Consideration of Lords amendments
Power to make healthcare payments
It is a pleasure to be in the Chamber this afternoon. We now have the opportunity to turn our attention to an issue of great importance which, I know, commands the support of the House: the issue of reciprocal healthcare. As Members know, our ability to fund healthcare abroad brings invaluable benefits to people, and it is our responsibility to ensure that we continue to make them available to the public. I thank Members on both sides of the House for their work in considering the Bill so far, including those who have spoken to me about it outside the Chamber.
The amendments deal with the global scope of the Bill. It was intended to provide the Secretary of State with powers to fund healthcare outside the UK, to give effect to healthcare arrangements and healthcare agreements between the United Kingdom and other countries or international organisations—such as the European Union—and to make provision in relation to data processing, which is necessary to underpin these arrangements and agreements. Although it was introduced as a result of the UK’s exit from the EU, it was intended to be forward-facing and not to deal only with EU exit. It offered an opportunity to implement new comprehensive reciprocal healthcare agreements with countries outside the EU.
I am sorry that the Minister was not able to join us at St Helier Hospital yesterday. I understand the reasons for that perfectly, but I hope that he will back the plan for the hospital.
The Minister mentioned the international scope of the Bill. Does he accept that that was a mistake in view of the concerns that people have expressed about, for instance, the opening up of the NHS in future international trade deals with countries such as the United States?
I thank the right hon. Gentleman for his words about why I was unable to go to St Helier Hospital. He knows that, as a Minister, it would have been inappropriate, but as a constituency Member of Parliament, I have no doubt that I will be visiting there again soon. I do not accept his criticism. That was never the point of the Bill. We made that argument consistently both in this House and in the Lords. But we have listened carefully to what has been said about the scope of the Bill and I am about to address that now.
As we prepare for our imminent exit from the EU, the global scope of this Bill has been the source of much discussion in here, outside this House and in the other place. I am pleased that the noble lords did not fundamentally disagree with the idea of reciprocal healthcare arrangements outside the EU. However, it was strongly felt that this was not the time to provide for it. Although the Government would have welcomed that opportunity to provide for it, they have recognised that through this group of amendments their lordships voted to restrict the scope of the Bill to making provision only for EU/EEA countries and Switzerland.
The Government believe it is disappointing to lose at this particular time the opportunity to be able to help UK nationals to obtain healthcare when they visit countries outside the EU, such as when they are travelling, studying or working abroad, or if they want to give birth or obtain treatment. It remains the Government’s view that international arrangements on these issues could promote more life options for our citizens outside the EU, offer greater personalisation of care and assist further in the fostering of international healthcare co-operation. However, it must be our foremost priority to ensure that the Bill receives Royal Assent and is in place so we can respond to the different scenarios without delay and assist, as appropriate, the people who rely on these vital healthcare arrangements.
The Minister and I have form on this, in that we were in a Statutory Instrument Committee only yesterday when I was trying to get over to him the need to be very clear to our constituents that, when we leave the EU, the EHIC—the European health insurance card—will disappear and when our constituents go to anywhere in Europe the full bank of healthcare will disappear. Yesterday, the Minister suggested people should take out private insurance instead. Is it not his job as a Minister to tell his constituents and my constituents the truth about this?
It absolutely is my job to tell my constituents and the whole of the country the truth, and I did that yesterday in Committee and will do it again now. If the hon. Gentleman votes for the withdrawal agreement and it passes, the EHIC will remain in place, as I said yesterday. As I also said yesterday it has always been the Government’s advice that people should purchase travel insurance. None of that has changed and that is exactly what I said yesterday and it is exactly what I am saying today.
Does my hon. Friend agree that we need to be very clear that, with the EHIC, people will get treated as if they are a local; it is not the NHS on tour, so to speak, so we can still face some charges? Particular note should be taken of repatriation costs. If going abroad on something like a skiing holiday, people would be foolish not to take out full travel insurance.
My hon. Friend is right. I made that point yesterday; I made it when I was speaking at the Dispatch Box on Report; and I am happy to make that commitment again today.
It must be our foremost priority to ensure that the Bill receives Royal Assent and is in place so that we can respond to different scenarios. We take this decision with regard for the people who currently rely on the EU reciprocal healthcare arrangements and, only with that in mind, we are choosing not to disagree with the Lords amendments.
This is an important issue. If the Minister wants me to make a series of points of order, I will because this is so important. Yesterday in a Committee Room, none of us could understand this. At one point, the Minister said, “This is transitional. This will only cover the transition until we are out of the EU. After we have left the EU, EHIC won’t apply.” That is what he said yesterday. I am still not sure whether EHIC will apply only in the transition period, or will go on forever. He has not been clear about this.
I have been clear. One can say these things as many times as one likes, but if someone won’t hear, they won’t hear. I will say one more time to the hon. Gentleman—I am happy to take his interventions if he is going to move on to other points—that, as I made clear yesterday, if the withdrawal Bill passes, the current arrangements for reciprocal healthcare will continue throughout the implementation period. During that implementation period, it is the express intention of the Government and the EU to secure continuing reciprocal healthcare arrangements.
