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Health Tourism – Do EU citizens disproportionately use NHS services?

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Health tourism is often cited as a serious drain on the NHS’s resources. The figure of £2 billion is the widely quoted figure taken from a 2013 government report.[i] Since this figure represents 1.7% of the total NHS England budget of £116.4 billion for 2015 it has understandably fuelled lively debate. However, this figure is, at best, a rough estimate and at its worst is an arbitrary, highly misleading figure. Some think the real cost is far greater (16 times so) than the estimate,[ii] while others believe it to be far lower.[iii] Despite being a controversial figure, it is the best we have; but how much of this sum is incurred by EU users, both eligible and non-eligible?

This £2 billion of NHS expenditure is consumed by many different groups. For example, deliberate abuse of the NHS (those who come here to specifically receive free treatment) is thought to only account for roughly £110-£280 million per year. The remaining £1.8 billion is spent on ‘normal’ foreign nationals who have needed treatment while non-permanently living in, or visiting, England.[iv] These patients are legally entitled to use the NHS if they have met certain residency criteria, as the result of European regulations or because of exemptions.[v] This figure includes foreigners who are ‘ordinary residents’ in the UK. These are people who are settled in the UK and are exempt from charges. Non-EU students are permitted to use NHS services, but with  a £150 surcharge.

How much do European patients cost us and how much do we cost Europe?

It is believed that approximately £260million per year is spent on providing care to visitors and non-permanent residents from the European Economic Area (the EU plus Iceland, Liechtenstein and Norway).[vi] This is a significantly smaller figure than the £1.4 billion allegedly spent on those from the rest of the world. British citizens are also treated overseas with around 63,000 patients travelling abroad for treatment each year.[vii] In addition, freedom of information requests obtained by the Guardian show that the cost of treating British people who become ill while travelling in Europe is five times higher than the cost of treating ill visitors from other European countries in the UK.[viii] Collectively the freedom of information requests showed that £30 million was spent in 2013/14 to meet the costs of European visitors using the NHS, but £155 million was the figure it cost other European countries to treat ill British tourists.[ix] Germany, for example, pays 34 times more to treat British people than the NHS spends on treating Germans. However European countries normally charge each other for the treatment costs of their citizens.

In 2014/15 the UK paid £674 million to other European countries for the treatment of UK citizens.[x] At the same time the UK only received £49 million back to treat European nationals in the NHS.[xi] Evidence suggests that the NHS is quick to pay out for the treatments costs of its citizens who fall ill abroad, but performs poorly at claiming back what it is owed for treating EU nationals in Britain (using the current system, the costs of redeeming such funds may even be higher than the amounts won back in any case).[xii] However, the fact that fewer Europeans retire to the UK compared to the large numbers of British retiring in Europe might account for some of this disparity.[xiii] EU migrants who work in the UK are classified as residents and so receive free NHS healthcare. This even applies if they go back to their homeland for treatment. There is also positive health tourism. Around £60 million is generated for the NHS from people travelling to the NHS to pay to use our healthcare system including from EEA citizens as nations sometimes send their citizens to other EEA countries’ health systems at their home county’s expense.[xiv]

European Health Insurance Card Scandal

EU citizens can apply for European Health Insurance Cards (EHICs) in order to obtain emergency treatment from other countries.[xv] This allows the cost of emergency treatment to be recouped from the patient’s home health service. Such cards are necessary because health care in Europe is based on country of legal residence not on country of citizenship, thus passports cannot be used to determine eligibility for treatment. A loophole in the British system was uncovered by a Hungarian journalist working for the Daily Mail. She managed to register with a GP, providing a fraudulent tenancy agreement which then enabled her to obtain an NHS number and consequently an EHIC card valid for five years; essentially five years of free, NHS funded treatment anywhere in Europe.[xvi] It is hoped stricter identity checks will now eradicate such lapses in the future. However a lack of photographs or biometric data as well as a lack of a central database to check eligibility will hamper efforts to eradicate abuse of the cards that the NHS issues.[xvii]

Conclusion

Since estimates of the cost to the NHS of treating foreign nationals vary so widely it is impossible to have an accurate appraisal of whether the NHS receives more than it pays out or visa versa in terms of medical costs involving UK and other EU nationals. The fact that the figures the government itself presents are accompanied by the proviso that these ‘are impossible to estimate with confidence and are a structured judgment’[xviii] shows how little idea even the Department of Health has about the true situation. It would certainly be useful to have more reliable data on the issue, especially as current figures have often been used as ammunition by both the EU ‘remain’ and ‘leave’ campaigns. However, with NHS staff morale already at a low, and with many staff members claiming to be over-worked it would be a difficult challenge to set up the monitoring processes that could assess a recipient’s right to free healthcare. For this reason, it is probably inadvisable for these figures to be used to determine individuals’ voting decisions.

