Ramsay Santé has continued to support health systems in both France and Nordics countries despite being heavily impacted by numerous headwinds, including salary and procurement inflation, staff shortages.
Set of measures launched to support staff attractivity and mitigate inflation impacts.
Ramsay Santé has maintained its efforts on key initiatives in line with its Yes We Care 2025 strategic plan like being granted new imaging authorisations and launching new digital services.
Total revenues of 2.2bn€, up 8.4% vs last year including 5.8% growth from acquisitions and –2.2% foreign exchange impact, despite 2 less working days than the same period last year in France.
EBITDA down by 6.8% to €313m reflecting the headwinds faced by the health care markets in all of Ramsay Santé’s regions.
- Continued commitment to support the health care system in Europe by helping taking care of COVID-19 patients both in France and Sweden and to complement public hospitals capacity to cope with pressure on emergency departments in France during the Christmas break.
- During this semester, the Group has been granted in France 9 new imaging machines authorisations, up to a total of 28 and 4 new mental health day hospitals, up to a total of 15.
- Strong activity growth overall, largely driven by out of hospital segments, contributing to enhance care accessibility for the population (primary care, specialized care consultations, home care, imaging): +1.2% MSO admissions in France, including +4.2% for day patients. +11% in the Nordics, including +17.5% for day patients.
- Half-year turnover amounted to €2,209.5m, up 8.4% on a reported basis. Adjusted for changes in the consolidation scope and at constant currency exchange rates, turnover for the half-year ended 31 December 2022 was up with a solid 4.8% organic sales growth. Sales growth in France of 4.2% is mainly supported by volume growth and medical purchases rechargeable revenue, despite the ongoing shift towards ambulatory care. In the Nordics countries, organics sales grew at 6.4% for the semester on a constant exchange rate basis. The impact of past acquisitions, including GHP, amounts to €117.6m of additional revenues, or 19% of extra growth for the Nordics countries.
- Decrease in the reported EBITDA under IFRS16 of 6.8%, to €312.7m (last year €335.4m) with a margin of 14.2% (last year 16.5%). EBITDA and margin were mainly driven by the negative trend on inflation and the resources invested to support our medical staff. Recent acquisitions have contributed €12.4m to the overall half-year EBITDA, in line with our acquisition business plan. The revenue guarantee scheme put in place by the French government resulted in additional revenue of €62 million (same as last half-year) in the half-year ended 31 December 2022. Ramsay Santé was eligible to receive support from the French government regarding inflation of procurement and salary for a total consideration of €45.6m, which did not fully cover it, however.
- Net profit for the Group share was €43.9m, 2.0% of turnover (last year €59.6m and 2.9% of turnover), impacted by lower operational margins and reflecting increased funding costs.
- Total capital expenditure for the last 6 months was €110m, slightly below last year, including maintenance and optimisation, as well as improvement on our portfolio of clinics. This covers the ongoing maternity expansion of St Göran as well as significant effort to roll out our strategy to increase Ramsay Santé’s imaging assets portfolio, to invest on digital tools, amongst which the new version of the Ramsay Services portal, and on new equipment such as surgical robots for our French clinics.
- Net financial debt at the end of 31 December 2022 amounted to €3,820m, including €2,143m of IFRS16 lease liabilities. During the first semester of this fiscal year, Ramsay Santé successfully completed the issuance of a new Fiducie tranche for €150m. The group has as well participated in a real estate project involving one of our clinics in Olso, Norway.
- Net cash increased by €97.5m over the period with a €194.5m contribution from increased borrowings. The cash flow from operating activities was unfavourably impacted by the phasing of the payment related to the various subsidies.
- Ramsay Santé has continued to invest in initiatives in line with its Yes We Care 2025 strategy, and expect that this strategy will lead to a capex consumption trend in H2 FY23 similar to H1 FY23.
- Finally, discussions are ongoing regarding the potential extension of a modified French revenue guarantee scheme under which the government may prolong its support to the industry, although with a mechanism reducing over time.