The hon. Gentleman chunters that there is no guarantee. I have given him the guarantee that it is the express intention of both the UK and the EU to ensure reciprocal healthcare arrangements for our citizens post EU exit. I have set out clearly that, in the event of the withdrawal Bill passing and the implementation period starting, EHIC will continue and I think—
On a point of order, Mr Deputy Speaker. The Minister and I were in an SI Committee yesterday and you will know how pressurised they are. Four SIs were all blended together, so it was very difficult to separate them and do our job of scrutinising the legislation going through this place, which is our prime responsibility. What we could not get from the Minister was absolute clarity, speaking out to the public and saying that actually the likelihood of keeping EHIC after we leave the EU is on a wing and a prayer—there is no certainty at all.
The hon. Gentleman put that on the record yesterday. I answered the question yesterday. I did so with clarity, in a way that I think almost any member of the public could have understood, and I hope that with that we can move on.
The next amendment I wish to discuss is Lords amendment 3. Their lordships have amended clause 2 to limit the regulation-making powers at clause 2(1). Clause 2(2) was intended to be an illustrative list setting out examples of the type of provision that may be included in regulations made under clause 2(1). It is not, on its own, a delegated power. The effect of amendment 3 is to make the list at clause 2(2) exhaustive. Regulations made under clause 2(1) can now only provide for those things on the list at clause 2(2). The intention of the Government has always been to be prudent and transparent in the use of the Bill’s delegated powers and the list was included to be helpful by demonstrating the types of provision that the regulation-making powers at clause 2(1) could include.
On a point of order, Mr Deputy Speaker. I like the Minister—he is a nice man—but he is reading a brief that for most of my constituents and his is absolute gobbledegook—brackets, references here and sub-clauses there. Surely his job as a Minister is to tell this House in plain English what the dangers are to their future travel—their holidays and business in Europe?
Let’s calm it down a little. In fairness, I think the Minister needs to get to the end of his speech. We cannot have him being interrupted on points of order; it is not good form in this House to do so. What I would say is, “Who knows?” because I cannot predict what the Minister is going to say. He may well get to the points the hon. Gentleman feels are not being addressed.
On a point of order, Mr Deputy Speaker. As a Back Bencher who is keen to see this debate develop and move on so we can get on to other equally important business, what advice can you give me to stop other hon. Members asking pointless points of order in this debate?
Much of what we discuss in this House is clearly of a technical nature, and sometimes its language is impenetrable to others who are watching. However, as the hon. Members for Burnley (Julie Cooper) and for Ellesmere Port and Neston (Justin Madders) will know, the House has had a chance to look at this in a fairly exhaustive way. They will know exactly what I am referring to, and I am sure that they will wish to refer to it in their speeches.
Using “for example” to introduce an illustrative list of things that can be done under a regulation-making power can be found in a number of other pieces of legislation. Section 11(2) of the Automated and Electric Vehicles Act 2018 states:
“Regulations under subsection (1) may, for example”.
Section 48G(2) of the Banking Act 2009 says:
“An order may, for example”.
Using “for example” is not unknown. However, we acknowledge the concerns raised about the breadth of the delegated powers in the Bill, and the Government have taken considerable steps to address those concerns via a number of Government amendments that were accepted in the other place, which I will come to shortly. In addition, we are choosing not to disagree to this amendment, to give further reassurance that the delegated powers in the Bill are no wider than necessary.
The Minister knows that I have also been on another, similar Statutory Instrument Committee, which looked at the use of the green card that gives our constituents the assurance when they travel to Europe that if they are hit by an uninsured driver they will be covered by the insurance industry. That will be lost when we leave the European Union. I used that example yesterday, but the Minister did not come back on it. That is a right and privilege that our constituents expect, and now they are going to lose a similar one relating to healthcare. Is it not clear that these are both examples of the real damage that leaving the European Union will do to us?
The hon. Gentleman has confused various clauses of the Bill, but I will not trouble to explain that. I simply say that the green card is clearly an issue for another Department. I also say again, as I said to him yesterday, that citizens are not going to lose the benefits they enjoy under the EHIC if the withdrawal agreement is passed and the implementation period starts. I would guide him by saying that the easiest way to ensure that all the good burghers of Huddersfield whom he so ably represents can continue to enjoy those rights is to vote for the withdrawal agreement.
As I was saying, the Government have taken considerable steps to address these concerns via a series of Government amendments that were accepted in the other place. In addition, we are choosing not to disagree to this amendment, to give further reassurance that the delegated powers in the Bill are no wider than necessary. Our primary concern, as I have said, is to ensure that the Bill is in place so we have the legal mechanism to support people who rely on these vital healthcare arrangements, as may be necessary.
I would now like to turn to the Government amendments in this group. The Government have also sought to restrict the regulation-making powers in clause 2(1). Amendments 4, 5, and 6 will ensure that, if we confer or delegate functions, this will only be to public authorities. The Government have listened closely to the concerns that the regulations could be used to confer functions on “anyone, anywhere”. The hon. Member for Ellesmere Port and Neston argued in Committee that this wide-ranging scope was unacceptable. As I said to him, there has never been an intention to confer functions on private bodies in order to implement reciprocal healthcare arrangements, but, given the concerns that have been raised, we were prepared to make this restriction clear through these amendments to clause 2.
