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Brexit: Reciprocal Healthcare (European Union Committee Report)

Volume 792: debated on Tuesday 3 July 2018

Motion to Take Note

Moved by

That this House takes note of the Report from the European Union Committee Brexit: reciprocal healthcare (13th Report, HL Paper 107).

My Lords, I have the honour to chair the EU Home Affairs Sub-Committee, which produced this report, and I thank the members and staff of the sub-committee and our excellent specialist adviser, Tamara Hervey, for their support and advice. Perhaps I should say at this point that I have little doubt that if Gareth Southgate had known that, by losing to Belgium, England’s next match in the World Cup would coincide with this debate, he would not have rested Harry Kane and the result of the Belgium match would have been different—but we are where we are.

I think that we would all agree that reciprocal healthcare is one of the great benefits of our European Union membership. We almost take it for granted that, when travelling, we can access emergency care free of charge, or that we can retire to another EU country and rely on continuing to receive care on similar terms to that offered by the NHS. But, as in so many other areas, Brexit means that we now have to go back to the drawing board.

This inquiry was launched last autumn, when the overriding concern of our witnesses was over the status of UK and EU nationals who had already exercised their right to free movement—the 3 million or so EU nationals resident in the UK, and the more than 1 million UK citizens, many of them elderly, vulnerable or in poor health, who live in the EU 27. We heard compelling evidence of the fears felt by these people, most of whom, let us not forget, had no vote in the referendum.

Happily, the agreement set out in December’s joint report, and embodied in the draft withdrawal agreement published by the Commission on 28 February, has allayed many of those fears. Perhaps that reassurance could have been offered earlier, but it would be churlish not to pay tribute to those who reached what was, in respect of citizens’ rights, a largely satisfactory outcome.

Since the December joint report, the tone of the Government’s statements about citizens’ rights has been increasingly positive. This is exemplified by the Government’s response to our report, published on 13 June, which begins with confirmation that safeguarding citizens’ rights is a “top priority” for the Government. It also says:

“It is vital that NHS treatment is always available to those who need it”,

including EU citizens. Taken alongside the Home Office’s recent announcement about the process for acquiring settled status, this is good news. I take this opportunity to thank the department for supplying such a considered response, and thank the Minister, the noble Lord, Lord O’Shaughnessy, for the support he personally gave us throughout our inquiry.

So much for the good news. The more difficult issues relate to the long-term UK-EU relationship. Here the government response is thinner—perhaps not surprisingly, given that a White Paper on the future relationship is expected next week. However, it restates the Government’s wish to retain in any future agreement the key benefits of reciprocal healthcare. These are described as: first,

“the rights of UK state pensioners who retire to the EU (and vice versa) … to benefit from a reciprocal healthcare scheme”;


“the rights of UK residents to continue to receive needs-arising treatment in the EU under the EHIC scheme (and vice versa)”;

and, thirdly,

“the rights of UK residents to be able to receive planned treatment in an EU Member State when this is pre-authorised by the UK (and vice versa)”.

That list begs a few questions, which I hope the Minister will be able to address at the end of the debate.

The over-arching point is that contained in paragraph 75 of our report. Reciprocal healthcare rights in the EU do not exist in isolation; they exist to remove barriers to the free movement of people. So it is difficult to square the department’s laudable ambition to maintain such rights with the Government’s overriding objective of bringing free movement to an end. The government response, at page 9, states:

“Freedom of movement is ending but there will continue to be migration and mobility between the UK and the EU after the UK leaves”.

That is the crux of the issue and, while I acknowledge the Government’s point that there are agreements covering access to emergency healthcare with other countries, such as Australia and New Zealand, those agreements are simply not comparable in scope or depth to the comprehensive arrangements in place in the EU and the EEA.

I fully support the Government’s underlying goal, but I can almost hear the accusations of cherry picking that will be made when the Government propose continuing UK participation in this specific component of the free movement framework. How will the Government address such concerns? It is also notable that, in the passage I have quoted, the Government do not refer to the S1 and S2 schemes as such. They refer only to UK state pensioners, who are the primary beneficiaries of the S1 scheme, but the scheme is more widely drawn than that, covering, for instance, posted workers. Later in the response, however, the Government state that they will,

“seek UK participation in the EHIC, S1 and S2 schemes as a non-EU Member State”.

Can the Minister confirm that the Government will seek to replicate the full scope of the S1 scheme in any future agreement?

There is also the unfinished business of onward free movement rights. As things stand, UK citizens also resident in an EU 27 country will, under the terms of the withdrawal agreement, have their reciprocal healthcare rights protected, but they will lose those rights if they move to another EU state. That may not be an issue for UK pensioners who have retired to Spain, but it is a serious issue for UK citizens of working age who are pursuing careers and raising families in the EU.

The government response identifies this as an important issue, and underlines that the UK “pushed strongly” for it to be included in the withdrawal agreement. I should add that the European Parliament has also lobbied strongly for onward free movement rights for UK citizens to be guaranteed. The logic of the Government’s position, I think, is that it would be addressed in the context of proposed UK participation in the S1, S2 and EHIC schemes. Is that correct, or do the Government envisage a separate agreement specifically relating to UK citizens already resident in the EU—a sort of “citizens’ rights plus” agreement?

We have a long way to go and time is short. The agreement last December was a key milestone, and I hope the Minister can confirm that there will be no back-tracking on citizens’ rights. But, since March, when the last iteration of the draft withdrawal agreement was published, progress seems to have ground to a halt. We all hope that next week’s White Paper will get us back on track but, if it is to do that, it needs to be realistic, detailed and specific. No doubt, that is what the meeting on Friday at Chequers will be discussing. Simply restating the Government’s desire to maintain the status quo on reciprocal healthcare, without acknowledging the legal and political challenges—and suggesting ways to overcome them—will not be enough.

I do not expect the Minister to divulge the details of the White Paper this evening, but I hope he will at least persuade us that the Government are approaching their task in the right spirit. I beg to move.