Ramsay Santé has continued to play a major role in complementing public hospitals in Europe over the past six months. With the management of 5.8 million patient visits, up 18%, the “Yes We Care 2025” strategy of providing patients with physical and digital health solutions to coordinate pathways, is more relevant than ever, and implementation is on plan. Revenue grew by 8.4% over the period and operating margin fell by 6.8% due to inflation, which affects all costs. Finally, the integration of acquisitions, notably GHP, made last year, is in line with expectations.
Pascal Roché, Chief Executive Officer of Ramsay Santé
The Board of Directors that met on 22 February 2023 approved the consolidated financial statements for the six-month period ended 31 December 2022. The consolidated financial statements have been subject to a limited review by the statutory auditors.
Synthetic results
| P&L – in € millions | From 1 July 2022 to 31 December 2022 | from 1 July 2021 to 31 December 2021 | Variation |
| Turnover | 2,209.5 | 2,037.7 | +8.4% |
| EBITDA | 312.7 | 335.4 | (6.8)% |
| As a % of Turnover | 14.2% | 16.5% | (2.3) point |
| Current Operating Result | 113.1 | 149.1 | (24.1)% |
| As a % of Turnover | 5.1% | 7.3% | (2.2) point |
| Operating Result | 134.7 | 151.4 | (11.0)% |
| As a % of Turnover | 6.1% | 7.4% | (1.3) point |
| Net income, Group share | 43.9 | 59.6 | (26.3)% |
| Earnings per share (in €) | 0.40 | 0.54 | (26.4)% |
| Net Financial Debt – in € millions | 31 December 2022 | 30 June 2022 |
| Non-current financial liabilities | 1,916.4 | 1,763.6 |
| Non-current lease liability | 1,935.3 | 1,922.3 |
| Current lease liability | 207.5 | 196.0 |
| Current financial liabilities | 52.1 | 35.4 |
| (Cash and cash equivalents) | (220.9) | (132.5) |
| Other financial assets & liabilities | (70.0) | (74.9) |
| Net financial debt | 3,820.4 | 3,709.9 |
| Cash Flow Statement – in € millions | From 1 July 2022 to 31 December 2022 | from 1 July 2021 to 31 December 2021 |
| EBITDA | 312.7 | 335.4 |
| Change in Working Capital requirements | (83.5) | (291.4) |
| Net cash flow from operating activities | 183.6 | 23.8 |
| Net cash flow used in investing activities | (96.9) | (131.4) |
Breakdown of revenue by operating segment
| En M€ | From 1 July 2022 to 31 December 2022 | from 1 July 2021 to 31 December 2021 | Variation |
| Île-de-France | 517.9 | 497.3 | 4.1% |
| Auvergne-Rhône-Alpes | 295.2 | 275.2 | 7.3% |
| Hauts de France | 190.9 | 190.0 | 0.5% |
| Occitanie | 134.8 | 131.0 | 2.9% |
| Other regions | 349.1 | 335.4 | 4.1% |
| Nordics countries | 721.6 | 608.8 | 18.5% |
| Published Turnover | 2 209.5 | 2 037.7 | 8.4% |
Note: the table above details the contributions of the main operating segments to the Group's consolidated revenue.
Changes in reported turnover from the half-year ended 31 December 2021 to the half-year ended
31 December 2022. | Reported Turnover
31 December 2021 | Changes in foreign exchange rates | Acquisitions and disposals | Organic growth | Reported turnover
31 December 2022 | Variation | |
| In € millions |
| 2,037.7 | (44.0) | 117.6 | 98.1 | 2,209.5 | 171.7 | |
| (2.2%) | 5.8% | 4.8% | | 8.4% | |
Significant events of the financial year:
Healthcare market evolution including COVID-19 health crisis
The six-month period ending 31 December 2022 continued to be impacted by the global COVID-19 pandemic in all countries in which the Group operates, albeit at a markedly lower intensity level compared to crisis peaks experienced in prior periods.
