Call for new reciprocal health deal for Jersey and UK

STATES OF JERSEY

RECIPROCAL HEALTH AGREEMENT

WITH THE UNITED KINGDOM:

NEGOTIATIONS

Lodged au Greffe on 31st March 2010

by Senator A. Breckon

STATES GREFFE

PROPOSITION

REPORT

Introduction

Background

Financial and manpower implications

APPENDIX A

B.I.P.A. Cavan Transcript

TUESDAY, 23 FEBRUARY 2010 The Assembly met at 9.37 a.m.

PLENARY BUSINESS

Reciprocal Health Agreement with Isle of Man

The Co-Chairman (Mr Niall Blaney TD): Order, order. The Assembly will

now resume in public session. Item 1 is on the reciprocal health agreement with the

Isle of Man. I ask Andrew Mackinlay to introduce the motion.

Mr Andrew Mackinlay MP: I beg to move

That the British-Irish Parliamentary Assembly calls on the United Kingdom Secretary

of State for Health to defer the cancellation of the Reciprocal Health Agreement with

the Isle of Man planned for 1 April 2010 and to review the decision to abrogate the

arrangement, a decision which will not only be unfair to residents of the Isle of Man

but also substantially disadvantage United Kingdom residents and voters and in

particular the elderly, the chronically disabled and motorbike enthusiasts; believes that

Age Concern and all the major disability pressure groups and charities should be

consulted as part of the review; asks that the review be at ministerial level with the

Health Ministers of the Isle of Man, Scotland, Northern Ireland and Wales as well as

the United Kingdom Justice Secretary, who has responsibility for the bilateral and

constitutional relationships between the United Kingdom and Crown Dependencies;

demands that the details and totality of the costs of the reciprocal agreement to both

jurisdictions be published; seeks an explanation of the constitutional basis upon which

the Secretary of State relies to abrogate the existing agreement on behalf of Scotland,

Northern Ireland and Wales; and requests that the United Kingdom Secretary of State

for Health makes a statement on the modalities by which it is proposed to collect the

costs of emergency admissions and hospitalisation in each jurisdiction if the existing

agreement is terminated.

Colleagues and Co-Chair, I am very pleased to move the motion, and I do so

in the belief that it is wholly within the footprint of the terms of reference of this

Assembly. The decision by the United Kingdom Government arbitrarily to end the

reciprocal health agreement between the Isle of Man and the United Kingdom impacts

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on all our jurisdictions, including the Irish Republic, in my submission. The motion

refers to the Isle of Man, but the issue also relates to our colleagues in Guernsey and

Jersey, who have already endured and suffered the arbitrary ending of their

comparable health agreements with the United Kingdom. I am proud to have worked

closely with our colleagues Senator Alan Breckon from Jersey, Deputy Graham Guille

from Guernsey and Speaker Steve Rodan from the Isle of Man. Also from the Isle of

Man is David Cannan, a member of the House of Keys, although he is not here today.

A great campaigner, who is not in Parliament, is Eddie Power. We have worked

together on the matter, because we think that the decision is not just unfair—it is

potty; it is bonkers.

The arbitrary decision to end the reciprocal health agreement between the UK

and the Isle of Man has not been thought through, and it is not buttressed by any

evidence that there is a cost disparity, despite Ministers saying that there is. I have

challenged them in the House of Commons to demonstrate it, but they have singularly

failed to do so. In my view, it was a rather mean, knee-jerk decision, either by officials

or by Ministers—I know not—but we need to get it reversed or, at the very least, as

the motion proposes, deferred, so that mature reflection may be held and a view taken

on the impact not just on the people of the Isle of Man but on my constituents and

those of others in the Assembly.

The impact of this arbitrary decision, which is due to come in force on 1 April,

will fall on the elderly—on the grandfathers and grandmothers who want to visit

families in the United Kingdom. It affects the chronically sick and disabled, who will

either have to pay a disproportionately high cost or who will not be able to get health

insurance in order to travel to the UK. The decision impacts on us all, as it works both

ways. It means that our constituents who visit the Isle of Man in future stand in danger

of being billed for hospitalisation if they are admitted to hospital as a matter of

urgency and have to receive treatment.

