HC Deb 08 November 1978 vol 957 cc1145-56

Motion made, and Question proposed, That this House do now adjourn.—[Mrs. Ann Taylor.]

12.5 a.m.

Mr. John Pardoe (Cornwall, North)

I am very pleased to have the opportunity to raise the subject of the entitlement of foreign visitors to the United Kingdom to free health services while they are here.

The debate arises from the North Cornwall district council's representations over the last two years to the Department of Health and Social Security. I must also mention the name of one of that council's members, Councillor Laight, who has taken a great deal of personal interest in the matter.

Since the council first raised this matter with the Department in 1977 a considerable amount of correspondence has flowed, but we seem to have struck a brick wall. The Department, though prepared to give very full replies in correspondence to the letters that it has received on this subject, is not prepared to budge one inch. This debate will give the Department one more chance to think again.

The North Cornwall district council contends that the present arrangements for health treatment of foreign visitors to the United Kingdom and of United Kingdom visitors to foreign countries are very unfair.

Britain has a Health Service which is ostensibly free at the point at which one falls ill. Of course, it is not free, because the British people pay a great deal for it through their taxes.

The majority of other countries do not have free health services. Even in those countries with which we have reciprocal agreements, British visitors generally have to pay something for the health services that they use, while visitors from those countries to Britain do not have to pay anything.

There are only about 20 countries with which we have reciprocal agreements, including Common Market countries. Therefore, there are 140 countries with which we have no reciprocal agreements, covering 80 per cent. of the world's population.

Every year 6 million visitors come to this country from countries with which we have no reciprocal agreements. Such visitors are entitled to health treatment in the United Kingdom absolutely free, whereas British visitors to those countries pay the full cost.

What is the size of the problem? In 1977, 11½ million foreign visitors came to Britain. Alas, the Department has no idea how many of them fell ill and had medical treatment. It cannot even begin to guess at the cost to the National Health Service of providing health care to those people. In mitigation, the Department claims that few of them are in those age groups most likely to require medical treatment—the very young and the very old. But, even if that is true, it does not obliterate the fact that a large number of overseas visitors receive free health treatment here at considerable cost to the National Health Service and the British taxpayer. Nor does that take account of the cases of deliberate fraud—people with pre-existing health conditions who come here only because the treatment is free.

I know that the Department maintains that all kinds of checks are exercised. People are apparently inspected at the port of entry. How one tells whether someone is actually suffering from gout or a serious leg infirmity, or has just stubbed his toe on the gangway coming off the ship, I do not know. Indeed, I do not believe that skilled medical people would be able to tell. Therefore, again, the Department has no idea how many fraudulent visitors—one might call them health visitors—come to Britain.

It is inconceivable that the total cost of providing free health service treatment to overseas visitors in the United Kingdom can be less than £100 million a year—a not insignificant sum.

The Minister will no doubt speak in glowing terms of the reciprocal agreements that we do have—indeed, his hon. Friend has just come back from Hungary, which is the latest country to be added to the list—and will list the countries which provide free treatment. But the list is not very long. As I indicated, there are only about 20 countries with which we have these agreements. Only 12 countries outside the EEC provide free in-hospital treatment to British visitors, and to get up to that dozen we have to include the Channel Islands—hardly a foreign country. Only a majority—not all—of reciprocal agreement countries provide free general medical practitioner services, and very few provide free medicines.

There is also the fact that to get these reciprocal rights a British visitor must complete quite burdensome formalities, which he is advised to complete before leaving this country. Then, if he becomes ill, he has to go through many formalities again in the country in which he is taken ill. That is if he is able to claim any refund at all. Yet the foreign visitor to Britain has to go through none of those formalities, and can receive his treatment absolutely free.

The most comprehensive reciprocal agreements that we have are with other EEC countries, enshrined in EEC regulations. What happens under those marvellous reciprocal agreements, the best that we have when an English family needs medical care in, say, France? A large number of British visitors go to France, so it is not an untypical destination.

Here is a recent case history. It concerns a family living in the constituency of my hon. Friend the Member for Rochdale (Mr. Smith). The husband and wife and their two children went for a holiday on the Continent. Before they left they had sought all the advice they could about the EEC regulations and reciprocal agreements, and were told that if they completed the relevant form, E 111, and took it with them it would enable them to recover their full medical costs, and that there was therefore no need for them to take out private medical insurance.

In June the family had a car accident in France. The two children were detained in hospital and had to have operations. The parents also had to receive out-patient treatment. At this stage it is not possible to say exactly what the total cost of all the treatment for the family will be, as not all the bills are yet in, but my hon. Friend's constituents have estimated to him that the total amount may be as much as £5,000.

