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Eurohealth Vol 13 No 4 14
HEALTH POLICY DEVELOPMENTS
A key contextual factor which helps to
explain international retirement
migration patterns is the changing regu-
latory framework of the European
Union (EU). This phenomenon is
embedded in EU legislation and social
policy considerations, including Articles
48 and 49 of the Treaty of Rome on the
freedom of movement, the Single
European Act which removes barriers to
property rights across Member States,
Article 8 of the Treaty of the EU which
confers limited electoral rights and the
Social Charter which envisages the
potential to harmonise pension and
welfare systems across the EU.1In
addition, in the mid 1970s the then
European Economic Community recog-
nised that freedom of movement should
not be restricted to the healthy. In 1971,
Council Regulation (EC) No. 1408/71
on the application of social security
schemes provided avenues for statutory
cover of treatment received outside the
state of residence or affiliation. This
included EU pensioners deciding to
retire to another Member State through
the E121 scheme (See Box 1).
Some EU citizens have seen these mech-
anisms as an opportunity to move to
another Member State and they are
likely to have been a factor in the
growing numbers of northern Euro-
peans retiring to southern Europe.
Although this is a phenomenon that has
existed for many years (for example,
Irish people returning to Ireland after
spending their working lives in England)
the numbers involved, and the destina-
tions being chosen, have changed greatly.
There are now many people from
northern Europe retiring to southern
Europe, in particular to Spain, France,
Portugal, Italy, Greece and Bulgaria, as
well as to candidate countries such as
Croatia.2
The phenomenon of international
retirement migration in Europe
Systematic academic interest in the study
of European international retirement
migration only emerged in the mid-
1990s, mostly in the field of migration
studies and social gerontology. The main
focus of social gerontology is on the
The health care needs of UK
pensioners living in Spain:
an agenda for research
Helena Legido-Quigley and Daniel La Parra
Summary: There is a growing interest in learning how older migrants adapt to their
new country of residence, in understanding their motivations for migration and the
factors that influence international retirement migration patterns. However, there
has been little research into the health and health care needs of international
migrants retiring to other countries. This paper presents findings on health status and
utilisation of health services with a particular focus on UK pensioners retiring to
Spain. Future research should focus on the health needs of pensioners and their
perspectives as to whether and how these health needs are met.
Keywords: Older migrants, Inequalities in access, Social security, Spain, UK
Helena Legido-Quigley is Research
Fellow, London School of Hygiene and
Tropical Medicine. Daniel La Parra is
Senior Lecturer in Sociology, University
of Alicante, Spain.
Email:
Helena.Legido-Quigley@lshtm.ac.uk
Box 1: Background to the E121 scheme
The process described here refers to the adminis-
trative steps a pensioner has to go through when he
or she decides to move to another Member State.
The individual applies for an E121 form in their
home country so that their social rights are trans-
ferred from the social security system of the home
country to the ‘receiving country’. Together with this
transfer of rights, a lump sum of money, agreed
upon in the Social Commission on Migrant Workers,
is also transferred to the central government of the
receiving country to cover costs for health care. The
information is passed to the region or locality where
the pensioner is planning to settle. The long-term
resident receives a national health insurance card in
the new country and is thus integrated into the
system. No distinctions are made between older
newcomers and any other member of the social
security system.
These communication routes and information flows
involve no direct contact between the local health
care provider in the new country and the state-level
public authorities of the home country. Thus, in the
event of the death of a long-term resident, the home
country might not be informed and will therefore
continue to transfer money.
Through the E121 scheme long-term residents obtain
the right to health care in the new or ‘receiving
country’ and at the same time renounce their right to
health care at home. However, Directive 1408/71
also requires that the receiving country provide the
pensioner with an E112 (form for planned treatment
abroad), regardless of whether the treatment is
already available in the ‘receiving country’.
reconstruction of older people’s lives by
connecting individual biographies to the
history of society and the study of social
change. Through the analysis of different
cohorts of older migrants and the identifi-
cation of positive attributes of retirement
in later life, it has helped to challenge
previous misconceptions on retiring
migrants by providing a more solid
empirical base.1
A growing literature has focused on deter-
mining the number of retirees migrating in
Europe, choice of location and reasons for
migrating. Key socio-economic and
personal characteristics of migrants,
including life-stage, cultural, attitudinal,
recreational and environmental factors and
personal influences have been analysed.
