per municipality is allocated to providers in advance.So,all bed construction for 2025 has been decided and already contracted out to operators.Only 5,000-10,000 extra beds have been al
28、located for the whole of Belgium(whilst the population 80 is set to double before 2025).High occupancy rates are therefore likely,but access points for investors are more challenging.NETHERLANDSNew legislation came into force in 2022,the Care Providers Accession Act(Wtza).This law has new entry rule
29、s for care providers,which include increasing the level of regulation that needs to be met before a new home can be opened,and increasing the barriers to entry for new operators.Though it can be contentious for providers to make a profit on the provision of healthcare,operators can charge rent while
30、 the care is state-funded.According to Aedifica,revenue per bed can amount to 7,000 for the highest levels of care(c.3,000 in rent and 4,000 for care services from the state).This explains why providers maintain smaller,more exclusive operations.Fig 4:Proportion of total public spending on long-term
31、 careAs a proportion of total public spending on long-term care,institutional care(i.e.care homes)makes up over 50%in every market,except in Italy where it accounts for just 28%.The UK and France have the largest share of institutional care provision and the smallest share of cash benefits.Cash bene
32、fits give recipients greater choice,with the freedom to use cash as they see fit,such as to employ domiciliary carers or to complete home improvements,to allow people to stay in their homes for longer.Alongside Spain and Italy,cash benefits are also prominent in the German and Dutch markets.Care is
33、provided in different ways across Europe Source Social Protection Committee(SPC),European Commission,OECD100%90%80%70%60%50%40%30%20%10%0%Proportion of total public spending on long-term care UKFranceBelgiumGermanyNetherlandsSpainItalyCare homesHome careCash sizingSource Healthcare Business Internat
34、ionalSource OECDSource Savills using CQC,ltccovid.orgAssets and bedsMarket sizingThe value of the European elderly care home market was worth 115bn in 2022,according to Healthcare Business International.The private sector makes up 40%,equivalent to 46bn.The vast majority,32bn(70%),is in the UK and G
35、ermany the two biggest private care home markets.Germany is the largest market in Europe,both in terms of value(35.8 bn)and the number of care home beds(900,000).This is perhaps unsurprising given that it has the largest population.However,the UKs private sector is larger;making up 82%of its total c
36、are home market(17.8 bn)compared to Germanys 40%(14.3 bn).Although Germanys percentage might seem low compared to the UK,it still makes it the next largest private market as a proportion of its total,amongst the seven largest European markets.In the southern European countries of Italy and Spain,fam
37、ily members are much more likely to care for elderly relatives rather than place them in institutional care.As a result,these care home markets are smaller relative to the size of their population.This cultural difference however appears to be changing,with smaller families and fewer people per hous
38、ehold making this more challenging.This will result in opportunities for investors as these markets are likely to increase in size.The private care home market is worth 46bn across the big 7 European countries Germany,Italy and Spain typically have far bigger care homes than in the UK.In Germany,42%
39、of care homes have more than 75 beds.C.37%of homes have more than 75 beds in Italy and Spain.The UK has a far higher proportion of smaller care homes-just 7%have more than 75 beds.75%have 50 beds or less.The Netherlands is closer to the UK than Germany,Italy and Spain,also having smaller sized care
40、homes.According to Healthcare Business International,care homes in the Netherlands are typically built with 20-25 beds,though some are now pushing 30-40.Investors looking to acquire portfolios to build scale may therefore find opportunities harder to come by in the UK and the Netherlands.UK care hom
41、es are smaller than their European counterpartsThe development and delivery of new care home stock has been inconsistent.The Netherlands and Belgium have the most amount of stock proportionate to people aged 65+,with the ratio between the two remaining fairly static between 2010 and 2020,according t
42、o data from the OECD.In the UK,although around 8,000 beds have opened each year over the past decade,nearly the same number have ceased operations each year.Therefore,the total number of beds has remained static.Alongside an ageing population,the number of beds proportionate to people aged 65+has th