My Lords, I thank my noble friend Lord Jay—I use that term advisedly, as he chaired our committee with great skill—for securing and introducing this debate.

It is clear that the major issue still to be resolved in the Brexit negotiations is the border arrangements between Northern Ireland and Ireland. From a medical perspective, that border does not exist and healthcare has been freely exchanged for some time. Indeed, it predates the UK and Ireland joining the EU.

In my role as secretary of the Association of Surgeons of Great Britain and Ireland in the early 1990s, I met a young trainee surgeon in Dublin who was blazing a trail for the adoption of laparoscopic surgery for gall-bladder disease and hernia repairs. He subsequently transferred to the Central Middlesex Hospital as a consultant general surgeon and, soon after, was invited to become professor of surgery at St Mary’s Hospital in London. That surgeon was the noble Lord, Lord Darzi, from whom we will hear more on Thursday when he presents the debate on the NHS at 70.

Free movement of people allowed many surgical trainees to gain experience of laparoscopic surgery in Ireland. This was to the benefit of the UK, which was a little slower to adopt the technique of laparoscopic cholecystectomy. Free movement is a two-edged sword and, as our report demonstrates, children in Belfast have benefited from having their cardiac surgery performed in Dublin after the service ceased in Belfast in 2015. They are now in the all-Ireland children’s heart surgery centre.

Here I must declare an interest. When I was chairman of the Independent Reconfiguration Panel, we reviewed the report of the Joint Committee of Primary Care Trusts on children’s heart surgery in England. The report was called Safe and Sustainable and was published in 2012. It proposed a mandatory standard of four full-time surgeons and 400 paediatric surgical procedures per centre, driving a need for reconfiguring services. We concluded that centres providing surgery and interventional cardiology must have,

“at least four full-time consultant … surgeons”,

to provide,

“comprehensive … round the clock care, training and research”.

Although the Joint Committee of PCTs found the unit at the Royal in Belfast safe, it was not sustainable. The decision to centralise on one site in Dublin justifies its recommendations at the time.

In our report on reciprocal healthcare, we noted that there were probably as many people using directly agreed services through bilateral arrangements as there were using the EHIC, S1, S2 or patient rights’ directive. Services across the border serve both communities and reach enough patients to achieve economies of scale, and make it possible to recruit consultants to work in rural areas and communities which, on their own, would not justify a consultant appointment. I can testify to this, having visited Northern Ireland as president of the Royal College of Surgeons and seen the services provided at that time.

We also noted that joint services included oral and maxillo-facial services and a radiotherapy centre at the Altnagelvin Hospital, which opened in 2016 and was co-funded and co-planned by both jurisdictions. This form of co-operation would be threatened by a lack of agreement in the run-up to Brexit. One of our witnesses, Ms Bernie McCrory, described how co-operation in the ENT services had led to improved access to healthcare on both sides of the border. As is quoted in our report, she said:

“Children were waiting for maybe four years for their first appointment if they had hearing difficulties, with all of the problems that that would have thrown up education-wise and so on. There was a very robust ENT service in the southern trust in Northern Ireland where we had four ENT surgeons working on a rota. The EU money allowed us to employ two more ENT surgeons. The surgeons rotated into the south of Ireland, into Monaghan, where they did out-patient and day-case work. Then the patients travelled to Northern Ireland, to Craigavon and Daisy Hill Hospitals in the southern trust, to receive more complex surgeries that were not possible in a small rural hospital … [In 2016] 155 patients travelled from the south of Ireland to Northern Ireland for complex surgery, but the consultants who travelled down to the Republic saw over 2,000 patients in both out-patient and day-case procedures”.

We also heard evidence of how patients’ lives have been saved because of free and open access to emergency services across the border. They made the case for not returning to the bad old days of the Troubles when ambulances would park on one side of the border while the patient was transferred across to another ambulance on the other side. The Belfast agreement took years to broker and cross-border healthcare was described as one of the success stories of the Good Friday agreement. Surely nothing should be done to jeopardise this agreement. I know that my noble friend the Minister and the Government share this view.

The December joint report acknowledges the importance of these cross-border arrangements on health and notes that,

“the UK and Ireland may continue to make arrangements between themselves relating to the movement of persons between their territories (Common Travel Area)”—

the CTA predates our EU membership. We urge the Government to avoid such a hard border for patients and the health professionals who treat them. The continued access under the CTA to emergency, routine and planned care must continue if we are not to destabilise healthcare in the border areas. It is therefore not surprising that our report asks for healthcare to be treated as a priority in the negotiations on the island of Ireland, and the future relations between the EU and the UK.

In parallel to this report, we also took evidence on the impact of leaving the Euratom treaty and how this would affect the movement of radioisotopes, which we rely on for diagnosis and therapeutic treatments. There are some 700,000 nuclear medicinal procedures per year in the case of technetium-99m, which is used in 80% of all diagnostic procedures. We flagged up the importance of developing a new generation of alpha and beta-emitting isotopes for cancer treatment to mitigate any possible interruptions to treatments through delays at the ports, mindful that some radioisotopes have a short shelf life. I would like to ask my noble friend the Minister what the UK is doing to accelerate cyclotron production, in addition to the proposed new plant by Alliance Medical, which the Minister referred to in his letter dated 1 March to the noble Lord, Lord Jay.

Another form of treatment is proton beam cancer treatment. This begins at the Christie hospital in Manchester this August and is a first in the UK, with the University College Hospital in London following in 2020. Hopefully, this will prevent patients such as Ashya King being transferred from Southampton to Prague for treatment—if your Lordships recall, that caused quite a hullabaloo in this country. Can my noble friend say when we can expect more of these to mitigate the impact of leaving the EU and in the event that the S2 arrangements fail to be honoured? After all, nothing is agreed until everything is agreed, but it is difficult to see how we can secure reciprocal healthcare while we continue to oppose freedom of movement of people from the EU, as my noble friend pointed out.

