Cross-border healthcare – overseas patients

16 March 2017

Article by Philippa Watkins, National Assembly for Wales Research Service

Darllenwch yr erthygl yma yn Gymraeg | View this post in Welsh

Image of a health professional holding a clipboard The UK Government recently announced that NHS hospitals in England will be required to charge patients from overseas upfront for non-urgent, planned care unless they are eligible for free treatment.

How does this apply to the devolved administrations? What are the arrangements for non-UK residents to access NHS healthcare, and for Welsh (and UK) patients to receive treatment abroad? Is this likely to change following the UK’s withdrawal from the EU?

Access to NHS services in the UK – ordinary residence

Entitlement to free NHS healthcare is based on being ‘ordinarily-resident’ in the UK. Ordinary residence is not dependent on nationality, paying UK taxes/national insurance, having an NHS number or being registered with a GP, or owning property in the UK. It has become accepted to mean that a person is living here lawfully, voluntarily, and for settled purposes. Under the Immigration Act 2014, a person must have indefinite leave to remain in the UK in order to be regarded as ordinarily resident.

Across the UK, some types of healthcare, including GP services and treatment in an accident and emergency department, are currently free to all patients whether they are ordinarily resident or not. For non-UK residents, most hospital treatment is subject to charge, although some groups of people are exempt, for example refugees, asylum seekers and looked after children. Additionally, patients who have rights to healthcare under EU legislation or other reciprocal healthcare agreements may also be exempt from charges. More detail about these arrangements – which also apply to UK residents receiving treatment abroad – is provided below.

As of April 2015, non-EEA nationals coming to the UK for longer than six months may be liable to pay an immigration health surcharge as part of their visa application. This entitles them to NHS treatment on the same basis as permanent UK residents.

Charging regulations

NHS organisations across the UK are required by regulations to establish whether someone is liable to pay for NHS services and to charge them accordingly.

The UK Department of Health has said that the new requirement for hospitals to charge overseas patients upfront will come into effect in April 2017. This applies to England only – separate regulations govern the charging arrangements in the devolved administrations. In Wales, the Welsh Government is reviewing the existing charging regulations and guidance, and is expected to publish updated versions in draft form for consultation in spring 2017.

Residents of EEA countries (including UK residents)

Unplanned treatment

Residents of European Economic Area (EEA) countries and Switzerland can apply for a European Health Insurance Card (EHIC), which will allow them to access state-provided healthcare during a temporary stay in another EEA country/Switzerland. The EHIC covers any necessary medical treatment that cannot be postponed until you’ve returned home. This includes treatment for chronic or pre-existing medical conditions and also routine maternity care (this includes unplanned childbirth, but would not provide cover for someone planning to give birth abroad).

Treatment should be provided on the same basis as it would to a resident of that country. In many cases this will be free, however in some countries patients are expected to contribute towards the cost of their state-provided treatment, and this will also apply to EHIC holders receiving treatment in those countries.

It’s emphasised that the EHIC is not an alternative to travel insurance – it will not, for example, cover someone for rescue and repatriation following an accident.

Planned treatment

There are two potential routes under which EEA residents can travel to another EEA country for planned healthcare:

  • the EU Directive route;
  • the S2 scheme.

Under the EU Directive on patients’ rights in cross-border healthcare, patients are able to purchase state or private healthcare in another EEA country and seek reimbursement from their home country (up to the cost of that treatment at home). The EU Directive route does not apply to Switzerland.

Prior authorisation is not necessarily needed, although this will be a requirement for some types of healthcare, generally inpatient care and highly-specialised, cost-intensive treatment. Under the Directive, patients are not able to obtain reimbursement for treatment that they would not be entitled to at home.

Further information about arrangements under the EU Directive can be found in the Welsh Government’s guidance for the NHS on cross-border healthcare and patient mobility.

Under the S2 route, EEA and Swiss residents are able to seek planned treatment in other EEA countries/Switzerland, but must obtain prior authorisation from their own Member State, which bears the cost. The S2 route applies only to state-provided (not private) treatment.

The S2 form acts as a form of payment guarantee – in the majority of cases, the patient is not required to pay anything themselves (other than any relevant statutory charges that would also apply to those ordinarily resident, for example prescription and dental charges in the UK).

Pensioners living abroad

Under the S1 scheme, pensioners settling in another EEA country or Switzerland are able to access healthcare services in that country on the same terms as ordinary residents. The S1 form is issued by the country that pays your pension, and must be registered in the country in which you now live.

