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    Healthcare and the National Health Service (NHS) budget were a key element of the Brexit referendum narrative: Vote Leave infamously promised that savings from paying into the EU budget could be spent on health, a pledge from which campaigners have since disassociated themselves. Indeed, the NHS is unlikely to benefit from Brexit – very much the contrary. Indeed, Brexit weakens the financial sustainability of the NHS.

    According to estimates from the King’s Fund, in 2015–16 the NHS had the largest deficit in its history. NHS funding has been unable to keep pace with a growing demand for services. These financial constrains come at a time of staff shortages in most British hospitals, which have had to rely, as is common practice, on private temporary contract agencies and, more generally, on private providers who already make up 18% of the NHS spend on community health services.

    Leaving the European Union in such a context creates a conundrum for English hospitals. How can they square their need for cost savings with maintaining quality? Better-quality services inevitably mean extra resources, which are not available without extra funding. So Brexit raises questions about the financial sustainability of an unreformed NHS – that is, an NHS without additional money. Leaving the EU will lead to significant restrictions on labour mobility, which can shift labour costs upwards – for example, higher wages will be required to incentivise a declining medical workforce, and more vacancies might need to be covered by temporary staff. In addition, we can expect higher transaction costs for intermediary goods. Brexit is estimated to lead to a reduction of 6.3–9.5 % of national income which will mean even less revenues to fund the NHS.

    Effect on the workforce

    Even before Brexit, the NHS has struggled to recruit and retain permanent staff. In 2014, there was a shortfall of 5.9%, and in social care 5.4%, rising to 7.7% in care services in the home, and about one-third of all UK nurses are due to retire in the next ten years. The problem is even more alarming when one looks at the GP workforce. A recent report of the Royal College of Physicians suggests that, in 2016, 86% of physicians experienced shortages across clinical teams.

    Reducing EU immigration would increase wages on both ends of the wage distribution. In such a scenario, the options available include incentivising EU immigration or expanding health and social care spending in an attempt to transform it into a higher-wage sector, with the aim to increase its productivity. Therefore, the trade-off is between saving NHS funds by hiring health professionals from overseas, or expanding health investment further to incentivise local recruits (with some delay as they are trained).

    Brexit may offer an opportunity to get rid of the contentious European Working Time Directive  which limits the maximum amount of time that employees in any sector can work to 48 hours each week. In turn, raising working time limits is likely to cause a deterioration in the quality of NHS employment and make working for the NHS less attractive.  

    Effects on patients

    The balance of payments associated with free patient mobility seems to have traditionally benefited the UK, given that British expats (who stop using the NHS) tend, overall, to be older than EU residents in the UK – who are on average younger, healthier and more highly skilled. After Brexit, UK citizens are unlikely to have the right to travel to the EU for treatment and therefore will enjoy less control over their healthcare. Furthermore, British tourists might be excluded from the European Health Insurance Card  programme. The only advantage, from a welfare perspective, of restricting mobility is that discouraging it reduces competition between health systems. Hence it could be argued that mobility deters a ‘race to the bottom’ in healthcare investment.

    Brexit almost certainly means higher costs for the NHS, especially labour, as I argue in more detail in a recent article in the Journal of Social Policy. As a consequence of Brexit, it will become more difficult to attract qualified staff and other inputs affected by non-tariff barriers (e.g. rules of origin checks, regulatory barriers, border controls etc.), and procurement will become more expensive. Certainly, Brexit does bring some opportunities too – including the possibility of redefining the NHS in new directions. Nonetheless, it takes place in the midst of a process of fiscal consolidation (leading to longer waiting lists, waiting times etc) and will create additional and unnecessary financial pressures.

    This was first published on the  British Politics and Policy blog

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    Commenting on a paper published today which suggests that the UK government does not want any border posts between Northern Ireland and the Republic of Ireland post Brexit, Dr Andrew Dearden, BMA treasurer, said:

    “We absolutely agree that we should maintain a soft border after Brexit to help ensure that cross-border health services and patient access to healthcare are not affected by leaving the EU. Introducing border restrictions would risk reversing this progress and damaging patient care.

    “As separate health services, Northern Ireland and the Republic often do not have sufficient demand to provide cost-effective, highly specialist medical services, such as the all-island children’s cardiac service. The only viable way to provide these services to patients is to deliver them on an all-island basis, and to do this we would need to ensure that doctors and patients can move freely across the border.

    “Over the last two decades, a significant growth in the provision of all-island healthcare has improved care for patients and allowed both Northern Ireland and the Republic to retain highly trained doctors, who otherwise may not have had the patient demand necessary to warrant their full-time expertise.”

    ENDS

    Notes to editors

    1. The BMA has previously warned that cross-border health services and patient access to healthcare, including the cooperation of emergency services and other organisations in response to major emergencies and public health risks, must not be impeded following Brexit.
    2. The BMA is also calling on the UK government to safeguard the future of vital health services by ensuring that doctors in Northern Ireland and the Republic of Ireland maintain the ability to move freely between both countries, and that mutual recognition of professional qualifications between Northern Ireland and the Republic of Ireland continues.
    3. Cross-border co-operation with regards to healthcare has increased in recent years. Figures show that between 2003 and 2015, more than €40m was invested in cross-border health and social care initiatives via CAWT (Co-operation and Working Together), with additional projects amounting to €53m submitted in relation to acute hospital services, prevention and early intervention, tackling health inequalities and other services.
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    The decision to leave the EU, and the government’s commitment to leave the Single Market and Customs Union, has led the media, academics, and politicians to use the term ‘crisis’ when articulating the number of potential implications (e.g. for the economy, citizens’ rights, and for the EU project as a whole). Less attention has been given to the management of cross-border threats within the EU, and the possible implications of Brexit for the UK’s influence on EU policy-making. This hasn’t been a matter for the early negotiations nor can it really be described as a matter that’s been given much attention by political elites (perhaps when the next disease crisis happens – like pandemic flu, foot and mouth, avian flu outbreaks etc. – this situation will change!).

    In recent history, officials within the Department of Health, Public Health England, and the Department for the Environment, Food and Rural Affairs have proven to be very influential in shaping EU policy regarding the managements of cross-border threats to public and animal health. Much of this influence comes from the fact that the UK has considerable expertise in epidemiological and disease management, developed significantly since the disastrous 2001 foot and mouth crisis.

    After the foot and mouth crisis, the EU legislative architecture for crisis management tightened, resulting in new governing arrangements within the European Commission for planning and dealing with health threats (including for those at the animal and human interface). In many senses, these developments echoed broader moves in European integration, resulting in the EU being described as a ‘crisis manager’, with both internal and external dimensions.