First, the family has to find the £5,000, as it can receive no reimbursement until it can provide receipted hospital bills. That is a lot of money for a family to find in the first place—a bridging loan, perhaps. But when it claims the reimbursement, with the receipted hospital bills, the most it will get back is 80 per cent. of the £5,000. In other words, there will be a permanent cost to the family of a full £1,000 for the treatment. Had it been a French family visiting Britain, the treatment would have been absolutely free, gratis and for nothing—no bills, no receipts, no aggro, no claims, and certainly no £1,000.

That is what the reciprocal agreements have meant to one English family in the past few months. We cannot go on like this. It is all very well being a Good Samaritan. Being a Good Samaritan is one thing, but being taken for a permanent ride by the rest of the world is quite another.

The North Cornwall district council has suggested compulsory health insurance. It suggests that it should be compulsory for all non-United Kingdom residents to be in possession of a medical voucher during their stay in Britain. It has suggested a cost of £7 for cover for a six-month period. The voucher would cover emergency use only.

I believe that the scheme has great merit, and the Government should seriously investigate it. It was never intended that the National Health Service should be available scot-free to 12 million overseas visitors. Does the Minister really believe that the authors of the original scheme—let us put them in their proper order: Beveridge and Bevan—intended that? Of course, they did not.

Indeed, the present Foreign Secretary wrote when he was a Health Minister: the National Health Service is intended for people who are ordinarily resident in this country. Just so; of course that is right.

If reciprocal agreements really gave British visitors overseas the same treatment conditions as are given to foreign visitors here, and if all countries in the world from which the visitors come were governed by reciprocal agreements, there would be no cause for complaint. But only Denmark, of all the countries in the world, gives British visitors true equality and parity.

As long as the Government play the Good Samaritan and do nothing, other countries will fail to follow Denmark's example. That is why I believe that the Government must act now.

12.15 a.m.

The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)

I am grateful to the hon. Member for Cornwall, North (Mr. Pardoe), for initiating this short debate, which gives me an opportunity to explain the Government's attitude to the provision of treatment under the National Health Service for visitors to this country.

My Department frequently gets letters from members of the public about the use of the NHS by visitors from abroad, and it is useful to have this opportunity to explain our policy and the reasons for it.

First of all, because there has been some misunderstanding about this in correspondence that we have had with North Cornwall especially, I had better explain who is properly eligible to use the NHS. The National Health Service Act 1977, and the 1946 Act on which it is based, do not specify that any particular group of people is entitled to use the Service: they simply make it clear that the NHS is intended to improve the health of the people of England and Wales. It has been understood from the outset that this meant that anyone who belonged to the people of England and Wales could use the facilities of the NHS. The Acts also specify that the facilities of the NHS are available free at the time, except where there are statutory powers to charge.

As to what is meant by the people of England and Wales", the view has been taken from the outset that this referred not to nationality, or to people's ultimate origins, but to their residence in this country. In practice, it is taken to mean that anyone who is ordinarily resident in England or Wales is eligible to use the NHS in England and Wales. This has been taken to include not only people who are permanently resident in either of these countries but people who have come here with the intention of becoming permanently resident, people coming for the purpose of employment, and people coming to stay for prolonged periods.

I need hardly remind the hon. Gentleman, but the point is perhaps worth stressing, that the NHS is not a contributory service. It is financed largely from general taxation, as he emphasised, and the health element of the national insurance contributions in total amounts to only about 10 per cent. of the cost of the NHS. There are, of course, a number of taxes which visitors to this country pay which go towards the revenue income from which the NHS is funded.

There is nothing in the legislation which precludes the Secretary of State from making the facilities of the NHS available to other people while they are in England and Wales, and it has been the policy of successive Administrations to make them available to three categories of persons who are not people of England or Wales. First there are people of countries with which we have reciprocal agreements; there has, for example, been full reciprocity with Scotland and Northern Ireland from the outset, and somewhat more limited reciprocity with a number of other countries since then. I shall have something more to say about that in a moment. Secondly, since 1973 there have been people covered by EEC social security regulations. Thirdly, it has been the policy all along that visitors from overseas should not be denied what used to be referred to as " emergency treatment " but what I should prefer to describe as treatment of immediate necessilty for conditions arising or unexpectedly and seriously exacerbated in this country. There is no suggestion that they are in any way entitled to this—unless they happen to be covered by a reciprocal agreement or EEC regulations.

