The claim

“The NHS could face a bill of almost half a billion pounds if retired British people currently living in other EU countries decide to return to the UK in the event that their right to healthcare in those countries is withdrawn after Brexit.” – Nuffield Trust, 31 May 2017.

The background

A new report by the Nuffield Trust warns of a massive bill for the NHS if the government fails to reach a good Brexit deal and expat pensioners return to the UK.

Under the EU’s reciprocal healthcare scheme – known as “S1” – British pensioners living in other EU countries are entitled to local healthcare rights, with the UK ultimately picking up the bill.

After Brexit, the concern is that the UK may not be able to continue in this scheme. If this happens, the Nuffield Trust says pensioners could return to the UK for their healthcare, putting added pressure on the NHS.

It says 190,000 British pensioners live elsewhere in the EU and the Department of Health pays around £500m to other countries to cover their care costs. “If British pensioners lost their health care cover in EU states and had to return to the UK in get the care they need, the extra annual costs to the NHS could amount to as much as £1 billion every year.”

The analysis

The Trust’s claims are confusing. The press release says the bill could increase by £500m rising to £1bn. But the report itself repeatedly refers to “an extra £1 billion a year”.

So which is it? An extra £500m or £1bn?

A spokesperson told FactCheck that they actually meant what was written in the press release. They’re saying the bill could double from £500m to £1 billion. The report appears to have garbled this.

Statistics on the S1 scheme are extremely difficult to pin down. Incredibly, its administration is still done on paper with “big cardboard files of papers being posted backward and forward across Europe, which people then have to process”.

Nuffield’s statistics about the current scheme originate from oral evidence given in Parliament by Paul MacNaught, an executive from the Department of Health.

“The actual amounts we pay in any given year are greatly affected by the exchange rate, but, if we are talking in general terms, we spend about £650m a year on the reciprocal healthcare arrangements,” he said. “Of that, about £500m is on pensioners, so that is UK-insured pensioners, of which there are about 190,000 in other EEA countries.”

However, the Department of Health told FactCheck that MacNaught’s figures were merely “estimates intended to give a steer of the typical amounts”.

In reality, the UK paid out just £429m in 2015/16 to cover the costs of UK-insured pensioners under S1. That’s 14 per cent less than the the £500m figure used by the Nuffield Trust.

The figures are also shaky when it comes to the number of people we’re talking about. The Trust’s analysis says 190,000 pensioners are living abroad under the S1 scheme. But an FOI request by the BBC in January appeared to put the number at 145,000.

According to the Department of Health, the disparity is because of the inclusion of the Republic of Ireland in the figures. There is a bilateral health agreement between the two countries, but the UK government “do not exchange S1, S2 or EHIC forms with the Republic of Ireland”.

So the Nuffield Trust’s 190,000 figure includes thousands of pensioners who are not actually part of the specific scheme being discussed. However, that’s not to say that the Irish deal could not also be affected by Brexit in a similar way, so this is possibly a bit of a technicality.

Will expats really move back to use the NHS?

Beyond the raw statistics, the Nuffield Trust’s analysis rests on a huge assumption. The figures show what would happen if all expat pensioners moved back to the UK to use the NHS if the S1 deal falls through.

But we don’t know how many would return to these shores.

How about expats who decide to stay abroad using private healthcare? Or those who choose to apply for citizenship in the country they now live, after Brexit? Indeed, in Spain (which is home to the largest number of British expats in the EU), there has been a surge in the number of Brits applying to take the Spanish citizenship test.

The other assumption here is that none of these expats are currently using the NHS in Britain at the moment. After all, government guidance says: “UK state pensioners who live elsewhere in the EEA will now have the same rights to NHS care as people who live in England.”

If a certain proportion of expats are already travelling to the UK to use the NHS, this again suggests Nuffied’s warning figures could be inflated.

Will the S1 scheme fall through?

The scheme is considered part of the EU’s freedom of labour system, which both main parties in the UK have said they will withdraw from.

But whoever wins the election will almost certainly try to negotiate to provide continued protection for British expats.

It seems unlikely that all healthcare rights of UK expats would be scrapped immediately because of Brexit. After all, there are many people from other EU countries living in Britain who depend on the NHS.

So although it’s possible that no agreement will be reached, it is in the interest of many member states to want a negotiated resolution on this.

The verdict

The Nuffield Trust raises legitimate concerns about Brexit’s impact on healthcare. If no agreement is reached, returning expats could put extra pressure on the NHS.

But the statistics they use may be shaky.

The latest figures show the UK’s healthcare bill for these pensioners was £429m, not £500m.

The number of people covered specifically by the S1 scheme appears to be significantly less than the 190,000 claimed, because UK pensioners living in Ireland are covered by a similar but separate scheme.

Plus the analysis assumes an unlikely worst-case scenario where all expat pensions return to the UK.

What’s more, the overall billion pound figure that is reached has been rounded up from £979m.

While rounding up is standard practice, it nevertheless adds the extent to which the billion pounds – a figure repeated across the media today – is an inflated one.