The Government have also brought forward amendment 7. Arguably the most persistent criticism in both Houses has concerned the Bill’s delegated powers. The Delegated Powers and Regulatory Reform Committee and the Constitution Committee both raised particular concerns about the breadth of the powers. The powers in the Bill were sought to provide options in the event of no deal to mitigate the detrimental effects of a sudden change in healthcare overseas for UK nationals living in the EU. In particular, the regulation-making powers in clause 2 (1)(a) and 2(1)(b) provide a means for dealing with situations where there is no bilateral or multilateral agreement in place.
The Government listened carefully to the concerns raised by parliamentarians across both Houses about the scope of the Bill’s regulation-making powers and concluded that the powers used to establish unilateral healthcare arrangements outside of reciprocal healthcare agreements should be sunset for a period of five years following the UK’s exit from the EU. During the five years before the sunset, we will have the ability to use regulations under clause 2(1) as appropriate. These powers can be used to support UK nationals in the EU in different EU exit scenarios. After the sunset, making use of the regulation-making powers under clause 2(1) would be limited to clause 2(1)(c) only. This provides the Government with a mechanism to give effect to future complex healthcare agreements with the EU, individual EEA member states and/or Switzerland.
Will the Minister give a crystal clear guarantee to all those people who are related to our constituents and who live across Europe and have perhaps retired there that, if they have a long-term health need, the benefits they enjoy under the EHIC at the moment will continue? I do not want to hear anything about the difference between transitional and long term; can he assure those people that they will continue to get those health benefits in the long term?
If the hon. Gentleman votes for the withdrawal agreement, he will be able to give them that reassurance.
I want to turn now to Government amendment 11. The matter of financial reporting and parliamentary scrutiny has also been a matter of legitimate concern to this House and the other place, and amendment 11 speaks to this concern. As I explained in Committee, the Government are firmly committed to transparency in the use of public money. We have made this commitment plain in the Bill with a duty on the Secretary of State to lay a report before Parliament each year. This report will outline all payments made during the preceding financial year in respect of healthcare arrangements implemented by the Bill. I believe that this amendment directly addresses the concerns raised by hon. Members in Committee, particularly those raised by the hon. Member for Burnley. The nature and implementation of future reciprocal healthcare agreements is a matter for future negotiations. However, we envisage that through this reporting mechanism we would also be able to provide Parliament with further information on the operation of future agreements. For example, we anticipate that this report would include details of both expenditure and income to reflect the reciprocal nature of the agreements.
Before I speak to Government amendment 12, I am pleased to report that we have secured legislative consent motions from both the Scottish and Welsh Governments, in addition to having positive and productive engagement with colleagues in the Northern Ireland Department of Health and the Northern Ireland Office. I want to put on record my thanks to all of them. We have amended the Bill to reflect the outcome of our productive discussions, and the Secretary of State must now consult the relevant devolved authority before making regulations under clause 2(1) that contain any provision that is within the legislative competence of a devolved legislature. To underpin and facilitate this consultation, we have developed and agreed a memorandum of understanding with the devolved Administrations. The MOU sets out a practical and mutually beneficial working relationship that will ensure that the devolved Administrations continue to play a vital role in delivering reciprocal healthcare for the benefit of all UK nationals. We believe that this practical and pragmatic agreement allows us to move forward in a collaborative way with all our colleagues in the devolved Administrations.
The Minister will remember that, in our previous encounter on this matter in Committee, we asked him how far he had spread his discussions about the impact of this Bill in Northern Ireland. He was very honest and said that he had spoken mainly to officials and civil servants, and not to the politicians who represent the constituents there. Has he changed his mind about that, because that seems like a strangely narrow sort of consultation?
I do not think that it was narrow in the slightest. We have discussed matters with the Welsh and Scottish Governments and, given the situation in Northern Ireland, which the hon. Gentleman well knows, with the Northern Ireland civil service, the Northern Ireland Department of Health and the Northern Ireland Office here. I think that that is exactly what I said yesterday, and I am happy to repeat it.
Turning to amendment 15 and transparency, we have also amended the Bill to allow for further parliamentary scrutiny of the list of persons who can lawfully process data as a part of implementing new reciprocal healthcare arrangements under the Bill.
Finally, amendments 13 to 17 amount to the removal of the consequential Henry VIII powers from the Bill. It will come as no surprise to hon. Members that the inclusion of Henry VIII powers in this Bill has been the source of considerable debate both here and in the other place. The powers were initially included as a future-proofing mechanism. They were never free standing and were capable of being used only in a limited set of circumstances, because we cannot rule out that it may be appropriate to amend primary legislation to give effect to a reciprocal healthcare agreement. However, the Government have chosen to alleviate any fears that we are taking powers in this Bill that are not absolutely necessary, and we have taken the significant step of removing the entire Henry VIII consequential powers at clause 5(3) and within clause 5(4).
