The last week has seen IHH, Schoen and Life all talk of expanding their hospital chains into new European countries.

At a recent meeting with a banker we were told that there only around a dozen healthcare service operators who could genuinely be called international in that they were operating in several countries.  “60-70 others are thinking about it,’ the banker added.

He is, in fact, already behind the times. We can think of over a dozen european and emerging market lab groups alone which are already genuinely international, in that they are operate reasonably substantial businesses in at least three countries.

The figure for hospital groups is also surprisingly high and rising fast. Beyond the formidable first tier made up of Ramsay, Life, Netcare, Mediclinic and Capio, there is a raft of second tier players in Europe, which have already gone international, such as Clinics da Monza and GVM from Italy. We know of a further twenty Emerging Market hospital operators who are already active in more than three countries. Many of the big ASEAN groups are already in more than three countries, for instance.

You can also identify eight European nursing home chains, which are international today.

And we would argue that the prospective list of would be international players of all types now stretches to well over 100 – many of the big French and Spanish hospital groups are now looking to North Africa and beyond, for instance. Asisa is investigating Brazil!

Not that international expansion will be easy. There have been, and there will be, many casualties along the way.  It is particularly difficult to export medical practice to other countries.  Parlaying between different types of specialist doctor within one country is hard enough.  Getting them to work together in the same way in other countries may be all but impossible. Schoen is a highly competent company but in planning to export its model it has set itself a real challenge.

Healthcare services is seen as a safe industry by investors. Internationalisation will add big, and far less quantifiable, risks.