Brexit FAQs: Health

The EU-UK Trade and Cooperation Agreement largely preserves the reciprocal healthcare arrangements between the UK and the EU. This means that UK-residents on holiday in EU countries can still access emergency or necessary medical care for the same cost as a resident in the country they are visiting. Previously, reciprocal healthcare was also available for those visiting Iceland, Liechtenstein, Norway and Switzerland, but that is no longer the case at present.

People with existing UK-issued European Health Insurance Cards (EHIC) which have not expired can continue to use them in EU countries to access necessary healthcare during temporary stays.

People applying for new UK-issued cards from 1 January 2021 will do so under the UK’s new Global Health Insurance Card (GHIC) scheme. GHIC covers necessary healthcare during temporary stays in EU countries only. Some specialist treatment, such as kidney dialysis and chemotherapy, will require to be agreed in advance. UK residents can apply for a free GHIC card here.

Some people are eligible for a new UK-issued EHIC (which does include cover in Iceland, Liechtenstein, Norway and Switzerland). These people include EU/EEA citizens resident in the UK before 1 January 2021 who have rights protected under the Withdrawal Agreement and associated agreements. Details of who can apply for a new UK EHIC are available on the NHS Business Services Authority website. Old-style UK EHICs are now not valid in the additional countries, so a new card should be applied for.

Entitlement to an GHIC is not based on nationality. The UK operates a residency-based healthcare system (in the form of the NHS), which means access is generally determined by residency and not by the past or present payment of National Insurance contributions or UK taxes.

• A resident in the UK who is not insured by another EU country, Norway, Iceland, Liechtenstein or Switzerland, is likely to be considered to be insured by the UK and will be entitled to a GHIC.
• However, a resident in the UK who is insured by another country in the EU, Norway, Iceland, Liechtenstein or Switzerland is not entitled to a GHIC.

Access to healthcare for UK residents in the EEA was subject to EU social security coordination regulations, so eligibility for access to healthcare was tied to these. This is a very complex area and access to healthcare for UK residents in the EU is linked to more general residency, welfare and employment entitlements.

The UK Government states that if a UK citizen was legally resident in an EU country before 1 January 2021, their rights are protected by the Withdrawal Agreement, meaning that people will have broadly the same rights to access public services, including health care, that they had previously, and depending on the country they are living in. However, the UK Government has provided detailed guidance for each country. The guidance states that a new application for residence status might be required to secure those rights and entitlements.

Rights to healthcare will continue, as under the Withdrawal Agreement if someone is resident in the UK under the S1 scheme – which provides a certificate of entitlement to healthcare in EU countries. However, UK citizens should read the country by country guidance because accessing entitlements will depend on being correctly registered as a resident in each country. The Government advises that people ensure that they check procedures in the country they are living in.

If a UK citizen decides to return permanently to the UK to live, their rights to access healthcare have not changed and are in place.

EEA citizens currently living in the UK will continue to be able to access health and social care, because eligibility is based upon residency. However, EU citizens who start to live in Scotland from 1 January 2021 are not protected by the Withdrawal Agreement, and they cannot apply to the EU Settlement Scheme (EUSS). Citizens living here before 1 January, must apply to the EUSS by 30 June 2021, unless someone has indefinite leave to enter or remain in the UK. Irish citizens can apply, but do not need to. One of the benefits of the EUSS is being able to use the NHS for free.  More information can be found on the mygov.scot site: EU citizens living in Scotland after Brexit.

People moving to the UK from 1 January 2021 must apply through UK Government immigration process – permits or visas might be required. People should also apply for an S1 certificate and might have to pay the ‘immigration health surcharge’ – a condition of acquiring a visa that allows access to NHS services and provides access until the visa expires. S1 certificate holders do not have to pay the surcharge. Payment amounts vary. This gives people the same access rights as residents in the different UK nations, according to the charging in each country. For example, in England prescription charges are paid for, in Scotland they are not.

See (Will UK citizens visiting an EEA country be able to access health care?)

Valid (in date) EHIC cards will remain valid for visitors to the UK. People are still advised that they should have valid, comprehensive health insurance cover before visiting the UK or they are likely to be charged for any treatment they receive. For further information see UK Government guidance. The guidance also advises that visitors bring any other proof of eligibility they have, such as S1 or S2 forms. If proof of eligibility, such as an EHIC card, can’t be shown, a person might be charged, and at a rate of 150% of the national NHS rate. Emergency treatment would still be provided but would be charged for afterwards. Norwegians are entitled to medically necessary healthcare in the UK on production of a valid Norwegian passport because of a separate deal signed in January 2020.

