Hi, and good morning everyone, and welcome to Elekta's Q3 earnings call. Maybe it's a good idea to start with introducing myself. My name is Peter Nyquist, and I will be the head of IR here at Elekta. I have previous experience from some other Swedish blue-chip companies, like 10 years at Ericsson as head of investor relations, and before that at Electrolux as head of investor relations, and before that at SCA Essity. So I have quite a few years in this line of occupation, experience from a lot of different kinds of businesses, and I am really looking forward to working here at Elekta. So with me here today in Stockholm I have our CEO Gustaf Salford and our CFO Tobias Hägglöv, who will present the result later on here.
Today's agenda: we will start then with Gustaf presenting some highlights of the development of the quarter, then Tobias will give you details on the financials on the presentation, and it ends with Gustaf's view on Elekta's outlook. The presentation there will be, as usual, time for questions after that. But before starting, I would like to remind you that some of the information discussed on this call contains forward-looking statements. This can include projections regarding revenue, operating result, cash flow, as well as products and product development. These statements involve risks and uncertainties that may cause actual result to differ materially from those set forth in this statement. With that said, I will hand over to Gustaf. Please, Gustaf.
Thank you, Peter, and a big welcome to Elekta. It's amazing to have you on board as our new head of investor relations, and thank you to all of you attending the call. So we continued to deliver on our strategy ACCESS 2025 in Q3 towards a world where everyone has access to the best cancer care. We drove significant improvements and generated the fifth consecutive quarter with revenue growth and expanded EBIT margin. Order intake was negatively impacted by a slower China market, together with tough comparables in several regions. Order intake declined by 17%, and we expect the order situation to improve in Q4. So if we now look a bit on how we delivered the strategy, and I'll give you a couple of examples of how we delivered on it in Q3.
One example is our MOSAIQ oncology information system, and it's part of our software suite, Elekta One, and it won the Best in KLAS award, and I'll come back to this later in the presentation. We also announced a collaboration with Bristol-Myers Squibb to develop a digital solution for patients with melanoma based on our digital platform, Kaiku Health. We won a major order for proton treatment planning software with our partner, IBA. And as a part of giving access to the best cancer care, we have signed an important order with the Croatian Ministry of Health for Elekta Linac and brachytherapy systems. And we also won an order to transition a US center to the MR-Linac program with Elekta Unity.
In our efforts around resilience and process excellence, we focused on improving cash flow, which resulted in the best Q3 cash flow in Elekta's history, and going forward, we'll continue our activities to structurally improve working capital. Now a couple of more words on the Best in KLAS award. It's based on feedback from thousands of clinical users collected and evaluated by an independent research firm, KLAS, and last year's introduction of Elekta One. Our software as a service offering demonstrated our focus on personalization, integration, and a streamlined user experience. And it enables clinicians to boost productivity and enhance personalized care. And winning this prestigious award and the increased use of Elekta's digital solutions globally is the result of our investments in software during the recent years. And we now really see how accelerated innovation brings a direct benefit to healthcare providers and the patients they treat.
I would also like to take you through our strong innovation agenda that will drive growth in the years to come. We have three main focus areas: personalized precision, elevated productivity, and integrated informatics. If I start with personalized precision, it means that routine personalization of every treatment from comprehensive motion management with Unity, but it's also about bringing online adaptive treatments to our CT Linac portfolio. Personalized precision also means utilizing patient-reported outcomes to monitor and optimize care based on our digital platform, Kaiku Health. If we then turn to elevated productivity, it's truly enabled by our comprehensive Elekta One software suite. Elekta One will drive towards 50% cost reduction per treatment from automating workflows with SmartFlow and from also automating planning and delivery from SmartView and Auto Planning.
Elekta One is integrated informatics and analytics across all our software, improving decision-making from data insights and real-world outcomes. This creates new exciting opportunities for us to further leverage AI to optimize the patient's treatment journey. If we now turn to the order development during the third quarter, we saw that order intake declined by 70% in Q3 and year-over-year to date. However, if you look at the book-to-bill ratio, it came out at 0.98, and the order backlog amounted to SEK 42 billion, and we continue to pursue a faster conversion rate from order to revenue. And looking at the order backlog, it's still on a robust level, and rolling four quarters book-to-bill ratio is well above one, a platform for future growth. And if you look at the order development per region, America showed a flat development in the quarter.
