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Medical Facilities (European Reciprocity)

Volume 982: debated on Wednesday 2 April 1980

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Motion made and Question proposed, That this House do now adjourn—[ Lord James Douglas-Hamilton.]

12.56 am

The circumstances of the case that I wish to bring to the attention of the House tonight highlight what I consider to be a serious anomaly within the rules governing reciprocal medical treatment between this country and the other countries of the EEC.

The specific case concerns 13-year-old Siobhan Jernskaw, who plans to spend the Easter holidays in Italy with a party of children and teachers from the St. John Fisher school in Gateshead, where she is a pupil.

During the preparations for the holiday it was discovered that Siobhan, for reasons which I shall explain, was not eligible for, or covered by, health care in Italy in the same way as the other children and the teachers. In view of this, I understand that at one stage Siobhan's continued inclusion in the party was in grave doubt. On my advice, she obtained private insurance cover which will meet the cost of any medical treatment that may be required while she is in Italy with her school friends. The disappointment of missing the holiday has been prevented, but this girl, at a tender age, has been cast in the role of being somewhat different from the rest of her school friends. There is no possible justification for this highly embarrassing situation, because Siobhan is no different from her friends and, therefore, should be treated in the same way.

The categories of person covered by the EEC regulations are explained in the leaflet SA /28/30 /June 1979 published by the Department of Health and Social Security. Briefly, to be covered for reciprocal medical care one must be a United Kingdom national and currently insured as an employed person. Siobhan is a United Kingdom national—she was born here and has never lived anywhere else. Being a child, Siobhan obviously cannot be insured, but children are normally covered by virtue of their parents' qualifications.

At this stage the difficulties began. Although Siobhan is a full British national, her father is a Norwegian national who married a British girl and established the family home here in Gateshead 16 years ago. In almost every respect this is an ordinary, normal British family. Siobhan's father is gainfully employed. He pays his full national insurance contributions and pays all the taxes required of him. He is exactly like millions of other fathers throughout the land. He meets in full his family, economic and social responsibilities. Because he has not chosen to renounce his Norwegian citizenship, his children are discriminated against in a very embarrassing way.

When Siobhan has been abroad on other occasions, she has travelled on her mother's British passport. During my inquiries into the circumstances of the case, I discovered that she could have been treated in the same way as the other children on the visit if her mother, who is a United Kingdom national, had been currently employed and insured.

Like millions of other mothers who have a young family to care for, Siobhan's mother is not insured. Her full-time occupation is that of looking after the family and the home. This is a classic "Catch 22" situation. The father is insured. He pays all his United Kingdom taxes but is not a United Kingdom citizen. The mother is a British subject but is not insured because of her family responsibilities. In the meantime, the poor, innocent child must suffer. The EEC regulations are in need of urgent amendment in order to clear up this anomaly and many others that undoubtedly exist. Once a person is covered, his dependants are also covered, irrespective of nationality and of whether the covered person travels with them. If one can believe it, stateless persons and refugees are covered.

I do not claim that that should not be the case. However, I strongly maintain that the claims of Siobhan Jernskaw are immeasurably more justified. This single case highlights the anomaly that exists. There must be many more similar cases. I strongly urge the Minister to use all the power at the Government's disposal to bring about changes and to ensure that justice is done and is seen to be done.

1.2 am

I was particularly interested to hear the remarks of the hon. Member for Gateshead, East (Mr. Conlan), as my two children will shortly go overseas on a school holiday. I could well imagine their concern—and, indeed, mine—if they were to be confronted with the problem just described. I welcome the initiative that the hon. Gentleman took in recommending the option of private insurance and in enabling the girl to go on holiday as she had planned. He is to be commended for giving the correct advice to his constituent. I commend him also on the way that he has presented the case.

I welcome the opportunity of explaining the basis on which United Kingdom nationals may receive medical care when on holiday in other member States of the European Community.

The National Health Service provides care only while a person is in the United Kingdom. If he should be taken ill or have an accident while abroad, he will usually have to pay the full costs of treatment. However, the European Community has regulations which enable the majority of citizens to get urgent medical treatment free, or at reduced cost, during visits to other member States from the sickness insurance scheme of the country concerned, on exactly the same terms as its own insured people.

As I will explain, not everyone is covered by the Community regulations. Medical treatment in other countries can be extremely expensive, and my Department advises those who are not covered by the regulations to take out adequate private insurance to cover emergencies. Travel agents and insurance brokers are accustomed to giving advice in those cases.

The question of entitlement under or cover by the regulations is, I fear, rather complicated, because the purpose of those regulations is to co-ordinate the social security schemes of nine individual member States. I emphasise that the aim is to co-ordinate, not to harmonise, and there are bound to be difficulties where national provisions and national priorities differ. The regulations were revised in the light of experience of their operation even before we entered. They reflect largely the insurance-based health care schemes of the original Six, and on joining we had to accept them as they stood.