My Lords, it is a privilege to speak to this report. I pay tribute to the noble Lord, Lord Jay, and to his diplomatic skills in putting such a positive face on yet another report on Brexit, which again faces us with very worrying findings. I also thank the committee members and staff for their contributions; the staff provided us with very high-quality support.

In the words of one of our witnesses, Raj Jethwa, director of policy at the BMA,

“the best situation is one in which you are able to replicate or mirror as closely as possible the current reciprocal arrangements”.

So for many people it is a something of a “mad riddle”—to quote another recent discussion of Brexit—to understand quite how so much time, money and effort are being devoted to achieving something as close as possible to what we have already. Worse still, having taken part in this inquiry, I realise that lots of people simply have no idea of the risks ahead in healthcare post Brexit.

I add my thanks to the Minister, who has clearly attempted to reassure us and has put quite a lot of time into doing so. As such, I do not doubt his motives in any way; I am sure he wants to achieve the best possible solution. The report, however, provides us with a clear picture of the enormous benefits that have accrued to us as members of the EU.

There are the four routes to healthcare in the EU. First, the European health insurance card allows freedom of movement and access to healthcare wherever we might be. For holidaymakers and workers alike, there is no problem in accessing care or medicine. Secondly, the S1 scheme for people who live in the EU provides a simple, easy, accessible system. I am old enough to have lived in Europe before the EU. The system that existed before was so complicated and difficult that many people came home to the UK to get treatment where they could, rather than try to access it in Europe. Thirdly, there is the S2 scheme, which entitles British people to be referred to a specialist provider for treatment. Fourthly, the parent’s right directive gives British people the right to access high-quality treatment in the EU, particularly that which is unavailable in their own country, and to have the cost reimbursed. We often find that cheaper treatment for UK residents can be found in the EU than in the NHS. The average cost per pensioner has recently been calculated at €4.173 in Spain, as against £4.396 under the NHS, so there is even a savings benefit.

The noble Lord, Lord Ribeiro, spoke about Northern Ireland. I, too, was particularly moved to hear of the improvements and not just the peace dividend but the health dividend that has resulted from cross-border working, close co-provision and co-planning and, on an island as sparsely populated as Ireland, the absolute need to access high-quality healthcare, which had not been available before. The noble Lord also talked about children waiting four years for ear, nose and throat treatment, with all the ensuing difficulties that that entailed for their development. So there are enormous benefits.

I welcome the joint report, which tells us that the Government want the common travel area to continue, and the assurances that there will be no hard border. However, this gives rise to quite a few questions. I am sure that many people I know are unaware that the EHIC system is even at risk, but if it does not exist after March, can the Minister tell us about some of the issues that people will face over insurance? In the report, the insurance industry tells us that it is not completely prepared for a major impact of this kind after Brexit. How can families deal with this? What will the cost be for pensioners and people with long-standing illnesses? How will they be able to afford insurance and how much more will their holiday cost?

If we are to keep the common travel area—I understand that, as people say, nothing is agreed until everything is agreed—how will it happen? How exactly will this work with the red line of no freedom of movement and with the Government saying, as the Minister said yesterday, that there will be no barrier between Ireland and the EU? People need confidence; they need to understand what is going to happen and they need to make their own plans.

We heard Simon Stevens on “The Andrew Marr Show” on Sunday saying that the NHS is now planning contingencies for a no-deal scenario. This was one of the things we were assured: that there will not be a no-deal scenario. However, when we hear that the NHS is planning for this, it must raise all sorts of worries. The Government need to come clean with people, let them know what the risks are and let them understand what we are facing. All these things take time to resolve. They cannot be changed overnight or a magic wand easily waved so that everything will be as it was before. People need to know this. There is a huge lack of trust as these effects seem to come out slowly and have to be dragged out, whereas if people were able to understand that there were these risks, they could make their own plans for them. As the clock ticks, we can see that there is an urgent need for the Government to lead and reveal their plans; to make clear the extent of the shortfall in healthcare; and to let members of the public know what they can expect in terms of healthcare after March and after Brexit.

My Lords, I begin by thanking the chairman and the members of the committee, of which I am not one, so I hope my intrusion will be forgiven.

On Thursday your Lordships will debate the 70th birthday of the NHS—it is just slightly younger than I am. Evidently it is one of the great post-war success stories but 45 of its 70 years have been spent inside the European Union. Over those 70 years, we have seen a continuing internationalisation of medicine and Europe working together more and more. I spent some 25 years in the European Parliament and represented the great teaching hospitals of Guy’s and St Thomas’ and had dealings with them from time to time. There was never a straightforward medical role for the European Union, but it was certainly involved in medical priorities.

The NHS is probably the best-loved child of the Attlee Government and probably a beneficial outcome of the Second World War. Throughout the Second World War, the first thing that people realised was that you had to have an efficient health service. You could not have people bombed out of their houses without adequate medical care. The predecessors of the NHS—people like Ernest Brown, the wartime Health Minister—did a lot to set down the parameters within which the health service has existed.

As we know, it is quite different from continental health systems. Having had a residence in Brussels for the better part of 40 years, I have had dealings with both the Belgian and French systems, which are pretty good and comprehensive. We see a lot of figures and tables, and I noticed one this morning in which we are just behind France in what we spend. However, they seldom take account of the insurance costs and the cost of running the insurance schemes. Every time you go to the doctor in Belgium, you do not pay much but you generate a lot of paper. You fill in a form; you part with €40; the doctor fills in a form to claim back the money; then you fill in a form to claim back about €35 of the €40 using yet another form which the doctor has given you. I am sure that the Minister will be aware of the cost of running an insurance-based scheme. It is certainly a factor which we need to keep in mind when we look at European schemes and how we can benefit from them. One direct benefit from the European Union that I was involved in was its funding of videos which were made by doctors at Guy’s Hospital in London who were doing certain operations, mainly on joints. These were then used to teach doctors in Portugal. It was remote learning of a kind which would now be done more easily with Skype, but even in the 1980s we had reciprocal healthcare and that has been quite a success story.

