The debate over Britain's membership of the European Union, culminating in the 23 June referendum, has been dominated by claims about the economy and immigration. For many people, those claims are abstract or swept up in accusations of fear-mongering. The question of "what does this mean for me?" is rarely addressed. One area where this needs urgent attention is a Brexit effect on the UK's public services, particularly the National Health Service.
Yes, the economy matters, in the sense that the NHS will struggle to retain its current level of funding, let alone receive a much-needed increase, if the UK leaves the EU. Yes, immigration matters, not just because Brexit will not only unsettle the NHS by possibly reducing the number of qualified staff, but also because it may limit the ability of UK citizens to get health services in the EU.
The economy and the NHS
Since the NHS is largely funded out of general taxation, it is inevitable that levels of NHS spending are closely related to the state of the economy. Its so-called protected status has meant the NHS has escaped the effects of fiscal austerity better than some other public services. That said, two-thirds of NHS Trusts in England are already in deficit and the NHS faces a very cold financial climate in the coming years which will be compounded by an ageing population, rising demand, technological advances and plans for a `seven day service.’ Future NHS spending will continue to rely on taxation derived from economic growth.
The Leave campaign has claimed that the £350 million weekly cost of EU membership could be spent on other `priorities’ such as the NHS. As Sarah Wollaston MP (who chairs the Health Select Committee and who switched sides in the debate last week from Leave to Remain) noted, this ignores the benefits that are derived from membership, including cross-European research collaborations, many of which support UK universities’ health research.
The scale of re-couped EU membership costs is relatively marginal in the overall NHS finances. If these costs could be retained and some of it spent on health care, it would only fund the NHS for 19 days, according to Simon Stevens (NHS Chief Executive, NHS England)4. Moreover, many other public services (and especially social care) could make equally strong claims for this additional spending.
Whatever the result of the Referendum, the NHS will require more than the £8 billion additional spending, announced last year. Comparatively, the UK’s share of national income spent on health has slipped to 8.5% of national income (2013-14; compared to the OECD average of 8.9%). (With recent accounting changes, UK spending rises to 9.9%2 but many countries have yet to implement these changes, which will increase the average).
Migration and the NHS
The pressure on public services from migrant populations has been part of the Leave debate. A rising population does indeed put pressure on existing services. However, this overlooks the net benefit of migrants (who are generally younger and healthier) to the economy, including paying taxes to fund the NHS.
More specifically, the NHS workforce relies heavily on migrant staff to deliver services. Through the EU’s recognition of common qualifications and free movement of labour, clinical staff are able to work in any EU country. Currently, about 130,000 EU nationals work in the NHS. Also, over a quarter of doctors working in the UK were trained abroad (compared to 9% in other countries). That said, NHS staff from Commonwealth countries supported the NHS for many years prior to the UK entry into the EEC.
Due to previous European Courts of Justice rulings, patients (who are EU nationals) are able to receive cross-border care. Indeed, recent evidence shows that while 52,000 patients came to the UK for treatment, 63,000 patients left the UK for treatment (albeit not just to the EU), commonly for fertility treatment, cosmetic and bariatric surgery. So, whilst the attention has been primarily on `migrants’ coming to the UK, it is equally possible that UK nationals can both work and receive care in other EU countries. This is particularly important for those working elsewhere in Europe or who live there as retirees.
For some, the Transatlantic Trade and Investment Partnership (TTIP) has been a reason why the UK should leave the UK and absolve itself from trade agreement which might open up the NHS to (more) foreign competition. The amendment to government legislation, passed last month, seems to have placated some of these concerns but the scale and nature of the impact of TTIP will depend on continuing negotiations.
In summary, the NHS gains much already from EU membership and faces uncertainty if it leaves. The pressures facing the NHS are complex and will not be easily solved whatever the outcome on 23 June. However, this decision will shape the fortunes and future of the NHS for many years to come.
The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of the University of Birmingham.