Often, I'm told that there are no synergies in being present in more than one country. But investors may change their tune on that one.

Yes, it is hard to see the synergies from being present in more than one country, given the huge differences in payor and regulatory structures. 

But that is precisely why being international does make sense - it spreads the regulatory risk. Companies like Ramsay, Sonic and Netcare are no longer bets on national operators, but on companies which can continue to generate good returns even if a national regulator turns rotweiller. Ask Sonic, which has recently seen Austrailian prices savaged. When they float, the fact that Europe's large diagnostic lab groups are multinationals should give them higher, not lower multiples than if they were national operators.

In any case, many of these companies can point to a set of skills that can and will travel. Ramsay has shown that Australian management techniques can nearly double profitability at a British hospital chain. Big lab groups, whether private or quoted, should have a central knowledge base which gives them an edge over national players.

The companies who disagree that synergies exist tend to be those who believe their national market is unique. Large German, many French and some UK hospital groups epitomise this view, partly because their national markets have (until recently) been large enough to keep them busy. But, often, I think this accepted wisdom reflects a narrow inward-looking corporate culture.