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Reciprocal and Cross-Border Healthcare (Amendment etc.) (EU Exit) Regulations 2020

Volume 807: debated on Monday 16 November 2020

Motion to Approve

Moved by

My Lords, this instrument amends regulations from 2019 to remove provisions that have now been superseded by the protections for people contained within the withdrawal agreement. It makes some technical fixes to reflect this and ensures that the statute book is fit for purpose. It also provides protections for people benefiting from the cross-border healthcare directive, as the directive was not carried forward in the withdrawal agreement.

Before I turn to the details, I will start with an overview of current reciprocal healthcare and our steps to prepare for the end of the transition period. Reciprocal healthcare arrangements with the EU have continued during the transition period. This means that people will see no changes in their access to healthcare for the rest of the year. From 1 January 2021 healthcare arrangements will also continue for those within the scope of the withdrawal agreement. I hope that this provides much welcome reassurance. State pensioners and workers who have moved from the UK to the EU or vice versa, and are residing there before 31 December 2020, will have lifelong reciprocal healthcare rights for as long as they remain in scope of the agreement. That includes the use of the European Health Insurance Card, the EHIC.

The agreement also protects those who are in the EU on a short stay at the end of the transition period. For example, someone who travels to an EU country before the end of the year can continue to use their EHIC there until they return to the UK. UK students on a stay in the EU, beginning a course of study before 31 December 2020, can also use their EHIC in that country for immediate and necessary healthcare for the duration of their course. Finally, people receiving planned treatment can commence or complete their treatment if authorisation was requested by 31 December 2020. All this provides much-needed certainty for UK nationals already living in the EU and vice versa.

As noble Lords are aware, future reciprocal healthcare arrangements are subject to ongoing negotiation with the EU. We understand the value of access to healthcare when travelling on holiday or for work, and I know that this is particularly important for those with pre-existing or long-term conditions. This is why the UK has been clear that it wishes to establish necessary healthcare arrangements such as the EHIC for tourists, short-term business visitors and service providers. I am sure that noble Lords will be aware that these discussions are continuing. I reassure them that, should these discussions not conclude with a healthcare agreement, we will continue to look at this issue carefully.

Should we not achieve an EU-wide deal, we would seek to agree reciprocal arrangements with EU and EEA countries bilaterally. But we cannot start these discussions until the negotiations with the EU have concluded. The one exception to this is of course Ireland. I am very pleased to report good progress on agreeing a healthcare arrangement with Ireland, under the common travel area. These arrangements will mean that residents of the UK and Ireland can continue to access necessary healthcare when visiting the other country, and it will cement co-operation between UK and Irish healthcare providers.

The instrument that we are debating today is a technical instrument to update legislation made in 2019. This now needs updating to reflect the terms on which we are leaving the EU. We need to ensure that our legislation is ready for the end of the transition period. We also need to ensure protections for those accessing cross-border healthcare on an ongoing basis at the end of the year, as this is not covered in the withdrawal agreement.

In April 2019 the Government made three statutory instruments to correct deficiencies in retained EU law relating to reciprocal healthcare. This was part of the UK’s preparations for leaving the EU without a deal. Those instruments made provision to revoke that body of retained EU law, protected people in the middle of a course of treatment and provided a mechanism for the UK to maintain bilateral reciprocal healthcare arrangements on a transitional basis until 31 December.

Some of this has now been superseded by the transition period and the withdrawal agreement protections. If we do not agree this instrument, the retained law will be incoherent and unworkable. There will also be uncertainty over protections for patients in the middle of a course of treatment.

As such, the first change our SI makes is a series of consequential and technical amendments to four EU exit instruments to make them workable and coherent. These instruments are: the Social Security Coordination (Reciprocal Healthcare) (Amendment etc.) (EU Exit) Regulations 2019; the National Health Service (Cross-Border Healthcare and Miscellaneous Amendments etc.) (EU Exit) Regulations 2019; the Healthcare (European Economic Area and Switzerland Arrangements) (EU Exit) Regulations 2019; and the Health Services (Cross-Border Health Care and Miscellaneous Amendments) (Northern Ireland) (EU Exit) Regulations 2019. The second change is that this SI updates EU references in NHS legislation that will no longer be appropriate at the end of the year. Thirdly, as I mentioned, it will clearly set out transitional protections for people accessing healthcare under the cross-border healthcare directive.