France
In France, private hospitals have continued to actively participate in the national plan to combat the
COVID-19 epidemic in conjunction with and in support of public hospitals. Depending on the evolution of the health situation during surges of COVID-19 as well as other seasonal viruses prevalent in autumn and winter, the activity of private hospitals was carried out under more or less normal conditions.
Ramsay Santé has continued to participate in the effort of caring for COVID-19 patients with more than 4,000 patients treated in France, including 1,600 in critical care.
As other public and private hospital providers, Ramsay Santé has continued to operate for the full six-month period under the French Government’s revenue guarantee which was extended to 31 December 2022. The provisions of the revenue guarantee are similar to that in place in the prior corresponding period except for the mental health activities which are now out of its scope due to their new bundled payment funding structure. In addition to the revenue guarantee scheme, the government has throughout the pandemic also prolonged the funding of healthcare facilities to compensate the additional costs related to the COVID-19 epidemic that would not otherwise be covered.
Nordics:
The group’s facilities in Scandinavia have actively participated in the care of COVID-19 patients as well as in the screening and vaccination of the population, in support of public institutions and in close collaboration with the supervisory authorities.
The positive development in adding listed patients into our Proximity care business has continued in both Sweden and Denmark through a dedicated work to improve both availably and attractivity in our facilities. Patient demand in our Specialist and Orthopedic businesses in all countries has been increasing. The integration of the newly acquired GHP business is progressing according to plan and synergies have been realised as expected to date. Finally, during the period two new geriatric contracts were awarded in Sweden for a period of 4+4 years representing an annual turnover of approximately €50m (SEK500m), starting in May 2023.
Scope of consolidation
During the first six months of the current financial year Ramsay Santé has completed one small bolt-on acquisition in the Nordics. Compared to the prior corresponding period, this half-year included the full contribution of the 8 acquisitions completed throughout FY22.
Comments on the half-year accounts
Activity and turnover:
In the six-month period 1st July 2022 to 31st December 2022, Ramsay Santé Group reported a consolidated turnover of €2,209.5m, compared with €2,037.7m for the prior corresponding period, up 8.4%. On a like-for-like basis and at constant exchange rates, the Group's sales increased by 4.8 % despite 2 less working days than the same period last year in France.
France
For the six-month period ending 31 December 2022, Ramsay Santé's French total the number of patient admissions increased on last year by 2.2%. The breakdown by business line is as follows:
• +1.2% in Medicine, Surgery and Obstetrics
• +11.6% in Follow-up Care and Rehabilitation
• -0.6% in Mental Health
Revenue growth in France of 4.2% is mainly supported by this activity growth but also by an increase in revenue from rechargeable medical purchases, and despite the ongoing shift towards ambulatory care.
In March 2022, average tariff increase was set for the year at 0.7% for the French market. For Ramsay Santé and given its care mix, the average increase was at 0.1%, including the ability for the French government to adjust this evolution by up to 0.7pt downwards under certain conditions (“the prudential coefficient”). Only half of the prudential coefficient on the 2022 tariffed revenue was released in December 2022 versus a full release in 2021. This decision means that the 2022 prices were in fact a – 0.2% reduction from the prior year, applied to our mix of activities.
The 3 Nordics countries
Revenue growth in the Nordics of 18.5% was mainly from the impact of the latest acquisitions that have represented €117m of additional revenue during the last 6-month period. A €(44)m negative foreign exchange impact on Nordics revenue partially offsets this growth. Organic sales growth in the Group's Nordic activities for the first six-month of the financial year was +6.4% compared to last year, arising mainly from our primary care and specialist clinics in Sweden and Denmark.
EBITDA
Group EBITDA reached €312.7m (last year €335.4m) for the six-month period ended 31 December 2022, down – 6.8% on a reported basis. It includes a €8.3m EBITDA contribution from Nordics acquisitions and a €(4.3)m unfavourable FX variance impact. On a like-for-like basis, at constant consolidation scope and exchange rates, EBITDA for the group therefore reduces by – 8.0% compared to December 2021.
