Aug13

Update 13 August 2025

Update 13 August 2025

It has been a long break since the last update, due to a fantastic summer vacation by train in Scandinavia. Due to the long break since the previous, some of the news is somewhat stale, but hopefully still of interest. In this update we cover:

  • More M&A activity in the Dutch healthcare sector but less Private Equity. What is going on?
  • Lower investments in healthcare real estate. What has happened to foreign investors?
  • Move towards complex elderly care in a home setting. Is the trend gaining ground?

More M&A activity in the Dutch healthcare sector but less Private Equity activity

In the last update before the summer holidays we described three acquisitions that have taken place in the Dutch healthcare sector. The NZA (Dutch Healthcare Authority) has to give positive advice on any merger or acquisition in the Dutch healthcare when at least one of the organizations has more than 50 employees. The NZA also regularly publishes a fairly detailed overview of the M&A activities it has assessed. The newest overview covers 2024 and in this period the NZA has reviewed 214 cases. This is the fourth year with a growing number of transactions, and highlights the ongoing trend of consolidation in the sector.

The s with the most activity includes dental care, long term care and pharmacies. The high number of transactions in dental care and pharmacies is to a substantial extent driven by owners wanting to retire. Most activity in the long-term care sector is traditional, non-profit operators joining forces to improve economies of scale and/or improve the overall financial position. 20% of the M&A activity was related to a foreign buyer, this is slightly lower than in 2023 (24%). There has also been a reduction in acquisitions related to Private Equity (either directly, or through a company controlled by PE). In 2023 59% of all healthcare related M&A activity included a PE-company. In 2024 this was 46%.

In recent updates we have written about the wish of a majority in Parliament to forbid PE-investments in the healthcare sector, and some commentators believe that the negative political climate can explain why private equity investors are more hesitant about investing in the Dutch market. However, the probability of such a ban actually taking place is close to nihil (due to EU-rules and extreme difficulties in implementation) and this limited slowdown in the Dutch market needs to be compared to what is happening in the overall European sector. In addition, there are signs that the interest of private equity in the Dutch healthcare sector has picked up in 2025, with a couple of ongoing deals.

Lower investments in Dutch healthcare real estate

In 2013 there was almost no investment in healthcare related real estate. A recent report by Capital Value, investments in this sector grew steadily, reaching a maximum of more than €1.4 billion in 2022. After the uncertainties due to the war in Ukraine and increasing interest rates, investment in the following years have been less than half of the level in 2022. 2025 does not appear to be an exception to this situation, with healthcare real estate investments only totaling €268 million in the first six months of the year. The majority of the investments so far in 2025 have been in elderly care units with 35% of total volume going to real estate related to commercial operators and 36% of total volume going to real estate for traditional non-profit providers.

The most worrying aspect of the first six months of 2025 is that there have not been any deals involving international real estate investors. In fact, the only activities for foreign investors have been on the sell side (total €48 million or approximately 18% of total volume). Aedifica and Cofinimmo have both been sellers of Dutch healthcare real estate but hopefully the recently announced merger will bring them back as more pro-active participants in the market. More real-estate capacity is sorely needed in the Dutch healthcare sector (especially in elderly care), so it is to be hoped that international real estate investors find their way back to this market.

Move to complex elderly care in a home setting gaining ground

A few years back the Dutch government decided that the intramural capacity for complex elderly care would not be increased from the existing level of approximately 125.000 beds, and that an increasing share of complex care would be provided in a home setting. This sounded very ambitious given the ongoing demographic changes, even with the opportunity of using a broad definition of “at home” based on differences in financing schemes (ZIN vs VPT). However, recent data shows that it is (maybe) happening.

The latest WOZO-monitor shows an overall growth in the number of clients that need complex elderly care (from 137.000 in 2015 to 197.000 in 2024). This increase is in line with demographic developments. The data also shows a large change in the type of indications given. The share of indications for less complex care has decreased from 23% in 2015 to 13% in 2024, while the indications for more complex care have grown. The reasons for this are not given, but could be either that clients are waiting to ask for help until their needs are more complex, or that there is wide-spread “up-coding” of the indications given. The reason for this could be that the lower indication for less complex care (VVT4) does not provide guaranteed access to a nursing home.

This is confirmed by data showing which share of the lower indication (VVT4) actually receive care in a nursing home. In 2021, 59% of clients requiring less complex long-term care were receiving this in an intramural setting. At the end of 2023, this percentage had been reduced to 46%, meaning that more than half of clients with an indication for less complex elderly care now receive ongoing assistance in what is officially seen as a “home” setting. This includes both then care provided by commercial nursing home providers (who have been growing strongly in the past few years) and clients receiving care in the “home” where they lived before requiring complex elderly care.

More analysis is clearly required, and it will be interesting to see if this is conducted and published.