Brexit and the NHS

What are the implications?

The nation has spoken, and during the debate the main reference to the NHS was the funding that might be made available for public services through the repatriation of EU funding.  But there will be wider implications of the exit from the European Union.  As the politicians reflect on the vote and work out what to do, the NHS will be thinking about the downside risks and upside opportunities that the vote will bring.  I’ve been thinking about what the impact on the NHS might be and sharing my thoughts below.  And some of those implications might be immediate.  Join in the conversation, as the NHS will need to influence how the plans for Brexit develop.

More Money for the NHS?

Post referendum the commitment of an extra £350M a week to the NHS has proved to be controversial.  Yet the biggest risk to the level of national GDP that is spent on the NHS is the combination of the state of public finances and the prevailing political attitude of whichever governing party is in power.  It is too early to tell whether the British economy will retract, as has been predicted, or whether the actions of the Treasury and the Bank of England are sufficient to keep what momentum the British economy has afloat.  The signs are clearly not good.  If there is a recession, any gains that might have been made through the recycling of the funds paid to the EU will be wiped out.  The demands on the NHS will continue to grow, driven mainly by an ageing population.  NHS staff have already weathered reductions in their future pensions, increased pension contributions and a freeze on pay.  Can more of the same be anticipated to help keep control of costs.

A worsening staffing crisis?

Even ten years ago I recall the team looking after me during my stint in hospital included nurses trained in Spain, the Philippines and Botswana, and what a wonderfully diverse team they were.  Restrictions on non-EU NHS staff are already affecting the ability of the NHS to fully staff its core service provision, and the strategy for filling the gap with home grown staff is weak.  In the medium term a points based system (which didn’t need an exit from the EU to be put in place for non-EU migrants) may actually help to simplify the process for the NHS to identify and fill skills shortages.  In the short term there is the possibility that Europeans will look less favourably on Britain as a place to seek work, due to the uncertainty of their position and the perception of the reception they might face.  Equally what we don’t know is what the EU nations may do about the rights of British citizens living and working in the EU.  There are therefore two scenarios to plan for – one where the principles of free movement are retained, and one where there is a greater level of restriction and control.

What a points based system won’t do is support the migration of unskilled workers.  Britain faces a crisis in those industries that rely on unskilled migrants from the EU.  This includes the care sector in general and the agricultural and horticultural industry.

The upside is the potential to loosen employment law.  The NHS is a 24/7 service with the European Working Time Directive being one of the most expensive directives to be implemented due to the implications for staffing.  Loosening of employment requirements may enable the NHS to negotiate a more flexible and productive arrangement for its workforce.  Recent negotiations with junior doctors in England however demonstrate how any such changes may be fraught with difficulty.

Research and Development

European research funds such as Horizon 2020, directly finance research, but importantly also help to facilitate the academic links between EU countries.  In the UK healthcare research is inextricably linked to the NHS through the university medical schools and other health related research.  International research is an important part of healthcare as it facilitates learning and sharing from the best academic departments, and in some cases enables research of sufficient scale that could not be achieved within single nations.

Assurances that this funding will be retained may miss the point.  Existing programmes are likely to be allowed to run, though some of these have a long timescale and will be in doubt.  Seeking future EU research finance is a highly competitive market.  The problem for bidding departments is that it is highly likely that our European partners will be cautious about including Britain in bids that are due to be submitted in the coming weeks and months, for fear of the uncertainty that this will affect their chances of success.

In the longer term direct funding of research in the UK by government instead of the EU funding route will not be enough.  Researchers will want to be able to find a way to either continuing to participate in international research at the EU level through the British government continuing to contribute to the EU, or being able to buy their way into research programmes on an individual level.

Cross-border access to healthcare

As UK citizens, we are able to take advantage of reciprocal healthcare arrangements with other countries, including some outside of the EU.  In Europe this is supported by the European Health Insurance Card (EHIC), which replaced the old E111 system.  This system pre-dates the EU, and is likely to remain in place in some form, though we may see some renegotiation.

As a UK citizen we also have rights to seek healthcare in the European Economic Area under the Cross Border Healthcare Directive.  The EU Directive on Patients’ Rights in Cross Border Healthcare was approved in April 2011, although the rights contained within it have been around for many years, and the UK has developed systems to help those rights to be exercised.  These systems were refined following the European Court of Justice ruling in the case of Yvonne Watts in 2006, which confirmed that the NHS should authorise and reimburse treatment for patients facing an ‘undue delay’ for treatment in the UK.

Commissioning bodies across the UK haver systems in place to enable people to exercise these rights, although many would not mourn the loss of this additional process, and insist that the right to free treatment is only in the UK.

Cross EU public health bodies

The Maastricht Treaty of 1992 bought health and particularly public health into the purview of the EU for the first time.  Public health does not recognise borders as we have seen with the global transmission of HIV and AIDS or Swine Flu.  What many people maybe do not know is the influence that the European Union has on public health policy, with a number of institutions across the EU working with national government and agencies to protect public health.  It will be essential that our relationships with these bodies is maintained as communicable diseases are probably the greatest threat to the European population and shared approaches to control and intervention are vital to protecting our health.  The EU also shares information, knowledge and methodology for approving new medicines.

Beyond this the EU has also had significant impact on the key public health policies of our time:  tobacco control, healthy ageing and physical activity for example, smoothing out the commitment or otherwise from UK governments to addressing public health.

Procurement

There are probably not many in the NHS who would mourn the loss of requirement to follow EU procurement rules, although the reality is that rarely that non UK businesses win contracts from the NHS, especially in the lower value contracts.  Freedom from EU procurement rules may enable the NHS to achieve what it wants in supporting local business and economies, even though this is already achievable when complying with the current regulations.