Healthcare (International Arrangements) Bill

Lord Ribeiro Excerpts

2nd reading (Hansard): House of Lords
Tuesday 5th February 2019 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, it is indeed a pleasure to take part in this debate, and in particular to follow the noble Lords who have spoken and to welcome our new Minister to the Front Bench in her new position. I declare an interest as a member of the EU Home Affairs Sub-Committee and commend to the House its report, Brexit: Reciprocal Healthcare, published in March 2018.

Like many of your Lordships, although I use travel insurance when I am in Europe, I am always grateful to have in addition my EHIC. Some years ago, while I was on holiday with my family in France, one of my children broke a toe while going down a slide. Faced with having to pay for her surgery and then claim back the cost, I produced my E111 form with a flourish—noble Lords may remember those days. I managed to convince the hospital authorities in my pidgin French, although that was more challenging. The E111 form worked a treat and surgery was performed at no cost to me. The current EHIC is equally reassuring, but mine runs out in May 2019, so I seek reassurance from my noble friend the Minister that I will be able to renew it during the implementation period of the withdrawal Act—if it is finally implemented.

What happens in the event of a no-deal Brexit, the drums for which are continuing to beat in some quarters? Our report confirmed that some 27 million cards, as has been mentioned, exist in the UK, from which only 250,000 claims—less than 1%—have been made so far each year. In relation to UK citizens living in Europe, approximately 190,000 UK state pensioners, as we have heard, rely on the S1 scheme. This provides ongoing access to healthcare, the costs borne by the member state with the social security system to which the individual has contributed the longest. The scheme supports the elderly and ensures that reciprocal healthcare is a portable benefit. On page 10, paragraph 16 of our report says:

“A disproportionate number of UK citizens benefit from the S1 scheme. There are only around 1.2 million UK citizens living in other EU countries compared with around three million EU citizens living in the UK. But some 190,000 of those UK citizens are pensioners, who are more likely to benefit from the S1 scheme, compared to only 5,800 EU/EEA citizens who have registered for the S1 scheme in the UK”.


That is quite a disproportionate number.

In all this, we remain net beneficiaries. I hope that noble Lords will forgive me for focusing on the no-deal scenario, but the implications are dire for this group of UK citizens and the 27 million EHIC holders I mentioned, many of whom, as we know, voted to leave the EU. If the EHIC is not maintained—which is a distinct possibility with no deal—short–term visitors to the EU would need travel insurance. In giving evidence to the committee, Mark Dayan of the Nuffield Trust told us that the highest cost of travel insurance was the medical cost. Without the EHIC, the cost of travel insurance is bound to rise.

There is also concern about the onward movement of UK citizens living or working in the EU in relation to free-movement rights or rights to reciprocal healthcare, which are not covered by the joint agreement or the withdrawal agreement. It has been suggested that bilateral and multilateral arrangements, as currently occur with countries outside the EU such as Australia or New Zealand, could be applied to the EU. But these arrangements largely cover emergency healthcare and not the arrangements we currently enjoy through the S2 scheme in relation to planned treatments. For example, as I mentioned in my speech on 3 July 2018, the proton beam cancer treatment available in Prague and other European cities is not currently available here, although we hope it will very soon come on stream. So what reassurances can the Minister give that future relations and arrangements will protect the current S1 and S2 arrangements, which form part of the four routes to reciprocal healthcare? Reciprocal healthcare is assured until December 2020, as we have heard—if we have an agreement. In the event of no deal, which is fast approaching, what assurances can the Minister give that the deadline of December 2020 can still be maintained to allow “alternative arrangements” to be negotiated between individual EU countries and the UK?

It is important that we provide reassurance to UK citizens, many of whom are in their twilight years and have chosen to reside in EU member states, that their health needs are protected. This should happen, deal or no deal. If we end up with no deal, analysis by the Nuffield Trust shows that British pensioners will lose healthcare cover in EU states and have to return to the UK to access care. The cost of that care in the NHS is estimated at about £1 billion—pounds, not euros, although it is about the same—which is twice as much as the UK currently spends on the care of people abroad under the S1 scheme, as spelled out earlier by the noble Lord, Lord Foulkes, when he referred to this. The resource implication of such expatriate return to the UK is the equivalent of two new NHS hospitals the size of St Mary’s Hospital, Paddington. We noted in our report a large amount of evidence expressing concern at the additional costs to the UK and the NHS of returning expats. What contingency plans do the Government have in the event of such an outcome occurring?