Because eligibility to use NHS services for free relies on being resident in the UK, UK citizens living in an EEA country will not be able to travel to the UK to access NHS services, except through the S2 route, which is still operating under the Withdrawal Agreement i.e. eligibility continues to apply to those who were resident before 1 January 2021. UK citizens abroad in the EEA will need to pay for their treatment if they come to the UK, and will need to arrange cover for healthcare costs according to the local rules in their home country.

Some former UK residents do not have to pay for NHS treatment when visiting UK. This includes UK war pensioners, UK government employees, and UK nationals living in the EU on or before 31 December 2020.

The UK Government wrote to suppliers of medicines and medical product suppliers on this topic, on 17 November 2020. Because it was unknown what border checks would be in place, the UK Government indicated alternative routes for supplies, in the event of any delays. Health supplies are included in category 1 goods – Goods “critical to preservation of human or animal welfare and/or national security for the UK”. It includes the following:

“Department of Health and social care

• human medicines, covering prescription-only, pharmacy and general sales list medicines, clinical trials and children’s vitamins (for import and export)
• medical devices and clinical consumables (for import and export)
• vaccines (for import only)
• nutritional specialist feeds, including infant milk formula (for import only)
• biological materials such as blood, organs, tissues and cells (for import only).”

The letter contained advice, contingency planning, information on buffer stocks and links to other information.

The Nuffield Trust has compiled a helpful Q&A on how Brexit will affect the supply of drugs to the UK. (Also published in the British Medical Journal on 6 November 2020).

Suppliers were asked to build up a six-week stockpile ahead of the previous possible no-deal exit dates in 2019. Suppliers were advised to do so again, ahead of the end of the transition period on 31 December 2020.

The Nuffield Trust’s Q&A provides the following answer to the question of supply of medicines and stockpiling by suppliers (i.e. not pharmacists):

“ Trade data from last year suggest firms were able to build up a sizeable stockpile quickly just ahead of planned exit dates. The size and frictionless nature of the single market made it relatively easy to shift stocks into the UK as long as we were members, which we are until 31 December.

There is now a risk, however, that the exceptional demands and disruption caused by covid-19, and the need to rebuild the separate pandemic stockpile at the same time, may make this harder for some drugs. Again, medical devices and clinical consumables may be more of a concern, particularly given the higher need for items such as personal protective equipment (PPE) in caring safely for patients with covid-19.”

At time of writing, it does not appear that there are any Brexit-related supply issues so far, which may reflect the advice to wholesalers to stockpile. However, as in other areas, increased paperwork and uncertainty about requirements might lead to some delays in the importing of certain medicines and medical devices. Further information was made available to NHS organisations by letter on 10 December 2020.

Wholesalers in the UK that import medicines may require a Responsible Person (Import) (RPi) to be identified in order to import certain Qualified Person (QP) certified medicines from the EEA into the UK from 1 January 2021. This relates to ensuring products are properly certified by a ‘Qualified Person’. The RPi and the QP can be the same person, and must be registered by the Medicines and Healthcare Products Regulatory Agency. A further blog will provide more detail on changes to medicines and medical device regulation following Brexit.

According to news reports, prescriptions for a particular medicinal cannabis oil from the Netherlands to treat epilepsy in children were not being fulfilled because of supply issues in the Netherlands. The UK Health Secretary is aware of the issue. This appears to be related to UK issued prescriptions and their validity in EU countries post Brexit. Prescriptions are subject to the rules of the country where they are dispensed, so it is a matter to be resolved between the UK and the Netherlands.

Will COVID-19 vaccine supply chains be disrupted?

It is difficult to say with any certainty whether the UK’s exit from the EU will lead to delays in receiving shipments of vaccines. It also depends on which vaccine will be most widely adopted. The Oxford/AstraZeneca vaccine is being manufactured domestically and is therefore not susceptible to delays and disruption at ports and borders. Reuters published a report in December about vaccine supplies post-Brexit.

“The drug substance is made in Britain by Oxford Biomedica and Cobra Biologics and then sent to other companies for “fill-and-finish” packaging. An all-UK supply chain would see fill-and-finish being provided by Wockhardt in Wales.

However, the Pfizer/BioNTech vaccine which was approved and deployed first in the UK is imported from Belgium.

It is difficult to say with any certainty whether the UK’s exit from the EU will lead to delays in receiving shipments of vaccines. It also depends on which vaccine will be most widely adopted. The Oxford/AstraZeneca vaccine is being manufactured domestically and is therefore not susceptible to delays and disruption at ports and borders. Reuters published a report in December about vaccine supplies post-Brexit.

“The drug substance is made in Britain by Oxford Biomedica and Cobra Biologics and then sent to other companies for “fill-and-finish” packaging. An all-UK supply chain would see fill-and-finish being provided by Wockhardt in Wales.

However, the Pfizer/BioNTech vaccine which was approved and deployed first in the UK is imported from Belgium.