The NHS itself is a success story and one of the reasons for this is that the middle class supported it. It is a universal service and middle-class intervention has been quite crucial. This all leads me to the point that there is a lot of concern about Brexit and a desire that it should not impede the rights of citizens. If it does, there will, to put it crudely, be a lot of trouble. Europe is far too small not to have reciprocal healthcare arrangements. They are an absolute necessity. On page 6 of the government response to the report it states:

“The UK Government and the Commission have stated that providing certainty for citizens was a priority and we believe it would be unlikely for any deal on citizens’ rights agreed early on to be reopened”.

However, recommendation 4 states quite clearly that,

“nothing is agreed until everything is agreed”,

as we keep learning. In other words, it may be unlikely to be reopened, but it will be if there is no agreement. Leaving the EU without an agreement, as is the wish of some of the more extreme supporters of Brexit, would mean no healthcare cover for UK citizens abroad or for EU citizens here, presumably. I am quite sure that there would be a scramble to get some emergency measures in place, but that is not the best way of making public policy.

The noble Baroness, Lady Janke, referred to the interview with Simon Stevens on Sunday, repeated in the Times, which said:

“NHS prepares for no-deal drug and doctor shortage”.

The article outlined the problems potentially facing the NHS, including a worst-case scenario of hospitals running out of medicines in just two weeks, and the fact that it is now planning. Apparently 37 million packs of medicine arrive in the UK from the EU every month, with 45 million going back the other way. There is a very big common market in drugs. When Simon Stevens, CEO of NHS England, says that “extensive work” for a no-deal scenario is being done in collaboration with the pharmaceutical industry, I need to ask the Minister when he will be in a position to tell us about the nature of this extensive work. Although it is not his direct responsibility, has he been in contact with the devolved Administrations and are they also doing “extensive work”?

Paragraph 11 of the report’s conclusions asks the Government,

“to confirm how it will seek to protect reciprocal rights to healthcare of all UK and EU citizens post Brexit”.

In their response, the Government state that they want,

“a wider agreement with the EU on reciprocal healthcare into the future”.

Of course we do, but how are we going to get this alongside ending free movement? This is all part of a package. What is the status of current negotiations in pursuit of this wider agreement? Are they currently ongoing, and which department is in the lead—DExEU or Health and Social Care? Again, are the devolved Administrations involved, and how are they being co-ordinated?

Finally, it is clear from the briefings that I and other noble Lords have received that there is still much work to be done with regard to the position of reciprocal healthcare if the Government carry out their intention to end free movement. We need to prioritise access to reciprocal healthcare and we need a realistic assessment as to whether ending free movement is necessary or desirable. Simon Stevens has drawn attention to the fact that 10% of NHS doctors and 7% of nurses are nationals of other EU member states. This supply is apparently drying up because they do not have the confidence to come and work here. A solution is clearly needed, as is devising a retention strategy for the staff who are here.

I will make a prediction to the Minister. Being a bit of a cynic, I have said all along that Britain will end up in a Norway situation. We will be within the single market; we will have free movement, maybe with a minor concession at the edges; we will pay a very large bill; we will need extra staff in our embassy in Brussels to keep an eye on things. We will be represented at none of the meetings but will be subject to all of the decisions. That is the direction in which we are going. I finish with an absolutely true story. A year ago, I was in a ministry in Norway, talking to the Minister. He said: “You are going to find it is really difficult. We find it difficult in Norway, but at least we have got a direct line to Sweden and we are roughly the same size as them. Sweden and Norway have a long tradition of working together”. He went on to say: “The only other English-speaking country you have to fall back on is Ireland. Your relations are not quite as close with them, and there are a lot of problems that you are going to have to solve”. When we are outside the tent, so to speak, we are going to have far more difficulties in getting influence than Norway. I hope that I am wrong, but I fear I am right.

My Lords, I have no Nordic stories to offer in succession to the noble Lord. I had the privilege of joining the sub-committee part way through this inquiry, under the chairmanship of the noble Lord, Lord Jay. I support the report: it is very good and clear, and the staff did a very good job in summarising a highly complex area in a very readable way. I am sure that the report is being read with great care by a lot of British people in the EU and by EU citizens here.

As other speakers have said, there is still a lot of uncertainty for British citizens travelling to the EU after Brexit day and for EU citizens here. The Government’s response makes clear the aspiration to be clear about what the future will hold, but it will be important to turn those aspirations into agreements as soon as possible.

I want to follow the noble Lord, Lord Balfe, in concentrating on the 1.2 million British nationals living in the EU who have settled there, and in particular the 190,000 pensioners. These are not statistics; they are people who have organised their lives in good faith on the basis that they can go on counting on access to healthcare, particularly under the S1 scheme. The report brings out very clearly that the scheme is a lifeline for many British pensioners, particularly those dependent on regular treatment: for example, diabetes sufferers, but also many others.

I have had discussions with the British expatriate community, particularly in France. I know that there is a broad welcome for the agreement set out in the joint report that S1 rights should continue for those who have them now. Understandably, I think that those who are dependent on them will not relax until these rights are set out in legislation. Many of them are vulnerable and unable to adapt their lives to new circumstances at short notice.

So what are they to make of demands by prominent Brexiteers, including one in the Daily Telegraph this week who said:

“At Chequers, the Prime Minister must stick to her ‘no deal is better than a bad deal’ mantra”?

For many British pensioners dependent on S1 healthcare arrangements, surely no deal would be a catastrophe, for the reasons given by the noble Lord, Lord Balfe. If the S1 scheme lapsed in a no-deal scenario, many such pensioners would have no alternative but to try to sell their houses for whatever they could make and return to the UK, where they may not have roots, in a scramble. I have heard it said that “no deal is better than a bad deal” is an important negotiating card, but I hope that those who brandish it will bear in mind the real anxiety that it is causing to many British people abroad and, no doubt, to many EU citizens here.

The Government’s reply to the report refers in a rather delphic way to,

“developing contingency plans to minimise disruption for patients”,

in the case of a no-deal scenario, and,

“building our understanding of the systems, processes and infrastructure needed in Member States to prioritise the safety of UK and EU patients”.

