London School of Hygiene & Tropical Medicine

A team of authors have modelled the likely impact of three Brexit scenarios on the UK health and health care systems, finding that each of the Brexit scenarios pose major risks to health, which will require serious considerations that should be incorporated into Brexit negotiations.

Writing in a Health Policy review published in The Lancet, the authors consider three possible Brexit outcomes: soft Brexit (a similar agreement to countries in the European Economic Area, with access to single market but restrictions on free movement of people), hard Brexit (a free trade agreement between the UK and EU) and failed Brexit (falling back on World Trade Organisation rules).

They argue that even under the scenario of a soft Brexit, which would minimise the impact on health, there are serious issues that government and policy makers need to consider, including workforce recruitment and retention, NHS financing, and governance issues on competition, trade as well as the vast amount of new legislation – such as public health protections on tobacco, air quality, but also legislation of medicinal products – which once transposed into UK law by the EU Withdrawal Act could be changed without scrutiny by elected MPs.

Martin McKee, Professor of European Public Health at the London School of Hygiene & Tropical Medicine, and one of the authors, said: “Our analysis of how Brexit will affect the NHS, although the UK's desired outcome remains unclear, is that Brexit in any form poses major risks to almost every part of the NHS, with a ‘no deal’ scenario potentially catastrophic. The EU has shown that it recognises many of these threats, and we hope that our paper encourages the UK negotiating team to make health issues a priority.”

One of the major risks is to NHS staff, and the authors note that it will be increasingly difficult for the UK to be self-sufficient in terms of its NHS and social care workforce. Estimates for 2017 suggest that 60000 people from the EU work in the NHS and 90000 work in adult social care, with an aggregation of staff working in London and the South East, which makes these regions especially vulnerable to a loss of labour. Equally, with Northern Ireland and the Republic of Ireland sharing a health and social care workforce, Northern Ireland is also susceptible.

Another risk is the loss of funding to the NHS, which could occur directly through loss of European funds and indirectly as a result of the possible impact of Brexit on the UK economy. The NHS has benefitted from €3.5 billion in funds from the European Investment Bank since 2001, helping to fund various public-private partnerships. Additionally, the NHS forms the largest part of the UK’s public expenditure and would naturally be impacted by any events which affect the UK economy. The authors warn that, while the UK economy has performed relatively well since the referendum, once changes due to Brexit are put in place, they will likely have a significant long-term impact, and this will be likely to put pressure on NHS finances.

Other major issues relating to funding would likely affect individuals living abroad and people travelling to the EU for work, study or leisure – all of whom may lose their health coverage. Currently the UK pays around £650 million per year for care provided to British people abroad (including £500 million for pensioners living abroad), which is marginal compared to the NHS budget and represents good value for money as treatments costs for pensioners in the EU are about half of their equivalent value in the UK. With an estimated 190000 British pensioners living in other EU countries, this is likely to impact them most profoundly.

In terms of public health, the loss of the EU’s structures for managing public health pose a range of threats. For example, the UK relies on EU law for its tobacco policies, and the authors warn that without these the UK could become a prime target for the tobacco industry post-Brexit. Equally, without EU laws to improve air quality and the risk of sanctions for not achieving these, the UK’s environmental standards for air pollution levels may slip further.

Lastly, Brexit poses a significant issue to research funding in the UK where the EU’s direct funding accounts for 17% of research contracts held by British universities and an estimated 16% of academics in the UK are from other parts of the EU. The UK attracts substantially more EU grants than it contributes to, and loss of this would have severe consequences – particularly as the UK lags behind comparative economies in its investments in research and development nationally. Even more, the EU provides research networks, infrastructure, legal frameworks, research standards and policies that underpin scientific research, and replacements will be needed after Brexit.

The authors also note potential opportunities with the hard and failed Brexit scenarios, such as adapting competition laws, but this will only benefit the NHS if the government chooses to take them on board.

Currently, due to UK government decisions, the NHS in England sits within EU competition law, meaning that private firms that bid to provide NHS services are able to challenge the NHS’s decision in court if they do not win the contract. Removing these rules by exiting the EU could in theory protect against further competition in the NHS. However, the authors note that the 2012 introduction of the Health and Social Care Act aimed to introduce competition, so the likelihood of the government taking this opportunity is unclear.

Publication

Nick Fahy, Tamara Hervey, Scott Greer, Holly Jarman, David Stuckler, Mike Galsworthy, Martin McKee. How will Brexit affect health and health services in the UK? Evaluating three possible scenarios. The Lancet. DOI: http://dx.doi.org/10.1016/S0140-6736(17)31926-8