The reasons for allowing visitors who are not entitled in these ways to use the NHS are twofold. First, there are humanitarian considerations. It has never been thought right that a visitor who has an accident or falls suddenly ill should be told that he cannot have treatment unless he can pay. I am told that there are some countries in which this can happen—though I believe that in most European countries it would not—but even if it were the general custom it would, I think, be unacceptable to most people in this country if the NHS were to behave in this way.

Secondly, there is a set of purely practical reasons for our policy. As I explained, everyone who is ordinarily resident in this country is eligible to use the NHS, and there is no quick and simple way in which one can tell who is ordinarily resident. If a patient seeks treatment which is not immediately necessary, there will be time to establish whether he is ordinarily resident here, but if it is a matter of treating without delay, it will often be difficult to be certain. A patient who looks and sounds English, or Welsh, may well have emigrated and be here purely as a visitor. A patient who does not look or sound English, or Welsh, may perfectly well be ordinarily resident here. To be certain that no one who is eligible is refused, one may either have to make some pretty full inquiries—which as I have already suggested is not always practicable—issue everyone who is ordinarily resident with a document to establish his ordinary residence, or do as the NHS has done from the outset and provide treatment of immediate necessity without first ensuring that the patient is eligible.

The idea of issuing documentary proof of eligibility attracts some people, but in practice this would be the same sort of exercise as the national registration we had in wartime, requiring a large administrative machine. I do not think I need expand on this, except to remind hon. Members that the register would have continually to be updated and new documents issued, so the cost of such an operation would be a continuing one. Governments have looked at this repeatedly over the years, but it has always been clear that it would not be worth it.

To identify those visitors who are entitled to immediately necessary treatment and distinguish those to whom treatment is provided as a concession would involve additional administrative processes. It is likely that the administrative cost of making the additional inquiries necessary would be as great and probably greater than the revenue which would be received from charging visitors for the cost of emergency treatment.

I must make it clear that visitors who come to this country specifically for treatment, unless they are within the people of the EEC regulations or one of the small members of reciprocal agreements which provide for this, are expected to pay for their treatment whether it is given at an establishment in the private sector or at a National Health Service hospital at which there are still some pay beds.

I have already mentioned reciprocal agreements, and the hon. Gentleman said something about them. This country has entered into agreements with a number of countries by now—Austria, Bulgaria, the Channel Islands, Czechoslovakia, the German Democratic Republic, Gibraltar, Malta, New Zealand, Norway, Poland, Rumania, Sweden, USSR and Yugoslavia, and only last week my right hon. Friend the Minister of State signed an agreement with Hungary. Then, separate from the reciprocal agreements, but, like them in giving some overseas visitors a right to use the NHS, there are the social security regulations of the European Community, which apply to workers and pensioners and their families. EEC regulations are, of course, binding on this country.

Mr. Cyril Smith (Rochdale)

Has the treatment to be provided free of charge? That is the issue.

Mr. Deakins

I am coming to the facilities provided for people in other countries. All these provide for treatment of immediate necessity to be provided to visitors from the country concerned, though the Austrian one refers only to hospital treatment, while our people going to those countries are similarly entitled to use their health services on the same basis as the people of the other country. I understand that about half the visitors to this country are covered by either EEC regulations or reciprocal agreements. We are continuing to make efforts to conclude agreements with other countries.

Mr. Bruce George (Walsall, South)

Is my hon Friend aware that a constituent of mine who went to Canada contracted cancer, that it is costing £200 a day for hospital treatment, and that the family he is staying with is facing bankruptcy?

Mr. Deakins

I am coming to the question of Canada.

The United States is one of the relatively small number of countries visited by large numbers of United Kingdom residents with which we have no reciprocal health care arrangements. There is a long history of efforts to try to make such an agreement. Recently the suggestion has been raised that there might be some limited arrangement to allow elderly visitors to use Medicare. Cover for a wider range of visitors cannot be considered at the moment in the absence of appropriate United States legislation.

We would welcome also a health care agreement with Canada, and there have been preliminary talks with the Canadian authorities—but early progress is unlikely because of the legislative difficulties that it would present to the Federal Government and the problems that have arisen in connection with reciprocity of social security benefits, particularly pensions.

There have also been discussions about the possibility of a reciprocal health agreement with Australia, but the recent severe cuts in the Australian health service make progress in this direction unlikely in the near future. Nevertheless, we are continuing to press for ever wider coverage.

The hon. Gentleman referred to adequate reciprocal arrangements. It is easy to make play with the fact that in some other countries British patients might find themselves paying rather more than does a foreign visitor who uses the NHS. But it would be wrong to represent these arrangements as being in some way a poor bargain for the United Kingdom. It is worth bearing in mind, if we are concerned with the balance of advantage between countries, that the number of United Kingdom citizens going on holiday to reciprocal agreement countries generally exceeds substantially the number of their visitors here.