EMEA declined by 11%, and it's mainly due to tough comparables year-to-date, year-over-year, with last year's large tenders in Southern Europe. And as I mentioned earlier, we received an important deal from the Croatian Ministry of Health, including Elekta's full suite offering. Orders in APAC decreased by 36%, mainly driven by China. However, we were increasing our market share in China, and we expect order growth to come back during the spring. And overall for Elekta, and in the fourth quarter, we expect the order intake to improve. And if we then turn to revenue, Q3 was the fifth consecutive quarter of revenue growth. We grew with 4% in Q3 and 8% year-to-date. Solutions increased by 4% and service with 5%, and the negative impact from the disruptions in the Red Sea was approximately 1 percentage point in Q3.
However, this is, of course, a timing effect where revenues will be delivered in Q4. We are addressing the continued impact from inflation with price increases and new product launches across our portfolio, and we see that the effect from the price increases will gradually be seen as of Q4. APAC grew revenue by 7%, where most of the market increased installations. China showed a strong double-digit growth, and we continue to have a market-leading position in the country. America's sales increased by 6%, mainly driven by solid sales in North America, and EMEA declined by 1%, mainly due to tough comparables from the installations of last year's large deals in Southern Europe and the U.K. At the end of the quarter, Elekta had an installed base of approximately 7,300 units. That was up 3% year-over-year. With that, I turned over to Tobias for the financials.
Thank you, Gustaf, and good morning everyone. Before starting, I also would like to take the opportunity to welcome you, Peter. If we then look at our financials, Q3 marked the fifth consecutive quarters with profitable growth. In constant exchange rates, revenue grew with 4%, supported by solid growth in APAC and Americas. Adjusted gross margin increased sequentially by 90 basis points. Year-over-year, gross margin declined by 150 basis points. While logistics costs are starting to come down, we have inflationary pressure from higher material and salary costs. Our operating margin improved by 90 basis points in the quarter, supported by continued sales growth and improved operational excellence.
If we look at the financial development in more detail, we can see that foreign exchange rates had a positive impact on net sales of 1 percentage points, a slight negative impact on gross margin while contributing positively on adjusted EBIT margin by 80 basis points. Then, looking at the operational drivers to our gross margin, we benefited from continued sales growth. Inflationary pressure from materials and salaries costs continued in the quarter, with pressure on the margin. Moving down to our EBIT margin, we benefited from higher sales and lower operating expenses. Then, if we continue then to look into our expenses in more details, all in all, despite salary inflation, the operating expenses decreased by 3% year-over-year, driven by continued cost control. Selling expenses decreased by 2% and administrative expenses by 3% following cost reductions.
We continue our focus on keeping a solid cost control to further leverage our margins. Net R&D expenses declined 4% year-over-year. We remain focused on our innovation pipeline, as Gustaf previously mentioned. R&D is the ultimate way for us to improve our profitability by launching market-leading product solutions. It is key for us to continue to deliver new innovations to improve our margins. In the quarter, gross R&D declined to 11.9% of net sales on a rolling 12-month basis. This is a sequential decrease from 12% in Q2. Moving over to working capital. Net working capital, as a share of sales, ended at minus 6% in the quarter, a significant improvement versus Q3 previous years. The improvements compared to last year were mainly driven by lower accounts receivables and inventory. Accrued income has come down due to strong collections from projects in Southern Europe with longer billing terms.
We have also managed to decrease our inventory levels through an efficient supply chain management. Cash flow after investments amounted to SEK 631 million, and it was almost SEK 800 million better than Q3 last year, and it marks the best Q3 cash flow in Elekta's history. This strong cash flow was primarily driven by higher earnings and reduction of working capital. Cash conversion amounted to 94%, well above our target of 70%. Over to you, Gustaf.
Thank you, Tobias. I'll just give you some words about the outlook. We are reiterating our midterm outlook of revenue growth above 7% and EBIT margin expansion, as well as a dividend policy of at least 50% of annual net profit. We continue to focus on driving shareholder value.
For Q4, we expect revenue and EBIT levels to be in line with last year's strong quarter, and we'll continue to drive profitable growth in fiscal year 2024/2025. As I just said, our midterm outlook is unchanged, and it's our daily focus to deliver on our ACCESS 2025 plan. We continue to see long-term market trends to support growth and investment in what we do, high-end radiotherapy equipment, and we also see a margin expansion. We will continue to drive access to the best cancer care and creating shareholder value. To summarize our third quarter, Q3 marked the fifth consecutive quarter with net sales growth and EBIT margin expansion. Our investments in innovation and in software are paying off. That's shown, for example, in the Best in KLAS award, and we delivered a record high cash flow in the third quarter, the best Q3 in Elekta's history.
Thank you. Thank you, Gustaf, and thank you, Tobias. With that, we will then start the Q&A session. Before starting a housekeeping topic, we will limit the number of questions to two per interaction. With that, operator, I hand over to you.