    Cooperation is just good common sense? Surely it’s not a political matter….

    Yet even before Brexit was on the table it would be incorrect to assume that there was a lack of politics between Member States regarding ever closer collaboration on health security governance. The fact that diseases cross borders, and that inter-state collaboration might be intuitively just ‘good common sense’, it would be incorrect to assume that integration processes have somehow been devoid of political interests or power posturing at a civil service or technocratic level.

    On a recent health security project, I cited an interview with a senior official in Public Health England who maintained that, although pan-EU cooperation on disease control is important, it can also be a ‘distraction’. This is because the UK’s experience and expertise in health security governance draws them into unwelcome politico-bureaucratic situations where they are required, along with France and Germany, to build capacity with less developed and often newer Member States in the interests of the European project.

    On the plus side, for the UK, this has led to the accumulation of a great deal of soft power and influence over EU policy-making. Indeed, the UK provides EU institutions with much of its expertise given that the UK’s world-leading scientific research laboratories have made vital contributions to the development of public and animal health management capacities in several Member States. James Wilsdon reflects on this point in his article in Nature. He notes that the referendum result poses challenges for the future of expert-based networks:

    The difficulty is that UK–EU networks of expertise, guidance and oversight are complementary, and have developed in tandem over many years. Generations of British scientists and experts have shaped EU frameworks… Around every issue that is codified in law or regulation there exists a softer sphere of influence, information exchange and standard-setting.

    Soft power leading to solid outcomes for the UK?

    There are unknowns with regards to whether the UK’s soft power will be to its advantage in securing gains within the Brexit negotiation processes for more scientific or technical areas of public policy. It will be the role of political scientists at a later point to determine the implications of Brexit for the dynamics of bureau-political relationships pertaining to disease management and control, yet it is highly conceivable that established networks in the UK for health security governance will play key roles in determining the extent and architecture of change processes.

    A major challenge, however, is that disease-induced crises can come from various sources and can have cascading effects for a range of policy areas. For example, EU procedures for health security governance have implications for agricultural policy and for policy regulating the food chain – the governance of which affects the operation of the Single Market, which the UK has decided to leave.

    Similarly, Brexit has produced unprecedented uncertainties with regards to coordination between policy communities. Take the veterinary profession as a case in point. Brexit will have major implications for this profession (who are often key crisis responders to disease outbreaks) given that EU public policy has implications for their work across public health, animal welfare, food safety, and farming.  This is highlighted by the recent editorial commentary in the Veterinary Record:

    Vets, along with everyone else, will be affected by Brexit, but because of the wide range of roles they fulfil in relation to animal health and welfare and public health, and because much of this activity is governed by EU legislation, they could be affected more than most…[T]he decision to leave will inevitably have an impact on many aspects of veterinary endeavour, whether in relation to farm and companion animal health and welfare, disease surveillance, food safety and public health, or veterinary education and research. It could also have implications for the availability of veterinary medicines and the position of EU agencies and disease reference laboratories currently located in the UK.

    So…lots to decouple if ‘Brexit means Brexit’. Theresa May often repeats this mantra but if we take this comment to its logical conclusions then, for health security, the UK will be excluded from the European Centre for Disease Control and will not, in theory, be privy to intelligence through the alert and communication systems (known as the EU Early Warning and Response arrangements). Broader information-sharing with regards to public health initiatives and practices will be affected, with aspects of these having population health dimensions. So, if there was evidence of bureaucratic politics pre-Brexit, then it is not ‘bad sense’ to hypothesise that Brexit poses further risks for multi-level and inter-state cooperation on health security matters.

    ‘Post-Brexit’ – a red herring?

    Moreover, Brexit provides no guarantee that the UK will be part of procurement arrangements for new vaccines. The European Medicines Agency (a key organisation in the single market for medicines to protect public and animal health) is actually located in Canary Warf in London and the agency itself is unclear as to it will be located post-Brexit – this will be a decision for the European Council, expected by October 2017.

    But the agency is clear about the fact that it is likely to see major organisational change and that this will likely lead to ‘major staff losses’. The spill-over effects of Brexit will also be seen in related areas such as a changed relationship with the European Food Safety Authority. This body aims to protect the public, animals, and the environment from food-related risks. In a typical year, approximately 180 UK-based experts contribute to the work of the Authority and Brexit has thrown up uncertainties about the future roles of such experts ‘who tend to be more rigorous than their continental peers’.

    A further challenge is around departmental inputs to Brexit negotiations. The UK Department for the Environment, Food and Rural Affairs (DEFRA) has a significant and very broad policy remit as one of the most ‘Europeanised’ government departments. But, at the same time, the department has suffered consistent cuts in its budget since 2010.

    Public Health England, as the UK’s key agency for coordinating the public health aspects of health security, has made no announcements regarding the possible implications for contingencies management for transnational public health crises. This clearly reflects a general unease across civil service departments and agencies about putting out any messages that might contradict negotiating lines being put together by the government’s Brexit department.

    Another point here is that Brexit was never really meant to happen – it was a political gamble gone wrong by Cameron’s government – and civil servants are simply in a state of policy and organisational ambiguity about the direction and consequences of the negotiations. Officials will be trying to bring rationality to a very irrational set of policy circumstances.

    That said, it is important to not forget that Brexit is a process and there might not be any post- about it i.e. it will be more likely of a case of policy refinement, recalibration, and incremental adjustment to existing governing relationships given the fact that the EU institutions need UK expertise on health security matters. This knowledge and expertise (or soft power) is likely to help the UK’s position in the negotiation processes. A broader point is that the UK’s ‘softer’ power sources could do with some more attention by political commentators because this might be where the real influence on the contours of the Brexit negotiations actually lie.

    This was first published on the British Politics and Policy blog

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    The triggering of article 50 starts a period of uncertainty in our NHS. The decision is momentous, but after seven years of neglect from successive Tory governments the prime minister and health secretary must finally give the NHS and patients the certainty needed through the Brexit process.

    So far the complacency in government is astounding. Last week, Jeremy Hunt published the department of health’s “mandate to NHS England” to set “the government’s objectives and any requirements for NHS England”. Amazingly the 24 page document made no mention of Brexit whatsoever.

    And during the prime minister’s statement yesterday confirming the triggering of article 50, she failed to mention the NHS even once. Neglecting our health and social care system during the most significant period of political and economic uncertainty in decades is completely unacceptable.

    The prime minister has already turned her back on the clear promise of £350 million a week for our NHS, but perhaps it shouldn’t come as much of a surprise that the NHS isn’t taken seriously as a Brexit priority for the government. Indeed, the health secretary isn’t even a member of the relevant cabinet committees managing the exit strategy.

