Letter from Bristol

Three Challenges for UK Health Services in Brexit Britain

The UK is set to sever its ties with the European Union (EU) on 29 March 2019. In the summer of 2016, as the EU referendum campaign reached its crescendo, a large red bus was criss-crossing the UK. Emblazoned on it were the words: ‘We send the EU £350 million a week. Let's fund our NHS instead. Vote Leave.’ Although this slogan was inaccurate—for example, it did not account for the rebate the UK receives from the EU, many credit it with swinging the referendum vote.^[1]

Following the vote to leave, the politicians who support Brexit have been universally evasive about this additional source of funding for the National Health Service (NHS), and those who voted to leave based on this promise have realized that it is unlikely to be kept. Health funding has slowed substantially in recent years, increasing the pressures on the NHS. Although a 4% annual increase in spending was the norm, it has decreased to just 1. 1 %^[2] with a danger that it may fall further if Brexit leads to a considerable economic shock.

While NHS funding has been a perennial challenge, Brexit is likely to bring new challenges to the NHS. We briefly explore three key issues: staffing, research and development, and the future of UK pharmaceuticals.

Issue 1: Staffing

The NHS is the world's fifth largest employer with 1.7 million staff (the Indian Railways is at number eight with 1. 4 million)^[3] and has always relied on a workforce that was initially trained overseas. One in 10 doctors working in the NHS graduated from the European Economic Area (EEA, EU plus Iceland, Liechtenstein and Norway). Apart from doctors, the NHS employs a large number of EEA nationals in a variety of roles ranging from management, nursing and healthcare support workers. The vote to leave the EU has brought major uncertainty to the future of these employees and we are already witnessing the beginning of an exodus of EU nationals from the NHS. It is estimated that around 10 000 EU nationals, including 1794 doctors have quit the NHS since the referendum. Research from the British Medical Association, a trade union for doctors, revealed that 4 in 10 EU doctors were considering quitting the NHS since the leave vote.^[4] The issue may be compounded by the fact that the number of new recruits coming to work in the NHS from the EU has declined dramatically. For example, in April 2017, just 46 EU nurses came to work in the UK, a drop of 96% since the previous July, just after the Brexit vote.^[4]

There are concerns that EU nationals will no longer be attracted to working in the UK because in Brexit Britain many legal entitlements, from voting rights to access to primary or secondary education to social security have not been guaranteed. There has been an outcry for clarity on these issues. Professional bodies, trade unions and politicians are just some of the voices that have asked the government to clarify the position and guarantee the legal rights of thousands of EU nationals working in healthcare.

NHS Providers, a membership organization and trade association for NHS acute, ambulance, community and mental health services, has expressed deep concern for the future of the NHS workforce, stating: ‘The government must deliver certainty for EU staff. It should reassure them that their commitment to the NHS is greatly valued and will continue to be welcome. It should also provide assurance on immigration policy so trusts can continue to recruit overseas while we strengthen our workforce here. ‘^[5] In its survey of NHS chief executives, 85% stated that recruiting from outside the UK would be important over the next 3 years; however, Brexit was cited as a key barrier.^[5]

Issue 2: Research and development

One of the secrets to the UK's global dominance in research and development is its numerous collaborations with EU member states and its scientists. Freedom of movement has meant that many members of the EU scientific community have moved to live and work in the UK. With its global reputation, the UK is a desirable destination, able to attract the sort of talent that has helped to maintain its position as a global research leader. With a future where EU nationals may not be able to move to the UK so freely, that global leader status is under threat.^[6]

Another major threat to the UK's position is financial. British universities have enjoyed a steady source of funding from the EU, securing €8.8 billion between 2007 and 2013, far more than the €3.4 billion that the UK contributed to the fund. The current EU research funding programme, Horizon 2020, has a €74.8 billion budget to cover 2014 to 2020. Although the UK government has agreed to cover any funding for projects approved by Horizon 2020 before March 2019, the future access to this important source of science funding is uncertain. Numerous groups of researchers in UK universities rely on EU funding and there is a danger that entire laboratories or research programmes might have to close should alternative means of funds not be available.

Issue 3: Pharmaceutical market

The pharmaceutical sector is another strength of UK manufacturing. It was here that a quarter of the top 100 prescription medicines were discovered and developed. The sector employs around 70 000 people and, even during a period of slow economic progress over the past 10 years, pharmaceutical manufacturing has grown steadily.^[6] More than a dozen global pharmaceutical companies are UK-based, including the two largest: GlaxoSmithKline (GSK) and AstraZeneca.^[6]

With its robust legal system, particularly regarding intellectual property, the UK has long been a desirable base for the world's pharmaceutical manufacturers. Nevertheless, the sector's success has relied on a close UK–EU connection and much of its regulation is in fact under EU law. The EU’ s regulating body, the European Medicines Agency (EMA), is currently based in London but is set to move to Amsterdam following Brexit. Because the EMA oversees medical licensing and authorization of medicines across the EU, its members enjoy swift access to a huge market. A disorderly Brexit may lead to major problems in the supply chains of medications moving across the UK–EU borders due to disputes over quality/testing requirements, regulation, tariffs or customs requirements. If it severs ties with the EMA, the UK would have to set its own version of regulatory procedures and this is likely to lead to longer waiting times for patients to access new drugs.

These examples illustrate that currently, it is difficult to see any positives of Brexit in relation to the NHS and the problems seem to be compounded because of the uncertainty surrounding what will actually happen on 30 March 2019. With time running out, there is little consensus among the UK and EU negotiators, and little detail on the substance of the UK government's plans. In the meantime, everyone, from NHS and pharmaceutical chief executives to healthcare workers to the millions of patients cared for by the NHS are left to speculate on the outcome, and the red bus promising £350 million a week for the NHS is nowhere to be seen.