Right. Good afternoon, everyone, and welcome to our CVS Capital Markets Day. I'm Richard Fairman, Chief Executive, and I'm delighted you're able to join us as we highlight the great strengths of our company and we outline our plans and ambitions over the next five years. On the next slide, we set out the agenda for the day. We will start with a formal presentation, and during the presentation, there'll be two opportunities for you to ask questions. We'll start with questions from those of you here in person, and those of you who've joined through the live stream facility can also ask questions through that facility. We will break for lunch around 2 :00 P.M., and during the lunch interval, you can participate in some of the interactive demonstrations at the back of the room. This afternoon, we have two practice tours.
We are visiting our Springfield Rotherham practice, which is one of our larger 1st-opinion practices, and also the site of our relocated Carrick Vets practice at Dobbies Garden Centre in Chesterfield. Then after those practice tours, buses will take you back to Chesterfield train station for your return trains to London. One of the buses will bring those who need to be back here to the football ground. After the bus tours, you all have name badges actually on you, and they all have a time for your practice tour and also a color coding for your tour. For logistical purposes, it's really important that we have the tours leaving here on time. We'd welcome your support from that.
Five years ago, we set out a new strategy as a management team at CVS. Our purpose is to provide the best possible care for animals, and our vision is to be the veterinary company people most want to work for. Underpinning this purpose and vision are four clear strategic pillars. We recommend and provide the best clinical care every time, and our integrated model allows us to provide joined-up, high-quality care to clients and their animals 24/7. Our 2nd pillar is to be a great place to work and have a career. We've spent a lot of time over the last three years repositioning CVS as an employer of choice in the sector.
We are now seeing the benefit of that from an increase in the number of vets and nurses we employ, and also increased colleague engagement as measured through our employee Net Promoter Score. Our 3rd pillar is to provide great facilities and equipment. We are consciously investing in these areas because we recognize the importance of this in our ability to provide great care, but also our ability to recruit and retain the best talent in the profession. Fourthly, we want to take our responsibilities seriously, and that's whether it's driving improved standards of clinical care within the profession, in providing more wellbeing support to our colleagues, or in reducing the impact of our operations on the environment.
Through a focus on this strategy and these four pillars, we've transitioned CVS from a buy and build company to one that's focused on organic growth and is now well positioned to make further investment. That investment will be across a number of areas, and it will do two things. It will drive further organic growth in our business and also inorganic growth through acquisitions. Through our focus on these areas, I've mentioned people as being a key element, and we are effectively a people business. We are fortunate to have a great team of colleagues, so I'm now gonna show you a video that highlights some of our colleagues. It features some of our colleagues, and it highlights the great strengths of our company and also the integrated model. Hello, and welcome to CVS Group plc.
We are an AIM-quoted veterinary group and one of the U.K.s leading providers of integrated veterinary services, with operations throughout the U.K. and also the Netherlands and Ireland. I'm Richard Fairman, Chief Executive Officer, and I look forward to providing an insight into our great company. We operate a fully integrated veterinary model with 1st Opinion veterinary practices at the core of our company. These 1st Opinion practices are supported by our specialist-led, multidisciplinary referral hospitals, our dedicated out-of-hours centers, our own diagnostic laboratories, our network of crematoria, and our dedicated online retailer of food and drugs, Animed Direct. Through this fully integrated model, we are focused on providing high-quality, end-to-end care to our clients and their patients 24/7.
We continue to deliver our strategy with our clear purpose to provide the best possible care for animals and our vision to be the veterinary company people most want to work for. This purpose and vision are underpinned by our four strategic pillars, recommending and providing the best clinical care every time, being a great place to work and have a career, providing great facilities and equipment, and taking our responsibilities seriously. This video highlights our integrated model and showcases our great company as shared by some of our talented and passionate team.
We've been in our beautiful, spanking-new hospital for a year now, and it's been absolutely fantastic. It's made a huge difference. We're all really enjoying having suitable facilities to be able to do the work that we really want to do. We've got higher levels of care. The vets and the nurses in particular are really enjoying the clinical aspects of work and how much we can offer and the increased range of services that we can provide for our clients now.
I took the job and moved down to Falmouth, to further my career, basically as an ophthalmologist. Since I've been here, the practice has grown. We're now in our new hospital, and that's given us our CT scanner.
CVS for me has meant that I could realize the value of the practice while keeping investment in the property. It's meant that I can focus on my clinical work while still keeping some local control.
I studied at Duchy College Rosewarne, which is in Camborne. That's our local training center, and CVS and Dr. Villa provided the facilities for me to enable to train in practice while still working full-time.
The good thing about working for a large veterinary corporation is that there's a big network of people that you can rely on for support. I really like that CVS is really hot on staff development and training, and they're always keen for staff to progress their careers and undertake extra qualifications, and they seem to be really keen on developing the practice that you work in as well.
I've worked for CVS for 16 years, and we've gone from being a normal, conventional small animal veterinary practice, but the investment in people, the investment in the premises has allowed us to go from probably a 12-vet practice to being a 30-vet practice now.
My long-term career l goal has been to take up a clinical directorship at Springfield. To help me prepare for this, I recently did a six-month secondment as clinical director at another practice within our region, and have recently just rejoined Springfield in the CD capacity. I now have responsibility for about 50 staff and running our 24-hour hospital. Love working for CVS. Personally, I've had a real investment of time and money in my career. I'm somebody who very much likes to look for the next challenge, and there's been several points in my career that I've wanted a new project or the next step. Every time I've been in that situation, either locally or nationally, CVS have provided an opportunity that I've never had to look elsewhere to meet my career goals.
Within our dedicated out-of-hours team, we always aim to give the best possible patient care, and not only do we achieve that by having those dedicated teams, but with all our colleagues, there is a comprehensive support package for continued development. In any clinical field, things change so quickly, and with a dedicated team responsible for our emergency and critical care across many of our sites, it means that we have the opportunity for them to come together to share best ideas and challenges, and to make sure that we really truly are at the forefront of veterinary medicine, offering the best possible care to all of our patients.
I used to work at an independent practice, and I loved it. I was a little suspicious about working for a corporate firm. However, I love it. I really enjoy working at CVS. I find that the support from head office is phenomenal. It's great having an HR team, a finance team, recruitment, property team. You know, we've got backup plans for all sorts of things because that support exists. Career progression within CVS is great. It's given me a lot of scope that I wouldn't necessarily have known about before to progress my career in lots of different ways. I've got my own plans. I've had conversations with people about what I'd like to do in future, and I feel like it's achievable.
The summer camp's been a great, sort of, introduction to working life. It's eased being a vet and made that transition a bit easier from vet school to being a vet, and it's also been a great chance to make new friends and meet people that are gonna be working in the same area, so there's a network of us all together that we can keep in touch with and help each other out.
My function as practice development lead is very diverse. Together with my team, I support all practices to achieve better results and further develop themselves in clinical work, but also in management. This includes coaching young veterinarians, which I really enjoy, and ensuring good further education for all our employees within CVS.
I started working with CVS Netherlands because they are willing to look at work in the veterinary sector in an innovative way. Especially the focus on staff, good career opportunities. I think I am a good example of that myself. I also started as a para veterinarian and have now progressed to a role as regional director.
Within CVS Netherlands, we have started with mobile laparoscopy because there was a lot of demand from practices for minimally invasive surgery, but there was not yet an option. With our mobile team, we can offer this modern technology to all our patients.
I really enjoy the management and the challenges that come with management. Also what I really enjoy is the fact that there are so many opportunities within CVS that aren't, wouldn't normally be available in 1st opinion practice. I've had opportunities to travel within Europe to look at other practices. I've met a lot of vets, and we can have very open conversations because, of course, now we're all one happy family, one big group.
I've been part of B&W Equine now for 10 years. I completed my nurse training at B&W. I went under the degree route, so I qualified in 2014. I became head nurse in 2016, taken over by CVS in 2017. With the help of CVS, I've undertaken a nursing certificate in anesthesia, and that's enabled me to help the hospital team. There's now a great variety of training for equine nurses down the degree pathway or the diploma route. That's really beneficial for the nurses we have within the division.
The laboratories are able to offer nationwide coverage with the use of our courier fleet. Samples are picked up throughout the night, all across the country and couriered on various hubs to arrive at the laboratory for about between four and the morning, and then lab staff start coming in from six onwards and start processing those samples all the way through to 7 o'clock at night when the whole system starts again with those couriers.
The thing I enjoy most about working for CVS is the support that you get. The support that I get from my line managers, from my team, but from the wider organization as well, is just overwhelming, and it's really lovely to have.
I'm the general manager of the pet crematorium at Durham, and I also cover Larkhall. We deal with veterinary clients, external vets, CVS vets and clients alike. We collect pets and veterinary waste from veterinary practices. We deal with clients over the front door that's lost beloved pets, and we provide them with the service they require, either companion cremation or individual cremation. We supply them with paw prints, fur clippings, and any of the things that they request. We collect any waste from the veterinary practices. We bring it back to site, the waste segregated, and then disposed of in the correct manner.
The direct pet crematorium project has benefited CVS clients because it's a specialized project. It gives clients the chance to grieve properly for their pets. When they bring their pets to ourselves, we can give them that direct service. They get to get their wishes out exactly how they want. There's no stupid questions. If you're grieving, then you need to know exactly where your pet is and what we're doing with your pet and what you want as their final wishes. I feel like this project is there to support our clients and give them exactly what they want.
Our fully integrated model and our clear people-focused strategy are key to delivering our purpose to provide the best possible care for animals and our vision to be the veterinary company people most want to work for. Key to the delivery of this care are our people, and I would like to take this opportunity to thank all our colleagues for their continued dedication and professionalism. Thank you for listening.
What clearly comes out from that video is the passion of our team of people, and you'll see that passion this afternoon as if you accompany us on the practice tours. That passion is all about delivering 1st-class quality care to our clients and our animals. Through our integrated model and our strategy, over the last three years, we've delivered significant growth.
Revenue has increased by 36% to GBP 554 million. We've seen adjusted EBITDA almost double to GBP 107 million. We've seen an improvement in adjusted EBITDA margin to 19.4%, and our focus on providing high-quality clinical care is key to that margin enhancement. Through our focus on people, we've seen a 27% increase in the number of vets we employ. This strong financial performance on the next slide positions us really well for further growth and to benefit from the favorable market trends we are seeing. We operate in a sector that's proven resilient in past economic downturns. We continue to benefit from the humanization of pets and owners willing to spend more on their care.