Thank you. We will now begin the question- and- answer session. Anyone who wishes to ask a question may press star and one on their touch-tone telephone. You will hear a tone to confirm that you have entered the queue. If you wish to remove yourself from the question queue, you may press star and two. Participants are requested to use only headsets while asking a question. Anyone who has a question may press star and one at this time. The first question from Erik Cassel, Danske Bank. Please go ahead.
Hello, hello. So first question, I would just like to have some help to understand what happens with the order backlog bridge compared to Q2. So it's down SEK 4.3 billion Q-on-Q, with just SEK 1.2 billion coming from the Genesis cancellations. So I'm just curious to learn what happened to the other SEK 3 billion of orders.
Hi, Erik. Good to hear you. Yes, I can explain that. What you see here is quite large impact from the currency moves in the quarter. So you actually have a strengthening of the Swedish krona or a depreciation of mainly the US dollar, but also the currency. So that currency impact sequentially between the quarters are more than SEK 2.5 billion. So that is the delta, I think, that you are looking for.
Okay, perfect. Good that it's not any other big cancellations. And then, Gustaf, if I heard you correctly, you indicated earlier in the call that what I at least interpreted as that we should expect organic order growth in Q4 again, that's still feasible. Is that mainly on China coming back quite sharply, or do you expect any other large tenders to materialize, say Poland, for example?
Thank you, Erik. So China is an important market for Elekta, as we said, and we've seen now two quarters with a very slow market, almost down 50% for both quarters. So we expect China to come back. We've seen quotas coming out. We have a more positive outlook for, for example, MR-Linac in the country, and we expect also the larger tenders when it comes to regular Linac will see better development during the spring and the summer here. So that will be a key driver. But we also see other parts of Asia as growth drivers, and so we'll try to drive growth in most of our markets during Q4, for sure. But China will be maybe one of the larger drivers into that. So we expect Q4 to show order growth.
Okay, perfect. Thanks very much. I'll come back if there's time.
Great. Thank you, Erik. We move to the next question. Please, operator.
The next question from Mattias Vadsten, SEB. Please go ahead, sir.
Hi, thank you. My question relates to Unity. If you could update us on the progression here during the third quarter and the degree to which you're able to capitalize on opportunity from the bankruptcy at ViewRay. I mean, it doesn't look, at least when I look at Americas in the quarter, that you gain momentum from it. So yeah, maybe some flavor and explanation for Unity in the quarter.
Thank you, Mattias. No, so it was a good Unity quarter. We see a great momentum on the clinical side, patients, volumes treated, new indications treated. And I have myself visited many Unity sites around the world during the quarter. We have great interest from Europe as well when it comes to Unity and MR-Linac, shift to MR-Linac. In the U.S. specifically, I mentioned it in the call that we had 1 transition to Unity from a competitor in the quarter. And I think that's a very important signal for Unity that we start to see those opportunities that we've been talking about the last quarters actually materializing. And I expect that to continue into Q4 and into the next year as well. So that's an important trigger point for Unity volumes going forward as well. But a good Unity quarter.
Thank you. My next one is, I mean, in the CEO letter, sales and earnings flat year-over-year in Q4. At the same time, I think you have a positive effect from price increases from quarter four, and it seems it will still be sort of easier to install and so on. So yeah, just some underlying how you think about it and how you come to the conclusion that you expect it to be flat, perhaps, and what the main headwinds are in terms of sales and EBIT. That's my second question.
Yeah, I mean, we go through the installation plan for the next quarter and also look into the next year. What we see there is it will be in line with last year's strong level for Q4, but we also expect continued profitable growth and good installation in Q1, Q2, and also the second half of next year to support our outlook for more than 7% in the ACCESS 2025 period. I think it's a bit of a comparison in the fourth quarter. We see price increases coming through on our products that has been in the backlog now turning to revenue in the P&L. That's a positive driver, and we will continue to drive growth in the first half and throughout the next year. I think it's a bit of a comparison where we grew quite strong 10% in last year's Q4.
Okay, thank you.
Thanks, Mattias.
Thank you.
We move to the next question. Please, operator.
The next question from Kristofer Liljeberg. Carnegie, please go ahead.
Hi, Kristofer.
Yeah, thank you. Two questions then from me. First, when you say order growth returning in Q4, is that yes to be back above zero or something more significant growth? And the second question relates to the gross margin and what do you think about the ability to improve that in Q4 and into next year? Thank you.
Hi, Kristofer. Sorry. I'll take the first order question, and then I think Tobias will take the gross margin question. But looking into orders, what we see right now is positive order growth. I don't mention a specific number, but we'll drive for a good number in the fourth quarter. And that's a big priority for us here in the coming weeks and months.
