The devastation Brexit is bringing to the NHS will be felt from the moment a patient is admitted to hospital, right through the course of their treatment
The message couldn’t have been clearer. Leave the EU and give £350 million a week to the NHS. At a time when the NHS was clearly struggling, it is entirely understandable that many people thought that this would be a good idea. Yet, as we now know, within hours of the referendum result, the claim was being disowned. Speaking on ITV, Nigel Farage said, of VoteLeave, that ‘I think they made a mistake in doing that.’
Even during the referendum campaign, the claim had been demolished, with many commentators noting that it took no account of the British rebate, the cost that would be incurred as the UK repatriated responsibility for everything the EU did, and the damage that Brexit would do to the British economy. Yet, for many, the precise figures were less important than a sense that, somehow or other, Brexit would be good for the NHS. This view was, of course, encouraged by those who painted a picture of British people standing in line for treatment behind a long queue of EU migrants, even if the reality was that any migrants present were likely to be providing treatment rather than using it. So, now that Article 50 has been triggered, what will Brexit really mean for the NHS?
The immediate problem is that nobody really knows. This is because we still have very little idea what Brexit will look like. Neither the Prime Minister’s speeches nor the government’s White Paper provide us with any real insight. Ministers chose to pad out the White Paper with pages that were either blank or filled with large blue rectangles. The costings and impact assessments normally associated with such documents were conspicuously absent.
Although not alone in being virtually ignored, the lack of detail on health is particularly striking, especially as it was one of the first things that Jean-Claude Juncker raised at the now notorious Downing Street dinner. He brought up in the context of citizens’ rights and it was the apparent absence of any comprehension by the British side that left him sceptical about the prospects for any progress.
Perhaps he should not have been so surprised. Previously, when appearing before the Commons Committee on Exiting the EU, David Davis had expressed surprise that anyone should ask him about reciprocal health rights, admitting that his department had not actually looked at them. The Commons Health Committee, in a report that bears close reading, expressed surprise that the Department of Health was being excluded from the Brexit negotiations. In other words, health does not seem to be particularly high on the government’s Brexit agenda.
This seems remarkable, given the enormous damage that Brexit could do to the NHS. Much will depend on the eventual deal. Should the UK end up with a relationship similar to that of Norway then some, but not all, of the problems could be overcome. However, this would require the Prime Minister to go back on many of her commitments, and in particular, paying into the EU budget. On the other hand, a Hard Brexit, or worse still, no deal, could be catastrophic.
The relationship between national health systems in the European Union has always been complex. In the treaties, European governments have jealously guarded their national sovereignty, reserving the right to organise health care in the way that they chose. Yet, almost everything that is needed to deliver a modern healthcare system whether it be the health workers, the medicines and equipment, or the research that underpins clinical decisions is subject to EU law.
Over the past 40 years, enormous progress has been made on developing shared approaches, and in particular, regulatory systems, that will take decades to disentangle. Many of these deal with the incredibly complex issues, requiring scarce, highly skilled expertise, that will be impossible to replicate at a national level. Perhaps the easiest way of thinking about this is to see the challenges through the eyes of the patient:
When they become ill, the patient will go to a health facility, such as a general practice or a hospital. In some cases, the building will have been constructed with financial support from the European Investment Bank, which has provided more than 3.5 billion euros of low interest funding to the NHS in recent years. That will soon be gone.
When they enter the building, they will see a health professional. If it is a doctor, there is a one in ten chance that that person will be from another EU member state. Altogether, some 60,000 people from the rest of the EU work in the NHS. Many are now thinking of leaving, deterred by the notorious 85 page application form for permanent residency, as well as the growing hostility they face even, remarkably, when in the act of providing health care in a few cases.
However, it is not just those who are already here. The Guardian newspaper recently reported that there had been a 92% drop in EU nationals registering as nurses in England, something the Royal College of Nursing attributed directly to the lack of security about the future.
This is happening at a time when the NHS is already facing a staffing crisis, especially in places like London that are already highly dependent on EU staff. Brexit supporters argue that the NHS simply needs to train more staff. Of course, it does. But it takes about 10 years to train a medical specialist. Trained nurses can be produced more quickly, in perhaps five years. However, the challenge of doing so when the government has removed nursing bursaries will be immense. Moreover, this presupposes that there are enough people to provide the training. There are not, so that some British nursing courses already employ so-called virtual placements, in which their students must learn from paper patients.
The problem is not just in the NHS. One of the main reasons why the NHS has been struggling in recent years has been the inability to transfer elderly patients to social care. Some 90,000 EU citizens work this sector. There is no reason to believe that they will be any more willing to come and stay in the future. What’s more, the situation could get much worse, as British pensioners living in countries such as Spain discover that they are no longer able to pay for health care and have to sell up and return home. Although the UK does pay for their care in these countries, it is far cheaper than doing so here, even if we had the staff.
Of course, it could be that the government plans to recruit large numbers of health workers from other parts of the world. The obvious problem is how to square this with the Prime Minister’s commitment to reduce migration drastically. But even if it did, it would throw away all the work that has been done to ensure consistent professional standards within Europe, including a now well-functioning alert system, developed with substantial input from the UK, that ensures that information on a doctor who has transgressed in one member state is immediately distributed to regulators elsewhere.
The health worker will want to diagnose the patient. Sometimes this will require complex technology. Medical equipment moves freely within Europe, governed by the rules of the single market. Outside it, no doubt some other arrangements can be made, but it is not yet clear what they are. There is a particular problem if the diagnosis requires the use of radioisotopes, as is the case with many types of scanning systems.
The UK imports most of its medical isotopes, doing so under the provisions of the Euratom treaty. For obvious reasons, you cannot simply put radioactive material in the post. The treaty includes numerous provisions related to the transport and safety of these products, all of which will, somehow, have to be recreated and a mechanism found to ensure their continued consistency with those in the rest of the EU. Again, this is possible, but given the scarcity of people with the requisite skills, it is far from clear how it will be done.
If the patient requires a medicine, it is likely that it will have been approved for use by the European Medicines Agency, based in London. The agency will definitely move elsewhere, with other member states competing jealously for this jewel in the crown. The impact on the British economy will be severe, given how’s presence here is a magnet for investment by the pharmaceutical industry. Many of its responsibilities will have to be taken up by the UK’s Medicines and Healthcare Products Regulatory Agency, but as it gets more than half of its existing budget from the EU, there will be a need for very substantial investment, assuming, once again, that it will be able to attract and retain skilled staff.
Yet this is far from a perfect solution. First, in Canada and Switzerland, which have similar models, new drugs are introduced some time after they appear in the EU. Secondly, if the drug is for a rare condition, manufacturers may ask whether it is actually worth going through all the regulatory hurdles for a small market in the UK, compared to a much larger market in the EU. Staying with rare diseases, the UK risks being excluded from the recently created European Reference Networks, in which 33 NHS hospitals already participate. The number of patients involved is small but in each case the loss of this access could have a devastating impact on them and their families.
Of course, the interaction between the patient and the health professional is only possible because of a huge amount of work that goes on behind-the-scenes, including medical research, and in particular clinical trials, and transfer of information, both heavily dependent on our EU membership. Also less visible is the contribution made by public health to keeping people well in the first place, including policies and air pollution, tobacco control, our participation in the European Food Safety Agency and European Centre for Disease Prevention and Control, and much else.
So, given the importance of the EU to health, it does seem right that the NHS was painted prominently on a bus during the referendum campaign. The problem is that it was the wrong bus.
Martin McKee is professor of European Public Health at the London School of Hygiene and Tropical Medicine. He has been undertaking research on health and health policy in Europe for three decades