    Later this week health bosses will publish the updated five year forward view. NHS chief executive, Simon Stevens, must ensure it includes the NHS’s plan for Brexit and not duck its responsibility to staff and patients.

    After all, Britain’s health and social care system is dependent for its success on tens of thousands of European staff. Many of them have settled and built lives here while caring for our sick and elderly: safeguarding their futures should be an absolute priority in the Brexit negotiations.

    So our first test of the government plans will be whether they deliver a right of remain for the 140,000 European Union nationals working in the NHS and social care system.

    Secondly, on funding we know that the EU’s horizon 2020 scheme is due to invest £7.5 billion in health research across the EU over the next five years, and Britain will be by far the largest recipient of those funds. This long-term funding is crucial for our medical institutions and universities planning major research projects. So we need to know whether access to these funding streams will continue after Brexit, and if not, how does the government propose to make up the shortfall?

    Our third test is on reciprocal healthcare arrangements. It is a key principle that British citizens can obtain free healthcare elsewhere in Europe, just as they would here at home from the NHS. Therefore, we want a guarantee that British citizens travelling and living abroad in Europe will continue to receive healthcare.

    Finally, our fourth test is on EU healthcare collaboration. Effective joint working with our European partners has been vital for the NHS over recent years on everything from infectious disease control and the licensing, sale and regulation of medicines. The government must clarify whether the UK will continue to participate in the centralised marketing authorisation procedure for medicines governed by the European Medicines Agency. And how will Brexit will affect the UK pharmaceutical industry when exporting medicines to other member states in future?

    These are of course difficult and complex questions to answer, but they are all of absolute importance to the future of our health service and of our medical research sectors.

    The NHS is already in crisis over funding and staffing. But without a proper plan Brexit has the potential to tip those crises into unprecedented disasters. Patients and NHS staff should not be bargaining chips, and, at the very least, the public deserves clarify and certainty from the government.

    First published on Labour List

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    Everyone knows that after seven years of neglect from the Conservative government, the NHS is undergoing a serious crisis of funding and staffing. The last thing needed is more uncertainty. That is exactly what the NHS faces with Brexit.

    On Wednesday Theresa May will trigger article 50 and later this week health bosses publish the updated Five Year Forward View. It is time for the prime minister and the health secretary, Jeremy Hunt, to give the NHS and its patients the certainty needed through the Brexit process. May has already turned her back on the promise of £350m a week for our NHS and now she is walking away from her responsibilities to protect the health service through a turbulent Brexit process that will hit it hard.

    The complacency in government is astounding. Last week Hunt published the department of health’s Mandate to NHS England to set “the government’s objectives and any requirements for NHS England”. Amazingly, the 24-page document made no mention of Brexit whatsoever.

    Will health professionals from other EU countries be able to come to work in our NHS after Brexit, or will there be a cap on their numbers? As long as the issue is left unclear, more and more EU workers are voting with their feet and leaving on their own terms. In a recent survey, 42% of European health staff working here said they are now thinking of leaving the UK. Almost 5,500 have left since the Brexit vote according to NHS Digital, a 25% increase on the 2015 figures. And others are being put off from coming here at all: only 96 European nurses registered to work in the UK in December – that figure was 1,304 for last July.

    So our first test of the government plans will be whether they deliver a right of remain for the 140,000 EU nationals working in the NHS and social care system. Secondly, on funding, we know that the EU’s Horizon 2020 scheme is due to invest £7.5bn in health research across the EU over the next five years, and the UK will be by far the largest recipient of those funds. We also receive EU funding from the Innovative Medicines Initiative, the European Cooperation in Science and Technology programme, and the Active and Assisted Living programme for older people.

    This long-term funding is vital in giving security to those medical institutions and universities planning major research projects. They cannot just wait and see what will happen after 2019. So we need to know whether access to these funding streams will continue after Brexit. If not, how do the government propose to make up the shortfall?

    Our third test is on reciprocal healthcare arrangements. It is a key principle that British citizens can obtain free healthcare elsewhere in Europe, just as they would at home. That is an important safety net for British holidaymakers, and for UK citizens living elsewhere in Europe. Does the government intend to maintain those arrangements? If not, how will it address the increased insurance costs for UK holidaymakers?

    These are difficult and detailed questions, but they are all of absolute importance to the future of our health service and of our medical research sectors. There is no reason why May should refuse to give us the answers. That will allow us to understand with greater clarity what the impact of Brexit will be on the NHS – and most importantly, it will allow patients and staff the opportunity to scrutinise the government’s plans closely over the next two years.

    The NHS is already in crisis over funding and staffing. But Brexit has the potential to tip those crises into disasters. Patients and NHS staff should not be bargaining chips in May’s hard Brexit negotiations. They want a world-class NHS delivering the best quality healthcare. As article 50 is triggered, the very least the public deserves is clarity and certainty from its government.

    First published by The Guardian

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    In the past few days, the misleading term ‘Comprehensive Sickness Insurance’ (CSI) has suddenly become a hot topic among EU citizens in the UK. For many of them, as well as their British relatives and friends, this was the first time they have ever heard about CSI. The chilling discovery was that for many years now the CSI has been a requirement for all EU citizens studying in the UK or residing here as self-sufficient persons. Without it, they cannot exercise their treaty rights and acquire permanent residency, which would normally be automatically granted after spending a continuous period of five years in the UK. At the moment, without a valid CSI the years spent in the UK do not count towards PR. Ominously, the current rules – some of which were introduced as recently as February 2017 – seem to give the Home Office the power to deport EU nationals who are not exercising treaty rights.

    The British media scrambled to publish curious assurances that the rules on deportation will not be acted on, and if they were, only selectively. The Independent went as far as quoting an immigration barrister saying that he does not think that “the Home Office is going to enforce this against say, the French wife of a British citizen. I think they’re using it against people they don’t like, like Polish rough sleepers.”  While these speculative news reports were not particularly reassuring, they highlighted a passive acceptance of the arbitrary and demeaning use of regulations.

    The Comprehensive Sickness Insurance is a concern for thousands of EU nationals who, during their period of residence in the UK that would otherwise count towards PR, were at any time either a student, or a self-sufficient person (e.g. carers, stay-at-home spouses, or part-time workers not earning enough to cross a threshold set by the government). This would include cases in which an EU national worked full-time for 4 years and then enrolled at a UK university without having a CSI, thus unwittingly interrupting the 5-year residency rule.

    Permanent Residency card

    Permanent Residency card issued by the Home Office, image by @RochDWlicensed under Public Domain Mark 1.0

    A failure of communication

    It is hard to understand why the fact that the Comprehensive Sickness Insurance is a central requirement for many EU citizens in the UK has surfaced only now. It is indicative of a systematic failure of public communication that so many have learned about it only through confusing posts on social media. Many of the posts spoke of fears of deportation, of not being let back into the UK after holidays abroad, or being separated from British children or spouses at the border once Article 50 is triggered.

