Healthcare (International Arrangements) Bill

– in the House of Commons at 1:50 pm on 14th November 2018.

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Second Reading

Photo of Stephen Barclay Stephen Barclay Minister of State (Department of Health and Social Care) 1:51 pm, 14th November 2018

I beg to move, That the Bill be now read a Second time.

This is a short Bill, with six clauses, to enable continuity of healthcare for British nationals and EU citizens after Britain leaves the European Union. 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.

Photo of Henry Smith Henry Smith Conservative, Crawley

A few years ago, I presented a private Member’s Bill on the recovery of costs under the European health insurance card scheme. More than half of NHS trusts did not record the treating of foreign nationals at all so that they could claim back on those reciprocal arrangements. Can I get an assurance that, under the new arrangements, the NHS will be properly refunded for the care it provides to those from other countries?

Photo of Stephen Barclay Stephen Barclay Minister of State (Department of Health and Social Care)

My hon. Friend makes an important point. Perhaps I should declare that, when I was a Back Bencher, I tabled a number of parliamentary questions on that very issue, relating to my hospitals and to claiming. We pay out around tenfold what we recover. I will come on to that point, but part of the Bill relates to the NHS’s increased focus on the issue, which he is correct to raise.

Reciprocal healthcare agreements benefit people in all regions and nations of the United Kingdom. The Department of Health and Social Care currently funds and arranges EU reciprocal healthcare for people from England, Scotland, Wales and Northern Ireland. The Bill will allow us to continue doing that, if agreed with the EU. We have been working for some time now with the devolved Administrations and will of course continue to do so to ensure that we legislate for reciprocal healthcare in a way that fully respects the devolution settlements.

We can all agree that access to healthcare is essential both for British nationals living in European countries and for EU citizens living in the UK. The Bill will also allow us to strengthen existing reciprocal healthcare agreements with non-EU countries and explore new arrangements. As the Prime Minister said last night, the negotiations for our departure are now in the endgame and we are working to reach an agreement. As Members would expect, we are continuing to make the necessary preparations for all scenarios. It is in everyone’s interests to secure a good deal, but it is the job of a responsible Government to prepare for all scenarios, including in the event that we reach March 2019 without agreeing a deal.

In the event of no deal, the powers in the Bill will help to implement deals with EU countries that will seek to provide continuity of care for UK nationals and avoid a cliff edge. The powers will enable the UK to act swiftly to protect existing healthcare cover for British nationals in the EU, the European economic area and Switzerland, whether deals are made with the EU or individual member states. That is in the interests of everyone and, most importantly, will benefit millions of UK nationals who live, study, work or travel in mainland Europe.

British people who have paid their taxes in the UK their whole working lives and have retired to Spain, France or other EU countries should not have to worry about healthcare and how much it is going to cost them. Similarly, the millions of British people who travel to mainland Europe each year should be able to do so with the peace of mind that the European health insurance card scheme brings. These schemes are popular across the UK. There are currently 27 million EHIC cards in circulation in the UK, with 5 million issued each year. Reciprocal healthcare arrangements enable UK nationals to access healthcare whether they live in, work in or visit EU countries.

The current arrangements involve EU member states reimbursing one another for healthcare costs. We support UK nationals in the EU by spending approximately £630 million a year on healthcare for British expats and tourists. At present, we recover £66 million each year from EU member states under the same rules, but that amount is increasing as the NHS gets better at identifying EU visitors and ensuring that the UK is reimbursed for care provided, which speaks to the point that my hon. Friend raised. It is a net spend because many more British pensioners and tourists go to Europe than the other way around.

It is clearly in the interests of the British public to ensure that reciprocal healthcare arrangements similar to those currently in place continue when we leave the EU. The Bill does not affect the UK’s ability to negotiate or enter into international agreements, and the details of any new reciprocal healthcare arrangements will remain subject to negotiation and parliamentary scrutiny.

Until now, the majority of UK-EU reciprocal healthcare has been enabled by EU regulations. Once we leave the European Union, the EU reciprocal healthcare arrangements will no longer apply in the UK in their current form and we will need new legislation to provide for future arrangements. With a deal, the withdrawal agreement will enable the continuation of existing reciprocal healthcare rules during the implementation period, and afterwards for people covered by that withdrawal agreement, but it is not a long-term arrangement for the British public as a whole, does not provide for the event of the withdrawal agreement not being concluded and does not cover healthcare arrangements with countries worldwide.

The UK already has important agreements in place with Australia, New Zealand and many of our Crown dependencies and overseas territories and the Bill will help us to strengthen those, should we wish to, or seek new arrangements with other countries. The Bill underscores the Government’s commitment to reaching a robust reciprocal healthcare agreement with the EU.

This is important and necessary legislation, introduced so that the British public can look to the future with confidence that they will get the healthcare they need, when they need it. I commend the Bill to the House.

Photo of Justin Madders Justin Madders Shadow Minister (Health and Social Care), Shadow Minister (Business, Energy and Industrial Strategy) (Labour) 1:59 pm, 14th November 2018

Of course, the Opposition welcome any efforts to safeguard healthcare for the estimated 190,000 UK expats living in the EU and the 50 million or so nationals who travel abroad to EEA countries each year. We have concerns about some clauses, which we will address in Committee. It is 874 days since the UK voted to leave the EU, although for many of us it seems a whole lot longer. It is also a year since the European Union (Withdrawal) Act 2018 was introduced, so it is a matter of some concern that this Bill is only now being introduced.

As the Minister rightly said, the Bill gives the Secretary of State wide-ranging powers, including the power to amend primary legislation through a Henry VIII-style clause, but it places no obligation on the Secretary of State to report back to Parliament, even in the event that a reciprocal deal cannot be reached. That, combined with the scope for extensive use of statutory instruments under the negative procedure, represents to us an unacceptable lack of parliamentary oversight of an issue that will impact on the daily lives of millions of people. The Secretary of State ought to have learned from previous attempts that this Parliament does not react kindly when asked to sign a blank cheque. We will, therefore, seek to ensure that any new powers granted are proportionate and that all regulations are subject to the affirmative procedure.

We recognise the need for this Bill, because without a reciprocal agreement, UK citizens living in the EU, and vice versa, could find themselves having to pay for and make complicated arrangements to access healthcare in the country in which they live or that they visit. The biggest impact will be felt by the 190,000 state pensioners living abroad, and by those with long-term health conditions who could be prevented from travelling for business and leisure by prohibitively high insurance costs. There does appear to be some doubt about the figure of 190,000. The DWP website Stat-Xplore, which provides details of UK pensioners across EU and EEA countries, shows the figure for the EU27 as 468,793 in May 2018. I would be grateful if the Minister offered some clarification on that discrepancy.

We support the Government’s aim of retaining the current model of reciprocal healthcare. We are, however, extremely concerned that, with just over four months to go until we leave, there is still a great deal of uncertainty about whether all the hoops can be jumped through. Although the arrangements may continue as part of a withdrawal agreement if it gets through Cabinet, Parliament and the rest of the EU, there is just as much chance that we will need a whole new set of arrangements, which could radically alter the situation.

The Government’s impact assessment seems seriously to underestimate the consequences of a no-deal scenario, and I would welcome clarification from the Minister on that when he sums up. There are a number of reasons why I say that. As one would expect, the impact assessment sets out that the cost of establishing a future reciprocal healthcare arrangement on the same basis as the current one would be around £630 million per year, which is about the same as the cost of the current arrangements. However, the impact assessment goes on to say that, in the event of a no-deal scenario, the costs are expected to be similar or less, depending on the number of schemes that are established. Assuming that we still need and want to have an agreement with every country with which we do now, that would seem to imply that fewer people might need treatment. I doubt that even the biggest advocates of a no-deal Brexit would claim that leaving the EU without a deal will somehow miraculously lead to an upturn in people’s health.