43、erefore gone down.There is a similar trend in Belgium and France,albeit not to the same extent.In Italy,where culturally it is more common for family members to care for elderly relatives,the number of care beds is now increasing at a faster rate than the ageing population.Spain,which is closer to I
44、taly than the UK in terms of institutional vs home care arrangements,has more beds than the UK,when compared against the number of people aged over 65.Only Spain has seen a significant increase in beds relative to its ageing populationFig 5:The total value of care home markets Germany has the larges
45、t care home sector.The UK has by far the largest private sector market.Belgium is the most consolidated market in Europe,with a few big players.The UK,Germany,France,Netherlands and Spain have highly fragmented markets.The care home market in Spain and Italy has been slower to develop,as families ar
46、e more likely to care for elderly relatives at home.SUMMARYFig 6:Care home stock by number of bedsFig 7:Care home beds per 1,000 people aged 65+50 40 30 20 10 08070605040302010040%30%20%10%0%-10%-20%-30%-40%100%80%60%40%20%0%Total market size in 2022(bn)No of beds in residential long-term care,per 1
47、,000 people aged 65+Change in long-term care beds per 1,000 people aged 65+between 2010 and 2020Private market as%of totalUKUKFranceFranceBelgiumBelgiumGermanyGermanyNetherlandsNetherlandsSpainSpainItalyItaly40%23%82%24%33%24%15%100%90%80%70%60%50%40%30%20%10%0%Proportion of all care home stock,by n
48、umber of bedsGermanyItalyUKSpainPrivatePublicPrivate%% market Investment in European care homes continues to increaseCross-border investment dominates capital flows in European care homes Source MSCI,*across the seven markets profiledSource MSCI,Source MSCI,Fig 8:Total net capital flowsFi
49、g 10:Largest active players in the last 2 yearsFig 9:Total net capital flows(2020 to Q2 2022)Investment across the European care home market has been steadily rising over the past decade,reaching a record high of 5.7bn in 2021.Total annual acquisitions have averaged 2.4bn since 2012.As the major ope
50、rators such as Korian and Orpea,and major landlords like Aedifica,Cofinnimo and Swiss Life,become more pan-European in their focus,so too does the investment market.Over the 30 months between 2020 and Q2 2022,the German care home sector received the greatest volume of net capital flows,at just under
51、 2bn.The vast majority of this was from cross-border investment at 1.6bn.At the same time,there was a 900m net loss of private investment in Germany,with many more parties exiting the sector by disposing assets for use as other real estate sectors,compared to entering it via acquisitions.It is a sim
52、ilar story across all other markets apart from France.Institutional investors,REITs and listed companies are buying and holding stock.Together they invested more than 3.7bn since the start of 2020,with a net capital flow of 1.4bn.However,this has been dwarfed by the 4.2bn invested cross-border,with
53、net flows nearly double that of institutions and REITs/listed companies combined.Last 2 yearsRankingBuyerAcq()No.of Properties Belgium1Cofinimmo 198,699,996102Aedifica70,000,000 53Swiss Life AM35,000,000 1France1SCPI Primovie300,000,000 332Caisse des Depots225,341,585 143Korian66,999,980 5Germany1Vo
54、novia SE1,244,919,575 752Swiss Life AM492,732,895 323INP Holding AG315,500,000 22Italy1Caisse des Depots249,962,488 192Cofinimmo211,999,908 83Threestones Capital52,000,000 3Netherlands1Bouwinvest50,000,000 12Holland Immo Group31,232,685 43Cofinimmo30,070,451 2Spain1BAE Systems Pension26,866,758 22Co
55、finimmo20,544,859 2UK1Lone Star284,154,497412Octopus Real Estate232,341,400143Impact Healthcare REIT226,572,968 41 Investment in European care homes has seen sustained growth with investment totalling 2.3bn,3.8bn and 5.7bn in 2019,2020 and 2021,respectively.Germany is by far the most liquid market,w
56、ith more than 5bn transacted since 2020.The UK is a clear second with 2.5bn,followed by France and Italy with around 750m each.Cross border capital dominates the sector,with large players investing across Europe.As domestic markets become saturated,more investors are looking to diversify their portf
57、olios.SUMMARYIn Germany cross-border investment made up 50%of total acquisitions between 2020 and Q2 2022.Vonovia SE made close to 1.25bn of acquisitions over the last 24 months for 75 properties,the most of any company in Europe.The UK had the second highest total acquisitions in Europe,with a fair
58、ly even share of investment from cross-border investors,institutions,REITs/listed companies and private companies.Italy is a less developed market with smaller home grown players.91%of acquisitions in Italy were made by cross-border firms.Meanwhile in Belgium 91%of acquisitions were made by domestic
