This article is an adapted version of a letter written to Dr. Richard Horton, editor of The Lancet.
On 28 Sep 2017, The Lancet published online an article called How will Brexit affect health and health services in the UK? Evaluating three possible scenarios. The authors claim to prove that leaving the European Union will be negative in all potential scenarios for healthcare in the UK and particularly the NHS. It has been widely cited by the mainstream media (e.g. The Guardian, The Independent, HuffingtonPost and BuzzFeed) and shared thousands of times on social media.
While this article has been presented as peer-reviewed "expert" analysis, it is in fact one-sided, un-scientific political advocacy, largely written by ardent Remain campaigners, and should not have been published in The Lancet in its current form.
Scorecard: 3 Brexit scenarios:
The authors present the following summary assessment of their article:
Scorecard: Fahy et al in The Lancet:
Okay, lets use the same traffic light method against this article, using standard peer review criteria for a scientific or scholarly article as a benchmark:
1. Two authors fail to declare potential conflicts of interests. Whilst most of the authors declare their interests, two do not. One received an $11,000 research grant from a European healthcare organisation - a key co-author is Co-Director on the management team of that same organisation. Another wrote a book published by that organisation with help from the same Co-Director's own daughter.
2. Basic errors. Despite making authoritative statements about the UK’s supposed reliance on the “European Food Standards Agency”, the authors don’t even get the name right – it is the European Food Safety Authority (and they also misrepresent how it works). There are other basic errors such as sources being misquoted, and failing to cite appropriate sources. And in an article largely about the NHS, there is not a single direct reference to actual NHS primary data.
3. Seriously misleading or outright false claims. That the UK’s achievement of Air Quality Pollution targets lags relative to the rest of the EU (false, it does not, according to the EU itself), and that there is no agreement between the UK/EU Brexit negotiators on reciprocal healthcare arrangements (false, there is, again according to the EU). Other claims are just misleading: access to European Investment Bank financing, the “unsurprising” nature of the UK’s economic performance post referendum, and risks to NHS future financing.
4. Poor evidence base. Citations made by the authors do not support the statements made in the article (4 cases). Citations are misleading or taken out of context (2 cases). Citations contradict each other (2 cases). Multiple citations to authors own work without independent/peer support (7 cases). This is over half of the substantive citations to facts and evidence.
While most authors do declare competing interests, which is laudable, there are still relevant disclosures missing:
Scott Greer (SJ) received a recent $11,000 research grant (2015-2016) from the European Observatory on Health Systems and Policies, where he is currently also an Expert Advisor. Co-Author Martin McKee (MM) is a member of the Core Management Team (Co-Director) at the same Observatory. The Core Management team has overall governance of distribution of grants, and presumably over whether to utilise Mr Greer for advice and career opportunities - obviously a potential conflict of interest.
Holly Jarman (HJ) co-authored a book with The Lancet article co-authors Nick Fahy and Scott Greer, which was published by the Observatory. Co-author Martin McKee’s own daughter even assisted with this book. Readers would have no idea this close relationship between the authors exists.
And while Martin McKee may have declared that he campaigned to Remain in the EU, his prior angry hyperbole of it being “insanity” and “dangerous fantasy” is hardly a rational assessment of the pros and cons.
The lack of these disclosures should have been discovered during peer review. In addition, the close, often quite personal relationships between the authors (and their likely confirmation bias given most of their past “Remain” positions) should have warranted a more thorough review of their claims and supporting evidence.
The European Food Standards Agency [sic].
The correct name is the European Food Safety Authority (EFSA). This basic error does not give confidence the authors have researched this issue in any detail, despite their impressive credentials.
Beyond the name, authors misrepresent basic facts about how the EFSA works. While the EFSA is EU funded, it does not have any members, merely partners - both EU states and from around the world. The EFSA has formal agreements on co-operation with regulatory agencies in Australia, New Zealand and the United States - none of these states are in the EU, and none of these even have a trade agreement with the EU. It also co-operates without formal agreements with many other non-European states, including Libya, Israel, Egypt, and Azerbaijan (unlike Eurovision I do not count Israel as part of Europe).