The EBITDA margin as a percentage of sales was 14.2%, down from 16.5% for the same period last year on a reported basis, or 14.5% this half-year versus 16.5% on a constant scope and foreign exchange rate basis. This decrease reflects the impact of the effort made on the compensations and benefits made to our medical staff and the impact of the inflation on our medical purchases and indirect costs. Such impacts have not been fully mitigated by the level of subsidies received or the upsides of our productivity measures.
Grants
Group EBITDA for the six-month period that ended 31 December 2022 includes €62m (last year €62m as well) related to the French revenue guarantee scheme, which has been recognized in the consolidated financial statements of the group as “Other operating income”. This line also includes Covid costs compensation and support grants from the French government for €20m (last year €32m).
As there is a timing delay between when the costs are incurred in the business and when the regional health agencies notify our facilities, a large part of the subsidies accounted for in the six-month period relates to the period prior to the current financial year, a similar situation to the comparable six-month period last year. The whole amount recognized in the current six-month period of €20m (last year €27.5m) relate to the preceding financial year.
In addition to those Covid-related subsidies, specific grants totalling of €46m were extended to the French facilities to fund inflation that had not been sized in the applicable tariffs, as well as national healthcare staff salary increases applicable from 1st July 2022.
Conversely in the Nordics countries, Covid-related compensation grants and additional revenues have been significantly lower than in the previous period negatively impacting results and margins compared to the previous period. In total, the amount of aid received by our facilities in Sweden was €8.7m in the period, compared to €15.5m in the previous period.
Personnel costs
Personnel costs increase due to inflationary pressures that have to date only been partially compensated by government funding. French minimum wage has been lifted by 8.0% from successive increases effective from October 2021 to August 2022. Concomitantly, the French national private healthcare employee award lifted the minimum award wages by 3%, for which we have received subsidies from the government, and raised the penalty rates for night, weekend and public holiday time by 50%, effective 1st July 2022. In addition, specific salary revalorisation for midwifes and critical care nurses also took effect with the corresponding funding.
Attractivity and retention measures in favour of hospital personnel and shortage of certain staff categories resulting in a higher use of agency staff also added to the inflationary burden across our different geographies. For these areas targeted actions have been initiated to improve the situation over time.
Current Operating Result
Current operating result amounted to €113.1m (last year €149.1m) for the first six-month period representing a current operating margin of 5.1% (last year 7.3%), down 24.1% over the previous period primarily from inflation pressure.
Non-recurring items
Other non-current income and expenses net to a profit of €21.6m (last year €2.3m) for the six-month period ended 31 December 2022, including a €29.2m profit on the sale of the land and car parks adjacent to one of our hospital in Oslo.
Financial result
The cost of net financial debt amounted to €68.7m (last year 59.9m) for the six-month period ended 31 December 2022. The increase in the cost of funding results from new borrowings bearing interest over this period compared to the half-year closed December 2021, namely the Euro PP €100m bond issued in December 2021 and the new Fiducie Sureté €150m tranche drawn in July 2022, as well as an uptick in margins and floating rates.
Other financial expenses and income include a positive mark-to market valuation of our interest rate derivatives offset by the interest expense recognised upon the sale of long-term receivables.
Group’s share of net profit reached €43.9 million (last year €59.6 million) for the six-month period that ended 31 December 2022.
Financing:
Net financial debt as of 31 December 2022 increased to €3,820m compared with €3,710m as of 30 June 2022, and has been negatively impacted by the timing of payments of various grants accrued over the period.
Net debt includes €1,916 million in non-current borrowings and €52 million in current borrowings, offset by €221 million in cash and cash equivalents. IFRS 16 leases debt amounts to €2,143 million including €1,935 million in non-current lease debt and €208 million in current lease debt.
During this half-year period, Ramsay Santé has strengthened its financing structure thanks to an additional €150m tranche of its Fiducie Sureté.
The Group complies with all commitments relating to the financial documentation in place. The application of IFRS 16 has no effect on the methods used to calculate the financial aggregates referred to in these debt agreements.