Yes, and hi, Kristofer. I can answer upon the gross margin. I think when you look into the Q4, essentially in line here with last year's Q4, big drivers there are that we continue to see inflationary pressure. As you mentioned, that we also have a positive impact here from the price mix component as such. Looking into next year, yes, as we communicated earlier on, is that we are looking into gross margin expansion. Q1, we had a very strong gross margin this year that can be taken into consideration. But otherwise, we determine to deliver profitable growth here next fiscal year.
So yes, to make sure I understand, so what you're saying is flat Q4 gross margin versus last year, approximately?
Yes.
What is then driving the sequential improvement from what we have seen in the second and third quarter? Is that volume-related, or is it that you're starting to see this positive impact from higher prices now?
Yeah, it's both. As you know, the Q4 is, in general, a big quarter. So you have some more leverage here from the sales component in general, but also a positive contribution here, price mix both sequentially and year-over-year, while also when you look at the year-over-year component, the inflationary pressure continue.
Great. Thank you.
Thank you.
Thanks, Kristofer. Operator, we move to the next question.
The next question from Sten Gustafsson, ABG Sundal Collier. Please go ahead.
Good morning, Sten.
Good morning. Thank you for taking my questions. Regarding, obviously, a lot of questions about the order intake here, but just to clarify, you talk about growth coming back in China in Q4 and for the full quarter. But do you expect to see positive order intake for the full year since you're, I think, down 7% or something like that year to date? That would be my first question. And also, do you actually see you talked about that you had seen the activity level going up in China, but have you actually started to sign orders already now in the quarter? And given that the softness we have seen over the past two quarters, what's the likelihood of those orders now being signed in Q4? That would be my questions.
Good question, Stan. Hi, it's Gustaf. And thanks for those. So if we start on the overall order growth, we will be growing in Q4. That's what we see at the moment. I think we'll need to get back on the overall growth. But of course, the -17% in the quarter is a weak number, and we're driving for a good growth number in Q4, but we'll see where the full-year number will end up. If it comes to the Chinese situation, what we've seen during the last month or so is increased activity. And it's also important to say if you look at the revenue side, we mentioned a high double-digit growth. So it's a strong installation number in China at the moment. So we're just waiting for these larger orders to come through.
As you asked, we have seen increased activity during the last months.
Okay. Thank you very much.
Thank you, Sten. Operator, we're ready for the next question, please.
Next question from Rickard Anderkrans, Handelsbanken. Please go ahead.
Good morning, Rickard.
Morning, Rickard.
Good morning. Thank you for taking my questions. So follow-up on China. So we have seen a province in China implementing volume-based procurement for Class B large medical equipment, including Linac. So what are your thinking around this dynamic for the Chinese market? That would be my first question.
Hi, Rickard. Rickard, sorry, Gustaf. So now we saw that announcement coming out, and I think it was a great lots of interest around that topic in previous medtech companies reporting. I think we have the same view that we haven't seen any specific impact except that announcement that came out in what we do, high-tech, CapEx, complex products. So we don't see that the volume-based ratios will have a big negative impact on this segment. We will continue to compete with innovation, new product launches, localization in China, and we foresee that we'll maintain and have a good price level there going forward as well.
All right. Good. Just coming back a little bit to the Red Sea situation, you talked about the 1 percentage point headwind to growth in the quarter. Should we expect a disruption of a similar magnitude in Q4 relating to Red Sea situation, or what's your forward thinking and current status with that situation?
Yeah, we saw this effect, I mean, from the Red Sea shipping from China to Europe and Europe to China, so to say. That was around 100 basis points in the revenue impact on the revenue in the quarter. We'll install those kind of delayed units in this quarter, but we foresee some continued disruptions in the logistics chains here in the next quarter to come as well. I don't have any specific number on the impact, but I think overall, as we mentioned, we expect the quarter to be on the same level as Q4 last year. So I think that's the situation. We've seen logistics costs coming up a bit, but it's not that dramatic based on this.
That's very clear. Thanks for taking my question.
Thanks. Thanks, Rickard. Operator, let's move to the next question, please.
Next question, Patrick Ling, DNB. Please go ahead.
Good morning, Patrick.
Morning, Patrick.
Good morning. Thank you. Just a short follow-up on the previous question regarding the order backlog. Maybe I did my math wrong, but to me, it seems like if FX impacted the backlog by SEK 2.5 billion, I'm still missing approximately SEK 0.5 billion from the backlog. So are there any other larger cancellations, or are there any other effects that we should know about in the backlog?
No, no other major effects. I said that it's more than SEK 2.5 billion actually coming from currencies. So we do have the GenesisCare, which you could read in the report, but other than that, it's no other larger cancellations in the quarter.
