Brexit: the implications for health and social care

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Brexit could have major implications for health and social care in England. Here we look at some of the latest developments that could have an impact.

A new deadline to achieve, and ratify in parliament, an EU withdrawal agreement of 31 January 2020 was set on 28 October 2019. With a general election approaching and uncertainty as to how events will unfold between now and the agreed deadline, a no-deal Brexit remains a possibility. Over the past year the government and the NHS has put considerable work into preparing for a no-deal Brexit. The Department of Health and Social Care has published guidance for organisations to prepare contingency plans and has established a national operational response centre to lead on responding to any disruption to the delivery of health and care services. The government has also published the Operation Yellowhammer documents, which set out the ‘reasonable worst case scenario’ impact of a no-deal Brexit. This includes a risk of significant disruption to the supply of medicines and increased instability in the adult social care market. In early October 2019, anticipating Brexit on 31 October, the government published a full overview of its preparations to date in their No-deal readiness report.

While government, the NHS and the social care sector continue to prepare for the possible eventuality of a no-deal Brexit, considerable effort has gone into successfully agreeing a new withdrawal agreement with the EU. If, in due course, parliament ratifies the current withdrawal agreement, it will allow us to move on to the next stage of Brexit, known as the transition period, which will run from the day of exit to December 2020.

During this period, our current relationship with the European Union as a member state will continue, while the government and European Council work towards agreeing what the future relationship around trade and regulation will look like.

If a withdrawal agreement is not passed by parliament by 31 January and a further extension is not granted, we again risk entering a no-deal Brexit scenario, with no transition period to agree the detail of future trading relationships, and the UK’s existing relationships with all the European Economic Area (EEA) countries will come to abrupt end. This would have serious implications for the NHS and social care with regards to shortages in supplies of vital medicines, price increases for some medicines, greater difficulty in recruiting international staff, increased demand for services as British emigrants in the European Union return to access health care, as well as the potential for economic disruption which could place further restraints on public spending.

This article focuses on the potential impact that any form of Brexit could have on the provision of health and social care. However, we must remember that Brexit could also impact health outcomes in the short and long term. For example, a no-deal Brexit that impacted on fresh food supplies could affect people’s diets and access to nutrition, with potential knock-on consequences on their overall health.

Staffing

Brexit - staffing image

Across NHS trusts there is currently a shortage of almost 100,000 staff (representing 9 per cent of posts), severely affecting some key groups of essential staff, including nurses, many types of doctors, allied health professionals and care staff. Vacancies in adult social care are rising, currently totalling 122,000, with around 9 per cent of care worker roles unfilled. International recruitment is a key factor in addressing these vacancies. Brexit and immigration policy will have an impact on the ability of the NHS and social care providers to successfully fill these vacancies.

The policy of freedom of movement and mutual recognition of professional qualifications within the European Union means that many health and social care professionals currently working in the United Kingdom have come from other EU countries. This includes nearly 65,000 (5.5 per cent)1 of the 1.2 million workforce of the NHS in England and an estimated 115,000 (around 9 per cent)2 of the 1.3 million workers in England’s adult social care sector. The proportion of EU workers in both the NHS and the social care sector has grown over time, suggesting that both sectors have become increasingly reliant on EU migrants.

The UK has a greater proportion of doctors who qualified abroad than any other European country, except Ireland and Norway. Latest General Medical Council (GMC) data shows that the number of doctors from the EEA joining the medical register is now holding steady (but still down 40 per cent on 2014). A combination of relaxed visa restrictions and active recruitment by trusts means that the number of non-EEA doctors joining the register doubled between 2014 and 2017. However, some specialties not currently on the Home Office’s shortage occupation list are still facing difficulties, for example, child and adolescent psychiatry.

The situation in nursing is similar, in 2018/19 only 968 nurses and midwives from the EEA joined the Nursing and Midwifery Council’s (NMC) register, a decrease of 91 per cent since 2015/16. This fall has only been partially mitigated by more non-EEA nurses joining the register – their numbers increased by 126 per cent in 2018/19, with 6,157 non-EEA registrants joining during the year. As with GMC registrants the likely causes of these trends are relaxed visa restrictions, nursing being added to the shortage occupation list in 2015 and active recruitment from outside the EEA by trusts.

However, even with both EEA and non-EEA registrants taken into account, these figures are considerably below the peak of around 16,000 international nurses on the NMC register in 2001/02. Although there are other contributing factors, including the introduction of new English language requirements in 2016, Brexit has had a significant impact.

In the longer term, the potential economic impact that Brexit may continue to create could act as a powerful disincentive for health and care staff to work in the NHS and social care. For example, a fall in the value of the pound would mean the money staff earn in the UK is worth less in their home country.

One of the main priorities in the first phase of the negotiations between the United Kingdom and the European Union was clarifying the status of EU citizens currently living in the United Kingdom and of UK citizens living in other EU countries. Any EU citizen currently living in the United Kingdom, including the 165,000 EEA staff already working in health and social care are able to apply for the EU settlement scheme. They will need to apply by June 2021 (or December 2020 in in the event of no deal) in order to be able to stay in the United Kingdom.