Why would the UK be unable or unwilling to continue participating with the EFSA? Why would the EFSA not co-operate with the UK Food Standards Agency on the same basis as those in the United States or Australia, or at the very least Israel or Egypt? No evidence is presented to answer these questions, and they are not even asked. Also, “lesser engagement” does not a priori equal serious threat – the magnitude of the lesser engagement and how relevant this is to any risk would need to be quantified, which the article does not do.
Misquoting sources, mutually contradictory sources
Authors misattribute a quote to the Royal College of Nursing (RCN), the 92% statistic is contradicted by another of the authors own citations (plus the RCN itself), and the authors ignore obvious evidence in their own sources that runs counter to their argument
The RCN did not say the phrase “on the failure of the government to provide EU Nationals in the UK with any security about their future” – this was The Guardian’s words, not the RCN. While the RCN was quoted, and has expressed similar sentiments, it did not even use the word ‘failure’ in any of its statements to the paper.
The “92% drop in EU Nurse registration” statistic does not compare like for like months - in addition, authors twice cite the House of Commons Health Committee report on the NHS (Citations 2 & 4). Yet that very same report says that the NMC "do not know conclusively what caused the decline in EU nursing applicants", that “the reduction in applicants may, in part be a consequence, of the introduction of language testing for EU nurses" and "a slowdown in recruitment from R-EU nations this may not necessarily be wholly attributable to the outcome of the referendum” (and as I'll argue later, when you look at changes in EU staff by nationality it is hard to attribute the slowdown to Brexit even as a major factor).
In the evidence session for that report, the Chief Executive of the RCN confirmed a true like for like figure is actually 75% (see Q295), saying “the point at which we introduced the language test [Jan 2016]—from the data, we saw a hike in applicants from Europe beforehand, understandably, and now we have seen a reduction in the number applying to join and a small number seeking to leave. We can speculate as to what that is about; it could be the language test, it could be Brexit or it could be all sorts of things. At the moment we do not know”. The RCN is careful not to attribute a specific, sole cause, as the authors do.
No use of publicly available NHS data in a prestigious journal article about the NHS
It is astonishing to find an article published in The Lancet that purports to describe the potential impact of Brexit on the NHS - particularly for EU staff - which does not once cite any NHS primary source data as evidence. It only briefly refers to recent high level EU staffing levels and cites an article published in The Guardian as its only evidence for recent trends post-referendum. And the authors couldn't have picked a worse article to cite - it contains numerous misleading distortions and outright false statements.
NHS workforce data (for NHS England) is publicly available via NHS Digital, in a variety of easy to use formats. If authors wanted to inform readers of The Lancet of the trends in NHS staffing pre & post-referendum overall, for EU Nationals (and Rest of World foreign nationals for that matter), they could have easily done so. For example, rather than cherry picking from The Guardian's alarmist article (written by the paper’s Brussels correspondent), they could have shown the actual trend of EU nationals post Brexit and either analysed this and made projections, or allowed readers to simply see the data and decide for themselves (see Table B and Table A).
NHS EU Nationals (Table A)
NHS EU Nationals - Joiners and Leavers (Table B)
The Guardian article relied on by the authors as their sole evidence for short term Brexit effects on the NHS makes the following claims:
All four of these claims are seriously misleading, or false, and so the article shouldn't have been cited:
92% drop in EU Nurse registration: this is not supported by other author citations (House of Commons Health Committee Report) and as mentioned already, the true like-for-like figure may be 75%, with not even the RCN claiming this was solely attributable to Brexit in testimony to that Parliamentary Health Committee.
2,700 v 1,600 leavers: Using exactly the same date ranges cherry picked for comparison by The Guardian (Dec 2014-Dec 2016), NHS workforce data shows that the number of EU Nurses actually increased by 41% from 15,591 to 21,981. Simply stating leavers of 2,700 versus 1,600 is highly misleading without this context.