For example, I understand that about 10 times as many United Kingdom visitors go to Yugoslavia as come from Yugoslavia to the United Kingdom. We cannot expect the other countries to give our people better terms than they give their own. This is an important point of principle. It seems to me that any agreement in which one country gives the other country's visitors the same substantial benefits as it gives its own people is fair and reasonable.

In the case of the English family mentioned by the hon. Gentleman and the hon. Member for Rochdale (Mr. Smith), the family would have been treated basically in the same way as a French family in the same position in France, or, to put it another way, a French and an English family would be treated the same way in England and they would be treated the same way in France.

I should say at this point that we have gone some way towards eliminating the disparity between EEC social security regulations, which apply to employed persons and pensioners and their families, and our own broader approach. Since joining the EEC we have concluded a bilateral agreement with the Federal Republic of Germany to provide for medical treatment of immediate necessity for self-employed and non-employed United Kingdom visitors. We have a similar agreement with Denmark. As a result of developments in case law a large proportion of the self-employed are now covered by the regulations. Largely as a result of United Kingdom pressure the EEC Commission has presented to the Council proposals for the extension of EEC regulations to cover the self-employed and non-employed. Revised proposals to this effect are now under consideration by the Council.

The hon. Gentleman mentioned some proposals advanced by the North Cornwall district council to raise a levy on visitors from abroad, which would finance the cost of its health service treatment in this country. My Department, and indeed Ministers, have corresponded with North Cornwall and with the hon. Member at great length on these proposals. I assure the hon. Member that a great deal of time and effort has gone into considering the suggestions put forward not merely by my Department but by several others and the British tourist authority. It is almost a case of Uncle Tom Cobbleigh and all. This has been done to give the hon. Gentleman and his constituents the comprehensive reply to which they are entitled.

I regret to say that I still find the proposals totally unacceptable. They have two aspects. On the one hand, it is suggested that this country should cancel its reciprocal agreements and renege on its obligations under EEC law. The only advantage of this move would be that it would make the second part of the North Cornwall proposals seem more feasible. This part refers to the introduction of a levy on visitors to this country. They would be compelled as a condition of entry to purchase vouchers which they could then present when they needed Health Service treatment. Absence of a voucher presumably would mean that they would be refused treatment. But perhaps no one would be able to slip in without obtaining a voucher.

I find it difficult to see how such a scheme could be seriously propounded. The practical difficulties which would arise at ports are a matter for my right hon. Friend the Home Secretary. But it does not take a great deal of imagination to see what will happen at Heathrow, or some other airport—and it is basically at airports rather than seaports that the bulk of foreign visitors arrive—when 400 or 500 passengers, all arriving at the same time, have to be sorted out into those who were ordinarily resident in this country and those who are not; and the latter have to have it explained to them that unless they purchased a voucher for £7, or whatever, they would have to turn around and go back home. There would be the passengers who claimed to have a voucher and to have lost it, and those who considered that it was wrong to make them pay; and those who did not understand; those who needed to change their travellers cheques. Traffic at the ports, and particularly the airports, would grind to a halt. But even if these technical difficulties could be overcome as perhaps they could if very large numbers of extra staff were employed, and such extra accommodation and space were made available—I am still not satisfied that it would in fact be proper to impose such a levy, and other countries would no doubt take the same view. We should be lowering the portcullis and pulling up the drawbridge and telling the world that we did not care whether they came here or not.

Leaving aside questions of tourist income, and so on, it would be going against the trend in today's world towards easing travel restrictions between different countries. Certainly entry into Britain can be tough for some people. For the bona fide visitor it is straightforward. We would not want to put further hindrance in the way of extra visitors coming to this country. This is not a posture which we should wish to adopt.

I am aware that the use of the Health Service by visitors from abroad is an emotive subject. It is not merely the hon. Member and his constituents who write and express their concern on a subject about which they feel strongly. I receive letters during the course of the year from Members of Parliament and others on this subject. Looking at the matter dispassionately it seems that the present policy it both sensible and right. Where it needs to be improved—this is where the way forward lies—is in continuing our efforts to negotiate new agreements which ensure that more of our people, about whom the hon. Member is concerned—I fully support him—when they go overseas are entitled to the same health care treatment, on the same conditions, as the nationals of the country to which they go. That is as much as we can expect.

Question put and agreed to.

Adjourned accordingly at twenty-nine minutes past twelve o'clock.