Okay. Okay. Then I also have a question on Unity. And I mean, you've talked about Unity and your installation before. So could you update us a little bit on where you are on installation and how many you're installed now per month and how you're progressing with that?
Yes, Patrick. No, I think, as I mentioned before, it's a good Unity quarter. We have a much shorter installation cycle compared to what was a year or two ago. So we're learning. We're installing faster. We still have the capacity to do the 24. We don't disclose any specific number quarter over the quarter, but we start to see a lot of installations around the world from our backlog.
We also have this opportunity, as I mentioned before, to transition previous MR-Linac into a Unity program in the U.S., maybe particularly, but also in other places in the world. We also see bigger volumes that will come from China going forward. So I'm very positive on Unity in the quarter, and I'm positive on Unity in the coming quarters as well, especially on the installation side. So it will continue to be an important growth driver for Elekta because it is truly a paradigm-shifting technology. And we start to see so many fantastic cases and patient treatments being done out there that was not possible before or even today with CT-based Linac.
Okay. Great. Thank you. I'll jump back in the queue.
Thank you.
Great.
Thanks, Patrick.
Let's move to the next question, please.
Next question from Oliver Reinberg, Kepler. Please go ahead.
Good morning, Oliver.
Oh, yeah. Thanks. Good morning. Thanks so much for taking my question. The first one would be coming back on the order situation. So can you just talk to what surprised you? I mean, -17% has been a meaningful decline. So we knew about China, but can you just talk to which regions have been probably disappointing you? And considering that you now fully canceled the Genesis orders from your backlog, would you expect to take new Genesis orders going forward? That's question number one. And second question, please, just on the situation in America/U.S. Obviously, the orders have been flat in Q3, low single-digit growth, I think, in the first nine months. So can you just probably provide a general outlook in terms of how you're performing in the U.S. and how happy you are with the progress since you have implemented the changes there? Thank you.
Yes. Thank you, Oliver. I'll start with a bit around the world question on the order side. So we talked a lot about China and APAC, I think. But if you look at the EMEA, we are kind of exiting a period that had a lot of recovery programs from the COVID situation and investments from the European Union into Southern Europe cancer care. We have then seen good progress in Ukraine, and we've seen good progress now in Croatia. So we're getting large deals this year as well, but not as large as the previous quarters or previous year, sorry. We also start to see more private investments throughout that region. That will be a positive driver because the region needs more capacity and more cancer care. That is true both for Europe and Africa.
If you look at the Middle East, it's a bit more of turmoil, as we all know, in that region. But I was down at Arab Health myself just a couple of weeks ago. And it's a lot of positive parts in the Gulf States and the Middle East. In Saudi Arabia, for example, that would be a growth driver going forward. So we're quite optimistic there as well. If you look at the U.S., I think one of our biggest opportunities going forward in the U.S. is what we mentioned before, MR-Linac initiatives, but also on the Gamma Knife side with our new Esprit product as well as Elekta One. So I think we have a product offering that's well-suited to drive growth in the U.S. So that's a bit more flavor on those other regions.
We expect other parts of APAC to come back in the quarters to come.
Just to follow up, anything that surprised you negatively, and do you expect to book orders from Genesis going forward?
Sorry, on the GenesisCare side. So GenesisCare have gone through a reconstruction now, and it's kind of split into two different parts. It's the U.S. part versus the rest of the world part. So we are continuing to deliver to the rest of the world part. It's Australia, it's the U.K., and Spain, whereas with the cancellation, that was for the U.S. part of the business. So we expect to continue and partner with GenesisCare in the rest of the world side of the business going forward as well.
But not in the U.S.?
Not as much in the U.S. Correct. That's why we do the cancellation, as we said before, as well.
Generally, the progress in the U.S. outside MR-Linac?
It's a good progress in the U.S. MR-Linac side. So the Unity is great interest in the U.S., in many of the sites. And as I said also, it's a very important trigger for us that we're now transitioning one of the competitor systems into a MR-Linac situation or program.
Thanks, Oliver, for those questions. And we'll move to the next question, please.
The next question from Anchal Verma, JP Morgan. Please go ahead.
Good morning, Anchal.
Hi. Good morning. This is Anchal Verma on behalf of David Adlington. I have two questions, please. The first one on the tailwinds from ViewRay. Could you potentially quantify the tailwinds and provide just a bit more color on the opportunity there? How are your discussions going with ViewRay's clients around converting them onto Unity and anything you can disclose with the conversion of backlog there? That's question one. And then question two, kind of coming back to your P&L, your capitalized R&D has been increasing, and it was up for the quarter again. And just trying to understand by when should we start seeing that kind of come back through the P&L and the gap close between amortization and capitalization of R&D?
