Cashing out on Casino Health Tourism

Thursday, April 7, 2016
Dr. Jon Stanley


John Mann’s done it. He’s hit the nail on the head and smashed his thumb in the process.  It is now apparently an EU scandal that the NHS pays more to the EU than we receive.


It is a scandal of incompetence both by the government and by the EU.  They are both to blame and neither side wishes to even address the very obvious causes.  It is EU member state governments that are freeloading, not their citizens. This is a very important point to recognise. Their governments are freeloading off an NHS designed to do everything possible not to charge people. Our government knows this and does nothing.

Labour’s health team bizarrely told Mr. Mann MP the reason why we pay £650 million and get £50 million back is because more people retire abroad. Is that the reason Ireland receives ten times more from the UK than what we receive from them?

Are these people serious?

Considerable anxiety surrounds unpaid health tourism in the UK, given the large number of migrants from Eastern Europe and the inability or unwillingness of healthcare providers to assess their liability to charges.

British patients lose out if treatment is provided to migrants without recompense.  The migrant profile, the funding system of the NHS and the test of ordinary residence contribute to considerable strain upon the NHS from EU migration.

A ploy by pro-EU campaigners is that the UK has many of its citizens in the EU and so we cannot reasonably complain.  This is untrue:

·        The number of UK citizens abroad is overestimated as many spend much of their time in the UK.

·        The bulk of these UK migrants live in Spain, Ireland and France, while the bulk of EU migrants to the UK come from countries joining after the 2004 enlargement round.

·        UK migrants abroad overwhelmingly work at or above the member state average salary, or are pensioners who have their healthcare paid by the NHS via the S1 form.


EU migrants to the UK earn much less than the national average and so pay less tax. Hence, they do not fully pay their way. Thousands of EU migrants are posted workers meaning that they pay tax to the home nation, often at a lower rate than the UK, yet receive NHS care based on residence alone. Migrants to the UK are very different to those from the UK and ignoring this distorts the debate markedly and needlessly.

NHS provision is divided into three main groups. Primary care funds GPs and pharmacies in the main.  Secondary care involves overnight stays and outpatient clinics by specialists.  Secondary care services are purchased via primary care through Clinical Commissioning Groups (CCGs). The third group is urgent care provided via out of hours GPs, A&E and acute hospital stays. 

Urgent care is expensive but it is covered for European Economic Area (EEA) migrants via the European Health Insurance Card (EHIC) system.  There are, however, major issues with how this operates.  There is no duty to show the EHIC card and no incentive to given that A&E treatment is free at the point of delivery.  There is a strong incentive for hospitals not to identify patients as EEA migrants because unless the EHIC card is then shown, the hospital has created a customer to whom the local CCG has no duty to fund. However, if a patient is not identified, the A&E fee is paid by the CCG. 

This drives underreporting and the result is that the NHS is not reimbursed by the migrants’ home country. The only way to insist on proof of entitlement legally is to ask this of every patient attending, including UK patients.  This is politically unacceptable and places an undue burden on healthcare providers they are free to avoid.

For non-urgent care this lack of duty to identify EEA migrants provides primary care with a double dilemma.  While CCGs pay for hospital services, the government provides block grants for primary care.  GP practices have neither time nor duty to report whether an EEA migrant is here temporary (not entitled to full NHS care) or is ordinarily resident (full entitlement assured). 

The British Medical Association specifically states GPs have no such duty and that treatment should never be delayed on this basis.  Primary care will be provided anyway given its block grant funding, and then secondary care will be provided by the CCG without public awareness.  There is every incentive to simply not report health tourism and inside the EEA at present, the UK simply has to deal with this.

The test of ordinary residence by the UK is set at six months. This is ridiculously short and very close to the three month limit placed on EHIC. It also requires little concrete proof of intention to stay as most landlords will not issue a rental agreement for less than six months so no completed rent agreement needs presenting.

This current failure within the EU and EEA is important to Brexit campaigners, given the reliance on EEA membership to maintain working healthcare relations with the EU.  Outside the EEA, it is a simple matter of applying non-EEA rules to EEA migrants and insisting every non-UK citizen pays health insurance at the point of entry or beforehand. However, this will require the S1 programme, at least for new retirees, to be abolished.

If we are to stay in the EEA, the government has four areas to act on:

·        The Department of Health must centralise liability for unpaid health tourists with a statutory duty for emergency care providers to check either prior GP permanent registration or health insurance from patients.  Central government then has an incentive to ensure it is paid.

·        Ordinary residence as a test should be replaced by an automatic liability register with a GP for all UK residents, or be extended to two years from six months. The EU makes it clear posted workers are classed as temporary residents for up to two years.

·        Freedom of movement needs to be made conditional on an EHIC card.  Data collected by the UK Border Agency must be used to negotiate a common purse agreement from the EEA or each member state to fund its citizens abroad.  The difference in the number of migrants to and from the UK from different EEA states requires this for fairness and must include posted workers regardless of where they pay tax. The only alternative is to levy a flat NHS fee on EEA migrants as a condition of formal employment. The EEA agreement does suggest this is possible.

·        Parallel provision, where the NHS pays for treatment for EU migrants in their home country via the issue of EHIC cards to non-UK citizens or by granting ordinary residence must stop.  The home country, not the host country, must be assumed liable where doubt is raised.  Outside the EU, the UK can act unilaterally in this regard and simply refuse to issue EHIC to non-UK passport holders.

The EEA agreement was signed in 1992, when movement was limited in scope, scale and duration. The expansion of the EU has changed the EEA profoundly.  Gross mismatches in numbers of migrants between states, and their duty to contribute to the host nation’s health service, require settlement. 

Ordinary residence of six months as a test of entitlement has no credibility in a modern, fully mobile Europe. Leaving the EU gives the UK a choice between making reciprocal healthcare fit for purpose or requiring automatic GP registration for UK residents and compulsory health insurance for everyone else.  Inside the EU, given the recent negotiations through the European Council, neither is possible and resentment to freeloading will only increase.


Dr. Jon Stanley is a member of the Royal College of Surgeons and graduate of Sheffield University.