Introduction
The British population resident in Spain is growing fast, and it is highly likely that the number of British migrants will grow substantially during the coming years. Although the phenomenon of British retirement in Spain dates back to the 1960s, the number of British citizens who had signed on the municipal population registers (the Padrón Municipal) amounted in 1998 to just 75,600. By 2001, however, the Padrón recorded over 100,000 British residents, and by 2006 the number was 274,042. The underlying causes are deep-rooted: population ageing, economic growth, technology improvements and the lowering real cost of transport and telecommunications, and, more generally, societal modernisation (although some part of the reported increase has arisen from more diligent registration) (Warnes et al. Reference Warnes, Friedrich, Kellaher and Torres2004). The main motivation for this migration is to improve the quality of life, particularly during the winter months (Casado-Díaz, Kaiser and Warnes Reference Casado-Díaz, Kaiser and Warnes2004). Although some factors might slow the growth, such as a rising cost of living, other changes such as improved public services in Spain might boost it. We should also bear in mind that the Spanish authorities are encouraging this phenomenon. The development policies of Costa Blanca's coastal towns focus on promoting the sale of properties targeted at non-Spanish citizens. It is difficult to estimate the actual number of Spanish homes owned by British nationals. According to the country's Ministry of Housing, 1,303,787 homes were owned in 2001 by people from outside Spain; five years later, in 2006, 410,000 homes were owned by foreign nationals living in Spain (Aranda Reference Aranda2006; Rubio Reference Rubio2006). This figure, however, does not specify how many belonged to British citizens. It has been estimated that 700,000 British nationals own homes in Spain (Centre for Future Studies 2004).
According to the Padrón data, most British expatriates live in four areas of Spain: 95,204 in the Province of Alicante (named the Costa Blanca by the tourism industry), 51,047 in the Province of Málaga, especially the widely known Costa del Sol, 29,803 on the Canary Islands, and 17,602 on the Balearic Islands (Spain, Instituto Nacional de Estadística (INE) 2006). The Padrón is a population register maintained by each town. To sign on it, or to become empadronado, foreign nationals are only required to show their passport and a document that proves they are living in the town, such as electricity or water bills, a tenancy agreement, or a title deed. Since 2000, empadronados have been guaranteed the right to use the Spanish health-care and education systems, and are entitled to help with other formalities (such as dealings with banks or solicitors), regardless of whether or not they have a residence permit. In fact, many British nationals do not have this permit. The Ministry of Interior has issued 149,071 such permits to British citizens living in Spain (those who spend more than three months a year in the country), which means that only 54 per cent of the British expatriate empadronados have a residence permit (Spain, Ministerio del Interior (MIR) 2006).
In this sense, the Padrón is a more reliable source than the Ministry of Interior's register for estimates of the actual number of British nationals who live in Spain. The Padrón provides a good estimate of the British population permanently resident in Spain, i.e. those who spend most of the year in the country, but it probably under-estimates the number of highly mobile British residents who own properties in several countries and spend a few weeks each year in Spain. In fact, the number of resident empadronados matches the figures provided by the United Kingdom's (UK) Department for Work and Pensions (2005), which indicate that in November 2005, 72,200 British pensioners lived in Spain. This agrees with the Spanish Padrón, which in January 2006 counted 58,166 people aged 65 or more years, and 15,888 women aged between 60–64 years, a total of 74,054 people.
Despite a widespread presumption in both Spain and Britain, most British expatriates living in Spain – up to two-thirds – have not reached retirement age, but over 50 per cent are aged 50 or more years. Previous research has shown that most of these migrants make the decision to settle in their new country gradually. First they visit as tourists, later they take up temporary residence and then they become permanent residents. Eventually, many return to the home country. In this process, buying property abroad is for many a financial strategy to maximise material wellbeing in later life. These migrants are mainly couples who move to Spain when they are in their fifties or early sixties (Casado-Diaz, Kaiser and Warnes Reference Casado-Díaz, Kaiser and Warnes2004). This explains why the British population resident in Spain is balanced in terms of gender (49.7 per cent are women), and has a relatively high average age but under-represents the highest ages. Early retirement may explain why in 2005 the average pension of British men resident in Spain was £85 per week, whereas the average pension of those resident in the UK was £102.37 per week. A similar difference applied to women (£57 as against £74 per week) (UK Department for Work and Pensions 2005).
