Feature Briefing

Are migrant patients really a drain on European health systems?

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6444 (Published 29 October 2013) Cite this as: BMJ 2013;347:f6444
  1. Sophie Arie, freelance journalist
  1. 1London, UK
  1. sophiearie{at}fmail.co.uk

All over Europe access to health services by migrants is being tightened, but does the evidence show this is necessary? Sophie Arie reports

What’s changing?

Britain is proposing to introduce a levy on temporary migrants from outside the European Economic Area (EEA), such as students and people on temporary permits (allowing them to work in the UK for six months to five years), who until now have had free access to the NHS. Students will be charged £150 (€176; $242) a year and others £200. The Immigration Bill also proposes that general practitioners should charge for services to short term migrants (those with permission to live in the country for up to six months), and illegal migrants, who currently have access to free primary care. And a better system is being created for retrieving costs that should be paid by foreign patients or by their countries under EU agreements.1

How does this compare with systems in the rest of Europe?

Many European countries are tightening access to healthcare for visitors and migrants as health budgets are squeezed. Since 2012, Spain has barred illegal migrants from receiving any healthcare except emergency care (including childbirth).2 In Spain, non-EU students pay €59 (£50; $80) a month for access to health services and those over 60 must pay €259 a month for the same access.3 In Greece, although healthcare has been free at the point of access, from January it will introduce e a €25 charge for entry to all hospitals and health centres (people earning less than €11 000/year are exempt) and a €30 charge for any interventions after an initial consultation as part of the country’s efforts to reduce its health budget.3

What does the European Union require?

Since 1971, EU regulations have obliged EU countries to provide the same access to healthcare for visiting EU citizens and non-resident migrants as they do for their own nationals. The costs are then supposed to be reimbursed by the visitor’s country of origin. Just as Britain is recognising it has difficulty retrieving the costs of treating other Europeans, a new European directive on cross border healthcare, which came into effect on 25 October, seeks to make it easier for Europeans to have treatments in whatever European country they choose,4 5 This allows people to choose, for example, to travel to countries that have shorter waiting lists for treatment or to be closer to their relatives during treatment. In most cases, a patient would pay for the treatment in a foreign country and be reimbursed by the health service in their home country for the sum that the same treatment would cost there.

Do migrants drain national resources?

In economic hard times, public opinion perceives migrants as a drain on resources.6 Yet several recent studies conclude that the majority of migrants travel for work, many paying taxes in the host country. “The fiscal impact of immigration is close to zero,” across the countries of the Organisation for Economic Cooperation and Development (OECD) according to the organisation’s International Migration Outlook 2013.7 “Most immigrants do not come for social benefits, they come to find work and to improve their lives,” the OECD says. “Regarding healthcare expenditure, although little direct information is available, there are a number of indications suggesting that immigrants are on average less costly for the public purse than the native-born.”

Other studies point out that most migrants do not access healthcare in the host country because of lack of knowledge of the services available, bureaucratic hurdles, and language problems.8

So why are European visitors part of the problem?

In many EEA countries patients pay up-front for health services and claim back costs through social security and insurance programmes. Non-resident patients from other European countries are therefore obliged to pay for most care they receive and then claim back the costs from their own national health service. In the UK, care is free at point of entry so the onus is on the health system to secure the payment afterwards. In practice, UK hospitals often do not bill foreign patients because they do not have systems in place to pursue those payments even though trusts are liable for these costs if they cannot be recovered. The government’s latest research says that it spends £388m each year on patients who should be paying for their care and most of that— £305m—is incurred by patients from the European Economic Area.9

How much is too much?

A recent report from the European Commission attempts to assess the effect on health services of migrant EU citizens who have residency but do not work in the country they have moved to.10 The report finds that “non-active” EU migrants—that is, students, pensioners, spouses, and job seekers—represent a very small share of the total population of migrants resident in each member state.

“On average, the expenditures associated with healthcare provided to non-active EU migrants are very small relative to the size of total health spending or the size of the economy in the host countries,” the report says. The commission estimates that on average, the costs of treating this group amount to 0.2% of total health spending. Cyprus has the highest costs for this group—close to 4% of total health spending, followed by Ireland (2.3%), UK (1.1%), and Malta (1%).

In the UK, this translates to €1.8bn annual spending on this group. The EU sees this as a relatively small amount compared with the overall size of national economies and points out that most “non-active” EU migrants live in working families who are paying taxes. But the government is concerned that these EU citizens should not be using NHS services without personally contributing to them. And the numbers of unemployed EU citizens resident in the UK and other EU countries have been growing in recent years (in the UK there was a 42% rise between 2006 and 2012, from 432 000 in 2006 to 612 000 last year).

Elderly migrants

France has the largest share of “non-active” EU migrants who have lived in the country for over 10 years (71% in 2012). Many of those are UK pensioners. France has changed its system in recent years so that foreign pensioners now must have health insurance as a condition of residency.10 Until 2012, EU pensioners in Spain often needed only to be registered as residents in a municipality to access the Spanish healthcare system. Now to register as residents they too must provide evidence of minimum resources and healthcare insurance.

So who are the “health tourists” the government is concerned about?

The EU says there is little evidence to suggest that the “main motivation of EU citizens to migrate and reside in a different member state is benefit-related as opposed to work or family-related.” The commission says it has called on the UK to provide evidence of so called benefit tourism among this group and so far has not received any.

Details on those who travel to the UK deliberately to use the health services without paying for them are hard to find, and the government’s latest research does not specify numbers of people who use the system this way. The research estimates that the cost of treating people who deliberately travel to the UK to get free NHS treatment is between £70m and £300m.11 It also refers anecdotally to problems reported in different trusts of west African women suspected of travelling to the UK to make use of maternity services.

What about British patients who travel for healthcare elsewhere?

Research published in PLoS ONE on 24 October suggests that Britain in fact exports more health tourists than it imports.12 The study by researchers at the London School of Hygiene and Tropical Medicine and the University of York found that only 7% of patients at 18 NHS foundation trust hospitals were international private patients and that their treatment generated £42m for the trusts involved, almost a quarter of the trusts’ private income. In 2010 an estimated 63 000 UK residents travelled abroad for treatment, while around 52 000 patients came for treatment in the UK. The number of patients travelling to the UK has remained relatively stable over the past decade, while there has been a substantial increase in the number of UK residents travelling abroad for medical treatment. However, this research only compares figures for health visitors who pay in full for the services they use.

Illegal migrants and access to healthcare

Most countries have laws that give illegal migrants the right to free access to essential healthcare. Many countries have reduced access for non-documented (illegal) migrants recently. In Spain, they have not had access to any healthcare since 2012. In the UK, undocumented migrants have access to primary care services, but the government is proposing they should pay for that. In Belgium, illegal migrants can access healthcare only by going through a series of bureaucratic steps, which often prevents them from doing so. One of those is a mandatory visit by authorities to the applicant’s home to establish financial hardship. Many undocumented migrants do not apply because they do not wish to impose that visit on the people who are hosting them. Organisations like Médecins du Monde provide vaccination programmes for undocumented migrants.

Germany is one of the few countries in which doctors, social workers, and civil servants can face legal action if they fail to report illegal migrants.13 A report from Médecins du Monde, which provides care to people unable to access health services in seven countries of the EU, found that many do not seek care for fear of being reported to immigration authorities.3


Cite this as: BMJ 2013;347:f6444


  • Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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