Healthcare (International Arrangements) Bill

Lord Ribeiro Excerpts

Committee: 1st sitting (Hansard): House of Lords
Tuesday 19th February 2019 Lords Chamber

[Lord Brooke of Alverthorpe (Lab)]

My Lords, first, I apologise to the Committee for not having been able to speak at Second Reading. Secondly, I welcome the Minister to her new post and wish her well with it, although I am sorry, like the noble and learned Lord, Lord Judge, that she has been given a hospital pass on this one. I shall speak briefly in support of Amendment 1 in the name of the noble Baroness, Lady Thornton. I am sorry to hear that the clause stand part may not be pushed to a vote, but perhaps the way that the debate goes may necessitate that.

My interest goes back before the Minister came into the House. I asked a series of questions about the proposed trade agreement between the UK and the USA. I have been particularly concerned, as have many in the health industry, that this agreement will open up an opportunity for the USA to come in very strongly indeed. The health industry in America is a very big part of the economy, and one area in which it has not been able to make great movement is within the NHS. Some of us have been concerned that the trade agreement would open that up, and we have been seeking to have it taken off the agenda. I have tabled Questions asking for it not to be on the agenda, and the Government have so far not been prepared to give any such assurance. I have contemplated moving an amendment to this Bill to ensure that, while the Minister is saying that this has nothing to do with that, she could accept such an amendment and set my mind at rest very quickly.

I read very carefully what she said in response to similar criticisms of the Bill at Second Reading:

“The Government are completely committed to the guiding principles of the NHS—that it is universal and free at the point of need. Our position is definitive: the NHS is not and never will be for sale”.—[Official Report, 5/2/19; col. 1488.]


She was not saying anything there with which I would disagree, but one worries about trade agreements whereby people can effectively take over and, while not owning it, can run parts of a major utility such as the NHS. That is why some of us have been seeking an agreement that it would not be on the agenda at all and the NHS would be left as it is, free of any trade agreement, particularly with the United States. I would be grateful, therefore, if the Minister could reassure me that in no way would a trade agreement with the USA have the NHS as part of it. If not, I may have to go away and see whether I can bring back an amendment on this issue.

[Lord Ribeiro (Con)]

One can see why, in the event of a no-deal Brexit, the amendment moved by the noble Baroness, Lady Thornton, would be attractive, as it focuses our minds on restoring reciprocal healthcare arrangements with the EU 27, other EEA countries and Switzerland. As I said on Second Reading, a disproportionate number of UK citizens benefit from the S1 scheme compared with EU citizens in the UK, so there is much to lose in a no-deal scenario.

In March 2018, the UK reached an agreement in principle with the EU on the implementation period which would ensure continuation of the current reciprocal healthcare rights until 31 December 2020. If we crash out, there has to be a plan B which allows us to consider reciprocal healthcare arrangements with other countries. Although I understand the need to write “international arrangements” into the Bill, it presents problems. They were identified by the Delegated Powers and Regulatory Reform Committee, as mentioned by the noble Baroness, Lady Jolly, which described as “fanciful” the idea of providing the Secretary of State with wide powers to fund the costs of healthcare anywhere in the world—for example, as the noble Baroness described, mental health provision in Arizona or all hip replacements in Australia.

This is far too wide, and the focus of international arrangements should in the first instance be applied to Britain’s 13 overseas territories, far-flung as they are—some in the Falklands and the Galapagos, as the noble and learned Lord, Lord Judge, stated—but the closest of which is Gibraltar: close to us and close to Europe. Ninety-six per cent of Gibraltarians voted to remain in the EU, and our focus should be to ensure reciprocal healthcare for those overseas countries for which we have responsibility. Post Brexit, whatever the arrangements are, we can then think about the wider international arrangements; but for now, we should focus on the areas for which we have responsibility.

I hope that my noble friend can provide assurances as to how best to protect the overseas territories in the event of no deal and give further consideration to what the Government intend “international arrangements” to cover.

[Lord Lisvane (CB)]

My Lords, it is a great pleasure to welcome the new noble Baroness to the Front Bench and I echo the welcome offered by other noble Lords. I am only sorry that the first task that has fallen to her is, as described by my noble and learned friend Lord Judge, a hospital pass. I prefer to see it as a sort of legislative grenade with the pin out.

As my noble friend Lord Patel mentioned, I am a member of the Delegated Powers and Regulatory Reform Committee, but of course I do not speak on its behalf: this is an entirely personal set of observations. Delegated powers of unacceptable scope and inadequate arrangements for scrutiny are simply getting worse. Noble Lords may recall our extended debate on the EU withdrawal Bill in Committee and at Report, when noble Lords rightly became very agitated about the use of the word “appropriate”—widening the way in which ministerial powers might be used—as against “necessary”, which provided some sort of objective test as to whether those powers should be deployed. Amendments which would have fixed that went down the oubliette in the Commons. With my noble friend Lord Wilson of Dinton, I declare a degree of interest because my name and his, along with that of other noble Lords, were on those amendments.

