Okay, good afternoon, everybody. And before Mark starts, the formal presentation today, I just need to run through the usual housekeeping points. Firstly, the slides we're about to go through will be available on PHP's website, along with a video recording of today's presentation, and those will be made available as practical as possible after we've concluded today. For those of you who are present in person today, please, can I ask you to make sure your mobiles are on silent? If you want to use the Deutsche Numis guest Wi-Fi, the passcode is twenty-six o five nineteen ninety-nine, and that is also set out on the agenda page of your presentations. And lastly, in true Ayrshire style, the toilets are at the back of the room, highlighted by the green sign, and emergency exits are over to your left and at the back of the room.
So without further ado, I'm going to hand over to Mark to introduce today.
Thank you, Richard. What a good turnout! Good afternoon, everybody, and welcome to PHP's 2024 Capital Markets Day. My name is Mark Davies. I'm the CEO, and may I begin this afternoon's presentation by thanking you all for being here, for those of you in the room with us today physically and for many of you, who are dialing in virtually, particularly our international audience, including several of our South African investors. We are very pleased to have you with us today, and I'd also like to extend a special thanks to our investors, analysts, bankers, advisors, all of those of you in the room today and online who've played a crucial role in our journey, and your support has been instrumental in PHP's near thirty-year successful track record, so thank you to you all.
Our presentation team today is up on the screen in front of us. Happy look, bunch of guys. Clearly love doing what they do, as do I. And during our presentation, you'll hear from several members of the team, including Richard, our CFO. Many of you will obviously know. You'll hear from David Austin, our Head of Asset Management. You'll hear from Tony Cooke, our Development Director, and James Buckley, our Managing Director of our Irish business, Axis PHP, and our expert and external speaker, Dr. Arvind Madan. Each of the team will present themselves, later in the presentation, introduce themselves, and give a bit more on their background as I comment on shortly.
There will be two opportunities to ask questions, 'cause we would love it for you to interact with us and engage just before the break and at the end of today's agenda. So moving on to the agenda. Slide four. So this afternoon, myself, the team, we're looking forward to communicating to you the company's strategic vision. We'll provide an update on the business. We'll talk you through our growth prospects, how we create shareholder value, because that's what we're here to do. During the sessions, we'll aim to demonstrate our clear strategy and the significant opportunity that we see ahead in the future of primary care. But just before I get going on that, and we start our formal presentation, you may have seen this morning that we put out a trading update.
We announced that at today's Capital Markets Day, we'll focus on the significant opportunity that we see ahead in primary care and PHP's continued dedication to dividend growth. We'll also be highlighting the growth drivers and the political momentum we see in our sector, and how this will deliver future earnings growth and rental growth. We talked about rental growth in our update and how we are well on track to deliver like-for-like rental growth, 3% this year. Richard and I will talk about that later on in the presentation. Finally, we referenced our investment and development activity and how we are seeing a range of interesting opportunities now in the UK and in Ireland, and you will see some of these in our presentation this afternoon. It's been an interesting news morning.
Alongside PHP's announcement this morning, we saw that inflation announced at 1.7% versus 2.2% previously. That was a welcome surprise on the day of a Capital Markets Day. I think the market was expecting 1.9%. Of course, you know, core inflation, as we saw as well, is materially reduced and, you know, this bears well for the interest rate market over the next coming weeks and months. In early trading, the gilt, 10-year gilt, which obviously we look at very closely, fell by six basis points. All very welcome news on the day of a Capital Markets Day presentation. Onto our agenda that you have there in front of us. We've given this careful thought and consideration.
Firstly, I'll set the scene for the afternoon by running through what I think are the growth drivers for PHP now and in the future, and our continued dedication to dividend growth. Second up, Dr. Arvind Madan, who's going to talk about the future plan of the NHS. Very, very lucky to have you here with us this afternoon. Very grateful for some of your experience, and you'll get a chance to introduce yourself in a moment. The next session will: James Buckley, who's in the front row here, a very tall gentleman who stands out, co-founder, Managing Director of our Irish business, Axis PHP. And James is gonna talk very enthusiastically about the primary care market in Ireland and opportunities that we see in that market for PHP to expand.
We will pause at that moment of the presentation, open the floor and the wider audience to questions. We would really encourage you to do that. So think carefully and closely as we go through our slides this morning, and your insights are extremely valuable to us as a management team, as we continue to build a company that's focused on delivering shareholder value for all our stakeholders. We'll then take a break, chance to grab a coffee and some refreshments, interact with management, maybe ask any of the questions you've not had the chance to do at that point. First up after the break, David Austin, our Head of Asset Management, followed by Tony Cooke, our Head of Development. The theme of those presentations is all about delivering value through active asset management and development, respectively.
After that, Richard's gonna come on, just talk to us about rental growth, a pretty important driver of future earnings, and also give an update on our, financing strategy. I'll wrap up the capital markets day with concluding remarks, thoughts for the future, open the floor to, to questions. I'm sure you'll have many by the time we get to that point. When we do get to questions, there'll be a roaming mic, and as I said earlier, there's a virtual, capacity to throw questions at management as we go through. During the course of these presentations, we will show you a number of videos, and these assets that we're going to showcase, I think is probably the right word, across our portfolio, from sunny Eastbourne to Norwich to less sunny Ballincollig in, in Ireland, just outside Cork.
We would, of course, love to take you to all of these places to show you what we do and what we do really, really well, but I would encourage you to observe carefully. There's lots of interesting detail to take on. And, you know, quite frankly, we're here to show you some of the really good things that we do in our portfolio, not just creating value, but the social impact that we have in the communities that we invest in. We do plan to stay on schedule. We do plan to finish on time, because we know you're all very busy people, but there will be drinks as well, when the air conditioning is working well through there.
And again, obviously, that's an opportunity to speak to management, but we're also very grateful that the wider PHP board is also in attendance here today, so good chance to ask us questions. So on that note, I'd like to start by introducing our company, Primary Health Properties, often referred to as PHP. Now, there are many of you in the room here today that have known us, supported us a long, long time, but there are also some members of our audience who are dialing in, particularly, who are less familiar with the story. I'm gonna start this morning's presentation by just giving a bit of high-level background. PHP is a healthcare, in fact, healthcare-focused REIT with a strong and successful thirty-year track record in primary care property. We're a FTSE 250 company, and have a continued dedication to dividend growth.
We have a forensic focus on growing our earnings and rental income, and 90% of our rent is paid for by the UK and Irish governments. We own a high-quality portfolio, and our business model is highly resilient, with a strong but ever-increasing demand for more space in medical centers that we own and medical centers that we can develop in the future. There are high barriers to entry in our sector, and you will see today our team has a very strong technical skill set, and our stakeholder relationships go far and deep, and that enables us to add value to the portfolio that we own. There's no speculative development in our space. We are able to develop new primary care assets on a risk-controlled basis, and my colleague, Tony, will talk about that a little later on. We are a business with high ESG credentials.
We have a huge positive social impact in the communities that we are invested in, and I'll demonstrate in a moment the growth drivers and the tailwinds behind us, which are, we think, very strong. And there's a significant opportunity ahead in primary care in the UK, Ireland, and also other markets that we always continue to assess. So now on to the significant opportunity ahead of us. Our long-term goal remains. The core of our business will always be primary care, and our mission is to be the number one owner, manager, and developer of primary care properties. Government-backed income will remain the foundation of our business. We stand today at 90%, and we would always expect this to be close to this level, and typically in the 85%-95% range on new projects that we look at.
We have a market-leading position in the UK and in Ireland, and we will continue to look at other opportunities, particularly those with government-backed and secure income can be achieved. We're also able to create shareholder value in a capital-light way through our asset management activities, rent reviews, risk-controlled development, and we will look at joint ventures, and I plan to say a little more on that later. Rental growth will play an important part in our future, and we are confident that above inflation level, rental growth is achievable, and an annual growth rate over the next five years of 3%, or hopefully more, is our aim. We think on government-backed income, that's an extremely compelling investment proposition. Dividend is sacrosanct in this business and how we run the company. Earnings growth will always drive our strategic decision-making and capital allocation. Slide seven, managing the challenges.
We are now operating in a higher interest rate environment. I don't think that's a surprise to anybody in the room today. Interest rates could stay high for longer. That could act as a brake on everything that we would like to do and like to achieve. However, the government has made it very, very clear it wants to change the way that healthcare is provided. Reform is on its way. We are really well-positioned at PHP to facilitate that change and benefit from that change. It's not completely without its challenges. Rents must increase for new sites to be forthcoming, and Tony's gonna talk about that, and it should be economically viable to build or extend, as David will talk about later. The green shoots are evident and definitely more on that later.
As you will read on the slide, Wes Streeting's quote recently, I think it was the 4th of October, sorry, there is staunch political support for what we are talking about here. And look, this sets to be provide a stable growth environment for PHP for many years ahead. More on that a little later. So over the next four slides, I'm going to talk about some of the macro drivers of PHP's future growth. Firstly, as I described on the previous slide, the political momentum around our sector is significant and positive. We will see three big shifts in our space, all of which work to our advantage. There is a need to shift services from the hospital into the primary setting. We read about that now all the time. There's ongoing shift from analog to digital and increasing focus on preventative health.
Primary care will be the winner in all of this, there's no doubt, and Arvind is gonna present on that shortly. The Darzi Report, the ten-year plan, all very pro-primary care, shifting patient footfall from hospitals into the community. At long last, government has realized that hospitals are overstaffed, spending too much money. Reform will drive redistribution of spend into primary care. Historically, not enough money has been invested in primary care. This is gonna change, we believe. There's no doubt more money will be invested in healthcare in the future. More importantly, government now has a stated intention to reallocate spend and resources from secondary into primary care. The cost versus benefit analysis is very clear. That's why it's the first bullet on the slide. Cost of going into a secondary environment, GBP 400 or more.
Costs coming into a community primary care setting, where we're invested GBP 40 or more. The math is undeniable. One thing history tells us is that a Labour government does invest heavily in the NHS. You can see that on the, on the chart there, and I'll make reference to it in a moment. Keir Starmer's first term of office is the one thing he has to fix, and expectations on the public, from the public are very, very high. This was further endorsed only yesterday by Chancellor Rachel Reeves, who in The Times, these are her words, "Planning to announce a big investment in the NHS and public services." But we're all awaiting this month's budget with anticipation. But the message is very, very clear, and the future of primary care is very, very strong and has a very strong political backing.
Just a little bit on the chart below, which I will comment on. That's the actual spending in the NHS, going back to, on this chart, 2000. If you went back further and had a bit more width, you can see from 1997, when Blair and Brown came into power, the last time we had a new Labour administration, spending GBP 35 billion a year on the NHS. By 2010, when the Cameron-led coalition came in, that was GBP 110 billion. In fact, you can see on this chart, from 2000 to 2010, when Brown was Chancellor for most of that time, spending on the NHS more than doubled.
Now, I'm not saying that's gonna happen again, but what it does tell us is that a Labour administration is very focused on healthcare, NHS spend, and investment. We also know from Darzi that 50% of all primary care medical centers around the U.K., hastened to add, not those owned by PHP, and David's gonna talk to that later, are not fit for purpose, and we're gonna see significantly more investment into primary care as a result. The private sector will play a big part in this. PHP is clearly very well-placed as a beneficiary, as a leading sector specialist with focus and expertise in primary care properties for nearly thirty years. The next slide is proof as to why all of this needs to happen. We have a growing and aging population. I'll not dwell on this slide too much.
The structural social drivers, I think, are pretty well understood by everybody in this room and dialing in virtually, but PHP is set to benefit from demand for more primary care space. We will see this later in James' presentation, absolutely in David's presentation, and also in Tony's presentation. Not only do we see lots of extension and asset management opportunities in existing assets, but after several years of stagnation, I think most people are quite aware of that, we're now beginning to see our development pipeline growing again, and we did make reference to that in the update this morning, and this is a reflection of high demand.
And the accelerators of this are often new housing developments, as you, as you will have seen before, growing patient lists, and as I highlighted on the previous slide, an NHS primary care estate across the U.K. that's just not fit for purpose. And finally, before I pass on to Arvind, the way the public health will be managed in the future is changing with advances in tech and a move towards prevention. Our assets are increasingly incorporating these changes, and we will see later on in our presentations this afternoon, diagnostics, imaging, scanning, all of these things, operations are taking place in assets that we own in our primary care portfolio.
Technology has the ability here to not only just enhance the quality of care in primary settings, but also allows providers, as you will see from medical practitioners on some of the videos later, to coordinate services far more efficiently. In fact, save the NHS money, believe it or not. Diagnostics is really interesting. The pandemic has really heightened the importance of early diagnostics to manage public health. We're seeing a growing supply of this, and demand on things like community diagnostic centers in the UK and Ireland. We see opportunities within existing PHP assets, alongside PHP assets, and in other locations around the country, in Ireland and other places, sometimes adjacent to retail offices, where people typically work, shop, and live.
To conclude, we are excited about the growth prospects of our company in the future, significant opportunity ahead in primary care, and it's being shaped by the drivers that I've described. You've heard it from me. In a moment, I'm gonna hand over to Arvind, who's a leading expert on primary care. And before I do that, he's gonna introduce himself in a moment. But just a couple of things I'd like to say. We're very grateful that you're here with us today. Arvind has been a GP now for nearly thirty years. He's a founding partner of The Hurley Group, which provides NHS general practice to, I think, over one hundred and twenty thousand patients. Yep. So in the market, if that's the right term, certainly in the field every day of the week.
Importantly for today's presentation, Arvind was previously Director of Primary Care for NHS England and managed to achieve several billion pounds more of funding during his tenure, so really does know what he's talking about. Arvind's gonna talk to us today about the government's ten-year plan. No doubt Darzi is gonna come up. I'm sure there'll be a political slant to all of this, but what we really want to hear, and Arvind's gonna get there for us, I'm sure: what does this mean for primary care, and what does this mean for PHP? On that note, Arvind, I'd like to hand over to you.
Hello, everyone, and thank you for inviting me. So Mark said, "expert," a lot of times there, which has triggered my impostor syndrome massively. And it reminded me of a parable. It's an Indian parable, but I'm sure you may have heard of it, of six blind men walking through a forest who come across an elephant for the first time, and one grabs a leg and says, "It's like a tree." One grabs the tail and said, "No, no, no, it's a snake." One grabs an ear, and he said, "No, it's like a fan." And I guess what I have done in my career is had multiple viewed the NHS through multiple lenses. So I'm a GP. I still practice.
