The decision for the UK to leave the EU signals a period of great uncertainty at a time when the NHS already faces huge pressures on funding and the way it delivers its services.
Possible repercussions include:
- NHS funding
In 2012, the Nuffield Trust estimated that the NHS needed an average annual increase in real terms of about 4% to continue to provide the same services. This was without taking into account increased demand due, for example, to population growth, increased levels of chronic ill-health and a rise in treatment costs (http://www.nuffieldtrust.org.uk/publications/decade-austerity-funding-pressures-facing-nhs). But between 2010 and 2015, the NHS received an annual increase of just 1%, after inflation, and this low-level of increase is due to continue until 2020: that’s 10 years of serious underfunding, and the most austere decade that the NHS has ever experienced. Before any impact from Brexit, there is already a growing gulf between the funding available for the NHS and what is needed to provide a quality, comprehensive service for patients.
Apart from political choices (such as to privatise the NHS), one of the most important influences on NHS funding is the performance of the UK economy. Before the referendum, the Treasury said that leaving the EU would lead to an immediate and profound economic shock, causing instability, uncertainty, and the UK becoming permanently poorer. One initial threat is the possibility of recession, leading to spending cuts, with some claiming that a post-Brexit economic slump could mean a cut of £10.5 billion to the Department of Health’s budget by 2019-20. This would equate to every hospital in England having to shed 1,000 nurses and 155 doctors (see, for example, https://www.theguardian.com/politics/2016/jun/07/brexit-blow-billions-hole-nhs-budget-heidi-alexander-eu-refendum-immigration).
Until now funds for the NHS have been ring-fenced – the government has guaranteed that money allocated for the NHS will not be spent on anything else. Despite this though, NHS funding is already being used to supplement the budget for social care, which is not ring-fenced and has been suffering massive cuts. Even if the NHS budget remains ring-fenced, further cuts to social care funding as the result of recession will have a further knock on effect on the NHS. And if the economy nose-dives, the government may feel it can justify removing the ring-fencing of the NHS budget – or claim that a publicly funded, universal health service is not longer affordable.
Academic and medical institutions have also warned that Brexit may be a disaster for British science because of its impact on the ability of UK researchers to attract research funding and collaborators in the EU.
At the moment, UK citizens can get free emergency health care when travelling in the EU. UK citizens who are on dialysis can still holiday in an EU country without disrupting their treatment. As members of the EU we also benefit from membership of European Reference Networks in which EU countries share information, expertise and resources to find ways of tackling complex or rare medical conditions. Membership of the EU has also speeded up access to innovative medicines. Many such benefits will have to be renegotiated with Brexit.
The result of the referendum led to an immediate fall in the value of the pound. If this fall in value continues long-term, inflation will increase, leading to higher prices for some drugs and other goods and services that the NHS buys. The immediate shock following Brexit already appears to have led to delayed decisions about funding some medicines and treatments in case these are no longer affordable.
The Secretary of State for Health has indicated that, following Brexit the UK will leave the European Medicines Agency. This organisation, currently based in London, is responsible for the scientific evaluation, supervision and safety monitoring of medicines developed by pharmaceutical companies for use in the EU. One outcome may be that it will take longer for the UK to have access to new drugs and medical devices.
Until now, the UK has benefited disproportionately from EU funding for medical research. But following the referendum vote, opportunities for new research funding from the EU are disappearing. And already, British academics are being asked to leave existing EU-funded collaborative projects, or to step down from leadership roles, because their share of existing funding is no longer certain.
- NHS and social care staffing
There are around 58,000 non-British EU citizens working in our health services, partly because it has been a struggle to recruit and retain enough permanent staff from within the UK. The impact of losing EU nationals could mean a serious loss of staff from the NHS and collapse in the social care sector. One in 10 doctors in the NHS are from the EU. There has been some government reassurance that, while the UK remains a part of the EU, the EU policy of freedom of movement and mutual recognition of qualifications will remain in place. However, and not least because of the high level of anti-immigrant feeling revealed by the Referendum, many healthcare workers from the EU will feel discouraged from working in the NHS or concerned about their uncertain legal position and ability to remain in the UK in the long-term.
Rather differently, there are systems in place within the EU for exchanging information about health professionals coming from abroad and raising any concerns.
There are also 90,000 staff from the EU working in the social care system – a system that, according to the Secretary of State for Health, would fall down without them.
The Department of Health now faces the massive task of reviewing individual EU regulations that apply to the UK and deciding whether they should be repealed or replaced with UK-drafted alternatives. Many of these regulations affect the NHS.
