Tom Singer, Finance Director of BUPA, the healthcare insurer, says that "the rate of growth in PMI is likely to be slower in a challenging market."

In the first half, pre-tax profits at the company, which is limited by guarantee, were flat, at £165m on sales up 28% at £2.7bn, with 10% organic growth and the rest from acquisitions. Strip out the cost of exiting Ireland, and a poor performance from its non-cash investments, and BUPA pre-tax profits rose 9% to £156m. Click here to see the results in full.

But there are worrying signs in both the UK and Spain, BUPA's other main European market.

Exclude Ireland, and health insurance sales rose 9% in the UK to £968m, where BUPA has a 40% market share. Some consumers are cancelling insurance as the recession bites. He warns that next year could see UK insurance flat, or growing by just a few percent.

UK care homes have been hit by a cost crunch, as the rise in fees paid by local authorities averaged just 2.4%. BUPA and the industry are currently in talks with local authorities about this. 

In Spain, BUPA hospital, insurer and care home arm Sanitas has also seen problems. The insurance business has been hit by a move away from individuals towards corporates, who are better able to drive a hard bargain. And Singer says that, affected by the squeeze, some Spanish are downgrading their insurance cover.

Also, following the acquisition of Euroresidencias, new care homes have not filled their beds as fast hoped.

The next year is most unlikely to see further acquisitions, after the radical changes of last year, which saw BUPA sell its UK hospital chain to private equity group Cinven and buy the flagship Cromwell hospital in London, plus Australian insurer MBF, Antipodean care home chain DCA and Health Dialog, a US company which helps 23 million manage chronic illness. It also pulled out of health insurance in Ireland.

Singer has high hopes for BUPA's new joint venture in India, which is aimed at the huge new middle class. He indicated that such emerging markets were perhaps more interesting than moving further into health insurance in mainland Europe. The new acquisitions leave BUPA making nearly half its sales abroad.

But the bottom line is that BUPA generated £242m in cashflow in the half, up £47.6m on last time, and is still sitting on cash. It doesn't face the problems of Southern Cross and other UK operators caught in the property downturn or the NHS squeeze.