It will be necessary for me to give some explanation of the regulations before I can explain the action taken in the case of Siobhan Jernskaw, which has given rise to this debate.

The arrangements for free or reduced-cost medical care for visitors to other EEC countries are made under the EEC regulations 1408/71 and 574/72
"on the application of social security schemes to employed persons and their families moving within the Community."
While the EEC regulations provide cover for medical care in a variety of circumstances, the most commonly used provision is that for the visitor who, while still employed in and contributing to the social security scheme of his "home" country or in receipt of benefits as the result of such employment and contributions—for example, retirement pension —goes for a short period, for example, on holiday or business, to another member State. If he falls ill, and provided that he is covered by the EEC regulations, the visitor is entitled to immediately necessary treatment from doctors and hospitals operating under that State's national medical care scheme.

Treatment is given on the terms and conditions that apply to insured people of the other country. To ensure that he receives free or reduced-cost care under the EEC arrangements, the visitor must usually show the authorities of the other country a certificate of entitlement to treatment—form E111.

It is the duty of the appointed "competent institution" in each of the member States to issue certificates only to those people to whom the EEC regulations apply. My Department is the competent institution responsible for the issue of forms El11 in the United Kingdom.

As the EEC regulations do not apply to everyone, the certificate of entitlement cannot be issued without confirmation that the applicant is a person covered by the regulations. Therefore, a form of application containing statements giving such confirmation is necessary. That is incorporated in an explanatory leaflet, SA28/30:
"Medical treatment for visitors to other EEC countries".

I appreciate that the hon. Gentleman is trying to make out a case, but to a 13-year-old child leaflet XYZ does not make a great deal of sense. Can the hon. Gentleman defend the situation where a man living in this country pays a contribution lawfully geared by the NHS and suddenly finds that he is not fully covered? The man has paid his dues and yet a 13-year-old child suddenly finds that she is different from her people. All the leaflets and numbers in the world cannot explain that.

I hope to outline the action that the Government are taking to try to remedy the injustice. The case that I was developing was that it is not within this Government's power to alter regulations that apply to other countries. We have to proceed by consent.

The leaflet that provoked the hon. Gentleman to intervene explains who is covered by the EEC regulations and how and when to apply for form EIII, and the procedure to obtain treatment in each of the other countries is summarised.

The sickness insurance schemes of the Community countries vary and none is comparable with the NHS. Nevertheless, most member countries provide their insured people with free medical and hospital treatment—although, as in the United Kingdom, there are some charges for dental treatment and medicines—and similar treatment is therefore available to visitors from the other EEC countries.

Three countries—France, Belgium and Luxembourg—have national sickness insurance schemes which require their insured people to be personally responsible for a proportion—usually 25 to 30 per cent.—of the costs of any treatment received.

Visitors to countries which require payment of a part of the costs of any treat- ment are advised to take out private insurance to cover that risk. Forms E1ll are generally issued from local social security offices, which also hold stocks of leaflet SA28/30. There is a provision in the EEC regulations that if a visitor does not obtain form El11 before going to another EEC country, and requires treatment there, the sickness insurance institute of the country concerned will apply on his behalf for the form El11 to the sickness institute with which the visitor is insured. In the case of a visitor from the United Kingdom, that would be to our overseas branch at Newcastle-upon-Tyne. If for any reason use of this procedure is impractical, and thus full charges are made for treatment, the visitor may apply on return to his home country for a refund of the costs.

Article 2 of regulation 1408/71 provides that the regulations shall apply to workers
"who are nationals of one of the member States or stateless persons or refugees residing within the Community and also to members of their families".
In other words, in order to have access to social security and health benefits in other member States, it is necessary for two conditions to be fulfilled. The first of these is the nationality condition. The regulations do not apply to people living and working in the Community who are not nationals of one of the member States, although there is provision to cover stateless persons or refugees residing within the Community and their families.

On signing the Treaty of Accession to the European Community, Her Majesty's Government made a declaration that, so far as the United Kingdom was concerned, the term "nationals" should, for the EEC purposes, be taken to refer to persons who were citizens of the United Kingdom and colonies, or British subjects not possessing that citizenship, or the citizenship of any other Commonwealth country or territory, who, in either case, have the right of abode in the United Kingdom and are therefore exempt from United Kingdom immigration control; and persons who are citizens of the United Kingdom and colonies by birth or by registration or naturalisation in Gibraltar, or whose father was so born, registered or naturalised.