    The official governmental channels of communication have done their best to be opaque on the topic of CSI. Also, while the House of Lords and many institutions and individuals, including British citizens living in the EU, have been calling for EU citizens’ rights to reside in the UK to be secured, it is not clear if this would involve any amendments to the CSI requirement. At least up until the time of writing (13 March 2017), the UK government website used the following description for a ‘qualified person’ who could apply for a registration certificate, and ultimately also for PR:

    Fig 1: Information on Permanent Residency on the gov.uk website (13/03/2017).

    Unfortunately, this information is rather incomplete, and EU nationals acting on it could unknowingly lose their right to acquire PR, and face uncertainty over their legal status.This might have been avoided if only the UK Government website was upfront about who might classify as a ‘qualified person’ (Fig 2):

    Figure 2: Suggested amendments for improving  the gov.uk website on residency in the UK for EU/EEA nationals

    Information on Comprehensive Sickness Insurance is curiously sparse on the gov.uk website. CSI is mentioned briefly in the guidance notes and the PR application, documents that very few would have checked before actually beginning their application process. This is particularly unlikely as the gov.uk website seems to discourage EU nationals from applying for residency certificates:

    Fig. 3: Information on the gov.uk website suggesting EU nationals do not need to apply for residency certificates

    More broadly, the UK government has been passing laws on CSI without communicating them widely, not even through the organisations directly in contact with EU citizens, such as universities. EU nationals arriving to the UK have not been provided with clear information on the requirement to obtain health insurance in order to secure their rights.

    Not so ‘comprehensive’ after all

    Once an EU citizen somehow finds out about Comprehensive Sickness Insurance, they face another challenge – there does not seem to be a reliable source of information on what private insurance coverage would qualify as CSI in the eyes of the Home Office. Some private insurers advertise CSIs, but state they are not liable if their insurance ends up not meeting requirements. An insurance broker contacted by the author claimed that the Home Office has not issued guidelines on CSI and that they go by what is reported in the media and by their own experience with PR applications.

    The mere fact of having health insurance from another EU country does not necessarily mean an EU citizen has CSI. They should have had a European Health Insurance Card (EHIC) issued by another EU member state for every period in which they were a student or self-sufficient person in the UK. However, by being a resident in the UK, some EU citizens may have lost access to healthcare in their country of origin. In a further administrative paradox, relying on an EHIC issued by another EU country for the PR application will only be accepted if one confirms their intent not to live in the UK permanently (see Fig 3).

    Comprehensive Sickness Insurance

    Fig 4: Screenshot from the PR application and a note on CSI requirement.

    It is unclear as to how the Comprehensive Sickness Insurance would relieve the potential burden an EU citizen might pose to the NHS. The PR application only requires one to have a CSI, not to have made use of it. Indeed, people with CSIs can still access GPs and all treatments on the NHS. EU citizens are in many circumstances required or strongly encouraged to register with a GP (including when enrolling at a university). Moreover, private insurers do not cover all treatments (even under the ‘comprehensive’ sickness insurance), often delegating the treatment of chronic conditions to NHS.

    Furthermore, CSI is discriminatory. Contrary to the Immigration Health Surcharge paid by international students in the UK, there is no standardised rate for private CSI for EU nationals. The CSI premiums depend on one’s age, sex, health, and prior conditions, among others. This disadvantages EU nationals who are women, older, have comorbidities or prior health conditions. Even the cheaper options for healthy young adults (c. 30-40£/month) could be difficult to afford.

    Obtaining CSI seems to be a purely administrative, box-ticking task for the PR form, without much real-life relevance or benefit to EU citizens, or to the NHS. In its current form, the CSI confers an unnecessary financial burden and a discriminatory barrier to residency.

    How about the universities?

    It seems that the UK universities were not prepared to offer their EU students (some of whom are their former employees) comprehensive information about Comprehensive Sickness Insurance. In certain cases, they offered false reassurance that EU students do not require health insurance. For example, still in February 2017, the UCL website dedicated to health advice contained the following statement: “If you are an EU/EEA student, […] you may wish to consider private health insurance as well as there can be long waiting times for some NHS services. […]. However, medical insurance is not compulsory and is your decision whether you wish to purchase it or not.” A few days before the publication of this article, a rather unhelpful statement was added: “For EU/EEA students, the information provided above concerning medical insurance is relevant for accessing healthcare during your time as an enrolled student at UCL. More information about comprehensive sickness insurance can be found on the UK Council for International Student Affairs (UKCISA) website.”

    This further testifies to the lack of clear guidelines and bureaucratic chaos surrounding CSI, with few institutions equipped to offer specific guidance even today.

    The author of this article has yet to meet an EU student who knew about the CSI before the issue surfaced in the media in the last weeks. Many still do not know about it. Some websites suggest that some university application forms for EU/EEA nationals ask whether the student holds CSI. However, given the legal implications of not having CSI, it does not seem sufficient to be informing students about it via a box-ticking exercise or a brief mention on application forms. Crucially, the information about CSI should always be contextualised and accompanied by information clarifying that (i) access to the NHS does not count, and (ii) that CSI is required to exercise treaty rights and accumulate residency rights.

    What should have been done about CSI

    The Comprehensive Sickness Insurance regulations have not been implemented effectively, but this could have been avoided. The legality, practicality, and logistics of CSI should have been scrutinised before implementing the rules, and if they were still deemed to be appropriate, then:

    1. The UK government should have been more transparent and vocal about the rules for EU citizens, and particularly CSI.
    2. There should have been procedures in place to ensure that EU citizens planning to come to the UK, and those already residing here, but also British citizens (who might be partners, in-laws, employers, tutors to EU nationals), are appropriately informed.
    3. Information about the CSI requirement should have been disseminated in a useful and non-threatening manner through many channels: at passport controls, via GPs, schools, religious associations, banks, TV and radio stations, unions, as well as universities (emails to EU students and their supervisors/tutors, at orientation days, freshers’ weeks, special inductions). Such an information campaign should have been initiated ahead of the proposed changes to legislation and should have continued ever since.
    4. A simple government website should have been set up with comprehensive information on CSI, listing (a) clear rules as to what cover would qualify for a private CSI, and (b) a list of approved providers. This could also ensure that EU nationals do not fall victim to ‘sham’ offers, or purchase wrong policies.
    5. Universities should have been provided with guidelines on CSI, and so that they could inform EU applicants about the rules, and the implications, e.g. that they may be losing their residency rights if they start degrees without being covered by CSI.
    6. The EU citizens should be provided with means to acquire CSI in time, including ‘buffer periods’ to accommodate a change in circumstances.
    7. EU citizens should be able to make direct contributions to the NHS fund, if they wish to, rather than private insurers, with the rates standardised.

