Brexit—what might it mean for global health?

This week, the United Kingdom (UK) has made the unprecedented move of leaving the European Union (EU), an economic and political union of 28 member countries. After a close result, the Leave campaign won the referendum with 52% of the votes compared to 48% for the Remain campaign, with a 72.2% voter turnout. As the country now grapples to come to terms with the consequences of this election, this rejection of EU membership threatens to have a great impact on the health of people both within the UK as well as internationally.

Immigration and Healthcare

UK health system financing is provided through central taxation to the National Health Service (NHS). Increasingly, many are finding that the NHS is struggling to cope with the demands of the UK population, and questions arise regarding the source of this strain. A key pro-Leave argument has attributed this to the rise in levels of migration to the UK and their increased use of public service goods including healthcare.

However, research by University College London has shown that most recent migration (2001-2011) actually has had a positive effect on the economy. "EEA immigrants contributed to the fiscal system 34% more than they took out, with a net fiscal contribution of about 22.1 billion GBP. In contrast, over the same period, natives' fiscal payments amounted to 89% of the amount of transfers they received, or an overall negative fiscal contribution of 624.1 billion GBP"1. Furthermore, the Office of Budget Responsibility forecasted economic growth in the UK as dependent on higher rates of inward migration2. This suggests that migrants are net contributors to UK economy rather than draining it. And while contributing to the economy, migrants are also likely to be contributing to the NHS, as nearly 15% of clinical staff, including 30% of doctors, are foreign nationals. As Dr. Sarah Wollaston MP explains "if you meet a migrant in the NHS, they are more likely to be treating you than ahead of you in the queue".

Another more obvious issue regarding sources of strain on the NHS can be found closer to home. According to The King's Fund, the NHS budget has been effectively frozen for the last 6 years, with health spending as a proportion of GDP decreasing year on year, and a struggle to match the rate of inflation3. Increasing privatisation of key public services and a demoralised health workforce, as well as a systematic underfunding of the NHS – all policies implemented by the current government – perhaps show a clearer link to the current issues seen in service delivery, a link that is conveniently overlooked by many who continue to blame this to increasing levels of migration.

Furthermore, during campaigning, the Leave group argued that stopping the contributions that the UK made as part of the EU would lead to £350 million pound saving which would increase NHS funding, even emblazoning this pledge on the side of "Vote Leave" tour bus. However, after the results of the referendum were announced it was publically announced that this was no longer a given.

In fact, it is suggested that the Brexit result will reduce funding to the NHS even further, with the Institute for Fiscal Studies suggesting there will be a £36 billion net loss due to lower rates of economic growth prompted through the economic instability the decision will bring4. As Simon Stevens, Chief Executive of the NHS describes "when the economy sneezes, the NHS catches a cold."

The effects of this can already be seen: since announcing the results of the referendum, the value of the Great British Pound (GBP) has plummeted to its lowest in the last 31 years, with many predicting an impeding economic recession for the UK. As well as reducing funding to health services, a rise in inflation is likely to increase living costs disproportionately for the poorest households, increasing the rates of poverty-related illness further in the most vulnerable groups.

Environment and Health

One of the great public health successes of the EU, has included improving environmental health and air pollution. Directives issues by the EU which limited the quantity of sulphur in fuel and volume of sulphur emissions has led to an 80% decrease in sulphur emission in Europe; road traffic emissions were found to be reduced by 63% due to implementation of EU standards5. Data from 2015 shows that only two London boroughs had acceptable NO2 levels according to EU standards6, however, it is unlikely the UK will have an incentive to invest in complying with the EU Air Quality Directive in the absence of such penalties after leaving the EU. Air pollution is an issue that disproportionately affects vulnerable groups such as young children and the elderly, whether they be British or European; without the EU, there will be decreased accountability mechanisms to ensure that clean air is a right for all.

Trade and Health

The Transatlantic Trade and Investment Partnership (TTIP) has received widespread criticism across Europe due to potential health consequences such as leaving public sector organisations open to privatisation and weakening of food safety and agriculture policies. Several senior European politicians have stated opposition to the EU signing such a deal with the US. As the UK is no longer within the EU, it will now have to negotiate a separate trade agreement with the US. Due to the smaller size of the UK market in comparison to the EU, it is likely the UK will have decreased negotiating power, plus combined with an increasingly right-leaning post-Brexit government, some have called this new deal the equivalent of "TTIP on steroids". There is some room for optimism as it is clear that TTIP will not apply to the UK; the only concern is whether the alterative will be better or worse.

Commercial Interests in Health

Many health issues require tackling industry interests in order to pass progressive policy, for example, addressing tobacco, food and drink industry and alcohol industry to reduce non-communicable diseases (NCDs) prevalence. The UK strategy to tackle tobacco use has been particularly effective, and has even surpassed EU legislation, such as implementing plain packaging and the ban of smoking in public places. However, once the UK loses the protection provided by EU law it may be difficult to implement such progressive policies in other areas, with many suggesting Brexit may make the UK particularly vulnerable to renewed lobbying pressure by the tobacco industry, as seen in Switzerland, a country which has not yet ratified the Framework Convention on Tobacco Control (FCTC). The UK already has been criticised for being influenced by commercial interests and being an obstacle to progressive making within the EU; it is a worrying thought to see how these competing interests will shape policy making now the UK stands outside the EU.

It is true that EU laws influencing health are not as strong as many health professionals hope for, and one could argue that autonomy through Brexit will allow the UK to move forward, faster. However, motivation for Brexit has rarely centred on leaving in order to make stronger health policy than currently possible within the EU. Instead Brexit campaign has been based on inward-looking, fear-invoking tactics – an inadvisable platform for creating progressive global health policy. Only time will tell whether Brexit will cause more problems for progress towards greater industry regulation than it will solve.

The issues that concern most Brexiters are essentially global in their nature (immigration, economic stability). Such issues have health consequences which transcend national boundaries and governments, making them important global health concerns. However, at a time where the solutions to global problems require collaboration and looking outwards, the UK has decided to retreat inwardly. As McKee and Galsworthy write, "the idea that any country can act independently in a globalised world, or should do so, is a dangerous fantasy"7.

Autonomy is a double edged sword: being within the EU afforded the UK some basic accountability mechanisms. Now outside, accountability must become our collective responsibility by advocating that exit negotiations reached prioritise a rights-based, social determinants of health approach. Perhaps this is one way to shed some light on this dark, dangerous fantasy of autonomy that has all too suddenly become a reality.