In 1991 I was seconded from the Department of Health to the European Commission, and during my subsequent years there, the prevailing view in the UK, with a few limited exceptions, has been that the EU had little to do with health and virtually nothing to do with the NHS. So I never thought that health questions and the impact of Brexit on the NHS would be raised in the referendum debate, let alone that they would feature so prominently. 

I was invited to work in the Commission initially to set up a new public health programme, “Europe against AIDS” as I had worked in this area in the UK. This was an archetypal EU health initiative in that it addressed an issue which required an international response; in this case tackling a serious communicable disease that “respects no borders,” as we used to say. It complemented national efforts by fostering cooperation and exchange of best practice between countries, providing funding for prevention and health education activities, supporting non-governmental bodies in their work, helping to improve data and information on the epidemic and building expertise and capability in those countries with the least resources. It also promoted policies across Europe based on what would be most effective in public health terms rather than pandering to fears and prejudice, for example by fighting against stigmatizing people with HIV or imposing mandatory screening of travellers at national borders. The programme was accompanied by EU funded research on HIV/AIDS and by work on safeguarding blood supplies, and it was followed in 2005 by the creation of the European Centre for Disease Prevention and Control in Stockholm to bolster capacity to tackle communicable diseases across Europe and beyond.

The work on AIDS is only one of many health and health service areas where the EU has played a significant role over the years—from tobacco control to food and consumer safety, from regulating medicines and medical devices to rules on tissues and organs, from health research and technology to development and humanitarian aid, from health and safety at work to the European health insurance card, from clinical trials to environmental pollution, from alcohol and drug abuse, to the free movement of health professionals and patients.

But though the current Brexit debate may notionally be putting a focus on health issues, in reality the two sides talk about health and the NHS only insofar as there is a connection with the two overriding themes of the campaign: money and migration.

On money, the Brexiteers say simply that the “billions paid to Brussels” would be saved once the UK left the EU and could then be entirely devoted to the NHS. The NHS budget for 2014-15 was about £135 billion. By contrast the UK’s net EU contribution is a relatively modest £8-10 Billion (depending on who you believe!). Spending it entirely on the NHS would no doubt be helpful, but this would imply that it could not be spent in other areas, such as replacing EU support for farmers, or for poorer regions, or research, let alone on schools and social services, or even setting up a fund to foster exports etc. More importantly, say the remainers, this contribution gives us access to the single market which is enormously beneficial for the economy as a whole. Leaving the EU’s single market would decrease economic growth which would in turn reduce the amount available for public spending, including spending on the NHS. It would also produce uncertainty and lead to an increase in interest rates and the amount the government had to pay to service its debts. Higher debt repayments (which cost £53 Billion in 2013-2014) alone would more than wipe out what we saved in our EU contribution.

As for migration, Brexiteers argue that the NHS is being swamped by EU (and non-EU migrants) and, like other public services, cannot cope with the continuing influx. Leaving the EU would enable us to reduce, or stop the flow completely so reducing pressure on healthcare and other services. This ignores the facts, say the remainers, that migrants are generally younger and healthier than the ageing domestic population, that they come here seeking (and finding) work not welfare hand-outs, and that they contribute more in taxes than they take out in benefits, thus helping to provide public finances for the NHS. Moreover, they point out, migrants make up a significant proportion of NHS and social service staff and that the NHS could not function without them.

Leaving aside the merits of these arguments—and it should not be too difficult to see where I stand on them—they make up in essence the whole of the debate about the EU and health. There is no discussion on important questions about how to maintain and improve public health and health services, and what the effect of membership of the EU has been in these areas.

Bernard Merkel retired last year from the European Commission, where he played a central role in the development of the EU’s actions in health, including the public health programmes; the overall health strategy; and, more recently, the growing work on health systems. Before he joined the EU, he was a civil servant in the Department of Health for many years, including a spell as a ministerial private secretary.

Competing interests: I am receiving a pension from the European Commission and I will also be doing the odd piece of work for them, as well as some paid and unpaid health policy consulting, teaching, and research.