I think that that will be of only limited reassurance to the many British and EU citizens whose lifetime plans would be turned on their head if we found ourselves in a no-deal scenario. Of course, we all hope that it will not come to that, but I hope that the Minister will be able to give us a little more detail on what the contingency plans are for a no-deal scenario in respect of reciprocal healthcare.

My Lords, I will first say what a great privilege and pleasure it has been for me to serve on this sub-committee under the chairmanship of the noble Lord, Lord Jay, and to debate and discuss this matter with some excellent witnesses from a broad range of backgrounds. My only knowledge and expertise in the health field is that I was a member of what was then called Northern Regional Health Authority back in the 1980s. In doing that job, I learned an enormous amount about the excellence of those who work in our health service, both then and, I know, since.

I have also seen the great changes that have taken place since the 1980s, in terms not only of healthcare but of international relations between our health professionals and those in particular in the EU. I shall not go over the ground so excellently covered by my noble friend Lord Ribeiro, but we have reached a point where the National Health Service in this country is highly dependent on those who come to us from other European countries. Whether or not that is a direct point on freedom of movement is a matter which no doubt the Government will want to consider—but, in all my experience and from my connections still in the health service, I am aware of the considerable problems that we are already starting to experience with either potential members of staff who are not confident in making applications because of the lack of clarity as to their future positions if they come over here to work or with those who have worked in the health service and have become unhappy about their future prospects for remaining in that service.

I agree with the points made by the noble Lord, Lord Jay, about the Government’s reaction to this report. I pay tribute not only to my noble friend the Minister but to his department for seeming to have reacted to our report in a better way than have, sadly, one or two other departments to what we suggested in other reports in other fields. It has been a positive reaction. However, of course, good intentions are one thing—there are plenty of those in evidence in the Government’s response—but delivery in a way that deals with the issues that we have raised is entirely another matter. Not being the major issue in the eyes of the Government, and in the forefront of the media, may or may not be a good thing. It may a good thing in the sense that we hope that negotiations are taking place which will secure the future reciprocity of healthcare satisfactorily—or it is possible that, because there is not the pressure or publicity so far, the Government have not yet have negotiated these things or set about them properly. I hope that the former is the case and not the latter.

I will raise one or two points about current relationships and how we need to improve things in a post-Brexit situation. We are talking as if there is a free healthcare arrangement for everybody around Europe wherever they may be at any time, but, more recently, we have had arrangements of cross-charging between the EU states and ourselves. From the evidence that we heard, we learned that the performance of the National Health Service in collecting moneys from the EU for the treatment of EU citizens has been, to say the least, extremely patchy. I am not convinced that, institutionally, the health service has equipped itself properly to deal with that matter. My noble friend Lord Balfe spoke about Belgian administration and paperwork. It seems that we are almost at an opposite extreme in some parts of the health service, where no one appears to be able to take responsibility for making the charges that they ought to make against other EU countries. As a result of that, the health service has been denied resources that it ought to have had and which it desperately needs. In the event of Brexit proceeding in the way planned, but with some safeguards in this field, to what extent will my noble friend’s department prioritise the ongoing collection of the moneys that the health service is entitled to have from our European friends?

Following on from that, there is an issue regarding educating the public. It is amazing that, even now, with the very close co-operation and arrangements that are in place, a considerable number of people in this country who travel in Europe are unaware of their safeguards, protections and entitlements in respect of health. The result is that there are quite a number of insurers which, in my opinion, take advantage of that situation. There are also many people who pay money to get insured in areas where, to be honest, they do not need to have that insurance. What concerns me is that if, post Brexit, we do not educate people clearly as to what they will then have to protect themselves from by insuring, it will result in considerable extra expense for British people—and, I would guess, probably also for EU citizens in reverse. It would benefit only the insurance companies, which may well take advantage of that situation.

Finally, I will comment that we have really achieved an enormous amount over the last few years. Like my noble friend Lord Balfe, I had the honour of serving in the European Parliament for a considerable time. I never intended to be there for 17 years, and the time flew. Throughout it, what impressed me most about our NHS, which we are so proud of, as we should be, was that many of the developments and innovations that came into our health service have been shared with our European friends. That has been recognised in the European Parliament, and no doubt here also. Nevertheless, it has been a big issue. The British component—leadership in so many fields of innovation, including in the health field—is something which our European neighbours would be loath to lose. Similarly, we should be loath to lose those connections. That is why I hope that, in response to this excellent report, the Government will at least determine themselves to conclude negotiations that do no damage to the people of our country, or indeed any European citizen, in the field of health.

My Lords, it has been a real privilege to be part of this important investigation and I thank the noble Lord, Lord Jay, for his consummate skill in leading us and guiding the committee through to such clear recommendations.

It is no surprise that many noble Lords have focused on reciprocal healthcare as it affects the island of Ireland. The most striking testimonies I heard as a member of the committee were from healthcare professionals from Ireland. Our witnesses came from both Eire and Northern Ireland and they spoke as one, with passion and very deep concern as to the future of healthcare in their countries. As a direct consequence of the Good Friday agreement, the common travel agreement and the EU’s positive support, health provision for the communities on both sides of the border has been significantly improved. We were told of the situation, before all these arrangements came into play, of ambulances stopping at the border to transfer patients. That is a thing of the past and it needs to remain a thing of the past.

We have heard from the noble Lord, Lord Ribeiro, about the joint commissioning of healthcare. Like him, I was very taken by the example we were given about children who suffered from hearing difficulties and the arrangements that were made for ear, nose and throat operations as a consequence. Children were waiting up to four years in the north for their first appointment. Following the EU funding which enabled more ENT surgeons to be employed, those surgeons spent some of their time in the south and some in the north. What a wonderful example of the Good Friday peace agreement it is that children are cared for and get the operations they need in a more timely way. We are putting that at risk. The Royal College of Physicians of Edinburgh warned that Brexit could result in “substantial disruption” of health services. We also heard a witness statement, which I found moving, saying that patients’ lives had been saved because of free movement across the border and free access to both jurisdictions’ healthcare.