"Haemorrhaging foreign staff": this is not just misleading, it is simply false. EU foreign staff have increased since the vote. Rest of World “foreign staff" have not only increased, they have accelerated since the Brexit vote, with the fastest growth (see Table D) and best retention rates (see Table C) in over 6 years. This is potentially a real success story of the NHS’s continuing (even improved) attractiveness to foreign nationals post Brexit-vote being completed ignored by the authors
Record number of EU nationals quitting: In terms of EU Nationals “quitting”, it is true that a “record number” of EU Nationals have left the NHS - 9,832 between June 2016 and June 2017. but EU nationals overall are simply numerically far larger than in the past. A “Record number” also left in 2012, 2013, 2015 and 2016, but this isn’t illustrative of anything significant. There has certainly been a noticeable slower net rate of growth. And while the leavers figure is the highest in 6 years, it is not that much higher than in 2011-2013 (see Table E)
NHS RoW Nationals - Attrition Rate (Table C)
NHS RoW Nationals - Total Staff (Table D)
EU Attrition Rates v UK Attrition Rates (Table E)
One of the key claims is that ‘Failed Brexit’ is “likely to have a severe impact”, in the context of “Recruitment and retention of EU nationals in the NHS”. This could be true, but it ignores that non-EU Rest of World nationals (from 164 nations) already successfully operate on these terms and are having their best recruitment and retention in over 6 years.
As of June 2017, 75,281 NHS workers, or 6.4% of the workforce are non-British or non-EU (compared to only 3.9% in the rest of the wide UK economy). They are overwhelmingly from the Commonwealth (India, Pakistan, Nigeria, Ghana, Australia, Jamaica), Asia (Philippines, Malaysia), or the Republic of Ireland (the 3rd largest number of foreign nationals, with which the UK has a Common Travel Area pre-dating the EU). In fact, Indian doctors equal the doctors from 23 EU states combined. Filipino nurses equal the nurses from 24 EU states combined. Cricket-challenged Australians have more ambulance staff than all EU states combined.
All of these RoW NHS staff have no freedom of movement (except Republic of Ireland), limits on voting rights, in-work benefits, and few/none of the other myriad EU-only benefits that are supposedly essential to attracting and retaining NHS staff, according to the authors. Authors give no explanation for how Indians, Filipinos and Australians - and RoW staff in general - can dwarf EU nationals in many roles, without the benefits of these EU “legal entitlements. And as noted already, post Brexit referendum RoW numbers are accelerating (see Table D).
The authors also don’t look at obvious real world counterfactuals to their argument: e.g. they do not explain how a nation like Canada (which they mention in another context) can maintain a healthcare system without joining the federated USA super-state next door (accepting US Supreme Court judgements as the law of the land, freedom of movement between New York and Ottawa etc.), even though they have comparable numbers of foreign born Doctors and Nurses to the UK (around 35% and 22% according to the OECD; see page 111 and data links).
In their single-minded focus on EU nationals in the NHS as an argument for retaining EU membership, I would argue the authors incorrectly and immorally downplay the very large contribution made to the NHS by other foreign staff, as well as the potentially positive news story of "Brexit Britain" continuing to be open to the wider world.
EU/UK Negotiating Positions on reciprocal Healthcare/EHIC have “no agreement”
This is false. There is no evidence in the citation for "no agreement" on the "crucial issue[s]" of reciprocal health-care arrangements, home country reimbursement and continued use of the EHIC. In fact, the opposite.
Healthcare is covered in three areas in the EU/UK joint technical summary document on citizen’s rights. I list these, with key concepts and status, from the exact same source used by the authors, see Table F. Words in quotes are directly from the joint technical note, (bold brackets) for clarity. Equal treatment for healthcare for UK/EU citizens, home country reimbursement, and continued use of the EHIC were all agreed*, rather than having "no agreement":
The UK has “lagged” behind other EU neighbours in Air Pollution Targets
This is false. In fact, the opposite is true.
The UK has been above the EU average in its implementation of air pollution targets - according to the EU's own data. For example, in Sulphur Oxides, the average EU-28 reduction between 1990-2011 was 82% - the UK achieved 90%, the 7th best performance in the EU.
The UK is also on track for its 2020 targets, and closer to that 2020 target than 18 other EU states are to theirs (including Germany). No evidence is cited for the statement that the UK is “often” lagging “behind its neighbours” (since no evidence exists).
The UK is not an outlier in Nitrogen Dioxide emissions, and the fact they are so high EU-wide is largely down to the EU itself encouraging the use of diesel vehicles. The UK regularly sets environmental targets below those of the EU so the idea they would “slip” post-Brexit is implausible.
