Many British people living in other EU countries return to the UK for routine doctors’ visits, and many fail to register with a local doctor in their new country, particularly in the early stages following a move abroad. In some countries, bureaucracy means registering with local health authorities can take years.
But under new rules that come into force this month, people who make use of the NHS in the UK will be asked to declare that they are 'ordinarily resident' in the country.
Those who live elsewhere in the EU, Norway or Switzerland, and who want planned treatment could find themselves forced to pay up-front.
"Free NHS treatment is provided on the basis of someone being 'ordinarily resident'. It is not dependent upon nationality, payment of UK taxes, national insurance contributions, being registered with a GP, having an NHS number or owning property in the UK," read a statement issued by the Department of Health.
Even expats seeking emergency treatment during short visits home could also face steep charges if they don’t have their paperwork from their new country in order, as the NHS seeks to claw back £500 million a year (€695 million, ($746 million) in lost revenue.
Claire*, from London, has lived in Italy for two years, but still isn’t registered with an Italian doctor. When she needed a smear test recently, she opted to have it with her old doctor in London.
"I wanted to speak to an English doctor who I could speak with, felt comfortable with and I knew. And I knew it would be swift," she told The Local.
"I haven’t registered with an Italian doctor as I haven’t got a residence permit in Italy yet, due to the kinds of bureaucratic delays that are typical in Italy. Without residency, I can’t register with the health service.”
Likewise in Spain, some new arrivals find that bureaucratic or language hurdles mean they have felt 'locked-out' of the heathcare system in their adopted country. The new regulations could leave people like them seeking private healthcare as the only option.
Joe Coaker of ALC Healthcare, a private insurer focused on expats, says Claire’s case is not unusual.
"We often hear from expatriates who question the need for international health insurance as they imagine they can return to the UK and fall back on the NHS or the State healthcare in whichever country they come from," he said.
Long-standing European arrangements state that EU citizens should seek healthcare in the country they live in, regardless of their citizenship. They can seek healthcare in other EU countries, but this must generally be authorised and billed back to their country of residence.
But in a change to UK rules, expats who want treatment in the UK have to show a European Health Insurance Card (EHIC) issued by their new country. Until this month, former UK residents were automatically entitled to use the NHS for free if they fell ill during a visit. In practice, many expats use the NHS for planned treatment too. But now this right is being removed.
In an email to The Local, the UK Department of Health confirmed that there is no 'grace period' following a move during which they can use the NHS - the moment they have left the country they lose their right to NHS treatment.
The charges faced by patients without an EHIC card or proper insurance can be significant. Intensive care beds are charged at a rate of £1,800 a day (€2495, $2683) plus the cost of procedures and drugs.
Even hospital outpatient visits can be costly, at £248 per visit (€348, $369). The Royal Berkshire NHS Trust, one of 59 NHS Hospital Trusts in England, says on its website that patients who leave a debt could find their details registered with the UK Border Agency, meaning they could be stopped next time they try to enter or leave the country.
David Harris, a registered insurance advisor focusing on expats in Spain and worldwide, says that the worry is for those British expats in Spain who don’t realize that they will need a Spanish issued EHIC.
He told The Local that expats deciding to legally stay in Spain "could be in for a rough ride" because it isn’t always straightforward to apply for the EHIC in Spain.
He provides some advice and links on how to start the process here.
However it will come as a relief to the tens of thousands who retired to Spain after spending their working lives in Britain that the new regulations do not affect UK state pensioners - as long as they fill in the correct paperwork.
"They will now have the same rights to NHS care as people who live in England. This applies to all pensioners who receive a UK state retirement pension and registered for healthcare in Europe with an S1 form," said the Department of Health guidelines.
Treatment in A&E departments and at GP surgeries will remain free for all under the guidelines.
A spokesman for the British Embassy in Madrid said: "Most expats visiting the UK will continue to get free NHS care provided they have a European Health Insurance Card (EHIC) issued by Spain – so they should make sure they get one, make a note of its expiry date and renew it before it runs out."
The good news for those who have relocated to Spain is that once the bureauratic hoops have been overcome they can expect world class healthcare.
Although beleaguered by cuts in public spending as Spain has weathered the economic crisis, its healthcare system was ranked seventh in 2000 on the only occasion the World Health Organisation has compiled a league table. The UK was 18th.
Regardless of that, some expats believe they should be allowed to choose where they want to receive healthcare, considering that in many cases they have divided their working life between the UK and Spain and therefore paid their taxes in both countries.
"If I was to fall seriously ill or needed a procedure that required a lengthy period of recuperation then I would prefer to have the treatment in the UK and that’s not because I am snooty about the healthcare system here in Spain," said Julia* an English teacher in her mid-fifties who has been living in Madrid for eight years.
"I have paid taxes in both places so I would like the choice. The Spain system presumes you have the family support network here and I don’t," she told The Local. "It would just be practical to be near relatives if I needed support."
*Not their real names