Unfortunately, I am sorry to say, the Government’s response to the committee’s report is far from convincing or reassuring. While the Government are clearly committed to retaining the enormous benefits to the healthcare of the people of Ireland there are no hard and fast proposals, let alone plans, to provide any comfort that they are determined to find a solution that retains—and continues—the significant cross-border joint commissioning of healthcare, even if doing so means that one of the famous red lines has to be erased. The Minister has given us a good and full response. However, can he give us any assurance that the priority for health provision in Ireland will be the health and well-being of all its people, regardless of other conflicting political demands?

The second aspect on which I wish to focus is that of the EHIC arrangements. Millions of UK residents take advantage of the insurance that EHIC provides when they take a holiday in an EU member state. The card provides peace of mind to holidaymakers and travellers that they will be able to access healthcare, wherever they are in the EU, if they have an accident or become ill. The Government continue to try to reassure us that they want the EHIC provisions to remain. However, doubts persist, certainly in my mind, because we are constantly reminded that nothing is agreed until everything is agreed. The committee investigated the potential consequences of the loss of the EHIC arrangements. The travel insurance industry told us quite clearly that the only replacement will be higher travel insurance costs. One figure we heard—it was a guesstimate—was that insurance may rise by up to 20% without EHIC. As the report clearly states, for some people with long-term health conditions, insurance costs may well become prohibitive.

In the Government’s response to the report, they state that they will seek continued participation in the EHIC scheme as a non-member state. However, they say:

“The exact nature of these arrangements is a matter that will be discussed during the next phase of negotiations”.

Yet people are already planning holidays for 2019; some retired people take a long period away from the rigours of a UK winter in the warmer and sunnier climes of southern Europe. Their contracts will be signed in the next few months and certainly before the proposed date for Brexit. What are these travellers supposed to do? Should they rely on the continuation of the EHIC arrangement or take out full travel insurance, which will cover the costs of any ill health eventuality? We simply do not know. The Government have a responsibility to provide advice on this matter.

All in all, the Government have acknowledged the soundness of the judgments made on many issues in the report. I am very pleased about that. Unfortunately, they have failed to provide what I would call the copper-bottomed assurances that travellers require, so that they know whether the Government’s Brexit plans will result in higher travel insurance costs and, for the people of Ireland both north and south, whether their cross-border health provision can continue and expand. These are serious questions and they require serious answers. I look forward to the Government’s response today from the Minister and, more significantly, to when clarity is provided—I hope—in the White Paper to be published next week.

My Lords, I join other noble Lords in congratulating the EU committee on its report Brexit: Reciprocal Healthcare. I suspect it was no accident that the committee turned its attention to this matter early on in its considerations about the effects of Brexit. I congratulate the Government on turning around their response in three months. This is better than the last healthcare response, which took a year, so we should be pleased and congratulate the Minister. I thank the BMA and the Nuffield Trust for providing the most up-to-date information.

I proposed and supported amendments on these matters during the passage of the Brexit Bill most recently considered, so I looked at the record to see how it compared with the answers that the Government have given. I spotted some advances but, I am afraid, not many.

In preparing for this debate, I learned from IPSOS Mori that Brexit has now joined the NHS as the top two issues the public are most concerned with—for 46% and 44% of people respectively. Today we have a confluence; it seems that as time goes on, millions may be justified in their anxiety about both Brexit and health. We heard, as several noble Lords have mentioned —including the noble Lord, Lord Balfe, and the noble Baroness, Lady Janke—that the head of NHS England is preparing plans for the supply of medicines in the event that the UK crashes out of the EU without a deal. I suppose the first question, as reflected in this report, is what happens after the implementation period? What planning is being done for a no-deal scenario for reciprocal healthcare? Indeed, the noble Lord, Lord Ricketts, mentioned the human cost of that.

Two years for implementation is not so long. Just think how the last two years have flown since the Brexit vote, with so little progress. It is, of course, important, as other noble Lords have mentioned, that the negotiations so far have enabled the Government to achieve their aims for reciprocal healthcare in the first and implementation phases of negotiations. These include access to the European health insurance card for those visiting the EU on exit day and continued access to the S1 scheme for existing retirees living abroad. But does the Minister agree that the next phase of negotiations needs to secure ongoing access to EHIC and reciprocal healthcare arrangements, either through retention, or comparable replacement of existing reciprocal healthcare arrangements with the EU after Brexit?

Some 27 million people hold a UK-issued European health insurance card and 190,000 UK pensioners living elsewhere in the EU are registered to the S1 scheme. The Nuffield Trust has calculated that, if the 190,000 UK state pensioners signed up to the S1 scheme and, living within the EU, needed to return the UK to receive care, it would incur additional costs to health services of between £500 million and £1 billion per year.

This simultaneous increase in cost and demand would place even greater strain on the UK health and social care sector. There is some anecdotal evidence that indeed people are returning from France, Spain and elsewhere since the Brexit vote and the ensuing lack of assurance and clarity. Are the Government monitoring the numbers who are coming home already?

As reflected in this report, ending reciprocal arrangements may also require the application of existing cost recovery methods for non-EEA patients to EU and EEA patients in the UK, or the development of a new, alternative system. This could increase the complexity of the cost recovery process, so well described by the noble Lord, Lord Balfe, as well as the administrative burden on clinical staff. Does the Minister agree with the BMA’s long-standing position that doctors and clinical staff should be able to devote their attention to treating patients and not to recovering the cost of care?

If the UK loses access to these arrangements, or fails to agree comparable alternatives, it could severely impact on the healthcare arrangements of UK and EU nationals and place additional strain on our already stretched NHS. Healthcare affects all of us who travel, work and live in Europe and, just as we might legitimately expect post-Brexit that we can take for granted the supply of the most up-to-date, clinically approved medicine and remedies, we expect to continue to travel and work all over Europe and for our healthcare to be assured, without having to take out insurance. On a scale of 1 to 10, with 10 being the most likely, what is the Minister’s best estimate of this being the case post the implementation period?

