On 28th October 2019, the deadline to achieve a Brexit agreement was postponed to 31st January 2020. Under the Withdrawal Act, not reaching an agreement on that date will result in a no-deal Brexit. This would be the worst-case scenario as the UK would automatically leave the EU without legal arrangements and it would be formally recognized as a third country (i.e. non-EU country without any special rights or privileges). The UK government is preparing for a no-deal Brexit with the so-called Operation Yellowhammer – a contingency plan to face the possible consequences of an exit without a withdrawal agreement. However, the adequacy of the preparations has been questioned by many economists and professionals in the healthcare sector.
The implications for the healthcare sector, both the direct and the indirect ones, are particularly concerning. Some of these effects are already visible, from the relocation of the formerly London-based European Medicines Agency (EMA) to Amsterdam, to the decision of the pharmaceutical research company Recardio to terminate its clinical trials in Britain. The aftermath of Brexit is extremely uncertain as many of its consequences have yet to materialize.
The Department of Health and Social Care (DHSC), in collaboration with the National Health Service (NHS), proposed a procedure to alleviate the health impact in the event of a no-deal Brexit, but little is known about this plan as the DHSC is preventing any disclosure of information.
The British Medical Journal summarizes in a simple infographic the concomitance of the already existing issues in the country and new ones caused by Brexit and explains how they will impact healthcare in the UK both in the short and in the long run.
To understand how healthcare will be affected under a no-deal scenario, it is useful to identify a series of losses, from the most straightforward such as the loss of funding, medical supplies and the loss of European privileges (i.e. free movement and access to common European institutions), to the less obvious ones such as the loss of social norms, the loss of trust in government and the loss of workforce. Inspired by the WHO Health System Framework, this article will summarize the plausible changes in the core components of healthcare caused by a no-deal Brexit. Furthermore, a rapid analysis of the consequences on food system will follow as it involves potential losses in the social care and healthcare spheres.
Although the economic consequences of Brexit are unclear, estimates show that a no-deal Brexit could reduce growth by £30 billion per year and government borrowing could almost double approaching £100 billion. While it is true that public health is not directly affected by economic fluctuations, the NHS funding depends on government subsidies; an underperforming economic environment could lead the government to cut spending on healthcare and social care.
Furthermore, a potential recession would imply a rise in unemployment with consequent rises in suicides, alcohol-related deaths and cases of depression, especially in vulnerable groups. This would lead to an unexpected rise in healthcare expenditure.
Looking at the long run perspective, the increase in bureaucracy and regulations, caused by the absence of a properly structured deal, will decrease the efficiency of pharmaceutical companies leading to a rise in drug prices. Considering the relative inelasticity of the medical products, customers will have to give up other goods because of higher medical expenses, contributing to the already expected poor economic performance.
Healthcare staffing and migration
A consistent immigrant labour supply is of paramount importance for the British healthcare system as it faces a shortage of approximately 100,000 professionals (9% of the posts). In fact, the UK relies heavily on international labour supply in the medical and social care sectors – respectively 5.5% and 9% of the workforce in the given fields comes from the Continent. A restrictive change in migration policies resulting from a no deal would complicate the recruitment of workers from other European countries. Furthermore, the sterling devaluation would result, once again, in a loss of competitiveness of the British labour market, disincentivizing work migrations.
Another problem arises if we consider the professionals from other European countries who are already working in the UK. What is their incentive to continue working in a country after their wage dropped below the competitive level and they are no longer protected by an adequate legal framework? The EU tried to ensure the position of its citizens currently living and working in the UK through the EU Settlement Scheme, but these arrangements are extremely complex and any technical problem could result in ambiguous legal status for many Europeans.
Healthcare Rights and Access to Essential Care Abroad
Another important issue concerns the future of healthcare rights. Up to now, the EU legislation provided a European Health Insurance Card (EHIC) to its citizens granting them the right to necessary public healthcare during a temporary stay in other EEA countries.
Without a similar agreement, the cost of travelling to Europe will increase substantially as travellers will have to rely on private insurance. At present, UK and EU have agreed to preserve reciprocal healthcare rights until the end of the transition. However, in case of no deal, there will not be a formal transition period, hence, these rights will be guaranteed neither in the UK nor on the continent. This scenario is particularly frightening as approximately 1 million British citizens live in other European countries and 3 millions of EU migrants reside in the UK.
Regulation and supply of medical products
The regulation and supply of medicine will be deeply affected by an unregulated withdrawal from the European Union. About three quarters of British medicines are imported from continental Europe. However, after Brexit, the introduction of new medicine from Europe will experience a retardation of 6-12 months as it happens in the other third countries such as Australia, Switzerland or Canada.