The S1 scheme is mostly used for pensioners but may also apply to other groups such as posted workers and cross-border workers.

The UK Government acts on behalf of the UK as a whole to reclaim costs from other EEA member states under the S1, S2 and EHIC schemes.

Impact of Brexit

The UK is a net ‘exporter’ under the EU’s reciprocal healthcare arrangements, paying out more to other EEA countries than it receives. This is largely due to the greater number of UK pensioners living abroad. In February 2017, the UK Department of Health told the House of C0mmons’ Health Committee:

on an annual basis, we pay out roughly £650 million a year to cover the costs of UK‑insured pensioners in other EEA countries and UK visitors to those countries.


Of that, about £500 million is on pensioners, so that is UK‑insured pensioners, of which there are about 190,000 in other EEA countries. I think the figures there are 70,000 in Spain, 44,000 in Ireland, 43,000 in France and about 12,000 in Cyprus. Those are the main countries.

The above arrangements remain in place while the UK is still a member of the EU, but it’s not yet clear how things might change following the UK’s withdrawal. In evidence to the Assembly’s External Affairs and Additional Legislation Committee, the Welsh NHS Confederation said:

If the UK were to leave the EU single market, these systems would in principle no longer apply in the future, unless bilateral agreements were negotiated. Consideration should be given by negotiators to possible implications for patients and how to ensure that a fair alternative system is put in place, either with the EU as a whole, or with those EU countries, such as Spain, which have high numbers of UK nationals living there.

Non-EEA countries

The UK has reciprocal healthcare agreements with a number of individual countries outside the EEA. These agreements may provide for immediately necessary treatment for conditions which arise, or existing conditions which become acutely worse, during a temporary visit. The level of care which may be provided free of charge varies. As with the EHIC, it’s recommended that those travelling in other countries take out adequate travel insurance to cover their stay abroad.

Some reciprocal agreements may also provide for a limited number of referrals specifically for the treatment of pre-existing conditions (this would normally only apply where the referring country does not have adequate facilities to provide the treatment needed).

Further information

  • National Contact Points in each EEA country can advise patients on their rights under the EU arrangements.
  • Information about accessing planned or unplanned treatment in another European country can be found on the EU’s Your Europe website.
  • Further information and advice for people visiting or moving abroad, and for those seeking treatment in Wales, is provided by NHS Direct Wales.

See our June 2016 briefing for information on the cross-border healthcare arrangements between Wales and England.


Getting there on time? Evaluating the Welsh Ambulance Services’ Clinical Response Model

24 February 2017

Article by Paul Worthington, National Assembly for Wales Research Service

Darllenwch yr erthygl yma yn Gymraeg | View this post in Welsh

Ambulance driving along a road

Background to the new clinical response model

Ambulance services in Wales have seen significant and recent change. In April 2013 the Strategic Review of Welsh Ambulance Services (the McClelland review) set out a number of recommendations for improving services, including proposals for new ways of monitoring performance on ambulance response times.

Following on from the McClelland review, from 1 October 2015 Wales Ambulance Services NHS Trust (WAST) implemented a new clinical response model for a 12 month pilot period, which was later extended for an additional 6 months. It was intended that during this trial, only the most serious calls, categorised as Red (immediately life-threatening), have had a response time target. All other calls would receive an appropriate response, either face-to-face or telephone assessment, based on clinical need. The new model has three categories of calls:

  • Red: Immediately life-threatening (someone is in imminent danger of death, such as a cardiac arrest). The target is for 65% of emergency responses to arrive within 8 minutes;
  • Amber: Serious but not immediately life-threatening (patients who need treatment delivered on the scene and may then need to be taken to hospital);
  • Green: Non urgent (can often be managed by other health services) and clinical telephone assessment.

The new clinical response model has also been supported by the development of a series of Ambulance Quality Indicators (AQI), which are published on a quarterly basis and contain a more detailed set of performance measures, including patient experience and clinical outcomes.