The ease with which people can continue to do what they are used to doing is what will colour how people will judge whether Brexit is succeeding and whether it has been worth while. In many ways, the most important recommendations in this admirable report, most of which I agree with, are those which concern clarity and transparency. Recommendations 5 and 6 concern free movement, and recommendation 11 asks if reciprocal healthcare will be included in the objectives set out by the Government, which we hope will emerge in a White Paper, with white smoke, some time next week.

This paragraph also concerns our children and grandchildren and their ability to work across Europe, which will be curtailed, as was so well explained by the noble Lord, Lord Jay. He said we have a long way to go and he is absolutely correct. The problem is, we have a long way to go but we do not have a great deal of time. I thank noble Lords for their usual high-quality contributions and I look forward to the Minister’s reply.

My Lords, I begin by saying that I will try to be concise, as all Lords have been, but I want also to cover the many interesting and important points that have been made. I congratulate the committee and the noble Lord, Lord Jay of Ewelme, for his chairmanship and for clearly putting together a very good-quality piece of work, and congratulate all noble Lords who contributed through that committee and, indeed, in this debate.

We have discussed tonight how reciprocal healthcare arrangements help people to live, work and travel across Europe in the knowledge that healthcare access is not a barrier. They are especially important for elderly people and those with long-term conditions. They enable people to access treatments or give birth abroad, promoting choice and healthcare collaboration. They have other economic benefits as well, such as tourism and helping the NHS to manage demand.

That is why we believe as a Government that a reciprocal healthcare agreement between the UK and EU is in the best interests of all. It is worth stating that good progress has been made in negotiations so far, and that is one reason why we are confident that we will secure good reciprocal healthcare arrangements as part of our future relationship discussions. Many noble Lords have asked why we have not done more, or been able to promise more, so far. It has to be said that the rate-limiting step has been the Commission’s mandate in what we were allowed to discuss and, indeed, in its insistence that nothing is agreed until it is all agreed. That was not our position, but the mandate the Commission gave to the Article 50 negotiating team. We have achieved as much as we possibly could within that mandate.

It is important to note—and many noble Lords have done so—that there is history in this area. The UK has a long-standing tradition of reciprocal healthcare agreements. My noble friend Lord Ribeiro pointed out that, for the last century, UK and Irish citizens have been able to access healthcare in one another’s countries. Noble Lords have talked about the many powerful ways in which that co-operation brings benefits to the peoples of both countries.

Since the 1950s, the UK and its European neighbours have had reciprocal healthcare and social security agreements too. I will deal quickly with the point my noble friend Lord Kirkhope made about whether, during negotiations, we are always as good as we could be at securing the moneys that are owed to us; I think it is fair to say that historically, we have not been. It is something we are starting to do better. One example is that we are now able to flag immigration and entitlement status on electronic health records, so that doctors do not constantly have to ask for that kind of information; it can be logged and secured through these agreements.

The UK also has agreements with the rest of the world, including Greenland, the Faroes, the Balkans, Australia, New Zealand and many of our overseas territories; there are precedents, current and historical, for the kind of deal we are aiming to strike.

The Select Committee report rightly recognises the importance of reciprocal healthcare. It has been pointed out in the debate that the NHS currently provides healthcare to over 3 million EU nationals living in the UK and that there are about 1 million UK nationals who live, work and use healthcare in the EU.

The noble Lord, Lord Ricketts, rightly pointed out that about 190,000 UK state pensioners have chosen to retire in Europe, notably Ireland, France, Spain and Cyprus. I am not sure that Ireland is where you would go on holiday if you were after sunshine in the winter but you would certainly choose the other three. It is worth mentioning that this is not just about the number of people who carry EHIC cards; 250,000 medical incidents affecting UK tourists are resolved via an EHIC, and a further 1,500 UK residents travel for planned treatment via the S2 scheme. That is what is at stake.

Several noble Lords referred to the achievements to date. The first of those was the joint report agreed in December 2017, which covered the entitlements of those exercising their reciprocal healthcare rights on exit day. I shall go into more detail on that shortly.

Following the agreement in December, there was further agreement in March 2018 on the implementation period. That means that the rights secured through the negotiations so far will, once the implementation period is agreed, continue until 31 December 2020, providing more reassurance. It includes healthcare for pensioners and workers, as well as the EHIC and S2 schemes, and nothing will change over that period.

Before turning to the impact on British citizens of the withdrawal agreement and implementation period, it is worth talking about the status of EU citizens living in the UK. That was raised by the noble Baroness, Lady Janke, my noble friends Lord Balfe and Lord Kirkhope, the noble Baroness, Lady Thornton, and others. The Prime Minister has been very clear that EU citizens who have made their lives in the UK should be able to continue with their lives here. We have that agreement and, indeed, we now have a route for that. As noble Lords have commented, we have opened the settled status route, which provides a specific legal mechanism by which people can secure their status to live in this country.

I reassure noble Lords that the department was one of the first to act on this new route. We have written to all NHS trusts to make sure that the many staff whom they employ and whose work we value so much are able to access that route as quickly as possible so that we can secure their future in the NHS and social care system. We want to allay their anxiety and I hope that that goes some way to doing so. It is worth pointing out, as always, that there are more EU staff working in the NHS today than there were two years ago, and of course we hope that they will stay.

What does the withdrawal agreement mean for UK nationals in the EU? The noble Lord, Lord Ricketts, and the noble Baroness, Lady Thornton, talked about the state pensioners living in the EU. We have agreed that the S1 scheme will continue for that group so that they continue to be able to access reciprocal healthcare in the same way as they do now. To answer the question from the noble Baroness, Lady Thornton, we will of course look at data on whether there are returners, although we have not seen any evidence of them yet. It is also worth pointing out that this group of S1 beneficiaries will also be able to use an EHIC to obtain healthcare if they visit other member states—the so-called onward rights.

