Tuesday, 7 July 2009

Reciprocal Health Agreements - the 1950s

With the recent cancellation of the reciprocal health agreement , I thought it might be interesting and instructive to look at the past history of the agreement. It begins in the 1950s, when Nye Bevan was the UK Minister for Health, and was asked some questions by a very young Mr Edward Heath (later to be Prime Minister in the 1970s).

Aneurin Bevan was very much the architect of the British National Health service and resigned later of the issue of introducing charges for dental care and spectacles. In his ground breaking book, "In Place of Fear", which is still in print, he summarises the principles for State health care: "The collective principle asserts that... no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means."(1)

It is interesting to contrast the no compromise attitude of Dawn Primarolo today with Bevan's more generous attitude back then - "If we are to have reasonable arrangements with other countries it is better to start off in an atmosphere of conciliation rather than of threats." Here is the exchange from Hansard (2):

Mr. Heath
asked the Minister of Health what reciprocal arrangements have been made during 1950 with other countries whereby British citizens may receive Health Service benefits without payment when abroad.

Mr. Bevan
Arrangements providing for varying degrees of reciprocity have been or are being made with the following places outside the United Kingdom-Isle of Man, States of Jersey and Guernsey, Belgium, France, Luxemburg, the Netherlands.

Mr. Heath
As there are comparatively few countries on that list, can the right hon. Gentleman say what the reason is for the small number? Is it generally the time taken to work out the arrangements, or is it that the other countries are unable to offer facilities? Will he press this as hard as he can, especially in view of the fact that it affects many merchant seamen who are away from this country for nine months each year and who pay their contributions but cannot get the benefits?

Mr. Bevan
We are trying to do this, but other nations have not got our advanced facilities.

Mr. Gerald Williams
Will the right hon. Gentleman use his bargaining power by threatening not to treat foreigners in this country or, alternatively, asking foreign countries to subscribe a lump sum for the services which their people receive here?

Mr. Bevan
If we are to have reasonable arrangements with other countries it is better to start off in an atmosphere of conciliation rather than of threats.

Mr. Heath
asked the Minister of Health if he will now make regulations under the National Health Service (Amendment) Act, 1949, whereby foreign residents visiting this country will have to pay a charge for using the Service.

Mr. Bevan
I am keeping this under review, but am not at present satisfied that there is enough evidence of abuses to justify action.

Mr. Heath
In view of the fact that the Minister said, in answer to an earlier Question, that most other countries do not have the facilities which we have here and that, therefore, reciprocal agreements cannot be made, how long is this one-way traffic in benefits to continue; and why does the right hon. Gentleman not use the powers which he took in the 1949 amending Act?

Mr. Bevan
It was made perfectly clear that the powers were being taken only to deal with abuse if it arose. I can assure the House that if I tried to take or use power to deal with the very small number of cases that might exist, the expense of administration would be far more than the gain to the Health Service.

Mr. Shepherd
Can the right hon. Gentleman tell the House what was the expense last year so far as foreign nationals were concerned?

Mr. Bevan
No, because if I was able to say what the cost would be I would have the administrative machinery that I suggested. We can only make a guess, and our guess is that it is a very small proportion indeed. My right hon. Friend the Home Secretary prevents the entry into this country of people who come only to use the Health Service.
The matter resurfaced in 1951, by which time Hilary Adair Marquand was Minister for Health. Despite the Jersey sounding name, he was in fact from a Welsh family (although there may have been a distant Channel Island connection). It is at this time that the arrangements with Jersey are mentioned as having been completed. Notice the reply that "I am satisfied that the cost of ascertaining whether a person is a foreigner or not would far exceed the present cost of providing him with treatment." The final riposte about proof of origin being on a "doctor's list" is rather amusing.
Mr. Nabarro
asked the Minister of Health which British Dominions and foreign countries are now providing visiting British nationals with facilities reciprocal to the National Health Service; the progress of negotiations for a wider measure of reciprocity; and the general nature of the response from Dominion and Foreign Governments.

Mr. Marquand
Arrangements for medical assistance to indigent persons in the Western Union countries have been ratified so far by Belgium and the Netherlands. Otherwise, there are no reciprocal arrangements with other countries, nor any being negotiated, although there are certain arrangements with the Isle of Man and with Jersey and Guernsey.

Mr. Nabarro
In view of the fact that those reciprocal arrangements apply to only one foreign country, would the right hon. Gentleman consider charging all foreign nationals visiting Britain for the benefits they receive under this service unless they come from this one foreign country?

