We have grown used to seeing life expectancy rise in Scotland. Today, a baby boy born here will likely live until he is 77, a girl until 81. This doesn’t happen by accident, but through the efforts of many people who work in public health and related fields. Rather than focus on individual patients with different illnesses, public health, in the words of Donald Acheson, one-time Chief Medical Officer, is the ‘science and art of improving health and preventing disease through the organised efforts of society’. In practice, achieving better health in whole populations is the result of a huge number of interacting factors.
What are the likely effects of Brexit on these factors? How might those of us working to safeguard public health in Scotland respond to these changing times?
One of the biggest factors in generating positive health in society is economic performance, which in turn can improve living conditions through better housing, sanitation, clean water, food and transport. Wealth creates health, but good health also creates wealth because it generates an active and engaged workforce. Since the referendum on leaving the EU, the UK economy has been sluggish in comparison with most of the other EU member states and, whilst employment is high by historic standards, the majority of new jobs created have been low paid and insecure. In-work poverty and private debt are rife, placing huge stress on families, which in turn has a negative impact on health, particularly mental health.
Business does not like uncertainty, which makes it more difficult to make long-term investment decisions. The turbulence being generated by Brexit preparations does not bode well for the economy of Scotland in the future and this is likely to be harmful to health because of lower incomes, poor quality work opportunities and unemployment. The extent to which employment rights will be diluted, following the repatriation of these laws after Brexit, is also unclear. This might exacerbate the health impact of Brexit on those of working age and their families, particularly for agency and part-time workers.
One corollary of lower economic performance is reduced income for government. This has significant consequences for the affordability of public services. Less money for the NHS, education, police, welfare and infrastructure investment will all have impacts on the public’s health. Indeed, with over seven years of austerity in the public sector, there are indications that these health impacts are already happening. This is an issue not just in the UK, but across European countries where, since the financial crash and the crisis in the eurozone, austerity measures have been implemented.
In addition to employment protection, the EU has, through the Lisbon Treaty, introduced widespread policies to promote public health and protect consumers. These include standards for drinking water quality, food production and processing, products and medicines. Outbreaks of serious water or foodborne diseases are mercifully rare. Because of the requirements for meticulous record-keeping in the food chain and water quality monitoring, the source can usually be identified speedily.
Cross-border collaboration is an essential feature of this work, particularly in controlling communicable diseases. The European Centre for Disease Control provides a pan-EU surveillance function and alerts member states to threats and emerging hazards. With these powers returning to Westminster post-Brexit, it remains to be seen if consumer protection standards will be diluted, co-operation reduced and the health of the public put at greater risk.
A further area where the EU has been very active in terms of regulation for public health has been in tackling tobacco. Plain packaging, a ban on advertising and cross-border efforts to deal with smuggling have all helped to reduce the burden of smoking-related disease across Europe. The lessons are being learned to address the health burdens of alcohol and obesity. Whilst litigation based on EU laws on trade for some time impeded the Scottish government from introducing minimum pricing on alcohol, there is widespread support from the European Parliament for its efforts. Minimum pricing in Scotland might now pave the way for similar measures in other EU states where alcohol is having a harmful effect on public health.
Many people have already described the impact of Brexit on the NHS and research institutions. The workforce challenge for health and social care is immense given the ageing population and the higher dependency ratio this generates. With relatively fewer people of working age to support an ageing population, inward migration of workers is essential to ensure hospitals and nursing homes stay open.
Can Brexit impacts on health be mitigated?
So what can Scotland do to mitigate the worst aspects of Brexit for public health and take advantage of opportunities to do things differently in future?
The main opportunity for Scotland is to insist that the powers returning to Westminster are then devolved. That would provide opportunities for Scotland to strengthen its public health protection – with minimum pricing not just for alcohol but possibly also for sugar, for example. Scotland may be able to retain some research collaborations if it pooled national research funds with European programmes.
A further question remains whether a Scotland outside the EU framework could go beyond the current limits in EU regulation in relation to agriculture, food and environmental standards and offer premier products for the market. It already has a strong reputation for its food and drink. Maybe stepping out beyond EU minimum standards and gravitating towards high-end quality products could be a way forward. Whilst this may have attractions for exporters, it would not help the home market. Scotland needs to think how agricultural subsidies could be used differently, encouraging small-scale and organic food production.
But what if these powers are not devolved to Scotland? How can Scotland mitigate a watering-down of regulation to protect public health? What is Plan B for public health? These are urgent questions which need the input from some key agencies to come up with answers. For example, the Health and Safety Executive, Scottish Environmental Protection Agency, Scottish Water, Food Standards Scotland, Animal and Plant Health Agency, Royal Environmental Health Institute for Scotland, Scottish Directors of Public Health and the Faculty of Public Health all have important perspectives and knowledge of this area. Experts across the UK could provide assistance.
Brexit poses many questions and challenges to public health in Scotland. Tackling them will require a lot of work and innovation across a number of areas and organisations if the health of Scots is not to be adversely affected by Brexit.
Dr Margaret Hannah is Director of Public Health at NHS Fife, visiting professor at Robert Gordon University and Fellow of the Royal College of Physicians of Edinburgh. She has worked on creating fresh thinking on public health, the culture of healthcare and wellbeing in health.