A classic example is somebody who suffers a heart attack. They will be billed

if the decision and the proposed change on 1 April are not kicked into touch. Let us

consider folk who travel to the Isle of Man from Liverpool, Glasgow, north Wales,

London or Belfast to attend the annual TT races, for instance, if they are motorcycling

enthusiasts—or they may simply wish to visit this wonderful Celtic-Viking heritage

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island. If they have an emergency hospital admission, they could be faced with an

astronomical bill, in addition to the anxiety that they will have experienced through

their illness.

There is also an important constitutional issue. It seems that officials in

London and the Ministers who are involved have not taken cognisance of the new

constitutional conventions and dispensations. The decision to tear up the reciprocal

health agreement with the Isle of Man, and with Guernsey and Jersey for that matter,

was taken without consultation with the other UK Health Ministers: Nicola Sturgeon,

Michael McGimpsey and Edwina Hart were not consulted about the decision but were

told by the Westminster Minister. That raises the question whether the Westminster

Minister, who is, basically, the English Health Minister, has the right or capacity to

make a decision on behalf of the other three Health Ministers in the United Kingdom.

I believe that the Westminster Minister does not have that right, and it is ridiculous

that they should be able to take such a decision, because the impact will clearly also be

felt in Northern Ireland, Scotland and Wales. When Almighty God decided, “Oh,

there’s a bit of space there in the Irish Sea—I’ll put the Isle of Man there,” he put it

there, and the decision clearly has an impact on visiting by people from Dublin,

Belfast, the west of Scotland, north Wales and north-west England. Constitutionally,

the decision is a great offence.

I have a further point about the support for the motion. Many ex-services

organisations in the Isle of Man are campaigning and seeking our support to get the

decision reversed. They feel affronted, after the service that has been given and is

being given by Manx people to the United Kingdom armed forces, in days gone by

and now, in current conflicts and peacekeeping operations.

I hope that, if we pass the motion unanimously, you, Co-Chairs, and Paul

Murphy in particular, will raise the matter with some expedition with the United

Kingdom Government, both with the Secretary of State for Health and with the

Secretary of State for Justice, who is supposed to be the custodian of the constitutional

conventions between London, Belfast, Edinburgh and Cardiff, to get the decision

postponed, so that we can all pause, so that people will not be put in jeopardy from 1

April, and so that the Isle of Man, together with Guernsey and Jersey, can reach a new

reciprocal agreement that endures into the next century.

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The Co-Chairman (Rt Hon Paul Murphy): Thank you, Andrew, for an

impassioned address on an important issue. I have a great deal of sympathy,

incidentally, with the points that you make.

This is an important debate, but I ask colleagues to restrict themselves to a few

minutes, as we have a lot of business today. That will allow us to call as many people

as possible who are interested in the subject.

9.45 am

Rt Hon The Lord Dubs: I congratulate Andrew Mackinlay both on his

initiative and on the way in which he put forward the argument. We will miss you,

Andrew—you are a valuable member of this Assembly. [Applause.] Lord Cope raised

the issue in the House of Lords, and I pitched into the debate. I felt that the British

Government response was weak and unconvincing, such that if there is a bit of a push

they will give way. It is our job to push hard.

Dr Dai Lloyd AM: I, too, commend Andrew Mackinlay for his motion and

all his hard work to date. The Welsh Minister for Health and Social Services tells me

that she knew nothing of the issue until a couple of weeks ago, when I discussed

whether I should support Andrew Mackinlay’s motion. Devolution has happened in

these islands, health is a devolved issue for us in Wales and we do not expect

decisions to be made on health matters by outside Governments or jurisdictions. We

are naturally shy, timid and restrained, but there is an undercurrent of anger regarding

the situation. We jealously guard the status of health as a devolved matter. We are

always saying that certain Whitehall departments do not see Wales on the radar, and

this is a case in point. I strongly commend Andrew Mackinlay’s motion to the

Assembly as the motion calls for the cancellation to be deferred to allow a pause and a

period of mature reflection by all the Health Ministers who are involved.

Diolch yn fawr.

Mr Robert Walter MP: I, too, commend Andrew Mackinlay for lodging his

motion. The situation is rather like the debate on the common travel area in that a

unilateral decision has been made by one Government that goes against the spirit of

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east-west dialogue and the spirit of what the Assembly is here for. It is therefore right

for us to debate the matter.