Some clarity from the Minister would be appreciated, because the impact assessment appears completely to underestimate the complexity and cost of implementing what might end up being a diverse array of agreements. When they gave evidence to the House of Lords European Union Committee, the British Medical Association and the Royal College of Paediatrics and Child Health were clear that should no EU-wide reciprocal agreement be achieved, the significant costs of establishing bilateral reciprocal arrangements with EU and EEA countries would fall on the NHS. The BMA said:

“Managing access to health services by non-EU citizens is bureaucratically more burdensome than managing access for EU nationals currently” which,

“in the event that the current reciprocal arrangements with the EU were to be discontinued, could have considerable resource and administrative implications for hospitals in both the UK and the EU.”

I therefore ask the Minister why those associated potential administrative costs have not been included in the impact assessment.

Expenditure on UK state pensioners and their dependants accounts for approximately 75% of the total amount that we spend on reciprocal healthcare and supports UK state pensioners and their dependants living in Europe. In 2016-17, that equated to an estimated £468 million. The Department for Health and Social Care has accepted that the system is extremely cost-effective for the UK, not least because treatment overseas is often cheaper than it is in the UK. For example, Spain’s latest average pensioner cost is €4,173, compared with £4,396 in the UK. If we were unable to reach a full agreement, there would be two likely outcomes. In some cases, UK expats would face having to fund private medical insurance. However, in many cases, particularly for those with chronic conditions or complex healthcare needs, such insurance could be prohibitively expensive, if it could be found at all. In those cases, the planning and funding provision for those individuals would fall on the NHS.

Analysis by the Nuffield Trust has found that, if British pensioners lost their healthcare cover in EU states and had to return to the UK to access care, the additional annual cost to the NHS could amount to as much as £1 billion. The trust also predicts significant additional resource implications. It said in a report from 2017:

“Looking at relative hospital demand by age group, we might expect 190,000 people to require 900 more hospital beds and 1,600 nurses, as well as doctors, other health professionals, and support staff such as porters. This number of additional beds would be equivalent to two new hospitals the size of St Mary’s Hospital in London.”

The implications and potential demand on resources if arrangements are not made are huge. Of course, if the higher figure for pensioners in the EU is correct, those demands could more than double.

The European health insurance card benefits everyone who travels from the UK to EEA countries, but it is particularly beneficial for those with long-term conditions. The Academy of Medical Royal Colleges has set out that the EHIC enables such individuals to do so

“without the need for expensive travel and health insurance.”

One example of that is the 29,000 patients in the UK who receive kidney dialysis, typically three days per week. For those 29,000 patients, who can currently access dialysis across Europe—from Rotterdam to Rome—taking away the EHIC would take away their freedom. Travelling for work, for leisure or to visit family would be prohibitively expensive for them if we were not able to reach a comprehensive reciprocal healthcare agreement. Even if the Government were able to negotiate bilateral agreements, it would be of little comfort to a kidney dialysis patient who wished to attend a family wedding in Italy if they could access treatment only in France, Spain or Ireland.

The BMA and others have set out that patients with disabilities would be among the most affected if there were no reciprocal healthcare agreement. According to the BMA, without the EHIC, people with disabilities could find that travel or health insurance was

“especially expensive and potentially difficult to arrange”.

The Law Society of Scotland has reported that more than a quarter of disabled adults already felt that they were charged more for travel insurance, or simply denied it, because of their conditions. It is a matter of concern that the impact assessment does not explore the consequences of not reaching a deal for disabled people and those with long-term conditions. I therefore call upon the Minister to ensure that such an analysis is undertaken as an early priority.

Another question mark that hangs over the entire process is how dispute resolution will work, in either a deal or a no-deal scenario. Throughout the entire Brexit process, one of the red lines in the negotiations has been the role played by the European Court of Justice. However, I have yet to hear any suggestion about how, if we manage to reach a full reciprocal healthcare agreement with the EU27, disputes could be resolved without some reference, ultimately, back to the ECJ. The same would apply to bilateral agreements. If, for example, we reach an agreement with Spain and there is a disagreement about a payment made or the administration of the scheme—that could happen from time to time—who will determine which side is in the right?

When he gave evidence to the Health Committee, Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, considered this dilemma and said that

“as the two simplest ways” of resolving dispute resolution

“have been ruled out by the Prime Minister, I do not see how you can do it.”

What kind of dispute resolution procedure does the Minister envisage either in a full agreement scenario, or in the case of bilateral agreements with individual states? Can he confirm whether the Government’s position is still that the ECJ will have no jurisdiction over such issues?

Clause 4 provides a legal basis for processing data to facilitate any agreements after the UK leaves the EU. Although facilitating data processing is a necessary element of any reciprocal agreement to support the making of payments for healthcare outside the UK, I note that appropriate safeguards are referred to in the Bill, and I ask for clarification about what those safeguards are and how they would work in practice. We have concerns that the Bill appears to allow the Secretary of State to hand personal data to private providers and to allow private providers to process that data. We will look to explore that further in Committee if the Minister, in winding up, is not able to satisfy us on the need for those powers, the extent to which they will be used, and what safeguards will be applied.

Another issue we will face, particularly if we are not able to agree a full reciprocal agreement, is cost recovery. Members have already referred to the challenges on that. The BMA set out clearly to the House of Lords Committee that:

“Managing access to health services by non-EU citizens is bureaucratically more burdensome than managing access for EU nationals currently”,

and that

“in the event that the current reciprocal arrangements with the EU were to be discontinued…could have considerable resource and administrative implications for hospitals in both the UK and the EU.”

As I set out before, it is deeply concerning that this potential challenge does not appear to have been considered in the impact assessment. Even under the current arrangements, cost recovery is something that we do not appear to have handled satisfactorily and the fault for that lies with the Government.

In 2012-13, the NHS charged only about 65% of what it could have done to visitors from outside the EEA and Switzerland, and only 16% of what it could have done to visitors from within that area. I accept that things have improved since then, and that the Department set itself a recovery target of £500 million overall and £200 million for EEA and Switzerland patients, which it hoped to achieve by 2017-18, but it still appears to be well behind on those targets. I would therefore be grateful if the Minister could advise us on the latest projections for that. He mentioned a figure of £66 million earlier, but it was not clear which particular period that related to.

The Law Society of Scotland was clear on the importance of this issue when it gave evidence to the Lords Committee. It said:

“as the NHS has never been very effective in reclaiming the fees owed to it by overseas visitors to the UK, the UK may find itself substantially worse off financially when new arrangements for funding cross-national use of health services are put in place.”

Even the Health Minister in the other place admitted that there was a “job to be done” on cost recovery. Irrespective of Brexit, it is deeply concerning that millions of pounds that should be spent on UK patients by the NHS is going to waste because of a failure to get a grip on cost recovery.

Giving evidence to the Public Accounts Committee, NHS Improvement said that it was going to monitor charging and cost recovery, and intervene where trusts have not met their statutory obligations. Will the Minister advise us on whether it has done so? If there is an additional administrative burden on the NHS in setting up new systems of cost recovery, will the Minister give a commitment that NHS providers will be adequately compensated?

It is a concern that the Bill gives the Secretary of State wide powers with little recourse to Parliament. Where are the checks and balances if the NHS ends up having to police 27-plus different sets of arrangements? What if the deals reached end up costing far more? What if our cost recovery continues to lag well behind what it should be? There needs to be greater parliamentary oversight of all these issues.

The importance of getting a good deal on reciprocal healthcare is more significant in the countries where it is accessed most, none more so than in the case of the island of Ireland. For anyone who has visited some of the more rural areas along the border between Northern Ireland and the Republic of Ireland, as I did during the summer, it is clear the extent to which crossing the border is a part of day-to-day life for those communities. The border area has a dispersed population of around 2 million people. Currently, this combined population offers the economies of scale necessary to provide health services, which would be completely unsustainable were a hard border to be put in place. Cooperation and Working Together, a partnership of health services from both sides of the border, has set out clearly that there are many examples where patients’ lives have been saved because of free and open access for emergency services across the border. If we do not get the right agreement in place, there is a real danger that we could see a situation where one ambulance drives up to one side of the border and another from the other side meets it to transfer a patient. These are the very practical implications of the Bill we are discussing today.