Locations of study have included coastal
Croatia, Spain (Majorca, Costa Blanca,
Costa del Sol), Italy (Tuscany) and Malta.
“in 2006, more than 300,000
UK citizens retired to other
Member States”
This research has illustrated how there has
been an increase in the number of older
Europeans migrating in retirement. This
needs to be understood in the context of a
rise in older people’s income and assets, as
well as major transformations in their pref-
erences and opportunities.1Moreover,
increasing life expectancy, along with the
increasing availability of new medicines
and medical technologies, has meant that a
growing number of older people are living
healthier and longer lives. At the same time
older people in most northern European
countries are no longer expected to take
care of their grandchildren or children and
are to a greater extent more concerned
with enjoying their lives.
The rise in consumption and mass commu-
nication combined with the move in
society towards individualism has also
influenced older individuals’ motivation to
move abroad. As Lipovetsky notes, we live
in a society with unprecedented social
temporality marked by the primacy of the
here-and-now.3This individualism and
social temporality also applies to older
people. Thus, pensioners retiring abroad
can increasingly access the internet,
affordable telephone calls and own
language cable television. With the advent
of low-cost airlines there are also greater
opportunities for travelling between home
and host country for both migrants and
their relatives.
Some of the evidence on patterns of
European retirement migration identifies a
series of key factors encouraging older
people to retire abroad. Boži´c looking at
ex-patriots in Croatia identified the most
important factors for migration as climate,
geopolitical location, level of property
prices and familiarity with the region.4
One study of 266 retirees to Tuscany5and
another looking specifically at UK
pensioners retiring to Spain reported
similar factors including favourable natural
resources and landscape, respect for
children and older people, friendly atmos-
phere, security and the slow pace of life.6
In addition, older people preferred Spain
over the UK because of perceived advan-
tages to health, a good climate, the oppor-
tunity to be active, the possibility of
spending more time outdoors and the
wider availability of recreational clubs and
associations. This study also emphasised
the lower costs of living in Spain as an
advantage over the UK in terms of value-
for-money.6
Another study reported that UK
pensioners form well-defined territorial
and social units, benefiting from the strong
value of their currency and previous
presence in Spain as tourists or residents.
However, a lack of proficiency in Spanish
has prevented them from developing closer
links with the local community.7Other
studies also suggested that these EU
pensioners tend to be isolated with few, if
any, close relationships with the local
population.4,7,8
The scale of the phenomenon
There has been a significant growth in the
number of UK citizens retiring abroad.
Aggregate data from the Department of
Work and Pensions indicated that, in 2006,
more than 300,000 UK citizens retired to
other Member States. This data is based on
the number of pensions transferred. A
breakdown of countries of destination
indicates that UK citizens have a primary
affinity with Ireland (103,667) followed by
Spain (76,357) and then to France, Italy
and Germany each of which receives more
than 30,000 migrants.9
The information available on the UK
population in Spain is somewhat limited.
The Instituto Nacional de Estadística
(INE) estimates that there are currently
314,098 UK citizens living in the
country.10 That would make UK citizens
the fourth largest foreign community in
Spain, following Moroccans, Romanians
and Ecuadorians. It is estimated that 53%
are over the age of fifty. However, the true
figures are likely to be higher because of
the underreporting of pensioners who stay
more than three months per year in two
(or three) countries. These pensioners may
travel back and forth without regularising
their situation each time they move.
The INE estimates, through the figures
provided by the municipalities (the
padrón), that the total number of UK men
aged over sixty-five and UK women over
sixty was 87,359 in January 2007. This is
Eurohealth Vol 13 No 415
HEALTH POLICY DEVELOPMENTS
Figure 1: UK long-term residents aged over 55 years in Spain by Autonomous Community
Source: Instituto Nacional de Estadística 2006.10
possibly the most reliable source of data on
foreign pensioners since migrants who
wish to access health and social services
need to register with local municipalities.