The pollution article cited is a news report, and over 2 years old. The latest available environmental information should be used for a paper published in 2017, particularly when purporting to describe a “trend”. The authors also fail to point out that 6 EU countries exceeded not only local, hourly or 24 hour limits (as in London), but their annual country limits for Nitrous Oxides (Austria, Denmark, Finland, Germany, Spain and Sweden).
The authors fail to mention the European Commission has infringement proceedings under way against 12 EU states (Austria, Belgium, the Czech Republic, Denmark, France, Germany, Hungary, Italy, Poland, Portugal, Spain and the United Kingdom). It has issued repeat warnings to Germany, France, the UK, Italy and Spain. And of those, France and Germany have breaches in more air quality zones than the UK (see EU Commission Press Release). The UK is hardly an outlier, with over 40% of the EU-28 having infringement proceedings against it.
What of the claim that “in absence of EU legislation”, “UK environmental standards could slip further”? First – UK environmental standards have not slipped in the first place, relative to the EU average, never mind further. Second, it is implausible - the UK often sets a target lower than the EU (e.g. for Sulphur Dioxide, the EU set a target of 40 μg m-3 annually in Directive 99/30/EC, to be achieved by 2010. The UK Air Quality Strategy had the same target, but brought achievement forward by 5 years to 2005). The UK is also continuing to set aggressive targets for when it is outside the EU (and since June 2017, the main government department has been led by prominent Brexiteer and Vote Leave leadership member Michael Gove).
The authors provide zero evidence that the UK would not tackle emissions outside of the European Union, nor that membership of the European Union is required for any state to do so. For example, across the EU-28, Nitrogen Oxides (inc. Dioxide) reduced by 52% 1990-2015. In the non-EU United States, Nitrogen Dioxide was reduced by 49% 1990-2015. Sulphur Dioxide? EU-28: 73.5%, United States: 69.5% (both 1990-2011) - all US figures from US Environmental Protection Agency stats.
Finally, one of the largest contributors to NO2 is road transport, in particular diesel vehicles. The European Union (heavily influenced by Germany) encouraged the take up of diesel vehicles throughout Europe to reduce Carbon Dioxide emissions. This contributed to higher market penetration of diesel, a nice side benefit for EU manufacturers with a comparative advantage over petrol dominated USA and Japan. The vaunted EU regulations and inspections - supposedly the guarantors of public health - failed to detect the "Diesel-gate" scandal, until the non-EU United States intervened. And the EU failed to even achieve the intended CO2 reductions in transport, relative to the mostly non-diesel USA and Japan - so citing the EU or EU Commission in the case of NO2 as a positive is astonishing chutzpah!
The UK’s economic performance post-referendum is “unsurprising”
“Unsurprising” is an astonishing piece of historical revisionism, and must come to a surprise to one of the authors.
Immediately post-Brexit vote (June 2016), 71% of economists surveyed by Bloomberg predicted the UK would enter a recession in 2016, with some major banks predicting an immediate 2.5% contraction in GDP. An immediate recession was also the official UK Treasury and Bank of England forecast pre-Brexit vote – with this recession caused simply by uncertainty from a “Leave” vote result itself, not from actually leaving the EU.
The UK actually grew 1.8% in 2016 (higher than both France and the United States) and this was a surprise to almost the entire political, academic and economic establishment, and even many Leave voters. Retrospectively claiming to be “unsurprised” is a bold claim – with no evidence. In fact, lead co-author Martin McKee himself said a financial meltdown was not only forecast, but confirmed, and even worse than predicted:
In the year since that "certain" prediction, the following pharmaceutical and other companies have announced new investment in the UK:
GlaxoSmithKline: additional £275m in manufacturing | Alnylam: new European headquarters in Maidenhead, brushing off the loss of the EMA | Novo Nordisk: £115m for new research centre in Oxford | AstraZeneca: continued to expand their largest worldwide R&D centre in the world in Cambridge, whilst having their best profit margin quarters in years | ING: moved banking jobs from Europe to London | Google: £1bn investment and up to 3,000 new jobs | Snapchat: made London its European hub outside the US | Siemens: “The company is willing to invest further, there are more opportunities than risks for us [post-Brexit]” | Deutsche Bank: signed 25 year commitment to new London HQ for 5,000 employees | Nissan: announced it would increase output from Sunderland plant by 20% and double quantity of UK-sourced parts to 80% | Aldi: up to 4,000 new jobs and 300 new stores | BMW: announced it would manufacture the new electric Mini in the UK | EasyJet: announced largest ever hiring intake of 1,200 extra cabin crew | Amazon: announced larger than planned expansion of Global R&D centre in UK, hiring 450 extra staff and occupying 4 new office floors | Toyota: £250m investment in Derby plant – with R&D spend in the automotive sector up 10% on 2015.