The directive gives patients the right to receive healthcare in another EEA country and receive reimbursement from their home country. It is separate from broader reciprocal healthcare under EU regulations and was not included in the withdrawal agreement. This means that the directive will no longer apply from 31 December 2020, and it is therefore important that patients who are in the course of being treated are appropriately protected. This instrument will specifically allow the Government to fund patients in the middle of treatment, or who have already applied for authorisation, at the end of this year.

Turning to the impact on industry, as this instrument proposes no significant changes to the current regulatory regime, there would be no significant impacts on industry or the public sector. As this instrument makes technical amendments and does not introduce new policy, we have not conducted an impact assessment.

The instrument also makes provision in relation to Northern Ireland and Wales. The devolved Administrations have been consulted. There has been excellent engagement between the department and the devolved Administrations and I am confident that we have clear arrangements in place.

I am pleased to say that we have worked openly and collaboratively with NHS England and NHS Improvement, as well as the NHS Business Services Authority. They are our key delivery partners and have continued delivering their day-to-day operations, such as issuing EHICs to people, while making changes to successfully implement the withdrawal agreement.

In summary, the overarching aim of the instrument is to ensure that UK legislation is functional and reflects the withdrawal agreement. It also ensures that there will be appropriate protections for people accessing treatment under the cross-border healthcare directive at the end of the year. I beg to move.

My Lords, I thank the Minister for his introduction. The removal of free movement rights in the recent Immigration Act is a matter of great regret to millions of British people, who knew their value. It will also become a matter of regret to many more Brits once they realise that their dreams of working in Germany or retiring to Spain without hassle or paperwork have been torn from them. The triumphant tweet from the Home Secretary celebrating the end of freedom of movement was a tasteless mistake.

The loss of the European health insurance card will be understood and felt immediately by any British person wanting to travel within the EEA next year. If the promise of the vaccines is borne out and travel opportunities open up, people will want to spread their wings. But they will get a nasty shock from the travel insurers, as the price of a policy will be whacked up to account for the loss of free emergency healthcare under the EHIC. In the other place, it was mentioned that some 30,000 people on dialysis can currently travel throughout Europe and receive their dialysis free of charge thanks to the EHIC. This is not covered by commercial travel insurers and in future it will cost them up to £1,000 a week. The Minister in the other place talked about a recently launched directory of specialist insurers covering serious medical conditions. Well, maybe—but the premiums are likely to be eye-watering.

Brits are also losing the ability to go to another EEA country for, say, an operation when the NHS waiting list is too long. Can the Minister tell me how many procedures have been done under the cross-border healthcare directive since it was implemented in 2013? It is perhaps appropriate that the amendment to domestic legislation entails deletion of references to “EU rights” because, very sadly, rights are being torn from British people in the healthcare sector as in so many others.

The only brighter news is that, thanks to the withdrawal agreement, some people will retain rights after the end of the transition period. First, UK nationals living and working in the EEA on 31 December 2020 will continue to be entitled to healthcare funded by their member state of residence and get an EHIC issued by that state. Can the Minster clarify whether that EHIC will grant that UK national free emergency healthcare wherever they travel in the EEA or only in their member state of residence? Will those British nationals get free NHS care when they visit here?

Secondly, British pensioners resident in the EEA on 31 December 2020 who hold a so-called S1 form will continue to be entitled to UK-funded healthcare, including a UK-issued EHIC. Will that EHIC be usable throughout the EEA, and will the S1 form mean they will get free NHS care in this country? EEA nationals resident in the UK on 31 December 2020 will continue to be entitled to access the NHS, which I assume means free of charge. They will also get a UK-issued EHIC, which will surely make their British friends very jealous indeed.

Lastly, a British national who has previously worked in an EEA country can get a UK-issued EHIC plus planned treatment in an EEA country under the S2 scheme. They can also apply for an S1 form—this debate has a horrible amount of jargon—issued by the UK once they reach state pension age, on the same terms as now. Is there a specified minimum length of time that they would need to have worked in an EEA country, or could it be for as little as, say, a week? Again, there will be some jealousy from their British friends that a British national, by virtue of having worked for I do not know how long in an EEA country, will be able to get a new EHIC.