However, this register is not used to define
the administrative residential situation of
UK pensioners, since municipalities are
not responsible for processing residence
permits. In fact, only 56% of the UK
population registered with the padróns
hold a residence permit. Figure 1 shows
UK citizens resident in Spain by
Autonomous Community (AC) and age in
January 2006. The ACs with the most UK
residents over fifty-five were Valencia with
58,779, Andalucia (33,021), Canarias
(10,809) and Baleares (6,520).
Health, health care arrangements and
experiences of EU pensioners retiring to
Spain
Looking at some studies on the health care
arrangements of pensioners retiring to
another Member State, one study, based on
interviews with key informants and a
survey amongst Germans aged fifty-five
plus living in Majorca in 1999, identified
several problems impacting on their
health.11 These included housing and
dwelling locations that were perceived not
to be compatible with the requirements of
older people; the lack of harmonisation of
the health and social care systems between
Germany and Spain which complicated
applying for access to the health care
system, and the scarcity of welfare institu-
tions for those who had become frail.
Another study using in-depth interviews
and focus groups obtained similar results
after studying the retired population in
Cambrils and Calvia (Spain).12
The migration of older Swiss people to the
Costa Blanca (Spain) in the period from
1999 to 2001 has also been analysed.13
Using a mix of methods, it suggested that
the majority of pensioners did not wish to
return to Switzerland under any circum-
stances, not even in the event of the death
of their partner. While this information is
not directly related to the health and health
care needs of Swiss retirees in Spain, it
points to a potential great future demand
for health care services for this population.
In contrast, Norwegian migrants were
found to have very different views.14 Based
on interviews with eighteen people aged
60 –75 years, the main concerns voiced
were the loss of social rights previously
enjoyed in Norway and problems related
to the process of repatriation. There was a
perceived lack of nursing homes in Spain
having staff familiar with the Norwegian
language. These Norwegian pensioners
tended to prefer to move back to Norway
to spend their ‘last days’ and be buried
near their families.
UK migrant retirees
As indicated above, there is little research
relating specifically to the health care needs
of migrants retiring abroad. We now
discuss the situation in respect of UK
migrants, drawing on data both from the
‘Europe for Patients’ project15 which
explored the health care arrangements of
long-term residents, including pensioners
in Spain through stakeholder analysis, and
from research carried out by La Parra and
Mateo.16 The latter looked at the general
health of UK older citizens living on the
Costa Blanca and their access to and utili-
sation of health care services (see Box 2).
“the lack of long-term care and
home care in Mediterranean
countries is a concern”
All the foreigners registered in the padrón
in Spain, have the right to access the
National Health System. The Spanish Law
on Foreign Nationals (LE 4/2000) guar-
antees this right to all EU and non-EU
migrants regardless of whether they are
undocumented or legal migrants. Once a
migrant has registered in a municipality,
he/she can apply for a health card. The
total number of health cards issued in
Spain for UK Citizens is difficult to
estimate, as each AC manages their health
care service independently.
As of March 2007, in the Valencian AC
alone the total number of UK citizens
holding a health card was 64,820, repre-
senting 52% of the total UK population
registered in the padrón .17,18 These figures
suggest that some citizens have no public
arrangements to cover their needs and must
be using private health care in Spain or/and
the National Health Service in the UK.
This has been confirmed in another study
which stated that 67% of UK pensioners
were covered exclusively by the Spanish
National Health System or the UK
National Health Service, 17% by both
public health care providers and private
medical insurance, 12% relied exclusively
on private health-care, and 3% claimed not
to be covered by public or private care.16
Among those who benefited from public
health care services, 73% made use of the
Valencian Region Health Service and the
remainder the UK National Health Service.
Foreign residents in Spain who do not
have a Spanish Health Card are primarily
those who spend half of the year in their
‘home country’. In these cases, patients are
only registered in one of the two health
care systems. Formally they should apply
for a new E121 every time they go back
and forth, but this option creates a huge
bureaucratic burden as it must be repeated
at least twice a year.
