Professor Martin McKee: The safety net being torn apart by red lines
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Public health in the UK has been underpinned by a network of cross-border initiatives. But they are all now at risk. Professor MARTIN McKEE reports
• PLAGUES AND PESTILENCE
Infectious diseases don't respect borders. In 1348 the Black Death swept through Europe killing a third of the population. The flu epidemic in 1918 killed more people than died in the First World War.
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These days we are much better prepared, with complex surveillance and response systems in place. Recent challenges have included ebola and SARS. Public health workers across Europe gain reassurance from the work that takes place in the European Centre for Disease Control, in Stockholm. Opened in 2005, it tracks health threats throughout the EU and beyond.
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Last year, when I was visiting the situation room, colleagues were studying the changing pattern of Yellow Fever in Brazil, so they could warn those going there and be prepared if anyone came back with a possible infection.
The UK, with a traditionally strong public health workforce, has played an important role in the centre's development. But can this continue?
The UK's Faculty of Public Health would like it to. But the problem is, once again, Theresa May's red lines – because co-operation between national authorities doesn't take place in a vacuum. It is built on a complex body of European law, overseen by the European Court of Justice, both things that the British government has rejected.
No doubt some mechanisms for co-operation will be developed, but as with anything that requires information-sharing, like policing and criminal justice procedures, it seems likely that the UK will be on the periphery, with a more limited role in policy or decision-making. That cannot be good for the health of the British people.
• The European Health Insurance Card
Every year, thousands of Britons pack their bags for a few weeks away, perhaps on the beach in southern Europe or exploring one of the continent's historic cities. They pack their guidebooks, their passport, and hopefully, a small blue card, the European Health Insurance Card, or EHIC. This ensures that, should they be unfortunate to fall ill, they will be able to receive care in the health system of any country in the European Economic Area, on exactly the same basis as the locals.
Once the UK leaves the EU, however, their ability to do so will almost certainly disappear. How do we know that? Like so many aspects on Brexit, only now are people realising that the British government's red lines get in the way of doing what is sensible. There is a simple reason.
The EHIC wasn't developed primarily to help people going on holiday. It was created because it was impossible to ensure real freedom of movement if there wasn't some system that would allow those exercising that freedom to know that they would be cared for if anything happened to them as they did so. And first and foremost, it was to allow people to move for work.
If the British government won't sign up to the parts of the European Treaties that provide for freedom of movement, and both Conservatives and Labour say they won't, then there is no legal basis for the EHIC.
But, the Brexiteers argue, something will be done. Surely it is in everyone's interests to keep the system in place. Yes, of course it is. But there are other areas where it is in everyone's interests to find a solution, yet without the EU having the legal power to do it, it just can't be done.
Take pension arrangements for the many people from North Africa who have spent most of their working lives in France. Pensions come under the same provisions as the EHIC, as both relate to labour mobility. Yet politicians and officials have been struggling for more than 20 years to put in place a system to cover these people. There are other challenges too. The operation of the EHIC depends on a whole body of EU law on issues such as data protection. If the UK opts out of those, it won't be possible to share information as now under the EHIC scheme.
So what would the loss of the EHIC mean for those travelling abroad? For those who are young and healthy, probably not a lot, as long as they remember to purchase health insurance. But if you are old, by which I mean over 65, and have pre-existing illnesses, then it could be a lot. We compared the cost of a week's travel insurance for people at different ages and with different conditions going to an EU country, France, and two outside the EU, Israel and Canada. In all cases, the cost was much more outside the EU, typically two to five times as much. An 85-year-old with angina would pay just over £100 to go to France. But if they went to Canada it would be almost £600. Once someone has multiple conditions, as a growing number of older people do, the prices increase rapidly, that is if cover can be found without going to a specialist broker. And there are others, such as the 29,000 Britons on dialysis. They can only go on holiday in the EU because there are arrangements in place to receive treatment. If they had to pay privately it could be up to £1,000 a week. The loss of the EHIC will hit older people hardest.
• MEDICAL RADIOISOTOPES
One of the many surprises in the explanatory notes accompanying the government's notification of Article 50 was that the UK would leave Euratom. Most people had never heard of it.
When it was suddenly suggested, after the vote, that the UK would pull out, Dominic Cummings, campaign director of Vote Leave, said that politicians suggesting it would happen were 'morons'. Yet, it happened. So why does it matter for health? Modern medicine depends on radioactive materials for diagnosis and treatment, especially of cancer. One of the most widely-used materials is an isotope of Technetium, Tc99m. It has one great advantage in diagnosis, a very short half life.
Soon after use it decays into harmless elements, leaving no residual contamination. But that is also a disadvantage, because it has to be produced just before it is used. And it is produced in only a few places, with all of what is used in the UK being imported, mostly from the Netherlands.
