What has emerged during our research for HBI Intelligence’s imaging report, now live on our site, is how fragmented the sector is compared to other services. It will be utterly revolutionised by regulatory and tariff changes, AI/teleradiology and changing service-supplier dynamics; it’s just no one is sure exactly how.

The privately-provided imaging sector in 2018 comes to around €17.7bn in Europe’s 16 major markets covered in our report (plus Saudi Arabia and South Africa, the figure is €18.6bn), growing 4.5% annually.

But only 6% of this is in the hands of the four largest operators, falling to 4% if you include the two non-European markets. That is far below the equivalent figures for hospitals, labs, nursing homes, IVF, all 10-20%, or 25% for psychiatry and 75% for dialysis, meaning heaps of national, let alone international, consolidation to be done.

Private sector growth varies dramatically by country. Mature and substantial markets Germany, France and Switzerland are seeing below-average growth of 2-4% as payors control costs. Elsewhere, 4-6% is common rising to 6-7% in private-pay focused markets like Poland and Spain and 10% or more in countries playing catch-up like the UK and Hungary. Harsh tariff cuts have been seen in Portugal, Switzerland, Turkey, Greece and France.

The long-term impact of AI on the sector is still unclear, perhaps because forecasting precise long-term impacts publicly risks upsetting your radiologists. The medium-term benefits will accrue to workflow optimisation and prioritising radiologists’ reporting workload. Most startups in the space target high-volume scans because that is where the data is but radiologists typically work through those high-volume images quickly anyway, leading to a catch-22.

Teleradiology is also revolutionising the sector, filling the radiologist supply-demand gap in hospitals and incentivising scale through single-location reporting. But it’s starting from a low base. The UK might be the biggest teleradiology sector, with estimated NHS spend on it reaching €90m in 2018 and growing 20-30%. We estimate that 3-5% of images are reported on remotely there, but no operator has been willing or able to provide similar estimates elsewhere. We are told that GDPR penalties are scaring large groups off embracing the technology more wholeheartedly.

Change is afoot in the relationship with suppliers too, with the growth of third-party managed equipment providers like Althea, now up for sale, suppliers from the Far East better competing with Europe’s dominant Troika of GE, Philips and Siemens, who are all developing a closer relationship with services, even competing with their customers.

We delve deeply into all of the above in the 14,000-word imaging section of HBI Intelligence having spoken to 15 contacts including nearly half of Europe’s 20 largest outpatient imaging service providers.