First of all, let’s consider the travelling population. The Office for National Statistics found that UK residents’ visits abroad increased between 2022 and 2023. There were 86.2 million visits overseas by UK residents in 2023, compared with 71 million visits in 2022. Europe was the most popular overseas destination visited in 2023, accounting for 77% (66.7 million) of the total visits abroad. However, this was an 8% decrease from 72.5 million in 2019. The top 10 countries were unchanged from 2022, with Spain remaining the most popular country visited by UK residents – 17.8 million British tourists visited Spain in 2023. France was the second most popular country, with 9.2 million visits in 2023, making up 11% of total visits.

Now we’ve established the travelling figures, we must next consider the insurance data. More tourists in Europe, ergo more insureds? Maybe. Research by Co-op Insurance in February 2024 revealed that 28% of UK adults didn’t purchase travel insurance. The fact that 72% do purchase it should be welcome news for the industry in the UK, as it’s a far cry from many other travelling populations. Business Insider recently established that just 38% of Americans purchase travel insurance before their trips.

Spain’s Instituto Nacional de Estadística (National Institute of Statistics) published its tourism figures for the first eight months of 2024, which showed that the country received 10.9 million international tourists in August, 7.3% more than in the same month in 2023. In the first eight months of 2024, the number of international tourists visiting Spain peaked, reaching 64.3 million. Statista reports that in 2023, France was the most visited country in the world, with 100 million international tourists arriving.

Millions of tourists descending on Spain, France, Greece and Portugal (mainly) will place an inevitable strain on healthcare facilities. Anecdotally, it can be said that for every 100 people who board a plane, one will need medical assistance of some kind while they are abroad. Simple mathematics would suggest that even the most developed healthcare system is going to feel the pressure of such a sudden influx of patients.

Insurers and assistance providers feel the effects

The Association of British Insurers (ABI) published its latest set of data for travel insurance claims recently. According to ABI figures from 2023, insurers processed 574,000 travel insurance claims in the past year, with total payouts reaching £511 million. A significant portion of the claims, nearly 29,000, were linked to Spain, amounting to £41.7 million – a reflection of Spain’s popularity as a top travel destination among British holidaymakers most likely, but also a potential indicator of rising medical inflation.

Europe was the most popular overseas destination visited by UK residents in 2023, accounting for 77% (66.7 million) of the total visits abroad

Dr Jon Sen, Medical Director of the Mayday Group, shared his recent experiences with ITIJ: “We’ve seen a clear increase in inpatient and outpatient caseload year on year since the end of lockdown restrictions. The reasons are likely to be multifactorial. Naturally, it could be a function of increasing numbers of travellers, but it may also relate to trends in background mortality and morbidity rates. I say the latter partly because in my opinion we are also seeing an increase in serious illness and critically unwell patients and more advanced disease at time of presentation. For example, in 2023 at times our background mortality rate was over 10% higher than at comparative times in previous years. In other countries this was hitting as much as 16% higher. These are staggering statistics, and the potential reasons are still under consideration.”

Increased severity of illness

Dr Sen told ITIJ: “When travel started to pick up again post-pandemic, several unique factors were in play: multiple patients presenting late, with already advanced disease, making treatment much more challenging, with consequent poorer outcomes. Flight options were relatively more limited (this still remains the case, due to multiple flight cancellations), which kept patients hospitalised for longer than usual.” Dr Sen also noted that obtaining beds in the National Health Service (NHS) is extremely challenging: “Our patients all require side rooms on admission from abroad, for infection control reasons. UK intensive care unit (ICU) beds are in general very limited (especially paediatric ICU beds) as there are severe ongoing UK health service staff shortages.”

Mayday saw particularly high numbers of serious trauma cases in 2022 and 2023; this has recently moderated somewhat back to more expected levels, according to Dr Sen, who suggested that after being locked down, many travellers were more reckless or encountering reckless and violent behaviour in the early aftermath of Covid-19. “We had multiple critical brain and spine injuries, and more fatal drowning/near drowning (hypoxic brain injury) patients than usual, including children,” he said. “We also had a very high number of vascular events, such as intracranial haemorrhages and clots, in this period (this remains the case).” He added: “We have seen, and continue to see, a high number of unusual infections, including e.g. neurological paralysis due to viruses affecting the nervous system. I have the impression that perhaps lack of everyday mild exposure to pathogens due to lockdown may have impaired immunity and increased susceptibility on exposure to higher viral loads.”

Pressure on healthcare systems in Europe

According to the European Commission, which performed an analysis of hospital beds per capita from data in 2022, there were 2.3 million hospital beds available for use across the European Union (EU). Around three-quarters of these were for the curative care function; most of the remainder were beds for rehabilitative care. Recent methodological changes in the classification of hospital beds have resulted in psychiatric care beds being included – alongside somatic care – among the various functions of beds (curative, rehabilitative, long-term care and other).