Aims and design
This paper reports an investigation of the comparative state of the general health of British older citizens living on the Costa Blanca and of their access to and utilisation of health care. Since there are few statistics on the population, to gather profiling information in 2005–06 we carried out a sample survey of permanent and semi-permanent British residents (i.e. those resident more than three months a year). The health status distributions were then compared with those reported by the Health Survey for England in 2003, and the National Health Survey in Spain in 2005.
We first examined whether the ‘healthy migrant’ phenomenon applied to British residents on the Costa Blanca; that is, are the migrants healthy individuals with an above-average quotient of personal autonomy (Carballo, Divino and Zeric Reference Carballo, Divino and Zeric1998; McKay, Macyntire and Ellaway Reference McKay, Macyntire and Ellaway2003; Nazroo Reference Nazroo2003; United Nations Population Fund 2006; Wingate Reference Wingate2006)? The converse hypothesis was also considered, that health reasons are a common motivation for moves. In some cases, people migrate to improve their quality of life and their health; in others, people with particular health problems, as with respiratory conditions, migrate for the benefits of a warmer and drier climate, or a lifestyle that enables more outside, physical activity (Casado-Diaz, Kaiser and Warnes Reference Casado-Díaz, Kaiser and Warnes2004; Rodríguez, Fernández-Mayoralas and Rojo Reference Rodríguez, Fernández-Mayoralas and Fermina1998; Gustafson Reference Gustafson2001, Warnes et al. Reference Warnes, King, Williams and Patterson1999). On the other hand, when dependency issues arise, some retired migrants move back to their countries of origin to seek informal and formal support. Among those who do not return, some experience loneliness and dependency (Hardill et al. Reference Hardill, Spradbery, Arnold-Boakes and Marrugat2005; Betty and Cahill Reference Betty and Cahill1998). Bearing this in mind, we expected those residents who took part in our survey to be healthier than the British or Spanish population of the same age and sex. Nevertheless, other factors led us to explore the hypothesis that these residents are exposed to certain problems that have negative health effects, such as loneliness, unhealthy lifestyles, financial strain and the cultural or administrative barriers that reduce access to health care.
The population of the Province of Alicante province (viz. the Costa Blanca) has access to the public health-care provided by the Valencian Autonomous Regional Government with the so-called SIP card (Service of Information for the Population). All residents in Spain, regardless of whether they have a residence permit or not, are entitled to this card through European and Spanish laws and the regulations of the Valencia Autonomous Region.Footnote 1 As of January 2005, 87,103 British citizens were registered on the Padrón in the Valencia Region. In October of that year, 61,676 SIP cards had been issued in the region, so approximately 71 per cent of British residents in the Valencia Autonomous Region had obtained it (Centro de Estudios para la Integración Social y Formación de los inmigrantes (CEIM) 2005a, 2005b, 2006a). It can be supposed that for the remaining 29 per cent, it took longer than nine months to obtain the card, or that they relied on private health-care, or had not established any kind of access to health care in Spain. The health statistics service of the Valencian Region does not provide details about the use of public or private health services by these residents.
Methods and instruments
The data analysed in this paper come from five sources: (a) a questionnaire on self-assessed health status and the use of health-care services that was administered by home interviews to a sample of the general population of British nationals resident on the Costa Blanca, and micro-data files obtained from (b) the Health Survey for England 2003(UK, Data Archive 2005), (c) the British Household Panel Survey (UK, Institute for Social and Economic Research 2006), (d) the National Health Survey for Spain 2003 (Spain, Ministerio de Sanidad y Consumo 2005), and (e) the Spanish Household Panel Survey 2000 (Spain, Instituto Nacional de Estadística (INE) 2005).
