The impact on public services, particularly the NHS, has emerged as a key battleground in arguments over the UK’s membership of the European Union. The complex interplay of funding, migration and regulation leaves assertions on either side open to debate.
But any argument should recognise the following ways that a Brexit would pose risks for the NHS.
In 2013 a common set of professional standards was agreed across the EU setting out the requirements in terms of the qualifications, training and competencies expected of healthcare workers.
While aimed at facilitating cross-border working between member states, the regulations that came into effect in January of this year establish standards that health workers are required to meet in the UK and that regulatory bodies, such as the Nursing and Midwifery Council, are required to monitor and ensure.
As the Royal College of Midwives comments:
“This guarantees recognition of professional competence based on minimum training requirements and allows for testing of language skills and exchange of information by national regulators. It is a vital, strong safeguard both for the profession and for the public. Britain leaving the EU would require something similar to be drawn up for the UK. How long would it take to negotiate? Would it be as strong as what we already have? Would it be respected by other European countries?”
To those in the Brexit camp, migrant workers are little more than a cost on the NHS balance sheet. But, of course, migration is not a zero sum game – we benefit from large numbers of EU workers in our health service and EU membership means we have rights to receive free health care in other member states.
Just under 50,000 citizens from the EEA work in the NHS, including over 9,000 doctors, 18,000 nurses, midwives and health visitors and 2,500 allied health professionals, such as physios and radiographers. While this represents just around 4.5 per cent of the total, these workers provide a vital source of skills and expertise plugging gaps left by the underfunding of training places in recent years.
Of course, a sustainable approach to workplace planning should not use migration as a substitute for training more UK-based health but with government plans to end training bursaries and another five year squeeze on NHS funding, there is unlikely to be a significant turnaround any time soon.
Meanwhile a decade of pay restraint and attacks on other terms and conditions is making public sector employment increasingly less attractive and competitive, particularly at a time of moderate but real pay increases in the private sector. Leaving the EU would almost certainly create a short term staffing crisis in the NHS with detrimental impacts on service delivery.
The cost of treating EEA visitors and non-permanent residents in the UK amounts to around £340m a year, most of which is recoverable through the mechanisms such as the European Health Insurance Card (EHIC).
Leaving the EU would mean you would need to take out costly health insurance before even a short break to Europe and UK pensioners retired in countries like Portugal, Spain, France and Ireland would be hit with large medical bills.
The UK government is currently introducing a complex and expensive new system of charges for non-EEA migrants, which the TUC has stated will increase demand on frontline health care professionals charged with managing the process. The new system will require a multi-million pound IT system and mean migrants with infectious diseases like TB could be deterred from seeking treatment thereby creating public health risks.
Leaving the EU would mean extending this new system to patients from more countries with even greater demands on NHS resources and increased risks to public health.
Membership of the EU brings with it access to a range of EU funding that supports research, development and innovation. Horizon 2020 will be investing £7.5bn in research into health and well-being initiatives over the next five years, interestingly the UK was by far the largest recipient in 2014/15 with around £232m supporting organisations such as Great Ormond Street children’s hospital, the London School of Hygiene and Tropical Medicine, University Hospital Birmingham and NHS Blood and Transplant.
Other funding streams such as the Innovative Medicines Initiative, the Active and Assisted Living programme for older people and European Co-operation in Science and Technology (COST) are making millions available to Higher Education, NHS organisations and industry to develop new technologies that benefit all of us.
Not only that but EU membership provides access to networks of other organisations across Europe working together on issues such as cross-border co-operation on HIV/AIDS, hepatitis and tuberculosis control and prevention.
The notion that any savings that might be made from Brexit will be reinvested in health services is undermined by the track record of a Conservative leadership that has imposed an unprecedented decade-long financial squeeze on the NHS.
Of course, there is also the significant risk that any such savings would be dwarfed by the broader economic impact of leaving the EU.
Estimates of the impact of Brexit on economic growth vary considerably and we would caution against sticking to any firm numbers, given the uncertainty of economic forecasting.
However, just over half of the UK’s trade is with EU member states, which would necessitate a very swift and unproblematic exit from EU membership and a subsequent renegotiation of trade deals whilst presumably seeking to avoid EU regulations and freedom of movement for migrant workers.
The challenge of achieving that balance in a short space of time would suggest that, at the very best, the UK economy would encounter a period of “troubled transition” if only in the short to medium term. Which is why a survey of 100 economists by the Financial Times found that over three quarters predicted adverse impact on the UK’s medium term economic prospects.