Reciprocal healthcare arrangements on the island date back to before the UK and the Republic of Ireland joined the EU, but they are now underpinned by EU law. We welcome the commitment by both Governments to ensure that the current arrangements will continue after Brexit, but the UK Government have yet to explain clearly exactly how they will approach these issues in practice. The border issue has clearly been a sticking point in the overall negotiations, so we will have to monitor very closely what the final deal says on that.

I want to say a few words about devolution. The Scottish and Welsh Governments have clearly and robustly articulated their support for a continuation of reciprocal healthcare agreements. I would be grateful if the Minister could set out the extent to which he has engaged with the devolved Administrations as part of that process. The House of Lords Committee was clear in its recommendations that there should be active participation of the devolved Administrations in setting the UK’s position on future arrangements, but I am not aware that anything has taken place to date. The Bill gives wide-ranging powers to the Secretary of State, but places no obligation on him to consult or engage with the devolved Administrations before making regulations. What assurances can the Minister give us that that will take place, particularly well ahead of any new arrangements being put in place?

In conclusion, this is a very short Bill, but one that will have far-reaching implications. The Secretary of State is asking for powers, which will have a direct influence on the day-to-day lives of hundreds of thousands of people without providing us with clarity on how he will use them. The Bill has been two years in the making and yet the impact assessment provided is totally insufficient, if not inaccurate, and there seems to have been little appreciation of the complexity of the task at hand or the implications if things go wrong. All of that is amidst the deal or no deal circus we have at the moment. The Government are asking for the powers to make agreements with other countries, but they cannot get an agreement around the Cabinet table. We will see, possibly by the end of the debate, whether that turns out to be correct.

We are in no doubt that the continuation of reciprocal healthcare is absolutely essential. We will not oppose the progress of the Bill today, but we will press for the safeguards needed to ensure that proper regulations and oversight are put in place, and that the interests of patients are protected.

Photo of Roger Gale Roger Gale Conservative, North Thanet 2:15 pm, 14th November 2018

I welcome this paving measure, which I think will give significant comfort to many thousands of mainly elderly and often very frightened United Kingdom expat citizens mainly in Europe, but also around the world. For reasons I will not bore the House with, I have a very extended network of contacts with the expat community mainly within European Union countries but also worldwide. I want to concentrate for a few minutes mostly on those people.

The people I want to talk about are expat United Kingdom citizens who by and large have spent their working lives paying taxes and national insurance here in Britain, and who, for reasons of family, health or sun, have moved to France or Spain. There is also a significant community living throughout the rest of the European Union and one should most certainly not overlook the needs of those who are resident in the EU for professional purposes. Those include all manner of circumstances, for example people working for companies or on Her Majesty’s service in one form or another. The degree of uncertainty that has surrounded their healthcare futures has been considerable and very worrying. I do not think we can over-egg that.

I want to raise one specific concern, which relates to the emphasis on reciprocity. I say that because I happen to chair the all-party group on frozen British pensions. A frozen pensioner is one who is living in any country other than the United Kingdom and is entitled to a UK pension, but who receives that pension frozen at the point of departure unless there is reciprocity. For example, a pensioner living on one side of the Niagara Falls in Canada has their pension frozen, whereas a pensioner living on the other side in the United States has their pension uprated in line with inflation. What I do not want to see is that situation replicated in this deal, so that we get a second class healthcare system whereby people in some countries within the European Union get healthcare while others do not. I hope very much it will be possible to strike a deal with the remaining 27 European Union countries, rather than cherry-picking each country and then having to work out who is entitled to “free” healthcare and who is not. That would be a nightmare. If we are going to get this right, and we must get it right, we have to make sure that everybody is covered.

Tourists fall under a slightly different category. Tourists who go right around the world expect to take out health insurance for their travel. I see no reason why they should not do so and why they should not do so in the European Union countries once we have left.

For those who choose to live in countries such as France, Spain, Greece and Italy in the European Union, we have to make very special provision. I would therefore like to take this opportunity to ask my hon. Friend the Minister to make sure that we do not allow this measure, which is very valuable indeed, to become subject to the law of unintended consequences. We must roll as smoothly as possible from EHIC to a new system that is fair to the taxpayer. I take entirely the point that this cannot be a blank cheque, but we must make sure that the elderly and vulnerable, who have chosen to live overseas having paid their taxes here, are well, truly and properly covered.

Photo of Martyn Day Martyn Day Scottish National Party, Linlithgow and East Falkirk 2:19 pm, 14th November 2018

Clearly, Brexit threatens the loss of reciprocal healthcare arrangements for millions in Scotland and across the UK. As a bottom line, the Scottish National party believes that all current reciprocal health agreements must remain intact, regardless of what form Brexit takes. The Bill is yet another rushed job on the part of the Government. In their panic, they have woken up to the fact that millions across the UK and thousands of expats abroad, particularly pensioners, could face having either no access to healthcare within the EU or paying exorbitant costs for treatment. It is another example whereby no contingency planning was done prior to the Brexit referendum.

With an estimated 900,000 to 1.2 million UK citizens living in the European economic area and 3.2 million EEA citizens residing in the UK, Brexit will potentially have severe ramifications for them and the NHS. Approximately 27 million active EHIC cards are in circulation as of September 2017. They are used to pay for around 250,000 medical treatments each year. Ensuring that all current reciprocal health agreements remain intact and in place must be the bottom line regardless of what form Brexit takes.

The consequences of a no-deal Brexit on healthcare are yet one more example of why this extreme Tory Brexit is not worth the cost. In evidence to the House of Lords EU Committee, a representative from the Association of British Insurers gave a rough estimate that in a no-deal scenario, travel insurance premiums for EU travel could increase by 10% to 20%. A no-deal scenario will end up restricting the travel arrangements of those with underlying health conditions and disabilities. In such a scenario, the British Medical Association said that the insurance issue will be

“a particular concern for those with disabilities or long-term conditions, as the cost of health and travel insurance for those with pre-existing conditions could be prohibitively high.”

The Bill’s impact assessment concludes that in a no-deal scenario:

“If UK citizens in the EU are treated as 3rd country nationals (i.e. they cease to have rights of movement and access to services in EU Member States, and are treated like citizens coming from non-EU countries) some may face additional financial costs or difficulties accessing healthcare services, with potential implications for their health and wellbeing.”

That is something none of us wants to see.

Reciprocal healthcare arrangements must not be viewed as affecting only those who live or travel abroad. The impact of a no-deal Brexit would have a devastating effect on our NHS services at home. The agreement in the joint report does not provide long-term assurances regarding the future of the EHIC. As things stand, health insurance will stop for millions of UK citizens post-Brexit.

While the UK Government have stated their commitment to securing ongoing access to the EHIC, the EU has been unwilling to agree to that due to the Government’s stance on freedom of movement post-Brexit. The UK would also be a significant outlier were it to retain access to reciprocal schemes while ending freedom of movement. The SNP position on single market and customs union membership would, of course, remove all such obstacles.

If these healthcare schemes were removed, it would inevitably lead to massive pressures on the NHS, as UK citizens return home to receive treatment. Those pressures are compounded by the impact of the health workforce reduction, which has seen England and Scotland lose 19% and 14% of EU doctors respectively and a 90% drop in EU nurses registering to work in the UK.

As we have heard, the UK contributes around £630 million annually towards UK citizens’ care and receives £50 million—I think the Minister mentioned £60 million—for care provided to EU nationals in the UK. The BMA and the Nuffield Trust has estimated that if the UK did not conclude a withdrawal agreement with the EU, and were all these pensioners to return to the UK, the NHS would need some 900 additional beds and 1,600 nurses to ensure sufficient capacity. All in all, providing this additional healthcare would amount to somewhere in the region of £1 billion.

Current EU nationals living in the UK could face losing access to health facilities. First, their residency was threatened and now their healthcare rights are in danger; we must give them peace of mind and security. Were the UK to lose access to existing reciprocal arrangements and no alternative be established, EEA citizens living in or visiting the UK would also face a significant change in their access to care. Depending on the deal secured between the UK and the EU on citizens’ rights, this could mean that EEA residents might face the same costs and terms of access to the NHS as other non-EEA visitors and migrants do currently.