    Challenging the CSI requirement

    The current regulations and procedures surrounding the Comprehensive Sickness Insurance requirement put EU citizens in the UK at a disadvantage when they apply for residency. Not surprisingly, CSI has been considered unlawful by some lawyers, and has been challenged in UK courts already, but with no success. Several petitions and MPs have also called for abolishing the rule. EU Rights Clinic tries to put a new case together and calls for stories on PR being denied due to lack of CSI. The time is also high for UK universities to join their plea to protect the rights of their current and former students.

    Abolishing the CSI requirements altogether, and especially for PR applications, seems the only reasonable course of action. However, abolishing the CSI itself will not be meaningful without further securing EU nationals’ rights in the UK post-Brexit.

    This article first appeared on the LSE Brexit blog

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    The long awaited Brexit White Paper has finally appeared. The timing was, to say the least, a little unusual, as it was published the day after members of Parliament voted to initiate the process of leaving the European Union. It is, of course, normal for White Papers to be published in advance of parliamentary bills, so that parliamentarians can make an informed decision about how to vote.

    On this occasion, the Prime Minister had made it very clear that she was opposed to them having any vote at all. The advantage of not having a written constitution is that prime ministers can, largely, make up the rules as they go along. It therefore seems especially careless to fight a long and expensive legal battle against some of the very few constraints on the executive that exist. But, of course, the Prime Minister, when home secretary, had form in this respect.

    Given the enormous implications that Brexit will have for health, catalogued in a series of earlier BMJ blogs, it seemed reasonable to hope that the White Paper would offer some clarity. What had gone before was of little help. For many months, all we knew was that “Brexit means Brexit,” later qualified by the news that it would be “red, white, and blue.”

    Faced with widespread puzzlement about what is actually meant in practice, the Prime Minister reluctantly gave a speech which, we were told, would be the definitive statement on the government’s negotiating position. Although welcomed by much of the British media, newspapers in the rest of Europe, whose correspondents actually understood the European Union, were much more sceptical. So were those British academics who have spent many years studying these issues, with one describing it as “vague, incorrect, misleading, hypocritical, or fantasist.” We were reassured that the speech was the final word on the government’s position, containing all that could be said.

    Yet, given its many contradictions, inaccuracies, and unrealistic aspirations, calls for a White Paper mounted and, eventually, the government conceded. Now, it appears that the Prime Minister was right. Her speech was all that the government could say. The White Paper, which was clearly rushed out in a hurry without adequate proofreading (for example, Chart 7.1 suggests that British workers are entitled to 14 weeks of annual leave), adds very little.

    The word “health” is mentioned four times and the NHS not at all. Two of these mentions relate to funding for research. The government has agreed to underwrite existing EU funded research—in health, as in other areas—that extends beyond Brexit. Of course, this does nothing to address the many other problems for UK research created by Brexit, catalogued in detail elsewhere.

    The sole mention of healthcare is that “we recognise the priority placed on easy access to healthcare by UK nationals living in the EU.” Of course, there is no indication of what the government actually plans to do about it. This should not, perhaps, be surprising. Despite penetrating questions by Dr Sarah Wollaston MP, Jeremy Hunt’s recent appearance before the Commons Health Select Committee also failed to shed any light on how the consequences for health might be addressed, except the rather unsurprising information that some people in the Department of Health were looking at it. The incredulity of some members, such as Ben Bradshaw MP, was all too apparent.

    The challenges are enormous. Tens of thousands of British pensioners now live in parts of southern Europe in properties that are, in effect, valueless. They have no prospect of either purchasing properties back in the UK or paying enormous sums for private health insurance. Yet what is often forgotten is that many British pensioners, in countries such as Spain, Italy, and Ireland, are not actually British citizens. Instead they are people who came here as young people, worked all their lives in the UK, and retired to their home countries with the British pension they contributed to for decades. It is not clear that anyone in authority has even thought about this latter group.

    The importance of the European Medicines Agency to the UK economy and to our rapid access to medicines has been discussed extensively. However, it gets only the briefest of mentions in the White Paper. Lumped together with a few of the other 40 plus agencies whose functions will have to be replicated in new UK bodies (if those with the necessary skills can be found), all that is said is that “the Government will discuss with the EU and Member States our future status and arrangements with regard to these agencies.” The European Centre for Disease Prevention and Control, crucial to our epidemic preparedness, does not even get a mention.

    Buried in the notes to the 137 word European Union (Notification of Withdrawal) Bill was the news that the UK would leave EURATOM. This organisation, which predates the European Economic Community, is responsible for regulating the nuclear industry. Over the years, it has amassed exceptional technical knowledge, especially with regard to nuclear safety. Given the Prime Minister’s determination to eliminate any links to the European Court of Justice, which is the final arbiter of the law in relation to EURATOM, this seems inevitable.

    Nonetheless, it has been greeted with widespread shock, being described as a lose-lose situation. Those who support nuclear energy, who have invested in new nuclear power stations, will see significant delays as a new regulatory system is developed. Those who oppose nuclear power will have justifiable concerns about who will be responsible for safety. There are also enormous implications for medicine, from health protection to radiotherapy. At least in this area, the White Paper identifies new arrangements as a priority, even if there is a complete lack of detail as to what they might look like.

    Parliamentarians now have an opportunity, albeit limited, to try to fill in the many gaps that this White Paper has left. These include the impact assessment and financial implications that would normally accompany a White Paper—both of which are missing. Unfortunately, as has been catalogued in detail in the aptly named book The Blunders of our Governments, there are few grounds for optimism, something that readers of The BMJ will understand given the passage of the largely unworkable Health and Social Care Act. We are often told of the great wisdom accumulated in the House of Lords. It seems to be the last chance of achieving even the most superficial clarity.

    This blog was first published on The BMJ’s blog website

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    Lifting our last remaining restrictions on privatisation. Secret corporate courts. You can see why Greens have always characterised deals like TTIP and the Comprehensive Economic and Trade Agreement as less of a ‘trade treaty’ and more of a corporate power grab.

    The irony that I am writing this post for Open Democracy is not lost on me. Trade treaties in general, and CETA – the Comprehensive Economic and Trade Agreement – in particular are a classic case of decisions being made behind closed doors and with information being withheld even from elected members of Parliament.

    The election of Trump and the vote to leave the EU has blown a massive whole in conventional trade policy.

    But what an irony faces those on the Left who voted to leave the EU because of TTIP and now find they are fast-tracked into a very similar treaty kindly offered by Trump, even as TTIP dies!

