Healthcare in England will be heavily influenced by the type of agreements the UK government can strike with other countries, writes Elisabetta Zanon

The UK’s “Leave” vote is a critical decision for all of us, given the impact of Europe on our daily lives. And especially for the NHS, which alongside the economy and immigration was a key battleground in the highly charged pre-referendum debate.

At this stage it is impossible to predict the implications for the NHS, as we do not know what kind of new relationship with the EU the UK government will seek, how long negotiations with the EU will last and what the outcome will ultimately be.

This situation is unprecedented. The European Union has never experienced the withdrawal of a member state before, so at the moment we do not know precisely how the negotiations on the exit agreement will be conducted and what concessions EU heads of state and government will be ready to cede to the UK when agreeing a new type of relationship.

Radical loss of influence

The key question will be whether the UK government will seek to maintain access to the EU internal market in the future. Given that it has been estimated that the annual benefit of the EU internal market to the UK economy is between £31-92bn per year, this has important implications for the NHS both from a financial and regulatory point of view.

If the UK wants to follow the example of Norway or Iceland – which are members of the European Economic Area but not members of the EU – and remain in the single market it will also have to comply with EU rules on (for example) the mobility of health (and other) professionals, the treatment of patients abroad, health and safety at work (including the Working Time Directive), public procurement and competition, the conduct of clinical trials, the authorisation of medicinal products, and data privacy.

The more radical alternative would be for the UK not to access the EU internal market, but instead to pursue trade negotiations with any country of choice through its membership of the World Trade Organization

However, under this scenario the UK would no longer have a seat at the EU negotiating table when EU rules are shaped and agreed, as it will have neither voting rights in the European Council nor members in the European Parliament. This would mean a radical loss of influence on decisions taken in Brussels.

The more radical alternative would be for the UK not to access the EU internal market, but instead to pursue trade negotiations with any country of choice through its membership of the World Trade Organization.  This could include seeking to negotiate a free trade agreement with the EU as a whole. Everything will be up for grabs, though it’s unlikely the UK will be able to pick and choose exactly which elements we want without having to concede other areas that the EU will want from us. 

Concluding agreements with individual countries would involve a high level of risk for the economy, due to the likelihood that the UK would sign significantly fewer comprehensive bilateral deals than the EU could achieve collectively, as well as the possibility of a number of businesses deciding to relocate to an EU country outside the UK.

Threat to innovation

Under this more radical scenario, EU law would not apply in the UK. This could possibly bring regulatory simplification in some areas, but would also come with the disadvantage that British citizens, companies and other organisations would not benefit from the advantages brought by EU law.

For example, all parts of the value chain for pharmaceuticals and medical products, including research, development and production, clinical trials and bringing medicines to market could be negatively impacted, as regulatory divergence between the UK and the EU in these areas might increase over time.

This could lead to less clinical research and innovation taking place in the UK and potentially higher costs for innovative health technologies to be borne by the NHS.

Everything depends on what agreements are negotiated between the UK and the EU, or other individual EU countries. For example, unless another agreement is in place, it’s possible that Britons living abroad may no longer benefit from health cover in their country of residence. This could result in people having to purchase private health insurance or come to the UK when they need elective care.

Currently, recruitment from the EU for unfilled NHS jobs is quicker than for non-EU nationals, as EU rules enable mutual recognition of professional qualifications for a range of healthcare professions. This could change if these rules are no longer applied, but the UK could instead decide to fast-track “shortage” professions in the same way as we currently do for non-EU citizens.

Debate around the NHS has generated much heat during the pre-election campaign, but little light has been shed on the actual practical consequences for the NHS in the event of a Leave vote. Now that we know Britain’s future is outside the EU, the NHS Confederation, through its European Office, will follow and assess the implications of the “Leave” discussions both in Brussels and in the UK. We owe this to our NHS staff and, above all, to the public they serve.

By Elisabetta Zanon, director, NHS Confederation European Office