Performance against the new targets

The most recent statistics on ambulance response times published by the Welsh Government are for January 2017; Table 1 below shows the trends and Table 2 sets out the figures for January 2017 by Local Health Board area:

Table 1: Average red calls per day, and the percentage arriving at the scene within 8 minutes, Wales


Table 2: Emergency ambulance responses in Wales to red calls, January 2017


The performance data for January 2017 also shows that:

  • There were 39,864 emergency calls, an average of 1,286 per day, 4.3% down on the daily average for December 2016.
  • Of the total, 1,980 (5.0%) were red, 26,456 (66.4%) were amber and 11,428 (28.7%) were green.
  • 75.4% of emergency responses to red calls arrived within 8 minutes, above the target of 65%, but down from 75.8% in December 2016.
  • Performance ranged from 66.2% in Powys to 79.5% in Cardiff & Vale.

Ambulance services inquiries during the Fourth Assembly

In 2015 the Fourth Assembly’s Health and Social Care Committee undertook a short inquiry into the performance of Welsh ambulance services; later in the same year the Committee held additional sessions to examine what progress had been made in response to its original recommendations. This was shortly after the pilot of the new clinical response model had commenced.

As a result of the follow-up inquiries, the Committee wrote to Welsh Government welcoming the fact that the all-Wales target for emergency response times had been met for the first month of new trial model. However, the Committee was concerned that significant regional variations persisted and stated that it would like to see these addressed as a matter of priority and that it expected to see sustained progress in relation to response times at the local and national level.

In his response, the Deputy Minister for Health welcomed the Committee’s recognition of the progress achieved since the initial 2015 inquiry and stated that:

I am proud that we took a step forward for patients by implementing a clinical response model pilot intended to prioritise patients who need an immediate clinical intervention. The pilot is designed to enable ambulance clinicians and resources to be despatched appropriately based on clinical need.

The response also noted the progress made month-on-month against the targets and the publication in January 2016 of the first set of the new AQIs. The Deputy Minister also noted in further correspondence to the Committee that:

During the year-long clinical response model pilot, the AQIs will be published quarterly to allow a clearer understanding of trends and the impact of seasonal variation, sitting alongside the monthly publication of ‘Red’ response times. I can only re-iterate that the way we are sharing key information on ambulance services in Wales makes us the most transparent country in the UK and among the most transparent worldwide.

Review of the clinical response model

The Cabinet Secretary for Health, Wellbeing and Sport set out in a Ministerial Statement in September 2016 that the final evaluation report of the clinical response model was due in December 2016 and that he would make a final decision on the future of the pilot by the end of March 2017.

An interim report on the model received by the Emergency Ambulance Services Committee (EASC) in September 2016 had identified no significant areas of concern. The EASC has also received an update on the draft final evaluation report which indicates that:

…the removal of time based targets for the majority of calls has allowed for more efficient dispatching of ambulance resources, increased opportunities for hear and treat; and supported timely responses to patients with the greatest clinical need.

The EASC was due to have sight of the final evaluation report in January 2017, prior to its submission to the Cabinet Secretary for Health Wellbeing and Sport, who is due to make a statement regarding the evaluation to Plenary on 28 February 2017.

Image Source: Image from Flickr by Diluvienne. Licensed under Creative Commons.

Well-prepared? Dealing with 2016-17 winter pressures in Welsh health and social care services

27 January 2017

Article by Paul Worthington, National Assembly for Wales Research Service

View this post in Welsh | Darllenwch yr erthygl yma yn Gymraeg

Winter is always a busy time for health and social services, and there has been recent coverage of the pressures on these services, both in Wales and across the UK. Building on the work done during the Fourth Assembly, in Autumn 2016 the Health, Social Care and Sport Committee undertook an inquiry into how well prepared health and social care services in Wales were for winter 2016/17. A Plenary meeting of the Assembly’s on 1 February will be discussing the report on winter preparedness which was published by the Committee in December 2016.

Terms of reference for the inquiry

Ambulance driving through a street which has heavy snow on the pavements and part of the road.

Image from Flickr by Chris Sampson. Licensed under the Creative Commons

In seeking assurance that the Welsh NHS was equipped to deal with pressures on unscheduled care services during the coming winter, the Committee’s inquiry considered:

  • the current pressures facing unscheduled care services, and how well prepared the Welsh NHS and social services were for winter 2016/17;
  • whether there was sufficient progress in the Fourth Assembly in alleviating pressures on unscheduled care through integrated winter planning across health, social and ambulance services, and lessons learned; and
  • the actions needed to produce sustainable improvements to urgent and emergency care services, and the whole system, ensuring the Welsh NHS builds resilience to seasonal demand and to improve the position for the future.