With the NHS finances in a perilous condition, a tax-funded system such as ours would be hugely affected by any economic shocks that reduced tax revenues, even in the short term. Could the NHS cope with a significant reduction of revenue over a five year period, given the demographic and cost pressures it currently faces?
The TUC has identified the employment rights that could well be under threat from a government no longer required to comply with EU legislation. Many of these support the long-term goals of the NHS in promoting health and well-being at work and home.
The Working Time Directive protects most of us from the stress and ill-health that arise from working excessive hours including health service workers. Junior doctors were brought fully within the scope of the WTR from 2009. At a time when unsocial hours has become a major issue with the government’s attempt to extend “plain time working” for junior doctors and to revise terms and conditions for Agenda for Change staff, withdrawal of Working Time Regulations could have serious implications for those providing our health care.
NHS workers also benefit from other EU-derived regulations, such as the equal pay and maternity rights that underpin Agenda for Change terms and conditions to safeguards against sharp instrument and needlestick injuries in health.
There are other ways that EU membership provides regulatory safeguards that promote public health, thereby helping tackle long term demands on the NHS.
Food regulations establish the rights of consumers to safe food and to accurate and honest information. In the European Union, labelling rules enable citizens to get comprehensive information about the content and composition of food products, helping consumers make an informed choice. Tobacco controls regulate the manufacture, presentation and sale of tobacco products. There are binding regulations on all EU member states ensuring the quality and safety of human blood, tissues and cells, and organs and a range of other public health requirements, such as the management of communicable diseases.
There is no doubt that trade deals such as the Trans-Atlantic Trade and Investment Partnership (TTIP) currently being negotiated between the EU and US, and the Canada-EU deal known as CETA, pose a significant threat to the NHS as a public service.
The lack of a positive exemption of public services, the use of ‘ratchet-clauses’ which make liberalisation measures irreversible and the power provided to corporations to challenge anti-marketisation measures through an unaccountable Investor-State Dispute Settlement (ISDS) mechanism in the current text of TTIP – which gives foreign investors access to special tribunals or courts to seek compensation for the decisions of democratically-elected governments - means that the government attempts to retain and promote publicly owned health services could be undermined.
However, it is unlikely that leaving the EU would protect us from the impact of TTIP, while leaving us excluded from the negotiating process – with UK-based trade unions and NGOs losing what leverage that provides in the process.
Outside of the EU, the UK would still need access to the European Single Market and therefore required to comply with a regulatory framework determined by TTIP. At the same time, is it likely that the UK government would want to a radically different approach in any bilateral trade deal that it negotiates with the US, given David Cameron’s strong support for TTIP? And even if we were to elect a new government less sympathetic to the public service marketization, would it be in a better negotiating position with the US outside of the EU?
There is much more that the UK government and the EU can and should be doing to protect the NHS and other public services from the scope of trade agreements like TTIP. But inside the EU, British trade unions have a voice which is influencing negotiations. Concerns around public services and labour standards that trade unions have raised have prompted the European Trade Commissioner to state they will take steps to make labour standards enforceable in TTIP and that the NHS specifically will be protected in any deal.
We’ve made clear that this isn’t enough – we need to see abuses of workers’ rights punishable by sanctions and protections for public services (including all part-privatised services) written into TTIP to be convinced, as well as no ISDS - but outside the EU we would have to convince an unsympathetic government that public services and trade union rights need protecting in any trade deal.
Let us not forget that the most active Brexit campaigners are not the biggest fans of the NHS.
Matthew Elliott, Chief Executive of Vote Leave is founder of the right wing pressure group the Taxpayers Alliance which advocates an insurance-based health system, cutting spending and increasing charging in the NHS.
Michael Gove is a co-author of Direct Democracy, a publication that describes the NHS as a “centrally run, state monopoly” that is "no longer relevant in the 21st century". Their ambition is to “break down the barriers between private and public provision, in effect denationalising the provision of health care in Britain.”
Eurosceptic MEP Daniel Hannan and Douglas Carswell MP, now of UKIP, both show up on the Direct Democracy project, as well as jointly producing The Plan which advocates giving the right for people to opt-out of the NHS and pay into an insurance based system instead.
Nigel Farage too believes that the NHS should be replaced with a system of private health insurance within the next 10 years.
None of this is a straight forward one way street. EU membership has its costs and benefits. But it is important to recognise how membership of the EU provides a mix of rights, responsibilities, shared funding and cross-border cooperation that supports public health and benefits the NHS directly.
And it is wise to caution against the hypothetical amounts of money being touted by the collection of small state, pro-healthcare privatisation and outright anti-NHS advocates who make up the leadership of the Brexit campaign.
For more information about EU referendum go to www.tuc.org.uk/euref
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