Martin McKee: The Brexit White Paper—making Britain great again?

By Martin McKee (London School of Hygiene & Tropical Medicine)

Cross-posted with kind permission from the BMJ Opinion blog.

CaptureThe long awaited Brexit White Paper has finally appeared. Yet Martin McKee finds it fails to shed any light on how Brexit’s consequences for health (or much else) will be addressed.

The long awaited Brexit White Paper has finally appeared. The timing was, to say the least, a little unusual, as it was published the day after members of Parliament voted to initiate the process of leaving the European Union. It is, of course, normal for White Papers to be published in advance of parliamentary bills, so that parliamentarians can make an informed decision about how to vote.

On this occasion, the Prime Minister had made it very clear that she was opposed to them having any vote at all. The advantage of not having a written constitution is that prime ministers can, largely, make up the rules as they go along. It therefore seems especially careless to fight a long and expensive legal battle against some of the very few constraints on the executive that exist. But, of course, the Prime Minister, when home secretary, had form in this respect.

Given the enormous implications that Brexit will have for health, catalogued in a series of earlier BMJ blogs, it seemed reasonable to hope that the White Paper would offer some clarity. What had gone before was of little help. For many months, all we knew was that “Brexit means Brexit,” later qualified by the news that it would be “red, white, and blue.”

Faced with widespread puzzlement about what is actually meant in practice, the Prime Minister reluctantly gave a speech which, we were told, would be the definitive statement on the government’s negotiating position. Although welcomed by much of the British media, newspapers in the rest of Europe, whose correspondents actually understood the European Union, were much more sceptical. So were those British academics who have spent many years studying these issues, with one describing it as “vague, incorrect, misleading, hypocritical, or fantasist.” We were reassured that the speech was the final word on the government’s position, containing all that could be said.

Yet, given its many contradictions, inaccuracies, and unrealistic aspirations, calls for a White Paper mounted and, eventually, the government conceded. Now, it appears that the Prime Minister was right. Her speech was all that the government could say. The White Paper, which was clearly rushed out in a hurry without adequate proofreading (for example, Chart 7.1 suggests that British workers are entitled to 14 weeks of annual leave), adds very little.

The word “health” is mentioned four times and the NHS not at all. Two of these mentions relate to funding for research. The government has agreed to underwrite existing EU funded research—in health, as in other areas—that extends beyond Brexit. Of course, this does nothing to address the many other problems for UK research created by Brexit, catalogued in detail elsewhere.

The sole mention of healthcare is that “we recognise the priority placed on easy access to healthcare by UK nationals living in the EU.” Of course, there is no indication of what the government actually plans to do about it. This should not, perhaps, be surprising. Despite penetrating questions by Dr Sarah Wollaston MP, Jeremy Hunt’s recent appearance before the Commons Health Select Committee also failed to shed any light on how the consequences for health might be addressed, except the rather unsurprising information that some people in the Department of Health were looking at it. The incredulity of some members, such as Ben Bradshaw MP, was all too apparent.

The challenges are enormous. Tens of thousands of British pensioners now live in parts of southern Europe in properties that are, in effect, valueless. They have no prospect of either purchasing properties back in the UK or paying enormous sums for private health insurance. Yet what is often forgotten is that many British pensioners, in countries such as Spain, Italy, and Ireland, are not actually British citizens. Instead they are people who came here as young people, worked all their lives in the UK, and retired to their home countries with the British pension they contributed to for decades. It is not clear that anyone in authority has even thought about this latter group.

The importance of the European Medicines Agency to the UK economy and to our rapid access to medicines has been discussed extensively. However, it gets only the briefest of mentions in the White Paper. Lumped together with a few of the other 40 plus agencies whose functions will have to be replicated in new UK bodies (if those with the necessary skills can be found), all that is said is that “the Government will discuss with the EU and Member States our future status and arrangements with regard to these agencies.” The European Centre for Disease Prevention and Control, crucial to our epidemic preparedness, does not even get a mention.

Buried in the notes to the 137 word European Union (Notification of Withdrawal) Bill was the news that the UK would leave EURATOM. This organisation, which predates the European Economic Community, is responsible for regulating the nuclear industry. Over the years, it has amassed exceptional technical knowledge, especially with regard to nuclear safety. Given the Prime Minister’s determination to eliminate any links to the European Court of Justice, which is the final arbiter of the law in relation to EURATOM, this seems inevitable.

Nonetheless, it has been greeted with widespread shock, being described as a lose-lose situation. Those who support nuclear energy, who have invested in new nuclear power stations, will see significant delays as a new regulatory system is developed. Those who oppose nuclear power will have justifiable concerns about who will be responsible for safety. There are also enormous implications for medicine, from health protection to radiotherapy. At least in this area, the White Paper identifies new arrangements as a priority, even if there is a complete lack of detail as to what they might look like.

Parliamentarians now have an opportunity, albeit limited, to try to fill in the many gaps that this White Paper has left. These include the impact assessment and financial implications that would normally accompany a White Paper—both of which are missing. Unfortunately, as has been catalogued in detail in the aptly named book The Blunders of our Governments, there are few grounds for optimism, something that readers of The BMJ will understand given the passage of the largely unworkable Health and Social Care Act. We are often told of the great wisdom accumulated in the House of Lords. It seems to be the last chance of achieving even the most superficial clarity.

Martin McKee is professor of European public health at the London School of Hygiene and Tropical Medicine.

Image credit: ITV News