I also work in urgent care, because we run some urgent care services in addition to 12 GP surgeries covering 120,000 patients, all based in London. Our urgent care portfolio runs two urgent treatment centers, and we also, you may occasionally see me as that doctor in that car roving around in Bexley in the middle of the night. Along the way, I've done a few other things. I've been involved in substance misuse services for Lambeth and Southwark, refugee services in Southwark, and growing this group of surgeries across London. In addition to that, we've picked up a lot of, a couple of other things along the way, which are services we've scaled.
We run something called the Practitioner Health Programme, which covers the 1.6 million NHS staff for their mental health in England, and we also do the same for Scotland. So we have a team of about 850 people in the Hurley Group. We also, during COVID, picked up on the fact that gambling addiction was taking root, so we set up a national service around gambling addiction for patients and their families. Back in about 2012, as an internal experiment for our own organization, frankly, we started to play around with whether we could convert a proportion of patients we were seeing face-to-face into online consultations.
You kind of have us to blame for that revolution that kind of took place during COVID, but on our platform, which others were interested in, so we turned it into a company called eConsult. We now have 20 million patients using our platform. Either you may be using it on your GP practice website or through the NHS App. And we've had 50 million online consultations. We took the same theory of can you triage a patient up front to make sure you provide the right care, and it's not always face to face to the accident and emergency environment.
So in twenty hospitals now, when you walk into the A&E, you will be given the opportunity to check in on an iPad, where we capture, not only your demographic details, et cetera, et cetera, but a bit about why you're there, your injury or illness. And then we can restratify you, so we can find that sepsis case even before they've sat down, all within five minutes. So we've done over a million eTriages in the A&E environment. That company, eConsult, and was recently acquired by Huma, which is a global AI tech research company, and I've been really excited to see, the technological toys and capabilities they have within their portfolio and actually how that can be applied to the front line of general practice and create further acceleration to that, change.
In twenty fifteen to twenty eighteen, I became the national director for primary care and was the author of the General Practice Forward View, which increased investment, but also kicked off issues around employment for allied health professionals, of which there are now 36,000 in GP practices in England, working alongside GPs and practice nurses. The likes of clinical pharmacists, physios, physician associates, pretty topical, but physician associates, and actually 15 different types of allied health professional. So the flavor of general practice has somewhat changed as a result, frankly, of us not being able to find enough GPs. And as a side mention, I'm also a part owner in two GP premises in London.
I guess I'm the person who's seen all the sides of the elephant or some of the sides of the elephant that I referred to. In this talk, what I'll do is I'll kind of try to walk you through what's the weather like in the NHS? What's the mood music? Actually, on a positive note, I'm seeing a level of alignment between ministers, the Department of Health and Social Care, between NHS England. They're all, for the first time, pointed in the same direction. We've kind of had the Darzi moment after the election to kind of set a benchmark for, all right, actually, what is the state of the NHS? No doubt, something the politicians will continue to refer back to if it doesn't all go well. Then we've got about three months of policymaking, blue-sky thinking, how can we be radical?
And then, no doubt, after that three months, there'll be three months of consultation and testing those ideas, and writing documents, and in spring next year, we should hopefully see this ten-year plan for the NHS. But the weather, and so I can see sunny uplands on the horizon, but the weather right now for GPs up and down the land is not good. It's not good because the complexity of the work they're dealing with is never been greater. Each GP is probably doing forty to fifty consultations a day, some of which are by phone, some of which are online, some of which will be face to face. Most patients come to their GP with two or three problems, so it's not as if that's forty or fifty problems. That's double or triple that.
Increasingly, the less complex cases are being taken off the list to go to the allied health professionals. So the complexity of what GPs are doing, the decision density that they're operating in, is actually pretty high, which means that we've got figures such as a high proportion, nearly 40%, considering leaving in the next five years or considering early retirement. We've got 39% who've actually had some sense of feeling burned out. We've got 86% feel the workload is excessive.
And it's quite often the case that, we find that there's a bit of media bashing of GPs working part-time, but actually, quite often, that three and a half days in the surgery, as their contribution, results in four and a half or five days worth of work when they go home, switch on the computer, and now do the blood results and the hospital letters and the referrals, et cetera, that they didn't get time to do during the day. So it's quite often taking more than three and a half days of their week. And there's a phrase I hesitate to use, but I'll use it, that usually is only shared amongst medical professionals, when consultants try to lord it over GPs.
We say, "GPs work in the jungle, consultants work in the zoo." And by that, what we're talking about is the fact that we deal with undifferentiated illness in a way that only really other appearance is in A&E. So when people come to us, we don't have the benefit of all your blood tests and your X-rays and your ultrasound. We put a hand on your tummy, and we make a risk assessment there and then. Can I let this person go home, or do I need to send them to the hospital? We are risk management consultants, and we do it at scale. So that also brings its own burden.
What I would say is in our Practitioner Health Programme offer, for all doctors and all staff across the country, GPs represent a higher proportion than they should of those coming with anxiety, stress, depression, burnout, and sadly, occasionally suicides, through our books. On that theme, I guess, the mental health of the nation is suffering, and every time someone comes in with two or three problems and one of them is related to mental health, it at least, well, it nearly doubles your appointment time, frankly, which is further adding to the challenge. In 2012, one in 17 people reported depression, and it's now up to one in eight, and even more worrying, in 2016, one in 10 children had a mental health issue. It's now 20%, one in five children. It's pretty shocking.
So that could be anxiety, depression, body dysmorphia. It could be an eating disorder, a phobia. We see the full range. You know, it's not unusual for me to spend 25 minutes with a worried mum who's dragged a kid into a surgery who's refusing to go to school. That's ordinary bread and butter for every GP up and down the land now. Demand on primary care is increasing substantially, and Darzi made a point, actually, of saying that general practice was actually the most productive part of the NHS by some distance. The productivity of GPs has gone up. In 2019, 309 million appointments for the nation, for England, gone up in 2022 to 367 million, despite having 2,000 fewer GPs. You've heard this mantra of: We need 5,000 more GPs.
You promised us five thousand more GPs. It was actually my fault, partly. I was part of the team trying to get them, and we couldn't get them for a variety of reasons. But that has meant the growth of allied health professionals, which was there to offer a proportion of the appointments, and the number of attendances a patient makes to their GP surgery has gone up as well. It used to be, it used to be pretty static. The average punter used to come to the surgery about five times a year and stayed at that level for a long time. It's now up to seven, a bit more for kids, a bit more for elderly, a lot more for elderly, little more for women than men, particularly around pregnancy and perimenopausal.
But actually, that complexity, that volume, has contributed to the demands on our general practices. And it used to be pretty unusual for many surgeries. They used to tick along at a week wait or less. It's now pretty common for a two, three, four-week wait for a GP appointment. And an increasing proportion of those appointments are happening on the phone or online. About 10% happen online, and more than 50% of those appointments are now being done by allied health professionals, and we can have a debate over whether that's a good or bad thing. So, as Mark mentioned, the new government has been clear in creating its focus around treatment, not prevent, but less, a shift from treatment to prevention, a shift from hospitals into the community, analog to digital with a focus on innovation.
But a fourth one that they don't shout about too loudly because productivity is a tricky word, but they're definitely saying behind the scenes, is we need a step change in productivity. Interestingly, hospital productivity has stagnated or gone down, whereas I mentioned general practice productivity has gone up substantially, and as a nation, we're spending disproportionately more on our secondary care than primary care in comparison to other European countries. So we actually have really well-staffed hospitals, compared to European countries, but actually, the capital investment in the diagnostics causing bottlenecks is one of the challenges. So at the risk of having my Donald Rumsfeld moment of known unknowns, et cetera, I'll describe to you something that a very senior NHS person said to me, about what they mean by reform. It's not more for the same offer.
It's not even more for more of the same offer. It's more for something different. Actually, I get the sense that we are in a particular moment, as I say, where policymakers are malleable to actually a step change in what the NHS could be. So moving on to Ara Darzi, I think most of you will probably know he's a cardiac surgeon, and his last big idea didn't go down that well in general practice around polyclinics.
What's interesting is I don't actually think I've now walked into a room where estate and primary care has been discussed, where everyone isn't pretty much aligned on, "Darzi was right, we just didn't want it from a surgeon." But actually, that's the direction of travel. His diagnosis was: we have rising demand, population growth, aging population, multiple morbidity. We've got the worst patient satisfaction on record ever, and that includes general practice. We've got massive waiting lists, as you know, and worryingly, a million people waiting for mental health support. And for the first time in a long time, we've got reduced life expectancy and reduced healthy years of life expectancy, which is a particularly worrying trend. Some statisticians would argue that's in part due to COVID numbers, but actually, things seem to have stalled.
We've got reducing supply, we've got staff shortages, we've got low morale and low discretionary effort among NHS staff, more so than previously. We kind of used a lot up during COVID, and actually, my view is that if you give a workforce the right tools and resources to do a job, they'll move heaven and earth to do it. But once it's tangibly the case, they've not been provided the right resources, they externalize the cause and won't necessarily go that extra mile because they know the job's not doable. It wasn't a fair playing field. There's industrial action going on in the general practice world at the moment.
GPs have been given a pick and mix by the BMA of measures they can take, all of which are carefully constructed, ideally not to cause patient harm, but to cause system inconvenience, in a sense, to try and bring negotiators to the table. And we have our hospital beds occupied by patients needing social care, about 16% of them, which is pretty shocking. We preside over worsening health inequalities at the moment. And just to give you a sense of it, in 2012, if you took a tube from Westminster going east, you would lose about a year of life expectancy for every stop. And actually, I can bring that to life for you. I remember one day doing a morning surgery at our practice in Chelsea, where...
And an afternoon surgery at our practice on a place called the Mardyke Estate, which BBC called the worst estate in Britain in the afternoon. And the problems I was seeing in the seventy-year-olds in Chelsea, I was seeing in fifty-year-olds in East London. So it gives, I hope that kind of brings to light the impact of health inequality. A schizophrenic will die twenty years younger than someone without that mental health disorder. So these are pretty stark differences that we preside over. And insecure employment, I think, is a big one. We had the fortune of meeting with Michael Marmot when we took over a practice.
And we said, "Okay, if there's one thing out of the box, we could do to help our patients, that the NHS isn't buying, but we want to do something." And he said, "Well, make links with the Jobcentre because people's health, not just them, but their family's health, crashes immediately after they lose their job, if they can't find something soon. And actually, that, give them a health check, immediately after they present to the Jobcentre, that will make a difference." And we did. So what does this all mean?
There is a really strong message from Darzi's work, and bear in mind, when he was appointed by Wes Streeting to do the work, the whole general practice world said, "Oh, not him again," but actually, his work has landed superbly in general practice because it's kind of turned into, "Oh, for goodness sake, someone is actually now seeing what we've been shouting about for a decade," but he's calling for faster investment into primary care in proportion to secondary care, and to further boost general practice's productivity, and what's interesting is there's also, and you'll see in the news, an increasing willingness to work cross-departmentally in government, such that there's a focus in doing something about the proportion of those who are economically not active, who may be supported back into a working role.
So, as I said, the ten-year plan hasn't been written yet. They're still working on it. But I would be surprised, these are my Arvind's predictions, if you like. A bit, my blue sky, a bit from talking to people, but I would be surprised if some of this stuff wasn't included. I think there will be a step change, good news, folks, in your experience of healthcare in the next decade. I think it will have a more personalized and consumerist focus, and I think there will be the emergence of global health brands. In the same way in the mobile phone world, we had the Samsungs and the Apples. I think there will be some global healthcare brands emerging. And we've kind of seen how the last decades have been around social media, banking, shopping, et cetera.
I think the next decade will be about healthcare, and notoriously, people have stayed away with it because of the sensitivities of the tech space around healthcare, but actually, I think its time has now come. I think the GP practice as an entity in a partnership format will continue. We've seen the growth in places like Somerset, Wolverhampton, Northumbria, of hospital foundation trusts taking over local general practice. I think that will probably continue. There'll be the super practices like Modality out there. I think this, it will be a mixed economy, which I think is a positive thing, given early indications from our Secretary of State that he was listening a lot to those who wanted to end partnership and have GP partners as part of the salaried workforce of the wider NHS.
Interestingly, the foundation trusts have, where they've taken over local general practice, pump-primed the investment into their GP surgeries on the basis that now if you're going to own the whole food chain and look at the bottom line, that's where we're better spending our money, upstream. I think we'll see a growth of Integrated Neighbourhood Teams, Claire Fuller's report. Integrated Neighbourhood Teams is effectively a long way of saying integration and horizontal integration with community trusts and services in the voluntary sector, and mental health trusts, and primary care, I mean, not just general practice, I mean, pharmacy, dentistry, optometry. I think we're gonna have that horizontal integration.
I think we're also gonna have vertical integration, where particularly medical specialties that don't need to be in an expensive, shiny hospital are gonna start coming into that more community-facing setting within a sort of polyclinic-esque environment, co-located with the likes of diagnostics and other services. I think we're gonna see digital transformation, as I've touched on already. I think you'll have a more sophisticated patient-held record. I think there'll be some significant changes to the NHS App or companion apps, as is emerging. I suggested I'd seen some what the future could look like in eConsults being sucked into Huma, and they've just recently showed me the ability to comment on a workspace, the ability to make your own app for any purpose within a few minutes. And it's got a frame of a iPhone there.
You type into the Gen AI, retinitis pigmentosa was the example, and myasthenia gravis was the other one. Really rare diseases. Make me an app on this condition, and it would autogenerate all the bits and pieces that you would want within that, and then there's a pile of widgets around tracking, around monitoring, around drug adherence, around notify me when it's time to take my medication, around actually a whole bunch of functionalities, including connecting to your home biometrics, like your Apple phone or your blood pressure machine or whatever else you want, and sucking all that information in. I think the future is gonna be those kind of personalized apps to your particular health profile, maybe embedded within the NHS App, to be confirmed, actually feeding information to a multidisciplinary team who are monitoring a dashboard to see if anyone's blipping.
And actually, what virtual ward assets do we need to point at that Mavis because she hasn't got out of bed today? And all those sorts of scenarios. And a growth in remote patient monitoring and virtual wards. There'll also be a focus on what we call population health management, which is basically a fancy way of saying, using big data and the insights it's giving us to stand up evidence-based services that address that population's needs, as flagging up from the big data.
So actually, what services do we need to mobilize within a community, that kind of meso layer of services that sits between 6,500 GP surgeries and all the shiny hospitals, that actually we can do in the community with a better patient experience, better health outcomes, better value for money, and happier staff delivering what they now know is more top of their license capability? I think there's got to be some reform in the payment mechanism in the NHS. We are providing too much of our care, and patients are suffering the consequences of poor patient journeys as a result of the perverse financial drivers in the system, which actually reduce clinical cooperation across primary and secondary care, because actually, if the finance director of a hospital is worried that they'll lose a chunk of their income.
