9.The EU’s reciprocal healthcare framework has 32 participating countries. It seeks to provide a mechanism for the coordination of separate national health systems, not to align them—meaning that provision under the scheme can differ from country to country. The framework includes the 28 Member States of the EU, in tandem with the three European Economic Area (EEA) European Free Trade Area (EFTA) states (Norway, Iceland and Liechtenstein). There is also a bilateral arrangement with Switzerland, which participates in the same way as the 31 other states.
10.There are currently four main ‘routes’ for EU and EEA citizens to access healthcare in Member States other than those in which they are ordinarily resident: the European Health Insurance Card (EHIC), the S1 system, the S2 system, and the Patients’ Rights Directive. These four routes are described below.
Provided for in Article 19(1) of Regulation 883/2004, the European Health Insurance Card entitles EU/EEA and Swiss citizens to “needs-arising” healthcare in another Member State, as if they were an insured resident of that country. The EHIC also covers treatment for long-term conditions, such as the costs associated with dialysis that EU/EEA and Swiss citizens with kidney conditions would otherwise incur when travelling.
The EHIC is not valid for private treatment and only entitles the holder to access state-provided healthcare during temporary stays in the EU/EEA and Switzerland. It does not cover costs such as repatriation; for this reason, the Government advises individuals to purchase travel insurance when visiting other EU/EEA Member States and Switzerland. In addition, the EHIC does not cover individuals who use the card to travel abroad specifically to have treatment—such costs are covered by the S2 scheme.
11.The EHIC is designed to be used by short-term travellers, including tourists and business travellers, and the vast majority of UK-issued EHIC cards go to UK residents. Charlotte Swift told us that “EHIC cards are not appropriate to anyone other than holiday-makers”, and Roger Boaden, of Expat Citizen Rights in EU, reported that fewer than 5% of UK-issued cards went to UK citizens living in the rest of the EU.
12.For the Brexit Health Alliance (BHA), these arrangements “work well for the mutual benefit of UK and EU citizens and healthcare systems”, giving “peace of mind to travellers who know that if they carry an EHIC they will be covered for urgent treatment, regardless of any pre-existing conditions”. The system, they claimed, was also relatively simple for healthcare systems to administer. Similarly, the Royal College of Paediatrics and Child Health (RCPCH) noted that care received by UK citizens in other EEA nations was frequently cheaper than the equivalent provided by the NHS, meaning that the UK spent less on healthcare funded through existing reciprocal arrangements than it would if that care had to be provided domestically. Indeed, John Trevor Moss claimed that costs of provision in the EU were about 60% of those in the UK. The RCPCH wrote that such discrepancies were partly a result of the use of co-payments in other healthcare systems.
13.According to the BMA, there were approximately 27 million active UK EHIC cards in circulation in September 2017. Of the 53 million visits made to the EU from the UK each year, and the 25 million visits from the EU to the UK, only around one per cent result in an EHIC claim, suggested the BHA. Hugh Savill, Director of Regulation at the Association of British Insurers (ABI), told us that estimated medical costs associated with the treatment of UK citizens under the EHIC added up to £156 million per year. The BHA said that in return for these reimbursements, the UK recoups about £70 million from other EU/EEA countries.
14.Under the present arrangements, according to Mr Savill, travel insurance “covers you for the cost of medical treatment that is not covered by the EHIC card”. It is therefore, as Professor Jean McHale of the University of Birmingham told us, “not an alternative to travel insurance”, but complementary to it. According to the Royal College of Physicians of Edinburgh, it also “almost certainly” keeps private insurance costs down.
Under the S1 scheme individuals apply for coverage by completing an ‘S1 form’, which allows ongoing access to health and care services for people living abroad, with the cost met by the government of the ‘competent Member State’ (usually the Member State to whose social security system the individual has contributed for the longest time). Pensioners’ entitlement to reciprocal healthcare is an exportable benefit under EU Regulation 883/2004 on the coordination of social security systems. Other exportable benefits, such as employment support allowance, also carry healthcare entitlements, while workers posted to another EU Member State can use the S1 scheme to fund their care.
The S1 scheme plays a significant role in healthcare provision for older people. Approximately 190,000 UK state pensioners now live in other EU/EEA countries.
Source: Written evidence from Department of Health and Social Care (), British Medical Association (), (Paul Macnaught); Regulation (EC) No. 883/2004 of the European Parliament and of the Council of 29 April 2004 on the coordination of social security systems, (30 April 2004)
15.John Trevor Moss noted that S1 assisted a cohort of older people who “carry substantial health risks”. Indeed, several witnesses spoke from personal experience in stressing the importance of S1 in providing their healthcare. One told us that it represented “a lifeline not only for those who have reached pension age, but also to those expats approaching it”. For the BMA, the S1 scheme was “particularly effective”, because allowing UK state pensioners living within the EU to access health and care services in their country of residence on an ongoing basis, with the cost met by the UK Government, ensured “simple access to care”. Roger Boaden of Expat Citizen Rights in EU outlined how some individuals relied on the S1 scheme while ‘topping up’ their coverage with private healthcare insurance.
16.A disproportionate number of UK citizens benefit from the S1 scheme. There are only around 1.2 million UK citizens living in other EU countries, compared with around three million EU citizens living in the UK. But some 190,000 of those UK citizens are pensioners, who are more likely to benefit from the S1 scheme, compared to only 5,800 EU/EEA citizens who have registered for the S1 scheme in the UK.