The Scottish Government have never been opposed to common frameworks, but these must be agreed in discussion and with the consent of the devolved Administrations. I was grateful to hear the Minister’s commitment to working with the devolved nations in this regard. We all understand the desperate need for all these reciprocal healthcare agreements to continue and the Scottish Government will work with the UK Government to ensure that they do.

Through the Joint Ministerial Committee, we believe that a common framework system can be achieved that ensures these specific health agreements can be administered through common agreement between the UK Government and the Scottish Government. Many issues need to be resolved for this to happen effectively, particularly if we are forced to deal with a no-deal Brexit. For instance, in Scotland, unlike in England, certain categories of resident non-EU overseas patients are exempted from healthcare charges, including the self-employed, volunteers and students. In Wales and Northern Ireland, regulations provide similar exemptions, and in Northern Ireland, they clarify that entitlements are applicable both to primary and secondary care.

As Professor Jean McHale told the Lords inquiry on this very issue, post-Brexit

“if there are no reciprocal agreements on healthcare made with other EU member states and treatment is sought other than in an emergency situation then certain EU citizens could be exempt from NHS charges for secondary care…if they are living in Scotland, Wales and Northern Ireland whereas this would not be the case in relation to those resident in England.”

In conclusion, I am not opposing the Bill, as it basically just gives powers to the Secretary of State to agree reciprocal deals, and I look forward to the Bill Committee where we can progress those further. However, I point out that today’s business is another example of otherwise unnecessary work related to Brexit coming before us. This prompts the question of just how much time and effort is being put into such work that could have been used for other things, had we not been going through the Brexit fiasco. I believe that we will not get a better reciprocal arrangement deal than we currently have.

Photo of Robert Syms Robert Syms Conservative, Poole 2:26 pm, 14th November 2018

I welcome the Government bringing forward the Bill. This is clearly part of a suite of legislation to prepare for the changes that Brexit will bring about. It is also pretty critical that at the end of the day, a deal is done to allow this to work in a smooth and effective fashion.

Brits like to travel; over 50 million go abroad. Most of them go with family members, and many retire abroad. Those who do not come to Poole may go to the Costa Blanca or elsewhere, and health for older residents is one of the big concerns. The European health insurance card system has worked pretty well. There is no point, just because we object to some aspects of European integration, objecting to other aspects that may be beneficial to our citizens and those of the EU, so the Government’s intent to try to replicate the system—whatever happens with Brexit—is very sensible and good. The fact that a quarter of a million people used the EHIC card last year indicates how important that is for many people.

I welcome what the Government are doing. It is a necessary precaution. I do not begrudge spending a bit of time in this House dealing with the concerns of older people retired abroad or of Brits who want to travel, so it is important to get the Bill through today. This measure will only be for two or three years and then there will be further legislation. Some Opposition Members talk about the Secretary of State being given powers, but we are living in slightly extraordinary times, and I suspect that we will come back to legislation in this area in a couple of years.

The Government are doing a very sensible thing. I hope that it is part of an overall agreement, because that would be the easiest way to do it. Clearly, if we have to do this on a bilateral basis, that will take longer and there may well be cliff edges that cause problems for some pensioners. Therefore, when Members sometimes say that there must be a deal when they are already somewhat committed to voting against a deal, I wonder whether they ought to look at the detail of what will happen if we have no deal. This is one of the areas that will cause problems for Brits who live abroad and travel abroad and for some EU people who come to the UK as tourists. We should understand that this country benefits greatly from the tourist trade. We have only to walk around London—around Leicester Square and other areas not far from here—to see the many thousands of people who travel. They, too, need peace of mind.

This is a good piece of legislation, then, but I agree with my hon. Friend Henry Smith that the ethos of the NHS is such that it does not like taking money off people, even when it should. I once stood in A&E and watched an American take out a credit card, only to be told, “You don’t need to do that here.” Sometimes people are busy and want to get on with their jobs and deal with backlogs, but there is an issue with us getting proper recompense. The former Health Secretary made a good point: it is a national health service, not an international health service.

Some years ago, when I was serving on the Health Select Committee, we interviewed chief executives of trusts, and they said there was a problem sometimes with the disproportionate cost of pursuing fees and that some people actually come to London on holiday who happen to be pregnant and who end up in London hospitals at a cost to the British taxpayer, so the health service does sometimes attract people who try to take advantage of the system as well.

The figures from the Library are stark. We pay out 10 times more than we claim back from the EU and the other states in the scheme. Although some of that is because there are older people abroad and Poles tend to have six jobs and be younger, some of the figures are still quite remarkable.

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons)

Does my hon. Friend accept, though, that the majority of the difference is due to the disproportionate number of British pensioners living abroad compared to the number of EEA foreign nationals living here as pensioners?

Photo of Robert Syms Robert Syms Conservative, Poole

That is a factor, but I still think that a 10:1 ratio is quite high. London has the second-largest French population, behind only Paris, yet we claim back only £5.3 million from France. That is quite a stark figure, and one wonders why we are not claiming back rather more. I gently make that point. I know the Minister is aware of it. When we redo this, we have to emphasise to trusts the requirement to recoup money, because that means more money for British people using the service and for other services, but sometimes it falls down the priority list. I am not sure there is a magic bullet. It probably requires drilling lots of people in A&Es up and down the land to focus on whether people should be paying or getting free treatment.

In conclusion, I welcome the Bill. It is a good step forward. It will help to reassure those concerned about what the future will bring, and I look forward to seeing what the Government bring back on Third Reading.

Photo of Wera Hobhouse Wera Hobhouse Liberal Democrat Spokesperson (Housing, Communities and Local Government) 2:32 pm, 14th November 2018

We have heard many comforting words from the Government today, but there is nothing comforting in the proposals in the Bill. If we Brexit, UK citizens here and abroad will lose their rights to automatic healthcare in other EU countries. The automatic right to healthcare in Europe has been one of the visible successes of the single market—a peaceful continent and EU countries working together. If we Brexit, new healthcare arrangements will need to be negotiated with the EU or EU countries individually, and the Bill is intended to make it possible for the Government to negotiate those new arrangements.

The Government intend to do this by using Henry VIII powers. Today could be the last time this Parliament discusses how 70 million UK citizens can go abroad and receive, or not receive, healthcare while there, not to mention the non-UK EU citizens who live in or travel to the UK. We have been through this debate before. Henry VIII powers are the preferred route for a Government who want to bypass parliament and get Brexit through at any price, including the price of democracy. This debate comes at a time when the Government are proposing a deal with the EU. There were only ever three possible outcomes for the UK in this negotiation: no deal, Brexit in name only, or staying in the EU. It looks like the Prime Minister has gone for Brexit in name only, although of course she will not call it that.

Brexit in name only means staying in the customs union and the single market, and it could mean retaining healthcare within the EU. That would be good news. The bad news is that no UK Minister or bureaucrat will be around the table with the EU27. We will be receiving our instructions, and that is it. When the EU decides changes, we will be notified and have to implement the changes. Henry VIII powers will be a way to hide our national humiliation.

The political question is why anybody would vote for Brexit in name only. It is not just a fudge; it is the worst of all possible worlds. It will, perversely, do the opposite of taking back control; it will keep us in complete dependency but without any say. Many parliamentarians have woken up to the fact, or have known for a long time, that our only secure economic future and the only way to guarantee all the rights we have negotiated, including free healthcare, lies in being a member of the EU. As we have heard today, rather than getting a Brexit dividend from the NHS, the new arrangement might end up being extremely costly for this country.

Why do we not dare to say it loud and clear? Not saying it loud and clear is dishonest; Brexit in name only is dishonest. To do something dishonest and call it the will of the people is a travesty. Only the people themselves should decide what is done in the name of the people. Let us ask the people. Let us give the people a say on whether they really had all this in mind when they voted in 2016. Let us give people a chance to decide that when all is said and done they want to stay in the EU. And of course that would make the Bill completely unnecessary.

