Healthcare (International Arrangements) Bill

Sarah Wollaston Excerpts

Wednesday 14th November 2018 Commons Chamber

[Sir Robert Syms (Poole) (Con)]

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 the Member for Crawley (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.

[Dr Sarah Wollaston (Totnes) (Con)]

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?

[Sir Robert Syms]

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.

--- Later in debate ---

[Dr Sarah Wollaston (Totnes) (Con)]

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 the hon. Member for Linlithgow and East Falkirk (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 the Member for Poole (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 the hon. Member for Ellesmere Port and Neston (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%.

[Mr Jim Cunningham (Coventry South) (Lab)]

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?”

[Dr Wollaston]

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?

[Madam Deputy Speaker (Dame Rosie Winterton)]

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.]

--- Later in debate ---

[Eddie Hughes (Walsall North) (Con)]

I want to make a brief but enthusiastic speech in support of the Bill. It is a pleasure to follow my hon. Friend the Member for East Renfrewshire (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 the Member for Wokingham (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.

[Dr Wollaston]

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.

[Eddie Hughes]

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.