The terms of reference included a focus on patient flow (including primary care out of hours, emergency ambulance services, Accident and Emergency (A&E) departments, and delayed transfers of care from hospital).

Evidence gathering

The Committee consulted on this topic – the responses have been published – and held a number of sessions where it heard evidence from a range of professional bodies and stakeholder organisations including local health boards, social services and representatives of domiciliary and care home providers.

A number of key themes emerged from the evidence the Committee received and heard:

  • Service integration: there was scope for better joint planning and delivery of services between health and social care, and there was limited involvement of the independent sector;
  • Demand: there are spikes in activity during the winter, but also significant and growing pressures all year round, driven especially by an ageing and frailer population – many of who have a number of complex needs. In addition, there are growing numbers of people with chronic conditions needing greater support from primary, community and hospital services. There was also evidence of increased numbers of children needing care for respiratory problems during the winter months;
  • Service capacity: concerns about the capacity available to meet this demand across health and social care, with pressure points including primary and community care, hospital beds and increasing concerns about the domiciliary and care home sector;
  • Workforce: difficulties in recruiting and retaining sufficient GP and hospital doctors, nurses and staff for domiciliary and care homes;
  • Delayed discharges: there is still a need to ensure people are able to be discharged safely, promptly and with the right support in place when they no longer need hospital care;
  • New models of care: there were calls for the development of new service models in primary and community care to avoid hospital admission, and different approaches to A&E services, potentially including primary care involvement and a possible role for ‘front-door’ physicians;
  • Learning and reviewing: The Committee heard evidence of positive developments in a number of areas, including ambulance services and schemes supported by the Intermediate Care Fund (ICF). However, there was a clear emphasis on the need to ensure lessons of good practice were more widely shared and adopted. Evidence also suggested potential for improved working in some areas, including in the flu vaccine programme, where uptake amongst staff remained low and greater clarity was needed on working arrangements in primary care.

The Cabinet Secretary and Minister provided written evidence to the Committee highlighting details of plans being put in place to relieve pressure on unscheduled care services and to deal with the winter season. This highlighted that planning had been undertaken –starting earlier than in previous years – at national and local level, involving local health boards, social services, the Welsh Ambulance service and others. At the same time, the Cabinet Secretary acknowledged to the Committee that “I think we’re as well-prepared as we can be, but that does not mean that the system is in a perfect shape and there is not further improvement that we would expect to make”.

The Committee’s recommendations

The Committee’s report set out a number of conclusions and recommendations to the Cabinet Secretary for Health Wellbeing and Sport and the Minister:

  • Securing greater integration of health and social care sectors should be a key priority for Welsh Government;
  • Options should be explored for enabling more effective working arrangements between GPs and pharmacists in national preventative initiatives such as the flu vaccination;
  • The Cabinet Secretary should ensure arrangements are in place to ensure that lessons learnt from effective services and Welsh Government-funded schemes are shared and learnt from;
  • The Cabinet Secretary should report back to the Committee on what the additional £50 million invested has achieved;
  • Research should be reviewed or commissioned into the effectiveness of primary care co-location in A&E departments;
  • Publication of market analysis of domiciliary and care home services, to provide a clear picture of the capacity and resilience of the sector;
  • Urgent consideration of the need for improved training, skills development and supervision across health and social care;
  • There should be clarity about long term funding of successful schemes financed by the ICF, details made available of how 2017/18 ICF funding will be used and what the expected impact will be.

New Publication: Access to Medicines

16 December 2016

Article by Elizabeth Norris, National Assembly for Wales Research Service

Darllenwch yr erthygl yma yn Gymraeg | View this post in Welsh

This factsheet (PDF, 461KB) provides a brief guide to Access to Medicines in Wales. It describes how medicines undergo an appraisal process prior to being made available to patients on the NHS. It also explains some of the ways patients can access medicines which are not routinely available on the NHS and new drugs which may be suitable for advanced or complicated health conditions.

Cover image for Access to Medicines paper









The Research Service acknowledges the parliamentary fellowship provided to Elizabeth Norris by the Engineering and Physical Sciences Research Council and Natural Environment Research Council, which enabled this blog post to be completed.

New Publication: Health Performance Indicators

16 November 2016

Article by Rebekah James, National Assembly for Wales Research Service

Darllenwch yr erthygl yma yn Gymraeg | View this post in Welsh

Our new briefing (PDF, 320KB) provides a guide to the targets and where statistics can be found for the main health performance indicators in Wales.