I welcome the agreement with Ireland that the Minister referred to. I was not sure whether the agreement had been finalised, but it is of course good news.

As the clock ticks down to 31 December, we know that even if a deal is reached with the EU, it will be a skinny one. How confident is the Minister that it will include any provision to continue reciprocal healthcare, including the EHIC? Discussion about rules of origin or customs arrangements might seem arcane to many people, but losing access to free healthcare if ill on holiday will hit home to most Brits. The Minister said that no impact assessment has been done because the instrument makes only “technical” amendments. British holidaymakers might disagree when they get their bill from their travel insurer. A Government celebrating “getting Brexit done” through gleeful tweets about the loss of rights might find themselves not so popular if they tweeted about the EHIC. They might think that the loss of free movement is popular, as many people have yet to discover that free movement is a two-way benefit, but the loss of the EHIC card will not go down well at all. I hope the Minister will be able to give us good news about continued arrangements.

My Lords, it is a pleasure to follow the noble Baroness, Lady Ludford. I thank the Minister for setting out what this technical amendment does. As the noble Baroness said, it may be very technical, but it will hit a lot of individuals hard when they suddenly realise that Brexit is about more than sovereignty, taking back control and all the things people talk about. It is one of the first things that people will realise hit them personally.

Brexit has happened and we have to live with it, but it is very disappointing that on something such as this, with only a few weeks to go before the end of the transition period, the future systems have not been sorted out. With the best will in the world, it seems there will be a gap in which existing rights to emergency healthcare and other rights for British citizens who do not live in Europe or fall into the categories that will be protected will be lost. Nobody knows what the future will be.

My first question follows on from the noble Baroness’s speech: where are we with negotiations on future arrangements? Are they part of the discussions taking place now, which are concentrating on level playing fields, fishing and so on, or will they have to wait until those are concluded—either with no deal or with some sort of skimpy Canadian deal or whatever—and new negotiations take place? How long will it be, assuming everything goes well and negotiations take place on a friendly and co-operative basis, before a new system is in place? Does the Minister believe that an EEA-wide system—or perhaps an EU plus British system, or whatever it will be—will replace the present system, or will it be a series of bilateral arrangements between the UK and individual European countries which might be different from one country to another, some perhaps having arrangements and some not? That seems a recipe for chaos. There will be a number of instances where people come up against things that affect them personally in ways they had not expected. This is perhaps the first and one of the most important.

It is important that the impact assessment to the original regulations, which was published in October 2018—it was certainly an impact assessment then—said that the number of uses of EHICs in the EU by UK residents in 2016, which was a few years ago but I do not imagine these things change terribly, was 233,000. That is a lot, although it is concentrated in a few countries. It does not seem to say how many were in the protected categories and how many were just people like me; I once fell down a hillside, went to the local health centre in the Pyrenees, got some excellent emergency treatment and was able to reclaim a substantial amount of the cost afterwards. That is extremely useful. I do not know how many people it affects. It may be that it does not affect all that many, but even if that is the case, it is a very important backdrop.

People living in the European Union, people who organise trips via package holidays, people who visit regularly, semi-residents—of whom there are a lot; people say there are 1.3 million UK citizens living in the EU, and it is fairly well known that the number who live in the EU for at least a substantial part of the year is considerably more than that—regular visitors and people with jobs there are likely to have health insurance over and above their EHIC. They will continue to have that, although, as my noble friend said, it might cost a bit more.

However, many people are going to be at a severe disadvantage: casual visitors; people on shopping trips to Calais, if people are still going to do that; people going for weekends in Paris; those taking long weekends, borrowing a cottage or house from friends; people on short family trips to see students on a gap year or an Erasmus year in Europe; those going to stag parties in Prague, where people go at the last minute; and people who, because they have long-term health conditions, are not easily able to get economical combined health and travel insurance. Even people in the protected categories will be protected only up to the end of this year—after that, they will not be protected at all. The world is going to be very different.

Then there are all the European citizens living in this country who will not be protected if they come to live here after the end of this year. They will be involved in a whole new range of National Health Service bureaucracy. Questions have been asked about how much that is going to cost and nobody seems to be able to give any answers. What I am really asking is this: what is the timescale for sorting all this stuff out? How long will the gap that people are going to fall into be?