    (Cecilia Malmstrom, the Trade Commissioner, admitted before Christmas that TTIP is ‘pining for the fjords’!)

    Liam Fox

    For a more detailed glimpse into what the future of the UK’s trading relations (and the style of their negotiation) could look like, check out the nearly finalised CETA (the EU/Canadian ‘trade’ deal). Liam Fox has quietly decided, without proper parliamentary scrutiny or any debate in parliament, that this deal will apply to us regardless of Brexit. Fox did manage to apologise to a disgruntled parliamentary committee for the ‘scrutiny override’, claiming he had been befuddled by the ‘jobs, investment and prosperity’ the Treaty would (not) create.

    So much for taking back control.

    Instead we’ve been quietly and undemocratically saddled with a deal which jeopardises many of our hard-won protections – health, environmental, workers rights – not to mention our public services.

    Perhaps most damagingly, CETA includes a proposal for an Investment Court System – a minor revision of the proposal for private, corporate courts that were the downfall of the TTIP treaty. It is clear that the arbitration courts for investors are not only undemocratic, they are also incompatible with European standards for a fair justice system. We need to end this special treatment for multinational companies, and the parliamentary scrutiny and vote on CETA should give us the chance to do this.

    While concerns about the future of public services worry many across Europe, CETA has launched us in a direction that could further undermine them. For the first time, all services will be subject to a liberalised trade system unless explicitly excluded in writing, under what they call a ‘negative list’ approach. Previously, EU trade deals liberalised only what was specifically listed and agreed by national governments. Now any service, public or otherwise, that comes into being in the future, will be automatically liberalised, thereby severely limiting our governments’ ability to bring a service back under public control. In a report called Public Services Under Attack a group of European NGOs make clear how this process turbo-charges and then sets in stone the process of privatisation:

    ‘A very limited general exemption only exists for services “supplied in the exercise of governmental authority”. But to qualify for this exemption, a service has to be carried out “neither on a commercial basis nor in competition with one or more economic operators”. Yet nowadays, in virtually all traditional public sectors, private companies exist alongside public suppliers – often resulting in fierce competition between the two. This effectively limits the governmental authority exemption to a few core sovereign functions such as law enforcement, the judiciary, or the services of a central bank.’

    There is no surprise that negotiators do not want politicians or those they serve to know what is going on, because the agreements they are reaching blatantly advance the interests of the corporations who have been so busy lobbying for them.

    So where’s the political fight-back? The Green Group has been at the forefront of battling CETA and we are still the leading opponents now it has reached the stage of being ratified – or not – by the European Parliament. This process began on 21 November and in an extreme acceleration of the normal process it was proposed that we vote on it in December! As part of the same stitch-up we are being deprived of a debate and a resolution and will only have a chance to vote Yes or No. Meanwhile consultation with national parliaments has been reduced to a single lunch meeting with one representative from each country’s parliament. Hardly the rigorous scrutiny we might expect for a treaty with such far-reaching consequences.

    The Greens managed to ensure that a number of committees could give written opinions on CETA, so MEPs had the chance to explore some of its content fully before we are asked to vote. Back in December, the employment committee voted to reject CETA because of the threat it poses to employment rights.

    Earlier this month the opinion in the environment committee saw the socialists split down the middle, with many ignoring Green concerns about threats that EU law on chemicals, pesticides, animal welfare, food safety and climate protection may all be watered down.

    Bart Staes, who wrote the opinion, was clear that:

    ‘[The Commission] has undermined the EU fuel quality directive to allow Canada to export fuel from dirty tar sands, and now even proposes to unlawfully modify provisions on endocrine disrupters in pesticide law. The Commission has acted in the interests of Canadian companies by refraining from banning cyanide in mining despite the European Parliament calling for a ban, and by recently authorising the use of carcinogenic substances in paints (lead chromates) even though EU companies use safer alternatives’

    The agriculture committee may not even give a view, despite the treaty having deeply troubling implications for Europe’s farmers. CETA includes the dropping of tariffs on 97% of products, including on most agricultural products, so as MEP for the South West England this concerns me greatly. The likelihood is that we will see our markets flooded with poor-quality North American food, stuffed with hormones and modified genes, from mega-farms that destroy environments, family farms and rural communities.

    As Greens we have been battering CETA for years but it limps along. To deal the killer blow we would need the whole-hearted support of the socialists in the Parliament.

    Sadly, they have been ambivalent at best. With so much heat on this issue at home, most Labour MEPs are now voting against committee opinions on CETA – but they are not bringing their European socialist colleagues with them.

    The European Parliament is now the last chance of blocking this damaging assault on democratic power. But without solid opposition from the socialists in the Parliament it is likely that CETA will be passed in February. As the vote in the Environment Committee showed, they are now divided. We need Jeremy Corbyn to keep true to his rhetorical opposition to CETA and to instruct his MEPs to vote it down. And please do what you can by making a noise about CETA and by letting your MEPs know that you want them to vote against the ratification of this damaging and anti-democratic treaty.

    First published by Open Democracy

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    Some public policies should carry health warning labels like cigarettes or uncooked meat. Certainly that is true for a reckless and ill-thought-out policy like the UK government’s current approach to leaving the European Union, after a close advisory referendum in which at least one of the campaigns would quickly have run afoul of trading standards law if had involved a consumer product. As controversy rages on about exit paths – ‘strategies’ would be too kind a word – health researchers and professionals are asking how Brexit could and will affect public health.

    Among the questions informed by a political economy perspective on health and its social determinants, five stand out.

    1. Whose living standards will be hit first, and worst, as sterling dives towards parity with the US dollar, or even lower? Make no mistake, it is headed that way. What will be the direct and indirect effects on the costs of housing, transport, the cost of a healthy diet?

    2. What kind of job losses are likely to be associated with the shift of corporate operations to locations where they are ensured of continued access to the single European market? It is plausible that the most severe losses will be concentrated among the so-called ‘unskilled’, whose mobility and options are limited by lack of credentials. If you doubt that the locational shift will be substantial, ask yourself: how much of your pension pot would you want to invest in a country with no access to any markets other than the 64 million within its borders beyond that ensured by time-consuming WTO disciplines that its government has no experience of negotiating?

    I thought so. Prime Minister May herself conceded the point during the referendum campaign.

    1. Beyond these impacts on social determinants of health are those on the NHS. The most recent figures from the International Monetary Fund show projected UK government spending as a percentage of GDP trending downward towards US levels – or, in historical terms, to the levels characteristic of the pre-war period, before the establishment of the NHS and the Beveridge approach to social policy.