More broadly, UK nationals living and working in the EU at the end of 2020 will be able to access healthcare on terms similar to those in place now under the implementation agreement, in line with the rights that we have agreed for EU nationals living in the UK.

Turning to the EHIC and the S2 scheme, during the withdrawal agreement and implementation period discussions so far, we have not agreed long-term continuation of the EHIC and S2 schemes for the reason that I gave. However, we have agreed that a transitional arrangement will ensure that people visiting the UK or the EU on holiday or for study will be able to continue to use their EHIC while in that state of travel. People receiving planned treatment via the S2 route will be able to complete their course of treatment abroad, however long the treatment lasts, so that there will be no disruption to their care. We will also continue to press for the right of people covered by the withdrawal agreement to move to other member states—a right that we have been able to secure for pensioners under the S1 scheme.

Inevitably, the debate has focused on what the future relationship will look like. The Government have been clear about what we are seeking to achieve: the right of UK state pensioners who retire to the EU to access healthcare in those states; full ongoing UK participation in the EHIC scheme; and the right of UK residents to receive planned treatment in the EU, when the NHS authorises it.

The noble Lord, Lord Jay, asked: why S1 rights? I think that he has in mind, for example, frontier and posted workers. It will inevitably depend on wider agreements about mobility and security rights. There is a co-dependency between those citizens’ rights and the more extensive application of the S1 right to healthcare. However, the other elements of the reciprocal healthcare rights do not have the same co-dependency with the wider citizen rights.

The noble Baroness, Lady Janke, my noble friend Lord Balfe, the noble Baroness, Lady Thornton, and the noble Lord, Lord Ricketts, also asked about the no-deal arrangement. Indeed, if noble Lords did not mention it, it is certainly on everyone’s mind. The committee obviously heard about and described the anxiety that there would be if people could not easily access healthcare abroad, and it suggested solutions that we could adopt, such as bilateral agreements. I reassure noble Lords that it is our intention to secure a deal, given the commitment to protect the interests of citizens from both sides in the negotiations. I should also reassure noble Lords that the department is doing everything it can and everything necessary to avoid any kind of cliff edge. There is a programme of work that aligns with the ideas already posed by the committee in the unlikely event of a no deal.

We are of course planning for all scenarios. I think that British citizens would find it bizarre if we did not prepare for all eventualities, not just on reciprocal healthcare but on other health issues and across the piece. I am afraid that noble Lords will have to forgive me: this is not the time for me to go into further details about what those no-deal preparations look like, although of course at some point in the future we will have more to say. I shall resist the entreaty from the noble Baroness, Lady Thornton, to give her probabilities—I am terrible at betting, so she would not want to trust me anyway.

Ireland has obviously been a heavy feature of the debate and the report. My noble friend Lord Ribeiro spent much time highlighting the benefits of that relationship, and the noble Baronesses, Lady Pinnock and Lady Janke, talked about it as well. As somebody who has an Irish connection, it is something that features heavily in my, as well as the Government’s, thinking. I reassure noble Lords that the UK and Ireland have agreed that we will protect healthcare access and co-operation for our populations whatever the outcome of the EU exit. That would take place under the common travel area and other agreements that we have made together.

The discussions are progressing well. I recently met my counterpart, the Irish Health Minister, Simon Harris. We are both satisfied by the progress in this area. I reassure noble Lords—particularly the noble Baroness, Lady Pinnock, who was very interested in this matter—that it is a priority for us and that we are making good progress.

My noble friend Lord Balfe asked about the devolved Administrations. We are of course engaging with them all the time and making sure that they are involved in the decision-making. As we go forward, we will be seeking a deal that works for all parts of the UK, and it therefore needs to work for and be agreed by the devolved Administrations too.

The noble Baroness, Lady Janke, made some important points about insurance, as did the noble Baroness, Lady Pinnock. We are continuing to engage with the Association of British Insurers. Clearly, the exact outcome and its implications for travel insurance will depend on the future relationship, we agree. But for the reasons that I have said, I will not go into the detail now of preparations for no-deal scenarios. I can tell the noble Baronesses that we have that open relationship and are having discussions, and we understand exactly what is at stake here.

Finally, my noble friend Lord Ribeiro raised the issue of radioisotopes. It is a topic that we have discussed several times. He will know that we are investigating not only domestic production but making sure that there are customs arrangements and other arrangements such as trading arrangements to make sure that the supply of radioisotopes is not impacted in any way by the circumstances under which we leave the European Union. I am reassured from the work that has gone on in this House through our debates on the withdrawal agreement and the Nuclear Safeguards Bill that we have a proper understanding of how we achieve that. Noble Lords made a fantastic contribution to that work. Of course, as the noble Lord will know, regarding the proton beam, there is a centre open at the Christie and another one to follow, so we will be able to provide more of that therapy at home for UK citizens.

I thank the committee again for its fantastic work, the noble Lord, Lord Jay, for his expert chairmanship and all speakers. I think we are all agreed on what we want to achieve from these negotiations and why we want to achieve it. It is inevitably a complex task. The input of the committee is highly welcome and has been very productive and influential on our thinking as a department. I want to make sure that that is reflected as much as possible in the work we do and the proposals we make, whether in a White Paper or other routes. I hope that we will continue that dialogue so that we can make sure that concerns are raised and properly dealt with and we end up with an outcome that protects citizens’ and patients’ rights after we leave the European Union.

My Lords, I am extremely grateful to the Minister for his characteristically thoughtful and considered reply and to all those who have taken part in this evening’s debate. I do not wish to detain your Lordships further this evening but I would like to say that the issues we have been discussing are not just abstruse. They may be abstruse and they may be complex and technical, but they affect the lives and livelihoods of enormous numbers of British citizens and citizens of other EU countries, including Ireland. Therefore, they need to be at the very top of the agenda of the Government in the very complex negotiations that lie ahead. I beg to move.

Motion agreed.

House adjourned at 7.40 pm.