My Lords, it is a great pleasure to follow the noble Lord, Lord Greaves, who, typically, has come up with some very important questions. I thank the Minister for setting out the terms of the regulations and their implications. I can see that, on one level, these are technical points, but in reality they are going to make a substantial difference to the lives of many millions of Britons. It is that that concerns me at the moment.

I accept that we are obviously moving out of the EU: that is a given. What is not clear is whether we are going to have an agreement at the end of the transition period, which is only some six weeks away. I can see that the six weeks of remaining rights relating to travel are not, in the great scheme of things, that significant, given that very few people will be travelling at the moment. But given the great news that we have had on the vaccines—and I pay tribute to the people who have worked on them, particularly the children of Turkish immigrants in Germany working for BioNTech, who made a massive breakthrough—the likelihood of increased travel, certainly towards the end of next year and thereafter, is very much in play, and we all welcome that.

Having heard the Minister setting out the position, I find it somewhat obscure, involving a rather confused set of rights and obligations. It is confused in the sense that there is any number of different combinations of obligations and rights according to how one looks at this; it is a positive Rubik’s cube of different obligations and rights, and is anything but simple.

What is clear—and it is good news—is that UK nationals living and working in the EU will be entitled to member-state-funded healthcare. That is good news. What is less clear—this was a point touched on also by the noble Baroness, Lady Ludford—is whether, if they return to the UK, they will be entitled to free healthcare here. Perhaps it is very much the case that that is so, but I would be grateful if the Minister could confirm it so that we all know, because it has not been set out very clearly. There are rights for EU citizens in the UK on a similar basis, and I certainly welcome that.

It is also clear that UK citizens who go on holiday or visit an EU member state for a business trip from the beginning of next year, in the absence of a comprehensive agreement, will no longer be able to use their health insurance card or a comparable card, and so will have to take out insurance to ensure proper cover in the absence of that EU-UK agreement, or in the absence at least of bilateral agreements with each of the other states—I think it would be 26 states in this instance, because Ireland is separately catered for. That is anything but simple, if we are going to have 26 separate agreements with different states. I hope we reach a position where there is cover with all of them, but it would be good to know that it is going to be the same cover; otherwise, the insurance position of, for example, young travellers or students on Interrail travelling overseas, having to get different insurance for different countries, will be anything but straightforward and anything but just technical.

I ask the Minister also about whether there has been proper publicity and promotion of the information that will be very much in play at the beginning of next year. If we have no agreement, then there is a need for insurance to ensure proper cover. I am not sure that people appreciate that, and I do not think there has been a sustained publicity campaign about this. I appreciate that we are still hoping for an agreement, but I think that some contingency arrangements should be put in place to ensure that people are aware of the position that will apply at the beginning of next year. The consequences otherwise could be horrendous. It is not simply the cost of insurance, which people will not welcome; it is the cost of what happens if you do not have insurance that is really serious. I would be grateful if my noble friend the Minister could say something on that.

I too am concerned about the position for people with deep-seated medical issues. The noble Baroness, Lady Ludford, mentioned dialysis, and it is a point well made. What is being done to cater for people in this category, who have been previously able to travel without massive insurance costs because of reciprocal rights being applicable? Are we doing anything in that regard? I appreciate the timescales here but, given that we have known these timescales for some time, it would be good to hear that some contingencies are being put into place in relation to these situations.

The last point I wish to raise is in relation to the healthcare that we provide throughout the United Kingdom—not just within England. The UK was, of course, a member state and was subject to reciprocal arrangements for reimbursement of costs that are applied by the healthcare systems of the four nations in relation to travellers from the EU. Are we liaising with the devolved nations to ensure that we have some sort of common approach to the recovery of any costs? It seems to me that there is a recipe here for red tape and bureaucracy beyond what is needed. It would be good to hear that we are on top of this and looking at how we go about seeking reimbursement of these costs. As I say, that is something that I hope does not need to happen, but it may need to happen.

I thank the Minister for confirming that the devolution arrangements are working well with the devolved nations and that that is happening on a very good basis. I am pleased to hear that; it is certainly music to my ears. It would be good to hear that we are on top of that reimbursement issue.