I think that, that has to change, and I've been advocating, and I've heard it pop up in a few policy discussions more recently around gain share arrangements, where Primary Care Networks, of which there are 1,250 in the country, each covering 30,000-50,000 patients in five or six surgeries, where, where they, if they act collectively to save the system money by investigating, by reducing unnecessary investigations, avoidable admissions, avoidable A&E attendances, actually, they should get a gain share from the saving they create in the system back into primary care to create a virtuous cycle of a richer and richer offer in the community.
I think if we're not careful about changing the contract around deprivation, we're gonna see bits of the general practice world, particularly our coastal cities, going the way of the dental world with deserts of provision. In the funding formulas at the moment, there's a disincentive for geographically agnostic GPs to go work in tougher communities. In part, because it's a tougher community, in part, because actually you're less likely to hit your targets, therefore financial take home is gonna be less. So you're, we're asking our GPs to go work in, tough inner cities, and earn less money than they would in, affluent Surrey. Apologies to anyone who lives in Surrey who's not affluent. Then we need to think about public health.
I mean, I can feel a sense of the mood music changing around this. It was kind of fearful of nanny state accusations previously, but I'm sensing, you know, conversations around smoking in pub gardens, conversations around should we be targeting our weight reduction drugs at people who are overweight, who are economically inactive? And some of that's filtering through to real-world frontline stuff. So there's a team within the NHS called the Get It Right First Time team, GIRFT, who probably for the last decade have, well, a little less than that, have done some fantastic work in going to every single hospital in the land, every single department, and actually saying: Look, this is the best evidence-based practice, and the hospital down the road, by the way, is achieving it. How do we work together to raise your standard?
Really kind of scientific quality improvement methodology to, you know, how are you gonna sweat your operating theater the same way everybody else does? Actually, these GIRFT teams are now targeting areas of the country where economic activity is a challenge, and then pathway transformation. If I said to you right now, about a third of patients sitting in A&E this moment don't need to be there. Probably more than a third, frankly. About a third of them who are attending their GP surgery don't need to be there, and a third of them sitting in outpatients. 10 million of 110 million a year don't even show up.
Actually, what we've got is, as a result of unsophisticated triage, about a third of the appointments, over a million today in the NHS, were either low or no value to the system or the patient. In fact, I'd go further. I'd say it was harmful to the patient because they bounced around the system in the wrong place, or they waited months for an appointment when they should have been somewhere else. Actually, that upfront triage to get people to the right place first time, every time, with the right clinician, with the right modality of communication, is it a video? Is it a phone call? Is it... Should we get some tests first? This person's got better. Find out and take away the appointment. This person's worse, tell them to come to A&E.
Actually, that we don't have that air traffic control of the system, and we're spending GBP 108 billion a year on this stuff. We wouldn't put up with it in any other industry, and I get the sense we're now of a mood that we're not gonna put up with it in health, which is great. And none of this is gonna be possible unless we have the right estate. When I was a national director, we completed 1,000 premises refurbishments or built new premises, 1,000 GPs practices, and I think we need a national program of that order. I'd be surprised if there isn't something akin to that within the direction of travel there should be. Finally, what does this mean for PHP?
I think I've already kind of scattered within everything I've said, things that are obviously of relevance. But we're gonna see this left shift in the system. What is yet to play out is something they keep talking about, and multiple governments have said we need to move more money into primary care and failed. But this new language of hardwiring in, I need to see what the hardwiring looks like, if I'm gonna believe it, if you're gonna believe it, and actually, I get the sense that they're serious about it, but in all honesty, they're probably. That's the work of the next few months.
To actually, if 90% of your contacts with the NHS are in general practice, but general practice is receiving less than 10% of the NHS budget, how are we gonna actually move significant sums from that secondary care, the expensive, very, consequences we deal with there of not doing the care upstream? And how do we, how do we make that change? And the BMA used to debate with me, Arvind, we're doing 90% of the work for 10% of the money because I used to be involved in those negotiations. And I said: Look, I don't have a hypothetical upper limit to what general practice should get of the pot.
What I am of the view of is general practice is suboptimized as a result of not having the share it deserves, but actually, its growth of that share has to be substantiated by actually something better for the wider NHS. And I think that kind of thinking is now coming through, and I don't think we can sit on this for much longer in terms of investment in the general practice estate. As Mark mentioned, 50% of GP surgeries are no longer fit for purpose. 20% were built before the NHS was born. So it gives you a sense of that. So I hope I've given you some idea of what the weather, the mood music is inside the NHS, and personally, I think this is extremely favorable for the future of primary care and the investment profile.
Thank you very much.
Thank you, Arvind, for that very insightful presentation. What an interesting insight into the NHS and more importantly, the future of primary care. I think it's great when our audience hears from myself and the team about the future of primary care in the U.K., but to hear it from you, who's actually in the field day in, day out, it's extremely compelling, and we're glad that you agree with us that there's a real shift going on here into primary care. There will be opportunities to ask Arvind questions later. Before that, next up is James Buckley. James is Managing Director, Axis PHP, our market-leading primary care business in Ireland. You'll see that James is very enthusiastic about and knowledgeable about primary care in Ireland. That'll come across loud and clear.
With his team, you know, we own the best portfolio in the market in Ireland. There's no doubt, and there is a significant opportunity for this to grow and for us to do more in Ireland. On that note, James, I'm gonna pass over to you.
Great. So thanks, Mark, and good afternoon, everybody. What I'm going to do for the next 15 or 20 minutes is give you an overview of PHP in Ireland, you know, what we've achieved so far. Talk a little bit about the structure of primary care in Ireland. The Health Service Executive, our equivalent of the NHS, and the changes that are coming. Looking ahead 5 years down the road, where do we think we'll be, what our current development pipeline is like. And strongly advocate for additional investment in Ireland. So I'm a civil engineer by background. I've lived and worked in London for a long number of years before moving back to Ireland. My career's been entirely in property and construction, and the last 7 or 8 years, more, actually, 10, it's been in healthcare property.
In 2023, at the start of last year, we sold our business, Axis Technical Services, to Primary Health Properties, and that's a management business, again, primarily focused on healthcare properties. And we retained a company called Axis Healthcare Assets, which is a property development business, again, entirely developing healthcare property, and that's not related, so to speak, to PHP. So rather than traveling to Cork to show you one of our latest assets and indeed get a feel for what we do, here's a video of one of our schemes in Ballincollig in Cork.
Hello, my name is Sarah McAleer, and I'm Operations Lead for the Cork City South and the West Cork Integrated Care Programme for the Prevention and Management of Chronic Disease. Westfield Integrated Care Centre operationalized in Q1 2024 as part of the integrated care program for chronic disease and the management of older persons. In line with Sláintecare, the main aim of both programs is to move patient care out of secondary care settings back into patients' communities, closer to their home and in their own locality. This building here in Westfield Integrated Care Centre, we serve four community health networks, each health network with approximately a population of 50-60 thousand people. So the way it operates is those patients are cared for primarily by their GP in their locality, and then if they need specialist input, the GP can refer them into the hub.
So we have the largest catchment area in Cork and Kerry Community Healthcare in this building here with four networks. One of the highlights of the building that patients keep coming to us with is just accessibility. They find it very easy to access the building from parking to the layout of the building. The feedback from patients has just been tremendous. They feel very welcome when they arrive at the center. They find it easy to find their way around the building. Patients and staff are reporting that our Do Not Attend rates are lower than the national average. We're constantly going back to our service users and to our staff and, you know, looking for that feedback as well in terms of the building and what we can do to improve.
To date, we've found working with Axis PHP excellent, because anything that we've wanted to progress or improve based on service user feedback, we've been able to do that. As time has gone on, we've found opportunities where other secondary care services were very much suited to also being co-located with us here. In recent weeks and months, additional services, respiratory outpatients from the acute hospital here, older person services that are separate from ICPC, and also some vascular services have moved out. Actually, only earlier this week, a vascular service locally have reported back to me a reduction in a waiting list from five months to six weeks, merely just from moving location. The building just lends itself to, I suppose, it's a positive working environment. I think that's probably the best way to describe it.
I'm James Buckley. I'm the Managing Director of Axis PHP in Ireland. Axis PHP in Ireland goes back a while. I have a long-term relationship with PHP when we developed the first primary care center back in 2016, and PHP acquired a business, Axis, that I founded, along with my colleague, Brian, a number of years ago. So when the pandemic struck, the HSE put a call out for proposals for an enhanced community care center, and O'Flynn Group converted this building from an office to a primary care center. Some interesting challenges, getting the BER, or what would be known in the UK as the EPC, right, so good, solid technical challenges getting the building done.
The opportunity came to market, we acquired it, and the feedback from the landlord was wonderful, 'cause I asked him, "Why us?" And he came up, what he said, "You offered us a reasonable price, you put the resources at it, and you're the best chance of doing the deal." So it was great feedback to get from purchasing an asset that the vendor had the most faith in us. The tenant is the Health Service Executive of Ireland. The equivalent, the UK equivalent, would be the NHS. We have a long-term lease. It's a 25-year lease over the asset, and they pay service charge and rent. It's part of the national suite of these types of facilities, primary care and enhanced community care centers.
The great thing about the lease with the HSE, it's index-linked, so we have rent and service charge increases are in line with CPI. Axis and PHP in Ireland is probably quite different to the U.K. model. Lots of us are engineers by training, so we have a very high technical skill set. Because we do a lot of property development, health property development as well, you know, we have electrical engineers, mechanical. I'm a former civil engineer. John is a former structural engineer. So we bring a very high level of technical skill set. We're going to see three diagnostic centers that we've recently completed for a private health insurer in Ireland called Laya Healthcare, and again, that'll give other people a sense of the scale of what we do. The HSE is obviously the largest client.
Our portfolio in Ireland is some 74,000 square meters. The HSE are 85% or thereabouts of the income that comes off that. Activities here, everything is scheduled. Everything is diarized. People turn up. We heard earlier that the number of no-shows is very small. You know, it is a very different model to an acute hospital. We have a healthcare problem. We have a major housing problem. The healthcare is being addressed, and indeed, housing is being addressed. The whole opportunity in primary care and the integrated care is growing significantly. There's a new procurement program that has recently been launched. On the other side of the house, we're working through planning on several sites. So we've had a hiatus of at least 2 years where practically nothing has happened in our space. We anticipate there'll be significant growth in 2025.
The lead time is relatively long for these schemes, but certainly for the next five years, there's unlimited opportunity for primary and integrated care in Ireland.
I'm here at the Westfield Integrated Care Centre in Ballincollig. It's actually my third visit here since I started at PHP. Every time I come back, I am so impressed by what I see. This is the future of modern, flexible primary care schemes, and I'm so, so proud of what the team have done here. The technical skills and capability that we have at PHP is beyond, you know, anything I've seen in the market, and I'm really, really confident that we can build more of these in the future in Ireland, but also we can take this skill set into the UK. And the new government has a clear plan to focus on prevention and developing schemes like this, with brilliant surface car parking, good access in a proper community location, surrounded by new housing developments.
Great roadside visibility and good access is the future of primary care in the UK and in Ireland.
Thanks, for watching that video. Mark, the sun does shine in Ireland, as we have seen, there. We have evidence of that. So recapping of the video, I suppose, you know, the next few slides, I'm gonna chat to people about what the market is like in Ireland, you know, and explain and indeed promote why Ireland is a good place to do business. In terms of asset valuation, I think Ballincollig is probably number three in our portfolio, so there's a sense of scale, about the Irish market, whereas it's geographically small and population-wise small, the assets are very valuable. Most of our assets in Ireland have an A3 BER rating, your EPC rating, so, you know, they're good assets in that sense.
I first met Harry and David back in 2016 when they entered the Irish market, when they acquired the first scheme we developed in Tipperary Town. Since then, we've PHP have developed or acquired a total of 74,000 square meters of assets, and we have thankfully less than 1% vacant, with 600 and something square meters vacant, which is great. Mix of forward funded, straightforward purchase. What this has done, the time in the market, has given us strong relationships with the HSE and indeed with other developers there. So we have, you know, early information, and we know when things are happening. Our rent roll is strong at EUR 17-odd million, and CPI indexation makes part of our work very easy. The average value is significantly greater than the U.K. in terms of scale.
The WALT, really a lot longer than the UK. You know, we have the service level agreement or the maintenance charge paid for by the HSE. It comes directly to Axis or PHP, and we look after the assets indeed. So we have much better assets in as far as they're maintained, and we have strong legal agreements to maintain them. I mentioned earlier about a related company, Axis Healthcare Assets. So we have a pipeline agreement with Axis Healthcare Assets, where PHP have the right to acquire any future developments, we will do, and we'll show you a number of those later. And we have ambition to grow Ireland to 15% of the portfolio, and we are confident that we'll be able to invest something in the order of EUR 250 million over the next 5 years or so.
There's been a period of inactivity, as I mentioned. Now, thankfully, we're at the end of that, and the reason there was inactivity is rents were just uneconomic. Construction costs had gone up so much that the schemes just didn't work from a development perspective. There's a re-tender process underway from the HSE at the moment, with 50 plus locations coming out to the market on a phased basis. In Ireland, public competition sets the rent, so when we, as a developer, go in to make a bid for a site or a location, we choose what rent we feel works best. We don't have the District Valuer process.
All of our rents are subject to CPI, and indeed, the service charge is also CPI-led, and we're typically twenty-five-year leases, and many of them have an option to extend that by a further five years. The tenant structure is very much the HSE and the allied healthcare providers. And we see a strong move to enhance community care. So very much like what was said by Arvind in the previous words, we're having a significant increase in community care to relieve pressure on the acute hospitals, and you heard it in the video from Sarah and the HSE as well. So what's the next number of years going to bring? So the HSE in Ireland is being reformed very much along the lines of the integrated care boards in the UK. So we now have regional health authorities in Ireland.
There are six of them, roughly a million people per health authority. So historically, acute was managed differently to primary. Now, we have an individual in each of these regional health authorities who's ultimately responsible for acute, primary, and community care, so hopefully, we will see more joined-up thinking. Sláintecare, sláinte being the Irish word for health, has cross-party support in government, and the next two sentences are the HSE's, not mine. They're the aims for people to stay healthy in their own homes and communities. And they're, you know, doing this by developing and improving primary and community care. So again, as with the UK, a very strong shift into the community. Rents are increasing, so our rents historically were in the mid to late teens.
They're increasing now to the mid-twenties and in some of the big cities, higher than that, so we're seeing significant increase in rents. If there is such a thing as typical scale, we're up at probably 2,500 square meters. Again, significantly larger assets than would be expected in the UK. We have rental growth coming, or it's starting to arrive, because we've had CPI between January 2019 and January 2024 of 19%. So as leases will age and rent reviews come up, you'll see significant rent growth coming out of Ireland. To give you a sense of scale, the very first slide that was on the pack was Enniscorthy, which is a scheme we developed a number of years ago. That scheme, I think, was 16.80 a square foot rent.