Yes. Good morning. So I'll take the first question. As mentioned before as well, we see a strong opportunity, big opportunity, especially in the U.S., but also other parts of the world, to transition competitive systems or competitive backlog into Unity programs at those sites. We have one great example in the quarter in the U.S. that we'll disclose later, but we will also see more of them going forward as well because it happened in September, I think, timeframe. Now we've been able to talk to those customers and transition them into new MR-Linac programs. More to come in that area. It's not something we quantify and disclose, but I would describe it as a big opportunity for Elekta going forward because many of those customers, they want to continue with MR adaptive radiotherapy, and then Unity is the best option.
I can fill in here in terms of the capitalization and the R&D development. What you will see here, just in line with what we previously have communicated, is that you will see the gross and net R&D continue to narrow. You saw in this quarter that it was a slight decline percent-wise in gross R&D that will continue into next year as well. You will also see that the amortization will gradually move up here. So you will see a continued decrease gap between those two lines there. Thanks, Tobias. And sorry?
Perfect. Thank you. And sorry, just on the ViewRay, can I ask, as you've highlighted, that would be a nice tailwind. Is that baked into your guidance for Q4?
I think first you'll see primarily on the order side, and then you will see it coming into revenue in later phases. It takes a bit longer than just a couple of months to do that transition also for this opportunity. So first orders and then revenue into next year. So yes, from that point of view, it's factored in.
Thanks. Thank you. And we'll move to the next question, please.
Next question from Hassan Al-Wakeel Barclays. Please go ahead.
Thank you for taking my questions. I have a couple, please. Can you talk about the drivers for the flat revenue development into Q4 and how we should be thinking about Q1 next year and whether next year is likely to be more backend-loaded given order dynamics and what really gives you the confidence in growing above 7% when the last nine-month order intake was down 7% in constant currencies? And then secondly, on orders, if you could expand on the development in the quarter because this time, last quarter, when we spoke, you were expecting good underlying demand outside of China. And so how are you thinking about orders into Q4 for China and outside of China into next year? And what about Asia ex-China, which looks to be down a third in the quarter on my math? Thank you.
Thank you, Hassan. I will start there. So I think we discussed Q4 on the same levels as the strong Q4 last year throughout the call and in the presentation as well. And we expect going into next year to see strong revenue growth from the first quarter and onwards. So it's not backend-loaded what we currently see in our installation plan. So it should be a good growth quarter by quarter into next year. And I think that is really how we focus and work now. It is really to deliver quarter by quarter when it comes to profitable growth and cash flow. If we look into then next year on the midterm outlook, as we call it, to the ACCESS 2025 period of more than 7% revenue growth, yes, we maintain that outlook, and yes, we'll deliver on it by growing into next year.
On the order side, I think we discussed China a lot throughout the call. APAC was not strong either outside China. We will also drive order growth in other parts of the markets in that region in Q4 specifically. We have a growth situation in those regions in Q4 is what we can see at the moment.
Thanks, Hassan.
Thank you very much.
We'll move to the next question, please.
The next question from Veronika Dubajova, Citi. Please go ahead.
Good morning, Veronika.
Hi. Good morning. Hi, guys. And Peter, welcome to Elekta. Thank you guys for taking my questions. I will also keep it to two. My first one is just trying to understand a little bit the competitive dynamics that you're seeing. And I'm curious, in particular, Gustaf, about the U.S. because I think a couple of quarters, you were quite confident that you were kind of turning the corner with the momentum in the U.S., obviously looking at the America's order intake growth. In the quarter, that doesn't seem to be the case. We're hearing a lot from your peers that broadly, the U.S. context dynamic is improving. So I was just wondering if you could help us shed some light on what is happening in the U.S. market.
As you think about your order momentum, what are you seeing, where you're winning business, and where, look, you might be losing some business? That's my first question, then I'll ask my second one after that.
Thank you, Veronika. So I mean, the competitive situation broadly, globally, if I start there and then I'll turn to the U.S., I truly believe and I see it every customer visit I do and every quarter in Elekta's model of being the leading standalone radiotherapy company with strong partnerships. And if we then look more into the U.S. situation, I think it's very difficult to know the competition's order numbers because they don't report them. I think they sometimes have comments about how they grow. What we see in the U.S. is growth if you look at the revenue and orders going forward as well, driven by our product portfolio when it comes to MR-Linac and upcoming adaptive CT-based Linac. And I think Elekta One is very important for Elekta in the U.S. because we have a large installed base of software in the market.