The sample of resident British nationals was obtained by selecting those towns in Alicante province in which British residents registered on the Padrón in 2004 were numerous and formed a large percentage of the total population (Spain, Instituto Nacional de Estadística 2006). The seven selected towns, which are located on Figure 1, accounted for over 45 per cent of British expatriates resident in the Province of Alicante. They are Torrevieja (with 7,815 British residents), Orihuela (7,123), Jávea (5,353), Benidorm (2,944), Pilar de la Horadada (1,991), San Miguel de Salinas (1,675) and Denia (1,028). The next step was to specify quotas of respondents by sex and age for each town, which was accomplished using 2001 population census data and the data from the 2004 Padrón.Footnote 2 The recruitment of respondents used random routes to select households in each town that were designed to ensure representativeness. Only holders of a British passport and resident permanently or semi-permanently (for longer than three months a year) in the specified towns were interviewed. All the interviews were carried out in English by two bilingual interviewers, one Spanish and one British. The fieldwork was conducted between November 2005 and June 2006. Overall, 155 face-to-face interviews were conducted.
The Province of Alicante and locations of the survey towns.
The questionnaire was originally written in English and included some questions identical to those asked in the Health Survey for England 2003, the British Household Panel Survey 2004, the National Health Survey for Spain 2003, and the Spanish Household Panel Survey 2000. The main variables analysed in this paper are age, gender, self-assessed health, long-standing illness, number of visits to general practitioners, hospital in-patient visits, the Euro-Qual health status measure EQ-5D (Brooks Reference Brooks1996; Rabind and Charro Reference Rabind and Charro2001), tobacco and alcohol consumption, total household income and other socio-demographic measures. The analysis compared the health status and the use of health-care services by British nationals resident on the Costa Blanca with the equivalent measures in the resident populations of England, the United Kingdom and Spain.Footnote 3 Unweighted samples were used. The direct percentages for each age and sex group were estimated, and logistic regression models run to obtain the odds ratios by various attributes adjusted for age and sex. Because of the low number of subjects aged less than 45 years, the majority of the analyses are for only those above this age (that is, nine in ten of the entire sample).
Results
The average age of the sample was 60 years, and the standard deviation 12.2 years. Women made up 49.7 per cent of those interviewed. The sample was equally divided between towns in the north (49%) and the south (51%) of the Province. The majority of the respondents (79%) were born in England, 16 per cent in other nations of the United Kingdom, and the remaining five per cent in other European or African countries (France, Germany, Ireland, Russia and Kenya). Regarding the number of household members, 61 per cent lived with their partner, 11 per cent lived on their own, 21 per cent lived in a household with three or four members, and the remaining seven per cent in larger households. Only a minority (14.5%) lived with children under the age of 15 years. As for their marital status, two-thirds (67%) were married, 12 per cent lived as a couple, 10 per cent were separated or divorced, seven per cent were widowed, and the remaining three per cent were single.
The year in which they took up residence in Spain ranged from 1980 to 2005. Around 20 per cent settled between 1980 and 1994, over 50 per cent moved after 1999, and 10 per cent during 2004–2005. Three-in-four spent 10 to 12 months a year in Spain. As to their housing, 82 per cent lived in their own property, which was either already paid for (63%) or being bought with a mortgage (19%). As for the rest, 12 per cent lived in a rented house and six per cent were borrowing a relative's house. At least one car was available to 94 per cent of the households. Approximately one-half (57%) of the respondents were retired, 21 per cent were still in paid work, and 14 per cent were dedicated to housework. The remaining eight per cent were engaged in assisting family members, in studies or in other activities.
Income levels were adjusted for the number of household members using the Organisation for Economic Co-operation and Development equivalence scale. The monthly median income was €1,120 per consumption unit (or person): 17.5 per cent of those surveyed did not exceed €640 per month per person, whereas those in the highest 20 per cent of incomes had on average €2,100 per month. One-in-four respondents indicated that they spoke Spanish as well as English, 19 per cent that they used both languages when speaking with friends, and 11 per cent said that they could read Spanish, and five per cent spoke both Spanish and English at home. Despite this low level of ability, the general attitude towards the Spanish language was rather positive: 47 per cent said they felt ‘comfortable’ or ‘very comfortable’ whenever they spoke Spanish, while 24.5 per cent said they felt ‘uncomfortable’ or ‘very uncomfortable’. The lack of understanding of the language had an influence on the choice of friends and television programmes: seven-in-ten respondents indicated that their best friends and their favourite television programmes were British.