We're also now seeing improved life expectancy of pets, and as a business that focuses on high-quality care, CVS is really well placed to benefit from that because clearly the older pets need more clinical intervention. We continue to see strong operating cash conversion. We have committed undrawn bank facilities. We have low leverage, and therefore, we are really well placed to invest in future growth. On the next slide, our strategy remains as relevant now as it did three years ago. Today, we are outlining six key areas of our ambition over the next five years. Organic revenue growth of between 4% and 8% per annum. Adjusted EBITDA margins of between 19% and 23%.
Investment in facilities, in clinical equipment, in technology, and also in greenfield sites to drive further organic growth and also to support with that margin enhancement. Acquisitions subject to our disciplined approach and subject to a minimum 10% internal rate of return, and that 10% IRR more than sufficient to cover our weighted average cost of capital. We are focused on operating cash conversion of 70% and above, and leverage remaining below 2x. Through this morning's presentation and the focus on these six areas, we will outline our ambition to double adjusted EBITDA over the next five years. The agenda for our presentation is shown here. First u p, Ben Jacklin, our Chief Operating Officer, and Robin Alfonso, our Chief Financial Officer, will talk about the investment we plan to make.
We'll discuss our capital allocation priorities and also talk through the opportunity we have to enhance margins. Now, the investment we plan to make is critical to our ambition to double adjusted EBITDA over the next five years, and hence, we will pause for questions at the end of Ben and Robin's session. However, we were keen that you also get to hear from other members of our senior management team. Today, we have Lizzie McLennan-Green, Small Animal Veterinary Director, who will talk about her career progression within CVS and outline our focus on providing high-quality clinical care in our 1st opinion practices. Helen Baxter, our Referrals Director, will highlight the advanced care we provide through our Advanced Clinical Service Network, through our Vet Oracle business, and also through our specialist referral hospitals. Dr.
Martin Whiting will talk about our people investment and also the career progression and support that we provide to colleagues throughout CVS. Then Graham Dodds will talk about sustainability and ESG, and there'll be a further opportunity for questions at the end of their session. Also here today, we have our colleagues on our executive committee. James Cahill, Director of Clinical Operations, Sarah Armitage, our Group Procurement Director, Helen Finney, our Group HR Director, Faye Roth, our Chief Technology Officer, and Paul Higgs, our Chief Veterinary Officer. A member of our executive committee will accompany each of the practice tours. I'll now hand over to Ben and Robin to outline our investment.
Thank you, Richard, and good morning, everyone. Robin and I are now gonna run through the investment opportunities that we see in our business, our experience of returns, and how these will form the building blocks of our ambition to double EBITDA. We'll cover our property refurbishment and relocation strategy, our greenfield investment opportunity, and our U.K. and international acquisition opportunities, both in terms of the impact on capital expenditure, but on returns thereon. As a management team, we believe there is still significant opportunity for organic growth within CVS, which will be achieved through our continued focus on the delivery of our strategy. On this slide, we've shared some examples of the organic growth opportunities that exist, and many of these will be familiar to you.
Vets and nurses are key to the delivery of our strategy, and we are delighted that we continue to take market share in the recruitment of clinicians into CVS. Our culture of clinical excellence and our people-focused strategy and continued delivery of people-focused initiatives means that we have reduced attrition to the lowest level we've ever recorded. Continued improvement in these areas will enable further organic growth through the delivery of the best possible care to even more patients. A further opportunity will come over the next three years with the rollout of a new state-of-the-art practice management system, which we'll cover more on shortly. The system will improve efficiency for our colleagues, improve the experience of our clients, and over time, deliver a range of benefits that will help to reduce leakage across the group.
We believe there continues to be an opportunity to enhance underlying EBITDA margins. In the left-hand chart, we show distribution of our practices' EBITDA margins across our veterinary practice division, and the bars represent a count of practices. The left-hand bar is a count of practices delivering margin of just below 10%, and the right-hand bar is the count of practices delivering a margin of greater than 40%. The average EBITDA margin being 22%. Bringing that bottom half up to the average will deliver significant EBITDA and EBITDA margin growth. Some of that will be delivered by the focus areas Ben has just outlined, and some will require further investment. My one caveat is that group margins are always subject to mix. In the right-hand chart, you'll see our EBITDA margins across our four operating divisions.
A good example is that we have an opportunity to invest in our practice management system. That will unlock a number of benefits, one of which is enhanced pet food sales. Now, increased pet food sales tends to be at lower margin, so although EBITDA improves in absolute terms, which is clearly a positive thing, margin may not. Having stated that caveat, our ambition is to deliver EBITDA margins and improved EBITDA margins of between 19% and 23% over the next five years.
On the next slide, as we've shared previously, all the clinical premises in our companion animal primary care estate have been rated against our established operational matrix, which assesses the quality of each premises in terms of how well it serves our colleagues that work there, our clients that use the practice, and the clinical work that that particular premises permits. As you'll see in the graph on the left, the spread of these ratings is broad, and that range and breadth represents the opportunity we have for investment, and that is one we intend to seize. Of those practice refurbishment and relocations that we completed in the calendar year of 2021, we've created outstanding work environments with improved workflows. We've increased the number of consultation rooms that our clinicians operate from. We've provided more dedicated clinical spaces, such as dental suites.
Where appropriate, we've installed state-of-the-art equipment, including CT and MRI machines. All of this facilitates the delivery of the best possible care for our patients. Critical to that purpose enables us to attract and retain the very best clinical talent, the majority of whom see the facilities in which they work as a crucial part of the employee value proposition.
The chart in the middle shows year-on-year EBITDA growth. The light blue bar is year-on-year growth within our small animal division. The dark blue bar is the year-on-year EBITDA growth of investments which were completed in 2021. You'll see for those investments, the growth was significantly higher than the small animal division. That growth represents a 12% return on capital employed. For every GBP 10 million we invest, we expect EBITDA to improve by GBP 1.2 million. With over 200 sites to invest in, we believe there's opportunity for us to invest between GBP 30 million-GBP 50 million per annum to deliver additional EBITDA.
On the following slide, we've shared some more detail on our Springfield practice in Rotherham, which those of you who are here will be visiting today. We acquired this practice in 2006, and since then have continually invested in and developed the practice under the leadership of Senior Clinical Director William Taylor. Most recently, we've undertaken an extension to install a CT scanner and dedicated dental suite, adding significant capability to the practice. Collectively, the investments we've made since acquisition have expanded the range of services we can offer, have enabled improved clinical care, and have delivered strong growth, outperforming the rest of the group in this period. At the very highest end of our investment spectrum, we're currently investing in a further two state-of-the-art multidisciplinary referral hospitals.
As previously announced, Bristol Vet Specialists, in which we're investing circa GBP 12 million, will open in the 1st quarter of 2023. The following year, we'll see the relocation of our Dovecote Veterinary Hospital into a similarly state-of-the-art facility. We'd now like to share a short video to show progress to date of our Bristol Vet Specialists.
Hello, and welcome to Bristol Vet Specialists, the new flagship state-of-the-art veterinary hospital for CVS. Here in this new space that we've got, we intend to provide every discipline available for dogs and cats, including all of the ones that we offer already, plus all of those that we're missing.
Most exciting of all, we also will be complementing our oncology service with its own radiotherapy department.
That's absolutely right, and we will be providing the 1st-ever stereotactic linear accelerator for pets in the South West, meaning that we can provide the best level of care to our cancer patients. This service is going to support all of our departments, making sure that we are providing state-of-the-art care for every patient who walks in through this door.
Now that we've got this wonderful space, we will be in need of developing a much larger team, including specialists, nurses, care assistants, et cetera. Watch that space. There will be some offers to come and join this wonderful adventure of ours.
Our whole team here are committed to ensuring that our values and our ethos are really built within the structure of this hospital in the way that it works and functions to ensure that we provide the best care, not only for our pets, but also for the world around us.
Well, that's clearly super exciting. We also have an opportunity to invest in greenfield sites, to make the most of our operational know-how and our integrated model. There are no restrictions to where we can open a greenfield site. We can open one up anywhere in the U.K. and indeed across any of our territories. I've included on here a case study for Bracknell, which is a small animal 1st opinion site that was opened in 2017. The investment for a greenfield site is on average about GBP 1 million, which is less than for a typical acquisition. Unlike an acquisition which is EBITDA positive from day one, it takes a period of time for a greenfield site to reach break even. You can see that in the chart in the bottom left.
In year one although Bracknell reached breakeven by month 12, it was still overall loss-making in year one. There was then a small positive EBITDA contribution in yearn and then maturity reached by year five, where it was delivering a healthy 18% return on capital employed. We intend to open three greenfield sites in the next 12 months, and subject to performance, there's potential for us to open many more.
Aligned to both our relocation and greenfield strategies, we've started to consider strategic partnerships for new locations, and as shared in September, have commenced an exciting partnership with Dobbies Garden Centres. Our 1st relocation opened in Chesterfield, Dobbies, in August, which is the 2nd site you'll be visiting today. The partnership is a good example of where we can benefit from co-location with a business with similar demographics to our own, as well as having access to a national land bank of suitable locations. These practices are full-service, standalone veterinary practices with separate entrances, but positioned on a Dobbies site to take advantage of their great parking and great visibility. We plan to open a further four practices in Dobbies sites over the next 12 months, and thereafter expand our relationship to many more of their 70 or so sites.
The investment opportunity continues through our investment in technology, and we shared in September the exciting news of a new partnership with Nordhealth, the leading provider of cloud-based veterinary practice management software, with whom we will launch their new Provet Cloud management system into CVS practices over the next 18 months. This is a dramatic step forward for CVS in technology and opens up a wide range of opportunities. Some of those opportunities are immediate, like online booking, better data collection, automation of billing, and a better experience for our colleagues. Additionally, their OpenAPI gives us a broad range of opportunities where we can integrate other areas of our business, or indeed business areas that don't currently exist, such as food sales, into the experience our clients have with us.
In summary, our ambition is to deliver between 4% and 8% organic revenue growth per year, with an opportunity to augment that with further investment of between GBP 30 million and GBP 50 million of CapEx each year.
We also continue to have a clear runway for acquisitions in the U.K.. Every practice in the U.K. needs to be registered with the Royal College of Veterinary Surgeons, and if you have a look at the RCVS website, you will see that there are over 5,300 practices. Of those, 55% are currently under corporate ownership. We don't expect that to ever reach 100%, but based on our experience of other sectors, we do believe that could reach 80%. We are not in control of when those practices come to market, but we anticipate over 1,300 practices coming to market in the coming years.
The recent CMA ruling, we believe, was helpful for us in that it gives us a clear understanding of how the CMA will look at local market competition, in that it will look at the target practice and surrounding practices. It will determine an area around the target practice based on the 80th percentile of customer post codes, and it will look to ensure that the share of practices or share of vet FTE does not exceed 30% within that area. Now, if you look at the map on the right, you will see there's lots of white space across the U.K. and areas where we have limited presence. Indeed, we can acquire practice right next door to one we already own, so long as we do not exceed the 30% threshold share of practices or share of FTE.
