21.It will be apparent from the preceding chapter that the most important route to reciprocal healthcare for UK citizens who are resident in the EU is the S1 scheme. There was general agreement among witnesses that this scheme was advantageous to both the UK and to its citizens. It benefits the former because it ensures that UK citizens living in the EU receive healthcare in their country of residence and means that the National Health Service can avoid paying the higher costs that it would incur should the treatment instead be provided in the UK. But, more fundamentally, the S1 scheme also benefits individuals, who can receive healthcare where and when they need it.
22.Stuart Scullion of the Association of Medical Insurers and Intermediaries (AMII) argued that the many UK nationals living in the EU27 and using the S1 scheme therefore stood to be “quite significantly” affected by the potential loss of reciprocal healthcare arrangements. Mark Dayan of the Nuffield Trust noted that it was unclear how many individuals would be able to cover themselves with private insurance in lieu of an S1. Other witnesses made similar points, with the BMA noting that UK state pensioners relying on the S1 scheme for their care would need to “take out personal health insurance, self-fund, or return to the UK for treatment”.
23.UK citizens living in other EU Member States were particularly concerned about the impact of changes to S1 arrangements on their insurance premiums. Christopher Chantrey from British in Europe told us that the cost of obtaining private medical insurance for people over 70 with pre-existing conditions would be “prohibitive”, and that people would “either be faced with a huge premium from a private insurer or be refused”. Brian Cave, a retired UK citizen living in France, wrote that while he also had French health insurance, he and his wife were financially “totally dependent” on the S1 reciprocal healthcare arrangements. The BHA believed that finding alternative healthcare insurance cover post-Brexit could be “expensive and bureaucratic” for pensioners residing abroad who are benefiting from the current arrangements.
24.The BMA told us that maintaining access to healthcare for EU/EEA citizens in the UK was also “highly important, as doing so prevents disruption or insecurity in access to care for EU/EEA visitors and residents”. Around three million EU citizens currently reside in the UK. As we have noted, their age profile means that EU citizens in the UK make less use of the S1 scheme than do UK citizens resident in the EU, and tend to access NHS services in the same way as any other resident taxpayer.
25.Nevertheless, the Government’s June 2017 position paper set out proposals for safeguarding their position, suggesting that EU citizens living in the UK would be able to qualify for “settled status” once they had been continually resident in the UK for five years. It also aimed to protect access to UK pensions, economic and other rights.
26.For Anne-Laure Donskoy, Founding Co-Chair of the3million, a grassroots organisation representing the interests of EU27 citizens and their families in the UK, guaranteeing such access to UK healthcare was a “moral argument”. She told us that “we have all been enjoying being able to come and live in other member states under [these] rules, and new rules should not be applied to us that will dramatically change our lives in a very unfair way.” This was, she said, because she had migrated to the UK as an EU citizen in “good faith”.
27.Anne-Laure Donskoy believed that there would be two outcomes should current healthcare arrangements end. Firstly, EU and EEA citizens might need to return to their countries of origin. She said that for many, returning home would mean “starting from scratch”, which in some countries involved “qualifying periods” before a person would be eligible to access the healthcare system in the same way as other residents. Secondly, they might be obliged to pay for their own care. She reported that members of her organisation, the3million, were concerned that “the Government would start to introduce charges … or force them to take out private insurance, which quite a few [members] said they could not afford”.
28.Ms Donskoy also reported that EU27 citizens had already faced “incidents of discrimination” in accessing healthcare. She related that identity checks of EU nationals seeking NHS treatment were already taking place, and in certain cases had gone beyond what the NHS could legally request. She told us that there had been “a number of reported incidents of discrimination against people with foreign names or accents”.
29.UK and EU citizens with long-term conditions such as diabetes are particularly dependent upon the S1 scheme. Robin Hewings, Head of Policy, Knowledge and Insight, Diabetes UK, estimated that around 4.5 million people live with diabetes in this country, of whom about 3.5 million have been diagnosed with the condition. Though it was difficult to obtain data on the number of UK citizens living with diabetes in the EU27, he believed that the numbers were “significant, particularly if one thinks of people retiring to France or Spain, given that … about a quarter of people in those age groups have type 2 diabetes”. Nor are figures available for the number of people with diabetes from other EU countries resident in the UK.
