The UK government last year signed a cheque for over €250 million in payment for healthcare received by British nationals in France.

The payment was made as part of its obligations under European regulations to meet the health costs of its citizens living in France and visiting France.

In order to facilitate international mobility, many countries around the globe have entered into similar agreements concerning healthcare for visitors and residents.

Underpinning these agreements is a reciprocal system for refunding the costs of healthcare, with payments made either on a fixed lump sum basis or by reimbursement of the actual costs incurred. In the vast majority of cases full recovery of costs applies, although in relation to the UK an average cost of reimbursement is used.

Retired EEA expats and cross-border workers in Europe are covered for their health costs through an ‘S1’ certificate of entitlement granted by their government, whilst visitors obtain health cover via the European Health Insurance Card (EHIC).

A recent report from international social security agency in France, 'CLEISS', shows that last year the British government paid €250 million for its own citizens in France, a quarter of the total of all payments made to France by other European countries.

Payments to the UK by France for its own citizens amounted to €1 million. Although there are actually more French nationals resident in the UK than there are UK citizens in France, the vast majority of French expatriates pay their own health costs in national insurance contributions from employment. More British expats are covered for healthcare via S1 certificates.

In addition, each year around 12 million British nationals visit France as tourists, whilst only 3 million French nationals visit the UK, so EHIC costs are inevitably higher for the UK.

However, the lower number of French nationals reliant on the reciprocal health agreement is only one explanation for the substantially lower bill, for the UK government has previously admitted that accounting procedures for charges incurred by international visitors using the NHS is inadequate.

According to a UK government report published in 2016, "cost recovery..... is poor because the NHS struggles to identify patients holding EHICs and other European forms. Consequently, the UK is unable to invoice the appropriate Member State for the costs of treatment." Although procedures are being tightened up, it has yet to become evident in accounting records.

Since 2009 the CLEISS reports shows that France has invoiced the UK €1.9 billion for health charges, whilst the UK has responded with bills totalling €33 million.

More broadly, over the same period France has received over €7 billion from its European neighbours for health costs, while it has in turn has paid out nearly €3 billion, a net surplus of €4 billion.

Beyond Europe, the cash payout by France is substantially in excess of proceeds, due to historic agreements relating to its overseas territories.