The next scheme will be probably EUR 22 a sq ft. Something in the order of 30 or 35% of an increase in rents are coming for new schemes to make them economic. We see the rollout of enhanced community care centers. Ballincollig is one of the first. A small one has gone into our existing scheme in Mallow, and we know that there are others coming along the way as well. And I think an important thing to say is we're known as a developer and an owner of choice by the HSE. When Mark came to Ireland many months ago and said, "Do we change the name from Axis to PHP?" Some of the people in the HSE said, "No, Axis are really well known here.
Don't, don't change the name." So that was refreshing to hear from other parties, other than Mark, who wanted me to change the name. So, what does this mean for us as we look forward? Well, there are huge opportunities. I believe there are huge opportunities going forward in Ireland. I mentioned my desire to invest significant amounts of money, but we're looking at leases with 25 years, larger lot sizes, greater rents. We're in the euro area. You know, Richard will no doubt explain to us, you know, what that means in terms of our capacity to borrow and in terms of, you know, what that will hopefully result in, in yields or valuation improvements. We have a solid pipeline of development opportunities, and it's a really good market to be in.
Before I go on to the actual development opportunities, I want to tell you a little bit about Axis Technical Services, the business, so to speak, that PHP have acquired. So in my video, we spoke a lot about engineering background. So Alan, one of my colleagues, is here in the audience. He's a building services engineer by training. I come from a civil background. We've lots of different technical expertise. We've done a whole lot of work in different aspects of healthcare: primary care, theaters, oncology, diagnostics, and so that's the area of skill set that we have. We do, obviously, all the facilities and property management for PHP, and some of the other things we've managed to do, we've put concierges on sites.
The HSE pay for them, and these are individuals Mark will have met Eddie on site in Ballincollig, and they build relationships with patients as they come in. They build relationships with clinicians, so we get multiple levels of feedback and relationship from the HSE. Part of it is useful to know intelligence, what's coming down the tracks in terms of future opportunities. A lot of it is about getting early feedback so problems can be averted. This year, we hope to turn over our little piece of the business, something EUR 17 million, and make something like EUR 1.5 million in profit. So what does this technical expertise deliver? So, Arvind mentioned earlier about healthcare brands and the whole area of health and wellness. So Laya Healthcare is Ireland's second largest private health insurer.
We have a significant proportion of our population, like 47% of our population, has private health insurance, you know, by comparison to the U.K., which is obviously significantly less as a percentage. Laya is rolling out a whole series of health and wellness clinics across Ireland, obviously focused where people live in the population centers. Laya, out of a total investment of EUR 20 million, spent EUR 11 million with us on delivering these 3 primary care centers. These are urgent care, where you can get minor injuries dealt with, 10 A.M. to 10 P.M., 365 days a week, guaranteed to be seen within an hour. I'd love the HSE to be that good, but it's interesting how the private sector is starting to fill some of this space.
Laya is one of the largest health insurers in Europe, so we'd expect to see more happening in that whole space as well. The skills that we have. For Laya, we did the site finding. We helped them through the planning process. We did the project management. We were their management contractor, so there's a whole range of contractual and delivery skills that we have in Ireland. It was rewarding to be appointed by Laya to undertake this work, because they see us probably. They see us for what we are. We probably undersell ourselves. They see us having this enormous technical capability, and it's really refreshing to see it as that. So Axis Healthcare Assets. PHP do not take development risk, as Mark said, so we have a separate business that takes development risk in Ireland, unrelated to PHP.
Forgive me for teaching granny to suck eggs, so to speak, but there are four levers of property development: size, the economies of scale, that's working for us now. The rent is beginning to work for us. It historically did not work for us, which is why schemes didn't happen. Construction cost inflation was huge. It has now stabilized, so they are starting to work. With the interest rates reducing, we're confident that we will have significant rollout of schemes across the country. Our selection criteria for schemes in Ireland are schemes of scale. We're looking at 2,000 sq m or more. The fixed cost of developing property, whether it's 2,000 sq m or 20,000 sq m, are largely the same, so we want some scale. We love the ECCs as the HSE's a single tenant.
It moves the proportion of government income from 85% to 100%. Very attractive from ourselves. We're really cutting down our reliance on non-core revenue, so all the schemes really are going to have a healthcare focus. We will only bid for work where we've a strong relationship or a high probability of success, and the geography really is all around the east coast of Ireland, again, where the population live. So, you know, we target carefully, and these are some of the opportunities we have. So this is a scheme in Youghal, where we acquired the land earlier this year. We're due planning permission next week for nearly 4,000 sq m scheme. We have an AFL, Agreement for Lease, signed with the doctors. That capital value is something in the order of EUR 15 million.
Enniscorthy, the existing scheme is in the orangey rust color, and this is the new scheme in green at the back of it. It will effectively double the size of the Enniscorthy project. We have planning permission. We own the land. This is 4,500 sq m, and it's due to come back out to the marketplace very shortly. This is something in the order of 20 million EUR capital value. Donnybrook, in the heart of Dublin 4, this is a scheme that we've been working our way through planning for a number of years. We have planning permission. We have our fire safety certificate. We've all of the statutory bits in place. 7,000 sq m scheme. Again, it too is on economics, and it's back out to the marketplace in the next six weeks or so.
We estimate that's going to have a capital value of something in the order of EUR 40 million. And these are just the schemes that Axis Healthcare Assets is working on. Inevitably, there are other developers that PHP have relationships working on similar schemes. So in conclusion, there is an opportunity to deploy a significant amount of capital in Ireland. Right? It's clear evidence that the HSE are moving from acute to primary care. You know, we have very high quality assets. People have seen a flavor of them here today, and the private healthcare market is also continuing to grow. So we believe that there is. Ireland is a great place to do business and a great place to invest. Thank you.
Thank you, James. I'd now like to invite my colleagues, my team, up to the stage, and it'll be an opportunity for questions. Then we're gonna take a break. I should say, James, thanks very much for that very good presentation. We have the best portfolio in the Irish market, and also the best team, and from that moment you met Harry back in two thousand and sixteen, it's been a you know, very positive experience for all of us and a real benefit to the company and obviously to our shareholders, and it's very evident from your insights that there are big opportunities for us to go after in the Irish market, so thank you very much for that. I'll stand up and take questions. Where I need to, I will filter the questions to my team.
We've probably slightly overrun, so we've got ten minutes for questions, and then we'll take a refreshment break. We have some roaming mics somewhere. Over there. Who would like to ask the first question? When you do ask a question, please wait for the mic to come to you. Maybe just say your name and which company you come from, just so we know exactly who you are. I'll be very grateful.
Hi there. Thanks, Mark. Tom Walker from Schroders. Could you just clarify the ownership of the development business that James was just talking about, and how that relates to PHP? I'm just not entirely clear. Apologies if I've missed it.
I should point the question to James, but I can't resist. You've been stood up for a long time, so why don't I give you a break? Yes, so we don't own the development company. We like development, but we think about development on a risk-controlled basis. We have a very good relationship with James, his team. We own the technical services business, which generates fee income and manages our portfolio. But the good news is, from a PHP's perspective, we have an arrangement, and a right to first offer on development schemes that James and his colleagues are pursuing. It's a very attractive arrangement and one that we are very, very, very pleased with. James, do you want to say any more about that?
We have such a long-term relationship with PHP that inevitably anything we lay our hands on, Mark and everybody, you know, in PHP will know about it first. You know, the risk on the development is taken entirely by the Axis team, so we by the Axis Healthcare Assets. So we've invested several million EUR on buying land for various primary care centers across the country. Some of them are options, and there's work going every day in sourcing more assets in Ireland. But in terms of risk, there's no risk, no contractual, legal, ethical, or moral risk taken by PHP.
And so, just with the Axis Technical Services, you don't work for them?
I work part-time for Axis Technical Services and part-time for Axis Healthcare Assets. So we had an earn-out as part of our agreement so that there's a contractual relationship on that one.
And then Alan, without embarrassing him, I think he's in the far right far left-hand corner, is our Managing Director of the business day to day.
Thanks.
You'll get a chance to meet Alan afterwards, but thanks, Tom. Two very good questions. Did you have any more?
No. No. Thanks.
Thanks very much. We've got... Okay, we're going over here to, I think that's Andrew.
... Thanks, Mark. It's Andrew Saunders from Shore Capital. I've got a question for Arvind, if that's possible. We've read a lot recently in the press from Wes Streeting about prevention being better than cure, particularly when it comes to obesity, which is one of the key strains on the NHS. I wonder if you'd give me your thoughts on whether weight loss jabs are a silver bullet in that regard, and how might the primary care sector feature in their delivery?
That's a really good question, very topical. In fact, one of my Hurley partners was on the radio this morning, the Today programme, talking about it, Professor Dame Clare Gerada. So look, I mean, we have an obesity problem. It is definitely putting a strain on the NHS, not in as much as we're having to stand up obesity services. That's a relatively small sliver of resource, but actually the cardiovascular risk, the osteoarthritis risk is multiple, right? And actually, what's interesting with this group of drugs is they're not only helping with the weight loss, they're actually having a cardioprotective effect is emerging from the evidence. So I think at the moment, we're kind of at the early stages of understanding how to position it.
I think the aspirations for what it could do are actually quite big, but there's an acceptance that, you know, we're gonna have to lower the BMI over time, so the manageable cohorts of patients enter the primary care space to service that need, but actually I think it could potentially be very impactful for the population, but it will be a lot of work for primary care to oversee. Actually, this is not just a jab and forget, it's a lifestyle wrapper that needs to go around that and support mechanism. I mean, it's extremely exciting.
Thanks, Andrew. Do you have any further questions? Next question is just the middle now.
Hi. Again, another question for Arvind. I wonder if you can just talk a little bit more about productivity. You talked a little bit about productivity, but I wonder if you can just talk about property, and the premises from a GP's point of view about improving productivity, because clearly from PHP's point of view, you know, they want to lease better buildings with more rent. That doesn't necessarily, maybe it does, increase the productivity equation for the NHS. So why does having more modern, bigger buildings, you know, help solve the productivity problem, from a GP's point of view?
So I think the ability to co-locate staff from different sort of teams of teams approach, the ability to use the facilities so that actually it may change the nature of the buildings. We might need a lot of co-working space and maybe smaller waiting rooms. I suspect it may have some downward pressure on, you know, we'll see the end of the, you know, terrace house GP surgery, and more of those GP practices with their lists being amalgamated into the kind of facilities that James has just shown us. I suspect they will also change the nature of the services. So there are parts of Scandinavia where the GP practices do the urgent treatment and are open twenty-four seven.
So all of those things are in play, which actually have an impact on the estate, and we're right in the foothills of actually seeing how artificial intelligence is going to start impacting how care is delivered. To give you an example, yesterday I was in a meeting where we discussed, is there a possibility for the online consultations using natural language processing to create not just an LLM summary, actually, a navigator tool to say which clinician, what urgency, and what modality of response. If it says lump somewhere in the words that the patient has deposited, don't send that to a remote doctor 'cause they're gonna need to examine them. Send the patient a self-booking link. There are tools now emerging which are being adopted at pace around voice transcription.
You come and see me as a patient. I won't be typing anymore. I'm talking to you, and the machine is making me a beautiful medical note, which is actually probably better than the one I would write myself. And as you walk away down the corridor, your phone pings, and you look down, "Thanks for coming to see me today. This is our treatment plan. This is what patient resources for your problem. Here's... Look at this video. Look at this NHS.uk information." So I think we're gonna see a wholesale change around the mix of what needs to be done physically in a building and what can be done remotely and empowering patients. And with that, there will be a sort of expectation that...
I think there will be a growing expectation of what the NHS should offer me as a patient, and that in itself will lead to that widening range of services. I think the GP practice of the future will be a community asset that isn't just focused on healthcare delivery, it will be on well-being. And actually, we know that a bigger proportion of your health trajectory is related on the wider determinants of your health, your education, your housing, your employment, your pollution, and your postcode. And actually bringing together all the people in one space that impact those elements, I think is gonna be an exciting phase.
But it's not just about more appointments effectively going through primary care?
I would like to break the currency of ten-minute appointments. You know, at the moment, it's kind of, you know, 15% of people who need a GP appointment get left outside the door or give up on the phone at 8:00 A.M. on a Monday morning. We are not supplying according to demand. I would start to think about it as health touchpoints, and actually increasingly penetrating into your smart home and your phone and your devices.
We know that, for example, someone has a problem with alcohol, and it's usually Friday night binges, and we're gonna send them a notification saying, "Walk past that pub you're walking past right now, and don't go inside." I think it's, it will be a, you know, we'll take as much of it individually as we choose to into our lives, but I think the opportunity to really penetrate your daily existence with technology and the physical things that will always be physical. I'm always gonna have to feel the pulse of a diabetic's foot to see if they've got peripheral artery disease. I'm always gonna need to do that.
Thank you. That was a really good response. Good question. In fact, in the presentation straight after the break, you'll hear from Dr. Alex Baker at our scheme in St. Stephen's, Norwich, and she talks about productivity savings. I think she talks about GBP 1.2 million, but I won't give too much away, but you'll see that on screen shortly. I'm quite conscious of time, and I'm quite conscious that there's a virtual audience out there that's now starting to fire questions, some of whom are actually shareholders in our company, so I think I should at least prioritize one or two of those. Unsurprisingly, a lot of the questions are coming in for you, Mark. And many of the questions for you, James, about our Irish business. So I'm sorry to put you on the spot.
I could probably deal with this straight away myself, but I think you should elaborate. So, this is coming from Charles Stanley. Why the Irish assets feature a higher footprint? So why are they bigger compared with the UK, is the first question. Is it evident HSE are more commercial than the NHS? I don't expect you to respond to that, but I think we all agree. And what's the political perspective in Ireland? Perhaps you could just cover that for me.
Certainly, we'll do the size piece first. We've learned from the UK. You know, we came to the table a lot later, and we benefit from second mover advantage. We saw the mistakes that people were making in the UK, so we. Let's not have the District Valuer, let's have CPI increases, much more predictable. We've learned our lessons in terms of scale, so the buildings are much more multifunctional, much broader teams and back what Arvind was saying. So we have learned a lot of those lessons along the way. So that's the reason for scale, I think the first thing. In terms of the political context, we have a very stable political system in Ireland. Sinn Féin at the moment are digging holes for themselves all over the place.
I think most people, most commentators in Ireland would accept that we're most likely to have the same government or versions of the same government back in power in the next three-to-four months when the elections are due.