Now of course, these individual anecdotes don’t prove Brexit is a good idea, or that they occurred because of the Brexit vote, or even that they wouldn’t have happened anyway. But they are certainly context that should be taken into account when claiming to evaluate the UK’s economic situation and prospects for the future – along with the more pessimistic or negative anecdotes, that could just as easily be cherry picked to suit an alternative argument. Note that the aggregate figures show that net foreign direct investment was higher in 2016 (£9.4bn) than 2015 (£9.1bn), reversing a declining trend since 2011.
Following the scientific method – when your hypothesis says recession/meltdown, and your observational experiment “confirms” it - if it turns out it never happened in the real world? You got it wrong, and should consider why when making future predictions. Not simply repeat the same claims again, whilst claiming you never made the original hypotheses in the first place. The Lancet should not have allowed the authors to do this without strong peer-review challenge.
European Investment Bank healthcare funding is “likely to be stopped”, even with an FTA
The UK provides 16% of the EIB’s financing, statistics are cherry picked, and no evidence is given for the “likely to be stopped” statement.
The UK contributes a larger than EU average per-capita of the EIB’s financing - a 16% share (joint 4th largest), and holds approx. £9.2bn in callable assets with the EIB. “EIB money” is “UK money”, recycled – similar to all other “EU money” spent in the UK. And the start date of 2001 is a cherry picked statistic to arrive at €3.5bn -in the last 6 years (2010-2016), the EIB has funded only €1bn in projects and €675m more recently (2011-2017). It funded no new projects in the entirety of 2016, 2014 and 2011 (and only €6m in 2012).The UK still partly owns these loans in any event via its stake in the EIB.
As for “likely to be stopped”, this is a much stronger claim than simply that EIB capital finance may possibly be reduced, and it is implausible. The EIB provided €230million for healthcare in Syria between 2001-2010 (yes, before the Civil War). Okay Syria is a lot poorer than the UK, but a non-European country led by Assad’s dictatorship can get EIB funding but not an FTA-linked UK defending the European continent with its armed forces? The authors provide no evidence for why this would be the case, despite citing this in prominently their article abstract. Authors would have been on stronger ground claiming the need to be an EU state to be a member of the EIB would potentially result in some reduction in EIB financing, rather than their exaggerated claim.
There is a “likely” substantial impact to NHS financing (implied due to a Brexit recession)
The NHS budget has been protected in past recessions.
Authors merely state without evidence that any potential future issue with the wider UK economy is likely to result in a reduction in NHS/healthcare funding. However, during the “Great Recession” between Q2 2008 and Q2 2009 the UK lost -6.2% of GDP, well above even authors own cited median estimate of hypothetical future Brexit losses. Despite this, NHS funding remained ring fenced and largely protected, though it grew slower than the mid 2000’s. Therefore, all other things being equal, it is likely even in a severe Brexit-induced recession, the impact to NHS financing would not be substantial and would fall in other areas.
The authors also do not state that the NHS budget continues to grow, with a planned additional £8.5bn or £163 million a week in real terms by 2020-2021 (this is the like for like comparison as the authors said “NHS”, not overall healthcare, but for completeness the overall Dept. of Health budget is only increasing by £4.6bn or £88m a week).
In context for the £88m-£163m a week, The Vote Leave campaign committed in its official ‘NHS Funding statement’ pre-referendum to an additional £100m per week to the NHS, rather than “£350m” as commonly claimed. According to Remain campaigners this fact is apparently refuted by taking the side of a bus - or posters - more seriously than a statement widely reported in the media at the time (e.g. on the front page of BBC News Online) and signed by the Vote Leave leadership (Michael Gove, Boris Johnson and Gisela Stuart).