The government published an immigration White Paper in December 2018 setting out proposals for a new skills-based immigration system to begin in 2021, which would treat EEA migrants in the same way as non-EEA migrants. It removes the limit on numbers of skilled workers but proposes an annual earnings threshold of £30,000, which is likely to have an impact on the ability to recruit certain health professionals to the NHS. The threshold generated fierce debate – in June 2019 the government commissioned the Migration Advisory Committee (MAC) to carry out an in-depth analysis of potential future salary thresholds. The MAC is due to report back by January 2020 with recommendations as to what level any future salary threshold should be set at.

The White Paper also acknowledges England’s reliance on migrants in the social care workforce. However, it proposes that for a transitional period such workers would only be allowed to work for a limited time, with no entitlement to bring dependants. Again, this is likely to impact the ability of the social care system to attract sufficient workers. In the event of a no-deal Brexit, for an interim period EU citizens would be able to enter the United Kingdom as they do now, but if they wish to stay longer than three months they would have to apply for permission under a new European Temporary Leave to Remain scheme. People who obtain this status would be entitled to live, work and study in the country for a further three years.

Separately the Prime Minister has announced that under new rules, international students will be entitled to the right to remain in the UK for two years after graduation. This will allow international graduates in medicine and nursing additional time to secure long-term employment. The previous rules only allowed four months.

Staff shortages across the NHS are a real challenge, for example, our calculations show that the NHS requires an additional 5,000 internationally recruited nurses per year to prevent current staffing shortages getting worse. Any post-Brexit migration policy which impedes this could have serious implications for future staffing of the NHS. The situation in social care is just as serious, with 90 per cent of staff in the sector qualifying for a permanent work visa under the reforms proposed in the immigration White Paper, as they earn less than the £30,000 per year threshold.

In short, the impact of Brexit on the health and care workforce will depend on future migration policy and the barriers or incentives to live in the UK and work in the NHS and social care that are put forward.

  • 1. Data presented on a headcount basis, excluding approximately 80,000 staff with no nationality recorded. Data excludes GPs and GP practice staff as data on the nationality of these staff groups is not collected. Data on the country where GPs gained their primary medical qualification is available at NHS Digital.
  • 2. Data represents posts in local authority and independent sector employers only. Excludes posts in NHS and personal assistants.

Accessing treatment here and abroad

Brexit - accessing treatment

Currently, European Union rules govern UK citizens’ access to health and care in the European Union, and EU citizens’ access to UK services.

EU citizens are entitled to a European Health Insurance Card (EHIC) which gives access to medically necessary, state-provided health care during a temporary stay in another EEA country.3 The cost of treatment under these schemes can be subsequently reclaimed from the visitor’s country of residence via reciprocal health care agreements. Around 27 million people currently hold EHICs issued by the United Kingdom. In addition, under EU rules, people who come from elsewhere in the European Union to live in the United Kingdom, or who leave the United Kingdom to live in another EU country, have access to health care on the same basis as nationals of that country.

Both sides in the Brexit negotiations have agreed, in principle, to preserve reciprocal health care rights until the end of the transition period, at least for those citizens already residing in another EU country. The transition period will run between the day of exit until December 2020 if the withdrawal agreement is passed by parliament. During this time, all existing regulatory arrangements will stay in place while the United Kingdom makes new bilateral agreements with each of remaining EU member states. In the event of a no-deal Brexit there will be no transition period and therefore no guarantee of reciprocal health care rights. However, some member states have already agreed and passed bilateral agreements with the United Kingdom which set out health care rights after the transition period or in the event of a no-deal Brexit.

Until the final outcome is known, uncertainty remains about the future of health care rights. Estimates of the number of people who will be affected differ among the available sources. However, it has been suggested that there are around 1 million British migrants living in other EU countries, compared with around 3 million EU migrants living in the United Kingdom. UK citizens living abroad tend to be older, and therefore more likely to use health and care services, than EU citizens living in the United Kingdom. Significant numbers of UK citizens returning to the United Kingdom would have implications for health and care services.

After Brexit, whether we leave with or without a deal, UK citizens will face new barriers to accessing health care while in the European Union. These barriers will differ between member states, each of which should have its own bilateral arrangements with the United Kingdom in due course. UK citizens may have to provide proof of residency, proof of current or previous employment, enter a social insurance scheme, or take out private insurance to access health care services in the European Union after Brexit.

If we arrive at a no-deal scenario where British citizens face significant barriers to accessing health care in EEA countries, it is likely that British emigrants currently resident within the EEA, particularly those with long-term conditions, will return to the United Kingdom for ongoing treatment. Around 200,000 British citizens currently access an EU scheme that guarantees health care provision to retirees, which risks being lost in the case of a no-deal Brexit meaning they would have to return to the United Kingdom for treatment. It is not known how many of the 800,000 other UK nationals living in EEA nations will be able to access or afford health care in the event of a no-deal Brexit.