With those thoughts, I rest the case. There are obviously some concerns, but I thank the Minister for setting out the position as clearly as he did.

My Lords, I thank the noble Baroness, Lady Ludford, and the noble Lords, Lord Greaves and Lord Bourne, for their very useful and sensible comments at the beginning of this debate. I also thank the Minister for his, as ever, very courteous and thorough explanation of the SI. It would have been wonderful if this evening he had had a road to Damascus moment, realising that, whatever new arrangements are being put in place, and no matter how complicated and effective they are, they are likely to be inferior, more costly and more inconvenient than what already exists. However, I suspect that that moment has gone. I therefore wish to seek guidance and reassurance from him on a small number of points.

The first is on cross-border healthcare. This is perhaps at its best and most innovative on the island of Ireland, where co-operation on everything from research to critical care, staff training and development has helped transform services for all residents, north and south of the border. Indeed, seeing one of my relatives in a very remote village in Donegal being offered one of the most up-to-date cancer treatments at the Altnagelvin Hospital in Derry, rather than having to travel to Dublin, was a very personal example. Another was the opportunity to address an all-Ireland nursing conference alongside Health Ministers from both sides of the border, where the discussion was on how to improve nursing services for all residents. It made me realise that cross-border healthcare was more than a political ideal; it is the bedrock of a more civilised society.

I was delighted when the Minister, in his opening remarks, mentioned that an agreement had been made with the Republic on cross-border healthcare. But are we getting exactly the same arrangements as we have now? Will they be translated into a legal document? If not, can he identify what will change for residents both in the United Kingdom and on the other side of the Irish border?

Secondly, I recognise that from 1 January UK and EU nationals who are working or studying in either the EU or the UK will be able to continue to be in receipt of the current reciprocal healthcare arrangements—I am delighted that that has been clarified again. However, most UK nationals, particularly in areas such as IT, are working as fixed-term contractors and not as permanent employees—they are not permanently in the country of their work. Will the Minister clarify whether any fixed-term contractor who currently works between the UK and the EU but is currently fulfilling a contract in the UK before returning to one in the EU will qualify for continuation of reciprocal cross-border healthcare arrangements, or will they have to be working in the EU on 1 January, as mentioned earlier?

Will EU au pairs who currently reside with UK families—their number has gone down from 90,000 to around 20,000 since the Brexit agreement—continue to receive free healthcare, should they, as is very likely, return home over the Christmas period? I realise that they will get it if they continue to stay after 1 January but, if they go home for Christmas for two or three weeks, will they then be denied that healthcare when they return to their families in the UK after Christmas?

Thirdly, I am incredibly worried about the cross-border flow of students. The noble Lord, Lord Greaves, mentioned the Erasmus programme, but it is not just that programme that has brought huge benefits to the UK, as well as to the EU over a great many years. Clearly, existing students will continue to enjoy reciprocal arrangements, provided that they continue in their course this year, but will universities—I use as an example Hull, which offers its German language undergraduates a year’s experience in Germany—as institutions have to fund health insurance? Will they pass on that cost to their students or will they be able to purchase exactly the same arrangements in some cross-border arrangement?

Finally—the noble Lord, Lord Bourne, referred to this briefly—will the Minister now, or in a note placed in the Library, say how successful the NHS has been in recovering health-related fees from non-UK residents over the past five years and what the administration costs have been as a proportion of overall recovered costs? I ask this because I have not seen anywhere assessments relating to the recovery of costs from the huge rise in claims that will be made by hospitals and other healthcare institutions when EU visitors, students and workers not currently operating in the UK do so after 1 January 2021. I am sure your Lordships would agree that it would be perverse if we had a system that costed the NHS in the UK far more than at present, simply because of the administration and bureaucracy surrounding those recharging facilities. As ever, I look forward to the noble Lord’s—as usual—courteous reply.

My Lords, these regulations are quite technical in nature but relate to a very important issue for many. I am grateful to my noble friends Lady Ludford, Lord Greaves and Lord Willis of Knaresborough, and to my friend the noble Lord, Lord Bourne of Aberystwyth, for their comments, questions and common sense.

Reciprocal healthcare has been and always will be of vital importance to those who travel between and live across European nations, in particular workers and students, as has already been mentioned. It ensures that health coverage is available as individuals undertake activities that are beneficial across our societies. However, it is extremely important that individuals are informed about their healthcare rights abroad, whether they need to be supplemented with insurance and whether they are covered by direct payment or a reimbursement system.

