THE Manises public hospital on the outskirts of the Spanish city of Valencia is a tribute to British health-care expertise. Behind the well-ordered facility is a public-private partnership led by Sanitas, the Spanish branch of BUPA—a London-based company that also runs other hospitals and health-care services in Spain. Local politicians like the model because it removes the headache of badly run clinics that need to be bailed out. Stuart Fletcher, BUPA’s chief executive, boasts of satisfied patients and shorter stays compared with Spain’s state hospitals. His firm is now providing health services in Poland and Australia too.

At home, though, it is a different story. The English NHS is mired in rows about the role of private providers, with Scotland and Wales even more resistant. Revelations that Serco, an outsourcing company, had cut corners on a contract to provide doctors’ services out of hours have not helped. Unions and professional groups decry plans to “marketise” health by allowing public hospitals to offer a greater proportion of their elective services privately. The coalition government’s health reforms have been watered down. Monitor, the regulator, was to be tasked with stimulating competition; now it will play a less active role. Public-sector health trusts remain the main bidders to take over failing general hospitals. Private chains have few incentives to get involved.

Independent suppliers have crept into Britain’s state health-care system. Since 2007 (following Labour’s last bout of health reforms) English patients have gone to outfits like Spire Healthcare, one of five big private hospital providers, with the NHS footing the bill. These not only add capacity but also help raise standards by introducing new techniques. The BMI hospital chain, for example, has just won an award for devising more reliable ways of preventing deep-vein thrombosis in bed-bound patients. Private diagnostic treatment centres perform high-volume operations like hip replacements for the NHS, while BUPA supplies care homes and outpatient cancer treatment to it.

Yet commercial outfits have mostly been kept away from hospitals. Only one privately owned health-care group, Circle, has so far succeeded in obtaining the franchise to run a former NHS hospital—at Hinchingbrooke in Cambridgeshire. Its first year has been rocky: Ali Parsa, the group’s boss, left suddenly last December. The company admits that its deficit is currently twice that of its original forecasts, although Steve Melton, its new head, says the hospital will break even next year.

Hinchingbrooke has at least proved wrong sceptics who warned of damage to patients’ interests. Results, including waiting times, have improved dramatically, as have the hospital’s ratings from patients.

Over time, resistance to “privatisation” may be worn down as large hospitals gradually become less important, specialist centres thrive and more chronic conditions can be treated at home through better use of the internet and mobile phones. But the reluctance to use the best of a vibrant private health sector to challenge failures in the NHS means that reforms often lack the spur of competitive innovation. It leaves a gap in the British health-care system which is filled in Germany by Helios, a company that specialises in turning around failing hospitals. Nick Seddon of Reform, a think-tank, notes that erratic reforms, pension liabilities and onerous rules on hiring and firing staff deter private providers, who can generally find quicker returns abroad.

Britain is not just falling behind countries such as Germany and Spain in embracing the profit motive. Cuba has launched Servimed, a medical company selling services abroad. Two big for-profit hospitals operate in Havana. That is one more than has been mustered after a decade of reform in Blighty.