Andrew Mackinlay described the process as “bonkers”. I believe that it is

mathematically and financially illogical. If I am correct—I googled it this morning—

the population of the Isle of Man is about 80,000. If all those people travelled to the

United Kingdom and fell ill, there might be a problem but, on the other side of the

equation, about 300,000 tourists visit the Isle of Man each year from Great Britain and

Ireland. In fact, if we add the Irish tourists, the total is more than 300,000. The balance

of the risk to the health system is therefore very much in the UK’s favour. People do

not usually travel when they are ill, so the likelihood of their falling sick is reduced.

Not only that, but the Isle of Man purchases elective health care from English health

trusts. I do not think that the Department of Health has properly taken that additional

money into account.

I just happened to be in Malta last week, and I asked the British High

Commissioner in Malta what the arrangements were there, because Malta is another

island that receives many tourists and visitors from the United Kingdom. The 450,000

people a year that it receives from the United Kingdom are treated as if they are

Maltese under the reciprocal arrangements for European Union health care. If the

entire Maltese population went to the United Kingdom, it would comprise only

400,000 people. Not only that, but the elective surgery that is carried out in the United

Kingdom for Maltese people is done for free. That is all the serious stuff. The position

is probably similar to the Isle of Man’s arrangement. Each year, some 180 serious

elective operations are carried out for free on behalf of Malta, and that is considered to

be a fair balance. By comparison, the UK Government’s proposal with regard to the

Isle of Man represents an extremely unfair balance.

Mr Iain Smith MSP: I add my support for Andrew Mackinlay’s motion.

When one Government acts in a unilateral way without discussing the matter with the

other Governments that are involved, BIPA should consider the matter. In this case,

the issue is not just that the UK Government has not reached an agreement with the

Isle of Man but that the UK Government has not discussed it with the other devolved

authorities in the UK that have responsibility for health. That is an unacceptable way

in which to behave. We have the British-Irish Council, at which such matters should

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be discussed. The UK Government should have taken the matter to the British-Irish

Council and had a proper discussion with all the parties who are involved, but it failed

to do so. As such, BIPA should condemn what the UK Government has done. I fully

support Andrew Mackinlay’s motion.

The Baroness Harris of Richmond: I entirely support what Andrew

Mackinlay has said.

I want to ask whether servicemen and women who are injured on duty in

Afghanistan or Iraq will receive free health care in the UK. If so, that will make the

residents of the Isle of Man and of Jersey and Guernsey second-class citizens, because

some residents will be allowed support while others will not.

Many people travel to the Isle of Man not just from the north-west and west of

England but from the north-east, where I live. I have dear friends and neighbours who

have always spent their holidays in the Isle of Man over the past 50 years, but they

now say that they will not travel there in case they fall ill. The situation is a disgrace.

We must try to do something to stop this nonsense.

Deputy Graham Guille: As far as I am concerned, this debate covers two

separate issues: the changing way in which the various jurisdictions have viewed such

agreements over time and the way in which the agreements have affected the people.

Let me just outline the Guernsey view—which I am sure is similar to the

Jersey view—of the agreement that we had. When the agreement was first entered into

in 1976, the islands were receiving large numbers of visitors and holidaymakers, a

proportion of whom, as we have heard, found their way through the doors of our

various hospitals. Pretty much from the start, because we were a holiday destination,

the number of visitors we treated was considerably larger than the number of our

residents who were treated in the UK.

Another factor that affected the agreement as things progressed was that, over

time, the profile of those seeking medical services changed. We found that we were

dealing not only with tourists and business travellers but what seemed to us to be

health tourists, who used the agreement to side-step the national health service queues.

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That was always a concern. When that worry was made known to the UK

Government, an attempt was made to redress the imbalance by agreeing to allow

certain island patient referrals to the NHS. That was a very welcome development,

given that Guernsey was spending in excess of £100 million on its health service for a

population—to put the matter in perspective—of only 60,000 or 65,000. One of our

problems, of course, was that we were never able to supply reliable statistics to the UK

Government on the number of its nationals who received treatment visiting the island

because we could never be wholly confident whether those people were genuine

tourists or people who just wanted to benefit from the agreement for health purposes.