The Minister is being generous in giving way. He will be aware that even Henry VIII in his full pomp would not have got away with stealing the right to health cover of British citizens travelling on holiday to Europe or visiting on business without full democratic scrutiny of the decision. Henry VIII would have been pleased to have had that privilege. This Government have been smuggling the decision through, both in Committee and here in this empty Chamber, and they are stealing the rights of British people.
Given that I just said that we have accepted the amendment that would remove the powers, that argument is hardly powerful. I also suspect that the Opposition spokesperson and the other members of the Committee will be surprised to hear that they had not fulfilled their role when they sat through the hours of scrutiny in Committee.
In conclusion, I offer my thanks to hon. Members from across the House and to the Lords for its constructive work in scrutinising and improving this Bill. We share a common goal in wanting to ensure that we can continue to benefit from the current reciprocal healthcare schemes and benefit from similar arrangements in the future. This Bill is an important and necessary piece of legislation that seeks to ensure that the Government are ready and able to respond to different EU-exit scenarios and that we are in a position to support, as appropriate, people who rely on current EU reciprocal healthcare arrangements. For that reason, it is critical that we take those steps and that the Bill can become law.
I rise to support the Lords amendments before us. I thank all the Members who have worked on the Bill at various stages and the staff of the House, who have provided invaluable support. I also put on record my particular thanks to my hon. Friend the Member for Ellesmere Port and Neston (Justin Madders) for his great work during the Bill’s earlier stages. I also thank those in the lords for their exceptional work on this Bill. Thanks to their endeavours, we now have a Bill that is fit for purpose. I am pleased that the Government have decided to listen to our noble friends and give full support to the amended Bill, which marks a welcome, if rather belated, climbdown by the Government.
As we prepare to leave the European Union, it is vital that the Government are able to respond to the widest range of possible EU-exit outcomes in relation to reciprocal healthcare. So many people are reliant on the continuation of reciprocal arrangements and the Government are quite right to seek to secure such arrangements as we leave the EU. The Opposition have supported the principle of this Bill from the outset. but our concerns have been around the scope and the wide-ranging powers that were originally proposed. We were not happy to give the Government a blank cheque to enter into any number of health agreements, with anyone anywhere in world, with no requirement to report back to Parliament, and with little or no opportunity for parliamentary scrutiny. These amendments have addressed our concerns, and I again thank those in the lords for their work.
Turning to amendments 1, 2, 8, 10 and 18 to 20, I want to stress to the House the scale of the issue before us, as pointed out by my hon. Friend the Member for Huddersfield (Mr Sheerman), who is no longer in his seat. Under the existing arrangements, 190,000 UK state pensioners and their dependants who live abroad, principally in Ireland, Spain, France and Cyprus, enjoy the benefits of reciprocal health agreements. The current arrangements also provide full access through the EHIC to healthcare and emergency treatment for UK residents who visit the EU on holiday, to study or to work. The same protections are extended on a reciprocal basis to EU nationals who reside in the UK or who seek to visit. For the sake of those people, I am glad that the Government have come to their senses. These arrangements, which give full peace of mind for healthcare, must be protected.
I remind the House of the evidence given by representatives of Kidney Care UK. We heard that 29,000 people in the UK are dependent on dialysis, which involves three five-hour sessions per week to ensure survival. Under the current arrangements, if those people choose to holiday in the EU, they can easily pre-book slots for dialysis, with Kidney Care UK saying that that
“means that people are able to go away with the confidence that they will be able to be supported and receive the treatment they need.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 12, Q39.]
That also means that they and their families are able to get a much-needed break. Kidney Care UK also made the point that
“it is easier to go away for two weeks in Europe and take a break in that way than it is to get two weeks in a UK unit”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 14, Q43.]
Perhaps there is a learning point for us there.
Based on that evidence, the Minister concluded at the time that without a continuation of these arrangements it would be more or less impossible for sufferers of kidney disease to travel. I totally agree, and I am delighted that the Government appreciate the urgency of the situation in which we find ourselves and are giving their full support to this amended Bill. That is important because we may yet leave the EU with no deal, and there will be many British citizens listening nervously to this debate because they have already booked holidays—some of them will be departing at the weekend or in the coming weeks. However, they can now be reassured that the legislation will pass without further delay.
I reassure Baroness Chisholm that the main Opposition priority is always to ensure that those who need care get it. Further to that, we are right in the first instance to protect the rights that UK citizens already enjoy. In short, we must protect our rights to reciprocal healthcare in Europe before we seek to acquire global healthcare provision. Similarly, those UK citizens who have retired to the EU will be relieved to know that treatment for chronic health conditions and ongoing health support will continue to be provided for them, as it is now, without interruption.
If that was not the case because the Bill was unable to receive Royal Assent in a timely fashion, there would have been much understandable consternation and anger among UK citizens currently residing in the EU. A significant proportion of these citizens are pensioners, and they would have been personally liable for healthcare costs after exit day unless a new agreement with the EU or new bilateral agreements with member states were in place. We must also consider the fact that if there is an interruption in provision, many British expats would have no alternative but to return to the UK, which would of course add to the pressures on our already overstretched NHS.