To mitigate the potential impact of this, the UK government has proposed to all EU member states that, in the case of no deal, reciprocal health care rights continue for six months after UK exits. The value of this offer depends on which states accept it.

  • 3. A valid EHIC entitles people to access state-provided treatment that is medically necessary during a temporary stay in another EEA country or Switzerland. Treatment is provided on the same basis as it would to a resident of that country, either at a reduced cost or for free. For example, some countries require patients to contribute a percentage towards the cost of their treatment, known as a patient co-payment.

Regulation

Brexit - regulation image

There are a number of EU regulations that impact on the health and care system, including:

Regulation of medicines

EU legislation provides a harmonised approach to medicines regulation across the EU member states. The United Kingdom is currently part of the authorisation system operated by the European Medicines Agency (EMA), which has now moved from London to Amsterdam, and participates in the EU medicines regulatory network (EMRN).

The EMA is responsible for the scientific evaluation of human and veterinary medicines developed by companies for use in the European Union. Under current arrangements, companies can submit a single application to the EMA to obtain marketing authorisation that is valid in EU, EEA and European Free Trade Association (EFTA) countries. Being a member of the EMA also gives the United Kingdom ‘tier 1’ market status, meaning that pharmaceutical and medical device companies prioritise the United Kingdom as a market for launching their products.

The United Kingdom has its own national regulatory agency, the Medicines and Healthcare products Regulatory Agency (MHRA). However, this currently deals with national authorisations intended for marketing only in the UK.

The EU withdrawal agreement sets out a transition period until the end of 2020, during which time the United Kingdom will continue to abide by all EU rules, to provide time for the United Kingdom to negotiate its relationship with the European Union, which would include the regulation of medicines. The intention is that eventually the MHRA will operate as a sovereign regulator outside the EMA, but with regulatory equivalence and working closely with the EMA and other international partners. There are already precedents for such arrangements – the EMA currently co-operates with regulatory bodies around the world and has specific agreements in place with countries including the United States, Canada and Switzerland. However, if there is no deal, the United Kingdom would cease to participate in the EMRN and the MHRA would take on the functions currently undertaken by the European Union for human medicines on the UK market. The government has passed a statutory instrument which will allow MHRA to take on this role, commencing on the day of exit. If the MHRA is to take on these new functions and do them effectively, it will need a significant increase in resource.

Some have also expressed concern that if the United Kingdom leaves the EMA arrangements and develops its own drug approval system, the United Kingdom may lose its ‘tier 1’ status and end up at the back of the queue for new medicines. For example, in Switzerland and Canada, which have separate approval systems, medicines typically reach the market six months later than in the European Union.

All medical devices in the United Kingdom are currently subject to EU regulations and must comply with EU standards. Higher-risk devices must be certified by an independent body (called an EU Notified Body) that is designated and overseen by the relevant national authority (the MHRA in the UK), following joint audits by two other national authorities and the European Commission. In the event of a no-deal Brexit the government has said that the United Kingdom will recognise medical devices that have been approved for the EU market, are CE-marked and comply with other EU regulations for medical devices, though will have no formal presence at EU committees in respect of devices.

The United Kingdom faces a similar issue in relation to future access to medical radioactive isotopes, which are used, for example, in the diagnosis and treatment of cancer. In 2018/19 the NHS performed more than 619,000 diagnostic procedures that rely on radioactive material.4 The European Atomic Energy Community (Euratom) creates a single market for nuclear energy in Europe and is responsible for co-ordinating and regulating access to these materials. The government has stated that when the United Kingdom leaves the European Union it will also leave Euratom, although it hopes to continue working closely with it in future.

Although the government has stated that the United Kingdom’s exit from Euratom will not have an impact on the availability of radioactive materials, many are concerned about the impact on future supply, including increased costs and a risk to patients, should access be disrupted.

  • 4. This count includes procedures under nuclear medicine, PET-CT scans and SPECT scans.

The supply of medicines and medical devices

There are also concerns that supplies of medicines will be interrupted after Brexit. Around three-quarters of the medicines and more than half of the devices that the NHS uses, come into the United Kingdom via the European Union. The government has asked suppliers of medical goods to build up at least six weeks of extra stocks above usual levels, as government plans show that in the event of a no-deal Brexit there is likely to be significant disruption to cross-channel import routes for up to six months. However, there are some concerns about this approach and the issues are not just about supply routes.

  • The Operation Yellowhammer document acknowledges that it would be impractical to stockpile for six months, stating that ‘DHSC is taking a multi-layered approach to mitigate these risks’. GP practices, hospitals, community pharmacies and patients have been told they should not stockpile medicines beyond usual levels.
  • NHS England and NHS Improvement board papers note that the health service, internally, is prepared for Brexit and that the anticipated risks to medicine supplies will be realised if public and pharmacist behaviour changes. Shortages will only happen if individuals and pharmacists stockpile.
  • The Association of the British Pharmaceutical Industry has warned that a decrease in the value of the pound could see existing stockpiles of medication sold off, as traders and wholesalers undertake ‘parallel exporting’, where medicines are sold across EU borders to maximise profits.