Mr. Marquand
I am satisfied that the cost of ascertaining whether a person is a foreigner or not would far exceed the present cost of providing him with treatment.

Mr. Langford-Holt
When the right hon. Gentleman says that no negotiations are taking place, does he mean that negotiations which were started have broken down or that no negotiations have been initiated?

Mr. Marquand
I am not aware that I referred to negotiations. I said there were no reciprocal arrangements with other countries. I beg the hon. Gentleman's pardon; I said that no arrangements were being negotiated. I must have notice of the hon. Gentleman's question.

Mr. Nabarro
What proof would be necessary in such circumstances? Presumably if a patient is not on a doctor's list he cannot be an English national, but must be a foreigner. Is that not so?

Mr. Marquand
If I go to Blackpool for my holidays I do not become a foreigner.

Lastly, in 1957, it is interesting to note that a question is asked about the other side of the reciprocal deal - what does the UK resident have available in Jersey. This was purely a reciprocal arrangement of free care, unlike the later agreements with the UK, Jersey received no financial assistance from the UK until it pressed to do so as a result of the increased tourism boom (and consequent medical needs) which took off in the 1960s. It is probably that if this simple "swap" had remained the agreement, it may well have been retained to this day. The problem with the tourism "charge" on health was that it remained much the same, while it was clear to the most obvious observer that the tourism figures had haemorrhaged after the advent of cheap package holidays, and by the late 1980s, was showing a significant decline.
Mr. Russell
asked the Minister of Health to what extent reciprocal arrangements are in operation in the Channel Islands for free medical treatment for United Kingdom residents or visitors.

Mr. Vaughan-Morgan
A free general practitioner service is available to visitors from Great Britain to Guernsey (including Alderney), which includes medical services, drugs and appliances but not dental or (except in emergency) ophthalmic treatment, and also in-patient hospital treatment. In Jersey, in-patient and outpatient hospital treatment is available.

Mr. Russell
Does not my hon. Friend agree, therefore, that we are under an obligation, almost, to give free Health Service treatment, certainly medical treatment, to visitors from the Channel Islands?

Mr. Vaughan-Morgan
Yes, that is quite correct, and we do have a reciprocal treaty. I should have added that, unfortunately, no reciprocal arrangements exist with Sark.

Reciprocal agreements are still possible, for example, only in 1997, the Australian government negotiated such an agreement with Malta (5). By 2004, the Australian Government noted the following such agreements with different countries:

United Kingdom 1 July 1986
New Zealand 1 September 1999 (amended)
Malta 6 July 1988
Italy 1 March 1986
Sweden 1 May 1989
Netherlands 3 January 1992
Finland 1 September 1993
Republic of Ireland 25 May 1998
Norway 1 March 2004

A reciprocal agreement with Denmark is being finalised and is anticipated to come into force in 2005. A draft agreement has been reached with Belgium and negotiations are ongoing with Slovenia.

The Agreements with the United Kingdom, the Netherlands, Sweden, Finland, Italy, Malta and Norway provide free care as public patients, subsidised out-of-hospital medical treatment (visiting a doctor) under Medicare and subsidised medicines under the Pharmaceutical Benefits Scheme.

Other places too still have reciprocal health agreements - Madeira, Canary Islands, Spain - all have some reciprocal arrangements. At present the climate is not right, the health authorities in the UK too intransigent, but perhaps the best approach might be to seek to negotiate reciprocal agreements with other countries on a fair basis of mutual care, and then return to see if the UK can be persuaded that such an agreement need not be a "rip-off" for the UK taxpayer.
(1) http://www.sochealth.co.uk/history/nye.htm
(2) http://hansard.millbanksystems.com/commons/1950/nov/09/benefits-reciprocity#S5CV0480P0_19501109_HOC_137
(3) http://hansard.millbanksystems.com/commons/1951/mar/15/reciprocal-arrangements#S5CV0485P0_19510315_HOC_101
(4) http://hansard.millbanksystems.com/commons/1957/jun/03/channel-islands-reciprocal-arrangements#S5CV0571P0_19570603_HOC_117
(5) http://www.health.gov.au/internet/main/publishing.nsf/Content/health-archive-mediarel-1997-mw8797.htm
(6) http://www.health.wa.gov.au/circulars/circular.cfm?Circ_ID=11976

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