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The UK has 14 Overseas Territories (OTs), with a population of over 270,000. Ten of the Territories are permanently inhabited by British nationals.

Healthcare is a responsibility of elected Territory Governments, though the UK does provide aid assistance to three Territories and allows for a limited number of Territory inhabitants to access free NHS care each year in the UK.

This research briefing describes the healthcare systems in the Territories, the responsibilities of the UK Government towards them and the support it provides, and the challenges of delivering healthcare in small communities.

The Commons Library research briefing, The UK’s Overseas Territories: An introduction, provides further background on the OTs and their relationship with the UK.

Territories are responsible for healthcare

As the administrating power for the Territories, the UK Government is responsible for promoting their welfare, economic development and self-government under the UN Charter. For three Territories (Montserrat, Pitcairn and St Helena and Tristan da Cunha), it also provides financial aid to meet regular budget needs, including their health services. 

While the UK is responsible for the defence and international relations of the Territories, healthcare, alongside education and other aspects of social policy, is a responsibility of individual Territory Governments.

As set out in section 5 of this research briefing, Territory Governments employ a range of systems to fund and deliver healthcare, with most requiring patients to be referred overseas when more complex cases arise. All inhabited Territories can provide some emergency care, and aside from the smallest Territory, Pitcairn, all the inhabited Territories have a hospital (Pitcairn has a clinic).

Some of the Territories fund healthcare out of general budgets, supplemented with charges and fees for users (as in the case for the Falkland Islands, Pitcairn and St Helena, for example).

Other Territories have established a system of compulsory public contributions or insurance (such as Gibraltar), and others provide options for private or public insurance (the case in the Cayman Islands (PDF)).

Challenges in delivering healthcare

Like many independent small island developing states (SIDS), the UK’s Overseas Territories face challenges as small, predominately island, communities to deliver and fund healthcare. A 2010 assessment by the UK’s Department for Health and Social Care cited challenges including:

  • Achieving economies of scale when delivering healthcare
  • Requirement for overseas staff to meet local healthcare staffing needs
  • Ensuring continuity of medical expertise (many medical staff are on temporary residence contracts)
  • Organising access to overseas care to meet gaps in local services.
  • Shortages of surveillance systems and laboratory support to identify, and respond to, outbreaks of infectious diseases
  • Delivering sufficient mental health care
  • Delivering sufficient healthcare in prisons.

Territory access to UK NHS healthcare

In the UK, overseas visitor charging for healthcare is a devolved issue. 

In England, individuals must be “ordinarily resident” in the UK to qualify for NHS treatment free of charge. There are some services exempt from charging regulations. These include A&E services and those for the diagnosis and treatment of infectious disease.

The UK operates a quota system with the Overseas Territories. Except in the cases of the Falklands and Gibraltar, where reciprocal arrangements mean that there are no limits on the number of referrals made to the NHS, five Territories have been limited to four referrals a year (these are Anguilla, the British Virgin Islands, Montserrat, St Helena, and the Turks and Caicos). The remaining Territories have been ineligible for referral to the UK.

The quota arrangement has been criticised by OT Governments as too limited and for not taking account of population growth or need in the Territories. In the May 2023 Joint Ministerial Council (JMC) meeting between the UK and OT Governments, ministers agreed for changes to be introduced to the system.

Final details of the changes have not been published but the JMC communiqué states that Bermuda, Cayman Islands, Tristan da Cunha and Ascension will now be able to refer cases to the UK for free NHS treatment.

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