We believe we are well-placed to win our fair share of those acquisitions, which could considerably improve EBITDA. For example, if we acquired 100 practices, that would be an investment of roughly GBP 375 million. Based on a multiple of 10x, that would add GBP 37.5 million to the bottom line. We also have a strong track record of delivering value and growth within our acquisitions. On this slide, we've included a case study of Newnham Court, which is a small animal 1st opinion practice in a garden center location in Kent, which was acquired in full year 2020. We've also included in the bottom left the EBITDA of that practice in the 12 months preceding acquisition and the EBITDA that we delivered in the following three years.
You can see we've delivered significant growth, and that's from our ability to focus on top-line revenue, from the focus on providing great clinical care, and on attracting and retaining talent. It's also in our ability to apply our economies of scale and buying power to improve gross margins, typically up to 5 percentage points, and it's also from our integrated model where we could drive additional synergies through our crematoria, our laboratories, our referral network, and our out-of-hours network. We typically work to a 10x multiple year one post initial synergies, but critically, we look at ensuring that those investments deliver an IRR of greater than 10%, which is above our weighted average cost of capital.
Under the previous management team, CVS expanded into the Netherlands, and we've since grown to have 27 practices there. Although there was a slow start, we believe there continues to be an opportunity for further strategic bolt-on acquisitions, particularly in key major cities where we are currently not present building our scale. However, the Dutch market is relatively small and already approximately 40% consolidated, and therefore, we are looking to new territories to unlock further medium-term growth. We've learned a number of lessons from our expansion into the Netherlands. Further international expansion would be supported by a strong local management team, and entry would be via a high-quality acquisition with a very clearly identified opportunity to grow the size of the group thereafter.
On this slide, we've included some data on potential international expansion opportunities which could provide exciting growth for CVS. Spain, although a smaller market, is unique to most European countries in that annually it qualifies a surplus of vets. There are a couple of small platforms forming, and we see good collaboration between U.K. and Spanish vets as a key opportunity there. France, where we see good collaboration between U.K. vets as well, is also attractive. It does have regulatory challenges where a practice has to be majority-owned by a local vet, although there are examples of corporate ownership still happening through shareholder agreements and preference shares. Multiples in France are higher for key practices, albeit we believe these will come down over time for additional bolt-on opportunities. Of these three European countries, Germany is by far the largest market, but is perhaps the least attractive.
Germany has some very large referral hospitals, but is supported by a highly fragmented market of small one or two vet practices. Our experience tells us that we see more opportunity with larger practices of four or more vets, which can support career development, investment in clinical equipment, and the delivery of the highest possible quality of clinical care. There are also other English-speaking countries such as Australia and New Zealand, which have similar regulation to the U.K. and strong collaboration with U.K. vets and are in their early stages of consolidation. We have a dedicated acquisitions team assessing these opportunities to make sure that we make the right next step.
We have an ambition to double EBITDA over the next five y ears. We believe we can grow organically by between 4%-8% per annum. We believe we can augment that organic growth with additional EBITDA from investment in our practice facilities, greenfield sites with an investment of between GBP 30 million-GBP 50 million per annum. We believe the balance can be delivered through acquisitions either in the U.K. or in other territories. We'll continue to apply financial rigor and discipline to those investment opportunities, ensuring that our IRR is greater than 10%, which is above our weighted average cost of capital.
We are also highly cash generative, and we continue to be, and our expectation is that those investments, depending on timing, will be funded partly, or if not fully, by cash that we generate internally and by debt that we currently have available to us, maintaining a leverage of below 2 x.
Just to conclude, our key takeaways from this morning are that our ambition is to deliver organic revenue growth between 4% and 8% per year. Adjusted EBITDA margins across the group between 19% and 23%. We intend to make investments in practice facilities, equipment and technology to support this organic growth and margin enhancement. We'll make acquisitions subject to our disciplined approach in a minimum 10% internal rate of return. We expect to deliver operating cash conversion of 70% or higher, and we anticipate leverage remaining below 2x. Our ambition is clear, to double EBITDA over the next five years. That marks the end of the 1st section of our presentation. I'd now like to invite Richard back to the stage for the 1st section of our Q&A.
Can we start with questions in the room, please? Charles. Could we have one question at a time, please? If you've got further questions, we'll come back to you.
That's very cruel, Richard. Could I just ask about the step-up in the investment plans? Is this because you're getting more confident, you've got more experience of investments in some of your existing businesses? Would this have happened sooner if it hadn't been for all the disruption of COVID?
I think it would have happened sooner if it wasn't for COVID. We are very confident with the returns we can get from this investment. We've also seen our balance sheet strengthen clearly in the last three years, and we are really well-placed to invest in that growth. We've got committed undrawn bank facilities. We've got cash on balance sheet, and we have very low leverage. We are ambitious. We are keen to invest. It might be worth Ben just talking through the improvements we've made to our property team because that's also, I guess, a key part factor in our plans.
Yeah. I think it talks to the question, Charles, around timing 'cause there's certainly a lead time to some of this. Some of that's involved in us been scaling up our property team and also the strategic partners that we work with to deliver on the design build, finding locations for us. There is certainly a lead time which, you know, post-COVID leads us to be able to say this now. We now have a really strong property team, really strong partners, and are well-placed to deliver that investment.
If I'm allowed to follow up, do you think differently about the payoff now between organic investment and M&A, or is it more a matter of the level of balance sheet capability you've got?
I think it's a combination of things. We as a new management team that formed three years ago wanted to focus on organic growth and I guess improve some of the underlying factors within the business. We've outlined a strategy three years ago that we've shared today again, and we believe is relevant as now, you know, as it was then. Under that strategy, we've really focused on people, on clinical care, and we've seen good organic growth from that. We are well-positioned and very confident to achieve additional growth from further investment. We're fortunate to have so many opportunities to invest. I think, Robin, the discipline around financial returns and you know, the IRR of 10% minimum will remain, and that's important clearly.
We are very confident with the growth in the sector and the opportunity to expand. Okay, thanks, Charles. Kane. Cheers. Nice and handy.
Good morning. Kane Slutzkin from Numis. If I just take you to slide 10, you've got the sort of distribution of margins. I'm just wondering, is there anything that less than 10% that sort of won't make it up the chart, and effectively you would look to maybe clean up at some point? You know, how many of your practices do you think could be in that bucket where maybe they don't make it? You know, if you were looking at a way to sort of improve the overall margins.
Yeah, I don't think there'll be many that won't make it. I think we outlined in the presentation that there are two elements to improving that margin. One is from the kind of organic growth opportunities and focusing on clinical care, using our hub clinical leads to help with those practices to improve their diagnosis and providing care within the consult room. Some of that will be delivered through our ability to attract and retain talent. And you're right to outline some will need investment that we've kind of outlined around capital investment to either improve the facility. If we're not able to improve the facility in its current location, then to relocate that practice into a purpose-built facility.
Just following up for you, Ben, about the focus over the last few years around branch practices as well.
Yeah, I was just gonna say that. You'll have seen that actually over the last few years, we have closed a number. We haven't generally just closed them in isolation. Relocations represent an opportunity to move some of the very smallest branches into more significant locations. Historically, consulting only branches, as we would call them, were a major part of the veterinary profession, where you would have a branch that really had only a very narrow level of service. We've moved away from that in CVS because clinical talent generally wants to work with other clinical talent in a more full service environment. We've closed a number of practices and consolidated them over the last few years, and there may be further opportunities to do that as we relocate. But I'd say we probably closed the major chunk that we've done.
Andrew.
Hi, sir.
Hello, it's Andrew Whitney from Investec. Just gonna follow up on Kane's point on margins. You've got the 70 greenfield sites with Dobbies, you've got acquisitions, you've talked about the pet food bit. Each of those things feel like at least initially, there might be a bit of margin pressure as those things roll out. Is there a risk on the downside to that 19%, like, as we go on this journey, and then you get to the upside later on? Or do you think your worst case is you sort of maintain the current margin and the mix in business actually drives the organic margin up, offsetting any dilution that you get?
Yeah. I think the investment opportunities are across a number of areas. Actually on the Dobbies site, initially they are relocations of existing practices, so they shouldn't be margin dilutive. You know, those relocations are improving margins as we relocate existing practices to better facilities. As Ben touched on, though, we have access to all Dobbies garden center sites across the U.K., and that may include some greenfield site startups in Dobbies locations in due course. Clearly they will be margin dilutive in themselves to begin with. We have plenty of opportunity to invest in growth. I guess key to margin enhancement and the graphs that Ben and Robin shared, there's a correlation clearly between the quality of the facility and the performance of that practice.
Key to that, I guess, is to provide great care, you need vets and nurses, and it's far easier to recruit and retain vets and nurses in better quality facilities. Clearly, to unlock the full potential, you need great equipment as well. That's why there's no kind of secret of our investment in facilities is key to that kind of organic growth and the margin enhancement.
That's clear. Thank you.
Some questions behind you, Jeffrey. Sorry, come up.
Hi, it's Michael from Half Sky Capital. Can you comment a little bit on just the availability of vets today, especially versus sort of when they were added to the shortage lists in late 2019? What has happened to wages? What are you seeing right now in the market?
The market for vets in the U.K. has been challenging for quite a long time. That hasn't very materially changed actually over the last few years. What we've been able to do is outperform the market, take more market share, despite the fact that the U.K. market's been relatively flat. There have been a number of challenges over the last few years. Brexit was one of them. Actually probably more impactful was coronavirus travel restrictions, 'cause we traditionally recruit a number of veterinary surgeons from Europe who are used to traveling regularly home. That became difficult.
The vet going back onto the shortage occupation list is very helpful, and we used to have, prior to 2011, when the vet was taken off that list, a lot of Australian and New Zealand and South African vets working in the U.K., and we certainly had a period of time where that just disappeared. We haven't really benefited yet from that change because post 2019, we were straight into COVID and travel restrictions, and clearly some of those countries were the most affected. So that is helpful for us, but it hasn't yet been a benefit. Perhaps the other two things I would say are a much bigger benefit to us going forward from the labor market perspective are the number of vet students qualifying in the U.K. is set to dramatically increase.
Today, we qualify just over 1,000 vet students in the U.K. each year. Over the next eight years, that will double. That's a combination of new vet schools opening, of which there are three already, and also vet schools increasing their numbers, including, for example, Nottingham taking a double intake as of three ears ago. Clearly, there's a fairly long time for those graduates to cook and turn into qualified vets, five or six years. Over the next eight ye ars, the number actually coming out of vet school will double, and that will be very material in terms of the supply into the U.K.. The other change on the horizon is the fact that the Royal College have consulted on legislative reforms of the Veterinary Surgeons Act, and that will enable nurses to do much more in the veterinary clinic.