Brilliant. And so we finish on time. I think I'll deal with this. In terms of the size of the portfolio in Ireland, we're 9% today. We'd like that to be 15% or more. I think we've said that before, and we're certainly saying that to you today. There's quite a few more questions here, and we will have a chance to ask more questions in the room and virtually at the end of today's presentation. So to ensure that we keep to time, now is a refreshment break. We've got half an hour. If we could do it in less than that time, that would be extremely appreciated. So that concludes the first part of our presentation, and thank you all for your attention.
We'd like to keep you all here, but in the meantime, refreshments. I think bathrooms that way. Get yourself comfortable. Please come back into the room as soon as you can at your earliest convenience. Thank you very much. Great! Welcome back, everybody, and welcome back to all our virtual attendees who are attending online. Hope you had a chance to take refreshments and engage with the management team and ask all sorts of questions. We very much appreciate it. Our next presentation is from David Austin. David's our Head of Asset Management, and David has a very hands-on approach to asset management, as you will see shortly.
And I really enjoy working with David and his team, and I get to see firsthand, day in, day out, how David and his team deliver value through the asset management work that we do. David and his team are extremely tenacious, very hardworking, and have good technical experience. The good relationships that David, his team, and my colleagues at PHP have with our tenants and other key stakeholders are enormously valuable to the business, and I'm sure you'll see plenty of this as we go through David's presentation this afternoon. So hopefully that's a helpful introduction, David, and over to you.
Very kind. Thank you, Mark. Good afternoon, everyone. I'm excited to share with you some new insights into our work, actively managing the PHP portfolio. I'd like to start by introducing myself and my role at PHP. My name is David Austin. I'm a chartered surveyor, and I lead the asset management business at PHP, incorporating the property management and facilities management functions. Within my role, I'm focused on unlocking and creating value-enhancing initiatives to protect and maximize investor returns. By way of my background, I began my career as a graduate trainee with JLL, and I then spent some enjoyable time with AXA and Land Securities on the landlord side before joining PHP back in 2016. There are many definitions of asset management. This one I chose for today, the systematic process of developing, operating, maintaining, and disposing of assets in a cost-effective manner.
Asset management is a key area of activity for PHP. It is a source of growth on our doorstep, using assets we already own and know well, deploying skills and expertise we already possess, and leveraging the existing symbiotic relationships we already have with our tenants in the NHS. Our AM activities involve one or more of the following aspects: maximizing value, minimizing cost, managing risk, and improving efficiency. For example, for us, it's about renewing our leases as they come to expiry, to maintain the long-term security of PHP's income, a source of steady and growing dividends. It's about growing rental income by investing in identified assets to improve them in return for more rent and longer lease terms and by leasing void spaces. This activity also helps generate ERV growth, benefiting PHP rent review outcomes on comparable assets.
But it's also about reducing risks and about achieving operational efficiency and cost management, being open to advances in IT to enable data-driven decision making, good traditional property and facilities management, more emphasis on planned preventive maintenance to improve reliability and maximize the life of our assets, and strengthening tenant relationships to ensure the long-term occupancy and rental growth. We also contribute to identifying areas of underperformance and reviewing strategies to redeploy or recycle capital to maintain a focused, high-quality portfolio. So pulling that all together and looking forward for PHP, our asset management is a key area of activity. It's a source of growth, and it aims to create sustainable value for all stakeholders and involves keeping assets fit for purpose and high-quality, maintaining high occupancy, getting the best rents and best lease terms we can.
Along the way, we seek to improve environments for staff and patients and society in general in an affordable way. We're open to selling assets when the time is right, but ultimately, our focus is achieving the best risk-adjusted outcomes for PHP from its investments in primary care real estate. So let's look at how we're getting on this year. Year to date, we've completed 23 asset management deals, and we're well set to surpass 2023 activity in terms of the capital expenditure and the yield on cost, as well as the number of deals. And those 23 deals break down into four asset management schemes so far, which involve more material PHP CapEx, and these are reserved for our government-backed tenants. Seven lease regears and six new lettings in the UK, and six further AM initiatives in Ireland.
These have secured over GBP 1 million of rent, including GBP 350,000 of additional rent for the long term, with a WALT of 18 years. We forecast we will have committed GBP 10-12 million capital expenditure by the end of 2024, and be on target to achieve our yield on cost of 6%, all on long-term leases of circa 20-plus years, and that would create an additional income of 600,000-700,000 for the year, if we manage to hit that target.
Our asset management pipeline in the middle of the slide includes opportunities across all regions in the UK, Scotland, and Wales, and includes 39 identified projects at an advanced stage with an estimated capital requirement of circa GBP 31 million, delivering an average yield on cost of 6% to generate circa GBP 2 million of additional income for PHP in the next two to three years. By being active in all areas of the UK, we are able to deliver a steady flow of accretive asset management projects off the end of our asset management conveyor belt. While staying on the slide, I thought it would be important just to pause and talk about risk. We keep a close eye on risk, as some of the previous speakers, James mentioned, and there are a limited number of schemes concurrently on site.
There are six on site at the moment, and three of which are due to complete by the end of the year, which effectively means most of the money's been spent on them. All our schemes are done on a pre-let, effective pre-let basis by an agreement for lease with the tenants, so they're de-risked, and in all cases, they will have receipt of a written confirmation from the NHS for the higher rent that they're going to be reimbursed for the duration of the new lease. We only use specialist contractors, meaning the centers remain operational throughout. There's no gap in PHP income, and the value of the works, the duration of the work is relatively low. The value of the works is relatively low compared with new build.
The duration of the works is relatively short compared to new build, and we only use fixed sum contracts with our contractors, but because the value's low and the duration short, it means they're less exposed to inflation. Now, we would have loved to-- I'd now like to show you a video. We would have loved to take you all out on the road, but it was not practical, so we've brought an asset virtually to you. Long Stratton was acquired by PHP in 2020 as part of a portfolio with under five years unexpired lease term. This was our first net-zero asset management project.
We designed the scheme, we held the hand of the GPs to get the NHS approvals, we obtained planning permission, we supervised and paid for the works, and we've now got a video we'd like to show you, so you can see it for yourselves. We're here today in Norfolk to show you two recently completed PHP asset management projects at Long Stratton and at St Stephen's Gate in Norwich City Centre. Long Stratton is a settlement town about 11 miles south of Norwich, with a population of about 5,000 people. The practice serves a patient community that extends far out into the surrounding rural areas and has a registered patient list of over 10,000.
In 2023, permission was granted for the creation of a new road bypass for the town and for the building of 1,800 homes, which has since been expanded.
We could be looking at six, seven thousand extra patients in the next five to six years. I think the partners were very progressive. The practice was expanded in conjunction with PHP, and we had an extension built. That's given us seven clinical rooms in the extension, plus a clean utility room. We then looked at the rest of the practice and did a refit, which was desperately needed at the time, and we've converted some office space into another clinical room, giving us, in total, eight new clinical rooms.
PHP's strategy is providing medical centers fit for the future. That's going to fit into the NHS strategy of providing additional services, especially in rural locations like Norfolk, where they can visit the practice and see a nurse practitioner, phlebotomy, a mental health practitioner, pharmacist, or a paramedic, rather than having to travel quite a long distance to the nearest hospital.
Every room in the building's been updated. I think it's... It gives the patient some confidence when they come into a nice, clean facility. It's allowed the nurses to be in one area, and they have their own little waiting room, so it's consistency throughout the whole practice. It's easier for the admin and reception staff. They know where to find people quickly.
So that is where I think my life has changed, for the better, and I wouldn't have had all of this under one roof if I didn't have the space.
As part of the PHP project, ESG initiatives included air source heat pumps, and the practice also installed PV panels, to reduce their running costs, and we have EV chargers in the car park, and we also have LED lighting throughout the building.
As a result of the improvements at Long Stratton, the EPC rating of the asset has improved from a C to an A rating.
Without PHP's involvement, we wouldn't have got this done. They were involved right at the start.
This asset management project showcases our in-house asset management team's capability to support the NHS. We've increased the net internal area by 20% in return for a longer lease of 21 years and for a higher rent, which is a 40% increase over the previous passing rent.
We are changing the face of healthcare. The staff are fully on board with what we're trying to do. I really want Long Stratton Medical Partnership to be that center of the community and actually be part of what's going on in a positive way.
I hope you enjoyed the video. We enjoyed making it for you. Each time I see it, I keep smiling, and I must say well done to my colleague, Gemma, who was very much at the heart of that project. It's not bad, is it? We bought it in 2020. We handed the completed project over to the grateful GPs, early this year. That involved, let's say, designing it, getting the approvals from the NHS, agreeing a deal with the District Valuer, which we managed to do, getting planning permission, and it's now got 21 years on the lease, and a significantly higher rent, too. So, you know, that just to give you a flavor of what we're doing in the background. We're trying to do this all over the country.
The next slide I thought would be useful just to... I'll go through this slide quite quickly because a theme of today is talking about the drivers, so I don't need to, hopefully, I don't need to touch on all these for you, because many of these you've heard before. But I thought, you know, a couple would be worth pointing out, if I may. The first one is the aging stock, and the reason why I want to point this out is because it's been said a number of times already today that from a variety of sources, including the Darzi Report, we know that a lot of the primary care estate in England is very old. It is non-compliant, and...
But what we necessarily what we haven't necessarily shown you or shown is this optic in terms of well where does all of PHP's properties then sit? And what we're saying there is all of PHP's properties would sit in the top 20% by age of all the primary care centers in England, which should mean they should get the top rents. It should mean that they're going to be primary care centers for many, many years to come. What it is meaning is that the NHS's priority should be the orange and the yellow segments in particular, which is the 71%, which they would say is, in their words, tail assets not suitable for the long-term vision of the NHS and ones that they would most likely be looking to dispose of.
And what we can say is that we're benefiting from that. We're benefiting from that in the form of requests to build extensions on our existing buildings. We've just seen Long Stratton, where we said we increased the net internal area by 20%. Over the last few years, we've built extensions on 17 assets in a similar way of that. The average net internal area we're getting across those 17 assets, it varies. Sometimes it's a bit lower, sometimes a bit higher, but the average is 20% of extra net internal area, giving us twenty-year plus terms, higher rent, and the key thing is it's usually on land we already own.
So, the other point I wanted to draw out from this slide is, if I may, this is a point around the scarcity of suitable alternative sites. And that we're blessed with very high tenant retention rates at PHP. The tenants have very limited options at renewal, given the muted development activity in the market, and because they have to be close to patients, and patients obviously don't move en masse, and the governments can't abandon the patients. And in any event, many of our tenants, as hopefully came over that video and will come through today, many of our tenants actually like us.
They like the service, the hands-on service we give, and having their current premises refurbished and extended by PHP is usually their preferred choice. And all of our buildings were built with a design life of about 60 years. So when we're talking about expiry on a 20- to 25-year lease, they're really only at their first trimester, so they really have got plenty of life in them. They're better proportioned, and they really do lend themselves to refurbishment. And once you're inside them, then generally you wouldn't know whether you're inside a refurbished PHP asset or a brand-new one. The rooms will be exactly the same in terms of how they're equipped out. Right.
Okay, so the main areas of opportunity for us will be in the UK, where we've got more leases that will be more mature and coming up for expiry. Our typical asset management activities include lease renewals, leasing void spaces, and surrender and reletting. Our typical works include refurbishments and reconfigurations and building extensions. Our GP practices want to improve their premises for a variety of reasons, and we say that by doing that, they're unlocking the value in their tenancy with PHP. To give you a flavor of some of those reasons, this is perhaps more micro level than the higher level macro drivers, is to provide a modern, more user-friendly environment for staff and patients.
From a staff perspective, there's a war on talent for staff, and they're trying to attract new staff. Then potentially having a nicer premises will assist them and helps them retain that staff. They like to create additional clinical spaces that will adapt easily to future needs. They wish to prepare for new service delivery requirements, so if they offer new services, obviously, then they will get paid more by the NHS, and it will make their practices more sustainable and more profitable. Sometimes they want to co-locate services on a single, more convenient site or merge with another practice. And sometimes it's, they're looking to reduce their overhead costs, and they're interested in energy efficiency and on-site power generation. And to the point, we talked about productivity.
From our perspective, in terms of productivity, it would be about enabling the tenants to have the space they need to move their business forward. An example could be about waiting areas, because GP tenant practice bring people into the building, having triaged them more than they ever did. At certain times, the waiting areas might be overly large. So we look at how we can put in folding walls, like you would have in an office, so that potentially, at quieter times, they can pull those across and create additional clinical or areas where they can see patients and use it in different ways. But if they then have a lot of patients coming in, they can push the walls back, and they can have the wider area that they might need to cope with additional capacity.
So we're looking very carefully at how the needs of the NHS are changing, and we're looking to cater for those needs and stay and move with them. You can see from our on this slide that our key objectives. We're being very disciplined about our deployment of capital. We're targeting a yield on cost of 6% on average, and we're very, very disciplined in making sure we keep to that. I would say to you that opportunities abound in the portfolio, having been here since 2016, having been around all the sites and met so many of our occupiers. There are lots and lots of opportunities.
Our pipeline is full of them, and you might say, "Well, why don't they all come forward?" Well, one of the reasons is we want to transact on a business basis that's accretive in terms of our returns. We know they're not going anywhere, so we're looking to move the rents on sufficiently, so that it's profitable for PHP and affordable for the NHS. And we feel that, and we see this as a multi-year opportunity. So, it's ongoing. It could be we refurbish a center, but don't build an extension, and the GPs might call us up and say, "You did a great job.
Could you come and extend it for us?" So there's, it's because we build these relationships with these tenants that they want to work with us. So I'd now like to show you a second video on that note, if I can. Now, this one is of another property in East Anglia, and it's called St Stephen's Gate in Norwich. This asset was purchased in two thousand and five and is located, as I say, right in the center of Norwich. It was originally let to a GP tenant practice for fifteen years. And the lease has been renewed by PHP, you'll hear in the video, for twenty-one years at a higher rent, which again...
Like at Long Stratton, at St Stephen's Gate Medical Practice in Norwich, we've also added value through asset management. This is a progressive GP practice with eighteen thousand patients in close proximity to Norwich City Centre. This has been a really good example of how we've sought to understand the needs of our GP tenant practice and how they wanted to develop their business to meet the needs of the population and the local NHS.
We wanted to challenge the concept of what would normally be provided. We talked to them about building an entirely new theater on-site, which was a project which not many people have done. There's a huge amount of mechanical engineering stuff that needs to go on.
With the construction of the new day surgery suite, a big part of that was the new air handling and ventilation system, and that is a big piece of plant that's located up on the roof, and then the ducting comes all the way through the building and serves those treatment rooms and the adjoining observation and recovery rooms to allow the practice to offer those surgical procedures to take some of the pressure off the hospital setting.
