So far, Brexit has only been prologue. It remains likely that some form of Brexit will happen, but we are still a long way from knowing how. Unless the next election produces a remaining majority or a second referendum, the UK is only at the start of a long process of political and legal change that will last a decade or more.
No analysis of plausible Brexit scenarios has shown any benefit to health or health care in the UK and the most elaborate have shown considerable harm. [1,2,3] But once the UK has officially left the EU, it still needs to start negotiating its future relationship. Understanding the EU and its many health effects will be important in limiting the damage to health and the health sector in the UK.
Although it might seem like Brexit would make EU health policy less important to the UK, most EU actions that affect health are the result of its large, integrated internal market. It will be impossible for the UK to ignore the impact of one of the world’s two largest economies on its healthcare system or its role as a standard-setter in health, social and environmental protection, especially when that economy is right next to it.
As we said in our new book, Everything you always wanted to know about EU health policies but were afraid to askmost EU actions affecting health occur outside the realm of “health policy” as defined in the EU Treaties.  Trying to understand the EU by looking at what the Commission’s Directorate-General for Health does is therefore like trying to understand health in the UK by focusing only on Public Health England. Much of the picture is missing.
We look at the big picture through the three ‘faces’ of health policy in the EU. 168 [of the TFEU] created the first face of EU health policy, a set of useful initiatives to improve the functioning of public health and healthcare in the Member States. These initiatives range from assistance with vaccines and health threats to work on antimicrobial resistance, from tobacco control to regulation of blood supply safety, and cooperation in the surveillance of diseases to comparative cancer data.
The other two sides of EU health policy are less visible, but more important as determinants of health in Europe. The EU was born as a common market, and the core of its legislation and policy is still the creation of a unified European market for goods, services, capital and people. The EU regulates occupational health and safety, such as requiring safe handling of sharps in healthcare, as part of its internal market laws. The leading role of the EU in pharmaceutical regulation is legally justified by the internal market. The EU bases its policy on cross-border healthcare on internal market law. It lays down the rules that allow European clinical professionals to work freely across the EU. The list continues.
The third face of the EU concerns its “fiscal governance” structures. These aim to prevent a repeat of the 2010 debt crisis by constantly monitoring and guiding member states on their policies. Health care is an extremely expensive item and a healthy population is good for the economy, so the fiscal governance system has come to include substantial and increasingly detailed policy recommendations to member states. of health and health care.
In this way, much of the important political activity of the EU affecting health relates to the economic aspects of the Union. With regard to Brexit, this is important because the UK will have to establish a new relationship with its most important trading partner. Even stronger economic relations with the United States or Australia, if they materialized, would not compensate for what economists call the law of gravity: countries trade the most with their neighbors.
The UK, if it is to avoid deeper economic problems, will need to access EU markets on good terms and would benefit from continued regulatory harmonization with the EU in areas ranging from the regulation of medical devices to data protection in clinical trials and labor standards. But while the EU is too big, close and important to the UK for it to be in the UK’s interest to diverge in key areas, the UK will not have its previous power to shaping European interior standards. 
This is likely to have immediate effects. The UK has influenced EU research priorities and pharmaceutical regulation, but once the UK is no longer part of the EU, they are both likely to drift in a direction that better serves the EU. remaining Member States. The UK is particularly dependent on EU citizens to staff all levels of its health and care infrastructure, and nothing in its current policy seems designed to make it more attractive to them. Loss of membership in the European Center for Disease Control and Prevention will interfere with surveillance and monitoring of cross-border disease threats.
Going forward, the UK will have to navigate its way through a world where its much larger neighbor influences every aspect of its environment. Having relinquished control of EU policy, the UK will have to learn to anticipate and adapt. Investing in understanding the EU will be more, rather than less, important for UK health policymakers because, having given up direct power, the UK will have to rely on persuasion in Brussels. Nevertheless, the EU’s global influence will continue to be relatively aligned with UK interests (compared to those of the US or China), perhaps providing areas where the UK can usefully cooperate for its own benefit and that of the world.
Scott L. Greer, Professor, European Observatory on Health Systems and Policies; University of Michigan
Holly JarmanUniversity of Michigan
Nick FahyUniversity of Oxford
Willy PalmEuropean Observatory on Health Systems and Policies
Sarah RozenblumUniversity of Michigan
Matthias WismarEuropean Observatory on Health Systems and Policies
Competing interests: None declared.
- van Schalkwyk MCI, Barlow P, Stuckler D et al. Assess the health effects of a “no deal” Brexit. Bmj. 2019;366:15300.
- Fahy N, Hervey T, Greer S et al. How will Brexit affect health and health services in the UK? Evaluation of three possible scenarios. The Lancet. 2017;390:2110-2118.
- Fahy N, Hervey T, Greer S et al. How will Brexit affect health services in the UK? An updated assessment. The Lancet. 2019;393:949-958.
- Greer SL, Fahy N, Rozenblum S et al. Everything you always wanted to know about EU health policies but were afraid to ask: second revised edition. Brussels: European Observatory of Health Systems and Policies; Link 2019: http://www.euro.who.int/en/publications/abstracts/everything-you-always-wanted-to-know-about-european-union-health-policies-but-were-afraid-to-ask- 2019
- Greer SL, Laible J, editors. The European Union after Brexit. Manchester: Manchester University Press; 2020