Actually, the list of things that nurses can do in a vet clinic is very restricted and restricted by the 1966 Veterinary Surgeons Act, of which reform has been recommended. What we don't know is how long that will take to actually go through parliament and become real. We clearly respect the fact there is a significant queue for legislative change post Brexit, so we don't know when it'll happen, but when it does, that will be certainly significantly meaningful. In terms of your question around wage inflation, we haven't seen very significant wage inflation amongst our clinical staff. We've always sought to try and pay above average 'cause that's what we're about. We're about the highest quality. Come to us if you want quality, not if you want low-cost care.
Actually we find some of the most meaningful things we've been able to do for our vets and nurses and our other colleagues is to create the work environment that people are looking for, and facilities and equipment are really high on that list, as well as a work-life balance. We've invested a lot in making sure our colleagues have the flexibility to take significantly more time away from work if they want. We've increased the standard amount of holiday. We allow people to buy and sell holiday. A range of other initiatives to make sure that when you come and work for CVS, it's a clinically focused culture. You're gonna work in good facilities, and the package we offer you is broader than just salary and award, because actually that's one of a range of things that are important to people.
Thank you. Question at the back.
Hi, it's Robert Chantry from Berenberg. Thanks for the presentation. Just interested in your thoughts around the international opportunity, 'cause I think interesting to hear your lessons learned from the Netherlands expansion. Largely it was too fragmented, too small. The local management wasn't there. It was just too hard to get the scale. So when you look at the fragmentation level in Spain, France and Germany, they're very fragmented markets. Does the opportunity exist to go and buy a decent bigger asset, which is a multi-site operator? Culturally, do you think these can turn into professional CVS organizations, or do you think there's a kind of hard yards to go in terms of the 1st round of consolidation to get there 1st?
That's partly why I guess our focus has probably evolved because when we 1st started looking at European expansion, Germany was the obvious market because as Ben said, it's by far the biggest and it had the largest number of practices and average spend per pet was probably closest to the U.K.. Germany certainly doesn't offer us that opportunity at the moment because it is so fragmented and there aren't any kind of practice groups of scale that we can acquire. That's why increasingly we've looked at other markets, including Spain and France and other English-speaking markets because there are certainly assets of reasonable scale with strong management teams that we are aware of and potentially do give us the opportunity to have that kind of strong platform from which to grow.
We haven't rushed into an international expansion yet because we want to focus on buying the right asset with the right management team and be very confident of that growth opportunity to come. This is not a vanity project, but we do see opportunities for good growth.
Thank you. Just a follow-up question on the kinda greenfield expansion, and you outlined the economics very clearly. You said three th is year and then kind of left it vague on how many more. Is this something. Well, firstly is this something other competitors are doing? Secondly do you believe that will displace other practices and hence reduce the total number of market assets in the market?
As you say, we're gonna do three over the next 12 months and closely monitor them. We've done seven i n the past, but the 7 we've done have been a real broad range of everything from referral hospitals to branch sites to brand-new sites that have out of hours to those that don't have out of hours. I think what we've established is the type of practice that we want to roll out, and we're gonna do 3 just like that this year. We certainly could do more. Clearly, there is an EBITDA strain in year one. The major limiting factor with greenfields is actually finding the right location. 'Cause if you think of our wish list, we're sort of 2,500-3,500 sq ft, ideally on a single level, loads of parking and great visibility.
That's not that easy to just come across. The rate-limiting step is often finding the locations. We certainly could do more. Clearly, slightly talking to Andrew's question around margin dilution, we will be cautious in how many we do 'cause we don't wanna do a great big bucket of them that are all EBITDA negative in year one. Oh, and sorry, there was a part about competitors. The majority of our competitors are private equity owned, and they're not doing greenfield sites, and I don't think it's probably in their plan to do so. Vets4Pets clearly have grown largely through doing greenfield sites, although a very different model. They're operating small clinics largely in the back of their retail sheds.
A very different model to what we're looking at, which is full service veterinary clinics in standalone units.
All right. Stephen English, Stifel. In terms of peers, does rising cost of interest rates, for the more levered, and also the CMA mean that your peers have already run out of white space? I'm wondering if there's gonna be a spillover from lower multiples or is it less about the multiples and more about extra availability of vet practices to acquire now?
Yeah, it's a good question 'cause we're aware that our private equity-owned competitors, and particularly people like IVC Evidensia and VetPartners, they've been the two most aggressive acquirers of practices over the last five to 10 years. We know they are highly levered, sort of 7 or 8x levered, we believe. Now, clearly they will have a big proportion of their debt protected through swaps and interest rate protection. Ultimately, those will run out and hence they will, you know, inevitably face higher cost of capital. Whether that really reduces competition in the sector, it might well do, and we are starting to see some signs of them being less active in the U.K., given their existing scale. There are others that will replace them, we expect.
We're not expecting multiples to come down, but we are confident with the returns we can get. Robin talked through some of those returns from our ability to drive revenue growth and also generate synergies post-acquisition. The Newnham Court example is a great example of us doing just that. Any more questions from the floor? Are there any from the live stream yet? Okay. There's a further opportunity. Question here.
Thank you. Hi.
Yeah.
Hi. Carmen Onali. RBC. Just to follow up on the acquisitions. For Europe, you said that there is moderate multiples and high. Can you give us an indication what that means? And also, in terms of synergies, my understanding is that when you do European acquisitions, there are no synergies. Is there any potential opportunity that you could see synergies across the different countries?
Maybe I'll start with the synergies question. You're right that we don't access the same synergies as in the U.K., but there are opportunities to access some of those synergies straightaway, principally around procurement. Our Group Procurement Director, who's here today, has worked very hard on the drug companies who prefer to offer operating country silos and not recognize our global spend and has made lots of progress there for us when it comes to our Dutch and Irish operations. But clearly, we don't get the same synergies there as we do in the U.K., but there is some. Broadly, the other synergies we have are businesses that we own, so laboratories, crematoria, and we see no reason why in due course those countries couldn't equally accommodate those kinds of businesses.
It's not likely to be the 1st step, clearly, but getting to a scale where we can operate those businesses would certainly be part of the ideal plan. Don't know whether you want to comment on the multiples, Robin.
I think, anecdotally, I mean, it's anecdotal, some of those multiples are higher in those European markets9, particularly in France. I think for a platform, even if we do face slightly higher multiples, the expectation is that multiples will come down with a strong pipeline of future acquisitions at lower multiples. Actually, the blended multiple and the returns that we get would be in line with our kind of minimum hurdle rates.
Great. Well, there's a further opportunity to ask questions at the end of this session, so thank you for your questions so far. We'll now hand over to Lizzie McLennan-Green. Lizzie is one of our small animal veterinary directors and covers the north of the U.K., and she will talk through our focus on providing high-quality clinical care in our 1st opinion practices and also outline her career progression within CVS. Lizzie.
Thank you, Richard. As always, it's been mentioned, my name is Lizzie McLennan-Green, and today I am going to explain how best clinical care and careers support organic growth within CVS. My entire career has been spent with CVS, so I thought I would start a little bit about telling you about me. My journey to be a vet began like most, at a fairly young age. I don't come from a farming or veterinary background, but I was always surrounded by animals, and by the age of 10, I was fairly resolute. In 2002, I went to vet school in Edinburgh and spent the next five years in and out of this fabulous building, having the time of my life. I graduated in 2007 and was so excited to join our wonderful profession.
The truth was that after five years of vet school, I honestly hadn't given very much thought to my future. I guess I'd assumed that my 1st job would be as a mixed vet, but after coming across a really well-written job ad, I jumped into small animal with both feet. I joined the team at Springfield Veterinary Group in 2007, and by doing so, became part of Team CVS. The main hospital site that you can see here in the picture is one of the sites that you're going to visit today, and it's actually been a veterinary practice since 1964, and it was one of the 1st recognized veterinary hospitals in the U.K.. It has changed a little bit in that time, though you'll be pleased to hear. My role during that 1st year was to provide holiday cover.
It's not something that we would necessarily encourage today, but it was a fantastic opportunity for me to see how lots of other vets did their job and gave me a real sense of the kind of vet that I wanted to be. I loved it so much that in 2008, I became a permanent member of the hospital team. I could see that there was real opportunity to improve the quality of service to our patients and our clients, and by introducing consistency in the provision and communication of care. I was supported to take on the new role of in-patient vet, allowing me to take ownership of what at the time was a relatively small but important service. Ownership led to growth and an increasingly busy hospital.
While around me, the rest of the team were working hard on bringing other great services such as endoscopy, laparoscopy, dental radiography that you can see here, and advanced orthopedics. I myself became an advanced practitioner and introduced a visiting CT service. A new role as head vet gave me the opportunity to develop my people and clinical leadership skills. I was really proud to be able to lead the team toward all six RCVS Awards Outstanding, making us only the 2nd site in the U.K. to ever do so. As they say, all great things must come to an end. My husband was offered a unique opportunity, and in 2018 we moved to Glasgow. Thanks to the positive and approachable nature of local and regional leadership, leaving the business was never really in question.
I was supported fully in my decision and was given the opportunity to take on a senior clinical director role. I combined this with the newly created hub clinical lead role in 2019, and this allowed me to focus on my passion for promoting great care in the 1st opinion setting and helping colleagues find the fun and excitement in veterinary practice. In October 2020, I gave birth to our now 2-year-old daughter, and being able to step away from work and focus on that 1st year of her life was not only encouraged, but supported by our industry-1st enhanced paternity benefit. Feeling comfortable to take this career break allowed me the time to settle into motherhood, standing me in great stead for returning to work full-time and balancing my work and home life commitments.
I became the Small Animal Veterinary Director early this year, and along with colleague Mark, who is also here today, now lead the Hub Clinical Lead team, who are a group of 15 highly experienced veterinary surgeons who work regionally to drive clinical growth across our small animal practices. It's a varied and exciting role, but the love of practice remains, and I continue to work as a clinical vet one day a week alongside my vet director role. Working for CVS has offered me the opportunity to challenge my expectations, reconsider what is possible, and reach goals I would never necessarily have thought attainable. Getting off to a great start is so important. The 1st job has the possibility to set the direction for the rest of your career.