If we look at Elekta's book-to-bill ratio, it's 1.08 if you look at the rolling 12-month basis. And then I think it's also important to say that we have different product offerings nowadays, Elekta and the competition. They've gone into more value-added services, physics services, quality assurance services. That's their path. Our path is to continue to be the leading technology provider helping our customers automate their processes by technology. So I think that's also it's not apples to apples anymore when you look at those different drivers.
Okay. That's helpful. And then my second question was on gross margin for Tobias. Just Tobias looking at the FX impact, it seems to me like there's still a pretty substantial FX headwind on gross margin. I might be doing my math incorrectly. Obviously, I know you guys hedge it, but just slightly surprised by your comment that you expect gross margin to be flat year-on-year in the fourth quarter given that. Is that commentary before currencies or inclusive of currencies? If you could clarify that.
It includes currencies.
Okay. So you would be up about 100 basis points underlying year-on-year?
I think actually what we are looking I mean, you saw the quarterly development here. The impact here from the gross margin was not that large. We had a slight negative margin impact. But essentially, I mean, we are responsible for the full P&L. So when we talk about gross margin, we talk about that including currencies as well.
Okay.
Thanks.
Thanks for the clarification, guys.
Yeah. Thank you, Veronika.
Operator, next question, please.
Next question, Lisa Clive Bernstein. Please go ahead.
Hi, Lisa.
Hi. You had mentioned in the commentary that you now have a shorter delivery time on Unity. Could you also talk about your lead time for Harmony and whether the length of it ever causes you to be in a sort of worse competitive position in terms of winning tenders, etc.? And if there's anything that can be done from here, especially on Unity now that you're more sort of at scale, whether there's also anything that can be done on the cost front. Unity obviously has a much higher ASP than a traditional Linac. Just wondering whether that gap can close over time. Thanks.
Thank you, Lisa. It was a little bit difficult to hear everything, but I hope I get it right when I start to talk about Unity and Harmony. So Unity is our MR-Linac, and Harmony is one of our CT-Linac platforms. But if we start with Unity, yes, we have a faster transition from order to revenue. That's a positive. Yes, we are doing faster installations as well. That is a positive on gross margin. And we also see better and higher prices on Unity and MR-Linac in the backlog. So that's also a positive. I think on the COGS side, it has been challenging to drive out COGS the last couple of years, both on the MR and CT-based Linac when it comes to material costs.
But we expect actually that to improve during next year where we see raw material prices and electronics prices to go down. So I think that will over the longer timeframe, that will be a positive. And then we'll also see the leverage from top-line volume when it comes to Unity. Harmony is then more the CT-based performance Linac that we have seen a good uptake on in emerging markets but also mature markets because one of the biggest challenges globally, as we know, is productivity. And this is a Linac that could go down to treatments lots of 7, 8 minutes. And that's out of great interest also in many, many mature markets. We also see the volumes going up. So that's a positive. And also gross margin drivers coming from Harmony because we have a lower COGS position there as well.
We will work more and more with COGS and material costs into the next year and the productivity when it comes to our service order fulfillment, manufacturing, workers, and get the leverage from the top-line growth. We'll see that flowing into our gross margins in the years to come.
Thanks, Lisa. We'll move to the next question, please, operator.
The next question is from Julien Dormois, Jefferies. Please go ahead.
Morning, Julien.
Hi. Good morning. Good morning, gentlemen. Thanks for taking my questions. I have two. The first one is partly a follow-up on Veronika's question about the order and sales trajectory in the U.S. where you seem obviously, well, less enthused compared to what you see in EMEA and APAC, especially in the past few quarters. So could this have an impact on your margin because obviously, the U.S. is the most profitable region? So as those orders in EMEA and APAC get converted, could those just represent a headwind to your overall margin? That would be my first question. The second question is coming back to your backlog because it's quite striking to see that your overall backlog has quadrupled in the past decade. It has moved up from approximately SEK 10 billion to now more than SEK 40 billion.
At the same time, your sales have hardly doubled over that same period. I know you expect significant backlog conversion in the coming quarters. What do you believe would be a normative level of backlog to sales once you've converted the majority of the backlog that has to be converted quickly?
Yes, Julien. I think I'll start with the order question. I think maybe Tobias will follow up with part of the backlog question as well. But orders, if we look at what we take as orders now, we've seen a good price increase throughout the year. But of course, there's always a market mix factor that you need to think about depending on what regions you see the growth. But overall, we see price increases in our portfolio. And there is different margin levels: U.S., Northern Europe, Japan, higher prices, and then China somewhere in the middle, and then some of the emerging markets a bit lower. But all in all, throughout a year and I don't think you should always measure Elekta's performance on one single quarter's order performer. You should look more at rolling 12 and also the book-to-bill ratio. That's 1.8.