At every stage, both here and in the other place, concerns have been raised about what those in the lords described as the breathtaking powers sought in this Bill. Lords amendments 3 to 7 serve in part to restrict the powers to those that are clearly defined and to those that are necessary for the purpose of protecting reciprocal health arrangements. In amendment 3, just removing the words “for example” assists in terms of essential accountability issues by restricting the powers of the Secretary of State to those regulations specifically listed. The powers listed remain extensive, and the lords was assured that they give the Government everything they need to take forward the negotiations on reciprocal healthcare. We welcome amendments 5 and 6, which ensure that the power to deliver functions is conferred only to a public authority. We are happy that the powers conferred by clause 2 should also be subject to a five-year sunset clause.
We support amendment 11, which provides an important and necessary requirement to consult with the devolved authorities, namely the Scottish Parliament, the Welsh Assembly and the Northern Ireland Assembly. We fully support the vital role that the devolved Administrations play in delivering reciprocal healthcare arrangements, and we welcome the memorandum of understanding that has already been achieved.
Amendment 12, which requires the Secretary of State to report on repayments made under this Bill, is also welcome. This amendment reasonably calls for annual reports to be published after the end of each financial year as soon as is reasonably practicable. It is anticipated that these reports will include details of both expenditure and income. This will facilitate transparency on the Government’s use of public money. I am especially pleased that the Minister has withdrawn his former opposition to that procedure.
On a wider point, in connection with repayments, it is important that we do not overlook the fact that many hospital trusts are struggling to recoup moneys owed under current EU arrangements. Indeed, some costs are never recovered. The UK recovers less than £50 million a year for the cost of treating European patients, while paying £675 million for the care of Britons in Europe.
The hon. Lady is pointing out the disparity in payments between the UK and the EU. Recognising that there are considerably more EU users of the NHS than UK users of health services on the continent, why is it that the Labour party, in the past, criticised the NHS and the Department of Health and Social Care for trying to recover sums due from EU citizens for taking advantage of our health service?
When talking about the disparity in numbers—there are more than 3 million European citizens here and approximately 1.5 million UK citizens there—is it not the case that the majority of EU citizens here are working and paying taxes and therefore are not covered by this system but are covered by the tax they already pay?
The hon. Lady makes an important point. I was referring to the fact identified by the Public Accounts Committee in its concerns about collecting what is due, but I take her point that many people pay for their own health provision while in the UK.
My point further reinforces the rationale of restricting the scope of this Bill to the EEA and Switzerland, which will help to ensure the priority is to improve the recovery of healthcare costs, where they are due, before we even begin to think of entering into non-EEA agreements.
We, of course, welcome the Government’s decision to remove the Henry VIII powers from this Bill. We repeatedly return to that issue in this raft of Brexit legislation, and I hope now, and certainly in connection with this Bill, that the Government agree it can never be right to confer on any Minister the same powers as are conferred on Parliament.
I understand that the Minister has a big vision and wants to take this opportunity to extend the current arrangements and to present a Bill that allows the Government to enter into any number of new reciprocal health agreements with any and every nation of the world, should they so choose. There could be a time and a place for such legislation, but it is not now because time is so short. There is not time for Parliament to scrutinise such an extensive range of proposals properly for such wide-ranging powers.
Our noble Friends raised some very reasonable concerns on that point, and they are correct to note the comments of the Delegated Powers and Regulatory Reform Committee when it concluded that the Bill, in its original form, gave law-making powers that were too wide. Our noble Friends were right to give serious consideration to the Constitution Committee’s recommendation that the scope of the Bill should be limited to countries that participate in the existing EHIC scheme:
“While the exceptional circumstances of the UK’s departure from the European Union might justify legislation containing broader powers than would otherwise be constitutionally acceptable, this does not extend to giving effect to new policy unrelated to Brexit.”
Above all, we now have a Bill that does what was intended: to ensure the continuation of the current reciprocal healthcare arrangements with the nations of the EU and the EEA. Given that that is the Bill’s principal target, there is no need to give the Bill worldwide scope.
I am pleased to join the Minister in giving our full support to the amended Bill before us.
It is a pleasure to be called to speak in this debate. I do not intend to detain the House long with my observations. I enjoyed the Minister’s introduction.
I welcome the Lords amendments, particularly the ones that change the thrust of the Bill to the EEA and Switzerland, but I hope that right hon. and hon. Members will bear in mind that, in the long run, the goal of having reciprocal healthcare arrangements with other nations is not a negative one in itself. I was disappointed yet again to hear from the right hon. Member for Carshalton and Wallington (Tom Brake) that this is all about opening up the NHS to the US health giants—it is not. It is about having reciprocal arrangements for visitors to other countries, including those on business and those who are travelling.
I meant it more as a comment. I accept the Lords amendments. To be blunt, given the pressure of time and the need to get the Bill on the statute book to give people certainty about their healthcare arrangements, if these amendments achieve consensus with Opposition Front Benchers and the other place, I am more than happy to support them.
In relation to the remarks of the right hon. Member for Carshalton and Wallington, who sadly has not stayed for the rest of the debate, this is about making sure that people who go to hospital to access emergency care are not suddenly faced with a bill for the full cost as if they were completely uninsured.
