Martin McKee: Decoding the Brexit white paper—what might it mean for health?

The government’s stated intention was to provide a degree of certainty, but in that it has failed

mcKee_martinJust over two years after the referendum on European Union (EU) membership, the British government has finally set out some concrete proposals for where it sees its future relationship with the EU. The new white paper is clearly a considerable improvement on the earlier one, which was widely criticised for having so many pages left blank and, in its initial version, containing a number of basic errors. This one, at least, attempts to engage with some of the issues, even if it continues to avoid many of the most contentious ones.

The government’s stated intention was to provide a degree of certainty for individuals and businesses in the UK and the rest of Europe. Regrettably, both technically and politically, it has failed to do so.

First, the technical. One of the most informed commentators questioned the need for 104 pages, arguing that it “is full of so much muddled thinking, desperation and fantasy that they could have done it in five.” The one clear principle underpinning it is what has now been termed “cakeism,” based on Boris Johnson’s argument that the UK could actually have its cake and eat it. It is essentially a long wish list, with no attempt to explain how this might be delivered. This is in marked contrast with the very detailed briefings that have been published by the EU, which spell out precisely the legal barriers that the UK will face. If these have been read at all, they seem to be ignored.

The situation is not helped by inventing new terminology, such as a “common rulebook,” that have no legal meaning but are used simply to avoid terms that have, such as “regulatory alignment.” Nor is it helped by assuming that, every time the EU agrees new rules, something the Brexiteers have long complained involves a lengthy and bureaucratic process, it will then start all over again to reach agreement with the UK. Finally, as has been widely noted, it proposes technical solutions that do not yet exist and, even if they did, would add enormously to the complexity of doing business.

Politically, the problems are just as great. The image of cabinet unity presented after the Chequers meeting was shattered within 48 hours, with the first of a series of resignations by ministers and party officials. The pro-Brexit wing of the Conservative party initially held their fire, but only until they had time to digest a detailed legal analysis, which was actually quite perceptive, and which highlighted the contradictions and ambiguities in the Chequers statement.

Although not known to be superstitious, Theresa May might reflect on whether it was entirely wise to invite Donald Trump on Friday 13 July, especially when she saw the newspaper headlines in which the president essentially reiterated what his predecessor had said. The model of Brexit that she had proposed would put the UK behind the EU in the queue for any future trade deal. He then placed the blame squarely on her shoulders, pointing out that it could have been much better if only she had listened to him. To put it mildly, this does not bode well for her plans to achieve Parliamentary approval, which anyway did not get off to a particularly good start when the government failed to make copies of the white paper available to MPs, even though journalists had already had them for several hours.

Yet, even if the white paper seems to be going nowhere, it would be wrong to think that nothing was happening. Since the Chequers agreement, there have been a number of leaks of government papers reporting on preparations for what has been described as a “no deal” situation. It would, of course, be entirely speculative to link this to the appointment of a new Secretary of State for Exiting the EU who has taken a distinctly harder line than his predecessor. However, while seemingly designed to show that the UK is serious about this option, these leaks are hardly encouraging. They include large scale stockpiling of food, confirming what Tim Lang and I have argued elsewhere that one of the biggest concerns about Brexit is food supply. They also propose bringing back military generators from Afghanistan to ensure electricity supply in Northern Ireland. Those, like me, who experienced blackouts there during the Loyalist strikes in the 1970s had thought that such days were long gone.

The white paper does, however, give some indication of the government’s thinking about where it wants to be in relation to health, although this requires some decoding as little of what is written can be taken at face value. The NHS gets only one mention, in the Prime Minister’s foreword, where she repeats the widely discredited claim that leaving the EU would release money that could be spent on the NHS. “Health” is mentioned 20 times, but five refer to the health of plants or animals.  

There are many worthy aspirations. The government seems to have listened to the detailed arguments of the Faculty of Public Health setting out the importance of continued collaboration with European activities on disease surveillance and control and monitoring of drugs, although it is silent on how this could be achieved without the underpinning of EU law on which these arrangements depend. It also seeks continued participation in a number of European specialist agencies, in particular the European Medicines Agency—a valuable asset now lost to the UK. And after months of denials that medical isotopes were even an issue, the government has finally recognised the importance of continued cooperation with the European Observatory on the supply of medical radioisotopes. The government concedes that, if such arrangements could be negotiated, it would continue to pay into the budget but be denied a vote, which seems far from “taking back control.”

The UK commits to maintaining labour protection, in particular in relation to health and safety. However, this is difficult to reconcile with the arguments by its supporters that one of the “benefits” of Brexit would be to do just that, with Jacob Rees-Mogg suggesting that the standards prevailing in India would be perfectly adequate. There is a clear intention to continue to participate in the arrangements for reciprocal healthcare and, in particular, the European Health Insurance Card (EHIC), although again, there is little discussion as to how this could be achieved given that the relevant legislation is based on the principle of freedom of movement, which the government has rejected.

Given the dependence of the NHS on health workers from the EU27, there has been keen interest in the proposals for mobility of people. The white paper contains proposals that would cover businesses moving individuals across borders to provide services, tourism, and students, but says nothing whatsoever about the needs of the NHS. It does, however, suggest that there should be mutual recognition of professional qualifications. This is, however, problematic, because as a third country, any concessions to the UK would have to be extended to all other countries having free trade agreements with the EU, such as South Korea, as these agreements contain “Most Favoured Nation” clauses. This does not appear to have been recognised by the drafters of the paper, who write “the UK’s arrangements with the EU should not be constrained by existing EU FTA precedents.” This is simply impossible.

The white paper has received guarded welcomes across Europe because, for the first time, it begins to outline the official position of the United Kingdom. Whether it has the full support of the cabinet remains uncertain; some have suggested that a few ministers may simply be waiting for its inevitable rejection by the EU27 because so many aspects are simply impossible, but that remains to be seen. At least it does suggest what the British government actually wants. With only a few months left to negotiate an agreement, that in itself is great progress.

Martin McKee is professor of European public health at the London School of Hygiene and Tropical Medicine.

Competing interests: None declared.