Could the Minister confirm the arrangements on the island of Ireland? He will be aware that, at present, residents in both the Republic and Northern Ireland have been treated freely on either side of the border. I do not mean “freely” in the financial sense, but in the sense that the border does not exist: ambulances travel from north to south without let or hindrance, and treatment for a single condition can be delivered in both the north and the south. I wonder whether the Minister could clarify whether the financial arrangements will have to change or be renegotiated—and will they be ready with effect from 1 January 2021?

I sit on one of the House of Lords Select Committees that has been looking at various issues relating to the situation in Northern Ireland with effect from 1 January next year. With a lot of despair, we have found that some departments have been very slow in working with the Assembly in the north. They are feeling abandoned by departments and anxious about whether things will be ready for 1 January. Could the Minister confirm that, as far as health is concerned, all arrangements will be completely wrapped up by the time 1 January comes?

Concerns have been raised that those with existing and underlying health conditions may not be covered when they travel to the EU. Can the Minister confirm whether any reciprocal coverage will be available, for those with a learning disability in particular? It is concerning if coverage is not complete for some individuals, as it will add extra pressure to an already stretched NHS resource, as well as having an impact on these individuals. Of course, a comprehensive deal with the EU, securing reciprocal coverage just as we have at the moment, would resolve any uncertainty there is. Can the Minister assure the House that the Government are still committed to negotiating such a deal? Can he confirm that agreeing a reciprocal healthcare scheme is a priority in these negotiations, as it is in the interest of both parties?

The withdrawal agreement agreed in October 2019 and ratified in January 2020, and separate agreements with other EEA states and Switzerland, made some provisions relating to this. First, the existing arrangements continue until the end of the transition period on 31 December this year. Can the Minister clarify who will retain rights after the transition period? What conversations have the Government had with the insurance sector, which I am sure is waiting for new business with bated breath? As was suggested by the noble Lord, Lord Bourne of Aberystwyth, this issue is important. I am concerned that there will be some less-than-ideal arrangements and wonder what assurance the public have that insurance offerings are reasonable and do not take advantage of the situation.

There are some provisions for health at the 23rd hour. UK and EU nationals in a cross-border situation over 31 December 2020—part-way through a holiday, maybe—can continue to use the EHIC to access needs-arising treatment, until they leave the country by travelling to another EU member state or returning to the UK.

People visiting the UK or EU for planned medical treatment under the S2 route can commence or complete their treatment if authorisation was requested on or before 31 December. If a UK national has paid social security contributions in a member state in the past but is not living in the EU on 31 December 2020, the rights that flow from those contributions, such as benefits, pensions and reciprocal healthcare rights, will be protected. This means that someone who has previously worked in an EU EFTA member state can apply for a UK S1 as well as EHIC S2 once they reach state pension age, on the same terms as now. So, we have a clearer picture of what the future arrangements of the EU on healthcare will be.

Many noble Lords have outlined how they have used their EHICs. My noble friend Lord Greaves has clearly had far more exciting experiences than I have in the Alps. I have managed to spend the last 50 years travelling happily around the EU without any problems at all and my EHIC has stayed happily in my wallet. These Benches regret that we are in this position, but we have to put our trust in the Government to arrange as good a reciprocal deal or series of bilateral arrangements as soon as possible. Will this be sorted by the end of the transition period? Can the Minister confirm that we will not be disappointed?

I thank the Minister for his introduction. I also thank all noble Lords who have taken part in this debate, raising an unenviable number of questions that the Minister will need to answer. I want to be clear that I understand the situation here. I am a veteran of this debate. I had a look and I have had this debate in one form or another at least four or five times in the last three years. This is the third Minister I have had dealing with it, so I hope noble Lords will pardon me for my sense of déjà vu.

My understanding is that we are all okay for the next six weeks while we are still covered by the transitional agreement, but on 1 January we are okay in terms of healthcare and other provision only if it already exists. If it does not exist and you are not resident in a European Union country—or, presumably, a European Union resident in this country—you will have to make new arrangements.