We have arrangements with Australia and New Zealand that are not at the same level as we have with other EU countries, but they could potentially be developed. I do not want to see that aspiration lost, because we want our young people to have the opportunity to travel and work abroad where appropriate. In many countries, as the hon. Member for Central Ayrshire (Dr Whitford) rightly said, people who work will start earning rights under that country’s social insurance system, which would trump the Bill.
My hon. Friend is generous in giving way. In talking about other Commonwealth nations to which we would like to extend such arrangements, does he agree that the dominions of the Channel Islands, which do not currently have reciprocal status with the UK, should not be ignored and should be a matter of importance once the EU arrangements have been completed?
As always, I thank my right hon. Friend for his incisive intervention. The Channel Islands might use our currency and, in many ways, fly our flag, but people forget they have a very different constitutional status and are not part of the European Union. For some visitors, it can be a surprise that there is not a reciprocal agreement. There is a reciprocal arrangement with Gibraltar, for example, and it makes eminent sense to try to have such an arrangement between the UK and the Channel Islands, not least given the strong cultural links and the fact that many families split their time between the mainland and the islands.
Looking across the Commonwealth more widely, it might make sense to have arrangements with countries such as Canada and Jamaica in the long run, based on the fact that they have comparable systems of healthcare provision. That is perhaps where the oft-cited example of the United States starts to fall apart, because it is one of the handful of modern, developed countries that do not have a guaranteed system of universal healthcare free at the point of need rather than a system based on insurance schemes for which people may pay.
It is welcome to have ambition, and the Bill is clear about where we are going. I have no problems with the Lords amendments, which are welcome, and I am happy to support them. I am conscious that we are looking to move the debate forward, but I wanted to get those thoughts on the record.
Obviously, the Bill itself is quite small. It does not extend or protect continuing reciprocal healthcare rights; it is simply an enabling Bill that gives the Secretary of State powers to try to do that. It enables him to pay for overseas treatment in the EEA and Switzerland. We have heard how the Lords removed the powers to extend that worldwide and increase the scope, as well as limiting some of the Henry VIII powers.
The Bill will allow the Secretary of State and his team to negotiate healthcare agreements with the EEA and Switzerland as a group through the EU system or, failing that, to make bilateral agreements. Unfortunately, that would mean having bilateral agreements with 31 countries, which would inevitably be more complex, more bureaucratic and more expensive.
Clause 4 allows data exchange, which most Members would recognise is absolutely critical not just for collecting payments or swapping money, but for accessing medical health records if someone goes for treatment in another country. It is important that that will be handled only by an authorised person who is part of a statutory body—a public body.
I welcome the new clause in Lords amendment 11, which says that the devolved Governments must be consulted, because it is the three devolved Governments who deliver healthcare in Wales, Northern Ireland and Scotland. It is critical that they are involved in any agreements.
This legislation is needed whether there is a deal or no deal. As came out of the points of order exchange earlier, the withdrawal agreement would extend through the transition period, but we have all seen how the last three years have melted away like snow off a dyke. The next 20 months will also disappear, so legislation is required for the long-term protection of those who already live in Europe and want to stay there, particularly those who have been there only a few years and do not have five years-worth of residency rights in the country they have chosen to settle in. After the Bill is passed, it is therefore important that the Government hope to negotiate the continuation of reciprocal healthcare.
The problem is that reciprocal healthcare is not a free-standing thing on its own; it is there simply to enable freedom of movement. People cannot exercise their freedom of movement rights if they simply cannot afford healthcare where they choose to live, work, love, settle or retire. We have had the right over the past few decades to retire and settle anywhere. People are well aware of my husband’s situation as a German citizen who lives here and has spent virtually all his adult life working in our health system. That was certainly his first concern after the Brexit vote, and I am sure it is a concern for all 5 million people who have either settled here from Europe or settled in Europe from the UK.
The problem is that, as the Government reject freedom of movement and talk merely about a mobility framework, any reciprocal arrangement is likely to be proportional to that mobility framework, as is described in the impact assessment. The Government are not offering visas of over a year for unskilled workers. They are demanding that people be high skilled, possibly that they earn more than £30,000 a year and that they are economically active and are contributors. Will pensioners still be able to retire elsewhere, since they are not necessarily contributors in a major sense and are certainly not necessarily economically active?
People highlight the difference between what the UK has to pay into the European system and what we get back from Europe. A lot of that difference is quite simply because of the number of UK pensioners who choose to retire to sunnier climes—who can blame them?—and the general lack of obsession with retiring to the drizzle and moving in the other direction. Living in Scotland, I can vouch for that. Who would choose to leave the south of France and come to live in the mist, fog and drizzle? That is why the number of European pensioners retiring to the UK is considerably smaller than the number of UK pensioners who retire to the south of Spain and the south of France. That is simple logic.
The right hon. Gentleman probably would not like me to get into the clearances of the 17th and 18th centuries when people were burnt out of their villages and put on boats, or when people were transported for criminal activities. There are all sorts of reasons why Scots have ended up all over the world, and they are not all about the weather.
