How would a decision to leave the European Union affect medical research and health in the United Kingdom?

On 23 June 2016, the United Kingdom will hold a referendum to decide whether we should remain in the European Union. Many professional medical and scientific societies, as well as international organisations, have advised a ‘Yes’ vote in this referendum in favour of staying in the European Union. ¹ Why have they reached this conclusion and how might the opposite outcome, an exit from the European Union, affect medical research and health in the United Kingdom?

The most important impact of a ‘No’ vote (in favour of leaving the European Union) on health would arise from its economic effects. ² A Treasury analysis concluded that leaving the European Union could lead to an annual net loss of income to each household in the United Kingdom of around £4300 after 15 years. Tax receipts could be up to £36 billion a year lower, the equivalent of an extra 8p on the basic rate of income tax. ³ The Organisation for Economic Cooperation and Development reached similar conclusions: a United Kingdom exit from the European Union would immediately hit economic confidence and raise uncertainty, and result in predicted Gross Domestic Product being 3% lower by 2020 than if the United Kingdom remained in the European Union. ⁴

In the economic shockwaves caused by an exit from the European Union, the United Kingdom would have to choose between the politically unpalatable alternatives of either imposing increases in taxes or making substantial cuts to government spending. Lower spending in areas such as health and social care would have an immediate negative impact on the health of the residents of the United Kingdom. The National Health Service, which is already under considerable financial strain, would find its financial situation even further compromised. ⁵ We would be faced with the prospect of major cuts in publicly-funded healthcare, or the introduction of compulsory health insurance and co-payments. Lower levels of spending on social care would further increase pressures on both community and hospital services; for example, it would become more difficult to discharge frail, elderly patients from hospitals. In the longer term, reduced levels of spending on areas that are part of the wider determinants of health – such as housing, education, pensions and benefits – would also affect public health in the United Kingdom with the greatest adverse effects likely to be seen in vulnerable groups such as children, the elderly and the poor. ⁶

The impact of an exit from the European Union on the National Health Service workforce would also be very concerning. Currently, around 50,000 people from the European Economic Area work in the National Health Service. This includes around 9000 doctors and 20,000 other health professionals. These professionals provide a vital contribution to the National Health Service by helping to address key shortages in its workforce. Their employment by the National Health Service if the United Kingdom left the European Union would be uncertain as would be the future recruitment of workers from Europe. For example, the European Union has established standards for the training of doctors and health professionals. These standards facilitate the free movement of professionals between member states, and ensure recognition of professional qualifications obtained in different countries. Undermining these standards would make future recruitment more difficult as we would have to negotiate with each European Union country separately to ensure that any doctors and other health professionals recruited to work in the United Kingdom were trained to the same standards we would expect from our locally trained staff. ⁷ Our doctors may also lose the protections afforded by the European Working Time Directive, which helped end the excessive hours without dedicated rest periods worked by many doctors in the past.

Membership of the European Union simplifies the procedures for treating visitors from the European Union. When these visitors are treated by the NHS, the United Kingdom is able to claim the costs from their own countries. European Union membership also gives United Kingdom citizens travelling in other European countries the right to access free or cheaper public healthcare through the European Health Insurance Card. Leaving the European Union would require setting up complex methods for charging people from the European Union for healthcare, and people from the United Kingdom would have to take out health insurance when visiting the European Union. The right to healthcare of the two million citizens of the United Kingdom who live in other European countries would also become uncertain and it is unclear if they would still be eligible for free treatment in their country of residence or if they would need to fund their care themselves, either directly through user fees or through health insurance. There are also benefits from membership for people with very rare diseases as the European Union has supported the creation of cross-national centres of excellence to provide care for these patients.

The European Union has had a major impact in public health from interventions in areas such as food regulations, road safety, air pollution, tobacco control, and chemical hazards. For example, the REACH process established by the European Union is the most stringent system worldwide for protecting both human health and the environment from the adverse effects of chemicals, with a duty on manufacturers to prove chemicals are safe before releasing them onto the market. ⁸ European Union directives have also addressed water quality, both for drinking and bathing, including the now well-known Blue Flag system for rating beaches. Our government would be under no obligation to implement future European-wide public health initiatives if the United Kingdom was no longer a member of the European Union. We may find our government less willing to support such initiatives, particularly those that required action against large multi-national corporations over which any single government has only limited influence. ⁹

The European Union is a major funder of research in the United Kingdom and currently the United Kingdom is second only to Germany in the amount research funding it obtains from the European Union. ¹⁰ The United Kingdom plays a key role in cross-national research projects, including many in health-related fields, which would be at risk in the event of an exit from the European Union. A recent example of world-leading research funded by the European Union and led from the United Kingdom is a study on the whole-genome sequences of 560 breast cancers. ¹¹ Universities in the United Kingdom are also able to recruit staff from other European Union countries because of legislation that supports the free movement of workers between member states. This liberal recruitment policy helps our universities recruit leading academics and retain their high rankings in international league tables of university performance. These high ratings in turn ensure that we attract both funding for research and overseas students to our universities, which are essential for ensuring the future prosperity of the United Kingdom. The European Union has also helped establish programmes, such as Erasmus, that allow students to undertake placements at other European universities as part of their education. The leading role that our universities play in global research and education would be threatened by loss of research funding from the European Union, from reduced opportunities for collaboration with European universities and from lower levels of public funding for universities in the United Kingdom because of the economic problems that arose from our departure from the European Union. ¹²

It is very clear that the United Kingdom currently engages very heavily with the other member states of the European Union and with European institutions over many health-related and scientific issues. A vote to leave the European Union would start an extremely complex programme of renegotiations, lasting many years and with uncertain outcomes, that would threaten these positive collaborations. The process of renegotiation of these agreements with other European countries would be complicated further by renewed calls for independence in an overwhelmingly pro-European Scotland.

Exit from the European Union would not preclude the United Kingdom from negotiating future agreements in areas such as research, healthcare, the regulation of health professionals and initiatives to improve public health, separately with each of the countries of the European Union or with the European Union as a whole. But the outcome of these negotiations cannot be guaranteed and the European Union will not allow a non-member country to be part of any future standard setting meetings. The United Kingdom would thus no longer be a participant in making policy in these areas, but would instead receive instructions from the European Union.

Given the very large potential negative effects of an exit from the European Union, doctors, health professionals, academics and their professional organisations should all be concerned about its consequences. If we want to protect the health of our citizens, healthcare provision, medical research and teaching, and the continued world-leading status of the top universities in the United Kingdom, then the logical vote in the referendum on 23 June is one that ensures we stay a full member of the European Union.