I remember being in a meeting with one of the noble Lord’s colleagues, probably about two and a half years ago, who assured us that, if necessary, we would have 27 absolutely rock-solid agreements on reciprocal healthcare, and that it would be okay. I have to say that I greet some of this with a certain amount of scepticism because I feel as though I have been led up this particular mountain at least three or four times in the last few years. I would like to know whether my assumption is right: that those of us who do not live in Spain, have not paid into the Spanish system and are not eligible to do so but who might want to retire there next year, will have to make our own arrangements. I suggest to the Minister that the way people will feel about Brexit will be judged partly on how this works, because healthcare and access to healthcare across the European Union is very personal to all of us.

I put on record some of the concerns that have been raised with us by a range of patient groups and healthcare organisations, who feel that the regulations do not go far enough in protecting the rights to healthcare of British citizens who travel in the European Union. As other noble Lords have said, this could leave some people with underlying health conditions not completely covered. The noble Baroness, Lady Ludford, used an example from Kidney Care UK that 30,000 people on dialysis can currently travel through Europe and receive their dialysis free of charge because of EHIC, even though dialysis for life-sustaining treatment for kidney failure is not covered by travel insurance; without reciprocal healthcare arrangements, it may cost up to £1,000 per week. I would like the Minister to answer the question of what will happen to people who receive dialysis after 1 January. How many more thousands of people with pre-existing health conditions will not be able to get insurance and could be put in the same situation if the Government fail to reach a deal?

If they fail to reach a deal in the next two weeks, will there be 27 agreements in existence? Are they there and ready to run? I would really like to know. The Brexit Health Alliance—a group of organisations that want to ensure that the views of healthcare users and providers are reflected in the Brexit negotiations, including the Academy of Medical Royal Colleges, NHS Providers, the Richmond Group of Charities and the Association of the British Pharmaceutical Industry—says:

“The current arrangements involve minimal bureaucracy for patients and healthcare providers, underpinned by well-established systems for reimbursement between member states. The NHS will face unwelcome increased resourcing burdens, if it is required to handle new, more complex administrative and funding procedures when providing care to EU citizens in future.”

The British Medical Association says that failure to reach a deal would,

“lead to significant disruption to … individuals’ healthcare arrangements, an increase in costs of insurance, and uncertainty regarding accessing healthcare abroad. Moreover, the NHS would face a drastic increase in demand for services, which could dramatically increase its costs and place greater pressure on doctors and clinical staff.”

I said those words to the Minister’s predecessor about two years ago. I said if we do not sort this out, there will be increased pressures on the NHS. Two years later, having increased pressures on the NHS is even more serious than it was.

Those organisations have been completely consistent in what they have been saying to the Government about this issue for the last three to four years and here we are now, weeks from possibly falling off a cliff. It is very important that the Minister not only answers some of the very relevant questions he has been asked by other noble Lords but seeks to reassure us that we are not all going to find ourselves faced with huge costs and, possibly, not being able to travel at all in Europe because we have failed to reach an agreement.

My Lords, I express admiration and gratitude for the stamina of the noble Baroness, Lady Thornton, for sitting through this debate several times. I have also sat through it several times. I fear that some of my answers will be the same as those the noble Baroness and others will remember.

I am grateful for this debate. It is a quite reasonable and touching reminder of a key fundamental that travel is massively valued, particularly by those who travel for work, for study and to see relatives, but also by the population generally. Travel is of huge personal and financial value and protecting your health when you travel is incredibly important. People have a close association with that and are naturally deeply concerned about it. I agree with those noble Lords who emphasised the importance of these arrangements and in no way do I undervalue the importance of the EHIC programme and its successor to the British public.

In the withdrawal agreement we have a robust framework for some reciprocal rights that include significant long-term and traditional protections for EU and UK nationals. This piece of legislation is very much in that spirit. It is there so that UK legislation remains functional by reflecting the withdrawal agreement and the transition period and ensures that there are appropriate protections in place for those accessing healthcare under the cross-border healthcare directive. As veterans of this area will know—I apologise if this creates a sense of déjà vu—I remind noble Lords that the changes in this instrument do not concern the future relationship with Europe. The UK has made it very clear, and we continue to work on the fact, that we want to agree clear arrangements for providing healthcare cover for tourists, short-term business visitors, service providers and for all manner of British people who are travelling to the EU and vice versa.

