Public Health after the Brexit vote: keep calm and carry on

Well, today we had the EU referendum result.  And whether you are happy with it, or not, you will doubtless have seen significant speculation and some forecasting about what it may or may not mean for public services.

Speculation abounds about the next steps. The vote to leave doesn’t exactly give a thumping mandate for leave, some say. Others are jubilant. Yet others suggest that Parliament, which still has to vote to invoke Article 50, may decide not to. A last minute deal may be found, some suggest. Nearly three million people have already  signed an online petition for a second referendum, and I will be out of date on that within minutes

All of this speculation feels overlaid by a mix of shock for many, elation for some and grief for others at a decision we have not yet as a nation fully understood the implications of, whether you were in, out or don’t know.  It feels a bit scary, both for Brexiteers and EU-romancers. I may well personally wish we had voted to remain, but the task now is to keep going, and adjust our strategy for the health of our population to the developing circumstances.

Whether you like the outcome of the vote or not, our job is clear: pull together, articulate what we need to do to make this work as best we can and make sure we are neither distracted by rumours nor dragged into needless scares. Recession is not inevitable. As ever, this will be complex and nuanced. Time to keep calm and carry on.

There will be a strong psychological dimension to this change – not just in relations between families, partners, friends and work colleagues who took different sides. The  nature of what it means to define ourselves as British or European will change, especially if the Union itself moves further towards independence for Scotland; and sovereignty changes in Northern Ireland as yet unkown. The facebook page for Britain will continue to say “it’s complicated” for some months, it seems.

Navigating forward will take leadership. Speaking to a few colleagues today, we are all wondering what the next steps for us are, and what public health leaders should seek to do. I think there are several tasks for public health leaders to be getting on with, to enact what the public have said they want. So here’s my attempts to put them into blocks.

Short Term (2016)

Let’s be honest, nobody really knows what will come out of the woodwork this year. There is no blueprint for this. We may see a reshuffle at Cabinet level. We may see a period of political instability. We will see a new Prime Minister. We will see a continued emphasis on reducing the defecit and the cuts will not reduce. Even if the economy picks up considersbly, I have alteady blogged peviously on hee about how government has chosen to shrink the public sector as a deliberate policy choice, and not just for economic reasons.  Will that reverse? Highly unlikely in the short term. We are not going to magically see hundreds of millions immediately reinvested into public services including the NHS because it will take two years at least to disentangle the web of finances from Europe.

In any case, signifiant proportions of the money we send to Europe already come back for investment. The Financial Times yesterday pointed out that those areas most heavily for leave were most economically dependent on the EU. Will that money be replaced from the UK’s eventually retained funds? We dont know. What will be the health impacts of that money not being available in whole or part? Could it be better spent? What happens to EU funded projects to get people into work? What about EU funded health research for innovation?  All of these are issues we will have to watch carefully.

And we just cant put ever more money into the NHS. We have to  face that fact. There are some major structural challenges to NHS estate, finance, organisation and ways of working which need a range of solutions. Brexit in and of itself will not answer all of those. It may bring some benefits, it may not.

We will almost certainly have a jumpy few months where scare stories in the media or from various sources will distract us, and then as things begin to become clearer we will doubtless settle down a bit. People we encounter at work – for or against exit -and in our personal lives will be curious, scared, worried, hurt or angry in different measures. We have a leadership task to keep our teams and our partnerships on track and sighted on the big challenges ahead.

  • In the short term, we need to keep running the system, calmly and determinedly. We are in the middle of significant cuts imposed by government and making sure services run is the most important thing. Very little is likely to change hugely in terms of the law before Autumn.
  • Our workforce may need reassurance. People will be wondering what this means, if anything. Non UK Nationals who work for us may wonder if they’re still welcome (I’ve been asked that already.) Well, they are still legally entitled to work where they work unless and until the law changes, and an important task is to reassure them they are still wanted and important, whether they work directly for our agencies or providers.
  • Some things we have been waiting on like the Obesity Strategy and Drugs Strategy may get kicked further into the long grass as government focuses on understandably more pressing matters
  • Procurement rules and regulations will still apply unless and until government changes them. Our biggest leadership task right now is making things work and reassuring folk they will.
  • All other sets of laws derived from Europe will continue to apply unless and until they are abrogated.
  • There will be no economic miracle which will see masses of money redirected into the NHS or Public Health. There will be a need for building a strong market economy for Britain.
  • We still have Sustainability and Transformation Plans to deliver with the NHS, and prevention is needed more than ever to reduce the burden of ill-health.
  • The NHS financial crisis is still with us, and the massive cuts in local government too. In the short term, that will certainly not change.

Am I sounding blunt?  Well, there are two other really important things we must be keeping our eyes on at this time, too:

  •  We have no idea whether the market upheavals will mean a recession and the need to either raise taxes or make more cuts in public spending. There seems, on the face of it, no reason why a recession must happen. After all, Germany alone exports 50 billion euros worth of goods a year to us.  The UK remains an important market economy. But markets, and people in them, can be perverse. We have a job to do to counter anyone who would simply talk us into recession when that needn’t happen. Whatever our views, now is the time to focus on keeping a strong economy.
  • Devolution discussions and plans may go into difficulty or delay as people wonder what the new context means. They dont need to, necessarily.