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons) 2:36 pm, 14th November 2018

I will be supporting the Bill today. I am only sorry it is necessary. There is no version of Brexit that will benefit people who rely on the NHS, social care, scientific research or public health; there are only varying degrees of harm. The Bill seeks to address one of those harms, and that is around our reciprocal healthcare arrangements, which have made such a difference to people’s lives both here and across the EU. As Martyn Day pointed out, 190,000 UK expats live in the EU and 27 million people hold an active European health insurance card, which covers about a quarter of a million treatments every year, but we are also talking about British citizens who travel or live in the EU to work and the 1,300 people who benefit from planned medical treatments in the EU under the S2 route.

I will turn first to the 190,000 British expatriates, mostly pensioners, living in the EU. Incidentally, 90% of them live in Ireland, Spain, France and Cyprus. They face a desperately worrying future. In the event of a deal, they will be covered by transitional arrangements until 2020, but in the event of a chaotic exit, with no deal and no transition, in just 135 days, they could be left stranded, many of them with access only to very basic medical care. Some of them will be uninsurable and many will have no easy path to return to the UK.

The Minister will know that, as I mentioned to my hon. Friend Sir Robert Syms, 75%—£468 million of the total £630 million in 2016-17—of the cost of our reciprocal healthcare arrangement relates to pensioners. When he sums up, will the Minister please respond to the updated estimated cost of those pensioners having to return to the UK and the net effect on the NHS? The Health and Social Care Select Committee heard that the current average cost of treating a UK pensioner in Spain was €3,500, but the average cost of treating pensioners in the UK was £4,500, and again the discrepancy between the pounds and euros makes that even greater.

In the future, the costs associated with EHIC— £156 million—and the S2 route for planned medical treatments will be borne directly by the 50 million UK nationals who visit the EU every year, but those costs will not be distributed evenly. The costs will fall disproportionately on those with pre-existing medical conditions. They will be exceptionally hard hit. As we heard from Justin Madders, many individuals will be effectively uninsurable and unable to travel. Will the Minister tell us what clear advice the Government are giving to people with pre-existing medical conditions who are thinking of making travel arrangements after 29 March? Is he being explicit with them, and telling them that they need to check now whether they may find themselves left stranded without medical insurance in the event of our crashing out in a chaotic exit with no deal whatsoever?

I recognise and welcome the fact that the Bill gives the Minister power to put in place an equivalent scheme, but that scheme will have to involve a dispute resolution process. In the deal that is about to be published, has the Minister seen what that process would be? Another thing that he needs to be very clear about when he sums up the debate is that if we crash out with no deal and no transition, we will not be making these reciprocal arrangements with a single body; we will be making them with 27 different European states, three European economic area states, and Switzerland. Is it even conceivable that we could complete negotiations on that scale with 135 days to go? We need to be really clear with Members throughout the House, and to the public, about what that means, so that people can make plans accordingly. May I also ask whether the Minister is setting aside, within the contingency fund, a sum of money that we could use to assist British nationals who find themselves in difficulties on the wrong side of the channel in the event of no deal and no transition? Those are all important points about which we must be very clear with people.

Does the Minister agree that during the referendum campaign there were very many different versions of Brexit? The Brexit reality with which we are about to be presented is very different from the fantasy version that was presented during the campaign. People will remember the “easiest deal in history” and the “financial bonanza” for the NHS, but the Brexit reality is that there will be a significant Brexit penalty, from the most damaging form of Brexit in particular. We are looking at effects across the entire health, care and research system. Yesterday I met representatives of the Royal College of Nursing to discuss their grave concern about the future workforce. While the overall number of registrants has increased, there has been a very worrying decrease in the number of joiners in the past year. The number of joiners from EEA countries has dropped by nearly 20%.

Photo of Jim Cunningham Jim Cunningham Labour, Coventry South

The Royal College of Nursing has been on to me as well, expressing serious concern about what will happen after we leave the European Union. The hon. Lady should add to her earlier question, “What will happen after 2022 in relation to medical care for expats in Europe in particular?”

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons)

That is, indeed, a question that I have been addressing. What will happen to expats in Europe? What we absolutely must focus on, however, is what will happen 135 days from now if we do not have a deal and people are left high and dry. It is a very worrying situation.

The issue of the workforce does not just affect nursing staff. We should bear in mind that 5% of members of the regulated nursing profession, 16% of dentists, 5% of allied health professionals and 9% of doctors are EEA nationals. We cannot afford to lose any more of that workforce, or to demoralise them further. I think it shames us all that the Health and Social Care Committee heard from nursing staff from across the European Union some of whom were in tears when reporting that they no longer felt welcome here. That is a terrible Brexit penalty, and no one voted for it when they went to the polls.

This does not just affect the workforce either. The Brexit penalty applies to the entire supply chain of medicines and medical devices, from research and development to clinical trials, to the safety testing of batches of medicines, and right through to the pharmacy shelf and the hospital. There are many unanswered questions about the issue of stockpiling, and about contingency plans for products that may require refrigeration, or products with very short shelf lives that cannot be stockpiled. There may also be brand-switching issues: for people who suffer from conditions such as epilepsy, switching brands is not easy.

I am sorry, Madam Deputy Speaker. I will bring my remarks to a close shortly. [Interruption.] I understand that you were merely coughing, Madam Deputy Speaker, so I will continue.

Refrigerated warehousing and special air freight do not come cheap. The companies whom we met, represented by the Association of the British Pharmaceutical Industry, made it clear that they were already having to spend hundreds of millions of pounds on contingency planning. The Government have said that they intend to reimburse companies, but the smaller companies need to know how quickly they will be reimbursed, because they may have cash-flow issues. They need to know the details of how the scheme will work, but they simply do not have the information that would enable them to make plans for the future. I hope that the Minister will be very mindful of that.

As I said earlier, the simple truth is that the many versions of Brexit have very different implications for the NHS, for social care, for public health and for research. Once this deal is published, we will have an opportunity to set out what this means, but, most important, to set all the risks and benefits of the deal that is on offer for the NHS and social care. The Minister will be aware of the important principle of informed consent in healthcare. No one would dream of going into an operating theatre and having an operation without someone telling them what is involved and setting out the risks and benefits so that they could weigh them up for themselves. That is called informed consent, and without informed consent, there is no valid consent.

Let me say to the Minister that we are all being wheeled into the operating theatre for major constitutional, economic and social surgery without informed consent, and let me ask him please to consider how things will be 136 days from now, after we crash out with no deal and when the serious consequences of that start to unfold and unravel and hit real people’s lives. What will he be saying to his constituents and the House if we have proceeded without informed consent?

Photo of Rosie Winterton Rosie Winterton Deputy Speaker (Second Deputy Chairman of Ways and Means)

I have now to announce the result of today’s deferred Division. In respect of the question relating to electricity and gas, the Ayes were 285 and the Noes were 223, so the Question was agreed to.

[The Division list is published at the end of today’s debates.]

Photo of Paul Masterton Paul Masterton Conservative, East Renfrewshire 2:48 pm, 14th November 2018

It is, as always, a pleasure to follow my hon. Friend Dr Wollaston. She speaks with incredible knowledge and expertise in this area, which I will not even attempt to match.

It is nice, on a day of significant Brexit chattering and uncertainty, to be talking about something to do with Brexit which generally seems pretty consensual. The Bill is, of course, necessary to ensure the smooth transition from our current relationship with the EU to our future relationship. The Government have been very clear about their willingness to consider the continuation of the UK’s participation in reciprocal healthcare. As we have already heard today, there are 32 participating countries in that framework, the other EU member states and all four nations in the European Free Trade Association. It is a mechanism to provide for the co-ordination—not, of course, the alignment—of separate national health systems, which means that provision under the scheme can differ from country to country.

There are 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 for state pensioners, the S2 system for planned treatment, and the patients’ rights directive. UK nationals living, working, studying or visiting EU or EEA countries and Switzerland will have continued access to healthcare after 29 March 2019. That is a vital commitment.

The Government’s position is to seek a wider agreement with the EU that covers state pensioners retiring to the EU, with continued participation in the EHIC scheme and co-operation on planned medical treatment. The Bill would allow for the implementation of such an agreement. My hon. Friend Sir Roger Gale when talking about ex-pats summed up clearly why that is such an important issue for individuals who have lived here and paid their taxes here and moved abroad; they need to know this system will continue to be available to them.