And, as an indicator of putting partisan claims before consistency and facts, Martin McKee’s own ‘Healthier in the EU’ Remain campaign organisation (he was an advisory board member), acknowledged the figure was £100m a week in its official factsheet. Yet post referendum, McKee claimed “Vote Leave could not have been clearer. They promised that leaving the EU would free up £350m for the NHS”. To accuse Vote Leave of being misleading while deliberately being misleading yourself is pretty breathtaking.
In addition to these serious issues, the article overall has a poor evidence base for claims made. Here some additional ones not mentioned already.
Citations that do not support the statements made in the article
Hard Brexit definition and increase in NHS costs (Citation 20)
The authors invented a new definition for “Hard Brexit”, unfortunately it is not even consistent with their own citations. And their citations also contradict other statements.
According to the authors, “Hard Brexit” apparently now encompasses a scenario where the UK actually secures a Free Trade Agreement with the European Union - rather than leaving on WTO terms, as commonly understood by almost every other commentator (though some Leavers would quibble with these terms, preferring “Clean” to “Hard”).
This is clearly contradicted by authors own citation 20 (Bloomberg News), which states “[Hard Brexit is] a scenario in which negotiations break down and the U.K. must depend on World Trade Organization rules”.
This citation isn’t even to the primary source - a report by the Economic Intelligence Unit - but only a five paragraph news summary by Bloomberg. While the Economist Intelligence Unit report supports the contention Brexit will impact NHS funding, they say “the UK economy has so far been more resilient than expected”, a contradiction of the authors astonishing claim it was “unsurprising”.
Finally, that Economist Intelligence Unit report only supports an “estimate” (with no evidence and no supporting data given) of a £7.5bn decrease in NHS spending, not an increase in NHS costs, two entirely different economic concepts. And this is only in the event of their “Hard Brexit” scenario, not either of their other scenarios: “Soft” or ‘Softish”.
Dept. of Health struggling to cope (Citation 4)
The Health Committee's report did not endorse the argument that the Dept. of Health is "struggling to cope".
The "evidence" for this statement is testimony from Martin McKee himself, one of authors, which is circular reasoning (and not clearly identified in the citation reference). Perhaps Mr McKee is right, but the Health Committee report does not provide any evidence for it in its conclusions and recommendations. It merely observes that "we consider it essential that the negotiating team for the health related aspects of Brexit has the expertise, competence and appropriate support for this complex task", which is common sense.
While it is correct that the number of roles at the Department of Health (DH) has reduced (by 26% since 2011), and will reduce further by another 500 (from 1,800 to 1,300), almost all - maybe all - of these leavers are under a voluntary exit scheme. In addition, many of the roles "lost" from the Dept. of Health were transfers into NHS England under the 2012 Act that restructured the NHS, so the knowledge/capability is not lost to the healthcare system (though reduced senior DH leadership ability is at least a reasonable case to argue).
The Health Committee’s report makes no specific recommendations regarding the planned reduction of DH staff, despite including them clearly in the report and having had regard to Mr McKee’s evidence.
Other Citations that are misleading or taken out of context
Lamb/Mutton tariff schedules (Citation 11)
The author of the blog post in question says this: "Is this [Lamb/Mutton] typical of all the tariff quotas? No.” Followed by: “Negotiations over the UK’s and EU’s schedules will be complicated and may take a long time.... [but] will this matter if the UK and EU end up with a free trade deal of some kind anyway? ... If the UK and EU are confident that they will strike a bilateral deal, then including UK-EU trade in the tariff quotas will be less critical"
This context is excluded and it being not being a relevant example according to their source under either the authors “Soft Brexit” (EEA) or “Hard Brexit” (FTA) scenarios is not identified anywhere in the text.
Multiple citations to authors own work without independent/peer support
Authors cite their own work on no less than 7 occasions: Citations 1, 4 (obscured), 9, 15, 16, 29, and 31. Of course there is nothing wrong with this per se, but with almost all of the other claims lacking any independent evidence base, it becomes a serious problem.