This Bill takes us into new realms of the use of delegated powers, albeit that the Trade Bill and the Agriculture Bill, both of which have already been mentioned this afternoon, are strong competitors for this legislative wooden spoon. I congratulate my noble and learned friend Lord Judge on his forensic dismantling of the need for the powers contained in the Bill and his warnings about the way in which they might be used. Any thought of his grandchildren saying that he was “banging on” should not inhibit him in any way from continuing to bang on about those subjects, and I hope that many other noble Lords will do the same.

Two points of principle have a general application but are particularly lively in the context of this worrying Bill. The first is the use of Henry VIII powers. I think that His late Majesty would be extremely jealous of some of what is contained in the Bill, as with the Agriculture Bill, the Trade Bill and the other Brexit Bills to come trooping our way. I accept that Henry VIII powers are sometimes needed, perhaps when there are urgent issues for which you need to make primary legislative provision, but you cannot get a Bill through in the normal course of events. However, where such powers are used, I suggest that there should be a test: that of the three Ss.

Healthcare (International Arrangements) Bill

Lord Ribeiro Excerpts

Report stage (Hansard): House of Lords
Tuesday 12th March 2019 Lords Chamber

[Baroness Chisholm of Owlpen]

No, let me finish. The Bill will not replace or limit the prerogative power to enter into international healthcare agreements. My understanding is that agreements will still be subject to appropriate parliamentary scrutiny.

It is surely right for us to take advantage of the Bill and look at the opportunities it can offer us. We are not trying to shoehorn something dastardly into it. It could offer all kinds of things. It seems to me that planning ahead is a refreshing thing to do. Many of the arguments raised have nothing to do with protecting or giving peace of mind to travellers. As a nurse, my main priority will always be those needing care. The Bill allows them reciprocal healthcare outside the EU and just that. Should there be a Division, I hope that noble Lords will keep in mind those people who, under the Bill, will be able to travel globally with renewed peace of mind about their healthcare.

[Lord Ribeiro (Con)]

My Lords, this is an enabling Bill and no more. In a letter to the chairman of the Delegated Powers and Regulatory Reform Committee on 8 March, the Minister confirmed that these powers would be used only in the exceptional circumstances of EU exit. We will discover the outcome of that tonight.

In these circumstances, the regulations’ implementing powers would be subject to parliamentary scrutiny. The assurances and clear message from our debates in Committee—when the Minister was very clear, in answer to a question from the noble Lord, Lord Brooke of Alverthorpe, that reciprocal healthcare arrangements with the United States would present significant challenges because of the different payment systems and such an arrangement was unlikely—should surely be enough to satisfy those who believe that the Government still have a cunning plan to sell the NHS to Donald Trump and others.

As I said in Committee, I believe that the implementation of our international arrangements should be phased, giving priority to our overseas territories, as has been noted; our Commonwealth partners, of which Australia and New Zealand have already been mentioned; and our important international partners, perhaps excluding Venezuela and the Galapagos Islands from that list, as suggested by the noble and learned Lord, Lord Judge.

Anything enabling this to happen should be considered seriously, given the risks of what I believe is likely to be a no-deal Brexit. I do not support these amendments and I hope that the Minister will be able to come up with suggestions for how this can be implemented to overcome some of the concerns expressed from the other side.

[Baroness Brinton (LD)]

My Lords, both the noble Lord, Lord Ribeiro, and the noble Baroness, Lady Chisholm of Owlpen, are missing the point of these amendments. While this is only an enabling Bill, it increases the scope of reciprocal health agreements with countries outside the EEA and Switzerland to include trade agreements. The noble Lords, Lord Lansley, and Lord O’Shaughnessy, at earlier stages of the Bill, raised exactly this point about setting up trade agreements. We are extremely concerned, for all the reasons given by the noble Baroness, Lady Thornton; this is the sort of large change that requires considerable consultation with the public prior to Green Papers, White Papers and bringing it through the House. We should not try to rush it through as one of the Brexit Bills, which it is, regardless of what happens over the next few days. This is one of the Bills that we were told must be passed by 29 March. Increasing the scope of the Bill means that we are moving into another area that the country, let alone this House, has not had a chance to consider.

I do not believe that reducing the scope would prevent some of the agreements already made; in fact, as the Minister has said when summing up previously, a number are already available. What it does is protect the NHS from being a bargaining tool, particularly—although not only—with the United States. Until the country has a chance to have that debate, it is important that we reduce the scope.

I endorse entirely the comments made by the noble Baronesses, Lady Thornton, and Lady Jolly, the noble and learned Lord, Lord Judge, and the noble Lords, Lord Marks and Lord Foulkes. Our task is solely to replicate the arrangements that may become out of date on 1 April; it is important that we remain focused on that.