17.On top of its EHIC expenditure, the UK spends approximately £500 million a year in reimbursements to Member States for healthcare provided to pensioners and others who have exported their accumulated benefits. The Department of Health and Social Care accepted that the system was cost-effective for the UK, not least because the cost of treatment overseas was often cheaper than in the UK. For example, Spain’s latest pensioner average cost—despite a recent upward revision—is now €4,173 compared with £4,396 in the UK.
The S2 system under Regulation 883/2004 gives patients authorisation to receive healthcare or maternity care on the same terms as the local population, with the cost of that treatment met by their country of residence. Individuals need to apply for S2 funding ahead of their treatment, providing evidence that they meet the eligibility criteria and a clinician’s statement regarding their case. S2 only covers treatments that are provided by a state-run or contracted service. Patients must pay any contribution to the costs that a local citizen in the other state would normally pay. In some countries this can amount to up to 25% of costs.
18.The S2 system delivers cover that S1 might not provide. The BHA described the “not infrequent situations on the Continent where UK citizens and their dependents may live in one country, work in a second and receive medical treatment” under S2 arrangements in a third. They also told us that the S2 scheme and Patients’ Rights Directive worked “very well” for UK or EU citizens who needed planned treatment in another EU country, and was especially valuable for patients with rare diseases or in border situations, where the nearest suitable facilities might be in a different country.
19.Lord O’Shaughnessy told us that in 2016 about 1,342 S2 portable documents were issued by the UK to its citizens, and about 1,100 were granted to EU, EEA and Swiss nationals for treatment in the UK.
Patients can access healthcare in another EU Member State under the EU Directive on the Application of Patients’ Rights in Cross-border Healthcare (2011/24/EU). The Directive clarifies patients’ rights to purchase healthcare in another EU/EEA country and apply for the reimbursement of costs from the Member State in which they are resident. It creates a framework for people to access high-quality healthcare in other European countries, for instance to access specialised expertise. Unlike the S2 system, the treatments that patients receive must be ones that they are entitled to in the healthcare system of the Member State in which they are resident. This rules out some procedures, for example proton beam therapy, which is available in Europe for a wider range of conditions than in the UK. Reimbursement is capped at the amount that it would have cost had the treatment taken place in the patient’s Member State of residence. Switzerland is not party to the Directive.
In the UK, patients are only required to apply in advance for a limited number of treatments (those currently linked to NHS specialised services); otherwise patients are entitled to apply for reimbursement without any prior approval. They pay the healthcare provider directly and, in England, apply to NHS England for reimbursement (which then bills the relevant NHS commissioning body). If approved, reimbursement to the patient under the Directive is set at the costs that the NHS would have incurred if it had provided the treatment, or the actual treatment cost if lower. The Directive also covers mutual recognition of prescriptions, and the establishment of European Reference Networks (ERNs)—platforms for cross-border cooperation on complex or rare diseases.
Source: Written evidence from UK Coordinators of European Reference Networks (), Department of Health and Social Care (), Law Society of Scotland () and Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients’ rights in cross-border healthcare, (4 April 2011)
20.In 2015 1,186 individuals from the UK were reimbursed for treatment in accordance with the Patients’ Right Directive. Poland, Latvia and France were among the most popular destinations for treatment. Around 40 NHS hospitals are involved in the European Reference Networks (ERNs) that were established under the Directive.
The Department of Health and Social Care funds and administers reciprocal healthcare on behalf of the UK as a whole, liaising where appropriate with the NHS in England, Scotland, Wales and Northern Ireland. There are two primary mechanisms in place for the reimbursement of healthcare costs between EU/EEA countries (and Switzerland):
The majority of countries now bill only on the basis of actual healthcare costs. Only eight countries, including the UK, use average costs (although the UK uses actual costs for the temporary visitor category). However, the countries that the UK pays the most to—Spain and the Republic of Ireland—also use average costs.
In addition, the UK has several waiver agreements with individual EU/EEA countries, which involve the relinquishment of healthcare costs between Member States. Waiver agreements exist where they are considered mutually beneficial to ease the administrative burden. The UK’s waiver agreements are with Denmark, Estonia, Norway, Finland, Hungary and Malta.
7 Written evidence from Caroline Swift ()
9 Written evidence from Brexit Health Alliance ()
10 Written evidence from Royal College of Paediatrics and Child Health ()
11 Written evidence from John Trevor Moss ()
12 Written evidence from Royal College of Paediatrics and Child Health ()
13 Written evidence from British Medical Association () and
14 Written evidence from Brexit Health Alliance () and
16 Written evidence from Brexit Health Alliance ()
19 Written evidence from Royal College of Physicians of Edinburgh ()
20 Written evidence from John Trevor Moss ()
21 Written evidence from Alexander Wilson ()
22 Written evidence from British Medical Association ()
24 Written evidence from Law Society of Scotland ()
25 Written evidence from British Medical Association ()
26 Written evidence from Brexit Health Alliance ()
27 For a full list of co-payment systems in EU/EEA Member States and Switzerland, see supplementary written evidence from the Depatment for Health and Social Care ().
28 Written evidence from Brexit Health Alliance ()
31 Written evidence from Department of Health and Social Care ()