Health status
Self-assessed health status is sensitive to age and sex. Table 1 shows that among British nationals living in Spain, men and women aged over 65 years perceived their health status more positively than the Spanish and British reference populations. On the other hand, British men aged 45–64 years living in Spain had a worse perception. As for the effect of ageing on how the respondents assessed their own health, this was weaker in the sample of residents interviewed than in the reference populations. In the case of men living on the Costa Blanca, self-perceived health status was higher in the older age group. Table 2 shows the perceptions of health-related problems on the five dimensions of the Euro-QoL for the Costa Blanca sample and the reference populations. There were no significant differences between British women living in Spain and the female population in England. The British female residents showed better results in terms of mobility and scored similarly on the other dimensions of this index. Male residents reported fewer problems with walking than men in England, but they claimed to have more problems when performing their usual activities, and felt more anxious or depressed. In addition, British men aged over 65 years resident in Spain experienced pain or discomfort more frequently.
Self-assessed health status by age group and sex: British residents on the Costa Blanca 2005–2006, England 2003, United Kingdom 2004 and Spain 2003
Mobility, self-care, usual activities, pain/discomfort and anxiety/depression by age group and sex, British residents on the Costa Blanca 2005–2006 and community-dwelling population of England 2003
Notes: CB: British residents on the Costa Blanca. Eng: population of England.
Sources: Micro-data from authors' Costa Blanca Residents Survey 2005–06 and the Health Survey for England 2003 (UK Data Archive 2005).
As for the patterns of alcohol consumption and cigarette smoking, we found interesting differences between men and women. British women living in Spain were less likely to be abstainers than women in the UK (13 versus 19%), but for men the inverse applied. Men in Spain (and women aged over 65 years) were more likely to be smokers than their compatriots in the UK. The questionnaire did not collect detailed information about the amount of alcohol consumed by the respondents. In any case, it is important to highlight the fact that 43 per cent of those who drank alcohol indicated that they had increased their alcohol intake since moving to Spain, in contrast to just 12 per cent of the UK home population who said that their alcohol consumption was higher than five years before. Similarly, about one-third (33%) of those surveyed said they smoked more since they had settled in Spain.
Health-care entitlements and coverage
When asked about health care, the majority (67%) of the respondents indicated that they were covered by either the British or the Spanish National Health Services, 17 per cent were covered by both public health-care providers and private medical insurance, 12 per cent relied exclusively on private health-care, and three per cent claimed not to be covered by public or private health care. Among those who benefited from public health-care, three-in-four (73%) used the services provided by the Valencia Region Health Service, and the remainder (27%) were under the UK National Health Service. Thus, the regional health service was providing health-care services to 62 per cent of the British expatriates living on the Costa Blanca. The rest were covered by the British National Health Service or by private health-insurance, while a small percentage had no coverage.
Visits to a general practitioner or family doctor
The number of visits by those aged 45 or more years to a general medical practitioner (GP) or family doctor was roughly the same in the three samples (Table 3). As regards the visits made by the British expatriates resident on the Costa Blanca, our survey found that 75 per cent of the respondents visited a GP in Spain, 16 per cent one in the United Kingdom, and nine per cent had appointments in both countries. Assuming that the number of visits reported by British residents on the Costa Blanca was distributed proportionately, we could say that 54.5 per cent of their visits to a GP were covered by the Valencia Region Health Service, 17.5 per cent were covered by the British National Health Service, and 28 per cent were paid for privately. A logistic regression model was run to examine the variations in the frequency of visits to GPs (Table 4). The oldest respondents, those who assessed their health as being ‘fair’, ‘poor’ or ‘very poor’, and women had a higher likelihood of visiting a GP three or more times a year. The British residents in the Costa Blanca had similar patterns to their Spanish neighbours and the British population, once adjusted for age, sex and health status.
Frequency of visits to general medical practitioners among those aged 45 or more years by sex: British residents on the Costa Blanca 2005–2006, United Kingdom population 2004, and Spanish population 2000
Notes: The reported frequencies are in response to the question, ‘During the last year, approximately how many times have you talked to, or visited a GP or a family doctor about your own health? Please do not include any visits to a hospital’. 1. British residents on the Costa Blanca.
