McKee M, Atun R. Brexit and health: a tragedy of errors. Harvard Public Health Review. Winter 2017-2018;12.
In 2015, a new word entered the English language. This was Brexit, short for “British Exit from the European Union”. The Conservative party, then led by David Cameron, had long been divided between those who believed that the United Kingdom’s (UK) future was only secure by remaining part of the by then 28 country European Union (EU) and those who portrayed the EU as some distant dictatorship, staffed by people who spent their days plotting how to damage the UK’s interests. The former view was held by most of the party’s Members of Parliament. The latter view was increasingly prevalent among the diminishing and ageing band of party members but, perhaps more importantly, the British tabloid press, dominated by a few powerful individuals. This split had existed for many years, seriously weakening the party, but the situation was becoming critical as the Conservatives were threatened, electorally, by the growth of the United Kingdom Independence Party. With no consistent, or indeed coherent policies except exiting the EU, it appealed especially to those who had been left behind by the process of globalization, a phenomenon that will be familiar to readers from the United States. Indeed, its leader, Nigel Farage, closely aligned himself with Donald Trump during the latter’s election campaign.
Those advocating Leave in the referendum campaign benefitted from the widespread lack of understanding of the EU among not only the British public but also many in the political class and the media, with the last of these seeking to achieve “balance” between the competing views in its presentations, rather than examining the facts.[1. McKee M. Fair and balanced? Science in a post fact society. 2016. http://blogs.bmj.com/bmj/2016/06/30/martin-mckee-fair-and-balanced-science-in-a-post-fact-society/ (accessed 11th August 2017).]
As a consequence, the Leave campaign was able to promulgate messages that bore no relationship to reality, the most notorious of which was that membership of the EU cost the UK £350 million a week, money that could instead be spent on the National Health Service (NHS). In fact, leaving will be disastrous for the NHS[2. McKee M, Galsworthy MJ. Brexit: a confused concept that threatens public health. J Public Health (Oxf) 2016; 38(1): 3-5.] and for the health sciences on which it depends.[3. Galsworthy M, McKee M. A plan for U.K. science after the European Union referendum. Science 2017; 355(6320): 31-2.]
As is now known, the referendum, which took place on the 23rd of June 2016, resulted in a narrow overall majority for leave, with both Scotland and Northern Ireland voting to remain. Cameron immediately resigned and, after a confused internecine struggle, Theresa May emerged as the party’s new leader. She declared that what had, legally, been only an advisory referendum was now to be viewed as definitive, an expression of “the will of the people”. The leader of the opposition Labour party, which was just as split on the issue, agreed. Yet, in a mirror image of the Cameron era Conservative Party, a majority of Labour members were enthusiastic supporters of remaining.
“Brexit Means Brexit”
So, it was decided. The UK was going to leave the EU. But what did that mean? For months, Theresa May, who had stated that she would not give a “running commentary” on the process, would only say “Brexit means Brexit”, although on one occasion adding, enigmatically, that it would be “red, white, and blue”.[4. McKee M. Brexit—the confusion continues. 2016. http://blogs.bmj.com/bmj/2016/09/08/martin-mckee-brexit-the-confusion-continues/ (accessed 11th August 2017).] It was only nine months later, when notifying the EU formally of the intention to leave, thereby triggering a two year, time-limited negotiating process, that her intentions became clear (sort of). A few western European countries, such as Norway and Switzerland, are not in the EU, because of domestic political considerations. However, they have substantially replicated the conditions of membership, for example by joining, or accepting the provisions of the Single Market, which ensures consistency in regulatory regimes in areas such as food production, medicines approvals, professional standards, and data protection. Although formally outside the Customs Union, which allows trade free of tariffs and quotas among EU member states, they have in effect accepted most of its rules. It was clear that the UK rejected such relationships, primarily because it rejected the role of the European Court of Justice (ECJ) in overseeing many aspects of these arrangements on ideological grounds. Moreover, buried in a footnote in background documents, it was announced that the UK would withdraw from EURATOM, a separate treaty covering nuclear materials, also overseen by the ECJ.
By notifying the European Council, which is composed of the heads of state of the EU Member States, of its decision to withdraw, the UK had set the clock ticking. The timetable was already believed to be completely unrealistic by those who understood the complexity of the process, a group that seemingly did not include British ministers. At a now notorious dinner party in 10 Downing Street, the President of the European Commission had expressed his incredulity at Theresa May’s lack of understanding of how the EU worked, at one stage showing her two documents, the Croatian Accession Treaty and the new trade agreement with Canada, some 7 kg of paperwork in total, in an attempt to help her understand the issues, finally concluding that she was “on a different galaxy”.[5. McKee M. The infamous Brexit dinner party—health was a major issue, but only for the EU. 2017. http://blogs.bmj.com/bmj/2017/05/03/martin-mckee-the-infamous-brexit-dinner-party-health-was-a-major-issue-but-only-for-the-eu/ (accessed 11th August 2017).]
