Book review: Not What the Bus Promised: Health Governance After Brexit

Those of us who were in the United Kingdom (UK) on the morning of 24 June 2016 are unlikely to forget our reaction following the result of the ‘Brexit’ referendum to leave the European Union (EU) that took place the day before. For some, it was unbridled joy – a victory for ‘taking back control’ of British sovereignty and no longer being tied to the EU’s heavy-handed approach to regulation and soft borders leading to unchecked immigration. For others, myself included, it was (perhaps naively) utter shock and disappointment – a tragedy for the country, and a result that blithely seemed to skip past the majority wishes of substantial parts of the voting public (including by a large majority in Scotland, where I resided, alongside Northern Ireland, Greater London, and Gibraltar) and would inevitably lead to a diminished country that would make everyone worse off, economically, culturally, and politically. Finally, for still others, undoubtedly the reaction was apathy – a sense that regardless of the outcome of the referendum, things would more or less be the same, or the impact simply would not be felt in any material way that would cause concern for one’s everyday living. The EU was somewhere ‘out there’; unseen, unfelt, unknown.

Whatever be one’s personal memory and reaction, as Tamara Hervey, Ivanka Antova, Mark Flear, and Matthew Wood deftly portray in their socio-legal study, Not What the Bus Promised, and as has become crystal clear some 8 years after the referendum, Brexit has had a detrimental impact on the UK, including for the health of Britons. Some degree of ‘buyer’s remorse’ also is evident: as of May 2024, 55% of people in Great Britain thought that it was wrong to leave the EU, compared with 31% who thought it was the right decision. ¹ Another poll in June 2024 suggested that 57% of the nationally representative UK population thought it was ‘wrong’ to the leave the EU in hindsight. ² As I write this review, in the days just after the July 2024 General Election, in which there was (as expected) a landslide Labour Party victory, the driving mood seemed to be one of collective punishment against the Conservative Party – both by liberals and centrists who have long been dismayed with the leadership and direction of the country and wish to forge closer ties again with the EU and by ‘Brexiteers’ on both the left and right wing who think the government has let the country down by failing to truly ‘get Brexit done’. And yet, there was also relatively little said about Brexit during the General Election campaign, as if Brexit was something ‘done’ in the years prior, and regardless of public opinion, there was not much left to discuss with the electorate in terms of Brexit-related law, politics, or policy. Seemingly, Brexit was the proverbial elephant in the room: interviews and manifestos covered concerns about the National Health Service (NHS) waiting lists, dwindling GP numbers, pesky inflation and the cost of living, weak housing supply, immigration, economic growth and productivity, and so on, but these were discussed as matters on their own, not set in the larger context of the UK’s having left the EU, much less set within a discussion of what any of the political parties, were they to be in Government, would do in terms of realigning the UK’s relationship with the EU.

In this co-authored book, Hervey, Antova, Flear, and Wood – who are legal scholars (Hervey, Flear), a political scientist (Wood), and human rights scholar and practitioner (Antova) – make a convincing case that Brexit, especially its health-related aspects, must remain a front-and-centre discussion point in law and politics for years to come. They provide a nuanced study of the impact of Brexit on health governance in the UK, asking, ‘In what respects have law and policy changed, or are law and policy changing, in health contexts?’ ³ This being the main socio-legal output of their interdisciplinary Economic and Social Research Council (ESRC)-funded project, the authors place a strong emphasis on positionality and reflexivity in this book – and connections to time and place, punctuated both by where their research took place (e.g. Newry, Derry, Rochdale, Rotherham, Sheffield) and by the time period, largely February 2019–March 2020, a particularly fraught period of Brexit negotiations with the EU and a tumultuous period in the UK Parliament.

The study is based on empirical data largely gathered in 2019, with a jurisdictional focus on Northern Ireland and north of England. Some of the data involved stakeholder consultation workshops and over 40 semi-structured interviews with health policy experts in the four nations and in Brussels, conducted between November 2018 and May 2019.

