03 January 2019
The UK Government introduced its Healthcare (International Arrangements) Bill in the House of Commons on 26 October 2018.
This is a short bill, focussing on a single issue. It is intended to allow the UK to maintain reciprocal healthcare arrangements with the EU and its Member States after Brexit, in the event of either a Brexit deal or no deal scenario. (The provisions are not limited to arrangements with the EU – the Bill would also allow the UK to strengthen existing reciprocal healthcare agreements with countries outside the EU, or to implement new ones).
Currently, residents of European Economic Area (EEA) countries and Switzerland can access medical treatment that becomes necessary during a temporary stay in another EEA country/Switzerland via the European Health Insurance Card (EHIC). There are also arrangements under which EEA residents can travel to another EEA country for planned healthcare (the EU Directive route and the S2 scheme), and for pensioners settling in another EEA country or Switzerland to access healthcare services in that country on the same terms as ordinary residents (the S1 scheme). Further detail about the current arrangements can be found below.
The Brexit Health Alliance (which brings together the NHS, medical research, industry, patients and public health organisations) has been campaigning for ‘straightforward and appropriate access’ to reciprocal healthcare for both UK and EU patients, preferably by preserving current arrangements.
The Healthcare (International Arrangements) Bill had its second reading on 14 November 2018. The UK Minister for Health, Stephen Barclay, said:
It is clearly in the interests of the British public to ensure reciprocal healthcare arrangements continue when we leave the EU, whether that happens through an agreement with the EU itself or through individual agreements with EU member states. By enabling us to implement those arrangements, the Bill will help us to help nearly 200,000 British pensioners living in EU countries to continue to access the medical treatment that they need, and it will mean that the hundreds of thousands of British citizens who require medical treatment each year during holidays in Europe can still be covered for medical assistance when they need it.
The Bill will help to ensure that UK nationals who live and work in EU countries can continue to access healthcare on the same basis as local people. It will mean that EU citizens can be covered for reciprocal healthcare here, so that the UK continues to be a place tourists want to visit and vital workers, such as our NHS workforce, want to live in. The Bill will also mean that we can continue to recover healthcare costs from Europe as we do now.
In order to give effect to any future healthcare arrangements, the UK is reliant on the provision of healthcare by the NHS in Wales. As this subject is within the devolved competence of the Assembly, convention requires the Assembly to give consent to the relevant provisions in the Bill. A Legislative Consent Memorandum (LCM) was laid before the Assembly on 15 November 2018. The Health, Social Care and Sport Committee and the Constitutional and Legislative Affairs Committee will consider the LCM, with a reporting deadline of 22 January 2019.
Welsh Government response
The Welsh Government agrees that the Healthcare (International Arrangements) Bill is necessary to ensure UK residents can continue to benefit from reciprocal healthcare arrangements, and shares the preference for a consistent UK-wide approach. It highlights the urgency of the legislation in order to provide assurances to residents in the case of a no deal exit from the EU. However, given the impact on the NHS in Wales, the LCM raises concerns about the extent to which the Welsh Government will be involved in shaping the healthcare arrangements to be delivered under the Bill:
given the significant impact on devolved areas it is crucial that Welsh interests are appropriately considered in the development of reciprocal health arrangements and that mechanisms are in place to ensure that the Welsh Government contributes to the making of decisions that affect Wales.
What are the current arrangements for reciprocal healthcare?
Residents of EEA countries (including UK residents)
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.
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.
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).
Draft withdrawal agreement
The draft Withdrawal Agreement agreed between the UK and EU on 14 November provides that EU Regulations on social security coordination will continue to apply to EU citizens living in the UK and UK nationals living in the EU at the end of the implementation period. This means that citizens who have moved between the UK and the EU before the end of the implementation period will have continued access to healthcare cover. In addition, the draft Withdrawal Agreement provides that where the UK or a Member State is responsible for the healthcare of these citizens, they will be entitled to reciprocal healthcare cover from their competent country.
In terms of reciprocal healthcare, the rights of UK nationals who are not living in the EU at the end of the implementation period but have paid social security contributions in a Member State in the past will be protected. The draft Withdrawal Agreement will also protect the rights of individuals who are in a cross-border situation at the end of implementation period, and who are entitled to a EHIC, so that they will still be able to benefit from that scheme for as long as they are in that cross-border situation. This applies to UK nationals who are studying in or visiting the EU.
The draft Withdrawal Agreement will also protect the rights of people visiting the UK or the EU for planned medical treatment, where authorisation was requested before the end of the implementation period, so they are able to commence or complete their treatment.
Citizens’ rights to healthcare cover including reciprocal healthcare and planned medical treatment will stay the same during any transition period.
Article by Philippa Watkins, National Assembly for Wales Research Service