That is why I live there, right beside the sea, but that does not necessarily mean that somebody living in the vineyards of France will think, “You know what? The weather’s a bit boring here. I fancy somewhere with snow, sleet, hail and sunshine all in one day.”
It is a fact that the disparity is because of the number of pensioners. It is often described as if it is the EU somehow tricking the UK—it simply is not. We are obliged to pay for the pensioners from the UK who have settled in Europe. Indeed, we pay a fixed rate per head that is considerably lower than—just over half—what would be charged for a European citizen settling here.
Does the hon. Lady agree that another reason for the disparity is that the NHS, in being free at the point of need, has not over the years been as geared up as other countries for recording the patient episodes of EU nationals and collecting that kind of data? Because it is not an insurance-based system but is free at the point of delivery, it does not necessarily have the mindset or the paperwork to think about healthcare in terms of money.
I totally agree that that is part of it. The Government have to consider, given the numbers involved, whether creating that entire administrative system will bring more money back in than is spent on administering it.
It is important to consider exactly how we will expect doctors and other health staff to demand to see someone’s settled status. Will it be based on a foreign sounding name, a skin colour or an accent? Will people have to produce an ID card if they were born here, they grew up here, they have never been anywhere else and their family are 20 generations English? That is the point: there is no ID card here. In other European countries, there is an ID card and it will show that UK citizens have whatever the equivalent of settled status is. I think doctors and others are anxious about the circumstances in which they should ask for proof of habitual residency.
We see that already in respect of universal credit. I have dealt with a German lady who has been settled here for 30 years and who was refused universal credit on the basis that she was not habitually resident. We are already seeing these things, and we do not want to see them around healthcare.
As we have heard, there are three main groups. The biggest group is the almost 200,000 pensioners using their S1 rights to register somewhere they have never paid tax—and yet they benefit as if they have. It is important that their rights continue, or they may end up having to come back home. They would cost more here than the Government are paying France or Spain to deliver their healthcare. It is important that they are not limited in some way, so that only people who do not have medical health risks are accepted, as happens with insurance. Ordinary pensioners who have exercised those rights would simply not be able to afford comprehensive private health insurance.
A lot of work is being done to protect those who have settled already, but what about the rest of us, who might fancy settling in the south of France or Spain? Will this be achievable by ordinary pensioners in the future?
Approximately 1,300 UK citizens use S2 forms for planned treatment, and the biggest number is the 250,000 claims a year that are made through the EHIC card, which allows people to travel or study all over the EU. As the hon. Member for Burnley (Julie Cooper) said, that includes people with expensive chronic conditions that require treatment such as dialysis three times a week. I defy any Member to find affordable health insurance that would cover such treatment. That is not a risk of healthcare, but planned healthcare, otherwise the trip simply cannot be made.
As I mentioned earlier, that should not be extrapolated to EU citizens who live here or UK citizens who live and work in Europe. If they already pay full tax and national insurance here, or the equivalent in Europe, they qualify through those payments, and the UK does not currently reimburse those countries.
The withdrawal agreement Bill only covers transition. It does not go beyond that. The problem is the prospect of no deal, which is still hovering over our heads. It is therefore important that the Government negotiate, but recognise that provision may well be on a much more limited basis. Reciprocal healthcare was not designed around a stag weekend in Prague, but to facilitate freedom of movement.
For me, the Bill highlights what we are losing with Brexit. We are losing freedom of movement, which has often been described from the Dispatch Box as something negative, the end of which we should celebrate. It is actually one of the greatest benefits that we as individual citizens have had from being in the European Union, and it works both ways. We all know people who have worked or studied in Europe; those who have met people from Europe and settled there, or those whose partners have settled here. Free movement has been a great contributor to friendship and love across Europe. The problem is that those rights cannot be exercised unless healthcare can be afforded.
We will not vote against the Lords amendments—they are necessary; the work needs to get done—but it still makes me sad, because all the measure does is highlight what we are losing.
It is a pleasure to speak in this debate—from the Back Benches on this occasion. Although I would have preferred to contribute from the Front Bench as I did during previous stages of the Bill, the Opposition are in safe hands, thanks to my hon. Friend the Member for Burnley (Julie Cooper).
It is curious that both the Minister who led for the Government on Second Reading and I, as Opposition spokesperson, have moved on since then, him to become Brexit Secretary and me to become a Back Bencher. We could have a debate—perhaps even a Division—on who got the better deal.
However, perhaps most curious is that, along the way, the measure has gone from being an international arrangements Bill to an EEA and Swiss arrangements Bill. I have been here for only four years, but I have never heard of a Bill changing its name—but then before this year, I had never heard of Cabinet Ministers breaking collective responsibility and staying in their job, or Parliament taking control of the Order Paper. There are obviously many other examples of the strange times we live in, and this is just another curiosity to add to the list.
The Lords amendments pick up on many of the anxieties we expressed previously about the implications of the sweeping powers in the Bill. I pay tribute to Baroness Thornton and her team who have obviously got greater powers of persuasion than us. They have come up with a series of amendments that rightly curtail the breathtaking powers the Government sought to claim for themselves.