Eurohealth Vol 13 No 4 16
HEALTH POLICY DEVELOPMENTS
Box 2 Health status of UK pensioners
retiring abroad
• UK nationals resident on the Costa score
higher than Spaniards and UK-based citizens
on some indicators, with fewer mobility
problems and a more positive perception of
their state of health.
• It is suggested that some residents who
become dependent choose to return to their
home countries to seek professional help and
support services.
• Other indicators suggest that all age groups
are more vulnerable to mental health
problems than the UK home population.
• Cigarette smoking and alcohol consumption
are higher among the UK ex-pats living on
the Costa Blanca; consumption of both rises
when they move to Spain.
• The number of visits to a general practi-
tioner by UK ex-pats was approximately the
same as for their Spanish neighbours.
Although, admissions to hospital are higher
than for the Spanish, rates for UK ex-pats are
comparable to those seen in the UK. This
normal level of health service use results from
access to multiple providers: the Valencia
Region Health Service, the UK National
Health Service, and the private sector
• UK residents on the Costa Blanca make
relatively high use of private health care
compared to the Spanish and UK popula-
tions. The reasons that encourage them to
turn to the private sector are likely to be
language difficulties in the public sector as
well as the usual advantages, such as short
waiting times, faster follow-up, fewer clinic
visits and less paperwork.19
• The most commonly cited problems involved
in using the Valencia Region Health Service
were perceived to be communication (use of
the Spanish language) and the administrative
processes (information, places, rights, proce-
dures, waiting times). However, their overall
perception was quite positive.
Source: 16
Some long-term residents are also
concerned that by applying for the E121
they will lose some social welfare benefits,
due to the difference in benefits provided
by each Member State. For example,
pensioners in the UK have supplementary
social benefits such as a winter heating
allowance, disability allowances and care
allowances. Another concern is the lack of
long-term care and home care in Mediter-
ranean countries where these services have
traditionally been provided by the family.
Furthermore, the processes involved in
transferring registration are perceived as
bureaucratic and inflexible. Long-term
residents who have been through the
process of transferring their rights using
the E121 are reluctant to engage in what is
seen as a lengthy and painful process to
reverse their registration. They are often
afraid of losing the option of returning to
their home country. Thus there are large
numbers of long-term residents who opt
not to regularise their situation, so forming
part of the ‘floating population’.15 There is
no clear provision for these groups, which
becomes particularly problematic for
patients with chronic diseases.
“hospitals are beginning to
include language skills as a
criterion when hiring staff”
It is suggested that this ‘floating popu-
lation’ of long-term residents in fact have
their health care needs met primarily by
means of the European Health Insurance
Card (EHIC)* while in the ‘receiving
country’. However, this scheme is
designed for use in emergency situations
only and does not ensure continuity of
care. Furthermore, the recording of
treatment provided under the EHIC
scheme is often poor, creating gaps in an
individual’s medical records.
It is also suggested that some pensioners
do not hold the Spanish Health Card
because of a lack of information or diffi-
culties with administrative procedures.
Stakeholders report that patients are often
not well informed on how the system in
the country works, partly due to the segre-
gation of expatriate communities, language
barriers and patients’ ignorance of the
problems as long as they have no real need.
Language barriers are reported by key-
informants, when the patient and the
provider do not speak the same language.
In countries with different linguistic and
cultural traditions to the home country,
these factors can constitute a barrier to
newcomers. Lack of a common language
could lead to considerable problems in
communication between patients and
doctors. However, hospitals are becoming
aware of the need to assist non-Spanish
speakers and are beginning to include
language skills as a criterion when hiring
new staff.15
Conclusion
Analysis to date suggests that there is a
great need for research on health needs and
utilisation of health services; to explore
UK pensioners’ perceptions of the need
for health care and their health care seeking
behaviour; and to assess UK pensioners’
perspectives of the responsiveness of
health care services in Spain. Health care
needs in this population are determined by
their demographic situation (as the health
profile of migrants differs somewhat from
that of the general home and receiving
country populations); their cultural back-
ground (language acting as a determinant
of their health care seeking behaviour); and
their administrative situation in a context
of higher human mobility (‘fixed laws,
fluid lives’).20 In addition, it is also
important to consider how local and
regional authorities are planning health
care services and what financial compen-
sation mechanisms are agreed between
Member States. An understanding of these
issues would be beneficial for all the actors
involved in planning health services and
assuring their financial sustainability, and
for those who wish to retire or have
already retired in another Member State.