    A public sector budget of that constrained size is simply incompatible with a comprehensive health service that is free at the point of use. The insurance industry, as shown by a tube advertisement from 2011, understood this point years ago.

    Crucially, these expenditure projections do not take into account the need (at least, so we will solemnly be told) for further austerity measures as government revenues drop with slower growth in anticipation of Brexit.

    1. In a similar vein, how will economic policy respond to the challenges of Brexit? Chancellor Hammond has recently warned (or threatened) that the post-Brexit UK might need to become a tax haven to an even greater degree than is already the case in pursuit of corporate investment, abandoning ‘a recognisably European-style economy’ in favour of ‘something different’ – travelling still further down the neoliberal road that my colleague Clare Bambra and I described in 2015. (Some of us think that was the objective of ruling class Brexiteers all along.) What is this likely to mean for public sector revenues, and for whatever solidaristic social policies have survived the post-2010 upward redistribution of income, wealth and opportunity?

    2. Finally, what will post-Brexit trade negotiations mean for the future of the NHS? A detailed legal analysis by the UK Faculty of Public Health pointed out the possible dangers of investor protections proposed as part of the Transatlantic Trade and Investment Partnership: ‘the worst case scenario for the NHS would then be that commercialisation becomes “locked in”, sealed by the threat of huge compensation claims by investors’.

    TTIP is now almost certainly dead, but the UK now faces post-Brexit trade negotiations with both the EU and the United States from a far weaker position that it occupied as part of the EU negotiating bloc.

    It is hard to imagine that UK negotiators informed by the health system wisdom of Jeremy Hunt would resist opening up investor access to health services, in particular when dealing with a United States in which the health care industry accounts for one-sixth of the entire economy, with associated domestic political clout. Indeed, the profit potential of a privatised NHS might be one of the most important offers available to those negotiators.

    One needs to remind oneself that the last word in Albert Camus’ famous essay about suicide is ‘hope’. But it is hard to sustain in these times.

    This was first published on Open Democracy

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    The rationale for international trade is clear. No country can be self-sufficient in everything it requires, whether this is because of the geographical distribution of natural resources, climatic constraints on agriculture, or the benefits that come with concentration of particular types of expertise. However, it is important that this trade takes place in ways that bring benefits for all concerned. Unfortunately, this is not the case with many existing global and regional trade agreements. Too often, they are designed in ways that allow the powerful to exploit the powerless, whether by exploiting weak labour standards, damaging the environment, or preventing poor countries from adopting effective public health measures. In particular, many incorporate systems of investor state dispute settlement processes that enable global corporations to undermine public health, avoiding the protections provided by courts.[1]

    There is now very extensive body of research on the health implications of international trade. For example, the removal of tariff and quota barriers can drive increasing consumption of unhealthy products.[2, 3] The following recommendations flow from this literature.

    1. All trade agreements should include an explicit commitment to safeguarding and promoting a high level of human health;

    2. Governments should be free to adopt evidence-based measures to protect health and the environment, which should not be considered to be non-tariff barriers to trade;

    3. International trade agreements should work towards the progressive realisation of equivalent standards of employment, health, and safety in those sectors included in the agreements in all of the countries participating;

    4. Disputes between parties should be addressed in a judicial setting, decided by judges selected by an independent body, meeting in public, with publication of all of the evidence being considered, and with provision for cases to be joined by other interested parties, including trade unions, non-governmental organisations, and professional associations;

    5. Independent monitoring systems should be established to ensure that international trade does not undermine health and the environment, drawing models such as the shadow reports produced by NGOs or the UN system of special rapporteurs.

    Finally, there is a need to address the particular circumstances of the NHS. Neither European Union law other international trade agreements require the UK to open up its health services to competition. Health care, along with education, social services, and public services broadcasting among others is considered to be a service of general interest. Internal market rules apply to the services only to the extent that public authorities have opened them up to the market and “insofar as the application of such rules does not obstruct the performance, in law or in fact, of the particular tasks assigned to them” (Art 86(2). Thus, in the United Kingdom, Scotland, Wales, and Northern Ireland have avoided many of the problems that have arisen following the Health and Social Care Act in England.[4] Moreover, in its rulings, the European Court of Justice has consistently given a high priority to the sustainability of national health systems.[5] Thus, the opening up of public health systems to competition law is entirely a decision for national governments.

    The recommendations above are already in place within the European Union (e.g. the Social Chapter). Thus, it includes measures to achieve equivalence of labour, health and safety standards in its trade agreements with countries such as Vietnam and Peru, the European Court of Justice has consistently emphasised a high level of human health in its judgements, and, it is notable, that in its negotiating position on the TTIP, the European Union was arguing for a judicial model of dispute resolution. Consequently, there is a real danger that these protections will be lost should the UK actually leave the European Union.[6] Indeed, it is apparent that the main justification for many of those advocating Brexit is to remove these protections.

    References

    1. Steele SL, Gilmore AB, McKee M, Stuckler D: The role of public law-based litigation in tobacco companies’ strategies in high-income, FCTC ratifying countries, 2004-14. Journal of public health (Oxford, England) 2016, 38(3):516-521.

    2. Mendez Lopez A, Loopstra R, McKee M, Stuckler D: Is trade liberalisation a vector for the spread of sugar-sweetened beverages? A cross-national longitudinal analysis of 44 low- and middle-income countries. Social science & medicine (1982) 2017, 172:21-27.

    3. Stuckler D, McKee M, Ebrahim S, Basu S: Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLoS medicine 2012, 9(6):e1001235.

    4. Reynolds L, Attaran A, Hervey T, McKee M: Competition-based reform of the National Health Service in England: a one-way street? International journal of health services : planning, administration, evaluation 2012, 42(2):213-217.

    5. Greer SL, Hervey TK, Mackenbach JP, McKee M: Health law and policy in the European Union. Lancet (London, England) 2013, 381(9872):1135-1144.

    6. McKee M: Brexit: the NHS is far safer inside the European Union. BMJ (Clinical research ed) 2016, 353:i2489.

    This is a proposed policy which the Association is considering.

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    The Tories must not use Brexit to harm the NHS

    Our national health service relies on the skills and dedication of workers from all over the world. If you have ever been treated for an injury, have had your life saved or given birth on the NHS, it is likely that an overseas worker will have helped. It is the United Nations of healthcare.

    That is why so many across the country are concerned about the impact of this Government’s approach to immigration. We know that Theresa May has chosen to prioritise immigration over trade in Brexit negotiations, no matter the impact on the economy, British business, public finances or working people’s living standards. What is less clear is the impact this will have on the NHS’ ability to meet patients’ needs.