From that point of view, we will drive and we will see that price increases across the portfolio also coming into our gross margin and bottom line. The inflation, we have been exposed, as all other companies, especially throughout the last 12, 18 months, from increased inflations on salaries, material costs, and so on. And we expect that situation to improve throughout next year, I would say. So I think that's the order situation. If I take our historical book-to-bill ratio, Elekta has often been at 1.2, maybe 1.3, sometimes 1.1 as we're now, the book-to-bill ratio historically. And now we see a situation where we'll install more of that and work hard with a faster order-to-revenue conversion. And that's what you've seen us focus on the last year. And you'll see us continue to focus that quarter by quarter into next year.
Then we have this SEK 42 billion order backlog that we will install from both on the solution side and, so to say, the service contract side going forward as well.
Yes. Hi, Julien. Thanks for that question. First of all, I think this is an important element of actually us when we have projected this outlook. We see our backlog. It's rightly so that it has grown. We see this as a strong asset for us to actually drive backlog conversion. It's a strong foundation for our growth. As you know, we have a certain time between order and revenues and a healthy pipeline for that. We have not explicitly set a target level for the backlog as such. It is. Again, it's a strong platform for future growth. That's how we see it.
Thanks, Julien. We'll move to the next question, please.
The next question from Mattias Vadsten, SEB. Please go ahead.
Hi, again, Mattias.
Hi. I had a follow-up. It's about next year how we should think about it because one part is the exchange rate difference item in the P&L. So I think eight quarters in a row at some material negative magnitude, if you could just speak about how we should think about it going forward. And then the amortization part of R&D, you got the question earlier. But at what magnitude should this item come up? Because I'm surprised basically every quarter that it is not coming up more. So this is my question here as a follow-up.
Yes. Hello, Mattias. Maybe I need to repeat a second question there. But in terms of the FX move, I think there it's structurally to look into the currency levels as such. I mean, one is just the P&L item. And that is when you look at the year-over-year impact. We have actually had a certain negative impact here this year as well from revaluations on our balance sheet and net of hedging. And that, when you look at the year-over-year, will become then a positive. When it looks to the currency levels as such, I mean, here we benefit from, in general, a stronger US dollar mainly. I think where the currency levels are right now, they are at fairly good levels for us when you look at it from a historical perspective.
Okay. How we will.
Okay. And then on amortization, how substantial of an increase we should expect there going forward, because it surprised me how slowly it is coming up given the...
Yeah. You will see an increase of amortization. You will see an increase of amortization here in Q4. It will also continue to increase here in next fiscal year. To give you some guidance of it, we are looking into maybe 100 basis points of impact here on the year-over-year impact from amortizations on the net R&D as such.
Okay. But because LTM, I think it's 7.5% net R&D to sales. Could you give us is it 100 basis points? Is that what you mean next year?
As a percentage of sales. So you will have an increase here next year of amortization in absolute terms.
Okay.
Thank you, Mattias, for those questions. We'll then move to the last question of this Q&A session, please, operator.
Last question from Mr. Kristofer Liljeberg, Carnegie. Please go ahead.
Yeah. Thank you. Yeah, so when you talk about online adaptive treatments on your standard Linacs. Is that going to come as an upgrade or are you now planning to launch a completely new Linac platform in the coming years?
Thank you, Kristofer. A great question. So the key trend in radiotherapy right now, I would say it's MR-Linac, but it's also about adaptive. And we are doing MR adaptive treatments on Unity. And this has also enabled us to look into the CT adaptive world. And we already today have some customers that are doing that with their current Linacs. But we are now making that into new solutions, new products. So we will launch CT adaptive Linacs. And we'll also launch capabilities to upgrade installed base Linacs into adaptive Linacs going forward. So I think that's a very encouraging and positive product initiative that we have to both the installed base but also for new Linacs going forward. So expect more news there going forward in the spring and during the autumn.
When it comes to new Linacs, is that something that could be launched already at ESTRO this spring or ESTRO during the autumn?
Yeah. We'll come back on the launches and so on. But I mean, we are quite close here. So I'm mentioning in spring and autumn.
Okay.
Thanks, Kristofer.
Thank you very much.
Thank you.
Before concluding the conference call, maybe some final remarks from your side, Gustaf?
Absolutely. So just to conclude a bit on the quarter, we saw our last quarter to be the fifth consecutive quarter with net sales growth and EBIT margin expansion. We're also seeing that our accelerating innovation and our investment in software is paying off with, for example, the Best in Class award. And we also presented a record Q3 cash flow for Elekta. So with those words, I conclude the call. And big thank you for all of you for listening in and very good questions. Thank you.
Thanks a lot.
Thank you.