The claim
VoteLeave says UK gives £5.8bn more to EU countries for medical costs than it gets back, which campaigners say means “health tourism from the EU has cost us billions”.
VoteLeave Chair and Labour MP, Gisela Stuart, April, 2016
Does the UK lose £723m a year caring for migrants in the NHS?
According to Vote Leave the UK pays an average £723m a year more to EU countries for the medical treatment of UK nationals than it gets back for EU nationals who use the NHS.
Since 2007-2008 Vote Leave says the gap between what is paid in and what comes back is £5.8bn.
Looking at last year – 2014-2015 – the Department of Health figures show the UK paid £667.4m to other EU countries and was able to recoup just £49.3m, leaving a deficit of £618m.
Although the figures show Britain pays out more than it gets back, Vote Leave make the assumption that this means the UK is automatically owed the £618m each year.
For this to be true, EU nationals would have to cost the same to the NHS as British people abroad cost to the various EU countries they visit or live in. But do they?
Not according to the Department of Health
The Department puts the total cost to the NHS of EEA visitors (the EU plus Iceland, Liechtenstein and Norway) and Swiss non-permanent residents at around £340m – around half what Vote Leave claim Britain is losing out each year.
It estimates that only £240m of this is recoverable from the EU through current arrangements.
This is because the NHS promises free healthcare at the point of use for people “ordinarily resident” in the UK.
Residence was so vaguely defined that doctors and nurses were confused about who to charge, according to Department of Health research. Now the rules have now been tightened so that only those who have been in the UK for over 5 years will be entitled to free NHS access.
The NHS is inefficient at claiming back the money that it is legally owed. It only managed to get back £50m in 2013/14.
Even if we claimed back every single penny we were owed, Britain would still be paying out almost double to EU countries to treat Britons abroad than it could claim back. Why?
Is this health tourism?
The phrase is not usually used by the Department of Health to describe tourists or recent migrant workers who use the NHS when they are in the UK and happen to fall sick, which is what Vote Leave seem to mean here.
The NHS defines health tourists as people who intentionally travel to the UK and turn up at A&E needing serious medical attention or surgery, or those taking advantage by registering with a GP when they do not live in the UK and using the service when they visit on a regular basis.
The Department of Health puts the total cost of deliberate health tourism at between £110m and £280m.
According to the Department of Health some of the biggest culprits are British expats who live abroad but come back and use their old GP when they no longer live in the UK.
What can we claim back?
Around 1.2 million people born in the UK live in other countries, and around 3 million people living in the UK in 2014 were citizens of another EU country.
While this suggests that the UK should be able to claim back more money as the UK is host to more people, it is not that simple.
Money can be claimed back for people who are not “ordinarily resident” in the UK and for tourists. Therefore recent migrants and tourists should be covered by the reciprocal deal, but not those who have made the UK their home.
The definition of ‘ordinarily resident’ was tightened in last year’s Immigration Act to include only those who have Indefinite Leave to Remain. This has yet to come into force.
However, because the NHS is based on the principle that it is free at the point of use the Department of Health itself admits this can be tricky to enforce.
Services provided in hospital in England are required to charge for overseas visitors. Which excludes services like A&E and walk-in centres.
The Department says that the NHS routinely fails to collect money from the countries of recent migrants and tourists because many health service staff are unclear about who they should be charging for and why.
Almost double the number of British people go on holiday to Europe than Europeans come to Britain which could also explain some of the discrepancy in healthcare costs.
Why the discrepancy between payments to the EU and the money back?
The data here is ropey because there are no comparative studies of how healthcare is accessed by foreign nationals across the EU.
However we can make some educated guesses: recent studies suggested that migrants tend to be healthier than the average Briton. They use the NHS have shown that new arrivals to the UK tend to use hospitals less (around half as much as England born residents), do not generally contribute to longer GP waiting times in the most areas and do not appear to clog up A&E departments.
This is because they tend to be younger, better-educated and healthier than the native population.
Dr Osea Giuntella of Nuffield College says migrants who move to another country are self-selecting – they work out a cost-benefit analysis of a move: if you are unhealthy the cost will be higher and the benefits lower and you are less likely to come.
While young healthy migrants appear to be coming to Britain, figures from the Foreign Office suggest that the Brits who move abroad are often older, retired people.
In 2010 some 400,000 people claimed a state pension abroad – 17.9 per cent of the total number of British people they estimate live abroad at least part of the time. This compares to 15.9 per cent of pensioners in the general population of the UK.
In the UK retired households cost almost twice as much to the NHS as non-retired as they are heavy healthcare users who often have multiple conditions.
As the UK guarantees to cover the healthcare of all those claiming a state pension abroad, the cost is likely to be higher than the cost of young, healthy new migrants to the NHS.
This chimes with Vote Leave’s own statistics: the top four countries where British people claim the UK pension are the the same as the top four countries claiming back money for medical care.
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Would this money be saved if we left the EU?
The £6bn that has been paid out is for the healthcare of British people who fall ill abroad – both visitors and pensioners. After Brexit people are still going to fall ill outside their home country – and that healthcare will still need to be paid for.
If Britain leaves the EU and does not negotiate a deal with other EU countries for reciprocal health care British people will either have to return to the UK for their healthcare, at a cost to the NHS, or the cost will fall directly on the heads of UK tourists, workers and pensioners wanting to travel in Europe.
Britain Stronger in Europe says that this will leave some people stranded unable to pay for their healthcare abroad. Vote Leave says the money paid for by the British state into the health services of EU countries would be better spent at home.
Verdict: It is true that there is a substantial deficit between what the UK pays to EU countries for use of their healthcare systems and what it gets back.
However these figures do not prove is that “health tourism” has cost the UK £5.8 billion since 2008.
What they show is that British people abroad cost other healthcare systems substantial amounts each year, possibly because many of the expats are older people claiming a pension, and that Britain claims less back for EU citizens using the NHS here. By it’s the Department of Health’s own admission this is in substantial part because of the NHS’s inefficiency in claiming costs back.
This healthcare of British people abroad would have to be paid for by someone in the case of Brexit – either the UK state or the UK expat pensioners themselves.
