The Overseas Territories and the NHS

By Craig Brewin, craig.brewin@fotbot.org

When the Foreign Affairs Committee reported last year on the relationship between the OTs and the UK, it highlighted one area that it described as “an important test of the FCO’s ability to fight the OTs’ corner”. This was the issue of access to the NHS. It really is very hard to defend the current arrangements and no one has ever really tried to. But the problems remain stubbornly unfixed.

The difficulty is that is the Overseas Territories are too small to provide the full range of services they require to meet the needs of their populations. But where are they provided, by whom, and who pays? The situation is different from island to island, and obviously some territories are dependent on UK aid, and other are not.

In Gibraltar, the Health Authority uses a healthcare model closely linked to the NHS and some tertiary referrals are delivered in the NHS and others in Spanish hospitals. Gibraltar was the only OT that formed part of the EU so the reciprocal arrangement with Spain was automatic. The UK has ensured that access to the NHS will remain in the future.

Falkland Islanders also have unrestricted access to the NHS for specialist treatments, and there is a reciprocal arrangement whereby UK residents also have unlimited access to the Falklands Islands health service should they ever require it.

After that it starts to get more complicated. Ascension, Cayman Islands, Bermuda, Tristan da Cunha and Pitcairn Islands, for very different reasons, have their own arrangements for arranging off island care when necessary. This is funded by the patient from their own funds, or from insurance, or by the Government.

This leaves Anguilla, Montserrat, Turks and Caicos Islands, St Helena, and British Virgin Islands, whose citizens have the right to access specialist treatments in the UK, but only four NHS patients each per year per territory are allowed. This quota was set in 1985, and since then the Anguilla population had doubled, and Montserrat has had a volcanic eruption from which its domestic health system has not yet recovered. Tristan da Cunha’s Chief Islander Ian Lavarello has expressed his annoyance at being excluded from this list all together, and having no quota at all.

The former BVI representative in London, Benito Wheatly, has described the quota system as “inexplicable”. There is no reason, he said, “why the current quota cannot be increased or altogether removed when the overall number of persons in the OTs who require such attention is miniscule. The current policy needs be revised altogether to be fairer to the people of the Overseas Territories who are British.” Blondel Cluff, the former Anguilla representative in London has gone as far as saying that current UK policy means “a British citizen’s life chances are diminished simply by residing in a BOT” as a matter of policy.

The matter has been a bit of a hot potato for a while now. At the 2018 Joint Ministerial Council representatives were told by the British Government that the Department of Health was reviewing the quotas. This claim was repeated a year later when the FCO stated in its response to the Foreign Affairs Committee report that the review was to be completed in 2019. However, a freedom of information request made in 2019, revealed that that there was no specific review or any changes being considered at the present time. The DHSC stated: “No formal report exists and there is no planned publication date for a formal report. DHSC is continuing its work to review how best to support the British Overseas Territories with respect to health outcomes.” Make of that as you will, but don’t forget that this is, according to a parliamentary committee “an important test of the FCO’s ability to fight the OTs’ corner.”

So there is no deadline, and maybe no review. But there has been a review in the not too distant past and this contains all the information that the DHSC needs to make any changes. This was produced in 2010 at the request of PAHO (which acts for the World Health Organisation in the Americas), and explains in detail how the OT health systems in each island fit in with that of the UK other regional networks. This report was highly critical of the quota system saying that “the system is inequitable”, “the quota is not consistent with the UK’s pattern of aid” and “has little impact on meeting actual need”.

The Government has had plenty of time to address the issue, and has had a review on its desk now for the past ten years. It promised to look at it in 2018 and again in 2019, but the situation is getting more urgent given that we are in the middle of a global pandemic. In Montserrat consultants are currently on island looking at what services the new hospital needs to provide, and there is a Cuban Medical Brigade on Island that is costing DFID a fair amount of money. Maybe things need to be a little more joined up, and hurried along.