Then, to widespread amazement, Theresa May called a general election. The next one had been scheduled for 2020. Thus wasted several months of valuable preparation time. Her aim was to increase her parliamentary majority. Instead, after a lamentable performance in which she seemed incapable of answering the simplest of questions, she lost it and was forced to seek an agreement with a Northern Irish party, many of whose members have fundamentalist religious views on matters such as creation and sexuality.
A One-Sided Conversation
Eventually, the UK government was in a position where it believed negotiations could begin. The EU side had laid out its negotiating position months earlier. The UK’s position remained a mystery, including, it seemed, to the UK delegation. The first week of negotiations was cut back to a single day, with a long lunch break. The next one, a month later, was symbolized by a photograph of the two sides meeting across a table, with large piles of paper in front of the EU delegation but nothing in front of the UK members. Informed commentators have asked whether this is an elaborate feint by the UK, which really has some well-prepared strategy. However, they have been forced to conclude that it doesn’t. Instead, the process of negotiation within the UK government has, it seems, yet to be resolved and, increasingly, its expressed intention of getting the best of all possible worlds, summarized by several politicians as “having its cake and eating it”, is slamming into the immoveable wall of reality.
The Implications for Health
So what does this mean for health and health care in the UK? The simple answer is that no-one knows. Parliamentary committees probing the preparedness of government ministries, including health, have expressed frustration at their inability to achieve any clarity.[6. Health Committee. Brexit and health and social care – people & process (Eighth Report of Session 2016-17; HC 640). London: House of Commons, 2017.] However, there is evidence that the uncertainty is already causing considerable damage, in several areas.
The first concern is the supply of workers. Prior to becoming Prime Minister, Theresa May had been Home Secretary, responsible among other things for immigration policy. In the eyes of the many Conservative supporters who wanted to close the country’s borders (always with the exception of whatever type of worker they personally depended on, whether doctors, carers, or fruit pickers), she had failed spectacularly. On the other hand, the country had benefitted enormously from the contribution of EU migrants, both in terms of filling skills gaps and as net contributors to the public purse. She now wants to reduce net migration to the “tens of thousands” and, by rejecting the EU’s offer to maintain the status quo, has sent out a message to EU citizens living in the UK that they are no longer welcome. Unmoved by a constant stream of tragic stories of families being spilt up and people who dedicated their working lives to the UK being told to prepare to leave, the UK government has failed to offer any reassurance. Understandably, numbers coming to the UK have fallen precipitously, with a 96% fall in applications to join the nursing register,[7. Health Foundation. New data show 96% drop in nurses from EU since July last year. 2017. http://www.health.org.uk/news/new-data-show-96-drop-nurses-eu-july-last-year (accessed 11th August 2017).] and many of those already in the UK are preparing to leave.[8. Boffey D. Record numbers of EU nurses quit NHS. 2017. https://www.theguardian.com/society/2017/mar/18/nhs-eu-nurses-quit-record-numbers (accessed 13th May 2017).]
Among them are large numbers of healthcare staff who work in the UK’s National Health System (NHS), on whom the service has long depended. About 10% of NHS doctors are EU citizens, but in some areas, such as London, the figure is much higher.[9. Health Committee. Oral evidence : Brexit and health and social care, HC 640 (2016-17): House of Commons, 2017.]
The same is happening with researchers in universities, with applications falling off and those who had been offered posts withdrawing. And the effect is also seen with students, who are looking elsewhere for their higher education. Unfortunately, the government has failed to understand the issues. It is not simply the right to be in the UK, it is the loss of all the rights that go with being a EU citizen. Thus, someone spending their working life in the UK but retiring to their own country could find themselves and their families without healthcare in retirement or inflation uprating of their pension.[10. McKee M. What will happen to EU citizens living in the UK after Brexit? 2017. http://blogs.bmj.com/bmj/2016/07/06/martin-mckee-what-will-happen-to-eu-citizens-living-in-the-uk-after-brexit/ (accessed 11th August 2017).] Together, these developments pose a huge threat to British medical schools in particular.
The second concern is about loss of regulatory co-ordination and harmonization. By leaving the EU, the UK will lose the European Medicines Agency, currently based in London. Aside from the loss to the economy that will result, perhaps £1 billion per year, and the damage to the UK’s pharmaceutical and related industries, withdrawal is expected to delay approvals of new drugs. The withdrawal from Euratom has caused particular anxiety, given its critical role in ensuring access to medical isotopes.[11. McKee M. Why we must stay in the European Atomic Energy Community. Bmj 2017; 358: j3527.] The precursor of technetium 99m is manufactured in only a few reactors worldwide, none in the UK. Moreover, it and its precursor have very short half-lives so distribution depends on a highly efficient “just in time” system. Supplies are monitored by the European Observatory on the Supply of Medical Radioisotopes, overseen by Euratom, and created because there have been critical supply chain problems in the past. Yet the UK government rejects the fears of the Nuclear Industry Association and all the professional medical organisations concerned,[12. Royal College of Radiologists. Further clarity and assurance needed for patients who require diagnosis and treatment using radioisotopes. 2017. https://www.rcr.ac.uk/posts/further-clarity-and-assurance-needed-patients-who-require-diagnosis-and-treatment-using (accessed 16th July 2017).][13. British Nuclear Medicine Society. PRESS RELEASE – British Nuclear Medicine Society statement on leaving Euratom. 2017. http://www.bnms.org.uk/news/press-release-british-nuclear-medicine-society-statement-on-leaving-euratom.html (accessed 16th July 2017).] simply stating that it anticipates no problems.