We've been able to free up a lot of capacity within our local hospitals, and we've also been able to provide quality care for our patients in the community in a timely way, and we are 100% NHS providers. We're currently running at around about 5,000 surgical procedures per year. This includes, if I remember them all correctly, hernias, cataracts, YAG laser, oculoplastics, hands, so carpal tunnels and steroid injections. We also work with spinal services, and we are constantly in negotiations or trying to contribute with other surgical specialties, in particular, urology and gynecology.
We've got a structured environment. We're small enough to be not daunting, like going to the hospital, but it's a professional building. You're clearly in a health center, and we've managed to create space that is structured, is signposted, and is designed for patient throughput.
We've been able to invite in and host numerous members of the sort of MDT and additional roles within the NHS. So we have a clinical pharmacist, mental health professionals, we have dietitians, we have a physio, to name but a few, and we've been able to do all of that in a building like this.
In return for its investment, PHP renewed the lease with the doctors for a new twenty-one-year term.
Our partnership with PHP has enabled our day surgical unit, Intus, to provide high-quality, cost-effective care in the community. We've been able to grow our services. By providing this second theater space, we're able to do even more incredible work, and this has enabled us to save the NHS over GBP 1.2 million, which is something we're just incredibly proud of.
So we chose that asset management project because, as you can see, the reasons for the GP practice wanting to do a deal with us were slightly different. They didn't want more space, but they wanted their existing space reequipped so that they could do these surgical procedures for this contract to the NHS, and they're saving money for the NHS. And I should say thank you to James. My colleague, James, is here, who was at the heart of that project. Well done, James. This next slide is probably the one that's gonna catch your attention, and this is to try to illustrate to you how our asset management is helping to drive rental growth. We're focused on East Anglia, where you've seen the two videos.
The four dots in the top right-hand corner, the four dots in the blue, relate to three completed asset management projects at Bradwell, Norwich, St Stephen's Gate, which you've just seen, Long Stratton, which we saw the video of, and Sprowston, which is another project which is currently on site and due to practically complete in quarter one, 2025. What it's showing is that over those four completed projects, we've increased rents on average by 10%, and we've got three further pipeline projects, which we haven't actually told you where they are deliberately, because they're subject to the finalization of the deals.
But we've got three further pipeline projects where we are in negotiation, final negotiation with the District Valuer, and rents are on the table, which gives us confidence that we are going to further increase the rental tone. It started off at £171 per sq m at Bradwell. It's now at sort of 220 to 220 at Sprowston, and we think that it will move on that level to 222 through these extra schemes. The point to point out is you can see that the rent per sq m increase seems to be rising, and now it's +20% for the advanced pipeline schemes.
There are nuances in each property, as each property is unique, as you'd imagine, but it's the upward trend, progression in, through, from the asset management deals that I wanted to show you, that's how we're helping the rental grow the rental growth. That should provide comparable, helpful comparable evidence for our open market rent reviews. In fact, looking at our rent reviews in the eastern region, which is this one, as at quarter three, we have 43 outstanding open market reviews, involving GBP 6.4 million worth of rent, and the majority of 2023-2024 reviews.
And we're currently and conservatively expecting that they will yield about GBP 500,000 of additional rent, which is 7%, and that would be in line with those earlier asset management schemes. Now, if we can capture some or all of the benefits from the later schemes through our reviews, then that could mean that additional income could be more like GBP 1 million and +15%. So it's with any market, if there's no development activity going on, you're looking at where open market rental evidence is being created.
Obviously, the evidence we can create is the next best evidence, and the beauty of the discussions we have with the District Valuer is it's not a sort of cost-based discussion, it's a value-based discussion, where we're offering to improve the premises if they can provide a rent, which gives us an acceptable return. So my last slide, this is my concluding slide. I'm proud of our in-house asset management team, some of whom are in the picture here. We couldn't get everyone here, but there's more. We have built the team since 2016, and it has contributed to the sector- and market-leading risk-adjusted ten-year total returns over the last three years that the company's achieved. Their expertise spans tenant engagement through to on-site completions, and the team follows a multi-stage process, which is full life cycle.
From project creation through documentation to completion, we hold the hands of the GP tenant practices and provide a bespoke service. To conclude, the team knows the idiosyncrasies of the sector, they know the assets well, and they know how to get the all-important NHS approvals. I believe looking forward, we are well set to continue actively managing the PHP portfolio to deliver value in the various ways we've seen described to you in the slides and in the videos, in order to protect and maximize investor returns. Thank you.
Thank you, David. There is a huge unmet need for new primary care estate. Darzi tells us 50% of the primary care estate in England is unfit for purpose. PHP is ideally placed to meet that need for new investment. This is one of our completions from 2021. It's Victoria Medical Centre at Eastbourne, and it's fundamentally changed primary care for 30,000 people. In addition to seeing their GP team, they can now get physiotherapy, have minor operations, cardiology, access mental health services, and social prescribing, all from a team of 20 GPs and 100 healthcare professionals. None of this would have been possible without PHP's new premises. I'll return to Eastbourne shortly. And yes, there is a video. So here I am. I'm Tony Cooke. I'm PHP's development director.
I've been twenty years in primary care development across GPI, MedicX, Octopus Healthcare, and PHP. My teams and I have completed over thirty schemes across England and Wales, from single GP practices through to service buildings with multiple occupiers and a bedded ward. Why such a long time? Why, oh, why do I still look happy? I, I'm lucky. I am both lucky and happy. I thoroughly enjoy what I do. Development's about people, it's also about talking, which is brilliant, relationships, financial, practical, and legal challenges, and making lasting, beneficial change to communities. What's not to like? As we've heard already, there's a huge challenge for healthcare in the U.K. Government and the NHS now realize that primary care is at the front of delivering that change. New estate's integral to meeting that challenge, and PHP is ideally placed for that opportunity.
Our Eastbourne development at the start of this deck is a great illustration of the challenges for primary care and how new estate enables lasting change. So we have four practices going to Eastbourne, and three sets of their premises are on the screen here. So we have a thirties house, we've an Edwardian villa in the center, and we have a lovely four-story Victorian villa with no lift and a wonderful long access ramp on the right-hand side there. The practices were small, organizationally fragile, and struggling to attract and retain staff. Those are common problems across primary care and are only magnified by service demand being at an all-time high. The project illustrated the collaboration at the heart of the development across the practices, the NHS, and PHP.
There was an agreed need for service change, and that change has been enabled by the building. The government and the NHS agenda is to fundamentally change matters, so let's see how PHP, this is the video intro, with the practices and the NHS commissioners, was able to make lasting change at Eastbourne. Victoria Medical Centre in Eastbourne reached practical completion in late 2021. It enables the delivery of medical services to 30,000 patients via a single primary care network. Long-term trends in the health sector are for delivery of primary care at scale and the delivery of a wider range of services in the community rather than in acute settings like hospitals.
So the Victoria Medical Centre is a brand-new, state-of-the-art building. It has something like twenty-seven consulting rooms and two operating suites and recovery rooms, and it has a large office for all of the doctors. We've got nine paramedics. We'll be getting more in due course. We've got the full pharmacy team, and the advanced nurse practitioners, and the physiotherapists. It's a magnificent building. It's much, much bigger than what we had in the past.
It's enabled the merger of four GP practices. In order to achieve service change, they really couldn't continue with the small businesses that they had delivering services, and what they needed to do was bring those practices together to enable a much stronger service delivery and a much stronger business model. Alongside that, all four practices were delivering services out of converted houses, which were fundamentally inappropriate for modern service delivery. So what the building and the service model together have been able to do is to significantly transform a comprehensive range of services for healthcare for that demographic in Eastbourne.
In the past, we had the smallest surgery in the territory. Now we've got easily the biggest surgery in the territory. We are, I believe, the second-largest health provider in the town after the hospital.
There's minor operations. There's community cardiology. There's social prescribing. There are mental health clinics, all alongside the usual range of general medical services delivered by the practices.
The operating rooms are deliberately on the ground floor because there's a very quick access straight through to the back to the ambulance bay. We can actually undertake more larger operations, and we'd be able to offer things like the dermatology side of removal of more minor lumps and bumps, which we've never been able to do because we've never had the space in our previous premises. With the rooms that we've got, we can certainly undertake plastic procedures, some ENT procedures, eye procedures, and we're hoping to bring in hospital consultants. We have community diabetology, dermatology. We've got community cardiology are already in the building, heart failure teams looking to come into the building, so we're really trying to drive forward on the services that we can provide for patients.
What PHP properties like Victoria Medical Centre achieve is a modern, sustainable, widespread general practice, delivering a wide range of services and allowing the shift of services from an acute setting into a community setting, so providing tailored services, but not just general medical services, but also services focused on the elderly population, which prevails at Eastbourne.
When we were designing the building, we took into account the patients, and we found that mostly the least mobile patients were seeing the nurses and more mobile patients were seeing the doctors, so we put the nurses as near to the front door as we possibly could.
In terms of remote and digital consulting, the building is fully designed to accommodate that, so it really boosts the ability to deliver those services. The building is at, right at the forefront of modern, sustainable design and operation. We have no fossil fuels used in its heating or ventilation. It's fully electric. We have on-site generation through solar. The building has full LED lighting and has a fabric-first approach, which means it's very highly insulated.
We're getting an awful lot of positive compliments and letters and cards coming in, saying it's fantastic. It's so different to anything that we've ever had before.
What this building brings is a modern, fresh, and invested environment to people engaged in the delivery of primary care services. You feel invested in. You feel as if you wish to give more. It attracts new people to the business, and it retains existing staff.
My partners love the new facility, the doctors. Everybody working here loves the new facility. It's, it's incredible. There's a feeling of space. There's a feeling of family. There's a feeling of getting together.
What the building and the operations have crystallized is really a very strong, and dynamic, and collaborative arrangement between the local commissioners, the GPs. We're happy people together.
I am very proud of what we've delivered here. I think it's absolutely the way forward, it is the future, and it is a fantastic opportunity for our patients, and the services that we can deliver are incomprehensible to what they were in the past.
So how does all this demand get manifested? We're on record identifying a medium-term opportunity for primary care premises at £3 billion-£5 billion. Now, this all will come through NHS England. NHSE is a huge organization, and it's run locally by 42 integrated care boards, the ICBs, and those are the organizations that will be responsible for commissioning the new premises. NHSE, as the strategic authority, has tasked all the 42 ICBs to bring forward their own estate strategies, and the deadline on those was the end of July. But it's the NHS, so some of them have done them by the end of July, and some of them are still doing them. But those will go through as drafts to NHS England, and those drafts will be used to inform the capital requirements of the ten-year plan due next spring.
Not many of the strategies are actually in the public realm, but there's some bullets here on some of the ones that we have seen, and the numbers are quite significant. You know, GBP 875 million across three strategies there, just on primary care estate. Now, how is all this estate going to be funded? Well, it's going to be funded through capital. Where's the capital going to come from? Well, it's two sources. It's either from the state, from NHSE capital, or it's from the private sector. PFI, as we all know, is no longer available. Public sector capital is fundamentally constrained. Now, I know we're hearing that more is going to come in, but bear in mind, that's going to be competing against education, defence, transport, hospitals, backlog maintenance, and RAAC.
The scale of the proposal, we think, is therefore very significant, and we also think that the most likely route is through private sector capital, which PHP is ready, willing, and able to invest. It's worth just touching, and this will be quite superficial because otherwise everyone's eyes gloss over and it becomes deadly dull, but on commissioning. GPs as private businesses, usually unlimited partnerships, contract with the local NHS to deliver primary care services to a given population, the list. That contract, usually referred to as a contract for general medical services, GMS, obliges the NHS to reimburse the cost of the space that's used for delivering those services. Fortunately for all of us, the contract, the GPs in particular, the contract has no end date.
But that gives rise to our investment proposition, the quasi-state covenant on a lease to GPs. Now, as a result of the value for money process that the NHS uses to determine that reimbursement, the current level is some 20%-40% lower than the cost of delivering new estate. Now, unfortunately, the process fails to recognize the construction industry inflation, that we've experienced and the yield expansion that we've also seen. It's no surprise, therefore, that deployment of private sector capital into the market has stalled. Fundamental change is needed if the government and the ICB's ambitions are to be delivered. In order to attract private sector capital, rents will need to recognize the cost of new premises. So why will rents rise?
Four days after starting the new government, Wes Streeting, on the right here, and Amanda Pritchard, the Chief Executive of NHSE, nipped up the road to a North London surgery and made some pronouncements about primary care. Wes Streeting said, he was going to fix the front door to the NHS by allocating a greater proportion of the NHS budget to primary care. That's quite a commitment. So it doesn't just say, "We're going to give more money to the NHS," it says, "The amount of money that we're going to give is going to be more focused around primary care." It therefore offers the prospect of significantly greater levels of funding into primary care. Subsequently, we now have the Darzi review and the commitment to a ten-year plan for the NHS in spring 2025, less than nine months' time.
So Wes Streeting talked about fixing the front door. Now, to extend the analogy, it's not really much good fixing the front door if 50% of the rest of the premises are inadequate. Put simply, delivery of the government strategy and the NHS strategy requires significant investment in primary care premises. State capital is in short supply, with myriad other demands. Private capital is available through a proven and simple model of development in an established market. Now, turning to individual project management. A key message here is that we have a disciplined and selective approach to projects. For any project, we can have significant variables and challenges. We work closely with the key stakeholders. We don't spend any money until we're satisfied on ICB and GP priority, which are pretty straightforward concepts.
But we also work at the same time to identify the capacity for realisation. Now, what do I mean by that? Well, I mean things like this: the GPs will stand there and say, "Well, we'll take a lease from you, but, we're insistent on six-month breaks throughout the term." Patently unfundable. Walk away. The GPs will say, "Well, yeah, we'll take a lease and we'll move, but unfortunately, we've mortgaged our property up to GBP 1,000,000, and unfortunately, the alternative use value is only GBP 500,000, so would you mind awfully just accommodating GBP 500,000 in your development appraisal?" The answer to which is generally no. Walk away.
On the assumption, and, you know, through that process, we get to agreed capacity for realization, we then move forward to our initial external control of an approved outline business case. And what this does is elicits the approval of the ICB to a given size of premises and a financial model, and crucially, a level of rent which meets our KPIs, 6% plus yield on cost, 10% plus profit on cost. We get to that point without significant expenditure. We then move forward, and we work to a board-approved level of WIP, sufficient for us to get the project to legal close with a number of stages and controls internally to move that project forward.
