As Article 50 is triggered, Bernard Merkel discusses the potential impact that Brexit could have on health
With the triggering of Article 50 we are now starting the formal process of leaving the EU. My abiding memory of the EU referendum campaign last June was of the Leave campaign bus trundling round the country with the brazen slogan that leaving the EU would save the UK £350 million a week, and that the money saved would go to the NHS. This dubious claim received enormous publicity and, tellingly, was disowned by those who made it as soon as they had won the vote. It has now been, not exactly abandoned, but totally overshadowed by a much bigger financial argument, which will certainly play a central role in the forthcoming negotiations: how much should the UK pay as a fee to leave the EU? The European Commission (which will lead the EU side in the negotiations) has indicated that the amount it will seek for outstanding commitments could be as much as £50 Billion. The UK may well start with a counter-proposal that they owe nothing at all. This issue will have to be resolved during the two year negotiations if they are to succeed. Any sizeable amount agreed would more than outweigh any conceivable extra money for the NHS which might be available much further down the line.
But apart from this, are we any wiser about the potential effects of Brexit on health than we were during the referendum campaign?
The short answer is not very much. There are, however, a few straws in the wind, some of them provided by the work of the House of Commons Health Committee which is conducting an enquiry about the possible impact of Brexit on health and social care. They are looking at various key areas, including the health and social care workforce, reciprocal health coverage (such as the EHIC scheme), regulation of medicines and medical devices, research, public health and resources for EU programmes, agencies, and networks. 
We are beginning to get some evidence that the uncertainty about their future position in the UK is having an impact on the many EU nationals working in the NHS as doctors and nurses. The General Medical Council surveyed EU doctors in the NHS. Only 2000 (about 10% of the total) replied, but of those 60% said they were considering leaving, nearly all because of Brexit.  The Nursing and Midwifery Council has found that 2,700 EU nurses left their register last year, and that in the last quarter of 2016 new nurses coming from the EU fell by 75% from the 2015 total.  The significance of these figures should not be overstated. Nevertheless, at a time when we are very dependent on EU staff working in the NHS and social care, they are certainly of concern. 
One other development that was not fully foreseen last year was the view eventually reached by the UK Government that Brexit had to mean leaving the EU single market. One consequence of this is the decision that the UK will leave the European Medicines Agency (EMA), and will have to set up its own alternative arrangements for licensing medicines. Many were surprised by this decision given the size and importance of the UK pharmaceutical industry—one reason the UK had fought to have the EMA based in London in the first place—and the major role played in its work by the UK Medicines and Healthcare products Regulatory Agency.  This decision, and the logic behind it, throws up questions about whether the UK will also be leaving other EU agencies and regulatory bodies and systems, such as the Food Safety agency and the European Centre for Disease Prevention and Control, and what this might mean for public health.
The House of Commons Health Committee is due to publish its report after Easter. One message that their work will serve to highlight is the considerable impact that EU membership has on health in the UK. But we cannot expect real clarity about the effects of Brexit for some time—possibly years—to come.
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.
 ‘What Does Brexit Mean For Health In The UK’, by Nick Fahy and Tamara Hervey in Eurohealth Vol 23, No 1 , 2017
 Evidence given to the House of Commons Health Committee by Charlie Massey, Chief Executive and Registrar of the GMC in the Hearing of 28 February
 Confirmed by The Secretary of State in his evidence to the Health Committee on 24 January.