Healthcare in Europe

Working Party on Public Health

The working party discusses issues concerning public health, health and medical care.

More details about Working Party on Public Health

EU Cross-border Healthcare Directive

The European Cross-border healthcare Directive was passed by Europe in 2011. The Member States Government and administrations were working to transpose the Directive into domestic legislation by October 25, 2013.

The Directive formally sets out the fundamental right to healthcare services across the European Economic Area for all EEA citizens, although this right has been in place for many years. The provisions under the EU Directive are similar the S2 route, but there are some important differences: see The Directive of the European Commission and of the Council on the Application of Patientsā€™ Rights in Cross-border Healthcare (Official Journal of the European Union, L 88, 4 April 2011)

How it works

The EU Directive provides a legal framework for people who wish to obtain healthcare under Article 56 of the Treaty of the Functioning of the European Union. It gives you the right to access healthcare services in another EEA country as long as the treatment is medically necessary and is also available under the NHS. It covers treatment provided in both state-run hospitals and by independent healthcare providers.

In most cases, you will have to pay the costs upfront. You can claim reimbursement when you return, up to the amount the treatment would have cost under the Member StateĀ“s national health system.

Prior authorisation may be required in some cases. This will confirm whether you are entitled to the treatment and the level of reimbursement you can expect. It will also ensure that you are aware of all of the possible treatment options within the NHS, which may be more convenient to you than going overseas.

As with the S2 route, if “undue delay” applies in your particular case, you must be granted authorisation. For more information and to ensure you that you do not have any difficulties when claiming reimbursement, you should contact your Member StateĀ“s national health system.

Entitlements and Rules – EU residents

Subject to certain conditions, EU residents are entitled to medical treatment in another EEA country. To get Member StateĀ“s national health system funded treatment in another EEA country, you must be ordinarily resident in the EU and entitled to your Member StateĀ“s national health system treatment and services.

What treatment am I entitled to?

You can only get reimbursements under the EU Directive for treatments that are funded by your Member StateĀ“s national health system Board. Your Board decides whether an individual treatment is available on the Member StateĀ“s national health system.

What is undue delay?

You must be allowed to have treatment abroad if you cannot have the same treatment on the NHS within a medically acceptable period. This applies both to the S2 Route and the EU Directive.

The waiting time is based on your medical needs and the evidence that exists for your condition. It also has to take into account your health and the likely course of your medical condition at the time of the decision.

Decisions on undue delay must be based on a medical assessment. This assessment must be kept under review while you’re waiting for treatment. Offering treatment within a national waiting time target does not necessarily avoid undue delay.

Appeal and review

Local health commissioners should have systems in place to deal with requests for treatment abroad. They are required to give such requests serious consideration, taking into account your circumstances.

If you’re unhappy with your local health commissioner’s decision, you should appeal in writing to your Member StateĀ“s national health system Board. Each Board has an appeal procedure, and you should appeal within the timeframe set by your Board.


The cost of your treatment abroad will usually be reimbursed up to the cost of the equivalent treatment on the NHS. This means if the treatment abroad is more expensive than under the Member StateĀ“s national health system, you may have to pay the additional costs. But if the treatment is cheaper, you cannot profit from it.

However, on a discretionary basis, the S2 route can be used for more expensive treatments, including treatments not available on the Member StateĀ“s national health system.

European Cross Border Healthcare

Whatever your reasons for going abroad for medical treatment, it is important to understand what you might be entitled to receive, how it might be funded, how to apply for reimbursement and importantly, what youā€™re responsibilities are.

While not always required as a condition of reimbursement, you are strongly advised to consult with your GP and NHS Fife before making arrangements to travel abroad for healthcare.

Your entitlement for treatment and/or reimbursement will vary based on a number of factors including whether you’re going to a European Economic Area (EEA) country for treatment or elsewhere in the world.

You are strongly advised to ensure that you have appropriate medical travel insurance cover before you arrange to travel abroad for treatment.

Obtaining Treatment Abroad

There are three ways to obtain treatment abroad. All are very different in what is provided and how it is funded. (See above).


The European Health Insurance Card (EHIC) replaced the old E111 in 2006 and is provided on request and free of charge.

All travellers should have an EHIC as it allows access to emergency state healthcare at a reduced cost or sometimes for free. It covers treatment that is needed to allow you to continue your stay abroad until your planned return.
The EHIC is valid in all European Economic Area (EEA) countries, including Switzerland.

The EHIC covers treatment that is medically necessary until your planned return home. Treatment should be provided on the same basis as it would to a resident of that country, either at a reduced cost or, in many cases, for free. For example, in some countries, patients are expected to directly contribute a percentage towards the cost of their state-provided treatment. This is known as a patient co-payment. If you receive treatment under this type of healthcare system, you are expected to pay the same co-payment charge as a patient from that country.
The EHIC also covers the treatment of pre-existing medical conditions and routine maternity care, provided the reason for your visit is not specifically to give birth or seek treatment.

The European Economic Area (EEA) is a free trade zone between the countries of the European Union (EU), Iceland, Norway and Liechtenstein. The regulations on access to healthcare in the EEA also apply in Switzerland.
Your European Health Insurance Card (EHIC) gives you the right to access state-provided healthcare at a reduced cost, or sometimes for free, on the same basis as a resident of that country.

It will cover you for necessary treatment needed to allow you to continue your stay until your planned return. It also covers you for treatment of pre-existing medical conditions and routine maternity care, as long as you’re not going abroad to give birth.