  • Edmund Stubbs – Health Research Fellow

Notes 

[i] ‘Quantitative Assessment of Visitor and Migrant Use of the NHS in England’, Perderi (for Department of Health), 2013, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/251909/Quantitative_Assessment_of_Visitor_and_Migrant_Use_of_the_NHS_in_England_-Exploring_the_Data-_FULL_REPORT.pdf#page=63

[ii] M. Chalabi, ‘Health tourists: are they really costing the NHS £2bn?’, The Guardian, 2013, http://www.theguardian.com/politics/reality-check/2013/oct/22/health-tourists-costing-nhs-2bn

[iii] ‘To defend the NHS, stop heath tourism’, The Spectator, http://www.spectator.co.uk/2015/08/to-defend-the-nhs-stop-health-tourism/

[iv] A. Sippitt, ‘Health tourists: how much do they cost and who pays?, Fullfact, 2015, https://fullfact.org/health/health-tourists-how-much-do-they-cost-and-who-pays/

[v] F. Karim, ‘Do foreign visitors owe the NHS £2 nillion?’, Channel 4 Factcheck, 2013, http://blogs.channel4.com/factcheck/foreign-visitors-owe-nhs-2bn-factcheck/16194

[vi] A. Sippitt, ‘Health tourists: how much do they cost and who pays?, Fullfact, 2015, https://fullfact.org/health/health-tourists-how-much-do-they-cost-and-who-pays/

[vii] C. Cooper, ‘The truth about ‘health tourism’: twice as many foreign visitors pay to use NHS as exploit free healthcare in Britain. The Independent, 2013

[viii] A. Travis, A. Nardelli, G. Arnett, ‘Treating UK tourists in Europe costs five times more than equivalent cost to NHS’, The Guardian, 2015, https://www.theguardian.com/society/2015/apr/07/treating-uk-tourists-in-europe-costs-five-times-more-than-equivalent-cost-to-nhs

[ix] A. Travis, A. Nardelli, G. Arnett, ‘Treating UK tourists in Europe costs five times more than equivalent cost to NHS’, The Guardian, 2015, https://www.theguardian.com/society/2015/apr/07/treating-uk-tourists-in-europe-costs-five-times-more-than-equivalent-cost-to-nhs

[x] A. Burt, ‘Health Services: British Nationals Abroad: written question – 27364’, Parliament Website, 2016, http://www.parliament.uk/business/publications/written-questions-answers-statements/written-question/Commons/2016-02-19/27364/

[xi] A. Bennett, ‘EU Facts: what would leaving the EU mean for expats?’, The Telegraph, 2016, http://www.telegraph.co.uk/news/2016/05/18/eu-facts-what-would-leaving-the-eu-mean-for-expats/

[xii] L. Donnelly, ‘NHS counts £900 million cost of treating EU visitors’, The Telegraph, 2013, http://www.telegraph.co.uk/news/health/news/10022601/NHS-counts-900-million-cost-of-treating-EU-visitors.html

[xiii] L. Donnelly, ‘NHS counts £900 million cost of treating EU visitors’, The Telegraph, 2013, http://www.telegraph.co.uk/news/health/news/10022601/NHS-counts-900-million-cost-of-treating-EU-visitors.html

[xiv] ‘Quantitative Assessment of Visitor and Migrant Use of the NHS in England’, Perderi (for Department of Health), 2013, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/251909/Quantitative_Assessment_of_Visitor_and_Migrant_Use_of_the_NHS_in_England_-Exploring_the_Data-_FULL_REPORT.pdf#page=63

[xv] ‘To defend the NHS, stop heath tourism’, The Spectator, http://www.spectator.co.uk/2015/08/to-defend-the-nhs-stop-health-tourism/

[xvi] P. Bentley, K. Faulkner, S. Borland, ‘Ministers order urgent investigation into ‘completely unacceptable’ revelations foreigners are charging the NHS for care in their OWN country

[xvii] ‘To defend the NHS, stop heath tourism’, The Spectator, http://www.spectator.co.uk/2015/08/to-defend-the-nhs-stop-health-tourism/

[xviii] ‘Quantitative Assessment of Visitor and Migrant Use of the NHS in England’, Perderi (for Department of Health), 2013, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/251909/Quantitative_Assessment_of_Visitor_and_Migrant_Use_of_the_NHS_in_England_-Exploring_the_Data-_FULL_REPORT.pdf#page=63