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Thursday 15 September 2016

Brexit: easier said than done

By Crag Ryan

Far from “taking back control”, Brexit has plunged the NHS into a period of radical uncertainty, with unpredictable consequences for funding, staffing and research.

uropean Medicines Agency staff
Moving out? European Medicines Agency staff at their headquarters in London’s Docklands. (Photo: EMA)

A month before the EU referendum, a poll commissioned by the Chartered Institute for Public Finance and Accountancy found that 31% of voters thought Brexit would benefit the NHS and 46% thought it would have no impact at all. CIPFA also polled NHS chief executives and financial directors: 95% thought Brexit would harm the NHS.

These findings reflect the stark division between “expert” and public opinion seen throughout the referendum campaign. Three months on, most experts haven’t changed their minds, but how bad it will get is still anyone’s guess. If all we know is that “Brexit means Brexit”, NHS leaders can only guess what Brexit means for the NHS. 

Mike Birtwistle, founding partner at think tank Incisive Health, sees Brexit as a “massive ball of tangled string” which will take years to sort out: “There’s a heck of a task unpicking what health policy and law comes from Europe, and where to have divergence or where divergence doesn’t make any sense whatsoever.” 

Hitting the NHS where it hurts

Start with the money. NHS finances depend on economic growth. Despite the stock market recovery and August’s consumer spending spree, economists still expect growth to dip sharply. If Chancellor Phillip Hammond wants to find any new money for the NHS – let alone £350m a week – without crippling other services, he’ll have to raise taxes or let borrowing rip. He doesn’t look like that kind of guy to me.

The devalued pound will also hit the NHS where it hurts, making imported goods, particularly drugs, more expensive. Worse still, any further cuts in things like social care, housing and welfare could pile costly new burdens onto the NHS.

“The economic uncertainty that Brexit has created is the last thing the NHS needed,” says Helen McKenna, senior policy adviser at the King’s Fund, which has called on the government to “be honest” about whether policy commitments like seven-day NHS services are realistic in the post-Brexit funding environment.

Putting people off

The NHS has 55,000 staff from other EU countries, with another 80,000 working in social care. While it’s unlikely any will be sent home, uncertainty over the outcome of the Brexit negotiations is threatening to choke off this vital source of skilled staff for the NHS.

“With the uncertainty over whether EU staff working in the NHS will be entitled to stay, people are rightfully going to be really concerned and worried,” says McKenna. “I’m sure people will be put off from coming until that’s been clarified.”

Even more severe problems face social care, where jobs are “often low-paid and undervalued, so it may be difficult to make exceptional arrangements for bringing people in from abroad,” she explains. The falling pound will also reduce the value of social care wages to migrant workers.

“People are thinking about where they want to live and bring up their kids, so it’s a lot to ask them to think about,” Birtwistle adds. “And these are people who have already shown themselves to be highly mobile.”

There could also be a nasty sting in the tail if other EU countries restrict migration from the UK. Exchanging a relatively young and healthy migrant population for elderly Brits returning from the continent would put a huge strain – financially and operationally – on the NHS.

Policy headaches

If these are managers’ headaches, Richmond House policymakers have plenty of their own. Unless the UK takes the “soft option” of joining the European Economic Area, they face spending years converting thousands of European regulations and standards into UK law or replacing them with British versions.

The working time regulations are probably near the top of any hit-list. Although strongly supported by unions, they remain a bête-noire of both ministers and the Royal College of Surgeons, which claims the regulations hamper doctors’ training programmes.

“When you don’t have enough doctors to go round, the idea of asking doctors to work a bit more might be appealing,” Birtwistle says. “It’s one of these things which is potentially in play again after a long time.”

But with doctors’ working hours already the touchiest of issues, this risks opening a very unappetising can of worms. “Our concern is the implications for NHS employment contracts at a time when relations with the workforce are tense,” says McKenna diplomatically.

Adding to manager’s staffing woes, ministers may be tempted to toughen further professional standards and language tests for migrant doctors and nurses, says Birtwistle. “If I were a minister, I’d be thinking about populist things I could do to demonstrate that Brexit is making a difference… I don’t expect managers will go into bat saying we must have more doctors who don’t speak English.”

With the European Medicines Agency now likely to vacate its offices in London’s Canary Wharf, the UK faces exclusion from the EU’s new harmonised approach to drug regulation and clinical trials, set to begin in 2018.

“If pharmaceutical companies have to apply separately to the MHRA [the UK medicines regulator] and the EMA, this would definitely be more burdensome,” says McKenna. “So there’s a question mark over whether companies will want to do that, and the knock-on impact with regard to our access to drugs.”

Threats to research

European workers aside, health researchers have most to fear from Brexit in the short term. The UK netted €3.4bn in EU research funding between 2007 and 2013, but “it’s not just about money,” says Elisabetta Zanon, head of the NHS Confederation’s European office. “It’s also about the possibility of collaborating with colleagues across Europe.” 

“Will people feel welcome?” asks McKenna. “If you’re coming as a researcher from another country to work in a university here, there’s also the message the UK is sending out. People are understandably going to be thinking twice about coming here when deciding where they’re going to do their research.”

Under threat is NHS participation in the €80bn Horizon 2020 research programme and the newly-established European Reference Networks for collaborative research into rare diseases. A quarter of these networks were to be led by NHS trusts. Outside the EEA, they become mere “observers”, unable even to join the networks they invested so much work in setting up.

“Our partners are very anxious, but we can’t provide any clarification,” says Zanon. “Can we invest resources in these initiatives or are we just wasting our time? And what does that mean for our leadership internationally in medical science?”

Speculating about scenarios

But until ministers set the direction of travel, the tiny Brexit units in the DH and NHS England can only really speculate about scenarios. “There’s a sense that everyone is very reluctant to say anything until they’ve got their marching orders,” says Birtwistle. And with a third of DH staff due to go by 2020, doubts persist over the shrinking department’s capacity to cope with this daunting workload.

“The government’s principal focus will undoubtedly be on negotiating favourable terms for trading and working with the EU,” says McKenna. “But the impact on health and social care must not be forgotten, particularly as these systems are already under considerable pressure.” 

But Birtwistle believes Brexit at least gives NHS leaders a chance to rethink things. “Any form of reconsideration brings opportunity. If I was sat in the NHS, I would be thinking, ‘Yes, I’m very worried about Brexit’, but also that I should use this debate to think about what, in an ideal world, I might like to change.”

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