So far, Brexit has been all prologue. It remains likely that some form of Brexit will occur, but we are still some way from knowing how. Unless the upcoming election produces a Remain majority or a second referendum, the UK is only at the beginning of a long process of political and legal change that will last a decade or more.
No analysis of plausible Brexit scenarios has shown a benefit to health or healthcare in the UK and the most elaborate ones have shown extensive harms. [1,2,3] But once the UK is formally out of the EU, it still has to start to negotiate its future relationships. Understanding the EU and its many effects on health will be important if the damage to the health and health sector of the UK is to be limited.
While it might seem like Brexit would make EU health policy matter less to the UK, most EU actions that affect health are the result of its large, integrated internal market. It will be impossible for the UK to ignore the impact of one of the world’s two largest economies on its health system or its role as a standard-setter for health, social and environmental protections, especially when that economy is right next door.
As we argue in our new book, Everything You Always Wanted to Know about European Union Health Policies But Were Afraid to Ask, most EU actions affecting health occur outside of the domain of “health policy” as defined in EU treaties.  Trying to understand the EU by looking at what the Commission’s Directorate General for Health does is therefore like trying to understand health in the UK by focusing only on Public Health England. It misses a large part of the picture.
We examine the whole picture through the three ‘faces’ of health policy in the EU. Article 168 [of the TFEU] created the first face of EU health policy, a set of helpful initiatives to make public health and health care work better in the member states. These initiatives range from assistance with vaccines and health threats to work on antimicrobial resistance, from tobacco control to regulation of blood supply safety, and from cooperation in disease surveillance to comparative data on cancer.
The other two faces of EU health policy are less visible, but more important as determinants of health in Europe. The EU was born as a common market, and the core of its law and policy is still the creation of a unified European market in goods, services, capital, and people. The EU regulates workplace health and safety, such as requiring safe handling of sharps in health care, as part of its internal market laws. The EU’s determining role in pharmaceuticals regulation is legally justified by the internal market. The EU makes policy on cross-border care based on internal market law. It makes the rules that permit European clinical professionals to work freely across the EU. The list goes on.
The third face of the EU relates to its “fiscal governance” structures. These are intended to prevent repetition of the 2010 debt crisis by constantly monitoring and steering member states on their policies. Health care is vastly expensive item and a healthy population is good for the economy, so the fiscal governance system has come to include substantial and increasingly detailed recommendations to member states on their health and health care policy.
In this way, a great deal of the EU’s significant policy activity affecting health relates to economic aspects of the Union. In terms of Brexit, this is important because the UK will have to establish a new relationship with its most significant trading partner. Even stronger economic relationships with the US or Australia, should they materialize, will not compensate for what economists call the law of gravity: countries trade most with their neighbours.
The UK, if it is to avoid more serious economic problems, will need access to the EU’s markets on good terms, and would benefit from continued regulatory harmonization with the EU in areas from medical devices regulation to protection of data in clinical trials to labour standards. But while the EU is too big, near, and important to the UK to make it in the UK’s interest to diverge in key areas, the UK will lack its previous power to shape EU standards from within. 
This is likely to have immediate effects. The UK has influenced EU research priorities and pharmaceuticals regulation, but once the UK is no longer part of the EU they are both likely to drift in a direction that better serves the remaining member states. The UK is particularly dependent on EU citizens to staff all levels of its health and care infrastructure, and nothing about its current politics seems designed to make it more attractive to them. Losing membership of the European Centre for Disease Control and Prevention will interfere with surveillance and tracking of cross-border disease threats.
In the future, the UK is going to have to make its way in a world where its much bigger neighbour influences every aspect of its environment. Having given up its control of EU policy, the UK will have to learn to anticipate and adapt. Investing in understanding the EU will be more, rather than less, important for UK health policymakers because, having given up its direct power, the UK will have to rely on persuasion in Brussels. Nevertheless, the EU’s global influence will continue to be relatively aligned with UK interests (in comparison to those of the US or China), perhaps offering areas where the UK can usefully cooperate to its own and the world’s benefit.
Scott L. Greer, Professor, European Observatory on Health Systems and Policies; University of Michigan
Holly Jarman, University of Michigan
Nick Fahy, University of Oxford
Willy Palm, European Observatory on Health Systems and Policies
Sarah Rozenblum, University of Michigan
Matthias Wismar, European Observatory on Health Systems and Policies
Competing interests: None declared.
- van Schalkwyk MCI, Barlow P, Stuckler D et al. Assessing the health effects of a “no deal” Brexit. Bmj. 2019;366:l5300.
- Fahy N, Hervey T, Greer S et al. How will Brexit affect health and health services in the UK? Evaluating three possible scenarios. The Lancet. 2017;390:2110-2118.
- Fahy N, Hervey T, Greer S et al. How will Brexit affect health services in the UK? An updated evaluation. The Lancet. 2019;393:949-958.
- Greer SL, Fahy N, Rozenblum S et al. Everything you always wanted to know about European Union health policies but were afraid to ask: Second, revised edition. Brussels: European Observatory on Health Systems and Policies; 2019 Link: http://www.euro.who.int/en/publications/abstracts/everything-you-always-wanted-to-know-about-european-union-health-policies-but-were-afraid-to-ask-2019
- Greer SL, Laible J, editors. The European Union After Brexit. Manchester: Manchester University Press; 2020