An analysis of the number of hospital beds in relation to population reveals that there were, on average, 516 hospital beds per 100,000 inhabitants in 2022 across the whole of the EU. Among the EU countries, Germany recorded not only the highest number of hospital beds (642,000), but also the second highest number relative to population size, with 766 beds per 100,000 population. The only EU country with a higher ratio relative to its population size was Bulgaria, with an average of 823 hospital beds per 100,000 inhabitants. Romania recorded the third highest ratio, 728 hospital beds per 100,000 inhabitants. Spain, Ireland, Finland, Denmark, the Netherlands and Sweden each recorded fewer than 300 beds per 100,000 inhabitants.

An analysis of the number of hospital beds in relation to population reveals that there were, on average, 516 hospital beds per 100,000 inhabitants in 2022 across the whole of the EU

The share of beds for the curative care function among all hospital beds in 2022 was highest in the Netherlands, Portugal and Ireland, at 95.3%, 94.9% and 93.3%, respectively. Elsewhere, curative care beds accounted for less than 90% of all hospital beds. Less than two-thirds of all hospital beds were for curative care in Croatia, Hungary and Czechia (where the lowest share was recorded, at 62.5%).

Between 2012 and 2022, the total number of hospital beds in the EU decreased by 6.8%. In the majority of EU countries, the number of hospital beds (in absolute terms) was lower in 2022 than it had been in 2012.

Rehabilitative care beds accommodate hospital patients with the intent to stabilise, improve or restore impaired body functions and structures. During the period 2012 to 2022, the number of rehabilitative beds relative to population size increased in 10 out of 17 of the EU countries for which data are available. The number of rehabilitative care beds increased by more than 10 beds per 100,000 inhabitants in Romania, Austria, Poland and Bulgaria – the last of these recorded the highest increase with an additional 36 beds per 100,000 inhabitants. By contrast, the number of rehabilitative care beds relative to population was unchanged in Italy, and decreased in six EU countries between 2012 and 2022.

What does this mean for travel insurers?

For UK insurers, the above doesn’t – generally – inspire much confidence when it comes to knowing that your client is going to be able to access the care they need when it comes to recovery from an acute illness or injury. While they will be treated in an emergency, beds for rehabilitation in some destinations are going to be hard to come by, and the hospital will want those beds freed up for their local population, not taken up by a tourist.

Dr Sen noted: “We are finding an increasingly difficult situation in certain countries in accessing quick hospital admissions and management, such as Austria, which is a new/recent observation, and previously uncharacteristic for this country. In these cases, we even struggle sometimes to obtain reliable and comprehensive enough information with which to guide our management.” Other countries he highlighted as being “problematic” to work in were Portugal, Greece and Italy.

“Even transferring from public into private can be challenging in these sorts of locations,” he told ITIJ, “and we have to essentially restart an admission via A&E, as opposed to being able to move straight to a ringfenced bed. Sometimes we have to send out a flight medic to ‘see and assess’, in order to facilitate appropriate plans.” Pressure on the general economic situation in Europe, placing staffing and resources under strain, is fundamental to the problem travel insurers and their medical assistance partners are facing, he added.

Furthermore, the UK itself has a serious bed shortage problem. So getting a patient back into the UK’s National Health Service can be trickier still. The British Medical Association notes on its website: “Compared to other nations, the UK has a very low total number of hospital beds relative to its population. The average number of beds per 1,000 people in Organisation for Economic Co-operation and Development EU nations is five, but the UK has just 2.4. Germany, by contrast, has 7.8. Combined with staffing shortages, an insufficient core bed stock means that hospitals are less able to cope with large influxes of patients, for example during winter or periods of high demand. This has ultimately impacted hospitals’ ability to provide safe and timely care and remains a major factor in growing backlogs.”

Medical personnel shortages

The World Health Organization (WHO) estimates a projected shortfall of 10 million health workers by 2030, mostly in low- and lower-middle income countries. Andrzej Rys, European Commission Director of Health Systems, Medical Products and Innovation, was asked what the biggest challenge facing EU member states is at the moment. His answer left no room for interpretation: “It is not possible for health systems to deliver high-quality care to all Europeans without a health workforce in sufficient numbers, with the right skills and in the right places. There is an estimated shortage of nearly one million health workers in Europe. There is also a ‘brain drain’ of doctors and nurses who move to countries with better working conditions and pay, leaving other countries with shortages.”

Efforts are being made to address the problem. The Commission, for instance, signed a contribution agreement in September 2024 with the WHO Regional Office for Europe to support member states in retaining nurses in their health systems and making the profession more attractive to nurses. The agreement, funded with €1.3 million from the EU4Health programme, will involve activities across all EU member states over a 36-month period. Particular focus will be given to those countries with significant shortages in healthcare workers, and specifically shortages in nurses.