Our industry-leading and well-established new graduate program, nurse training practices, and apprenticeship scheme has just been joined by an accelerated emergency and critical care program. Developing, nurturing, and retaining our own talent supports organic growth by fulfilling our commitment to delivering the best veterinary care. The pathway to progression is clear. Regular check-in conversations provide constructive, positive feedback and support all colleagues to explore their career development aspirations. The broad variety of businesses uniquely found in the CVS portfolio means that as well as 1st opinion and specialist clinical work, colleagues can consider careers in pathology and labs, research, procurement, marketing, product development, and clinical and business leadership, to name but a few. Well-being is so important. Having a happy and healthy team is key to being able to provide great care to our patients.
Supporting this are our dedicated out-of-hours services, flexible working opportunities, and our culture of psychological safety. Long-term retention of vets and nurses is one of the major challenges facing veterinary employers today. This is not simply highly skilled clinical staff going to work elsewhere, but permanent loss from the profession. Being able to provide flexible working alongside support for family life through part-time and job share positions, as well as a diverse range of career opportunities, all while being able to work for the same great company, is what I believe sets CVS apart as a great employer. The commitment to team wellbeing and constant focus on our people as our biggest asset is setting the standard for the wider veterinary profession. Patient Care Index is a KPI that measures the high quality of the care that we give to our small animal patients.
It matters because it correlates directly to the volume of investigation and targeted treatment undertaken. Quite simply, the more we understand about the disease process, the better we can manage the problem and improve the outcome for the patient. Patient Care Index also correlates well with average transaction value and ultimately drives practice commercial performance. Our practices' PCI is currently distributed around a high benchmark of clinical care, and this gives us opportunities to further enhance that care across our estate. In addition to the recent growth in domestic pet population and ongoing humanization of pets, we have an increasing aged pet population with committed owners who want to provide the best possible care to their animals.
PCI improvement is the focus of our team of hub clinical leads, who share their experience and knowledge with our clinical teams to further enhance care quality by supporting a recommendation culture and driving continuous clinical quality improvement. In the following case study, I want to share with you an example of what focus on PCI improvement can look like from a performance point of view. This is a single site example, but this progression has been replicated many times across the estate. Champion Vets is a three-site practice who joined CVS in 2017. Hub clinical lead involvement with the practice began in January 2019 and focused on promoting a best practice approach to each case by creating a practice recommendation culture, supporting progression of clinical staff to maximize clinical equipment, including ultrasound and radiography, and introducing new services such as laparoscopy.
During this time of focusing on best practice and higher quality service provision, revenue has grown by 50%, while in the same time period, PCI revenue has increased by 96%, and this has supported EBITDA to exceed 32% in this practice. The good news, however, is that our work here is not done, and we still have some way to go. PCI opportunity for this practice sits closer to 44%, but constrained by current facilities, this practice sometimes struggles with meeting client demand. The Ibrox site is due to relocate in mid-2023, and the other two sites are scheduled for remedial property work that will allow increased service capacity. I would like now to introduce my colleague, Helen Baxter, Referrals Director, who's going to talk to you a little bit more about advanced clinical care.
Thank you very much, Lizzie. I joined CVS nearly seven years ago after getting my fix of James Herriot-style mixed practice. It was the offering of a surgical position at CVS's biggest 1st-opinion hospital that enticed me to the company. I was mentored through a postgraduate certificate and expanded my clinical interest in advanced soft tissue surgery. I was further supported to develop my leadership skills, becoming a senior clinical director. I took a bold move with the largest 1st-opinion hospital, and supported by my team of practice leaders and the senior leaders of the business, we moved all of that routine 1st-opinion work out to a redeveloped branch site. What this allowed us to do was allow our clinicians to focus fully on their interests and offer discipline-specific referrals alongside a 24-hour emergency critical care center.
As I'm sure you can appreciate, there were a few eyebrows raised at this, but they did come down, achieving an adjusted EBITDA margin of 26.8%, which came up from 18% in just 12 months. Our attrition decreased. We grew from 16 to 36 vets within 18 months, and our Net Promoter Score or client satisfaction score increased as we were able to offer a higher quality of care and an increased service offering to all of our clients. Our employee Net Promoter Score increased, and that's not surprising because the majority of vets just want to continue to learn. We are tasked by our governing body every year to do a set amount of learning or continued professional development which needs to be recorded, and ultimately, all vets just want the best treatment for any animal that's under their care.
They want to be able to fix that broken leg, not just offer amputation. As my clinicians in that hospital setting gained in confidence, skills, and knowledge through exposure to more complex cases and increased utilization of their skills on a daily basis, that all important PCI metric that Lizzie spoke about went from 42% to 60% and continues to grow to this day in that specific hospital. Next slide, please. This graph over on the left there shows the additional revenue when our advanced practitioners were given the opportunity to utilize their skills 100% of the time, an increase of 60%. The graph on the right shows the difference in PCI with our main groups of clinicians which sit within our 1st opinion business.
Our general practitioners to those who undertake and are supported by CVS to undertake a postgraduate certificate and to those that go on to achieve advanced practitioner status, a recognized status in a specific discipline by our Royal College of Veterinary Surgeons. Lizzie is a great example of somebody who's achieved an AP status in medicine. The group at the far right-hand side of that graph, our ACSN network or Advanced Clinical Service Network, are a great example of people who are able to utilize those advanced clinical skills all of the time. They are a group of roving or peripatetic clinicians who go into all of our 1st opinion practices, offering the opportunity to upskill and use their advanced skills all of the time.
In January of this year, we redefined that vision and set it to offer unique clinical career pathway for our vets and our nurses, continuing to be advocates of excellent patient care while contributing to the development of our 1st-opinion, our lab, and our specialist divisions. How did we act on that? Well, we've doubled the size of the peripatetic team to date. We recruited our 1st nurse into this role in recognition of our commitment to continued nurse career development and to make sure that we are perfectly placed when that legislation changes with nurses that are willing and ready to commit to those advanced skills that they will be allowed to do. We also offered true hybrid flexibility.
For our general practitioners who have a loyal client base that want to keep that client bond but have undertaken the next steps of their career and have those advanced skills, the flexibility of a hybrid role offers them the chance to utilize those skills and keep them fulfilled throughout their career. What does this mean for our local practices? Well, we've got advanced practitioners in many of our 1st-opinion sites, so we invited all 330 of them to be part of a brand new Advanced Clinical Service Network.
The aim of this was to influence, inspire, and empower them to improve the utilizations of their skills through peer-to-peer supported discipline clinical meetings to share ideas, clinical knowledge, and confidence in building their own certificate-led services across the group. Accelerating that process of increasing the quality of care that we give, career progression, and ultimately, that measure of PCI. We know that from more exposure to advanced clinicians in general practice and increasing our clinicians' knowledge and the goals that our vets and nurses want to achieve, we see increased referral at every stage of the cycle on the left. We know that with our further plans for expansion for the ACSN and also our specialist referral division, we will offer a comprehensive referral offering to meet the needs of all of our clients.
It's a skill in itself to know when to refer that case that's in front of you, and very important that you know who and where is best to refer to. Not only do we allow our clients and patients access to our skilled clinicians, but we also allow our general practitioner colleagues and younger vets the opportunity to follow their cases, to allow those advanced practitioners to come in as a surgeon to scrub in alongside somebody who is more experienced, or the opportunity is encouraged to go and visit our specialist referral hospitals to see those that are at the very top of their profession and to be inspired to follow in their footsteps. We have focused referrals to our specialists, giving them time to devote to research and the development of state-of-the-art treatment within our specialist facilities.
Let's not forget that it is these specialists that define what good quality and best quality patient care is. It doesn't stop there. Our Vet Oracle team of specialists continues to expand. This unique service provides fast, high-quality care with interpretations of CT, MRI, radiography, and ultrasound images. With a global reach and a particular focus on teleneuro imaging, the expert skill of this team is vastly sought after. With a great demand and opportunity for continued expansion as leaders in the teleneuro imaging world, we reach all but one continent across the globe. Our in-house team have also branched into teleoncology, teleradiology, telecardiology, and teledermatology, allowing all CVS practices to have, at the click of a button, specialist input to their cases.
They offer a quick turnaround, meaning that answers and advice can be sought in an appropriate timeframe with a client stood in front of you and a personal service. They offer the opportunity to improve the advice on image quality that we obtain within our practices, contributing to that continued personal development that we spoke about earlier. It really is practical virtual assistance with a specialist virtually over your shoulder while you perform an endoscopy procedure, guiding you to those next steps of your advanced skills. It helps to increase our PCI as a direct result of the interactions between our general practitioners and our specialists and helps us to provide that best patient care. As our purpose is to give the best possible care, this can only be achieved by our clinical colleagues being kept up to date with the latest advancements in what can be done.
By adhering to our strategic pillars, there is so much more opportunity to continue the improved communication links between our own general practitioners, our advanced practitioners, and our specialists. I have no doubt that this will lead to continued excellence in care that we offer our patients, an ever-growing eNPS, and career development that is truly unique in our clinical setting. I thought I would show you a case that aims to highlight what I mean here. 1st of all, I'm going to ask you a question. Can anybody identify what the foreign body is in this abdomen that was eaten by a five-year-old Labrador who presented with vomiting and diarrhea? Any guesses? No? Well, it was a duck. I use this example. The patient did extremely well.
In fact, after 30 minutes of this radiograph being taken, the duck, shall we say, passed naturally, and the patient left the hospital feeling significantly better. When you are a clinician and there are day-to-day challenges of things that you are likely to have never seen before, to know that you have the ability to send that image to our Vet Oracle team, to ask a local member of our Advanced Clinical Service Network, or indeed to fully refer that patient to a specialist for the best quality of patient care, that's really important to the well-being of that clinician, to know that that support is out there for them at every step of the way, no matter what comes through their door. With our specialist referral division, we also continue to grow our centers.
We continue to invest heavily in our specialist sites, where advances in veterinary medicine continue day in and day out. Our CVS specialists are truly at the clutting edge of the industry, working in not just the clinical capacity but research capacities as well. There are huge opportunities for us to develop our residency and internship routes, and we have room to expand the training of specialists for the future to help not just with our own succession planning, but to complete our internalized referral offering. Our new Bristol Vet Specialists hospital will have the 1st stereotactic linear accelerator in the southwest, delivering state-of-the-art radiotherapy to our patients. Our 2nd hospital will also be equipped with this stunning new technology, providing the best possible quality of care to our cancer patients and improving the quality of life of pets at perhaps end stage cancer conditions.
A huge educational opportunity exists within the industry for us to benefit from these advanced treatments and to pass on our knowledge, and CVS will continue to be at the forefront of that with exceptional facilities and exceptional diagnostics to support our caseload. With a continued focus on our purpose and vision, underpinned by our four strategic pillars and future growth through our general practitioners, our ACSN network, and our specialist division, we truly are offering a unique career pathway. We're offering a commitment to continued career development with flexible opportunities at every stage, whilst always aiming to improve the quality of the patient care that we give. Thank you very much. It's my great pleasure to welcome Dr. Martin Whiting, who is our Director of Education, who will talk to us a little more about how we're continuing to invest in our people.
