Blog: A real risk that Brexit will damage public health – The BMJ – The BMJ

Leaving the EU will damage health in this country where it was suffering the most before the pandemic, and where covid-19 hit it hardest, says Martha McCarey

The UK definitively left the European Union and its underlying frameworks on 31 December 2020, both parties having signed a Trade and Cooperation Agreement (TCA) charting out their future relationship. Boris Johnson, the UK prime minister announced that the UK had “taken back control of laws and our destiny…of every jot and tittle of our regulation.” Taking back control, however, comes at the cost of aggravating systemic public health issues. This cost can only be offset through political commitment and transparent, long-term planning. This article explores these risks and how they might be averted. 

The risks of regulatory divergence cannot be wholly mitigated

A report funded by the Health Foundation set out some of the challenges that regulatory rupture brings to public health, such as the UK exiting EU structures for coordination and information sharing around responses to infectious diseases, the risk of decline in environmental and food standards, and the potential for the UK Government to block progressive legislation in devolved nations on areas such as alcohol pricing, environmental protection, or calorie labelling. 

To an extent, the TCA mitigates these risks. It secures ad hoc access to the EU’s Early Warning and Response System (EWRS) for infectious diseases and blocks the lowering of environmental standards, although the UK will leave the EU carbon trading system. Domestic statute now ensures some scrutiny of food standards as the UK regulates independently and strikes future trade deals. Under specific conditions, it also allows a free hand for devolved administrations to regulate on risk factors for non-communicable disease. Some of these changes could in theory present an opportunity for progress and accountability, although UK Government plans are largely unclear, if they exist at all. 

Worsening structural inequalities

Other long-term impacts throw into stark relief systemic issues pre-dating Brexit. Groups including, but by no means limited to ethnic minorities, deprived rural and urban populations, or older people, experience significant social inequalities and disparities in health outcomes and in access to healthcare in the UK. This translates into, for instance, child poverty, or higher rates of chronic obstructive respiratory disease, diabetes and obesity. During the pandemic, these populations have been subject to disproportionately high infection and fatality rates.

The Marmot review in 2010 flagged a concerning 7 year life expectancy gap and 17-year disability-free life expectancy gap between poorer and wealthier areas in England. By its ten-year follow-up review, overall life expectancy had stalled, disability-free life expectancy had declined, and inequalities in life expectancy had increased. Subsequently, the recession triggered by covid-19 in 2020 led to concerning rises in unemployment and food poverty

Leaving the single market is set to accentuate and prolong this economic downturn, and with it economic and health disparities. In November 2020, the Office for Budget Responsibility (OBR) predicted that leaving the single market with a trade agreement would lead to a permanent, 4% reduction in productivity compared to the status quo before 1 January, increasing pressure on income and employment and driving up food prices. The OBR subsequently estimated that the significant customs and trade disruptions following Brexit have led to a 0.5% reduction in GDP in the first quarter of 2021, on addition to a 9.9% GDP reduction in 2020 during the pandemic. 

Long-term commitment to public health funding

That loss of growth will feed directly through into the UK’s public finances, where again, long standing funding pressures have been affecting the health service and public health well before Brexit or covid-19. 

The UK Government ostensibly stands by the principle that prevention is better than cure, following a strong economic case for preventive public health investments lessening the physical and financial burden of non-communicable disease on the health system. The NHS Long-Term Plan, accordingly, heavily features prevention and the integration of healthcare provision, and is matched with a commitment to 3.4% per year real-time increase in overall healthcare funding. However, like for like local authority spending on the delivery of preventive public health services has actually decreased over the past six years. Meanwhile, the pandemic has already significantly reduced the overall health budget, even with additional resources poured into the response. 

We have already commented that public health cuts are a false economy. Vulnerable populations would, once again, be the first to feel the impact of shifts in health financing. There is a clear correlation between cutting funding for public health campaigns, and a decline in health indicators: the gap in smoking rates between poorer and wealthier populations has stopped shrinking after public health funding cuts in 2015 forced councils to slash their support to quit programmes. Similarly, failure to address obesity with a credible long-term strategy addressing individual and societal drivers not only comes at considerable long-term cost to the NHS but also, more immediately, puts a significant proportion of the UK population at risk of experiencing severe or fatal cases of covid-19. 

Under prolonged economic stress following Brexit, without sustained advocacy and scrutiny there is a risk that preventive public health investments may continue to be first in line for cuts. The budget does not appear to provide much needed clarity or reassurance.

This is likely to mean hospital admissions will see an increase in non-communicable illnesses or complex co-morbidities involving them, and ultimately an increase in the number of preventable deaths. 

Without a change in the direction of policy and priorities, there is a real risk that leaving the EU will damage health in this country where it was suffering the most before the pandemic, and where covid-19 hit it hardest.

Martha McCarey, Brexit and Health researcher, Nuffield Trust.

Competing interests: none declared. 

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