How reliable are these self citations as evidence?
An examination only of Citation 1 (McKee, M and Galsworthy, MJ. Brexit: a confused concept that threatens public health. J Public Health (Oxf). 2016; 38: 3–5) would not give the reader much confidence:
- Authors MM and MG call Brexit a “confused idea” and a "dangerous fantasy" (which is a step up at least from "insanity", used by MM elsewhere8). Leaving a voluntary transnational political organisation through a mechanism outlined in the organisation’s own treaties (Article 50) is not particularly confusing. It can be good, bad or neutral, but confusing it is not, unless the intention is to insult millions of voters as confused, a tactic that didn’t work so well during the referendum, which this piece was timed to influence.
- There are faulty and misleading claims about creation of European Law - in attempting to refute the argument the EU is “undemocratic”, it mentions every EU institution involved in rule making except the unelected EU Commission (which apart from “special’ cases, is the only institution in the EU capable of proposing new laws and repealing old ones): “Those advocating Brexit often argue that the UK is subject to laws passed by distant unelected officials. In fact, European law is actually made jointly by democratically elected national governments, in the Council of Ministers, and the directly elected Members of the European Parliament”
- Claims Vietnam is required to accept EU regulations merely to trade with the EU. This is not the case, as the examples of China, and the USA obviously demonstrate. Vietnam may have to accept EU conditions in return for a preferential trade deal, which is not the same as trade. This does not give confidence the authors have any expertise to make their comments about trade that they make elsewhere in The Lancet article.
- Cites future GDP projection studies that are reliant on the idea that the Single Market increases relative trade between its members and also raises productivity. This is the prevailing economic theory, and may be partially true for other EU states but this has not been the case for the UK since the creation and deepening of the Single Market in the early 1990's.  Hence, GDP projections on this basis are unreliable.
As there are major errors in How will Brexit affect health and health services in the UK? Evaluating three possible scenarios, it should be retracted from The Lancet, or at the very least have a correction appended.
The authors undoubtedly have a great deal of healthcare and academic experience, particularly in a European context. Rather than trying to over-turn the largest democratic mandate in British history, I’d suggest it would be a more productive use of their skills to provide constructive suggestions on how the UK healthcare system can embrace the opportunities of Brexit, whilst minimising the risks.
Vote Leave and £100m: The Vote Leave statement by Michael Gove, Boris Johnson and Gisela Stuart on NHS funding is reasonably clear on the £350m and very clear on the £100m: “The UK’s gross budget contribution is £350m a week … We get some cash back through a negotiated rebate and some other money we hand over to the EU is spent here in the UK on areas like farm subsidies … After we Vote Leave on 23 June, the Government should use some of the billions saved from leaving the EU to give at least a £100 million per week cash transfusion to the NHS”. However, it is true that Vote Leave were deliberately misleading at times on the £350m overall, apparently happy to have the figure in the headlines even if it was being fact checked (according to campaign chief Dominic Cummings).
EU Law and the EU Commission: It is not just “European Law” that is driven by the EU Commission, but 70+ other procedures where action cannot be taken or amended except “on a proposal from the Commission” (Consolidated Version Of The Treaty On The Functioning Of The European Union (Article 294). Article 17(2) of the Lisbon Treaty is even more explicit: “Union legislative acts may only be adopted on the basis of a Commission proposal, except where the Treaties provide otherwise” (and they often don’t provide otherwise).
Single Market and Trade: See Civitas report. This contains an analysis of 7 international trade databases, and shows UK-EU exports grew faster 1973-1992 (Common Market era) than 1993-2015 (Single Market era). It also shows this is not a question of growth limits due to UK exports already being large in size, as the USA’s exports to the EU in the same 1993-2015 period also grew faster than the UK’s, despite trading on WTO-terms, outside the Single Market, separated geographically, in a difference time zone. The USA has a similar culture, legal-system, services-led economy and the same language as the UK, so is a good comparator.
Single Market and Productivity: See the highly respected economic commentator (and pro-Remain) Wolfgang Münchau in Prospect Magazine: “if you look at the trend of EU-wide productivity, the single market leaves no trace…the single market is a giant economic non-event, for both the EU and the UK"