Brexit and Health: A Tragedy of Errors

So what does this mean for health and health care in the UK? The simple answer is that no-one knows. Parliamentary committees probing the preparedness of government ministries, including health, have expressed frustration at their inability to achieve any clarity. However, there is evidence that the uncertainty is already causing considerable damage, in several areas.

The first concern is the supply of workers. Prior to becoming Prime Minister, Theresa May had been Home Secretary, responsible among other things for immigration policy. In the eyes of the many Conservative supporters who wanted to close the country’s borders (always with the exception of whatever type of worker they personally depended on, whether doctors, carers, or fruit pickers), she had failed spectacularly. On the other hand, the country had benefitted enormously from the contribution of EU migrants, both in terms of filling skills gaps and as net contributors to the public purse. She now wants to reduce net migration to the “tens of thousands” and, by rejecting the EU’s offer to maintain the status quo, has sent out a message to EU citizens living in the UK that they are no longer welcome. Unmoved by a constant stream of tragic stories of families being spilt up and people who dedicated their working lives to the UK being told to prepare to leave, the UK government has failed to offer any reassurance. Understandably, numbers coming to the UK have fallen precipitously, with a 96% fall in applications to join the nursing register, and many of those already in the UK are preparing to leave.

Among them are large numbers of healthcare staff who work in the UK’s National Health System (NHS), on whom the service has long depended. About 10% of NHS doctors are EU citizens, but in some areas, such as London, the figure is much higher.

The same is happening with researchers in universities, with applications falling off and those who had been offered posts withdrawing. And the effect is also seen with students, who are looking elsewhere for their higher education. Unfortunately, the government has failed to understand the issues. It is not simply the right to be in the UK, it is the loss of all the rights that go with being a EU citizen. Thus, someone spending their working life in the UK but retiring to their own country could find themselves and their families without healthcare in retirement or inflation uprating of their pension. Together, these developments pose a huge threat to British medical schools in particular.

The second concern is about loss of regulatory co-ordination and harmonization. By leaving the EU, the UK will lose the European Medicines Agency, currently based in London. Aside from the loss to the economy that will result, perhaps £1 billion per year, and the damage to the UK’s pharmaceutical and related industries, withdrawal is expected to delay approvals of new drugs. The withdrawal from Euratom has caused particular anxiety, given its critical role in ensuring access to medical isotopes. The precursor of technetium 99m is manufactured in only a few reactors worldwide, none in the UK. Moreover, it and its precursor have very short half-lives so distribution depends on a highly efficient “just in time” system. Supplies are monitored by the European Observatory on the Supply of Medical Radioisotopes, overseen by Euratom, and created because there have been critical supply chain problems in the past. Yet the UK government rejects the fears of the Nuclear Industry Association and all the professional medical organisations concerned, simply stating that it anticipates no problems.

Withdrawal will also impact on the UK’s engagement in a range of other EU agencies with implications for public health. Perhaps the most obvious is the European Centre for Prevention and Disease Control. Despite the UK governments absence of any clarity, it is likely that some continuing association is agreed, but it will almost certainly be less satisfactory than the current one. Moreover, there is a danger that any loss of British staff from the Centre will weaken it, with implications for the UK as well as the remaining EU member states. Another is the European Food Standards Agency. In addition to its normative role, it oversees a network of inspectors in 130 countries who seek to ensure the safety of food supply chains. It will be impossible for the UK to replicate this, with potential consequences for food safety or supply. The latter is particularly concerning as the expected restrictions on free movement are already threatening the supply of seasonal agricultural workers and thus the UK’s agricultural production. At the same time, delays from proposed customs checks threaten what is a highly integrated “just in time” food supply system.

Potential loss of regulatory harmonisation poses a particular threat to medical research. EU legislation supports co-operation in areas such as exchange of data and conduct of clinical trials. The EU is an increasingly important research funder.  EU programs such as ERASMUS and Marie-Curie support mobility of students and researchers. Unsurprisingly, the academic community overwhelmingly opposes Brexit.

The third concern relates to global health. The UK makes a major contribution to international development, both in financial terms and in the form of expertise, The UK’s Office for Budget Responsibility, the independent body charged with technical oversight of fiscal and economic policies, which noting that the lack of clarity from ministers precludes any confident predictions, has stated that Brexit poses a major risk to the British economy.

While initial concerns about the economy were averted by effective action by the Bank of England, there is now growing evidence of the severe damage being caused, even before Brexit takes place. This will inevitably lead to pressure to cut back on the UK’s aid commitments. British expertise, especially in universities, will be eroded. Many of the leading research centres have taken years to build up, with critical mass and institutional memory, but often dependent on staff from other countries. These now face severe instability as staff evaluate their options for reasons set out eloquently by Andre Geim, awarded a Nobel Prize for his discovery of graphene, who is now planning to leave the UK.¹⁸

The fourth concern, and perhaps the most worrying of all, is government failure. Many commentators have noted how leaving the EU would be the greatest task facing the British state since the Second World War. However, it would do so with a much diminished civil service, both in numerical terms and expertise, as successive cuts have resulted in the departure of many of the most skilled individuals who have taken with them their institutional memory. This weakened structure must implement the transposition of tens of thousands of legal measures into domestic law, described by a former Lord Chief Justice as a “legislative tsunami”.¹⁹

The situation is complicated further by a lack of agreement between the UK government and the devolved administrations in Scotland, Wales and Northern Ireland about where repatriated responsibilities will go. Inevitably, concerns have been voiced about whether the UK could cope with any other major crisis.