Health and Care Services

Cross-border healthcare – overseas patients

The UK Government recently announced that NHS hospitals in England will be required to charge patients from overseas upfront for non-urgent, planned care unless they are eligible for free treatment. How does this apply to the devolved administrations? What are the arrangements for non-UK residents to access NHS healthcare, and for Welsh (and UK) patients to receive treatment abroad? Is this likely to change following the UK’s withdrawal from the EU?

16 March 2017

Darllenwch yr erthygl yma yn Gymraeg | View this post in Welsh

The UK Government recently announced that NHS hospitals in England will be required to charge patients from overseas upfront for non-urgent, planned care unless they are eligible for free treatment.

How does this apply to the devolved administrations? What are the arrangements for non-UK residents to access NHS healthcare, and for Welsh (and UK) patients to receive treatment abroad? Is this likely to change following the UK’s withdrawal from the EU?

Access to NHS services in the UK – ordinary residence

Entitlement to free NHS healthcare is based on being ‘ordinarily-resident’ in the UK. Ordinary residence is not dependent on nationality, paying UK Image of a health professional holding a clipboard taxes/national insurance, having an NHS number or being registered with a GP, or owning property in the UK. It has become accepted to mean that a person is living here lawfully, voluntarily, and for settled purposes. Under the Immigration Act 2014, a person must have indefinite leave to remain in the UK in order to be regarded as ordinarily resident.

Across the UK, some types of healthcare, including GP services and treatment in an accident and emergency department, are currently free to all patients whether they are ordinarily resident or not. For non-UK residents, most hospital treatment is subject to charge, although some groups of people are exempt, for example refugees, asylum seekers and looked after children. Additionally, patients who have rights to healthcare under EU legislation or other reciprocal healthcare agreements may also be exempt from charges. More detail about these arrangements – which also apply to UK residents receiving treatment abroad – is provided below.

As of April 2015, non-EEA nationals coming to the UK for longer than six months may be liable to pay an immigration health surcharge as part of their visa application. This entitles them to NHS treatment on the same basis as permanent UK residents.

Charging regulations

NHS organisations across the UK are required by regulations to establish whether someone is liable to pay for NHS services and to charge them accordingly.

The UK Department of Health has said that the new requirement for hospitals to charge overseas patients upfront will come into effect in April 2017. This applies to England only – separate regulations govern the charging arrangements in the devolved administrations. In Wales, the Welsh Government is reviewing the existing charging regulations and guidance, and is expected to publish updated versions in draft form for consultation in spring 2017.

Residents of EEA countries (including UK residents)

Unplanned treatment

Residents of European Economic Area (EEA) countries and Switzerland can apply for a European Health Insurance Card (EHIC), which will allow them to access state-provided healthcare during a temporary stay in another EEA country/Switzerland. The EHIC covers any necessary medical treatment that cannot be postponed until you’ve returned home. This includes treatment for chronic or pre-existing medical conditions and also routine maternity care (this includes unplanned childbirth, but would not provide cover for someone planning to give birth abroad).

Treatment should be provided on the same basis as it would to a resident of that country. In many cases this will be free, however in some countries patients are expected to contribute towards the cost of their state-provided treatment, and this will also apply to EHIC holders receiving treatment in those countries.

It’s emphasised that the EHIC is not an alternative to travel insurance – it will not, for example, cover someone for rescue and repatriation following an accident.

Planned treatment

There are two potential routes under which EEA residents can travel to another EEA country for planned healthcare:

  • the EU Directive route;
  • the S2 scheme.

Under the EU Directive on patients’ rights in cross-border healthcare, patients are able to purchase state or private healthcare in another EEA country and seek reimbursement from their home country (up to the cost of that treatment at home). The EU Directive route does not apply to Switzerland.

Prior authorisation is not necessarily needed, although this will be a requirement for some types of healthcare, generally inpatient care and highly-specialised, cost-intensive treatment. Under the Directive, patients are not able to obtain reimbursement for treatment that they would not be entitled to at home.

Further information about arrangements under the EU Directive can be found in the Welsh Government’s guidance for the NHS on cross-border healthcare and patient mobility.

Under the S2 route, EEA and Swiss residents are able to seek planned treatment in other EEA countries/Switzerland, but must obtain prior authorisation from their own Member State, which bears the cost. The S2 route applies only to state-provided (not private) treatment.

The S2 form acts as a form of payment guarantee – in the majority of cases, the patient is not required to pay anything themselves (other than any relevant statutory charges that would also apply to those ordinarily resident, for example prescription and dental charges in the UK).

Pensioners living abroad

Under the S1 scheme, pensioners settling in another EEA country or Switzerland are able to access healthcare services in that country on the same terms as ordinary residents. The S1 form is issued by the country that pays your pension, and must be registered in the country in which you now live.

The S1 scheme is mostly used for pensioners but may also apply to other groups such as posted workers and cross-border workers.

The UK Government acts on behalf of the UK as a whole to reclaim costs from other EEA member states under the S1, S2 and EHIC schemes.

Impact of Brexit

The UK is a net ‘exporter’ under the EU’s reciprocal healthcare arrangements, paying out more to other EEA countries than it receives. This is largely due to the greater number of UK pensioners living abroad. In February 2017, the UK Department of Health told the House of C0mmons’ Health Committee:

on an annual basis, we pay out roughly £650 million a year to cover the costs of UK‑insured pensioners in other EEA countries and UK visitors to those countries.


Of that, about £500 million is on pensioners, so that is UK‑insured pensioners, of which there are about 190,000 in other EEA countries. I think the figures there are 70,000 in Spain, 44,000 in Ireland, 43,000 in France and about 12,000 in Cyprus. Those are the main countries.

The above arrangements remain in place while the UK is still a member of the EU, but it’s not yet clear how things might change following the UK’s withdrawal. In evidence to the Assembly’s External Affairs and Additional Legislation Committee, the Welsh NHS Confederation said:

If the UK were to leave the EU single market, these systems would in principle no longer apply in the future, unless bilateral agreements were negotiated. Consideration should be given by negotiators to possible implications for patients and how to ensure that a fair alternative system is put in place, either with the EU as a whole, or with those EU countries, such as Spain, which have high numbers of UK nationals living there.

Non-EEA countries

The UK has reciprocal healthcare agreements with a number of individual countries outside the EEA. These agreements may provide for immediately necessary treatment for conditions which arise, or existing conditions which become acutely worse, during a temporary visit. The level of care which may be provided free of charge varies. As with the EHIC, it’s recommended that those travelling in other countries take out adequate travel insurance to cover their stay abroad.

Some reciprocal agreements may also provide for a limited number of referrals specifically for the treatment of pre-existing conditions (this would normally only apply where the referring country does not have adequate facilities to provide the treatment needed).

Further information

  • National Contact Points in each EEA country can advise patients on their rights under the EU arrangements.
  • Information about accessing planned or unplanned treatment in another European country can be found on the EU’s Your Europe website.
  • Further information and advice for people visiting or moving abroad, and for those seeking treatment in Wales, is provided by NHS Direct Wales.

See our June 2016 briefing for information on the cross-border healthcare arrangements between Wales and England.

Article by Philippa Watkins, National Assembly for Wales Research Service.


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