However, these effects are complex to
study and some contradictions can be
expected. Health status can act as a factor
when taking the decision to move abroad,
as well as influencing how long a migrant
stays in the host country. UK citizens are
entitled to use the Spanish health system,
but cultural barriers might prevent them
from doing so. They might instead prefer
to use private health care services or the
UK NHS. The relative use of health
services by unit is low (UK pensioners
have relatively good health and prefer
private and home care services), but the
absolute use of health services by this
growing and concentrated population
could have an important effect on the
dynamics of the health service. If
government and policy makers promote
immigration through the urbanisation
process, they should also plan services that
take into account the health status and
health care needs of these newcomers.
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Eurohealth Vol 13 No 417
HEALTH POLICY DEVELOPMENTS
* The establishment of the European Health Insurance Card (EHIC) was decided at the
Barcelona European Council (March 2002) to promote occupational mobility in the
context of the Lisbon agenda and to demonstrate the benefits of Europe to its citizens.
The EHIC, designed to replace all existing paper forms required for occasional health
treatment when in another Member State (E111, E110, E119, E128), was presented as a
way to simplify procedures for patients, providers and administrations.
Since 1955, when Milton Friedman
published The Role of Government in
Education,1the political right has had a
virtual monopoly on choice and compe-
tition in public services. Traditional
thinking on the right posited that greater
user choice of providers tied to a reim-
bursement system where money followed
users’ choices would promote both
allocative and technical efficiency. The
political left not only disputed the right’s
efficiency claims, but went one step further
and argued that any increase in user choice
would come at the expense of equity.
This left/right battle over choice and
competition continued until quite recently,
when left leaning policy-makers began to
come around to the notion that choice and
competition in public services might not
be such a disaster. Not only did the
political left begin to argue that choice and
competition could incentivise efficiency,
they began to draw attention to the fact
that injecting choice and competition into
public services could improve the care that
is delivered to traditionally under served
users.
We argue that this emphasis on the
potential positive impact of choice and
competition on equity is quite justifiable.
In what follows, we draw on theory, past
experience and empirical evidence to artic-
ulate a case for the equity benefits of
choice and competition.
A new rhetoric…
From 2002 onwards, Tony Blair’s Labour
Party embarked on an ambitious reform
agenda to modernise the English National
Health Service (NHS). At the core of the
former Prime Minister’s health service
reforms was a belief that greater user
choice and provider competition would
create a more personalised NHS with
better quality and less inequity than tradi-
tionally collectivist public health systems.
Speaking in 2003, Tony Blair said:
“People should not forget the current
system is a two-tier system when those
who can afford it go private…choice
mechanisms enhance equity by exerting
pressure on low-quality or incompetent
providers. Competitive pressures and
Choice, competition and the
political left
Zachary Cooper and Julian Le Grand
Summary: Choice and competition can no longer be viewed as an exclusive tool
of the political right. Beyond creating incentives to drive up quality and increase
efficiency in the English NHS, choice and competition stand to promote equity.
While many left-leaning critics are quick to point out ways in which choice and
competition could induce inequity, few critics objectively compare the equity
implications of choice and competition to the no-choice system which preceded it.
This article lays out the basic arguments for how choice and competition stand to
improve equity. If the political left is serious about reducing inequities in public
services, the time is right for them to open their eyes to the potential for choice
and competition.
Keywords: Equity, NHS, Choice, Competition, Collectivism, England
Zachary Cooper is reading for a PhD and Julian Le Grand is Richard Titmus Professor of
Social Policy, both at the Department of Social Policy and LSE Health, London School of
Economics and Political Science.
Email: z.cooper@lse.ac.uk
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HEALTH POLICY DEVELOPMENTS