The government has intervened to stop the parallel exporting of some drugs, including hormone replacement therapy. While the government has been clear that this is unrelated to Brexit, it underlines how fragile pharmaceutical supply chains are, irrespective of Brexit.

In the longer term, beyond the immediate disruption to supply, the additional bureaucratic and regulatory burdens that pharmaceutical companies will face, is likely to increase the price of imported medicines and medical devices. The Nuffield Trust estimates that the annual cost of this would be £2.3 billion to the NHS.

Whatever form Brexit takes, it is likely to impact the supply and pricing of medicines and medical devices. A no-deal Brexit could cause serious disruption to supply and even shortages, meaning some people may not be able to access vital medicines. A more orderly Brexit on agreed terms and with a transition period, would mitigate the risk of shortages, but looks likely to increase the bureaucratic and regulatory requirements of importing medicine, which could in turn create price increases.

Competition law

The impact of EU competition and procurement laws on the NHS is contentious. A combination of the Competition Act, provider licences and the Procurement, Patient Choice and Competition Regulations continues to prohibit anti-competitive behaviour by NHS providers and commissioners. Leaving the EU would allow policy-makers to modify these arrangements and other relevant legislation. As the relevant EU directives are incorporated into UK law, the government would need to repeal or amend UK law if it wished to reverse current competition policy so there are unlikely to be changes in the short term.

Many in the NHS would welcome changes in this area. Simon Stevens, Chief Executive of NHS England, has previously remarked that competitive tendering, in which commissioners invite bids from other NHS organisations and private providers, can often create ‘frictional cost and dislocation’ in the NHS, and has said that the United Kingdom will be in a position to ‘shape our own decisions’ in this area once the United Kingdom leaves the European Union.

Removing the overly rigid competition and procurement regime currently applied to the NHS is one of a number of recommendations for legislative change proposed by NHS England and NHS Improvement. The changes proposed are to support the implementation of the NHS long-term plan, though this legislation is not dependent on or a result of Brexit.

There has also been discussion about the impact of trade deals with the European Union and with countries outside the European Union, particularly the United States. The government has stated its intention to ‘ensure we protect our ability to maintain control of the provision of public services, like the NHS, in new trade agreements’. However, its ability to do so will depend on the United Kingdom’s future trading relationship with the European Union and its success in trade negotiations with other countries, which have not yet been agreed.

Working time directive

Among the most contentious pieces of EU legislation affecting the NHS are the European Working Time Regulations – usually referred to as the working time directive. The working time directive was introduced to support the health and safety of workers by limiting the time that employees in any sector can work to 48 hours each week, as well as setting minimum requirements for rest periods and annual leave.

The European Union (Withdrawal) Act 2018 transfers all EU directives into UK law. This fact will remain unaltered whatever the content of the withdrawal agreement or if there is a no-deal Brexit. This means that on the day of Brexit, under any circumstance, worker’s rights under EU law will continue, providing continuity to employers and employees in the short term.

Brexit may allow future governments to amend domestic legislation to change EU directives that have been bought into UK law, should they wish to, although their ability to do so will be subject to wider negotiations regarding access to the single market. 

Cross-border co-operation

Public health

Brexit co-operation image

Public health legislation for a number of policy areas, in particular food safety and nutrition, tobacco, alcohol, radiation, environment, housing standards, and chemicals is drawn from established EU legislation, standards and regulations, with relevant directives transposed into UK legislation.

EU legislation has had a significant impact in some areas, such as air quality, that cannot be successfully controlled at national level alone. In other areas, such as tobacco control, the United Kingdom currently leads the way in Europe, having gone further than required by a recent EU directive by introducing standardised packaging.

In May 2019, during the third reading of the European Union Withdrawal Act, the government signified its intention to transpose key legislation that maintains EU public health regulations, particularly the ‘do no harm’ duty of the Lisbon Treaty that means the government is required to consider ‘a high level of human health’ when making policy.

Public health organisations have since called on the new government to reconfirm this intention, though a response has not been received.

On the other hand, decision-making in a community of 28 countries can be cumbersome and slow, and the United Kingdom could choose to take bolder and faster action on public health after leaving the European Union (Faculty of Public Health 2016).

The European Union also operates systems for the early warning of communicable diseases, managed by the European Centre for Disease Prevention and Control (ECDC). These systems facilitate the rapid sharing of information and technical expertise in response to potential pandemics, communicable diseases and other cross-border health threats. Recent examples of collaboration include managing the H1N1 ‘swine flu’ pandemic and efforts to tackle anti-microbial resistance. Leaving the European Union does not necessarily mean the United Kingdom has to leave the ECDC; both Norway and Switzerland (non-EU member states) work with the ECDC, but do not have a formal role in its decision-making. However, the future arrangements for working with the ECDC are not mentioned in the current withdrawal bill.