Note: The EHIC is not an alternative to travel insurance and will not cover any private medical healthcare or costs, such as mountain rescue in ski resorts, being flown back to the UK, or lost or stolen property. The EHIC will also not cover your medical expenses if you are going abroad specifically to have treatment.

If you intend to move abroad or are going abroad specifically to have treatment, different rules may apply. Read about moving abroad or planning medical treatment abroad before you read about the details of the country you’re visiting.

If you find yourself in an emergency during your visit to Europe, dial 112. The European emergency number is valid in all EU/EEA member states and is free of charge. You can use it to reach emergency services from any telephone or mobile phone free of charge.

The following European countries do not accept the EHIC. Ensure you have adequate insurance before you travel:

The Channel Islands, including Guernsey, Alderney and Sark
The Isle of Man
San Marino
The Vatican

The S2 (E112) Route

If an NHS consultant recommends that you need treatment, the S2 route entitles you, in certain circumstances, to travel for state-funded treatment in another European Economic Area (EEA) country or Switzerland. Treatment will be provided under the same conditions of care and payment as for residents of that country. This could however mean you have to pay a percentage of the costs personally.

For example, in some countries, patients cover 25% of the costs of their state-provided treatment, known as a “co-payment charge”. The state covers the other 75%. If you received treatment under this healthcare system, you would be expected to pay the same co-payment charge as a patient from that country.

In some countries, as in the UK, care is completely free. This means the S2 will cover 100% of the costs of your care, so you would not be required to pay any treatment costs upfront.

European Cross Border Healthcare: The Article 56 Route

Article 56 of the Treaty of the Functioning of the European Union sets out circumstances in which patients may have a right to choose to travel to other countries in the European Economic Area (EEA) for treatment. Article 56 does not apply between countries within the UK as the UK as a whole is considered to be the Member State.

These regulations usually apply if you wish to travel abroad to receive care. If the care you are seeking is not available in the UK then you should apply through the S2 Route described in the section above.

The Directive

EU regulations on the coordination of social security systems that were in May 2010 already provided certain levels of reciprocal healthcare cover for EEA citizens ā€” by that, it means EU citizens plus citizens of Iceland, Norway and Liechtenstein. Those arrangements apply to tourists who require necessary care when visiting another member state under the European health insurance card (EHIC); people living and working in Europe; or, in certain circumstances and provided that they have received prior authorisation, those who travel specifically in order to receive healthcare.

Taking into account those existing provisions within EC regulations and the development of EC case law based on individual cases, particularly as a result of the Watts judgement in 2006, the development of an EU-wide directive was seen as necessary to clarify the law, which had been piecemeal, and the rights of citizens across the EU. For example, in the Watts case, the European Court found that the application of rights under the EU treaty applied equally to NHS-style health systems, whereas the UK had previously argued that it applied only to insurance-based systems. It also found that NHS regulations were deficient on the criteria for the granting or the refusal of prior authorisation and reimbursement costs. It found that the guidance on the procedure for an applicant to follow fell a long way short of the requirement for a procedural system that was easily accessible to citizens. It also found that, in this particular case, Mrs Watts had faced undue delay in accessing the treatment that she required within the NHS, and that the UK’s failure to grant prior authorisation in that case contravened the regulation and article 49 of the treaty.

The directive that comes fully into effect from 25 October 2014, therefore, only reflects existing rights under the treaties and the principles confirmed by EU case law, and it applies best practice in providing access to those rights. Its main objectives are to clarify and simplify the rules and procedures applicable to patients’ access; to provide EU citizens with better information on their rights; to ensure that cross-border healthcare is safe and of high quality; and to promote cooperation between member states. However, its aim is not to incentivise cross-border healthcare.

The directive sets out the information that member states must provide for patients from other states who want to consider coming to this country to purchase healthcare. Conversely, it also sets out the arrangements that a member state must provide to allow its own citizens to access their rights to reimbursement of the costs of cross-border healthcare if they choose to seek that healthcare in another member state. They may want to do that if they believe that that care is better, cheaper or more readily available.

There are a number of key points to note. The directive does not apply to social care, but only to healthcare that is provided by regulated providers. It does not require the home state to accept a directive patient or, indeed, to prioritise the needs of an EU directive patient to the detriment of people who reside in the home state. The home state also retains responsibility for deciding what healthcare it will fund on a cross-border basis, so the directive is not a way for citizens to gain entitlement to treatments that would not normally be available in their home state. In other words, if you can get it here, you can get it there, and the cost will be reimbursed.

So, under the directive, people in a Member State will enjoy the right to seek healthcare services in another member state that is the same as, or equivalent to, a service that would have been provided here. The patient will have a right to claim reimbursement of costs up to the amount that the treatment would have cost, had they had it here, or the actual amount, where that is lower. That principle of reimbursement assumes that patients will pay the overseas provider upfront for their treatment and then claim reimbursement when they return home, and the patient will also bear the financial risk of any additional costs arising.

The directive allows for a process of prior authorisation, which will be required for the more complex or expensive healthcare treatments. That is the mechanism by which individuals can get clarity about a range of matters relating to patient care. It includes confirmation that the treatment is one that the health service here offers, so that the patient knows that they are entitled to reimbursement and the level of that reimbursement. It also provides clarity on which elements of the care pathway are being funded and what the patient must do if there is a problem later on.

Leave a Comment