30.Mr Hewings told us that it was likely that UK citizens with diabetes living in other EU Member States accessed healthcare through the S1 scheme, “because diabetes is a condition that is associated with being older”. If, post-Brexit, these reciprocal healthcare entitlements were discontinued, he argued that it would become “harder for people to access basic primary care”. The risk for health systems in the UK and EU would be “that we store up serious complications for the future … that goes for both UK citizens in EU countries and vice versa; it is really important that EU citizens living here are accessing basic primary care, and that they are being diagnosed earlier.”
31.The RCPCH wrote that the current reciprocal healthcare system appeared to “work effectively for children who require healthcare services in other EU countries and for children from other EU countries accessing services in the UK.”
32.However, they were concerned that if an agreement on children’s access to healthcare were not reached by Exit Day, children might be prohibited from using services abroad, “which could be extremely detrimental to the healthcare of children”. The BHA were concerned that “dependents (e.g. children and elderly parents) of UK citizens working in EU countries (and vice-versa)” would lose healthcare rights. Samia Badani, Head of Campaigns, New Europeans, voiced a similar concern over family members who join EU citizens in the UK: “we cannot even conceive of families being split, or a member [of the New Europeans] being in a situation where they cannot reunite with their family because they cannot afford healthcare. We expect family members to be treated in the same way as EU nationals who are currently here.”
33.The RCPCH also warned that the children of EU/EEA citizens living in the UK could “face a significant change in their access to care … becoming liable to pay the Immigration Health Surcharge (IHS) or individual fees for their child’s care.” They therefore believed that it was “extremely important that children of EU/EEA citizens in the UK can continue to access healthcare services under the reciprocal agreement. If parents are required to pay for services, this could act as a deterrent to accessing services which could be detrimental to the health of children of EU/EEA citizens living in the UK.”
34.The S1 scheme has provided comprehensive healthcare coverage to many thousands of UK pensioners lawfully resident in other EU Member States, and has been especially useful for people living with diabetes and other long-term conditions. We welcome plans to include these people in the Withdrawal Agreement as the best means of securing clear legal entitlement to this scheme. We note that the legislation dealing with the implementation of this agreement in the UK will be presented to parliament in the coming months as part of the Withdrawal Agreement and Implementation Bill.
35.To allay any outstanding fears about the status of children and dependents, the Government should now provide details to EU27 citizens lawfully resident in the UK about its plans and timetable for legally protecting their rights, stressing in particular that they will continue to enjoy the same rights to access healthcare that they and their dependents currently enjoy under EU law.
36.We would be concerned if EU/EEA citizens were already being denied access to the treatment to which they are entitled, as witnesses suggested to us. We therefore underline the imperative of securing enforceability of rights in the Withdrawal Agreement. In addition, we call on the Government to restate as clearly as possible to the NHS and its staff the current healthcare entitlements of EU/EEA citizens, and to communicate the entitlements contained in any future UK-EU agreement on reciprocal healthcare as soon as it is possible to do so.
32 Written evidence from Department of Health and Social Care ()
35 Written evidence from British Medical Association ()
36 For example, written evidence from Beverly Townsend (), Brian Cave (), Charlotte Swift (), Brexpats in Spain (), John Trevor Moss (), Dr Lawrence Renaudon Smith (), Alexander Wilson (), Beverly Townsend () and British Medical Association ().
38 Written evidence from Brian Cave ()
39 Written evidence from Brexit Health Alliance ()
40 Written evidence from British Medical Association ()
41 Written evidence from Law Society of Scotland ()
42 HM Government, The United Kingdom’s exit from the European Union: safeguarding the position of EU citizens living in the UK and UK nationals living in the EU, Cm 9464, June 2017: [accessed 15 March 2018]
43 Written evidence from Law Society of Scotland ()
52 Written evidence from the Royal College of Paediatrics and Child Health ()
53 Written evidence from Brexit Health Alliance ()
55 The Immigration Health Surcharge is a fee levied on anyone who applies for permission to enter or remain in the UK. It is in addition to the visa application fee and is not optional, even if the applicant has purchased—or intends to purchase—private medical insurance. Home Office ‘Pay for UK healthcare as part of your immigration application’: [accessed 15 March 2018]
56 Written evidence from Royal College of Paediatrics and Child Health ()