Withdrawal will also impact on the UK’s engagement in a range of other EU agencies with implications for public health. Perhaps the most obvious is the European Centre for Prevention and Disease Control. Despite the UK governments absence of any clarity, it is likely that some continuing association is agreed, but it will almost certainly be less satisfactory than the current one. Moreover, there is a danger that any loss of British staff from the Centre will weaken it, with implications for the UK as well as the remaining EU member states. Another is the European Food Standards Agency. In addition to its normative role, it oversees a network of inspectors in 130 countries who seek to ensure the safety of food supply chains. It will be impossible for the UK to replicate this, with potential consequences for food safety or supply. The latter is particularly concerning as the expected restrictions on free movement are already threatening the supply of seasonal agricultural workers and thus the UK’s agricultural production. At the same time, delays from proposed customs checks threaten what is a highly integrated “just in time” food supply system.
Potential loss of regulatory harmonisation poses a particular threat to medical research. EU legislation supports co-operation in areas such as exchange of data and conduct of clinical trials. The EU is an increasingly important research funder. EU programs such as ERASMUS and Marie-Curie support mobility of students and researchers.[14. European Commission. Statistics – Marie Skłodowska-Curie actions research fellowships. 2016: http://ec.europa.eu/research/mariecurieactions/funded-projects/statistics/index_en.htm.] Unsurprisingly, the academic community overwhelmingly opposes Brexit.[15. Cressey D. Scientists say ‘no’ to UK exit from Europe in Nature poll. Nature 2016; 531(7596): 559.][16. Wright O. EU referendum: Leaders of 100 top UK universities warn of Brexit risk to global standing. The Independent 2016: http://www.independent.co.uk/news/uk/politics/leaders-of-100-top-uk-universities-warn-of-brexit-risk-to-global-standing-a7092516.html.]
The third concern relates to global health. The UK makes a major contribution to international development, both in financial terms and in the form of expertise, The UK’s Office for Budget Responsibility, the independent body charged with technical oversight of fiscal and economic policies, which noting that the lack of clarity from ministers precludes any confident predictions, has stated that Brexit poses a major risk to the British economy.[17. Office for Budget Responsibility. Fiscal sustainability report. London: OBR; 2017.]
While initial concerns about the economy were averted by effective action by the Bank of England, there is now growing evidence of the severe damage being caused, even before Brexit takes place. This will inevitably lead to pressure to cut back on the UK’s aid commitments. British expertise, especially in universities, will be eroded. Many of the leading research centres have taken years to build up, with critical mass and institutional memory, but often dependent on staff from other countries. These now face severe instability as staff evaluate their options for reasons set out eloquently by Andre Geim, awarded a Nobel Prize for his discovery of graphene, who is now planning to leave the UK.[18. Parkin S. Brexit: Scientist behind one of the century’s most important discoveries set to leave UK over EU exit. 2017. http://www.independent.co.uk/news/science/brexit-latest-scientist-andre-geim-graphene-discovery-university-manchester-eu-exit-withdrawal-a7886416.html (accessed 11th August 2017).]
The fourth concern, and perhaps the most worrying of all, is government failure. Many commentators have noted how leaving the EU would be the greatest task facing the British state since the Second World War. However, it would do so with a much diminished civil service, both in numerical terms and expertise, as successive cuts have resulted in the departure of many of the most skilled individuals who have taken with them their institutional memory. This weakened structure must implement the transposition of tens of thousands of legal measures into domestic law, described by a former Lord Chief Justice as a “legislative tsunami”.[19. Bowcott O. Brexit may cost MPs and peers the power to pass laws, says former judge. 2017. https://www.theguardian.com/law/2017/may/03/brexit-parliament-oversight-mps-peers-laws-legislation-lord-judge (accessed 7th June 2017).]
The situation is complicated further by a lack of agreement between the UK government and the devolved administrations in Scotland, Wales and Northern Ireland about where repatriated responsibilities will go. Inevitably, concerns have been voiced about whether the UK could cope with any other major crisis.
In this brief review, it has not been possible to cover all of the threats to health and health policy in the UK, some of which are addressed elsewhere.[20. Fahy N, Hervey T, Greer S, et al. How will Brexit affect health and health services in the UK? Evaluating three possible scenarios against the WHO health system building blocks. Lancet (in press).] However, even those issues discussed here reveal the severe threats involved.
There is, however, still some hope. It is increasingly clear that the UK lacks the ability to leave the EU while avoiding a catastrophe. Theresa May’s claim that “no deal is better than a bad deal” is now ridiculed. The political challenges involved in facing up to this reality are incredibly complicated, but the possibility of widespread popular acceptance that Brexit was a terrible mistake seems increasingly likely.