59、 REITs/listed companies.Germany has by far the most liquid market,followed by the UK 6 5 4 3 2 1 0Total investment(bn)20000212022YTDCross borderInstitutionalREIT/ListedPrivate 2.5 2.0 1.5 1.0 0.5 0-0.5%-1.0%-1.5%Acquisition by type of investment(bn)Cross borderInstit
60、utionalREIT/ListedPrivateUKFranceBelgiumGermanyNetherlandsI efficiencyInvestment caseThe investment case for care homesCare homes offer higher yieldsThere is a counter-cyclical relationship between the performance of healthcare assets and all real estate assets during economic downturns,with healthc
61、are real estate assets consistently outperforming.Data from both the UK and Australia supports this.The same is true in the US.According to NCREIF,senior housing and care is the only commercial real estate asset class that experienced positive asking rent growth during the Global Financial Crisis(GF
62、C).Rental growth has been steadier,less volatile,and has generally exceeded that of other commercial real estate property types since.Senior housing returns have annualised 11.6%in the 10 years to Q3 2020,comparing favourably to the 9.4%for all property,again according to NCREIF.Across the three cor
63、e living sectors of Multifamily/build to rent housing,purpose-built student accommodation(PBSA)and care homes,care homes offer the greatest potential yield.This is due to a number of factors,with investors likely pricing greater risk into the care home sector,which is highly regulated,requires great
64、er operational management and where margins for operators can be slimmer than traditional residential.The pool of potential investors in care home stock is also likely to be smaller than that of Multifamily and PBSA,giving care homes a yield premium over other living sectors.Care homes perform posit
65、ively in downturns relative to the wider real estate marketMultifamilyPBSACare homesBelgium3.50%-France2.80%-3.90%Germany2.10%4.25%4.00%Italy3.50%4.25%5.50%Netherlands3.50%5.10%4.50%Spain3.25%4.25%5.20%United Kingdom3.50%3.50%3.50%Average3.16%4.27%4.43%*3-year period for UK is 2007-09,Australia is 2
66、009-11 Source MSCISource Savills,MSCIFig 11:Average 3-year total return over period of global financial crisis(GFC)Fig 13:Residential stock by EPC rating Fig 12:European prime yields,Q2 2022A further challenge that the care home sector will face,and an opportunity for investors,is the growing need t
67、o meet energy efficiency regulations.As European investors look to scale their portfolios,the energy ratings for both new and second hand care home stock and the potential for their improvement will become increasingly important.Data on energy performance of care home stock is hard to come by.Lookin
68、g at all housing stock however as a proxy,the Netherlands is well ahead of the rest of Europe in the proportion of its housing stock with high energy performance ratings.63%of all Dutch homes have an energy rating between A-C bands,compared to just 6%in Spain.The high proportion of apartments in the
69、 Netherlands,and the much higher temperatures in Spain go some way to explaining those differences.Spain,Italy and Belgium have a high proportion of poor energy efficiency housing stock,with the vast majority of homes rated E or worse.In terms of care homes,64%of Aedificas stock is rated either A or
70、 B.To add to that,as part of a recent 200m green bond issued by Korian,the major care home investor stipulated that only A or B rated care homes were eligible for investment.Both of these examples show the importance of energy ratings and the sustainability of buildings for investors.The Netherlands
71、 leads the way in energy efficient housing stock Source:Buildings Performance Institute Europe(BPIE)(data unavailable in Germany)Healthcare outperforms all real estate in economic downturns(MSCI).Enduring demand for healthcare and strong government support makes it more stable.With ageing stock ther
72、e is a clear need for new energy efficient homes and investors are keen to acquire A and B rated homes.SUMMARYCare homes perform positively in downturns relative to the wider real estate market12%10%8%6%4%2%0%-2%-4%-6%-8%100%90%80%70%60%50%40%30%20%10%0%Average total return%of all residential stock
73、by EPC ratingUKAustralia*UKFranceBelgiumSpainItalyNetherlandsHealthcareAll real estateABCDD landscapeOperator landscapeOperator landscapeBelgium has by far the most consolidated market,with a few very big players.For example,Korian has nearly 9%of the entire market,with over 13,000 beds out of a tot
74、al 150,000.The five largest players in the country make up 24.5%of the market,around double the consolidation rate of any other country.As a result,for new players thinking of entering the Belgian market,opportunities to acquire existing stock are more limited,making it harder to build up a portfoli
