Robert Ede is a Senior Research Fellow in Health and Social Care at Policy Exchange.
In April 2016, the UK Government sent every household in the UK a leaflet entitled: Why the Government believes that voting to remain in the European Union is the best decision for the UK. Ahead of writing this blog I dug out this controversial pamphlet to compare the health elements to the Brexit deal agreed on Christmas eve.
What were the biggest perceived threats then, and how does this compare against the situation we find ourselves in, four years on? Were the supposed doomsters and gloomsters proved right in the end?
Unfortunately, my search did not yield much: the document makes only a couple of short references to health. It highlights the benefits of reciprocal healthcare sharing arrangements across members states, whilst referring to the 136,000 people employed in the pharmaceutical and chemicals industry, and the strength of exports to the EU from the life sciences sector.
In these areas, the deal agreed between the Prime Minister and Ursula von der Leyen stacks up. Those travelling to the EU and vice versa will still benefit from reciprocal necessary treatment, with the European Health Insurance Card (which 27 million Brits hold) to remain valid until expiry when it will be replaced by the new Global Health Insurance Card. This is a win for the consumer, who can feel reassured that they will be looked after if they fall ill whilst on the Continent.
On top of this, the deal appears to allow for UK citizens to seek treatment in the EU if the NHS cannot deliver the procedure or treatment within a ‘medically justifiable’ timeframe. It also extends to covering the costs of planned treatment – for example the 30,000 people who are on dialysis in the UK can now plan holidays to Europe knowing that they can arrange for the NHS to pay for their dialysis sessions in advance, without any upfront costs.
And whilst there has been important attention paid to the possible disruption which may be caused by new customs and border arrangements, there will be no quotas on the import and export of the 45 million packs of medicines which move from the UK to the EU, and the 37 million which go back the other way. The interdependency of medicine supplies has been underlined in the context of the current vaccine rollout – with the first batches of the Oxford/AstraZeneca vaccine to come from the Netherlands and Germany before the UK manufacturing centres come on stream later this year.
The UK has also agreed to pay an association fee to take part in the Horizon Europe research programme, enabling British researchers to bid for funding from an overall €85bn pot up to 2027, on more or less the same basis as their EU counterparts. Many working in the British science sector were pessimistic about this being achievable, but in reality there was a helpful precedent with a number of non-EU countries such as Israel and Switzerland being associate members of the predecessor programme.
This continuation will bring benefits for the EU too, who will be able to continue to fund world-leading scientific discovery. UK research already accounts for 12 per cent of all life sciences academic citations (second only to the USA) and has been central to the global scientific response to Covid-19. Two of the most critical breakthroughs, namely the discovery of Dexamethasone as a cheap and effective treatment and the development of a flexible vaccine candidate, both originated in the UK.
Beyond this, the deal gives the flexibility to diverge from current EU regulations. One obvious example is medicines licencing and approval, where the British regulator will be able to take a different path to the decisions made by the European Medicines Agency when a two-year extension period concludes in January 2023. There has already been some evidence that the MHRA will use this to take advantage of emerging trends in healthcare – such as the use of biosimilars, meaning that patients can access these treatments sooner.
So, this agreement will provide certainty and mitigate some of the most immediate risks that a no-deal Brexit could have posed. But things get a little murkier when it comes to assessing other longer-term impacts.
One point up for debate is whether Brexit will lead to the UK taking a less stringent approach to public health interventions – for example to tackle air pollution or to target the pricing and advertisement of tobacco and alcohol. The deal makes little consideration for these areas, and it is fair to question whether air quality measures will be introduced with the same vigour in a post-Brexit Britain, given that much of the original legislation was driven by Brussels.
But on subjects such as tobacco and alcohol regulation, the EU has often spoken with intent but failed to translate this into meaningful policies. The UK’s introduction of plain packaging for cigarettes required authorisation from the EU but was done unilaterally, whilst attempts to coordinate activity on alcohol related harm across Member States has been mired by disagreement and the pervasive influence of lobby groups. It would be naïve to assume these issues will get an easier ride in Westminster than Brussels, but it is similarly blinkered to believe that EU membership automatically enhanced our capability to tackle non-communicable diseases back home.
And for all the strengths of the deal, it does not help the NHS address its number one issue: the lack of staff.
It has been clear for several years that free movement of labour would end, but the consequences of this change feel especially sobering as the NHS tries to plug so many vacancies. There are 67,000 EU nationals already working in the NHS, representing around 5.5 per cent of the workforce. Without them, the health service would be even more stuffed (to use the technical term) than it is now in responding to the current crisis. Boris Johnson chose to highlight that he was cared for in St Thomas’ by Luis Pitarma, a critical care nurse originally from Aviero in Western Portugal.
Doctors and nurses will qualify under the new points-based system, however they will encounter fees and additional bureaucracy in doing so. Will this deter other Portuguese nurses from coming to work in the NHS?
Evidence since the referendum shows that the overall proportion of EU NHS Staff has remained relatively static, whilst there are hopes that the new rules will be accompanied by redoubled efforts to train staff domestically. There are already 14,000 more nurses working in the NHS than a year ago, but the Government could go further – for example by removing the need for NHS Trusts to ‘back-fill’ the costs of hiring staff to cover for those taking nurse degree apprenticeships when at college.
Back in 2016, the NHS played a central role in both the Vote Leave and the Stronger In campaigns. With the separation now delivered, the relationship between the UK and its European counterparts on health is different and less close, but perhaps more similar and more familiar than the ‘doomsters and gloomsters’ predicted.