Factors influencing frequency of visits to a general practitioner, samples of British and Spanish populations, 2003–05
Notes: Logistic regression model: dependent variable ‘visits a GP more than twice a year’; independent variables age, sex (women), self-assessed health status (fair, poor, very poor) and sample (Spanish from SHPS 2000; UK from BHPS 2004; and British residents on the Costa Blanca 2005–2006). CI: confidence interval.
Hospitalisation
The percentage of people admitted to hospital was higher among the British residents on the Costa Blanca than among the Spanish population. A logistic regression model adjusted for health status, sex and age showed that British nationals, whether they resided in the United Kingdom or on the Costa Blanca, were more likely to have been hospitalised than the Spanish. As Table 5 shows, the hospitalisation patterns of British expatriates living on the Costa Blanca were more similar to their compatriots in the United Kingdom than to Spanish older people in Spain. The majority (78%) of the respondents who were hospitalised in the last year were cared for in a Spanish hospital.
Factors influencing frequency of hospital visits, samples of British and Spanish populations, 2003–05
Notes: Logistic regression model, dependent variable: being hospitalised in the last year; independent variables: age, sex (women), self-assessed health status (fair, poor, very poor) and population (Spanish – SHPS 2000; British – BHPS 2004; Residents of Costa Blanca 2005–2006). CI: confidence interval. Sources: As Tables 1 and 3.
Discussion
Limitations and strengths of the survey
The small sample size (155) is the main limitation of the analyses, particularly in terms of statistical power. One must therefore be cautious in interpreting and generalising the results. However, we interviewed a sample of residents with the same age and sex structure and spatial distribution as the registered population. It is believed that the survey data provide reliable profiles of the circumstances of British nationals living (semi-) permanently on the Costa Blanca (as distinct from occasional tourists). The use of questions from British and Spanish national surveys has increased the comparability of the results.
The main comparative findings
Older British nationals resident on the Costa Blanca have a health profile that is comparable to those of the older Spanish and older British home populations. They score higher than Spaniards and British on some indicators, with fewer mobility problems and a more positive perception of their state of health. These findings are consistent with the ‘healthy migrant hypothesis’, that people who decide to move to another country have better than average health. More specifically, British residents on the Costa Blanca appear to have a high level of personal autonomy with few mobility or self-care problems. The findings also support the notion that residents who become dependent choose to return to their home countries to seek professional help and support services. A study of Norwegian expatriates living in the Spanish provinces of Alicante and Málaga found that the migrants prefered to go back to Norway when their health status worsened (Helset, Lauvli and Sandlie Reference Helset, Lauvli and Sandlie2004). Swedish residents also express their wish to remain in Spain only ‘as long as their health permits’ (Gustafson Reference Gustafson2001). Lurbe's (Reference Lurbe and Solé2006) research into the European population living in the towns of Calvià (Balearic Islands, Spain) and Cambrils (Catalonia, Spain) yielded similar results. Among the British residents on the Costa Blanca, men aged 45–64 years seemed to suffer worse health than women in the same age group, or in relative terms than older men. This suggests that a poor health condition could be a factor for an early retirement and for the move to Spain, which is consistent with the prescription of a drier and warmer winter climate for those with certain chronic conditions (Casado-Diaz, Kaiser and Warnes Reference Casado-Díaz, Kaiser and Warnes2004; Rodríguez, Fernández-Mayoralas and Rojo Reference Rodríguez, Fernández-Mayoralas and Fermina1998; Gustafson Reference Gustafson2001).