Thank you very much.
Right.
Thank you very much, Helen. Now, I joined CVS as the Director of Education following a career in academia, clinical practice, and the civil service. Majority of my time was at the Royal Veterinary College in London, where I was appointed the world's 1st lecturer in veterinary ethics and law. During my time in academia, I've taught nearly 3,000 vets and nurses across the U.K., and I'm passionate about education and people development. I've supported the profession and CPD at the national and international level, and as a specialist vet, my discipline is in animal welfare, which is a fundamental tenet of the veterinary professions. This subject sits at the core of what we do at CVS, as our purpose is to provide the best possible care to animals.
This strategic purpose sets CVS apart in the veterinary sector as it aligns the core motivation of our vets and nurses, whose constant endeavor is to animal welfare. What attracted me to CVS was the combination of this purpose with our focus on the people. Our vision to be the veterinary company people most want to work for means we focus on our people's lifelong development, and we commit to their growth. The commitment to nurture staff's development and the focus on Patient Care Index drew me as an academic, and a passionate educator here to support those exceptional clinical teams. Our education team has had substantial investment over the last 4 years, and it's grown to 30 strong team of vets, nurses, and learning designers. This includes our own accredited nursing school.
We build our internal training through a unique learning portal called Knowledge Hub, and it's a mix of webinars, blended learning, and face-to-face training. We have a state-of-the-art flexible wet lab training space, and this allows us to run practical courses such as dentistry or surgery, upskilling our clinical teams in a safe and highly cost-effective environment. Our industry-leading webinar series and e-learning packages are delivered by the many specialists that come from all of our referral hospitals and cover all veterinary disciplines. Our teams are supported 24/7 through this bank of hundreds of resources, and they were substantially grown during lockdown. This means that no matter what shift pattern you work on, whether you're a night vet or an equine ambulatory service, our learning is available for you.
This highly in-internalized training means it's much greater cost efficiency, and it enables us to quality assure and meet the exacting high standards we have. Rather than costly outsourcing, we leverage this greater value to the learner as part of their benefits package and their CPD allowance. That allowance becomes greatly enhanced, and currently over 60% of our short courses are delivered internally. To meet our strategic focus on having the very best leaders, we've developed an accredited program for leadership and management, and this continues through all stages of the career up to a level seven qualification. It's alongside our coaching and mentoring program, which is also externally accredited to level seven. With a network of professional coaches whose services are available to our staff on demand.
Our front of house teams are supported through modular training at level 2 and now an industry-1st level four qualification in client care. Within a few months of launching, over 400 of our reception staff enrolled on that course, demonstrating we have career pathways for everybody who works for us. It also ensures that our clients receive the very best care from the best in the sector. Now, developing employees of the future starts at the undergraduate level, and we utilize our network of practices across the U.K. to support veterinary students to complete their work experience or their EMS at our practices. We're also deeply embedded within the universities themselves, and we deliver clinical and professional training through lectures and final year rotations.
Our newly launched EMS program is an industry 1st, and we deliver a progressive course through students' 3rd, 4th, and final years within university. This also embeds that CVS culture within them, that we will support them and can develop their confidence and competence throughout their clinical careers. Successful students are then guided onto our new graduate program, maintaining that positive pipeline of talent. CVS sponsors undergraduate training at all U.K. vet schools to maximize our exposure and collaboratively work with them to build industry-ready veterinarians from day one. Our staff sit on university boards, we hold joint academic positions, and we also attend graduation to award prizes to students who demonstrate outstanding commitment to client care and patient care. Our industry-leading new graduate program is now in its 10th year.
We maintain a small group teaching to build the graduates' confidence, but also to help build those important social support groups. This grows out of that EMS program to feed into the streams of professional curricula we have available. This allows vets to further train, certificate, or specialize in the disciplines of their interest. We were the very 1st to make available the entire online library for the British Small Animal Veterinary Association, and that was made available to all of our staff. We continue to innovate. In fact, our innovation is so novel, we've presented our work at the Veterinary Schools Council's academic conference this summer. Our graduate program is in such high regard, I'm very proud to announce we maintain above market share of veterinary graduates. The training program for our nurses is equally diverse, ranging from consultation skills to surgery and anesthesia.
Nurses have a specific channel dedicated to them on Knowledge Hub. We have a dedicated advanced nurse CPD coordinator who helps build those training programs, pushing our nurses forward throughout their career, and constantly improving the retention. Nurse utilization means that we train our nurses to do as much as the legislation permits. They now run their own clinics for patients with chronic conditions like diabetes or geriatric patients, or those who need a little help with their weight management. The knowledge base for managing these clinics doesn't exist in the undergraduate training of our nurses, and therefore, this is all what we deliver in the postgraduate world. Making use of our wet lab, training our nurses to develop their practical skills through diagnostic imaging, dentistry, and surgery has also shown to be a strong recruitment tool to CVS.
It also has an important economic benefit in liberating our veterinarians, ensuring that all members of the clinical team are doing the right roles for their task. What is unique about CVS is we have our own externally accredited nursing school, also in its tenth year, and it's ranked excellent and top 7 by the government's apprenticeship assessment. It's received other accreditations from Ofsted and the RCVS, and this rare status of excellence is evidenced by the majority of our learners receiving distinction. It offers a dedicated level 2 apprenticeship for our patient care assistants and advanced level 5 qualifications for our veterinary nurses. We're actively preparing courses for our nurses to take on new clinical responsibilities for as soon as that legislation changes, putting us ahead of the curve for staff development and staff utilization.
It's in all the disciplines such as imaging and laboratory medicine, specifically linked to that Patient Care Index. This summer, the school moved to a new location, increasing its student capacity eightfold. Finally, our apprenticeship scheme is of a scale unseen in the sector. This year, our apprenticeship manager was appointed as a national apprenticeship ambassador by the government. We have over 20 different apprenticeship types in our clinical and support office teams, and we developed a unique collaboration with the University of Nottingham to deliver a trailblazing apprenticeship, which upon completion, our veterinarians will become advanced practitioners. We're so effective in utilizing our levy, we've invested GBP 4.4 million into date and have over 1,000 apprentices start since 2017.
In fact, I'm proud to further announce that over 5% of our staff are concurrently in formal training programs, apprenticeships, or in the graduate scheme. We're particularly proud of those who sequentially develop their careers through multiple apprenticeships, showing that CVS really does support that career development and that drive for lifelong learning. Apprenticeship schemes are particularly important for school leavers. We've expanded our engagement into the schools and to the T Level programs, which is synergistic with our community outreach programs such as Mini CVS, which raise awareness of the veterinary professions and of animal care in the broader community. It also helps to increase recruitment into those paraclinical roles. For me, after 15 years in academia and clinical practice, I'm very proud to be part of CVS and its demonstrable commitment to staff development.
Through our VetShare group and through the online learning portal, I'm even more proud to take this learning out to the wider profession, demonstrating and showcasing the quality of what we have to offer. Our extensive partnerships with universities and our deep engagement with the veterinary students and that long-standing graduate program, I'm very confident in the future of our profession. Our own excellent nursing school and our investment into the apprenticeship program demonstrates that we are committed to be a great place to work and constantly developing ourselves to give that very best possible care to animals. Thank you very much. I'd like to hand over to our Director of Innovation, Graham Dodds, who's gonna talk about how we take our responsibility seriously through ESG.
Good afternoon, everyone. My name is Graham Dodds, and I'm Director of Innovation and Transformation here at CVS. I've been with the company around eight years, and I'm a veterinary surgeon by background. One of the responsibilities I have is to consider the future of veterinary sector and veterinary practice and what that might look like for our clients and for our colleagues alike. One theme that keeps coming up is sustainability, quite rightly, as an important aspect of our future. Today I'm gonna spend a few minutes talking to you about our ESG focus at CVS. I suppose one of the 1st things to point out is, although we've got a separate ESG strategy at CVS, we don't really consider it as a separate entity, as it all folds nicely into our overarching business strategy.
You've heard a lot today about our efforts to achieve our vision to be the veterinary company that people most want to work for, and also to achieve our purpose of giving the best possible care to animals. I think through my colleagues, you've heard some really exciting initiatives that we've got in flight right now to achieve that vision and that purpose. Whether it's driving well-being, whether it's driving education and training, as Martin just described there, ultimately trying to push clinical standards forward and improve welfare for our patients and also the welfare of our clients. Everything we're doing at CVS is inherently ESG positive. So much so that we actually decided to come up with and coin the phrase "Care At Our Heart" to describe all of our ESG efforts.
I'm pleased to say that this year we published our 1st annual ESG report in that title. What was our approach to sustainability and how did we build the strategy? Well, every good sustainability strategy must start with a materiality assessment. What I mean by that is how does our company impact the world around us and what we do? We wanted to make sure we made that assessment relevant. We looked at what the world is trying to achieve with sustainability 1st and foremost. We turned to the UN Sustainable Development Goals, of which there are 17, you may be aware. Now technically all 17 apply to every company. It's just a measure of how much of them apply to yours.
We spent a good deal of time assessing them and understanding which ones apply to us the most, and they're highlighted here in color. The next thing was then to internalize our thought process and look at the three main pillars within sustainability, which are the environment, social and governance, ESG. There's lots of ways we can improve in every single column, but we wanted to make sre we tackled the low-hanging fruit and have the biggest impact possible. Looking at the environment, we as a company have decided to focus our efforts on our energy consumption and our associated carbon footprint with that. The next stream is waste 'cause as you'd imagine, as a provider of clinical services, we generate quite a considerable amount of clinical and non-clinical waste in the work that we do.
We have the term One Health, which we use to describe lots of initiatives that are principally focused on animal healthcare, that have a knock-on effect to human and environmental health as well. A good example of that, if you're wondering, would be our efforts on antibiotic resistance. For the past couple of years, we've been trying to drive down the amount of antibiotics we prescribe because of the concern of antibiotic resistance out in the world for both our veterinary and our human patients. Moving to the social pillar, it's probably not a surprise to see some of the elements there, given what we've talked about today driving our vision, but well-being is really important to us. We want to create a happy, safe environment for our colleagues to work within.
People development, as Martin has described, we want people to have a career at CVS, join and stay and feel enriched, to learn more and drive standards in the right direction. We are a company that want to be inclusive and accepting of everybody. We've very much got an open door policy, so our EDI efforts are really important to us. Then finally, the communities within which we operate in, our clients and their environments within which they live. Now, you'll notice looking at environment and social, I've numbered those work streams, and that's because as we were looking at this assessment, these seemed like great areas to engage across the business. As such, we set up working groups to own and run each of these areas across CVS.