Across 12 chapters, the authors weave substantive legal and political analysis with narrative – stories from each of them about how they got involved in the Brexit referendum and the focus on health and their experiences (emotional and intellectual) during this uniquely challenging time in UK and European history.

Following the scene-setting and personal narrative-focused Introduction, Chapters 2 and 3 detail the aims and approach of their study, which is primarily ethnographic. The authors do not shy away from their positionality and reflexivity in the project. As they observe, ‘personal identity and experience matters to how we – the researchers – know what we know’ and as such proceed to detail their background and experience to better ‘ensure that data collection and analysis did not align too closely with our own preconceived assumptions and expectations’ and to ‘ensure epistemic justice for our research participants’. ⁴ The methods deployed in the study comprised doctrinal analysis, interviews, and street conversations (by way of vox pops and photo elicitation, including the infamous photo on the side of the bus, promising that £350 million a week would be saved by leaving the EU and putting it into the NHS instead). In total, the authors held 417 conversations with a total of 489 participants.

Storytelling was evidently key to their study, as ‘the stories we tell underline our inherent researcher situatedness or positionality, as well as that of our research subjects and co-producers’. ⁵ But what also becomes clear early on is the blurred lines between ‘experts’ and ‘ordinary people’ – between professionals in health and the general public. While the study drew on a dense network of health policy actors, across the UK but especially focused on Northern Ireland and London, the street conversations held with ‘ordinary’ people suggested they hold a more sophisticated view of health, politics, and Brexit than the media might sometimes portray. Across the book, the six themes that emerged from the street conversations are illustrated in various ways: (1) the (mis)truth of the claim on the bus; (2) distrust in politicians; (3) (individual) responsibilisation for health; (4) the need for (more) frontline NHS resources; (5) the tenuous relationship between the NHS and Brexit; and (6) anti-immigration sentiment.

The themes are first picked up in Chapter 4, which discusses the scope of the rest of the book and details the ‘NHS Brexit Bus’ campaign. The authors note that ‘there is little doubt that the idea that voting Leave was a “pro-NHS” position had a crucial effect on the referendum vote’. ⁶ Yet many people the team spoke with seemed to know the claim on the bus was untrue: ‘At one and the same time, people are both drawn to the idea implicit in the image, while knowing on another level that it is false’. ⁷ Their analysis suggests that the claim on the bus ‘worked to manipulate the hopes of people who would like to see a better-funded NHS, by offering an implicit promise that the benefits associated would emerge from the process of leaving the EU, but without ever explaining how that process would lead to the desired outcome’. ⁸ From a legal and political standpoint, this was somewhat puzzling given the EU’s formal legal competence to affect national health systems is significantly constrained, and there was nothing about EU membership that constrained the UK in funding the NHS. Then, as now, these decisions were domestic policy choices made by successive UK Governments, which, it must be said, were consistently underwhelming.

Working from the World Health Organization’s ‘building blocks’ of a national health system ⁹ to explain how Brexit has an effect on health and the NHS, the subsequent chapters analyse the impact of Brexit on the health workforce (Chapter 7); financing; medical products, vaccines, and technology (Chapter 8); information (data standards) (Chapter 9); service delivery (Chapters 5 and 6, which include discussion of cross-border healthcare in Great Britain and Northern Ireland, respectively); and leadership and governance (Chapters 10 and 11).

One of the more significant and insightful contributions of this book is the focus on the unique position of Northern Ireland. Unlike England, Scotland, and Wales, Northern Ireland has been running an integrated health and social care system since 1973 and shares health services with Ireland (called Co-operation and Working Together). This has not changed with Brexit, although unlike in Great Britain, there was major concern about Brexit in relation to loss of cross-border health service access (indicating a more focused association of Brexit and health than perhaps existed in Great Britain). From medicines and medical devices to the healthcare workforce and specifically in relation to Northern Ireland, the authors rightly note that ‘Healthcare is not incidental to the Brexit process: it is a matter of central concern. [. . .] But because health was seen as incidental in the broader politics of Brexit, it could be – and was – sacrificed to larger political aims’. ¹⁰