However, any agreed arrangements will be entirely subject to the outcome of those negotiations. There is nothing I can do at this Dispatch Box to answer the great many perfectly valid but completely unanswerable questions that have been put about what those future arrangements might look like. However, I can update the House: the UK has had constructive discussions with Switzerland and the EEA/EFTA states of Norway, Iceland and Liechtenstein on our future relationship, including social security co-ordination and reciprocal healthcare. Those are promising and reflect well on our conversations with the EU. The progress of those discussions is, however, linked to the outcome of the EU negotiations on social security co-ordination, so I cannot offer concrete guarantees in that department.

To answer a point made by the noble Baroness, Lady Thornton, some people will be eligible for a UK EHIC under the terms of the withdrawal agreement. A new EHIC has been developed for those who are eligible, including people living, working and studying in the EU before the end of the transition period. We made that very clear very early on. Anyone with an S1 form or studying in a member state can apply for the new EHIC on the NHS website. For those not covered by the withdrawal agreement, the EHIC may not be valid from 1 January 2021, as the noble Baroness rightly pointed out. The Government are open to working with the EU to establish necessary healthcare arrangements that provide healthcare cover for tourists, short-term business visitors and service providers, but those conversations have not been finalised.

Future healthcare cover for tourists is subject to the future relationship. I understand that it is extremely frustrating not to be able to find exactly what that will look like. I acknowledge that one group which is particularly concerned will be those with pre-existing conditions; they will find it the most challenging to find the right travel insurance if there is no arrangement with the EU on necessary healthcare. This is something we are looking at closely. On a practical note, we know that getting insurance can be more difficult for those with long-term conditions. To support people, the Money Advice Service has recently launched an insurance directory for people with a serious medical condition, which brings together specialist firms with the aim of making it easier to find travel insurance that provides the right health cover. I understand that that service is proving of value.

In response to my noble friend Lord Bourne, communication has been incredibly important and we have gone about it in an energetic way. We have sought to prepare citizens for the change at the end of the transition period with advice tailored for different audiences, helping them to understand their choices and to act in their own best interests. Information is available and has been updated regularly on the NHS pages and GOV.UK to ensure that people are clear about their reciprocal healthcare rights. The Foreign, Commonwealth and Development Office has been leading a campaign, supported by DHSC reciprocal healthcare advisers, to UK-insured people living in the member states, and my understanding is that those communications have been effective.

The noble Lord, Lord Greaves, asked about readiness to implement the withdrawal agreement. I reassure him that the DHSC has made good progress, working openly and collaboratively with other social security departments and its operational delivery partners in NHS England, NHS Improvement and the NHS Business Services Authority, to ensure that reciprocal healthcare arrangements will be successfully implemented for those covered by the agreement. I also confirm that UK S1 holders in the EU and UK students studying abroad can now apply for their new EHIC under the withdrawal agreement.

The noble Baroness, Lady Jolly, asked about Ireland, and it is good news that we seem to have made progress on our arrangements for Ireland. The UK and Irish Governments have been discussing future arrangements for healthcare co-operation within the common travel area. Great progress has been made in these talks. These arrangements will ensure that residents of the UK and Ireland will continue to be able to access necessary healthcare when visiting the other country and benefit from co-operation between UK and Irish healthcare providers, regardless of the outcome of the negotiations with the EU. The example the noble Baroness gave of ambulances travelling across the border was very powerful.

These arrangements build on previous commitments that UK and Irish citizens who are living in the other country will continue to be able to access healthcare on the same terms as local citizens. The Healthcare (European Economic Area and Switzerland) Arrangements (EU Exit) Regulations 2019, which we debated previously, provide the mechanisms to implement these arrangements, so there should be no interruption in healthcare arrangements between the UK and Ireland.

The noble Lord, Lord Willis, asked about money reclaimed from other countries. That amount has grown substantially over the last five years. I cannot give the precise number that the noble Lord asked for, but the amount recovered from overseas healthcare visitors has risen to £760 million in 2019-20. That is a substantial amount, but we are continuing to work to make sure that all that money is reclaimed effectively.

These essential measures are being put in place to protect those who seek to travel abroad. For that reason, I beg to move.

Motion agreed.

Sitting suspended.