    The Government has repeatedly suggested that they will introduce a work permit scheme for EU nationals after we leave. They have said they want to achieve a largescale reduction in overseas workers in the NHS. And they have also doubled down on their arbitrary and extreme target to reduce net immigration to the “tens of thousands”. Achieving these ambitions will undoubtedly mean a significant reduction in the numbers of EU nationals working in the UK, and could therefore target those in the NHS, which currently stands at nearly 60,000 staff.

    The contribution of EU nationals to our healthcare system is immense. There are over 10,000 doctors, over 20,000 nurses and over 1,000 midwives. We should welcome and celebrate their contribution and recognise it as part of our national fabric. Liam Fox, however, has shamefully said that EU nationals here in the UK were “cards” in forthcoming EU negotiations, but no-one should be a pawn for ministers to trade away. I therefore support calls for all EU nationals that are already here have their rights protected – including those working in the NHS.

    Now, however, ministers must go further and commit to allowing the NHS to continue to be able to freely hire European workers to fill posts in the years ahead after we officially leave the EU. The NHS should not be hamstrung by any future work permits scheme. There should be no change in the NHS’ ability to hire EU nationals after Brexit.

    The NHS needs the skills of EU medical staff. If current capability to embrace these skills is hindered as a consequences of a flawed future immigration policy our healthcare system will be weaker. This would be a betrayal of all who rely on the many millions who rely on the NHS, but also the Leave voters who voted to make the NHS stronger.

    It is true that the Government’s mishandling of healthcare since 2010 means the need for overseas talent is greater than ever, but this campaign should not be a partisan issue. MPs and campaigners from all sides should get behind a strong NHS based on the skills we need and a Brexit settlement that protects our public services. That’s why I’m pleased to be supporting the cross-party Open Britain campaign, which is leading the charge on these vital issues. They are working with leading Royal Colleges and health experts, as well as politicians, to ensure the Government’s post-Brexit immigration crackdown does not harm the NHS.

    Our response to the referendum should be fair and proportionate. We don’t want to harm the economy or give succour to immigration scare stories that are without foundation. Indeed, I start from a position where I believe immigration is essential for our economy and makes our society more vibrant and innovative. Any reforms need to ensure people’s concerns are met but also that the benefits of migration are not lost. One of those is a strong NHS.

    This was first published on Labour List

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    The Murky Pro-Corporate Trade Agenda is Bad For Our Health

    In the run-up to the EU referendum, discussion of the threat posed by the Transatlantic Trade and Investment Partnership (TTIP) to the NHS and Britain’s wider public sector moved from the shade of the NGOs and think-tanks, through the Overton window, and out into the fresh air of public debate.

    Important but arcane issues were discussed, such as how TTIP’s procurement rules would force the NHS to contract out services, and the new rights afforded to private health companies to sue Britain for national public health policies that could harm their future profits.

    But while I am thrilled that the secretly-constructed Transatlantic Trade and Investment Partnership between the US and the EU has made headlines, I am concerned that Britain’s vote for Brexit will sap the fight against TTIP, which would affect us until we actually leave the Union.

    Jeremy Corbyn has said that Labour would reject TTIP in its current form. But the UK is threatened by other trade deals such as the EU-Canada deal CETA, and the highly secretive Trade in Services Agreement (TiSA).

    The Conservative government’s cheerleading of an unreformed TTIP suggests that after Brexit it will likely leave Britain with a bilateral US-UK trade deal that is even worse than TTIP.

    The Tories pushed the abolition of rules for big banks, offering up the NHS for locked-in privatisation while refusing to release legal advice on the issue, and ensuring the deal was kept firmly in the dark.

    Thankfully, TTIP has been subject to intense public opposition across Europe, putting its future in jeopardy. However, as I have previously written, due to the deal being conceived as a template to be imposed unilaterally on world trade, it is not just ‘Europeans’ who would feel the consequences of a completed TTIP.

    Through the dystopian Investor-State Dispute Settlement (ISDS) private justice system, trade deals such as TTIP and CETA are, quite simply, charters for locking in deregulation of our social and health rules, the privatisation of public services and consolidating corporate power. They have profound implications for our ability to uphold human rights, fight climate change and bring about equitable and sustainable international development.

    It is little wonder then that at the outset of TTIP negotiations, the European Commission applied a 30-year ban on public access to the deal’s key documents; or that when key texts were leaked earlier this year, it almost destroyed the deal.

    World Health Organisation director Margaret Chan, who I met earlier this year, has spoken of the new global threats to health driven by factors including climate change, spiralling drug prices, increasing drug resistance and the “globalized marketing of unhealthy products.”

    Chan argues: “Preventive efforts that aim to address these root causes [of new threats to health] often face fierce opposition from powerful economic operators, like the tobacco, alcohol, food, and beverage industries, and their equally powerful lobbies. Economic power readily translates into political power.”

    Trade deals such as TTIP, CETA and TiSA are a key means by which this opposition gains traction – at the expense of global public health.

    In this, the ISDS ‘corporate court’ mechanism is crucial: it grants big business the power to sue governments for policies affecting anticipated profits – it is nothing less than a form of “taxpayer-funded risk insurance for corporations” which must be abolished.

    At every level of TTIP, we can see trade rules being used to undermine public health goals.

    A key aim of the US is to ensure beef treated with growth hormones, including antibiotics, is no longer barred from entry to Europe by food regulations. The excessive non-clinical use of antibiotics in animal feed is at the heart of the crisis of antimicrobial resistance we now face.

    Under the influence of pharmaceutical lobbyists, drug companies are using trade deals to extend patents on their drugs. Campaigners in the USA call the move “big pharma’s death sentence clause.”

    Trade is also used to ensure countries cannot choose to run a public health service. After the Slovakian government won an election on a promise to nationalise health, it was successfully sued for doing so by a Dutch health insurance company accessing a deal between the Netherlands and Slovakia.

    And under ISDS, we have seen corporations challenge public health legislation covering everything from sugar taxes to patents for drugs and the use of plain packaging on cigarettes.

    Although TTIP appears to be on ice, our government’s complicity with the anti-democratic corporate trade agenda is continuing at full pace: fresh from the EU deciding last month that CETA must face votes in all EU national parliaments, the UK government confirmed that it supports the deal’s implementation before a vote.

    Worse still, if CETA is agreed before any Brexit deal is completed, it will apply to the UK until we leave, meaning that a huge number of US corporations in Europe which also have offices in Canada will be free to use ISDS to sue the UK under CETA. And in a grotesque dilemma, if the deal isn’t applied before a parliamentary vote, ISDS protections for investments will last for 20 years – regardless of Brexit.

    With a government bent on enforcing a pro-corporate trade agenda at the expense of the rights of citizens, public services and democracy itself, we have much to fight against – and for.

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