Medium Term (2016-18)

Public Health Leaders are going to have to be able to scan and span both the detail and the horizon for well beyond next two years at least.

The horizon scanning involves things like whether a recession is coming, where we and the NHS and Social Care get workforces for essential jobs from and things like whether during the changes population health gets better, stays the same, or worsens. Resricting UK jobs to UK citizens looks simply impossible in the short term given the amount of money we’d need to invest in training alone.

  • Those of us reliant on EU and extra-EU workforces to run services will need to think carefully about workforce planning, and start that thinking soon. What will government do, if anything, about non-nationals here? What about recognition, job supply, recruitment and retention?  How do we build our workforce and where do we get it from?
  • The speculation that diversity law will change massively seems to me to be scaremongering. The Disability Discrimination Act is an important UK Act, for example. That doesnt get abrogated because we leave. I cant imagine any government will simply take an axe to every EU inspired UK law. For one thing, people on all sides of the debate have said some of these laws are good – disability discrimination, for example.
  • Some EU health measures such as air quality will need to be considered – do we adopt them in UK law or not?
  • Those areas heavily benefiting from EU funding will need to consider the impact on health outcomes from what may happen to that funding. Will it simply be replaced from inside the UK or will it go into making the budget balance, effectively bringing further cuts in public spending and infrastructure, and with it population health issues from employment to economic performance to access to services?
  • Population mental health, self-harm, suicides, harmful alcohol consumption and a host of other things historically rise or fluctuate in times of national uncertainty. This is a current time of uncertainty. Monitoring this is going to be crucial.
  • Trends in employment and economic activity will impact on health. We know that. What way will this take us?
  • What are the health impacts of the changes in funding, law and governance?

The detail will include looking at whether, if we do go ahead, the process of leaving necessarily abrogates EU laws like the working time directive,and what, if anything, replaces them. Understanding this is crucial if we want to make sure that some of the avoidable cracks, missing points and dysfunctions arising from things not thought through in the 2012 health and care reorganisation don’t get repeated.

There will remain, despite exit, the need for public health and scientific collaboration across Europe. Health protection, disease surveillance, scientific collaboration on research and treatment and response to some common threats (pandemics, emerging infections, antimicrobial resistance and ‘flu) will continue to be important simply for reasons of economic migration flows (which won’t cease anytime soon), trade and tourism travel, geography, climate and 30 years of doing these things together. We’ll still be in NATO, WHO and other collaborations unless we decide to leave, and so Scientific leadership is going to be crucial to articulate what a new science collaboration framework looks like. And PHE will still work collaboratively with others to protect our health, including european nations. Monitoring health outcomes across the EU is likely to change. Losing skills and brainpower needlessly as bright and commited non UK academics, policy professionals, clinicians and providers move away is, at the stage, avoidable.

Longer Term (2018-2022)

Leaving the EU won’t necessarily abrogate the Human Rights regime or indeed existing related precedent in law (judge-made case law by European courts) unless and until government says so. So a lot of things will need time to change, unravel, be abrogated or simply absorbed. Expect policy confusion and complexity as we go on this journey. Its just part and parcel of such huge change.  A big question is whether we have the calibre of political and civil servant leadership at national level to do this strongly and coherently, and how that is replicated at local level.

Monitoring health outcomes and the economy and looking to see what kind of public services will be around in 2022 is going to be the most important task. Will the consequences of exiting the EU make us more or less prosperous?  What will the workforce look like?  What will be the picture of inequalities in health?  Will our public services be financially sustainable?

I don’t have answers to these, and I’m not sure I would trust anyone who claimed they did right now. As yet we see through a glass, darkly.  But one thing I am convinced of: more than ever this is the time to make prevention of need for costly services work.  More than ever this is the time to get people as fit and healthy – mentally and physically – as possible. More than ever this is the time to look at the big challlenges to an equitably healthy population.

These things remain…

Some things won’t change – the need to have a strong economy is crucial to good health, and a healthy population is crucial to a strong economy: our workforce can’t compete with China if it can’t get off the sofa. And our workforce needs to be emotionally and psychologically strong and resilient. Some economists suggest Brexit will make this better, not worse as others fear. Brexit doesn’t change that economic challenge- keeping the economy going. It may or may not make it more complex. It may or may not make it better. But building positive psychosocial working environments is going to be crucial to Britain’s economy, whatever shape our governance and sovereignty will take. Equally, ensuring schools and other public services improve and protect the health of the population will never have been more important.

All of this requires some British sangue froid, as they don’t say on the European mainland.

We have work to do. Even if all around us is flux, we can and should articulate the public health contribution to where and what Britain will be , and the risks and benefits we see in policy choices. As I said above, I may well personally wish we had voted to remain, but the task now is to keep going, and adjust our strategy to the developing circumstances, for the service and the good of our citizens.

Bon chance, mes amis, as they say in Scotland.