There were approximately 27 million active UK EHIC cards in circulation in September 2017, including the one in my pocket. 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 1% result in an EHIC claim. I am glad this Bill establishes the basis for a new arrangement allowing the scheme to continue after 2020, subject, of course, to an agreement with the EU. There are 250,000 medical treatments each year and when abroad, regardless of how well we know the country in question, it can be quite frightening to find ourselves in need of medical treatment; there is enough to be thinking about without not knowing what our access to healthcare will be.

I had experience of that myself in Portugal on my stag-do. I will not go into the story as to why we ended up in a Portuguese hospital, but it involved a roof and a shoe—we will go no further. It is good to know with some confidence that we are going to be able to access healthcare; we should always make sure we are covered by insurance and so forth, but having that extra bit of comfort is extremely important. It would be hugely damaging for us as a country going forward post Brexit not to have that level of assurance for our citizens.

The Minister set out in detail what the Bill will do, so I will not run through that, but he confirmed why this is a necessary agreement, particularly because the European Union (Withdrawal) Act 2018 does not provide all the powers and mechanisms needed to do this. The Bill provides the Secretary of State with the powers that are necessary to arrange for the provision of healthcare overseas, and, crucially to fund that, which is important. This is needed regardless of whether we are in a deal or no-deal situation. It is also important to note that, as the Minister said, we have arrangements with other countries, and making sure we have the power not only to continue what we have at the moment but to add to or improve arrangements with other countries is significant.

Fundamentally, this Bill means that UK nationals residing in another state may obtain treatment as a resident of that country. The range of medical services in some EU countries may be less than under the NHS, and in some cases patients might need to make a contribution towards the costs of their care, but through this Bill we can ensure access to healthcare at reduced cost, and in most cases for free.

I want to pick up briefly on the points about devolution made by the Labour shadow Minister and the SNP spokesperson. They were fair comments. While this is a reserved mechanism, the provision of these services is devolved and it is the devolved Administrations that have to provide structure and fund the services for EU nationals who rely on them, so it is not a massive step to ensure that they are appropriately involved. I would be interested to hear about how we are working with the devolved Administrations and the healthcare providers in the devolved nations to ensure seamless continuity of this going forward.

Photo of Eddie Hughes Eddie Hughes Conservative, Walsall North 2:53 pm, 14th November 2018

I want to make a brief but enthusiastic speech in support of the Bill. It is a pleasure to follow my hon. Friend Paul Masterton, although I have to admit to being mildly distracted by the tales of his stag-do in Portugal. I look forward to concluding my speech and finding out more details about that later.

An odd place to start would be my constituency, where 20% of constituents do not have a passport, and therefore do not get the opportunity to travel and have any concerns about reciprocal healthcare arrangements. However, they do need to worry about the healthcare arrangements that are provided in this country. Any country that might wish to engage in reciprocal arrangements with us will no doubt be looking jealously at our health service, which I understand employs 1.5 million people, making it one of the five biggest organisations on the planet. Clearly, it is an incredible organisation. We are spending over £100 billion a year on it, so why would other countries not want to enter a reciprocal arrangement with us? We have a lot to offer.

There has been some question about what the Brexit deal will be and what the future might look like next year, when we leave the EU. My right hon. Friend John Redwood has made this point a number of times: if you were to sit down with your iPad now with nothing better to do and try to book a flight for next year to Europe, you would have no difficulty doing so at all. We do not know what the arrangements are for international travel yet. We have not seen the detail of that, in terms of what has been signed and agreed, but we know planes will take off and will land in Europe and I think we are fairly confident that people will be able to get healthcare when they go to Europe and that there will be no unusual situation where ambulances drive up to one end of the border and hand a patient over. That is not likely to be the case, so let us bring a degree of practicality to the debate. That is what the Bill does: it is a practical Bill in order for us to make the necessary preparations because we are, of course, leaving the EU. It is necessary partly because 25% of Brits who travel abroad do not have holiday insurance. Perhaps they are taking a bit of a flyer and hoping that those reciprocal arrangements will be the safety net that protects them.

I have a particular concern because that 25% figure rises to 40% for 18 to 24-year-olds and 38% for those aged between 18 and 30. I am the father of two kids, aged 22 and 27. I think it is very unlikely that if they were travelling to Europe they would have the common sense to book travel insurance, despite protestations by their father. So I am hoping that we achieve those reciprocal arrangements, not least because my understanding is that nine of the 10 top holiday destinations abroad for Brits are in Europe—if it were not for New York, the top 10 would be entirely in Europe. So we are leaving the EU, but we are not leaving Europe.

Photo of Sarah Wollaston Sarah Wollaston Chair, Health and Social Care Committee, Chair, Liaison Committee (Commons)

Does my hon. Friend accept that at the moment people do not need to have health insurance as they are covered by the EHIC? The fact is that they will need to have such insurance if we do not have a deal. People who travel thinking and believing that they are insured next year may find, if they have a serious medical emergency abroad, that they are completely wiped out by the medical costs. We need to be clear about that with people.

Photo of Eddie Hughes Eddie Hughes Conservative, Walsall North

I completely understand, and to a degree accept, that point, except that I perhaps have more faith than my hon. Friend in the ability of our ministerial team and Government to negotiate an agreement with Europe that will mean that those worries are allayed. I confidently believe that the arrangements will be very similar.

Photo of Vicky Ford Vicky Ford Conservative, Chelmsford

I intervene on an extremely important point. The EHIC does give reciprocal care, but it is not the equivalent of health insurance. If someone has a very serious accident, it does not pay for the travel costs, for example, of coming back to the UK, which other health insurance policies would do. So while this is fantastic and I will be voting in favour of it, it is not the equivalent of having traditional health insurance.

Photo of Eddie Hughes Eddie Hughes Conservative, Walsall North

I thank my hon. Friend for making that point. I want to conclude my speech by saying that I am optimistic not only that we will get a good deal and these fears will be allayed, but that post Brexit people will look further afield than Europe for their travel destinations. Not only will we be getting trade deals across the globe, but we will be travelling more widely.

Photo of Gillian Keegan Gillian Keegan Conservative, Chichester 2:59 pm, 14th November 2018

It is a real pleasure to follow my hon. Friend Eddie Hughes. Like him, I am optimistic about securing a Brexit deal and continuing our international healthcare arrangements. Since the 1950s, the UK and its European neighbours have had reciprocal healthcare and social security arrangements, and I have personally made use of many of them, having spent years living and working in European countries. Good reciprocal healthcare arrangements give peace of mind to all of us, and they will be important as we continue. Current arrangements give all UK nationals a sense of security and the knowledge that they can access the healthcare they need when they live, study, work or travel across Europe. The same applies to EU citizens when they are in the UK. Healthcare co-operation is therefore actively supporting business and tourism by removing a barrier to people’s life choices. Arguably the greatest beneficiaries of these arrangements are our citizens who live on the continent, many of whom are enjoying their golden years in the sun.

The framework put in place by the Bill will ensure that the Secretary of State has the necessary power to maintain or negotiate arrangements in any Brexit eventuality. One of my constituents recently emphasised the importance of having these arrangements. His grandmother, who is now over 80, lives alone in France. A few years ago, she had a car accident that left her seriously injured. She required an operation and spent over a month in hospital. That was followed up by time in a convalescent home. All that care would have cost a small fortune but, luckily for her, she enjoys healthcare under the European health insurance card S1 route. Access to that is fundamental to her and to the other 190,000 pensioners like her, particularly as their health needs may increase over time. The Bill should calm the anxieties of our citizens abroad. It will also save the taxpayer money. The Nuffield Trust has calculated that, if those pensioners had to return home for their treatment, it would cost the NHS between £500 million and £1 billion a year.