In closing, let me say just a few words about the effects of the change. The

agreement with Guernsey and Jersey ended in 2009, so we are already a year ahead of

the Isle of Man. As we have heard, there is a detrimental effect on the elderly, on those

with pre-existing medical conditions and on those who, for whatever reason, cannot

get medical insurance. Potential visitors have a fairly stark choice: they either take a

chance or they stay where they are. The situation also affects those who are currently

serving in the armed forces. The Channel islanders especially are renowned for their

service in the armed forces—my son is currently serving on HMS Talent. Given that

many of those servicemen will inevitably bring back conditions with them when they

return home after their careers, where do they stand in view of their long-term health

needs?

Guernsey came to have reservations about the cost of the agreement, but we

were also conscious of the implications that ending the agreement would have on

some of our least fortunate citizens. Islanders have a number of attributes in common:

they readily adapt to change; they are usually fiercely independent people; and, most

of all, they are fully aware that there is no such thing as a free lunch.

We heard from Jim O’Keeffe yesterday about some of the discussions with

the Assembly’s Sovereign Matters Committee. At that meeting, I remarked that we are

more than happy to play a constructive part in seeking agreement, but what we really

need is a level playing field. Guernsey is interested in getting involved in discussions

with representatives of the dependencies and the United Kingdom health authorities,

but we really need to know the terms of a new health agreement, because we certainly

would not want to go back to the old one.

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Mr Jeff Ennis MP: I speak in support of Andrew Mackinlay’s excellent

motion. I have a reputation for being very much a Government loyalist and I try to

defend Government policy wherever I can, but, to be honest, there is no way that I

could defend this policy, which is indefensible. I have spoken on a number of

occasions to Andy Burnham, who is a good Minister and a good friend, in my role as

one of the vice-chairs of the British-Isle of Man all-party parliamentary group. Nearly

every member of the Manx group—certainly on the Labour side—has tried to get the

message across to Andy about the significance and knock-on implications of this

nonsensical policy, which Andrew Mackinlay set out in greater detail. I would like the

Assembly to agree unanimously to the motion, so that we can put the ball back in

Andy Burnham’s court, because the policy defies logic and I cannot understand why

my Government is putting it forward.

The Lord Smith of Clifton: I support Andrew Mackinlay’s motion and I

share Lord Dubs’s view that the Assembly will miss him badly. Almost a month ago, I

asked a question in the House of Lords on the cessation of the reciprocal health

agreements. I did so partly because, when I was in Jersey on holiday this summer, I

found to my horror that I was not covered by medical insurance—not least because I

cannot get any—so I have a personal interest in the matter. The cessation of the

reciprocal agreement means that at least one parliamentarian in the UK cannot visit the

Crown dependencies. That is an added constitutional element.

The policy is extraordinarily ageist. When we see in the airports the people

who are on their way to the Crown dependencies in the summer season, we might

make the mistake of thinking that they are going to Lourdes, there are so many

crutches and Zimmer frames, my own walking stick included. Lord Tunnicliffe, in

replying to me and other Lords a month ago, was, frankly, pathetic—and I have seen

some pathetic ministerial performances in my time. That is nothing to do with him

personally; he could not have been briefed adequately, because the policy defies logic,

as colleagues said. In my time in the House of Lords I have never had so many e-mails

on a topic that I have raised as I have on the cessation of the reciprocal agreements.

The amount of feeling that the policy has generated is quite extraordinary in my

experience. I hope that we will pass the motion nem con.

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Mr Michael German AM: The Minister for Health and Social Services in the

Welsh Assembly Government introduced the necessary legislation to give effect to the

policy in Wales just a few weeks ago. If colleagues here from Wales are prepared to

join me, as I hope that they are, I am prepared to pray against it and force a debate on

the floor of the National Assembly for Wales.

10:00

Mr Brian Adam MSP: The suggestion that the issue should go to the British-

Irish Council was a wise one. We could also write to the devolved Administrations

and the Crown dependencies to encourage the issue to be taken up through the joint

ministerial committee mechanism, which is meant to resolve disputes. I agree that this

has been done unilaterally through the English Department of Health, with the

collusion of the English Ministry of Justice, which, ultimately, do not have all the

powers. It is not just a matter of resolving issues to do with elective specialist health

care between the Isle of Man Government and some English health authorities; the

matter affects all people on these islands.

