When I wrote my last BMJ blog it was within hours of the result of the EU referendum. I admitted freely that, despite having studied the EU extensively for three decades, I had no idea what the implications of Brexit would be for health. This was because I was unable to ascertain what it would actually look like. After three days, during which the pound has fallen further in value, the Bank of England has put aside £250 billion (yes, billion, at a time when we are told that there is no money for the NHS, social care, or anything else) to prop up the banking system, the opposition has disintegrated, and support for Scottish independence has soared, I still have no idea.
In part that is because many of those who advocated Brexit have gone to ground. Daniel Hannan MEP, one of the most vocal advocates of Brexit, has told his followers that he is signing off Twitter for a month. Michael Gove, Gisela Stuart, and Kate Hoey are nowhere to be seen. But then, at 10pm on Sunday night, we got the answer we were all waiting for. Boris Johnson, by all accounts Prime Minister in waiting and the person who, more than anyone else, took the Leave campaign to success, set out his plans, not at a press conference or in parliament but in his newspaper column, perhaps understandably given that he is paid £5000 each time for it. In essence, he would have all the benefits of the EU, without any of what he saw as the disadvantages. In effect, it encapsulated his approach to life, which he once summed up as “My policy on cake is pro having it and pro eating it.”
The same Boris who had, only a month ago, compared Europe to the superstate he believed had been sought by Hitler and Napoleon, now called for “intense and intensifying European cooperation and partnership.” He made clear that any exit “will not come in any great rush”. These comments reveal a basic pragmatism. Those who understand the EU recognise that it could take a decade or more to disentangle the UK from processes, policies and laws built up over 40 years.
However, the problems begin when one gets to the details. And of course, Boris does not do details very well. As Andrew Tyrie, chair of the Commons Treasury Committee, famously noted when confronted by a litany of tales about bananas and cucumbers, “All very interesting Boris, Except none of it is actually true, is it?” Thus, a quick look at the data show that his claim that “the pound remains higher than it was in 2013 and 2014” is difficult to reconcile with the evidence that it is now worth $1.34, somewhat below $1.48, its lowest point in 2013/14. His failure to “detect any real appetite to have another [Scottish referendum]” may, however, be excused as he was playing cricket and writing his column rather than watching television over the weekend. This is the problem. The reader is compelled to factcheck everything Boris says, a lesson we should have learned after he was once sacked from The Times for making up quotes.
He continues by rewriting the history of the Leave campaign. Responding to claims that many voting Leave did so because of concerns about immigration, he says “I do not believe that this is so,” something contradicted by the polling evidence.
These problems continue when we look at what he proposes. In essence, he seeks to persuade the EU to ensure that “British people will still be able to go and work in the EU; to live; to travel; to study; to buy homes and to settle down” while enforcing “control of immigration policy, with a balanced and humane points-based system to suit the needs of business and industry” which, by implication, will deny to EU citizens the rights he expects them to grant to UK citizens. Given that this is almost impossible to achieve, we still have no idea what the implications will be for free movement, which has sustained the NHS and our research base.
In his vision, the UK will remain in the single market, but without the rules being enforced by the much maligned European Court of Justice (ECJ). This is something with profound implications for health services because if the rules are not enforced by the Court, which hears evidence in public, and based on the Treaties which provide extensive protection for the health, social, and educational sectors, the only alternative is a secretive tribunal system, such as that operated by the World Trade Organisation. This is precisely what those fighting the Trans-Atlantic Trade and Investment Partnership (TTIP) have been fighting against. Indeed, the decision by the EU to demand that disputes under TTIP would be resolved in a system like the ECJ was important in providing reassurance that it would not lead to the destruction of the NHS. And while European competition law has many problems, the alternative will be very much worse, with severe implications for contracting within the NHS. It seems that, under Boris, the UK is to abandon those protections we now enjoy.
Finally, there is the question that the Leave campaigners have avoided throughout the campaign. What will happen to the European institutional structures that we now depend upon in the health sector, such as the European Centre for Disease Control and the European Medicines Agency (EMA)? We continue to await an answer, and indeed may be waiting some time. What is certain is that, in these circumstances, those pharmaceutical companies that have invested in the UK, at least in part because of the location of the EMA in London, will be very unlikely to plan any further investment in the UK. But then it seems that no-one is planning to invest here now.
So, three days on, we seem no nearer to having any idea of what lies ahead but, as I said in the last blog, it won’t be good for health.
Martin McKee is professor of European Public Health at the London School of Hygiene and Tropical Medicine.