These working groups are chaired by a member of our senior leadership group or SLG as I'll refer to it going forward, because it's a bit of a mouthful. We've got some great work going on in each of these areas. The next thing to then consider was with each of these working groups, how are we gonna get them to progress and get things happening and moving? It was important for us to come up with it with a template for success, and that's what you see on the screen here. We came up with what we call the cycle of improvement, and it starts at the top right with target setting. Each group has to set targets within their area to try and achieve over the coming weeks, months and years.
We try and make sure those targets are smart, so specific, measurable, relevant. That's why we aligned them to the UN, SDGs. We tried to make sure that we had short and long-term goals as well, 'cause it's important, of course, to consider sustainability in the next 10, 15 years. There are changes we can make now, in the interim. An example, if we look at, our energy and carbon work stream, it would be great to have solar panels on every single roof tomorrow, but it's just not practically possible to do that. That doesn't stop us looking at how we procure energy in the meantime, and I'm pleased to say in the last year, we've done that. We've assessed where...
What energy we're purchasing and all of our electricity to 100% of our sites across all of our territories comes from renewable sources now. The next thing after target setting is to take action, of course. As I've mentioned already, the working groups are chaired by SLG members. It's endorsed by the board, and that gives them the remit to push the actions through and engage the business. After taking action, of course, we need to make sure that we measure the impact of those actions, and we try and do that in a quantitative way where possible. If there is a standardized report out there, I'm sticking with energy and carbon, we'll look at SECR, we will do that as well. SECR is our streamlined energy and carbon report. We've got to produce that annually.
We don't reinvent the wheel. We just use that as well with other measures to check progress with our energy and carbon work stream. The next point with measurements is that another key step we're taking this year is to link some of this improvement to executive remuneration. This is the 1st year we've done this, and I think you agree it demonstrates how seriously we take this responsibility. Finally, of course, is then reporting. I've mentioned already that we've published an annual ESG report for the 1st time, and I'll come back to that shortly. Beyond that, we also provide regular board updates, a monthly report to the board, and we also report to other stakeholders, both internally and externally throughout the year.
I thought I'd give you a bit of an example of some of the stuff that's going on in some of these work groups. We'll turn our attention to the waste stream, as I mentioned at the start. Our waste working group is chaired by SLG member, Rosie Naylor, who's not here today, but she's a veterinary surgeon. She's been with the company a while, and she's done fantastic work with a lot of people across the group. That group working group contains nurses in our practices, it contains people from our head office. There's a real amount of engagement.
Thinking back to that cycle of improvement that I mentioned and talking about the targets, one of several targets they've set themselves is to reduce clinical waste going for incineration by 5% over the next year. When we were looking at how we would do that, we know that our clinical waste gross tonnage is contaminated with non-clinical waste. In the real world, in a general practice, you would have a clinical waste bin, a general waste bin. Sometimes it's easy to put some things in the clinical waste because it's just there. Our efforts actually are looking at the holistic waste management, both clinical and non-clinical, and they've decided to take a reduced, reuse, recycle approach to manage this. One of the,
Looking at the top, by waste reduction, what I mean is not bringing materials into the business that'll ultimately become waste anyway. One of our most successful initiatives in this camp is a partnership actually with one of our main wholesalers, NVS. Our wholesaler deliver products, drugs, medicines, dog food, et cetera, to our practices on a regular basis, and they do so in these blue plastic boxes. I'm sure you've seen them before. Now, over the last couple of years, we've worked with them to use that infrastructure and capture excess packaging from stocking the shelves and putting things in the practice to send that material back to the wholesaler on their next collection and delivery.
Now, as a result of this, sending all that material back, they have been able to either reuse or recycle 90%+ of the material that we send back, which would have otherwise ended up in our waste streams. There's been a real, a positive turnaround with the amount of material produced there. Looking at reusability, that's the next opportunity. If you can't stop it from coming into the business, let's try and reuse what we can. We're the 1st veterinary company to be trialing a new bit of technology that will recycle sharps bins. Again, let's go back to that consult room. Waste goes in bins, but our sharps and needles and things go in sharps bins. You've probably seen them before. The traditional method for getting rid of those bins is to incinerate the whole thing with everything inside it.
As you can imagine, over lots of veterinary practices, that adds up to considerable gross tonnage. There's a trial on the go at the minute within our business where we take those bins, send them to a partner who empty them safely, sterilize them, wash them out, and send them back. If that turns out to be a successful trial, we'll consider rolling it out across the business to try and achieve that target that we mentioned at the start. Then finally, recycling. What can't be reused, what can't be reduced, you can always try to recycle. Over the last two years, we've put several different recycling initiatives across our business. Every single site now has the ability to have DMR recycling, which is Dry Mixed Recycling, your papers, your cans, et cetera.
If you take a moment today to look at the back of the hall, you'll see some interesting bits of kit up there. You'll see ophthalmoscopes and nasal scopes and things. All these use batteries. We use a lot of batteries across the estate, and we've also put out a battery recycling scheme to recycle batteries and minimize the harmful impact of throwing them out in the environment. Just one last slide, really. I've mentioned it several times throughout the presentation. We have produced our 1st annual ESG report this year, which contains lots of additional information and lots more of the initiatives that we're working on within an ESG under an ESG lens across CVS.
It's also worth noting that, when it comes to reporting, we've aligned ourselves to the SASB, Sustainability Accounting Standards Board. I knew I would trip over saying that this year. They have multiple frameworks for reporting and sustainability. They have medical, they have retail, but they don't have veterinary, so we've hybridized them, and you'll see how we've done that in that report. I'll also just take a moment to highlight another report that you can find on our website alongside that, which is our quality improvement report. We were the 1st veterinary company ever to produce this.
Linking back to the very start of my presentation when I mentioned antibiotic resistance and our efforts to reduce that, you can find a lot more information about that in there, along with a lot of other environmental, social, and governance initiatives that we've got under sustainability just now. I very briefly mentioned that executive remuneration this year is gonna be linked to our ESG efforts, and on the screen, you'll see some of the targets that'll need to be met in order for some of that remuneration to be paid. I mentioned already about the 5% reduction in gross tonnage of clinical waste going to incineration, but there are others that align themselves with the E, the S, and the G in our strategy.
I'd just like to finish by saying thank you very much for your attention to the presentation today. Obviously, COP27 is taking place in Egypt right now, so it's a timely reminder that we really must take care of the planet within which we operate. I'm proud to say that I think CVS are really ahead of the curve here, and doing a great job, and I'm very proud to be a part of it. Thank you for your attention, and I'll hand back to our Chief Executive, Richard Fairman.
Thanks, Wayne. I will now finish with some key takeaways from our presentation. On the next slide, we have a very clear strategy for growth, and we are well-positioned to invest in that growth. Today, we've outlined six key elements of our ambition over the next five years. Organic revenue growth of between 4% and 8% per annum. Adjusted EBITDA margins of between 19% and 23%. Investment in facilities, clinical equipment, technology and also greenfield sites to drive additional organic growth and also to support with that margin enhancement. Acquisitions subject to discipline and subject to a minimum 10% internal rate of return. Operating cash conversion of 70% and above, and leverage remaining below 2x. Through a focus on these six areas, our ambition is to double adjusted EBITDA over the next five years. We'll start with Charles. Thanks.
Can you give a bit more color on the rollout of the practice management systems in terms of how much it'll cost, what the risks are of implementing it, how comfortable people will be with using it, and sort of the scale of opportunities you are in terms of, what the opportunities are from it in terms of things like the food sales and then what's the scale of opportunity there?
We have a common practice management system that we currently use across our small animal practices in the U.K., and the current system is an on-premise system. It's called RoboVet, and it's supplied by Covetrus. Now that system isn't as flexible as a modern system. It's clearly on premise and not cloud-based, and it limits some of our opportunity to develop and expand our services that we provide to clients. We have signaled that we've chosen the Provet Cloud system. And Ben and the operations team have selected that system from all of the available systems on the market, and we believe as a company that that's the best system for our development going forward. We will cautiously roll this out, though, and we will trial the system in one practice to begin with.
That trial will help us configure the system because it's quite flexible, and then once we've got confidence that it's working, we will then roll it out to another 15 practices, and then across our entire group in due course. Now, the benefits of that system are that it allows us to provide better support to our vets and nurses, allows them to work remotely. As they move through some of our large practices, that can be quite helpful. It should allow us to interact with clients in a slightly more advanced way. For instance, at the moment, we can't offer online booking, and that's something we will be able to offer through this new system.
It gives us a more disciplined approach to billing in that it captures all of the procedures that are performed in a practice, and then makes sure we bill appropriately. Clearly, it's not on-premise, it's cloud-based, and that means we will reduce the support costs. We will be replacing one license fee with another, and that new license fee might be slightly more expensive, but by reducing the on-premise cost and the cost of supporting those servers, that should all be kind of fairly neutral. There is a capital investment as we roll out this system, but that capital investment is not significant. As we talk through all of the investment opportunities, it's probably the smallest of all of our investment opportunities. Thanks, Charles. Andrew.
Thanks. It's Andrew Whitney from Investec. Just a quick one. I think you mentioned it in the earlier presentation, Rich, and I think Lizzie McLennan-Green talked about it when she was talking about the Patient Care Index, and one of the things you're talking about is aging population of dogs or of animals. I just wonder, are you seeing a mix shift in the type of procedures that you're doing based on whether it be animal aging or even the animals that were taken out through the pandemic? Are you seeing a mix shift in what's required of you, and have you got the right infrastructure to serve it in the future if that continues?
Yeah. There'll be different elements to the response. We'll start with 1st opinion care and maybe Lizzie you can comment on any changes we're seeing in terms of our 1st opinion provision and then maybe Helen can talk about advanced care.
I think, from a 1st opinion point of view, we already offer a very broad range of services, and we're seeing with our clients that an ever-increasing commitment to actually undertaking the work that we're suggesting. We focus very much on this recommendation culture that we offer to all of our clients and patients, and we are seeing that there is significant and ongoing increase in uptake from those patients. In terms of our ability to be able to offer those services, the ongoing investment in our services and our technologies, as you can see from the equipment at the back of the room that's available in most of our 1st opinion sites, we are very capable of offering that full service to our clients, even in the 1st opinion setting.