There are complex systems in place to ensure it gets to where it is needed. But if there is a shortage, for instance, caused by a problem with the Dutch reactor, as happened in 2008-2010, then there is supply disruption. Euratom has created a system to make sure that what is available is shared out equitably. The UK can be reassured it will get a fair share… for now. All of the professional bodies, such as the Royal College of Radiologists and British Nuclear Medicine Society, have expressed grave concerns at leaving the collaborative framework. The British government described this as scaremongering and claimed that outside the Euratom framework, EU suppliers could still supply the UK.
However, beyond potential de-prioritisation, all this opened up another question – what happens to the mechanics of radioisotope supply if we leave the single market and customs union? Then we have no supply guarantees and any delay at customs means dropping half-life and rapid reduction in potency, pushing up the price. Given these radioisotopes cannot be stockpiled, that fragility of supply means potential cancellations or rescheduling for patients.
• Cross-border care in Ireland
Although the nuts and bolts of health care across the Irish border is based both on the Common Travel Area and on European law on patients' rights, much of what is now in place owes more to a quite different EU initiative, its funding for peace and reconciliation in the region.
With both Northern Ireland and the Republic having sparsely populated border areas, the case for co-operation was obvious and it had the added advantage of bringing the different communities together in ways that few could object to.
Now, health systems on either side of the border work very closely together. Patients often go to the hospital closest to them, regardless of which country it is in. Ambulances drive through the hundreds of border crossings on a daily basis.
So what will happen after Brexit? Who knows? As a senior police officer in Northern Ireland noted recently, it is not even clear who to ask about border security, although, just in case, the Police Service for Northern Ireland have halted planned sales of some of their border stations.
Some of the problems that might arise relate to movement of people, such as recognition of professional qualifications. At the moment, many health professionals work in both countries. But others relate to the movement of goods. Partly because of the BSE scandal, which originated in Great Britain, the EU has enacted strict rules to allow blood and blood products to cross borders within the European Economic Area. But what if the blood is moving to a third country, even if it is attached to someone's arm in the back of an ambulance while it crosses the border? And what if the ambulance is carrying morphine, as one would hope if the patient had a heart attack? Once again, a solution may exist. But two years after the referendum, the British government has yet to decide what it wants for the Irish border.
• Health workers' qualifications and monitoring
The NHS is facing a staffing crisis. Hospitals across the country struggle to fill medical rotas. In some places, nurse shortages are the norm. And the situation is getting worse. One figure captured the problem perfectly. After the referendum the number of nurses coming from other EU countries fell by more than 90%. Surveys of the many EU doctors in the UK show that many are planning to leave. No wonder that the British Medical Association, the Royal College of Nurses, and the Royal College of Midwives have all called for a People's Vote on any Brexit deal. They see the problems daily and they know what is causing them.
Health professionals can move within the EU, just like any other EU citizen. However, national governments and the European Commission recognise that, where mistakes could be a matter of life and death, safeguards are necessary. The result is a directive on professional mobility that balances free movement with provisions to ensure patient safety.
For example, those responsible for professional regulation, such as the UK General Medical Council, can require those coming to be competent in the national language. Of course they can also do that for health workers coming from outside the EU, so what is special about those from inside the EU? The answer is that there are other protections in place, and in particular an alert system so that regulators share information among each other. A doctor moving inside the EU cannot hide behind national boundaries.
But the EU plays a much greater role in professional mobility than ensuring professional qualifications. Medics are willing to move because of the many rights they enjoy as EU citizens. These include the right to return to their country of birth, for example when they retire or, as is often the case, to give birth near to their families. They also include the right to draw their NHS pensions, with full adjustment for inflation. And the right for their partner to work, even if they aren't in one of the government's shortage specialities.
No-one knows what will happen after Brexit, and cannot know until the British government reaches consensus. But what we can say is that the NHS will be less attractive for EU health professionals and because of that, potentially, less safe for patients.
• Rare diseases
Some diseases are rare, but expertise in them is often even rarer. How can we ensure that a child with a complex condition that affects, say, one in 10 million people can get the best possible care? The European Union has found a way, at least for some conditions.
It has created 24 European Reference Networks, bringing together the continent's leading experts in conditions such as rare forms of epilepsy, facial deformities, eye diseases, and childhood cancers. For example, Endo-ERN has groups specialising in adrenal disorders, disorders of calcium and phosphate homeostasis, of sex development and maturation, genetic disorders of glucose and insulin homeostasis, genetic endocrine tumours, disorders of growth, and pituitary and thyroid disorders.
The UK participates in 23 ERNs and leads six. They came about after years of lobbying by patient groups, who recognised the advantages that European co-operation could bring. They operate on the basis of European law, in this case the directive on patient rights in cross-border care.
That includes provisions on data sharing, clinical and financial responsibilities, and much else. And, as with almost all European law on health care, it is based on the single market and free movement of people. Opt out of that and you opt out of the ERNs. Unfortunately, that was never written on the side of a bus.
Martin McKee is a professor of European public health at the London School of Hygiene and Tropical Medicine and research director of the European Observatory on Health Systems and Policies