Similarly, continuing the European health insurance card scheme is crucial as it safeguards the 50 million UK nationals who travel throughout the European economic area every year. It is worth mentioning that this is not about the number of people who carry EHICs; it is about the stories behind them, because 250,000 medical incidents affecting UK tourists are resolved via the EHIC scheme and they include one of my constituents, who experienced at first hand the value of the cards when on a family holiday in Germany. Her husband was left seriously injured after being flung from a toboggan, leaving his shoulder quite literally in pieces. To her amazement, and despite the severity of the injuries, her husband was allowed on to the ambulance only once she had presented his EHIC. These sorts of accidents are quite common with many Brits choosing to travel to Europe to ski, which often leaves people—myself included, twice in recent years—in need of medical attention.

I welcome the Bill, as we have a long history of reciprocal healthcare arrangements in our country. UK and Irish citizens have been able to access healthcare in each other’s countries for the past 100 years—a long time before the European Union was established. The UK also has reciprocal healthcare arrangements with other parts of the world, including Greenland, the Faroes, the Balkans, Australia, New Zealand and many of our overseas territories. The Bill will allow the Secretary of State to continue to grow this network, and I hope that it will eventually lead to the global availability of free healthcare for British citizens, and to removing barriers to people looking to travel, work, study and live around the world.

Photo of Vicky Ford Vicky Ford Conservative, Chelmsford 3:03 pm, 14th November 2018

I want to speak briefly in support of the Bill. There are 190,000 UK expats living in other parts of the EU, many of whom are retired, as well as 50 million British citizens who travel to the EU on their holidays and on business every year, and they all need access to healthcare. Since 2004, they have been able to benefit from the European health insurance card, which has made it much easier for them to access medical care when travelling through the EU, and it is extremely important that we do all we can to ensure that our citizens can continue to benefit from easy access to healthcare, whether they are at home or overseas. I therefore welcome the Bill, and the fact that it gives us the ability to extend these provisions to other third countries.

Last year, I led a Westminster Hall debate on the wide array of consumer issues that would need to be dealt with in the Brexit negotiations. At that time, I felt that a lot of the focus was on the impact on business, and that not enough consideration was being given to the impact on consumers. I have been rereading the speech that I gave in that debate more than 12 months ago, and I am extremely pleased that the issues that I raised in it were then addressed by the Government’s White Paper before the summer. I believe that those points will now have made their way into the 500-page text that the Cabinet are looking at today. I am not going to comment on those 500 pages of text until I have seen them, because unlike some colleagues, I do not have magic reading glasses that allow me to read text that is not even available or to comment on it before I have even seen it. However, I will be looking out for the elements that affect individuals, consumers and patients, to ensure that they are covered in the deal. I believe that they will be, and the EHIC is just one of those issues.

It is important that we do not go over the top and promise that the EHIC can do things that it cannot do. For example, it does not cover repatriation, so anyone who has a crash on their skiing holiday would get emergency care under the scheme but they would not be covered for getting back to their home base. In my previous role as a Member of the European Parliament, I remember that we issued a press release every summer telling people not to forget their EHIC but also to think about whether they needed travel insurance as well. Members are completely right to say that, in a no-deal scenario, many other issues would face patients and that the most vulnerable people risk being the most exposed. If the cost of travel insurance does go up, it could be most challenging for them, but I am glad that Ministers are looking at that issue.

While the Health Ministers are in the Chamber, I should like to give them a big shout-out and thank them for certain other things. Somebody talked earlier about nurses. Nurse training is happening in my constituency. I know that the Minister for Health has previously talked about ensuring that there is additional funding for those entering the nursing profession after they have finished their qualification to ensure we recognise those in nursing areas where we need nurses most. I am glad that he has done that. I also want to say a big thank you today for the announcement from the NHS about diabetes monitors. That has been a major issue for some of my constituents. We must ensure that constant monitors, such as the one our Prime Minister wears, are available across the country. I was really pleased by today’s announcement. I want to say thank you very much to the NHS and to our Ministers and thank you for getting the devil that is in the detail of the Bill correct today.

Photo of Julie Cooper Julie Cooper Shadow Minister (Health and Social Care) (Community Health) 3:08 pm, 14th November 2018

I am grateful for this opportunity to close the debate on behalf of Labour. It is clear that Members on both sides of the House understand the importance of the Bill. The UK currently enjoys reciprocal agreements for the provision of healthcare with all the nations of the European Union. Under existing arrangements, the healthcare of 190,000 UK state pensioners living abroad—principally in Ireland, Spain, France and Cyprus—and their dependent relatives is protected. In addition, UK residents who visit the EU or the European Economic Area on holiday or to study may use the European health insurance card to access healthcare for emergency treatment and healthcare needs that arise during their stay. Anyone who is ordinarily resident in the UK qualifies for an EHIC and 250,000 claims for medical treatment are made each year under this scheme. By the same token, EU nationals visiting the UK can use their EHIC to receive free care from the NHS for any emergency healthcare needs and for healthcare needs that arise during their stay. I am grateful to Vicky Ford for reminding the House that the card does not cover repatriation and other associated expenses, but visitors to the EU can currently be reassured that their immediate emergency costs will be met. That is something that we would seek to protect.

By means of the S1 form and the EHIC, current arrangements also provide for the healthcare of employees of UK companies and organisations working in the EU and the EEA, as well as for that of frontier workers living there, and vice versa. Importantly, the agreement also provides funding for UK residents to travel overseas to receive planned treatment in other countries—for example, for procedures unavailable in the UK within a medically justifiable timescale, or to return home to give birth.

Providing for pensioners, visitors, students and workers to live, work, study and travel in EU member states with complete peace of mind with regard to the provision of healthcare is a priority for Labour. We therefore support this Bill in principle, although we are quite shocked that we have had to wait so long for it, given that there are only 135 days left until the UK exits the EU. It is essential that we seek to safeguard, through agreement with EU member states, the healthcare of the 190,000 expats and the 50 million who travel abroad every year. I do not for one moment think that anyone here would want to contemplate the consequences if an agreement were not possible when the UK exits the European Union. We therefore welcome the Government’s intention, as outlined in the White Paper on the future relationship with the EU, to continue a reciprocal healthcare arrangement by means of an agreement with the EU, the EEA and Switzerland.

We are concerned, though, about the scope of the Bill. It includes no detail of specific reciprocal arrangements, although at this stage we understand why it is not possible, in the absence of any certainty, to outline such details. We will not seek to block the Bill, because we want to ensure the seamless continuation of reciprocal healthcare arrangements, but we are not prepared to give the Government carte blanche to secure any agreement at any price. We are not prepared to hand them a blank cheque.

We are concerned that the Bill includes no requirement for the Secretary of State to report back to Parliament. Nor does it incorporate any facility for parliamentary scrutiny, even in the event that a member state decides not to reciprocate. The British Medical Association shares our concerns on this point. It rightly maintains that the discretionary powers granted to the Secretary of State in the Bill should be proportionate and subject to thorough scrutiny, and that all regulations should be subject to the affirmative procedure in Parliament. We also have concerns about the protection of patient data, and we wish to ensure that appropriate safeguards are in place in the Bill. We will look to address those concerns in Committee.

The Health Secretary is on record as saying with confidence that this is one part of the Brexit deal that is resolved. I welcome his confidence and that of Eddie Hughes on this—I wish I had their confidence. However, the Secretary of State does offer the proviso that that is

“so long as we land a good deal.”

That is surely the crux of the issue, given the current uncertainty about whether we will get a deal at all.

I hope the Minister is able to give some reassurances on this issue, because the failure to facilitate a reciprocal arrangement for healthcare would be catastrophic for UK citizens seeking healthcare routinely within the nations of the EU. The thought of 190,000 expats losing their right to free healthcare is unthinkable. As the Minister rightly said, UK citizens have paid their taxes all their lives, and they need and deserve the certainty of the right to free healthcare and of knowing that it is protected. That is something Sir Roger Gale was keen to support, and we agree with him. It is unthinkable that expats living in the EU should be reduced to the status of third country nationals in a queue for healthcare. Similarly, the 50 million visitors to the EU each year will need certainty, as Paul Masterton pointed out—I am sure the whole House is interested to hear more about his stag trip. Without a reciprocal agreement in place, costs for citizens overseas may well be prohibitive, and there are obvious implications for health insurance premiums.