What one concludes from reading Not What the Bus Promised is that overall, Brexit, in all its forms, is bad for health and the NHS, even if some forms of Brexit (e.g. a ‘hard No-Deal Brexit’) would have been worse than others. While leaving the EU could, in principle (and thinking very optimistically), have provided the UK an opportunity to put human health front and centre in law and policy making across the UK, to date, nothing of the sort has happened, although undoubtedly the unexpected COVID-19 pandemic had a significant impact on the Government’s focus from March 2020 onwards. Despite a changing of the guard now with a Labour Government in power, very clearly Brexit will not be undone. The UK will very likely forever more remain outside the EU and continue its steady, slow decline as a global power. The country will age demographically, co-morbidities will rise, and economic productivity is likely to remain close to stagnant; this, coupled with ongoing strict immigration controls, will dampen the desirability of the country as a place to move to and work in. The market will be much reduced for clinical trials of medicines and medical devices, and there is reason to think that access to new medicines and devices will be slower than when the UK was part of the EU (with Northern Ireland in an especially precarious position for medicines). The long-term outlook, then, is not pretty.

But, a ‘post-Brexit reset of the NHS across the UK remains a possible hope for the future’. ¹¹ If we want to improve our health and protect our NHS – and few in the UK would argue against that – it will require a healthier cooperative relationship with the EU, not to mention the Devolved Administrations in Wales, Scotland, and Northern Ireland, and a clear-eyed conversation with the entire UK population about the level of taxation needed to sustain the NHS and the creation of a new social contract required to keep the NHS working as a health service (and not merely a sickness service).

And yet, there is unlikely to be any accountability for the poor decisions made (or not made) leading up to and in the years subsequent to June 2016, including the misinformation campaign with the ‘message on the bus’ and the post-Brexit realities (the Brexit chickens coming home to roost, as it were). Objectively, one must agree with the authors that ‘The implied promise that Brexit would mean a better NHS is at odds with the reality that all forms of Brexit are, taken in the round, bad for health and the NHS’. ¹² While the health policy community was of the view that accountability should take place through political processes: through the ballot box, through proper scrutiny of the effects of proposed government policies, and through open and transparent parliamentary debate (at least the former is happening in 2024), there was nothing in the views of the health policy community that suggested any kind of legal accountability was expected. In contrast, and somewhat surprisingly, ‘ordinary people’ participating in the study evoked trust and belief in legal responsibility and accountability, for example, through criminal prosecution or removal of politicians, although other sources of legal accountability might include electoral law, common law offences, administrative and intellectual property law on the use of the NHS logo, and freedom of information requests. The authors, however, are sceptical of the success of any kind of legal accountability happening, outside a change in government, as am I: ‘. . . while many people could not imagine how [Boris] Johnson, or subsequent governments, could be held accountable for that broken promise [on the bus], a significant proportion of people thought that law should be a viable accountability process in this instance. What we have shown in this chapter is that UK law, as it currently stands, is wholly deficient in that respect’. ¹³

The authors of this fine book make a persuasive case that Brexit is bad for health. So what next? Political accountability is more achievable than legal accountability in my view, and that has already started at the ballot box with the General Election in July 2024, and by holding political leaders to account and demanding a sustained policy focus on protecting and promoting the NHS. In other words, it is up to Britons themselves to determine what, if anything, to do about their health governance, as a united and sovereign, yet still internationally connected, group of nations. Beyond voting and political accountability, however, it also requires mutual accountability through our democratic citizenry. As the authors remind us, that means telling and listening to people’s stories as Britons and Europeans (among other identities) across the four nations, respecting legal, economic, and political technical knowledge and expertise, and exercising a good deal of humility – understanding where people are coming from, respecting their knowledge and experience, and recognising the importance of time and place reflected in those stories. Not What the Bus Promised brilliantly starts the first step of much-needed post-Brexit health governance reform in the UK.