And we certainly will not take a project to site until it's de-risked through a fixed price design and build contract, with full revenue sign-off from the ICB, alongside exchanged agreements for lease. Last slide. The opportunity. We see the opportunity as very significant, with increased lot sizes, with multiple occupiers. This is not new ground for us. The images that you see on the right here are schemes that we have on site. Our scheme at Croft in West Sussex, in the middle, our scheme at South Kilburn, which is a fit-out on the ground and first floors of that tower block. We've 11 schemes, though, locked up in commissioning, of which Spilsby at the top there is one. So not new ground for us. We can see a big unlocking of the system.
We expect lot size to increase, and our expectation, conservatively, is for us to have at least six new schemes per year, combined GBP 45 million capital cost, maintaining our KPIs across profit and yield on cost. You've heard today, it's clear that primary care patients will be a winner in all of this, benefiting from much-needed modern GP surgeries and healthcare centers, which will support community needs in a far more effective, efficient, and localized way, and it's PHP that will enable that change. Thank you very much, and now it's Richard's turn.
Thanks very much, Tony. This afternoon, I'm gonna focus on the key drivers that underpin PHP's progressive earnings and dividend model, rental growth, and the cost of debt. These are also the top two issues we ask about on our usual results roadshows. Firstly, a bit about myself. I've been the CFO of PHP since 2017, and notwithstanding the pause in investment activity we've seen over the last few years, it's been a period of significant growth and change. During my time, the portfolio's grown from £1.2 billion to £2.8 billion, with the acquisition of MedicX in 2019 being the most significant event.
We've also spent a lot of time raising new equity and, more importantly, refinancing the group's debt book to successfully lock into historically low interest rates, which has provided significant protection to the group's earnings over the last two years. We've entered the FTSE 250, further extending the group's liquidity and investor reach and attractiveness to the community. We've internalized the management structure, generating GBP 4 million of cost savings, resulting in one of the lowest EPRA cost ratios in the sector. Including my time at PHP, I have over thirty years' experience in the listed real estate sector with a number of well-known FTSE 250 companies. Importantly, I've been through a number of economic cycles and have experienced both the good and the bad times. Firstly, I'd like to look at PHP's disciplined approach to both investment and management.
As you've heard from the previous presentations, we're keen to emphasize that investment activity is only ever undertaken if it is accretive to earnings, and this is even more critical in today's interest rate environment. As James set out earlier, Ireland continues to be our preferred area of future investment, and we're keen to take advantage of our significant strengths and competitive advantage in the country, along with a significant difference in UK and euro interest rates, and if you look at five-year swap rates today, there's around 150 basis points of difference, and you overlay that with higher, better yields in Ireland, we get a significant pickup to our earnings from investing over there.
We're currently undertaking a forensic review of the organic rental growth that can be derived from our existing assets, and consequently, we will look to recycle those with a lower rental growth outlook into higher growth opportunities, which we've highlighted today. As Mark mentioned at the beginning, we're also keen to explore potential JV opportunities into adjacent sectors, leveraging the strength of the PHP platform and team, and he'll come back and talk about that a bit later. PHP will always look to maintain a significantly fixed or hedged-out debt book, and today we have interest rate protection across 95% of the debt book, which will see us past the worst of the current spike in interest rates.
We expect the impact of compounding rental growth and the growth coming through our asset management projects and developments that Tony and David have highlighted already will continue to offset high interest rates, the impact of higher interest rates, as we eventually will have to refinance the group's debt book, and I will come back and discuss that in a bit more detail in a moment. Next, let's look at rental growth, which underpins both the group's future earnings projections and the portfolio's value. In this morning's Q3 trading update, we announced a further GBP 2.4 million, or just under 8% of rental growth from our rent review activities, and we expect this to increase further to GBP 3 million for the full year.
Importantly, we have seen open market value growth increase to 2%, continuing the positive trend we've seen in recent years, and today our forecasting is for growth to 3% over the next few years, driven by the initiatives across the portfolio that both David and Tony set out earlier today. Let's not forget that reviews in our sector are typically on a three-year cycle, so we capture the reversion much more frequently than the other real estate sectors, notwithstanding the time it can take to agree these reviews with the District Valuer; they do get backdated to the original review date.
Two-thirds of PHP's portfolio in the UK is reviewed on an open market value basis, driven by build cost inflation, and the significant increase in these costs in 2022 and 2023 has really yet to feed through into our rent review results, which relate mainly to years prior to 2021. Indexed and fixed uplifts make up the balance, which provide an element of certainty to our future rental growth outlook. As James has already mentioned, all rents in Ireland are linked to Irish CPI, and that is capped at 25% over a five-year cycle, and in the UK, only a quarter of the index portfolio has caps and collars, which are typically between 12% and 6% over a three-year cycle, which will allow PHP to capture most of the recent inflation in both the UK and Ireland that we've seen.
Most of you will be familiar with PHP's approach to debt and leverage, but for those of you new to the story, PHP has always looked to drive returns to shareholders using leverage at rates slightly higher than most other REITs, because of the security and longevity of the group's income profile and the limited exposure to development risk. Consequently, we have a leverage target of between 40%-50%, and today sit at 48%, albeit with significant financing headroom in excess of 300 million GBP. We have no plans to access capital markets in the short term. The group's average cost of debt has remained stable at around 3.3% for the last couple of years. We were forecasting this will increase to 3.5%, as certain refinancing issues fall due next year.
Interest cover and net debt to EBITDA ratios remain healthy, and obviously, we are keen to see these improve through our rental growth and asset management initiatives. Lastly, covenant headroom, with the relevant one for PHP being loan-to-value, today sits at a healthy one billion or 38% decline in values before these are hit, and that would imply the net initial yield across the portfolio has ballooned out to 8%, which we think is highly unlikely with interest rates now on a downward trajectory. PHP is not immune to future refinancing risk, and we spend a significant amount of time looking to develop a broad range of lending partners and to get the best deals for PHP to minimize the downside risk of future interest rate volatility.
Clearly, PHP has benefited from historic financing undertaken, with 95% fixed or hedged out for just under a weighted period of six years, and earnings have been significantly protected through those actions. However, we're not complacent. We've carried out a number of refinances in the current year with a view to the future and managing interest rate costs. Firstly, we've addressed refinancing risks that fall due in 2025, with a new GBP 170 million loan with Barclays. GBP 70 million of that has been used to repay a legacy variable rate bond, and this resulted in a 90 basis point saving in the margin.
We've also looked to extend PHP's shorter dated revolving credit facilities, extending the maturities out to 2027 and 2029, at which point we see an opportunity to potentially carry out a significant refinancing event, locking into the new long-term interest rate outlook, which will have hopefully stabilized at that point in time. Please note that of the GBP 620 million of facilities maturing in 2026 and 2027, over GBP 300 million remains undrawn today, and we have a further GBP 320 million as options to extend out further to 2029. We believe there's minimal refinancing risk, and our lending partners, including the convertible bond market, continues to remain very supportive of PHP and often keen to increase their facilities, demonstrating their continued long-term confidence in both PHP and the sector.
Hopefully, we have demonstrated today PHP has a clear and consistent strategy with a responsible approach to business integrated into everything we do. Ultimately, our aim is to deliver progressive returns to shareholders, and we believe our strategy has delivered results. We're extremely proud of the twenty-eight-year dividend track record, as set out in the chart, which will be very familiar to most of you. We consistently outperform both the wider real estate sector and our nearest peers, and our approach has been recognized. At the start of this week, we were announced as the winner of MSCI's ten-year Risk Adjusted Return Award, which is our third consecutive year in a row. As already mentioned, rental growth, along with accretive investment activity, will enable PHP to carry on with its progressive dividend policy.
Our disciplined approach to management has resulted in one of the lowest EPRA Cost Ratio in the sector, and then, as announced with the group's interim results in July, we've completed a further GBP 1 million of cost savings, which will feed through into our 2025 results. I will now hand back to Mark, who will sum up before we have Q&A.
... Thank you, Richard. Very informative as always. So we're coming to the final session of the afternoon, and we will have plenty of time for questions at the end. Today, you've heard from James, from David, from Tony, from Richard, and from Arvind. I've loved the videos. I think they're excellent. I think it really brings to life what we do. I've really enjoyed watching them, and we've got lots more Long Strattons and St Stephen's in our portfolio, and we'd love to do more Ballincolligs and Eastbournes, clearly. Hopefully, you can see, like I see, we've got the team, the technical expertise, the knowledge and the experience to do this, and why we, as a management team, are extremely optimistic about the future of PHP. We remain steadfast.
We will not distract from the fact that this is a resilient business with a long-term track record of success in a sector that's clearly going to grow. Our core portfolio is in a good place. That's evident from the presentations this afternoon. We've got identified opportunities to expand. We've shown some of those to you this afternoon. We've got clear opportunities to grow in Ireland, and James was clearly evident talking to us about that earlier. And in the UK, we can grow. We can look at joint ventures. We've got the skills, the knowledge, the expertise. We can leverage the platform. We can look at adjacent healthcare sectors where that skill set, that relationship, that knowledge is evidently transferable.
I was really excited about taking this role on about a hundred and twenty days ago as CEO in April, and I've now got to know the business really well and the opportunity that I've had to spend time with the team, visiting the assets, and I'm even more optimistic now about the significant opportunity that lies ahead for PHP and our future prospects. PHP and the management team are dedicated to continued dividend growth. I may have said that a few times this afternoon. I hope that's coming across. We will do this by having a forensic focus on earnings and rental growth, and I really hope we've been able to demonstrate that to you this afternoon. We have a very resilient business model, and you can see from everything that we've shown you this afternoon that there are significant opportunities ahead in our sector.
I've talked about joint ventures. We've talked about community diagnostics. We've got the technical skills to do all of this. We think the opportunities are coming our way. We've talked a little bit about health and wellbeing. We think there's opportunities there. All these are adjacencies and sectors. We've got the skills, the knowledge, and the deep relationships with the NHS, the HSE, and all the stakeholders that you need to pull all of this together and create value for our stakeholders. We've got a winning strategy at PHP, and so many growth drivers that will enable us to achieve our goals and deliver that shareholder value. That's very, very important to our company. On that positive note, I'd like to welcome my colleagues back to the stage, if that's okay. We've managed to do all of this to time, which is extraordinary.
Maybe it just reflects the amount of preparation that we've put into this afternoon. We've had your attention now for a hundred and eighty minutes. I think that's two football matches, one after each other. Hopefully, you feel it's been a Premier League performance by the team. I won't comment on myself. I think we're gonna go... We'll go room first. There's questions flying through here on my screen remotely. So we'll definitely deal with those. Not least, we've got shareholders wanting to talk to us, and they're very important people. So I'm gonna open the floor to questions, and we have two here in the middle. Again, just to remind everybody, if you could just, even though we know who you are, not everyone knows who you are, just say your name, your company-
Yeah.
and rest your question.
Angelo from Cohen & Steers, and thank you very much for the presentations. I have two questions on organic rental growth. The first one is on the table that you showed, related to the refurbishment. Is there any inverse relationship between the growth in the second derivative of the rental growth and the time from since the last review? Because we know some of your reviews, they are taking a little bit longer than others. And the second question is, the 3% organic rental growth, is that on the entire portfolio or only on the portion of the portfolio that has been reviewed and settled? Thank you.
David, do you want to deal with the first question?
Do I understand the question correctly in terms of if the reviews predate the date of the refurbishment?
No. So if, for example, you have a, you showed that the organic rental growth increases from the 7% on the ones that you recently completed to-
Mm-hmm.
-24% for the ones you could be on site with.
Yes.
Are the ones potentially clocking the 24%, dating back to a longer time since the last review? So you're taking a rent roll from, say, like six or seven years ago, versus the one where you see the 7% rental growth there-
Yeah.
But dates back to, I don't know, like two years ago, for example.
Yeah, I know. Yeah, I see what you mean. I think,
... The starting point on some of those schemes was quite similar. So Bradwell, which was the first one, was a 2022 completion, and that, the previous rent on that was GBP 170 per sq m, and we moved that up through negotiation with District Valuer to GBP 183. There's a scheme that we completed at Long Stratton, the Long Stratton scheme, for example, which was two years later. That started off GBP 180, and that one moved up to GBP 210.
Yes, you're right, the start date, it's an increase from the start date, but what we're saying is that by improving the properties, we're able to have that discussion with the District Valuer about making a larger jump in the rents than we are generally in the rent review process. And then the rent review process can utilize those for, hopefully, a more objective discussion with the District Valuers, utilizing those comparables we create to reduce scope for dispute and delay, effectively, hopefully, therefore, speeding up some of the reviews and speeding up cash flow.
Just to add to David's comments. On that slide, you saw the rent's grown to over GBP 220 per sq m across those four blue dots. Now, they clearly create evidence for all of the yellow dots in the surrounding area, and that's really the key, that is driving that 20% plus rental growth across that part of the UK. Now, you're right, it will take time to capture those, and that is one of the frustrating points about this sector. But as already mentioned, when they do settle, they do get backdated, the date of the rent review. But we've seen this positive trend. 7% is probably baked into our forecast across that region, but as David highlighted, that could quite easily grow to 20% plus over the next couple of years.
But I think just to link the two responses, particularly for David's response and maybe your second question, Andrew, the 3%. You could see from the announcement that we made this morning, in terms of how that rental growth is made up, you know, the strong degree of inflation that's being captured. Obviously, that inflation is reducing, but also the positive trajectory that we're seeing in our open market rent reviews. And when we're talking about the 3%, we've talked about 3% this morning, and then I think I said right at the very beginning on my second or third slide, that in terms of the trajectory for the future, as a consequence of all the, you know, factors that we've looked at, you know, we're talking about 3% annualized rental growth.
That's where we're targeting. Look, if we could do better, it would be great. If we don't do quite so well, it won't be for the want of trying. It'll be that things don't quite go our way. But we think the opportunity is there, and rents need to increase in this sector. There's no doubt about that. It is our job to get that point across to government and the stakeholders that we work with. Does that address your questions okay?
To confirm that 3% is on the entire rent roll or only on what you review each year?
No, on a forward-looking basis on the entire portfolio. Yeah, exactly. Yeah. Useful, yeah.
Thanks very much. Max Nimmo at Deutsche Numis. The comment was made about Wes Streeting saying, fixing the front door. Can you just perhaps give us a little bit more color in terms of what percentage of the NHS budget currently is going into primary care, and what that would kind of need to go to, in order to get to that sort of six projects a year that you want to kind of target? And, you know, is this something we should be looking for in the near term, in the autumn statement? Is there something we should be looking for exactly there to kind of flesh that out? Thanks.
Yeah. I'm gonna point to our... Before I do, the answer to the first part of that question, Max, is 10%. 10% of the entire NHS budget, and I showed that on an earlier slide. I've gone from 35 billion a year to 175 billion a year, between 97 and today, and it's clearly going to continue to increase. So I mean, I think 90% of all healthcare is in primary care, in terms of its execution, but it only gets 10% of the budget. So the point is, the money's been spent-
Yeah
... in the wrong place, and that's really what Darzi has very much picked up on. Do you wanna just extend on that question, if that's okay?