We are also concerned about the impact on our NHS in the UK if expats need to return here for treatment. Our system is already having to cope with unprecedented demand, and the thought of adding to that is something we are concerned about. I reiterate the concerns of my hon. Friend Justin Madders that the issue is not covered in the impact assessment. We also know that no assessment has been made of the impact on disabled citizens and those with pre-existing medical conditions.

Importantly, neither is there any mention, as Dr Wollaston said, of how any future disputes will be adjudicated. The Prime Minister has ruled out the future involvement of the European Court of Justice, so we are concerned about this issue going forward. Perhaps the Minister can advise us today which body he envisages being used to adjudicate in any such event. We also hope that the Bill can be used to outline processes for the efficient collection of moneys owed to the UK under any future arrangements for reciprocal healthcare.

We look forward to addressing these concerns in Committee. We want to see this Bill go further and be used as an opportunity to strengthen reciprocal arrangements further and to provide for enhanced arrangements with other nations worldwide, in line with the UK’s ambition to extend its range of trading partners.

Photo of Stephen Barclay Stephen Barclay Minister of State (Department of Health and Social Care) 3:16 pm, 14th November 2018

With the leave of the House, I thank everyone who has spoken in the debate. This is a short and sensible Bill, which will ensure that the Government have the appropriate legal framework to give effect to a deal in relation to reciprocal healthcare arrangements, which so many of us, both here and abroad, enjoy. I am grateful for the support in principle for the Bill from both sides of the House, including from the Opposition Benches.

The level of interest and the contributions to the debate demonstrate that it is clearly in the interests of the British public to ensure that reciprocal healthcare arrangements similar to those currently in place continue when we leave the EU. A number of questions have been raised in the debate, which I will endeavour to answer in my closing remarks. However, as my opposite number, Justin Madders pointed out, we will have an opportunity in Committee to scrutinise those questions in more detail. He raised a number of very pertinent points, which I will be keen to explore with him.

I would like to reiterate the offer I made in a recent letter to all Members of the House to have meetings with me and the team of officials working on the Bill if they want to explore the Bill in more detail. I recognise—this point was picked up by my hon. Friend Sir Roger Gale—that this issue genuinely concerns constituents of Members on both sides of the House. I am keen to engage with Opposition Members, the Chair of the Health Committee and other colleagues on the detailed issues they may wish to raise on behalf of constituents.

Photo of Philip Dunne Philip Dunne Conservative, Ludlow

I am grateful to my hon. Friend, and I would like to take advantage of his offer, but I would also like to highlight another issue. I do not wish to extend the competence of the Bill unduly, but it is an opportunity for us to look at the reciprocal health agreements we have with the overseas territories, as mentioned by my hon. Friend Gillian Keegan, and particularly with United Kingdom dependent territories—I am thinking here of the Channel Islands. Under the previous Labour Government, the reciprocal health agreement with Jersey was ripped up and terminated in 2009. Under the coalition agreement in 2011, it was reinstated. However, at present, there is no reciprocal health agreement with Guernsey, which is also responsible for Alderney and Sark. I ask the Minister to consider that during the passage of the Bill.

Photo of Stephen Barclay Stephen Barclay Minister of State (Department of Health and Social Care)

I am grateful to my hon. Friend for raising that. Understandably, much of the debate today has focused on the EU element of the Bill, but he is quite right to recognise that the reciprocal element extends beyond the EU and particularly to Crown dependencies, overseas territories and countries such as Australia, New Zealand and elsewhere. I am very happy to have those discussions with him.

My opposite number, the hon. Member for Ellesmere Port and Neston, raised a number of points, one of which was on the impact on people with long-term conditions. I agree that, without reciprocal healthcare, people with long-term conditions, including those who need dialysis, may find it harder to travel, which is the very essence of why the Bill is necessary, so that we can implement a reciprocal arrangement with the EU or, failing that, with individual member states to support the travel arrangements of those with long-term conditions.

The hon. Gentleman also questioned the £66 million figure that I referenced in my speech, and I am happy to point out that that was in relation to the 2016-17 value of claims made by the UK to EU member states. He also asked about cost recovery more generally and, since 2015, we have increased identified income for the NHS under reciprocal arrangements by 40%, and directly charged income has increased by 86% over the same period. I mentioned the increased focus on that to my hon. Friend Henry Smith, which I hope gives a signal of intent as to the direction of travel on cost recovery.

The hon. Member for Ellesmere Port and Neston also mentioned the role of NHS Improvement, and I am happy to clarify that it is now working with more than 50 NHS trusts to improve their practices further, with a bespoke improvement team in place to provide on-the-ground support and challenge in identifying and sharing best practice.

The hon. Gentleman also mentioned an important point, and one that we will probably go into in more detail in Committee, on data. Again, the policy intent is continuity, rather than a change in our approach to data. Clause 4 expressly contains a safeguard for personal data, which can be processed only where necessary for limited purposes or funding arrangements. That covers, for example, where someone is injured while abroad, where personal data of a medical nature often needs to be shared to allow treatment to take place. At the same time, there are safeguards in the Bill, which I am sure we will explore.

My hon. Friend the Member for North Thanet expressed concern about cherry-picking, and I recognise his point. That is why we are looking for the reciprocal arrangements to continue, although even in the event of no deal and no bilateral deal, local arrangements often apply for healthcare, such as on the basis of long-term residency or previous employment. Those would be local factors, but obviously the policy intent is to have an arrangement with countries across the EU.

Martyn Day and my hon. Friend Paul Masterton spoke about the work of the devolved Assemblies and how we liaise with them. Indeed, I spoke with my Welsh counterpart just yesterday. In the other place, the Parliamentary Under-Secretary of State for Health has been working closely with the devolved Assemblies, as have colleagues and officials in our Department. How we work with the devolved Assemblies is a pertinent point, and we are keen to continue that active dialogue.

My hon. Friend Sir Robert Syms correctly identified the importance of the EHIC card and of inward tourism to the UK. The point about continuity was reinforced by my hon. Friends the Members for Chichester (Gillian Keegan) and for Chelmsford (Vicky Ford) in their thoughtful contributions. It was also echoed by my hon. Friend Eddie Hughes when he highlighted the importance of taking a practical approach to how these arrangements apply.

My hon. Friend Dr Wollaston raised a number of detailed points, and I am happy to have continued dialogue with her on them, although I hope she will draw some comfort from recent quotes and legislative developments in a number of EU27 states. For example, the French Minister for European Affairs said, “France will do as much for British citizens in France as the British authorities do for our citizens.” France has legislation under way. The Spanish Prime Minister said, “I appreciate, and thank very much, Prime Minister May’s commitment to safeguarding those rights. We will do the same with the 300,000 Britons who are in Spain.”

Again, I hope the fact that we actually pay out more to the EU than we currently receive, and the fact that both nations benefit from a reciprocal arrangement, gives an idea of the starting point of the discussions. Like my hon. Friend, I would welcome it if that were done across the EU27 as a whole.

My hon. Friend also raised the issue of dispute resolution, and the current arrangements between the UK and other member states require states to resolve differences, in the first instance, between themselves. That is the existing position that applies, but clearly it would be a matter for negotiation as to how a future UK-EU agreement might be governed. That is a cross-cutting issue; it is not one pertaining solely to this Bill.

It is clearly in the interests of the British public to ensure reciprocal healthcare, arrangements, similar to those currently in place, continue when we leave the EU, whether that happens through an agreement with the EU itself, as we very much want, or through individual arrangements with EU member states.

Photo of Mike Amesbury Mike Amesbury Shadow Minister (Work and Pensions) (Employment)

Just for clarification, is the jurisdiction of the European Court of Justice still a red line in the sand?

Photo of Stephen Barclay Stephen Barclay Minister of State (Department of Health and Social Care)

The issue in terms of the ECJ will be dealt with in other areas of the withdrawal agreement discussions. In the event of a deal, and in the event of no deal, it will be governed by the bilateral arrangements.

I commend this Second Reading to the House, and I look forward to working with colleagues on both sides of the House in Committee.

Question put and agreed to.

Bill accordingly read a Second time.