Trevor Smith’s point about insurance was well made. Many people cannot

travel because of health insurance issues. That is grossly unfair. I am delighted to

support Andrew Mackinlay’s motion.

Hon Stephen Charles Rodan MHK: I thank Andrew Mackinlay for

championing the cause. His motion reflects the terms of an early day motion that more

than 50 Members of the House of Commons have signed. I thank the MPs and

Members of the House of Lords who have taken up the cause with the Secretary of

State, made representations and made the case firmly. I am also grateful for the

sentiments that have been expressed this morning. The debate shows the Assembly at

its finest. We are a family. When problems arise in the family, we step in and help

each other. I cannot tell Members how heartening it is to have heard the expressions of

support this morning.

The issue is serious, because it strikes at the heart of the concept of universally

available health care that is free at the point of delivery. The reciprocal health

agreement with the Isle of Man dates back to 1948, when the NHS was founded. In

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simple terms, it meant that we gave health treatment to each area’s citizens as if they

were our own, whether or not they were visitors.

It might help to note the background. Members will have seen the letter that

Gillian Merron, the Health Minister, sent to Paul Murphy, whom I thank for taking up

the matter as Co-Chairman. The letter says that the ground for ending the agreement is

economic and that the agreement does not

“represent value for money for the British taxpayer.”

I will explain briefly why that was said.

Over the years, the reciprocal arrangements have meant that the many

thousands of holidaymakers who traditionally came to the Isle of Man were treated in

our hospital if they fell ill and that the lesser number of visitors who went to the UK

were treated there. Under the reciprocal arrangements, the costs of elective surgery for

people from the Isle of Man in Liverpool and elsewhere in north-west England and of

referrals from the Isle of Man to those places for specialist treatment were also

absorbed by the UK NHS.

With the passage of time, a disparity in the arrangements became clear. By the

late 1990s, the thousands of holidaymakers were no longer coming to the Isle of Man

and the UK taxpayer was continuing to pay for elective surgery. In 2004, an updated

arrangement was entered into with the Isle of Man and the other Crown dependencies

whereby we paid for elective surgery—the cost is to the tune of £9 million annually,

which goes to the north-west specialised commissioning group, which organises

placements and referrals for specialist treatment in the north-west. The Isle of Man

Government is happy to pay that.

The point that provides the difficulty now is that the decision was also made

in 2004 to allocate money—to compensate the Isle of Man Government for treating

UK visitors to the island, if you like—that is to the tune of £2.8 million today. That

£2.8 million was deducted from the £9 million bill for elective surgery. The UK

Department of Health says that that no longer represents good value for money.

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Nowhere else under the bilateral health agreements that are in existence is a

specific fund allocated to treat UK visitors abroad. The UK Government’s position is

that it is the responsibility of individuals to take out health insurance when they

travel—a fair enough argument. Our view is that, instead of the UK Government

unilaterally tearing up the agreement so that we do not recognise one another’s

citizens at all and refusing to negotiate—the agreement ends on 1 April this year and

in Jersey and Guernsey it ended on 1 April last year, so we were given a bit of

notice— there was room for us to sit down and say, “Let’s recast a new health

reciprocal agreement that is good value to the UK taxpayer.” That would mean a

reciprocal agreement such as the UK has with non-European Economic Area

members, such as Barbados, Malta, Ukraine, the states of the former Soviet Union and

the states of the former Yugoslavia, all of which have bilateral health agreements with

the UK, whereby our respective citizens are not billed if they are admitted to hospital.

It is important to note that the traditional arrangements for free accident and

emergency care remain. It is only when people are admitted to hospital for further

treatment that the bill starts to rack up. The difficulty has been well articulated by

others in respect of those who cannot obtain health insurance—people with preexisting

conditions and the elderly simply cannot get it. Forty per cent of UK travellers

do not take out health insurance at all anyway—they run the risk. You can be sure that

it is only a matter of time before someone from the Isle of Man visiting England or

someone from England visiting the Isle of Man runs that risk, falls ill, is admitted to

hospital and ends up with a bill for thousands of pounds.