Research

Members of the academic, pharmaceutical and medical communities have expressed serious concerns about the impact of leaving the European Union on science and research in the United Kingdom (see, for example, Lechler 2016; Mossialos et al 2016). Nobel Prize winner and Chief Executive of the Francis Crick Institute, Professor Sir Paul Nurse, has warned that Brexit could be challenging for science in the United Kingdom because of its impact on the free movement of researchers across Europe and on the ability of UK researchers to attract research funding. We may already be starting to see evidence of this warning being realised, as the Russell Group of universities has published analysis highlighting the impact of Brexit uncertainty on recruitment and retention of academics in UK universities. In the year after the referendum there was an 11 per cent increase in EU academics leaving Russell Group universities.

The United Kingdom has furthered its scientific research agenda through EU collaboration, as a result of access to European research talent and to important sources of funding. For example, between 2007 and 2013 the UK received 8.8 billion euros for research, development and innovation activities while contributing only 5.4 billion euros to EU research and development. NHS organisations benefit from a range of EU funding schemes including Horizon 2020 and the European Structural Investment Fund (ESIF). The government has set an ambition for the United Kingdom to be a world leader in life sciences and medical research, but this will require it to address the loss of EU funding for research and development and the benefit from the collaboration of researchers and scientists across the European Union.

In the short term, the government has committed to honour funding agreements for ESIF projects that were signed before the Autumn Statement 2016, even where these continue after the United Kingdom has left the European Union. Funding for projects signed after the Autumn Statement 2016 will be funded if they provide strong value for money and are in line with domestic strategic priorities. For Horizon 2020 projects, the government will underwrite the funding for all successful bids that are submitted before the United Kingdom leaves the European Union.

In the longer term, arrangements are unclear. However, the government has stated that it wishes to ‘establish an ambitious agreement on science and innovation that ensures the valuable research links between us continue to grow. While it may be possible to continue to participate in some research programmes after the United Kingdom leaves the European Union (non-EU countries are able to participate in Horizon 2020 as associates or third countries, for example), it is unlikely that projects in the United Kingdom would be eligible to receive EU funding and the United Kingdom would have limited influence over work programmes.

Restrictions on the movement of researchers will have a significant effect on research, with about three-quarters of researchers having spent part of their career in a non-UK institution and more than 28 per cent of university academics currently from outside the United Kingdom.

Clinical trials

Clinical trials for new drugs are currently carried out at a national level but are subject to EU regulations, including registration of trials. Revised EU clinical trials regulations will not be in force in the European Union at the time that the United Kingdom exits the European Union and so will not be incorporated into UK law on exit day. The government expects to align, where possible, with these new regulations, subject to parliamentary approval. Any divergence between the United Kingdom and the European Union on the regulation of clinical research would have a number of consequences, including:

  • an impact on the status of UK-based patients who are participating in multinational EU clinical trials
  • recruitment issues for clinical trials, especially for rare diseases and paediatric medicine; if the United Kingdom becomes isolated it may be seen as a less attractive option for clinical trials recruitment
  • an increased burden on researchers and clinical trials sponsors if two different systems operate in tandem in the European Union and the United Kingdom.

Regulations on the transfer of personal data for research (currently overseen through the EU General Data Protection Regulation (GDPR) will also be affected by the Brexit deal.

Funding and finance

Brexit - funding image

In the long term, the performance of the wider UK economy will be one of the most important influences on funding for the NHS and social care.

During the referendum campaign, claims were made that leaving the European Union would result in a dividend equalling £350 million per week. This, it was argued, could be used to fund the NHS. As the United Kingdom remains a member of the European Union at this time, we still pay into its budget, hence no dividend has been received. Brexit does not guarantee a dividend. If a withdrawal agreement is achieved and passed by parliament, the United Kingdom may continue to make contributions to the EU budget.

However, since the referendum the government has committed to and set in train a multi-year funding settlement for the NHS, that within five years will see annual spending increases for the NHS of £20.5 billion. To be clear, this spending increase is not a direct result of Brexit – it is funded through existing fiscal measures and tax receipts (Office for Budget Responsibility 2018; Treasury Committee 2018).

With negotiations over the United Kingdom’s exit from the European Union ongoing, it is difficult to predict the economic outlook with any certainty. Indeed, the actual economic consequences of Brexit are hotly contested, with some arguing it will have a long-term positive impact. However, the weight of opinion suggests that the net economic impact will be negative, with a range of independent economic forecasts suggesting that Brexit will limit growth and lead to increased borrowing, whatever form it takes. (Bank of England 2018; OECD 2019; Office for Budget Responsibility 2019). In the Office for Budget Responsibility’s estimation, a no-deal Brexit of medium disruption would cost the UK economy £30 billion per year, while the Institute of Fiscal Studies have forecast that this scenario will see government borrowing almost double to £100 billion a year.

