It’s frustrating that for such an important issue, there seem to be so few solid facts to go on - instead we seem to be treated to spin, spin and more spin from both sides.

You can set your watch by the emergence of the same old tactics in any election – when there are a few weeks left to go, both sides start to invoke the NHS and say that if you don’t vote for them, the NHS will be destroyed.

It’s frustrating that for such an important issue, there seem to be so few solid facts to go on - instead, we seem to be treated to spin, spin and more spin from both sides. You can set your watch by the emergence of the same old tactics in any election – when there are a few weeks left to go, both sides start to invoke the NHS and say that if you don’t vote for them, the NHS will be destroyed.

Depending on which camp you listen to, this is what is going to happen on June 23^rd:

• If you vote to leave the EU, Britain is doomed.
• If you vote to remain in the EU, Britain is doomed.

With both sides trading insults and accusing each other of pulling out dodgy stats and suspect statements, I’ll be looking to unravel the uncertainty that still surrounds the possible impact of leaving the EU on healthcare in the UK.

The healthcare case for Brexit

The NHS costs about £100-116 billion a year to run. Even with increases in funding, there’s a projected £30bn shortfall by 2020, with “efficiency measures” hoping to recoup £22bn of that. The current cost of EU membership is £15bn a year, of which we get back £7bn in rebates and subsidies, so our net payment is £8bn a year.

If you listen to Boris Johnson and co, this cash will nicely plug the gap in healthcare without us having to make more cuts or increase taxes. However, NHS England boss Simon Stevens has said that retaining that net payment figure would only fund the NHS for 19 days of the year.

We (don’t?) send Brussels £350m a week, which could go to the NHS

This is one of the most fiercely debated claims of the whole argument. Brexiteers have been constantly using it as a reason to leave the EU, even after it was labelled misleading by the UK Statistics Authority, the HM Treasury and the Institute of Fiscal Studies.

The IFC issued the following statement after Michael Gove reeled out the disputed figures on TV: “Leaving the EU would not, as Michael Gove claims we said, leave more money to spend on the NHS. Rather it would leave us spending less on public services, or taxing more, or borrowing more.”

European immigration and staffing resources

Some in the Leave camp have said that EU migrants put a continuing strain on healthcare, claiming they are more likely to have children than UK nationals and therefore put extra strain on maternity or child services. Depending where in the country your practice is based, there may be a higher prevalence of EU migrants or asylum applicants registering for treatment. Where migrants are paying taxes though, it obviously benefits NHS funding – the government are the ones who fund the NHS, not the EU.

Another angle on immigration is that free movement across the EU means that you can recruit GPs or nurses without the problems of visa restrictions, so it is quicker to get them in post when you need them. More migration means more people coming through the doors – the NHS has benefitted greatly from the arrival of EU workers, who now make up at least 5% of the workforce (about 130,000 nurses, GPs and care workers).

Leaving the EU won’t necessarily mean losing those people, but if they did go, how would we replace them? The government just told us they were going to axe the nurse student bursary, GPs are retiring, practices are shutting down... If we close our borders on June 24th, what will attract the next home-grown generation to work in the NHS?

The issue of ‘medical tourism’

Cancer specialist Professor Angus Dalgleish, a professor of oncology at St George's, University of London, has said that the NHS would benefit hugely from an end to patients travelling to Britain from the EU for medical treatment. On the other hand, these people spend as any other tourist would; on accommodation, food, travel and various other things, bringing in an estimated £219m a year.

The NHS does itself send patients abroad for treatment, including for proton beam therapy in the Czech Republic (we don’t have this in the UK). It has contractual arrangements with these hospitals, but we also have similar agreements with the US, so it doesn’t really have much to do with Britain’s presence in the EU – if we leave, these contracts will still be in place.

It is possible to recoup the cost of treating EU nationals, but the difference between what we pay out and what we claim back is huge – for the £50m we claimed back for treating EU nationals in 2014-15, we paid out £674 million to other governments for the treatment of UK citizens abroad.

 The effect on ex-pats

In Spain, the large ex-pat community gets free GP access and the NHS pays for their hospital treatments because of long-standing EU agreements. If we left the EU, we would have to renegotiate similar agreements with several other countries or perhaps end them altogether, making our UK emigrants pay for their own treatment if they continue living abroad and their resident government refuses to pay for them. If they choose to come home because of concerns about their health provisions in their adopted countries, the return of some or all of these two to three million people would increase pressure on our GP practices and the NHS as a whole.

European health research

If we abandon the single market, we would likely have to set up our own versions of EU Institutions like the Food Safety and Environment Agencies. European law tends to lean towards supporting public health, funding health research to promote easy access to information in healthcare, and balancing the need to make new drugs available quickly while protecting research trial volunteers.

The UK is the largest beneficiary of EU funding of health research programmes, and we also get access to the EU’s public health strategy, ‘Together for Health’, which supports new technologies for health care and disease prevention.

Workers’ rights & employment law

Stepping away from the health arguments, employment law has been largely forgotten in this debate. European Union legislation recognises the role of social and employment policy in member states, and is there to protect employment rights, safeguard health and safety, and promote equality in the workplace.

The EU isn’t perfect, but it has guaranteed some of the most basic rights at work, which Brexit won’t necessarily do - leaving would mean that those laws would be subject to change. From an employers’ point of view, the EU has also limited the ability of unions to organise industrial action in some disputes, affecting collective bargaining agreements that cover whole industries.

Conclusion (well, sort of)

So is continued EU membership a threat to the NHS? From an economist’s point of view, the ability to fund healthcare in the UK is inextricably linked to its economic success.  Although austerity began with us as a part of the EU, the IFS has speculated that it could be extended if we opt for Brexit. Either way, any further cuts to healthcare are going to directly impact frontline services.

Nothing in EU law requires our government to organise the NHS in any particular way. If we stay or leave, it won’t make a difference to the government’s policies on the way the NHS are organised (e.g. ‘any qualified provider’ rules in England), or how much it chooses to spend on the NHS. Where services in the NHS are organised on a ‘market’ basis, EU trade and competition law apply, just as it would to other business sectors – even so, the way you apply EU law is modified for the healthcare sector.

Whichever side prevails in the Referendum, if the economy goes into a tailspin then the momentum of the NHS Forward Views (both Five Year and General Practice) will either stall or completely halt any further investment. The moments when primary care has been under most pressure are when the economy has stalled; the connection between those two points is essential to the future of the NHS.