When the Bill began its progress in November, there was a clear assumption on the part of the Government that agreement with the EU would have been reached by now and that arrangements would be in place to carry on very much as we are, at least in the interim period. That in itself raised serious questions about why the scope of the Bill was so wide, and it would not be an understatement to say that the orderly exit envisaged at the time is now not quite so certain. That makes it all the more important that we have a Bill with proportionality and transparency at its heart.
It is worth reminding ourselves that when the Bill first surfaced, the Delegated Powers and Regulatory Reform Committee in the other place set out very clearly its potential impact if it remained unamended. It said that the measure gave the Secretary of State the power to fund the cost of all mental health provision in the state of Arizona, or the cost of all hip replacements in Australia. Although we pushed the Minister on the reason for the need for such wide powers—accepting of course that they would be unlikely ever to be used—the only justification given was that they might prove useful at some future time in trade deals. Although that might be the case, without a clear objective, debated and agreed in Parliament, the powers were unnecessarily broad, so it is right that the Lords raised those concerns and amended the Bill accordingly.
We all have constituents who regularly raise concerns about access to the NHS being used as a bargaining chip in trade negotiations. If the Bill had remained unamended, it would only have given those people more reason to be concerned about such deals. Restricting its scope to EEA countries and Switzerland is therefore proportionate and sensible.
I want to say a few words about amendment 12, which is very similar to an amendment that the Opposition tabled in Committee. It deserves support because even under the current arrangements, cost recovery has not always been handled satisfactorily. Indeed, the Public Accounts Committee described it as “chaotic”. The Law Society of Scotland was clear on the importance of that issue when it gave evidence to the Lords Committee. It said that
“as the NHS has never been very effective in reclaiming the fees owed to it by overseas visitors to the UK, the UK may find itself substantially worse off financially when new arrangements for funding cross-national use of health services are put in place.”
The case for greater accountability is there and has been strengthened by the Government’s impact assessment, which seemed to seriously underestimate the consequences of a no-deal scenario. It set out that the cost of establishing future reciprocal healthcare arrangements on the same basis as now would be £630 million a year, but it went on to estimate that, in the event of a no-deal scenario, the costs are expected
“to be similar or less, depending on the number of schemes that are established.”
I do not think it has ever been clear why the costs might be less unless we stopped reciprocating with some countries, and I do not believe that has ever been an express policy objective of the Government. In fact, they have often—rightly—said the opposite, but the reality is that, in that scenario, the costs could be significantly higher. Both the BMA and Royal College of Paediatrics and Child Health stated that if no EU-wide reciprocal agreement was achievable, the significant extra costs of establishing bilateral reciprocal arrangements with EU and EEA countries in future could fall on the NHS. We need, but have never had, a commitment that, in those circumstances, any extra costs would not be borne directly by NHS trusts. I hope that today the Minister can give such an assurance.
The Lords picked up on a related issue, which we have raised previously, on the lack of clarity about how dispute resolution will work in the event of bilateral agreements being necessary. We know from what the Minister has previously told us that, if we manage to reach full agreement with the EU27, there will still be a limited role for the European Court of Justice, but we do not know what the dispute resolution procedure will be if we do not.
The Lords rightly pointed out that there would be little incentive for other countries to agree to a brand new dispute resolution procedure, and they would certainly be loth to do that if they were expected to pay for it, so in the event of a no-deal scenario, is it not the case that there will be significant additional costs for the UK taxpayer in setting up and resourcing a new dispute resolution scheme? Does the Minister envisage those costs being part of the reporting requirements under amendment 12 and again, can he give a commitment today that those costs will not be directly borne by NHS trusts?
The Bill is in a much better condition than when it started. It does what it is supposed to do, and no more. Crucially, it gives much greater parliamentary oversight than we originally had. I think it is called taking back control.
Lords amendment 1 agreed to.
Lords amendments 2, 8 to 10, 18 to 20, 3 to 7 and 11 to 17 agreed to.
Offensive Weapons Bill (Money)
Queen’s recommendation signified.
That, for the purposes of any Act resulting from the Offensive Weapons Bill, it is expedient to authorise the payment out of money provided by Parliament of any increase attributable to the Act in the sums payable under any other Act out of money so provided.—(Amanda Milling.)
Offensive Weapons Bill (Programme) (No. 3)
Motion made, and Question put forthwith (Standing Order No. 83A(7)),
That the following provisions shall apply to the Offensive Weapons Bill for the purpose of supplementing the Orders of 27 June 2018 (Offensive Weapons Bill (Programme)) and 28 November 2018 (Offensive Weapons Bill (Programme) (No. 2)):
Consideration of Lords Amendments
(1) Proceedings on consideration of Lords Amendments shall (so far as not previously concluded) be brought to a conclusion two hours after their commencement at today’s sitting.
(2) The proceedings shall be taken in the following order: Lords Amendments Nos. 27, 28, 1 to 26 and 29 to 95.
(3) Any further Message from the Lords may be considered forthwith without any Question being put.
(4) The proceedings on any further Message from the Lords shall (so far as not previously concluded) be brought to a conclusion one hour after their commencement.—(Amanda Milling.)
Question agreed to.