It is important to remember that funding for public services is not directly and intrinsically tied to national economic performance. Funding for the NHS is a political decision and a recession or economic downturn will not necessarily lead to reductions in public spending.

The NHS has benefited from the certainty of a multi-year funding settlement as part of the long-term plan. However, this spending announcement does not cover the health service in its totality, as it does not cover public health, spending on building and equipment or training budgets. It also does not cover the provision of social care, a sector which is fragile and particularly vulnerable to disruption that a disorderly Brexit may cause.

Social care

If there are economic consequences to Brexit which result in lower growth and politicians then choose to reduce public expenditure in response, then the implications for social care could be significant. Its budget is only set for one year ahead, it does not have the five years of certainty that the NHS does.

A no-deal Brexit could have a very damaging impact on social care providers. Operation Yellowhammer reports that increasing operational costs bought about increases in inflation could see smaller social care providers go out of business or hand back council contracts within two–three months of a no-deal Brexit. Larger providers would be affected within four–six months of a no-deal Brexit.

Conclusion

The United Kingdom’s decision to leave the European Union has already had an impact on the NHS and social care: for example, the EMA has relocated to Amsterdam and the number of certain groups of health and social care staff joining the workforce from Europe has fallen. It is also absorbing significant time and resources that could otherwise be devoted to the reforming the health and social care system and improving services for patients and service users.

Brexit may present some opportunities for the United Kingdom, in particular the chance to go further and faster on public health regulation and remove rules on competition that are seen to present obstacles to the integration of and collaboration between health services.

However, Brexit also presents the NHS and social care with a number of significant challenges. These include: the potential impact on the health and social care workforces that rely considerably on staff who are EU nationals; the impact on future trading relationships, which could affect the affordability and supply of drugs and other products; a weakening of cross-border co-operation on public health and research; and, of course, the impact on the wider economy, the performance of which will affect future funding for health and social care.

Despite the preparations that have been put in place to manage a no-deal scenario, were it to happen, it could have even more significant consequences for the health and social care system, compounding these threats and potentially causing serious disruption to medical supplies, significant damage to social care provision and the end of reciprocal health agreements, which could increase demand for services as British emigrants with long-term health and care needs return to the United Kingdom and leave British citizens travelling to EU countries to take out private insurance. Alongside this, a no-deal Brexit is forecast to bring significant economic turbulence, in the form of increased borrowing and decreasing growth rates. If this risk is realised, it may put further pressure on public spending and on the overstretched resources of the NHS and, to an even greater extent, social care.

References

The authors would like to thank colleagues from The King’s Fund for their input to this report: Siva Anandaciva, David Buck, Ben Collins, Leo Ewbank, Richard Murray, Anna CharlesLisa Oxlade, Megan Price and Patrick South.

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Comments

Roger Steer

Position
Director,
Organisation
HAC
Comment date
14 December 2017

I'm surprised that the issue of securing recompense for the NHS from the 3m EU migrants living full time in the UK is not more fully addressed.
In France a UK migrant has to pay c £2000 insurance on top of normal taxes.
Introducing a similar scheme in the UK would raise c £3-6bn for the NHS. Why does The Kings Fund not mention this?
Moving the UK away from a universal system to a contributory system as envisaged by Beveridge would be a way of funding the NHS and harmonising with europe. Pensions are provided on a contributory basis - why not health?

Simon O' Connor

Comment date
21 December 2017

The whole point of the NHS is that it is universal and free at the point of consumption. Pensions are not all contributory.

Mike Little

Comment date
11 January 2018

The NHS needs to change, from my recent experience the nurses and doctors on the front line are doing a valiant job is a disorganised, inefficient for example they seem more focused on taking away hearing aids, for 90 year old people leaving them with a poor quality of life, then when you take the elderly relative to A&E because they have fallen - they ask you to shout at them to ask the doctors questions, when you point out about their hearing aid - they simply ignore and say its nothing to do with them and blame budget cuts or say go to specsavers....really ?- all 3 of the pensioners I have tried to help in different counties in the UK, fought in WW2, one a glider pilot could not even get in to a hospice in the last days of his life as he was told he was to ill ? weeks before he was not ill enough 97 years of age....He fought for the NHS and it let him down in his hour of need.... Its not the government that's at fault here although they play a part in long term funding , its the layers of useless managers papering over the cracks that are at fault, robbing the elderly of their homes to pay for care when those with nothing get everything free, ........

Kieran

Position
Project Worker / Youth Worker,
Organisation
TMF
Comment date
13 January 2018

Studies show that in general EU migrants in the UK pay more into the system than they use, so there is no recompense to secure as such - there's no deficit as a result of EU migrants using the NHS, after all they pay tax like everyone else. The NHS could be doing more to claim fees from EU countries when EU tourists or those on short stays use the NHS. Full fact do a great piece on it:

https://fullfact.org/europe/eu-immigration-and-pressure-nhs/

Pearl Baker

Position
Carer Independent Mental Health Advocate & Adviser,
Comment date
23 February 2019

The Guardian reported 'Pay' 'The non -EU workers who'll be deported for earning less than £35.000 ' 'with Americans and Australians among the most affected' unless this changes the entire 'Care Sector' will collapse.