Against the generally positive picture of the health status of the British living on the Costa Blanca, some indicators suggest that all age groups are more vulnerable to mental health problems (anxiety/depression) than in the UK home population. Cigarette smoking and alcohol consumption seem to be higher among the British living on the Costa Blanca, and the consumption of both rises when they move to Spain. The trend among British women on the Costa Blanca is contrary to the available data about drinking trends in the United Kingdom. According to Anderson and Baumbert's (Reference Anderson and Baumbert2006) report for the European Commission, in the UK the rate of abstention from alcohol among women is double that of men. It was found, however, that among British expatriates resident on the Costa Blanca, the abstention rate was higher for men. Different hypotheses could explain the inversion, including acculturation stress (Unger et al. Reference Unger, Gallaher, Shakib, Ritt-Olson, Palmer and Johnson2002; Finch, Frank and Vega Reference Finch, Frank and Vega2004), having more spare and leisure time, the lower price of cigarettes and alcohol in Spain, being more isolated, or a change in activity patterns (Huber and O'Reilly Reference Huber and O'Reilly2004). We should bear in mind that British residents in Spain tend to spend a great deal of time with each other in bars, clubs, associations, other people's private homes and expatriate businesses, and that clubs are key locations that help them organise their lives and integrate into their new country (Huber and O'Reilly Reference Huber and O'Reilly2004; Betty and Cahill Reference Betty and Cahill1998).
The number of visits to a general practitioner by the British residents was approximately the same as among their Spanish neighbours. For admissions to hospital, British residents on the Costa Blanca showed a rate that was similar to the UK home population but higher than that among the Spanish. In this sense, British nationals living in Spain use health-care services at a level comparable to the British home population. That level of use, however, is the result of using multiple providers: the Valencia Region Health Service, the UK National Health Service, and private-sector health-care. As noted, the Valencia Region Health Service provides health care to most British expatriates; those who are not covered by the Spanish health system make up for it with other resources (travel and use of private health-care). In this sense, it should be remembered that European health law does not acknowledge all the mobility situations of this group of people, including those who live in different countries according to the season of the year. Ackers and Dwyer (Reference Ackers and Dwyer2004) summed up the circumstances as in the phrase, ‘fixed laws, fluid lives’. For this reason, inappropriate use of the European Health Insurance Card (EHIC) or the need to travel in order to access health-care services is predictable.
British residents on the Costa Blanca make relatively high use of private health-care compared to the Spanish and British home populations. The reasons that encourage them to turn to the private sector are likely to be language difficulties in the public sector and its usual advantages, such as shorter waiting lists, faster follow-up, fewer clinic visits and less paperwork (Lurbe Reference Lurbe and Solé2006). The questionnaire included open questions about the respondents’ perception of the Spanish public health-care system: the most commonly cited problems of using the Valencia Region Health Service were perceived to be communication (use of the Spanish language) and the administrative processes (information, places, rights, procedures, waiting times).Footnote 4 Nonetheless, their overall perception was quite positive.Footnote 5
For these reasons, the impact of the British expatriates on the Regional Health Service is lower than could be expected from an older population. In fact, only one-in-two British residents had visited a local GP (whether in the public or private sectors), and only one-in-two had experienced hospital episodes provided by the Valencia Region Health Service. Only two-thirds (62%) of those surveyed were covered by the Spanish public health-care services, which is in line with the data on SIP cards issued to foreign nationals (CEIM 2005a, Reference Ackers and Dwyer2005b, 2006). The number of cards issued in November 2005 covered 71 per cent of the British residents registered in the Valencia Region in January 2005 and 58 per cent of those registered in January 2006.
Implications for health-services policy
The results have important implications for the health services' priorities. Firstly, the public sector provides health care to a high percentage of the British residents on the Costa Blanca, but not to all. Health protection is a universal right recognised by Spanish and European law, but is not achieved in the expatriate population. For this reason, policies to guarantee the access of all European Union citizens to health care should be designed and specific problems should be addressed, for example the cultural and information barriers in obtaining the SIP card and accessing the health services.
There are also health-care financing issues. Although the use of Spanish public health-care resources is low among the British residents, population analyses, and particularly population projections, suggest that the situation could change. It is an ageing population and, if the rapid urbanisation of the coast and its rapid population growth continue, there will be a significant growth in the demand for public services. The authorities should take into account these demand effects and implement active policies for the integration of the British population into the national system of health-care protection. Last but not least, the relatively lower use of health services by British residents contributes to the financial feasibility of their current arrangements for health care, but this would be made more secure with more comprehensive and effective agreements between the European Union countries on the reimbursement of expatriates' medical expenses.
Acknowledgements
The findings reported in this paper are from a research project funded by the National Health Institute Carlos III, Instituto de Salud Carlos III, Ministerio de Sanidad y Consumo, Spain (Project reference: PI042287).