A person who is a United Kingdom national for EEC purposes will hold a British passport endorsed at the top of page 5 as follows:
"Holder has the right of abode in the United Kingdom".
Persons who are United Kingdom nationals for EEC purposes, but who hold British passports issued before the United Kingdom's accession, may apply to the Home Office to have the endorsement added.

The second condition is that the regulations apply only to "workers" and their families, and this is related to employment. Briefly, the following groups come under the heading of "workers" for the purposes of the regulations: those currently insured as employed persons, and those who are employed but are not liable to pay contributions; those who have at some time in the past paid contributions as an employed person, and are now paying contributions as self-employed persons; those who are not working but who have, in the past, paid contributions as an employed person and are now either paying non-employed contributions or are receiving a social security benefit or pension. The Department's leaflet SA28/30 sets out in detail the conditions for cover.

These conditions are, I accept, complex. But this arises, as I have said, first of all because the regulations were designed to meet the needs of the original Six in co-ordinating their legislation, and they cannot therefore be expected, even after adaptation, to fit in as neatly with our rather different national health and social security schemes. In the second place, it has proved possible, with experience of the regulations—which are made under article 51 of the Treaty of Rome—to extend the meaning to cover various categories of people who are currently self-employed or non-employed but have at some time been employed. It is in the nature of case law that such extension, whilst to the advantage of individuals, complicates the rules.

As the hon. Gentleman said, the Community's social security regulations do not cover everyone. The majority of self-employed and some non-employed individuals are, as a result of the case law decisions, now covered, but there are still a number excluded from the scope of the regulations and we have been negotiating in Brussels for some time to have the regulations extended so that the self-and non-employed, and their dependants, from this country should also have access to treatment of immediate necessity through the State health schemes of other member countries when visiting them. The hon. Gentleman is right to say that amendment is needed. These negotiations continue.

A draft regulation to this end is at present under consideration in the Council, but we have met more difficulty, and therefore delay, than we originally expected. Other member States have reasons which they consider, in their particular national contexts, give rise to difficulty in accepting the charges proposed. I accept this, but we have put a lot of effort into this. The Commission has given us assistance and other member States are cooperating in an endeavour to solve the problems which have arisen. I therefore hope to make progress and reach agreement. When we do, all EEC nationals resident in the United Kingdom will be entitled to medical care of immediate necessity when visiting other EEC countries.

I turn to the case under discussion. Siobhan Jernskaw is 13 years old, born in the United Kingdom of a British mother and a Norwegian father. As is usual for a dependent child, on application for a certificate of entitlement for her, form E111, covering a visit to Italy, was made by her father. This was sent with a number of applications for other children by the headmaster of St. John Fisher comprehensive school to the Department's Gateshead office on 5 March 1980.

Following the usual procedures, the application was considered and it was found that Mr. Jernskaw was not a national of an EEC country and form El11 could not, therefore, be issued to cover his daughter's visit to Italy. A written notice of the reason for rejection of the application was sent to Mr. Jernskaw on 7 March 1980. In a subsequent telephone conversation with him the possibility of cover being provided for his daughter through Mrs. Jernskaw was suggested but, although a United Kingdom national, his wife does not meet the "workers" condition as she has not been in employment for a number of years. As is usual in such cases, the father was advised to take out private insurance to cover Siobhan's visit. I am content that the action taken by the Gateshead local office was right.

Does the Minister agree that the various circulars and regulations to which he has referred are typical of EEC gobbledegook?

I prefaced my remarks by saying that the regulations were exceedingly complex. I should prefer my own description of them rather than "gobbledegook". However, they are the regulations with which we have to cope. We are seeking to get them amended to deal with this case. It is a matter of regret that Siobhan, who was born in and has lived in the United Kingdom, is not eligible under the EEC regulations for medical treatment while visiting another member State.

I think that there is no disagreement between us. As I have explained, we are aiming to remedy the situation by having the regulations extended. If the extension to the regulations as presently drafted is agreed, Siobhan will be covered both in her own right and because her mother would gain entitlement.

However, people like Siobhan's father will still be outside the scope of the regu- lations because they are not EEC nationals. The United Kingdom does not have the power to grant nationals of third countries living within its territory access to Community social security benefits. Only the Community as a whole is able to do this through co-operation agreements with third country Governments, which would, of course, need to be reciprocal.

Mr. Jernskaw is Norwegian. Norway has not joined the Community and nor has it made an association agreement with the Community which would give him cover.

I accept the deep sense of injustice that this girl must feel. The Government recognise her case as an anomaly. We have put specific proposals before the Community for extending the regulations so that the anomaly may be removed and a fairer situation is brought about. I ask hon. Members to bear with us while we seek to persuade the other member countries to make the much-needed alteration in the regulations.

Question put and agreed to.

Adjourned accordingly at eighteen minutes past One o'clock.