It is reported that Cancer treatment will be rationalised.

If travellers visit our COUNTRY they should pay for their treatment, or have INSURANCE to cover EMERGENCY treatment.

The BEST thing in leaving the EU will 'boot' out their GDPR the worse ever Data Protection 'idea' that does the opposite of 'Protecting' anyone. I have spoken to many Professionals and they all agree.

The Government have to 'step' up to the 'CHALLENGE' and start understanding how 'integration' should operate, and what 'PARTNERS' are recognised and required to make this a 'seamless' delivery of Health and Social Care. Germany has an excellent 'Programme' of Supporting those in advancing years becoming less isolated and unwell, they organise daily activities, including 'keep fit' sessions. Its called prevention.

Stephane Guegan

Position
IT Manager,
Comment date
25 February 2019

I would really like to see your source on the subject! For reference this is the link to the information to the sickness insurance: https://www.service-public.fr/particuliers/vosdroits/F12859. As a reminder the French system is not completely free (usually 70% / 80%), some have got dispensation (low income / unemployed resident) but the majority are paying for one part of their care. The part of their care can be covered by an health insurance (mutuel) that they pay for (and can be part of the package offered by their employers), this is for the majority of residents not only expat/ immigrants.
For more info: https://www.expatica.com/fr/healthcare/healthcare-basics/guide-to-healt…

Temporary residents are covered by the ehic (well at least for now...)
[..]EU, EEA and Swiss citizens

Citizens from the European Union (EU), European Economic Area (EEA – EU plus Iceland, Liechtenstein and Norway) and Switzerland and their families who are staying temporarily (and not working) in France can typically use their European Union Health Insurance Card (EHIC). However, French health insurance is applicable once you become a resident or stay long-term in France
[..]

Stephane Guegan

Comment date
25 February 2019

I also invite you to read the Migration Advisory Committee report EEA Migration in the UK from September 2018 requested by the UK government /Parliamentary Select Committee
https://assets.publishing.service.gov.uk/government/uploads/system/uplo…

Conclusion
[..]5.22. There is no doubt that EEA migrants contribute more to the health workforce than they consume in healthcare. This can be explained by their age profiles, they tend to be younger than the make-up of the resident population. They also tend to consider themselves to be healthier than the UK-born population. Furthermore, there is no evidence that increased migration has led to a decrease in the quality of health care services in the UK.[..]

full list of reports: https://www.gov.uk/government/publications/migration-advisory-committee…

Stephane Guegan

Comment date
25 February 2019

Pear Baker

You need to make sure that you do not confuse: residents and visitors, since under EU law they have got a different way to cover their NHS needs.
EU visitors require to use the EHIC (European Health Insurance Card: https://www.nhs.uk/using-the-nhs/healthcare-abroad/apply-for-a-free-ehi…) scheme to cover their NHS need (just like UK immigrants in the EU). EU citizens UK residents are supposed to be self sufficient & exercise treaty rights which allow them to use the NHS.

Cancer treatment delays are a concern due to lack of specialised staff: https://www.theguardian.com/society/2018/jan/10/cancer-charities-alarme… The fact that recruitment of EU registered nurses has decreased by 96% will not help...

One of the big issue with cancer and radiotherapy is the potential disruption by Brexit:
https://www.businessinsider.com/brexit-cancer-treatment-euratom-patient…
Why, because the UK / Brexit is trying to leave Euratom (treaty for nuclear regulation which oversees, speedy, smooth and safe movement of nuclear materials between European states). the nuclear material move to and from countries mainly takes the form of fuel for power stations, and radioactive isotopes, which are used to perform cancer treatment and diagnoses.
Up yo 80% of radioactive isotopes used in UK hospitals are imported, the financial time reported last year. The vast majority of these isotopes are imported form the EU membr states, "largely from the Netherlands, France and Belgium", the BMA stated in its briefing on Brexit and Euratom". NHs England data shows that these isotopes are used to perform over half a million diagnostic scans every year.
An while isotopes can be imported from outside the EU, Britain's reliance on products from within the bloc means failure to either remain inside Euratom after Brexit, or at least closely wedded to it, will "result in isotopes not reaching the patients in time or reaching them with a low level of activity"

Vaughan Starkey

Position
Retired Civil Servant,
Organisation
None
Comment date
13 November 2019

Is the any data of the number of NHS - trainee UK nationals who leave UK to work abroad?

Jonathon Holmes

Position
Policy Adviser,
Organisation
The King's Fubd
Comment date
18 November 2019

Hi Vaughan, unfortunately the data is a little bit patchy on this.