75、o of scale.The Netherlands is highly fragmented,with the largest 5 players making up just 5%of the market.Orpea,the biggest player,has just 2,500 beds.Orpea,Korian and Domus Vi are major players across almost all markets,with large portfolios spanning Europe.However,the UKs largest players,such as H
76、C-One,Barchester and Care UK,are very much UK based.Aedifica recently purchased four care homes in Ireland increasing their portfolio in the country to 460m in size.We expect operators to continue expanding to new underserved geographies.Source:Savills using Healthcare Business International,various
77、 company websitesSource:Investigate-EuropeThe 28 largest private equity funds with majority stakes in European care home operators control nearly 200,000 beds,equivalent to around 5%of the total market across Europe.This is less than half the percentage held in the United States where private equity
78、 investors control around 11%of the care home market,indicating strong potential for further growth.Half of the top ten largest care home providers in Europe are majority owned by private equity companies.French-based Domus Vi are the largest.Backed by Intermediate Capital Group,they operate care ho
79、mes in 5 European countries.HC-One are the largest care home operator in the UK,operating over 22,000 beds and are majority owned by two private equity funds:Safanad and Formation Capital.Consolidation rates vary significantly across European markets Private equity is well established across the Eur
80、opean care home sectorFig 14:Market size and consolidation rate of private market Fig 15:Private equity in European care home sector90%80%70%60%50%40%35%30%25%20%15%10%5%0%Old age dependency ratio(2022)%Consolidation rate of top 5 operatorsSize of bubble refers to CAGR rate of the private market,in
81、terms of value,between 2016-21GermanyItalyFranceNetherlandsSpain0.0%5.0%10.0%15.0%20.0%25.0%30.0%United KingdomBelgium90,00080,00070,00060,00050,00040,00030,00020,00010,00006420Number of European care bedsNumber of European marketsBeds in 2020Green operators majority private equity ownedO
82、perating in European marketsOrpeaKorianDomusViColiseHC-One LtdAlloheimMaisons de FamilleAttendoVictors GroupFour S landscapeConclusionsEurope has an ageing population,which is creating a growing need for care facilities.Over the next decade,Spain and the Netherlands are forecast to see the largest g
83、rowth(25%)in those aged over 65 years,according to Oxford Economics.The old age dependency ratio(the measure of people aged 65 relative to the number of working age people,14-64)is also rising sharply.Germany currently has the highest old age dependency ratio,at 35%and rising to 45%by 2032.The elder
84、ly care home market across Europe remains fragmented,with the top five operators in England,France,Spain and Germany only operating between 11%and 13%of their markets compared with 25%in Belgium,providing scope for further consolidation in these markets.But understanding the nuances of regulatory an
85、d funding regimes in each market is key to successful growth.The sector has seen increased investment activity in recent years,driven by growing levels of cross-border capital,as investors seek to build pan-European platforms.We expect increased interest in the sector over the coming years,with inve
86、stors attracted by the sectors strong countercyclical characteristics and by structural demand driven by the ageing population.Source Healthcare Business International,various company websitesTop 5 OperatorsBeds%of Total MarketGERMANYKorian30,0004.0%Alloheim24,0003.2%Orpea20,0002.7%Pro Seniore17,000
87、2.3%Kursana12,0001.6%Total900,000Total Consolidation Rate 11.4%ENGLANDHC-One13,9003.4%Barchester13,1003.2%Care UK10,0002.4%Bupa7,7001.9%Four Seasons7,2001.7%Total385,000Total Consolidation Rate 12.9%ITALYGruppo KOS8,7001.2%Korian7,0000.9%Sereni5,0000.7%Orpea2,4000.3%Gruppo Giomi1,3300.2%Total321,000
88、Total Consolidation Rate 7.6%FRANCEOrpea33,0005.5%Korian32,0005.4%Domus Vi19,1003.2%Colisee7,5001.3%Domidep7,0001.2%Total595,000Total Consolidation Rate 16.6%SPAINDomus Vi19,5002.6%Orpea8,3001.1%Vitalia8,0001.1%Ballesol7,3001.0%Bupa6,3000.8%Total385,000Total Consolidation Rate 12.9%BELGIUMKorian13,1
89、564.40%Colise(Armonea)9,3004.30%Orpea7,2232.50%Acalis Care5,5001.00%Vivalto1,5850.90%Total150,000Total Consolidation Rate 24.5%NETHERLANDSOrpea2,5532.1%Dagelijks Leven1,3801.1%Korian1,2181.0%De Herbergier6600.5%De Leyhoeve5200.4%Total123,000Total Consolidation Rate 5.1%Fig 16:Top 5 operators in each
90、 European Valentine-SelseyDirector,Head of European Living Research+44(0)7870 403 193 Savills ResearchWe are a dedicated team with an unrivalled reputation for producing insightful analysis,research and commentary across all property sectors throughout the UK,Europe,Americas,Asia Pacific,Africa,Indi
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