- The EU working time directive: It’s not clear whether workers’ rights currently enshrined in EU law will simply be dumped, or revised. For instance, the EU working time directive currently limits the maximum time that employees can work to 48 hours per week, and sets minimum requirements for rest periods annual leave, maternity leave and so on. If the UK government decides to repeal or amend the working time regulations, this would affect NHS employment contracts and require significant changes to Agenda for Change – the national pay framework for health workers. Amending the working time directive could allow the imposition of new, controversial contracts for NHS staff (such as the one at the heart of the junior doctors’ dispute). A revised directive would also ease the introduction of core elements of NHS England’s Five Year Plan, such as the extension of routine services over seven days a week (which many Trusts cannot afford to offer).
- Procurement and competition law: Some people have suggested that leaving the EU will stop the privatisation of the NHS as commissioning services would no longer be subject to EU competition law. However, the UK has introduced other measures that prevent anti-competitive behavior on the part of NHS commissioners and providers.
In addition, less than a month after the referendum the new Secretary of State for International Trade announced that ten ‘economic powerhouses’, including China, Australia and Canada, have already committed informally to forming strong trade deals with the UK. If these are anything like CETA and TTIP that the EU has been negotiating, we can expect them to include provisions to open up the NHS to competition from foreign investors, and investment protection measures that will make it hugely difficult to reverse the privatisation of the NHS.
- Regulation of medicines and clinical trials: the UK is currently part of a centralised European system (the European Medicines Agency or EMA) that evaluates new medicines for use in the EU. Leaving the EU means that the UK will lose influence over the EMA. The use of new medicines developed by UK companies will need to be authorised by both the UK and the EU, and the UK may not be involved in some clinical trials that might otherwise benefit patients.
- Public health and cross border-cooperation
The EU has systems for the surveillance and early warning of infectious diseases, such as the European Centre for Disease Control. These systems allow information and technical expertise to be shared rapidly in the fact of potential pandemics and other cross-border threats to health, such as antibiotic resistance. It is unclear now how cross-boarder cooperation will be managed in future.
Leaving the EU will also mean re-assessing and potentially amending the EU legislation that currently determines aspects of public health such as air quality, tobacco advertising, etc.
- Implementing health service policy
Like other government departments, the DoH has been reducing its workforce in recent years: staff numbers will fall this year from 1,800 to 1,300. With government and civil servants having to focus on so many issues as a result of Brexit, there may not be the capacity to deal with the demands of Brexit (or push through some of the massive changes previously planned for the NHS).
7. Negotiating new deals
Trade deals, usually seen to be as dry as dust, have taken on a new significance in discussions about Brexit. While we are in the EU, the European Commission negotiates all trade deals on the UK’s behalf: this means we now have little expertise in this area. Deals that we might have been signed up to while still part of the EU- and which posed considerable threat to public services like the NHS (see for example our pages on TTIP, CETA and TiSA) – now have less relevance, although we are likely to be subject to some of their measures from some time. What’s more, although Brexit provides an opportunity for the UK to negotiate trade deals that are in the interests of the public, its probable that existing deals, driven by corporate interests, will provide the template for deals in the future.
8. Effects of the Great Repeal Bill on the right to health
After Brexit, EU law will no longer have legal standing in the UK. The Great Reform Bill has ostensibly been introduced to deal with the legal ‘black hole’ that this will create: it is concerned with transferring EU laws onto the UK statute books, so that all EU legislation passed while the UK was in the EU still applies after Article 50 is triggered. But then the Great Repeal Bill also gives powers to UK ministers to change these laws through secondary or ‘delegated’ legislation – legislation that generally gets little parliamentary scrutiny. While there is some acknowledgement that there will need to be some constraints on ministers’ use of these new powers, it’s vague about what these constraints will be (https://www.instituteforgovernment.org.uk/brexit-explained/brexit-explained-great-repeal-bill ).
There is concern that the government is not planning to convert the EU Charter of Fundamental Rights into UK law. Article 35 of the Fundamental Charter identifies access to health care as a fundamental right. Without this charter, it will not be possible for UK judges to use charter rights when interpreting UK laws that have derived from the EU, and will weaken their ability to uphold the law if it’s challenged by corporations in the courts. Laws include those protecting public health (for example, on health and safety at work, food safety, the regulation of medicinal products, and air and water quality). Any public health laws introduced after Brexit will be similarly unprotected.
While the European Convention on Human Rights is the main legal basis for protecting civil and political rights in the UK, it does not include the Fundamental Charter’s many economic and social rights, such as rights to fair and just working conditions, as well as the rights of children, older people and this with disabilities. http://www.bmj.com/content/357/bmj.j2013
Sources and further information