Furthermore, after a no-deal Brexit, the cross-channel routes could be suspended for up to six months and a discrete stockpiling of medicines would be required to accommodate the short-term medical demand. A sudden fall in the value of sterling could make UK medicines relatively cheaper and could encourage ‘parallel exports’: unauthorized resale of medicines to other countries. This phenomenon would reduce the UK's national medical supply and potentially result in shortages.
Additionally, the UK would be excluded from the European Medicine Regulatory Network; therefore, the MHRA, the British medicine regulatory authority which up to now operated only on a national level, would have to assume responsibility for the tasks previously undertaken by the EMA. In case the MHRA became an autonomous sovereign regulator, it would have to drastically increase its resources in a short amount of time and build an intrinsically complex bureaucratic system to deal with the regulation and transportation of medical supplies.
Finally, other problems related to non-pharmaceutical medical supplies will arise. The supply of organs, plasma and tissues is heavily regulated by EU authorities and it risks to experience severe short-term disruptions.
The UK will also experience difficulties in importing radioisotopes from the Netherlands; these atoms are essential for diagnostic imaging and cancer therapy, but the withdrawal from the EU will also mark the exit from the Euratom Treaty which regulates their administration.
Public health governance and research
Many EU laws have have shaped the UK’s public health policy, from air quality control to food safety and nutrition. Although the coordination of such regulations with EU members can be slow, some of this policy areas cannot be successfully treated at a national level. While the UK is extremely well prepared for dealing with certain issues such as tobacco control, it would surely benefit from the scale capabilities of the EU in other matters – for instance, the distribution of clinical trials, in which England efficiency is well below the European average. Another example concerns the European Centre for Disease Prevention and Control (ECDP); the ECDP is a rapid information sharing system put in place to limit the spread of disease and pandemics. While the withdrawal from the EU does not imply a withdrawal from the ECDC, it excludes London from any decision-making in the body.
Furthermore, many academics and researchers are concerned about the impact that Brexit could have on research funding and on the free mobility of professionals. The UK benefited from a wide range of EU funding scheme collecting over €8.8 billions between 2007 and 2013 against a contribution of only €5.4 billions to EU R&D.
Without proper agreements, the British academic network could potentially stall; this phenomenon is already present at certain levels, as the number of EU academics leaving the Russell Group Universities has increased substantially following the Brexit referendum.
The absence of a deal would also deeply affect the UK food system on several levels: first, the food supply chain would be abruptly interrupted as it is highly integrated with the EU. Food production would be suspended as it relies on the cross-border imports from Ireland. In addition, the price of products would increase after the fall of the sterling, the imposition of new tariffs and higher transport costs.
The country would also be excluded from the EU standard framework and the level of bureaucracy and paperwork required on national level to issue health certificates would drastically increase. These changes would mainly affect the low-income part of the UK population and local retailers. Finally, in such a turbulent context, civil unrest and panic buying are not to be excluded.
At the early stages of Brexit, the Leave campaign misled the public audience promising to reinvest some of the money saved from the UK contributions to the EU in the NHS – allegedly £350 million per week. In the meantime, the ministers reassured the Faculty of Public Health (British association setting standards for the public health professionals’ practice) that any policy related to Brexit would not harm healthcare in any way. While the government still asserts this belief, a quick analysis exposes much less encouraging prospects for the UK healthcare sector.
The potential negative effects of Brexit are wide-ranging and pervasive, they influence each core component of the healthcare system as described in the WHO System Framework, completely reshaping the UK healthcare system. Major adjustments are necessary, but the British Government and the other European authorities seem to underestimate the costs the UK population will bear in case a sloppy or no agreement is reached. UK citizens should appeal to the representatives of their country to honour their commitment to maintain the same healthcare standards after Brexit.
Freely adapted from:
McKenna H., Baird B., Holmes J. (2019) ‘Brexit: the implications for health and social care.’ The King's Fund. Available from: https://www.kingsfund.org.uk/publications/articles/brexit-implications-health-social-care
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Fahy N., Hervey T., Greer S., Jarman H., Stuckler D., Galsworthy M., et al. (2019). ‘How will Brexit affect health services in the UK? An updated evaluation.’ The Lancet, vol. 393, no. 10174, pp. 949-58. DOI: 10.1016/ S0140-6736(19)30425-8
Schalkwyk M.C.I.V., Barlow P., Stuckler D., Rae M., Lang T., Hervey T., et al. (2019). ‘Assessing the health effects of a “no deal” Brexit.’ Bmj, vol. 366, no. 8212. DOI: 10.1136/bmj.l5300