I think the increased humanization of our pets and the fact that they are seen very much as family members, and also just the wider knowledge of our advances within the veterinary industry as a whole means that the general public have far more opportunity to understand what best patient and quality care is, and I think we see that in our consult rooms, and that allows us to really expand our advanced offering, which we continue to do. I think we've never gone for a low cost, high volume model, so we've always gone for that quality patient care. We've selected over a number of years those clients that really are invested in wanting the best treatment for their pet, and that puts us in a really strong position going forward.
The integrated model that we have with 1st opinion, the ACSN network, and obviously our specialist referral division really means that we've got the scope and integration to be able to offer a unique service.
A question behind Jeffrey, please.
Rob Chantry from Berenberg. I guess a follow-up question related to that actually. How are you seeing customers adapting to the broader range of technology and facilities that are available on the ground? I mean, does that vary geographically across the U.K.? Does it vary depending on the insurance provision that they've taken out? How is behavior changing? Not in terms of current trading, but in terms of the actual behavior of the customers.
Ben, do you wanna comment on that?
Yeah. Well, I'll probably hand to Graham as well, maybe to talk about some of the stuff that's coming up. I suppose the obvious change that we went through over the last three years was the necessitated introduction of teleconsultation. Interestingly for us, following that initial part of the COVID pandemic where all of our clients had to undertake teleconsultation, because they had no choice, the Royal College wouldn't allow routine and non-emergency procedures to come to our clinics, we very rapidly saw that fall away. 'Cause I think there's a lot of narrative that you can read that the vet profession is virtualizing and people are gonna have these consultations remotely, and actually our experience is very much the opposite. People wanna come into the clinics and have their patients looked at.
Probably worth me handing to Graham to talk about some of those other advancements that particularly Provet Cloud will unlock and the ways in which our clients might be able to interact with us through that.
Yeah. Thanks, Ben. As Ben mentioned, I think the telemedicine side of things isn't necessarily gonna be that massive change that you might be led to believe. I think the periphery of the veterinary consult, so how do I get my pet seen? Do I book an appointment online or do I pick up the phone? How can I get access to my pet's health information? At the minute, we still have a booster vaccination cards as a physical record of vaccination history. With Provet Cloud, that will enable us to create a sort of dashboard, if you like, of pet healthcare in the client's hands that shows that kind of thing. They'll have access to far more information.
I think the demand's starting to show that clients don't want to pick up the phone so much anymore. They're looking for the ability to book online in line with other sectors. I'm pleased to say, I think bringing this technology in will enable that.
We've got some questions, from people dialed in. Shall we have the 1st question?
Thank you, Richard. 1st question is from Pablo Cipriani, from CP Capital. Can you explain again your plans and ambitions on greenfield developments?
Ben.
We see greenfield as a really great opportunity to augment our organic growth. We have opened a number of new sites. When we talk about greenfield, we're talking about brand new veterinary practices. We've opened seven in the past, some of which were, or one of which was, two of which were referral hospitals, the majority were 1st opinion. Those 1st opinion ones varied from very small branch practices to full service clinical practice with night service included as well. We see the opportunity to roll out full service veterinary care clinics, not necessarily just referral. We're really focused on 1st opinion there, in small numbers each year over the next few years. There are no limitations to where we can put those practices. We can clearly choose, unlike acquisitions, where we're waiting for opportunities to come t8o us.
We can absolutely identify where might be the best area. Some of those decisions are based around where do we get the best synergies. We'll always get the procurement synergy. We'll always get the laboratory and crematoria synergy 'cause they're national providers. Perhaps it's the referral synergy that we wanna make sure that that new practice can feed in to our referral hospitals. We absolutely want to make sure it can feed into one of our night hospitals. There is a very, very long list of where we could do that. Clearly, we wanna do that in a measured way. We're doing 3 in the next 12 months. We could increase that number a bit.
Clearly, if we did a very large volume all at once, we would suffer the negative EBITDA of all of those practices in their 1st year all at once. As we shared today, those practices in year two, we expect to be profitable and actually reach their break-even point around two-year point. We long-term major ambitions, but probably in a more measured way, so we can get into a cadence of opening a smallish number of greenfield practices every year.
Thank you. Just a follow-up question from Pablo Cipriani on that. Can you please elaborate again the reasons of the increase of capital expenditure?
Robin, do you wanna pick it up?
We have a distribution of performance across our practices. I think as we outlined earlier, some of that will be unlocked through our focus, some of the key focus areas around people, around providing great clinical care. But what we have seen in the recent past is where we invest in a practice, we see an immediate uplift in performance 'cause it enables us to provide better clinical care, enables us to attract and retain talent. As we continue to see those improvements in performance, it gives us additional confidence to deploy more capital. If I think about our practice portfolio, we've historically grown inorganically. We've been historically buy and build. We have at one end, nice shiny hospitals that are really conducive to providing that great clinical care.
At the other end, we have former terraced houses, which are not so good. We see an opportunity in over 200 of our sites to invest in CapEx expenditure, and we believe we will deliver good returns from that investment.
One further question at the moment. We've got a few questions, but I'll one more. How does investment in property improve employee NPS, and what can we expect this to move to in the future?
Maybe Martin can answer this because Martin spoke a lot about our people development and our investment in property and facilities is key to our ability to attract and retain talent.
Y eah. Thank you, Richard. I think a lot of our practices do have training spaces within them, and as we develop our property, we're able to build that sort of educational space into those practice buildings. That's also a team-building space. Those teams are able to come together and have meetings there, and it increases that, like, cohesiveness. We're also able to bring together the new graduates into that space as well. I think there's a lot of work we can do for property in a very physical sense that can help increase the eNPS.
also just working in a nice environment with better kit, with better equipment around you, and a practice building that flows according to your workflow is also a better place to work and increase the eNPS.
Thank you.
I'll pass back to you just now for any further questions or if you need to summarize.
Any further questions? I think there's Kane?
Thank you. Is this on? Just on Vet Oracle. Is that, it sounds like it's more sort of a tool to help your vets at the moment. But is there a sort of bigger opportunity set here where, I don't know, you can sort of work with other vet practices, sort of 3rd party effectively? Where, you know, are these radiologists employed by you, or how does the model actually work?
Yeah. Helen.
That's a great question. Our tele-neuro imaging service at the moment and our radiologists, it offers itself out to all practices across the globe at the moment. That's really continuing to expand. Those radiologists are ours. We continue to invest in expanding those numbers. Our Vet Oracle telemedicine, oncology, dermatology offerings and the other ologies that come along with that are in-house at the moment. There are, as you say, vast opportunities to look at other options in the future.
Thank you. One thing that I found, 2, 3 years ago was that veterinary practices near me was just not taking on clients. My question is, are you often turning away patients 'cause you're at capacity? How do you measure capacity? Is it X number of animals per vet at that practice?
We haven't turned away clients. Ben, maybe you can comment on this.
Yeah. I suppose during the pandemic, we had periods of time where we were fairly long wait times to join and the puppy boom meant that we were managing resources. Part of the property relocation and refurbishment plan is to make sure we have physical capacity to take on new clients where there are practices constrained. In the past, the constraint's far too often been the number of clinicians we've been able to attract. Now, those two things are intimately linked because the minute you move into a nice facility, you can employ more people 'cause more people wanna work there. In fact, the 2nd site we'll visit today, in Chesterfield, in the Dobbies site, is a really good example. That site moved in August, and if you ask that team about their ability to recruit since then, it's really different.
Historically, the number of vets and nurses has been the limiting factor. I'd say that's far less of a problem now because of our improved performance in terms of recruiting and retaining them. Sometimes the physical facility is a limiting factor. Often, the number of consulting rooms, particularly 'cause we as a group have focused on making sure our nurses are also consulting because we know our clients particularly rate that experience, and we want to make the most of using our nurses. We are almost always in a relocation adding consulting room space and sometimes adding clinical space as well. We never shared the specific metric, and I'm not sure it's necessarily as clear-cut as you might think in terms of this many patients, because the mix of skills in each practice differs.
If you have a practice with a large group of really experienced nurses, actually the number of pets per vet can be much higher because your nurses are able to consult. They might be doing minor surgical procedures. Whereas if you have a very limited number of nurses and perhaps more patient care assistants, which might be the case in one of our clinics where you're a bit less able to recruit, your number of pets per vet would be lower. We never shared that specific number.
Okay. I think we've got time for maybe one more question and maybe we go to the live stream.
Yep, we've got a question from Evan Tempus from Jefferies. Can you talk about volume and prices in your revenue guidance? Volume, in that if new pets go to the vet more in the initial years, how does this impact your growth near term as the market normalizes before the number of chronic diseases develop, which require more visits? And price, in that do you assume that you can continue to increase prices at historical rates as part of your five-year plan, and would this impact demand?
Maybe we'll split the response. Maybe Ben, you talk about the volume piece.
Yeah.
The increased population, and maybe Robin with the price.
Yes. I think the increase in population is one of the things that's maybe not as well understood as it might be, because we certainly saw a spike in the number of patients that we're looking after as a result of the puppy boom or whatever you want to call that increase in pet numbers during the pandemic. What we do know is, yes, they do visit the clinic a bit more often that year one, but they are coming to you for the lowest value, lowest margin procedures that they have at any point during their life. So they're coming to you for vaccinations. They're coming to you for their spay and neuter. Those are about the only part of the entire experience that a pet has with us that is really sharply priced because that's about the one thing that people compare.
In fact, in reality, we often challenge ourselves because people don't choose us because of the price of our neuterings. Nonetheless, those are the most keenly priced and therefore the lowest margin, lowest revenue. Actually, we see revenue when you look at a lifespan of, for example, a dog from years 1 to, say, for example, 12 to 15, growing linearly. We don't see what's historically been considered to be normal, which is the sort of smile. That will be different if you're selling lots of retail products. If you're selling loads of dog beds, leads, collars, that sort of stuff, people do buy a whole bunch of that in year 1 for their puppy or kitten and very quickly stop buying that stuff as you realize you don't need 8 dog beds and cages, et cetera.
If you have a very significant retail component to your operation, which we obviously don't, then you definitely see that fall off after those 1st years. Our experience is that our growth in spend per pet is linear over time.
I suppose historically, we've put through low single-digit pricing. We believe we can continue to do so. I think the opportunity for us is less around price. It's more around Patient Care Index and making sure that we recommend in the consult room. By providing diagnosis in the consult room and providing the best care that animal can get, that invariably results in a higher ticket value from that visit.
Thank you. Thank you for your questions, and thank you all for attending today. We really appreciate your continued support. A big thank you to all of our presenters today. Now, you're used to hearing from Ben, Robin, and myself, so a special thank you to Lizzie, Helen, Martin, and Graham for their presentations and also for bringing our business to life through their discussions. Hope you can stay for lunch, and hopefully you can stay for the practice tours this afternoon. Thank you and appreciate your support.