Yeah, I mean, it is 90% of contacts for 10% of the, or less than 10% of the money, and this is the point I was making earlier on about the BMA saying, we want 12%, 13% or a fixed number, and I was saying, "Actually, you should maybe be 25%." Oops, that's my microphone. You should maybe be 25% of this thing, if you can demonstrate that primary care deserves 25% in terms of value for money and a health out. You know, it's what is the bang for every NHS buck, depending on where you stick it in the system? And actually, I think a lot of people are convinced it needs to be in primary care.
I'm no expert on property, as you've realized, but actually, I don't think that means... I think the sums involved make the proposals around how many buildings are built, that's a minuscule amount of the primary care spend, which is, you know, about GBP 12-15 billion.
Does that answer the question? Okay. This is quite useful.
Pass the parcel. Thank you very much for the presentation. Sakir Hashmi from Foresight Group. I kind of get the current opportunities, but I wanted to understand a bit more about the future opportunities you've talked about. You've mentioned joint ventures-
Mm-hmm
... adjacent sectors. I guess-
... given the focus on government-backed income, how adjacent do those sectors get?
Mm-hmm.
I guess, what sort of JV economics are we talking about for shareholders?
Yep. Yeah, can deal with all that. Good questions. So just on joint ventures. In a previous life, I'm very familiar with doing joint ventures. We built a GBP 1 billion joint venture with PIMCO. It's very, very efficient use of capital, and for many years, and very successfully years, 'cause you've seen the track record of PHP, we're externally managed. And JVs perhaps weren't, you know, as high up the priority list, in those days as they might be in the future. We would like to do a JV. To do a JV, a lot of things need to be aligned. You need to find the right opportunity, the right deal, the right price, the right counterparty, and the right money, all at the same time. There's no end of counterparties that would love to work with us.
We've talked today about the barriers to entry in our space, and adjacency spaces are, quite frankly, no different. It's a more complex technical sector within commercial property than perhaps I've ever seen. I'm still learning now. I can assure you of that. So we would like to do something. How long could it take? I mean, we have looked at something. There's been a live opportunity in the short time I've been here. That wasn't meant to be, but that gives me confidence that, at some point we will look to do something. In terms of the economics of that joint venture opportunity, we probably think about that in one or two ways.
We would either go for a 50-50 joint venture, going back to your second part of your question around the economics. Total alignment with a partner, where clearly the asset manager or the day-to-day manager, we, you know, look to create value through asset management, 'cause we've got the team here that David leads. We can do development through the team that Tony leads, and we'll get paid for that, and we will earn good returns. If we weren't to be 50-50 because we wanted to do it in a more capital-light way, we could look at a 90-10 joint venture. We would take 10%. Our return on capital at that economics is very attractive, and there's no end of partners that would, you know, want to do a deal like that with PHP. It's great for them.
They get access to all of this and all of us, and it enables them to deploy capital quickly. So this is how we think about it. The final part of your question is, in many ways, the more interesting part of the question, because you know, I've you know stood up here with my team, with my board here today as well, and talked about the resilience of the model and the importance of the government-backed income and the security that comes with that, and that's really, really important to us, and I know it's really, really important to our shareholders, of which you are one. And that's not gonna change. However, we can look at adjacencies, ideally with government-backed or quasi-government-backed income.
But if we were to move away from that, in all likelihood, we'd go back to doing that in more of a joint venture type structure. But it's all about the operator and the operator risk. I feel. Well, I know this. I've seen it. We had a live example I mentioned just now. We've got the skill set to evaluate that operator risk, and obviously, the stakeholder relationships we have are very, very deep. We know the good operators and perhaps the less well-financed operators that we might work with in adjacency spaces. So I think that answers all your questions. There were three or four points that you've made, and hopefully that's addressed them. Great.
Thank you very much for the insights, for sharing. Freya Ye from Federated Hermes. I have two questions. One is regarding the rental reviews. I know we have three times of those reviews. I just want to know more details about how NHS impact each of them. I suspect the open market valuation would be the most important one because of its scale, and it seems there's a lot of discretion out there, because I know this is determined by the District Valuer, the agency, and then you've been finding their valuation unsatisfying and unfair over the past decade. So I just wonder how this would change, or maybe NHS could also impact the other two types. Please give me more details. And the second question is about UK new development.
Yeah.
You've been suspending that for a while, given the inflation and base rate. Now that the BOE has started to cut rates, so I just wonder, what level of base rate would you feel comfortable that you may start to restart looking?
Yeah.
into this area?
Yeah.
Thank you.
Yeah. Three very good questions. I'm gonna work my way through those, and you guys can chip in as we go along. There's no doubt that the open market value rent reviews are the most important in our portfolio in England, Wales, and Scotland because it relates to two-thirds of the portfolio. One of the reasons why James stands in front of us with a big smile on his face, he hasn't got to worry about the District Valuer. All our portfolio in Ireland is inflation-linked. In terms of the NHS impact, I think the question that you're asking there is, you know, how do we interact with the NHS, and how does that help determine the rents? We've got a very willing-...
occupant, tenant, stakeholder we are working with, who themselves are not hugely sensitive to the rent that we are asking them to pay. That's where the second part of your question comes in, because the District Valuer, who in want of a better term, I've not sort of rehearsed this in advance, a bit like the rent review surveyor for the government, if you like. Maybe that's a technical term to be explored, but in essence, they. I think there's 42 or 43 of them guys, that we interact with, and they're part of the treasury, different department. Rachel Reeves looks after that department. Obviously, Wes Streeting looks after the Department for Health.
So one of the things that we are trying to encourage, through our advisors and directly through, through government, is getting obviously Treasury and Department of Health working together collectively, because without that, you won't see these new developments, you won't see some of the extensions that we've talked to, this afternoon. On the third point around development and the suspension of development, I mean, you know, Tony's showing us a scheme, which fantastic. Eastbourne looks brilliant. It's on the screen there. You know, that was best part of three years ago that we did that.
So we've had this stagnation, and one of the reasons that Tony's pleased to be on the stage today is that we're talking about development again, because we're doing South Kilburn, we've done The Croft, we've got Spilsby and others that we know are coming down the line, and a very nice development portfolio coming through in Ireland. In terms of the Bank of England rate, we obviously look at that. We all look at that. That's human nature on a daily basis, almost. But we look at the sort of forward-looking rates. Richard put up the curve early on the SONIA and the Euribor forward-looking rates.
And look, that's a very important part of the equation in all of this, but we do look at our developments on a levered and an unlevered basis. We look at IRR. We're always looking for yield on cost above 6%, profit on cost above 10%. We will not do anything unless we meet that strict criteria, and I think that was pretty clear from what Tony talked to us about earlier. You didn't actually ask this, but seeing as that we're on the subject, I'll get straight onto it. So we are confident that we can grow our rents by 3%. Hopefully, I'm right, and as I said, if I'm not, it won't be for the want of trying. The opportunity's there. You know...
It's, you know, there's a huge demand for the space that we own and more space. There's no doubt in the future that's gonna be the case. So we think about interest rates. I mean, Richard's done a really good job on the hedging. That makes life a lot easier for us. But, you know, like any real estate-backed company, we were pleased to see the inflation data this morning. You know, we would like to see interest rates lower, and if they are, we can do more, and if they're not, we can still create value because we can grow our rents. And, you know, we've got to work with the NHS and the HSE to be able to do that.
I think it's come across, hopefully this afternoon, that we've got that confidence that's now beginning to happen, having been on standby in the UK and in Ireland for two, three years. Does that answer your questions okay?
Yeah. Thank you very much.
Great.
Thank you. Hi, Kieran from Clearance. Thanks for the presentation. Just a quick one on sort of the markets and financing some of these opportunities. You've spoken to the massive potential program of new developments that could come in the medium term, the refurbishments that could be coming along the tracks, potential for a JV, which would be expansionary to what you're already doing. Yet the LTV is at 48%, debt costs are probably going to go up as you flagged, and earnings are going up by about 3% or so at a target. So I'm just trying to sort of square the circle on how we are financing and actually gonna be able to capitalize on some of that ambition and potential within the business.
Yeah, all good questions. Thank you. Richard, you can come in in a moment, but if I just sort of kick that off. I mean, the market, you know, in terms of the debt capital markets and the equity capital markets are very open and receptive to companies with an investment case like PHP's and the 30-year track record and the reputation of the team, of course. So there's no issues there, but we're not, you know, we're not complacent or arrogant about that. We know that in the sector that we operate in, there's an enormous opportunity. And, you know, the only question that we have is how quickly we can capture that opportunity.
We think we can do a lot of this stuff in a capital light way. A lot of the things that we've talked about today, as much as we'd like to do them tomorrow or the day after, they will take time. So this is a three-to-five-year type plan that we're talking about this afternoon. I think Richard's been very clear that we're in a good place on the debt side, what we need to do. Most of our group's bankers are in this room today. They're extremely supportive, if we need to do anything there, and Richard's been very clear that you know, this is not a company that's looking to raise equity anytime soon. So I think put all that together, JV, and the expansion of a JV could be very interesting.
Again, that's not something that we're going to rush into here. But I think opportunities will come our way, but talking about it this afternoon, there are 150 people at one point in this room earlier, and many more people online. So I think that message will get into the market, and... I'm sure if we needed the capital markets to be open and receptive to an accretive opportunity, then we'll have to just, you know, cross that bridge when we come to it. But in the meantime, valuations, we think. And funny, we haven't gone to valuations today. Maybe it's because it's not a results presentation. But, you know, our valuations, we think, are pretty stable, and at some point, hopefully, will start to move in the right direction.
Even if yields stay the same, we've got rental growth, that's clear. So we will get some valuation improvement that will reduce our LTV. That gives us headroom flexibility and, you know, we're very ambitious, and we want to do a lot of these things because they clearly create value. So does that deal with the question? Thank you. Maybe one more question in the room, because I've got a load of questions here. Miranda's just there.
Miranda Cockburn from Berenberg. Just following on from that, just a quick question in terms of, disposals or recycling. I mean, could that be an option that you would consider?
Yeah, yeah. I had it on two of my slides, I think earlier. Richard referred to that on one of his slides. PHP is an undeniable success. It's got a thirty-year track record, and we've accumulated a really good portfolio of assets over that time. But we know, because we believe this and our shareholders certainly tell us this, that it would be good to recycle assets from time to time, particularly if we can do that in an accretive way. So there are things that we'll inevitably look at, particularly those assets where we feel there's a more... I think Richard used the term lower rental growth prospects, but I think what we really mean by that is more sort of total return. And this is not gonna be a spreadsheet-driven process.
It's gonna be carefully thought through, and our asset management team, led by David, will be very involved in, you know, in our sort of recycling and disposal program in the future. I think the market and you, the audience, who do all of this day in, day out, do like to see companies who not just acquire assets, but dispose. So it's something that we are, you know, definitely capable of doing, and it's quite high up the list of priorities, which is why we've mentioned it on two or three occasions this afternoon. Is that okay, Miranda? Okay, so I've got some shareholders writing into us. In no particular order, I'll just read this straight out.
This is coming from South Africa: "Why does there appear to be a difference in approach to development between the UK and Ireland?" Tony, Tony, go on, you deal with that, Tony.
I think the UK has the disadvantage of first mover, to use James's earlier expression. UK development stems from the inception of the NHS back in nineteen forty-eight. You heard me talk about the reimbursement of rent. Now, that originally manifested itself as GPs largely converting their own dwellings. So you have the GP flat upstairs and have the waiting room and consult space on the ground floor. And really, through the forties, fifties, sixties, that was a very significant model. Now, what's happened latterly is, with far more activity going into primary care, we've had the establishment of a third-party developer market, of which we're now an established part, et cetera, et cetera.
So we've had this evolutionary process, which has actually resulted in the situation that we have now, where we have 50% of the stock being unsuitable for purpose, and that's largely those older premises that I've referenced. Now, I don't presume to know... I'm neither tall nor Irish, so I can't really comment on Irish stuff, but it seems to be a much more straightforward proposition.
We've just learned from what's happened in the UK, and we've changed the model, adapted and said, "Well, this is a much better model," so we don't have the legacy to deal with. It's a very new market, and it was a choice by government as to what the market should look like. It suited the investment community, and that's the way that one has evolved.
Perfect. The next question, I think, is also from a shareholder. What are the opportunities to work with housing developers if U.K. construction is set to increase? Well, I think that's an easy one, and we're already doing that. We're doing that in South Kilburn. We're gonna do it in Spilsby, and we'll do it in other places. When we engage with house builders, particularly on larger schemes, what I mean by that is two, three, four, five hundred homes or more, we've seen examples, recent and no doubt in the future, where to get planning, providing a new, modern, flexible primary care center is a key criteria if you're sitting on a planning committee, for that house builder to get consent. So I think we'll do...
You know, this is an accumulation of marginal gain type, mindset to this, but I think we will see more, and we've got good relationships with the house builders we're working with currently. I suspect there'll be some degree of skepticism around, you know, the government's desire to build, 1.5 million new homes, I think, over five years. But if they got halfway there, you know, we'll benefit from that, I'm sure, somewhere along the way, as we're seeing with the development pipeline that's been switched on. So, thank you for that question. I've got four minutes to go, so I'm not gonna get through all these. So can I just assure everybody who would like to ask a further question, for those in the room, we're gonna be hanging around for a while, so come and talk to us.
And for those who are not, we've got all of your questions here electronically, and we will respond to them all individually. I'm not gonna get through all of these in the time we've got, I'm afraid. So, I'm just gonna wrap this up and just say the following: I hope you agree this has been an informative presentation. It's provided a very clear understanding of how we are positioning PHP for the future. I'd like to thank you all for attending. For those who've joined us in the room, your ability to stand attention for such a long time, and I think we've really covered a lot of ground together, and for all of you who've dialed in remotely, we thank you for your participation this afternoon.
Thank you to our host, Deutsche Numis, for hosting this event in this really efficient and large room. Thank God we took it. And thank you to everyone who's helped organize today. It's an enormous amount of work that goes into these things. Our friends at BRR Media have done a brilliant job on the videos and everything. My team, you've done a terrific job. Very, very grateful. And I have to mention my very hardworking PA, Amanda, who has worked night and day and weekends for the last month or so to make all this happen today. So thank you to you, Amanda. I'd therefore like to close the meeting, almost bang on time, at 4:30 P.M. We've really enjoyed it.
Thank you very much for your engagement, your participation, for your long-standing support, and that brings an end to PHP's 2024 Capital Markets Day. Please join us and stay for a drink afterwards. Thank you very much.