This strikes at the very heart of reciprocity in its true sense—that we recognise

each other’s citizens when they are in difficulty and are admitted to hospital beyond

the normal accident and emergency situation. I am grateful to Andrew Mackinlay and

others for bringing this motion forward.

The Co-Chairman (Rt Hon Paul Murphy): David McClarty and Alan

Breckon wanted to make a contribution. Please make it reasonably brief, even though

the issue is very important, in case we run out of time.

Mr David McClarty MLA: Thank you. I will be brief. I thank Andrew

Mackinlay for bringing this issue to the floor of the house and the impassioned manner

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in which he spoke to the motion. I think that we have heard from every other region of

the United Kingdom. I just want to put Northern Ireland’s point of view. We fully

support the motion. A potentially huge number of Northern Ireland’s citizens could be

disadvantaged by this. A huge number travel every year for the TT races.

Senator Alan Breckon: Thank you. I will be brief. I support Andrew

Mackinlay’s motion and welcome and appreciate the work that he has done. Baroness

Harris, Lords Cope, Smith and Dubs asked questions in the House on this matter and

on the common travel area. Jim O’Keeffe has touched on some of this work, too, in

relation to constitutional issues. What concerns me is that there was not really any

effective consultation. Although it was done, it was more, “This is what we’re doing.

Here’s the information.”

As Andrew Mackinlay pointed out, there is a great deal of confusion about

this. I tested that from the ordinary person’s point of view—the situation was as clear

as mud. There is confusion for travellers either way, as Lord Smith pointed out. I have

not seen any meaningful statistics or costs with regard to why all this came about.

From Jersey’s point of view, enforcement would be a real issue. If we have a

sick person, I do not see their being taken to court for cost recovery. We do not have a

system to do that, so what follows the end of the agreement has not been thought

through properly.

I hope that Members will support the motion, as I think that it tries to redress

an imbalance that has been imposed.

The Co-Chairman (Rt Hon Paul Murphy): I thank Alan Breckon and David

McClarty for being brief and effective.

Before I formally put the question on the motion, I have a few comments.

First, I share the view of everyone who has spoken: the decision is daft. Bearing in

mind, for example, that the Isle of Man’s population is the same as that of my

constituency, one wonders what the fuss is all about.

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Secondly, the point has been very well made that the decision is about the rest

of the United Kingdom and these islands as much as it is about the Isle of Man. That is

an important point, and I urge all the Members who have spoken from the

dependencies and devolved Administrations to go back to their respective jurisdictions

and quickly ask their respective Ministers to make the case to Andy Burnham. That

would be very helpful.

Thirdly, however, there is a problem, which is that the Isle of Man

Government itself appears not to have asked the British-Irish Council to consider the

matter formally, which it is entitled to do. Frankly, that is a weak part of the case.

Members will notice from the letter sent to me that the Isle of Man Government met

the British Government on 19 January to discuss the issue. It strikes me that the most

effective line is the constitutional one. There has been insufficient discussion and

negotiation with the devolved Administrations on something that affects us all.

Finally, if the motion is agreed to, I suggest that the Assembly ask me to meet Andy

Burnham formally and also to alert Jack Straw, the Secretary of State for Justice, and

Peter Hain, whose responsibilities cover the British-Irish Council.

The Co-Chairman (Rt Hon Paul Murphy): As no one voted against or

abstained, that motion is agreed to unanimously. [Applause.]

The Co-Chairman (Mr Niall Blaney TD): We devoted a lot of time to that

motion, the result of which is that we have about 15 minutes left before Declan Kelly

is due to arrive. I propose that we just note the correspondence from the relevant

Governments. We then have Alf Dubs’s motion on returning the unemployed to work

and a late motion on membership.

With Members’ agreement, we will proceed.

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APPENDIX B

Letter from Secretary of State, Rt. Hon. Andy Burnham MP

APPENDIX C

Covering Note from Isle of Man Chief Minister

Hon J A Brown MHK

Chief Minister

APPENDIX D

Reciprocal Health Agreement with U.K. Newsletter –

Jersey Consumer Council article

Exempt diseases:

Exempt Groups