On the 29 March 2017, the Prime Minister of the UK Theresa May formally notified the European Union (EU) Council President, Donald Tusk, of the UK’s intention to leave the EU. Theresa May’s letter to Donald Tusk triggered a two-year process during which the UK will have to negotiate both the terms of its exit from EU and the arrangements that will replace those we have had for over 40 years with the other member states of the EU. The consequences of the United Kingdom’s departure from the EU (commonly referred to as ‘Brexit’) will be wide-ranging and will affect all areas of UK’s society, including the National Health Service (NHS).
For the NHS, Brexit comes at a time when it faces many other major challenges. These include severe financial pressures, rising workload, increased waiting times for both primary care and specialist services, and shortages of health professionals in many key areas (such as in general practice and in emergency departments), and rising rates of obesity and type 2 diabetes. The NHS also faces challenges from societal changes, such as population growth; and an aging population, which is leading to an increase in the number of older people with complex medical problems. Hence, Brexit has come at a difficult time for the NHS and will add further to the many issues the NHS needs to address in the next few years.
The most immediate challenges from Brexit will come in areas such as the recruitment and retention of doctors and other health professionals; and in negotiating new arrangements for accessing healthcare both for EU nationals living in or visiting the UK; and for UK nationals living in or visiting the EU. There are also numerous EU laws that affect the NHS and public health in the UK. For now, these EU laws will be incorporated into UK law via the ‘Great Repeal Bill’, which will end the primacy of EU law in the UK. Over time, parliament will decide which parts of EU law to keep, change or remove from UK law, a process that will take many years.
Further complications in dealing with Brexit arise from the devolved nature of the NHS in the UK, which means that the UK does not have a single NHS but rather, it has different versions in each of the four nations of the UK. Some issues arising from Brexit that will affect the NHS will be dealt with by the UK Parliament (such as freedom of movement); and some issues (such as how health services are organised) will be dealt with by the devolved administrations in Wales, Scotland and Northern Ireland.
For many decades, the NHS has faced shortages in its clinical workforce and has relied heavily on overseas trained doctors, nurses and other health professionals to fill these gaps. This reliance on overseas-trained staff will not end in the foreseeable future. For example, although the Secretary of State for Health, Jeremy Hunt, has announced that the government will support the creation of an additional 1,500 medical student places in England’s medical schools, it will be over 10 years before these students complete their medical degrees and their subsequent post-graduate medical training. Hence, these additional doctors will not address the immediate needs of the NHS and we will continue to rely on the nationals of other countries to staff the NHS for many years to come.
Furthermore, although the UK has been able to recruit health professionals from other countries in the past, we may find that this will become more difficult in the future. The changes in the political environment in the UK, for example increased antagonism towards immigration, may discourage health professionals from other countries from moving to the UK; as will the fall in the value of pound against currencies such as the Euro, which makes the UK less attractive to work in financially.
Like our own NHS, health systems in other countries in the EU and elsewhere in the world also face their own challenges; and other countries will be keen to retain their health professionals to help address the health needs of their own populations. There is a global shortage of health professionals and they will be in demand in many countries. The UK may therefore find itself a less attractive destination for health professionals in the future. Moreover, as we saw with the junior doctor contract dispute in England, when the NHS tries to impose unpopular employment policies on its staff, this can lead to an exodus of health professionals out of the NHS. We may therefore find other countries trying to recruit health professionals from the UK to address their own staffing needs, thereby further exacerbating staff shortages in the NHS.
The recruitment of overseas-trained staff by the NHS has been facilitated by EU legislation on the mutual recognition of the training of health professionals. This means that health professionals trained in one EU country can work in another EU country without undergoing a period of additional training. Moving forwards, it is unclear that this cross-EU recognition of training will continue in the UK. There are some in the UK who see clinical training here as superior to that in other EU countries and view Brexit as an opportunity to implement tougher employment checks on EU trained health professionals. This too may discourage health professionals from elsewhere in the world moving to the UK. We will therefore need to take urgent action to ensure that the NHS can continue to recruit sufficient professional staff to meet the health needs of our population.
The UK government will also have to address the issue of access to healthcare, both for EU nationals living in or visiting the UK and UK nationals living in or visiting other EU countries. Currently, all these individuals are entitled to either free or low cost healthcare. It is unclear what will happen to these arrangements for accessing healthcare in the future, until further progress is made in our negotiations with the EU. Access to healthcare is particularly important for the elderly, retired UK nationals living overseas, in countries such as Spain, who will have a high need for health care. Furthermore, as the NHS has never been very effective in reclaiming the fees owed to it by overseas visitors to the UK, the UK may find itself substantially worse off financially when new arrangements for cross-national funding healthcare are put in place.
There are also many other areas that affect the NHS that will need to be addressed. These include, for example, our involvement in future Europe-wide public health initiatives. These cover many areas including food regulations, road safety, air pollution, tobacco control, and chemical hazards; and are important when dealing with cross-national issues that do not stop at a country’s boundaries (e.g. air pollution). Although such initiatives have had important positive effects on health in the UK, there is strong resistance from some pro-Brexit politicians about participating in such programmes, as they often view them as unnecessary interference in the UK’s internal affairs. There are also risks to health-related research and development in our universities, the pharmaceutical industry, and the wider life sciences sector. This will include the ability of UK researchers to lead multi-national EU-funded research programmes, which is another area that is at risk post-Brexit.
At a time when the NHS is already facing major problems, Brexit will impose a further layer of complexity on the challenges the NHS must address in the next few years. Thus far, the negotiations with the EU over Brexit have been dominated by issues such as the size of the financial settlement the UK will have to make when it leaves the EU. However, it is very clear that Brexit will have wide-ranging impacts on the NHS and it therefore essential that the NHS engages with government to ameliorate these risks and ensure they are dealt with before the we leave the EU. This will include gaining support for the continued recruitment of health professionals from elsewhere in the world; addressing issues around access to healthcare; and the continued participation in EU-wide public health and research programmes that benefit the health of the UK population.
This blog was first published in Public Sector Focus in March/April 2017.