NHS Digital report the numbers of NHS staff who leave the health service, including the number who reason for leaving is to 'relocate'. However, it doesn't say where they are relocating to: https://digital.nhs.uk/data-and-information/publications/statistical/nh…

Separately, the General Medical Council registration data gives numbers on young doctors going to work overseas and number of doctors thinking about going to work abroad: https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/the-s…

While the Nursing and Midwifery Council data on number of EEA and non-EEA nurses working in the NHS who are planning on leaving to work overseas: https://www.nmc.org.uk/about-us/reports-and-accounts/registration-stati…

I hope that's all useful.

Jim

Comment date
18 December 2019

What is KF's actual position on the future of reciprocal healthcare? Your 'Our position' section doesn't really elaborate on what KF thinks should happen under the future relationship with the EU (or internationally, not just Europe) it just states the risks of losing these rights. It seems likely you'd want a continuation/replacement of the EHIC scheme in some form, but what about S1 and S2 routes? Would you wish for continuation of these either wholly or in some form?

It's worth noting that the new Government's intention is to negotiate an FTA with the EU, not some other bespoke form of future relationship. The current EU reciprocal healthcare rules aren't the kind of things that would typically come under the auspices of an FTA, and the fact the Government now seems to be heading to a legal commitment to no extension of the Implementation Period beyond 2020 means any FTA would be limited in scope due to the limited time in which to negotiate, so unlikely to include reciprocal healthcare unless there is an agreement to roll over the current rules untouched (either indefinitely or with the intent of making amendments in the future). So, if there is no rollover/continuation, should the UK continue to seek bilateral deals with individual EU Member States, which have the possibility of being more bespoke and tailored to the specific needs to UK nationals in any given Member State and that Member State’s citizens’ needs in the UK? Or should the UK accept that being outside of the EU means exactly that – we are a third country and the healthcare rights we have enjoyed during membership should cease, so UK nationals in the EU (EEA and Switzerland, where these rules also apply) have to take individual action to look after their healthcare needs (however tough the circumstances) as any other non-EU/EEA/Switzerland migrant/visitor would? What is KF’s position?

Finally, what to do with the Healthcare (EEA and Switzerland Arrangements) Act 2019, which gives the Government the powers to implement any prospective reciprocal healthcare agreements with any country in the EEA or Switzerland? In it’s original form, as the Healthcare (International Arrangements) Bill, these powers would have had international scope and wouldn’t have been limited to the EU/EEA and Switzerland. Should we leave this be, or should the UK look to be more ambitious in trying to improve the access of its citizens to foreign healthcare systems outside Europe? The anti-H(IA)B arguments tenuously promoted the hypothetical possibility that a Health Secretary could do a deal with, say, the State of Kansas to allow citizens of that state unfettered access to the NHS’ mental health services – whilst this was technically correct, in reality such access would never be granted without reciprocity, nor would a deal be struck with such limited/specific scope. However, increasing the scope of the powers under the Act to be international would enable the Government to, say, improve upon the pre-existing (but relatively limited compared with the EU) arrangements with Australia and New Zealand. It could enable us to promote reciprocal healthcare as part of a potential CANZUK agreement, if the Government chose to pursue that ambition. Whilst we must not forget that any reciprocal healthcare agreements would obviously mean some form of access to the NHS for foreign nationals of the country/countries we struck deals with, and that the current EU arrangements are on balance a massive financial loss to the UK (given the greater volume of UK travellers/migrants to Europe and the NHS’ current poor record of cost recover for EU citizens here), this could be a potential boon for a ‘Global Britain’ that encourages movement around the world (not just Europe) and would no doubt be popular amongst the host of UK visitors to countries like Australia or Canada. So what does KF think?

Jonathon Holmes

Comment date
19 December 2019

Hi Jim,
Thanks for your questions, I'll try to go through each one in turn.
1. The issue is that a no-deal would lead to a sudden ending of the existing health care access rights, which would create significant disruption to people's use of health care services, this is clearly a negative thing that we would be very keen to avoid.
Under a future relationship (if a deal is ratified) it seems necessary that some provisions about reciprocal healthcare are in place. This might be via bilateral agreements, as we currently have with Spain, Portugal and Ireland, alternatively it could be a continuation of EHIC or even a new EEA wide scheme. In terms of the detail, that will be a political decision. However in principal having some form of ongoing reciprocal health care provision would be welcome, as it would give certainty and security to all UK citizens living or working in the EU and vice versa.
2. On your question about whether the UK should continue to seek bilateral agreements in the event of no-deal or no continuation of EHIC, the answer would have to be yes in this circumstance, though it would be a time consuming and complex process with an outcome that would, I'm sure, be both inconsistent between member states and confusing to patients.
3. The honest answer is, I don't know, though I suspect that the Act's purpose is limited to Brexit transition/preparedness, though I can't imagine that health care access reciprocity will be within the scope of future trade agreements with non-EEA states.
Many thanks,
Jonathon

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