Regardless of what happens with Brexit negotiations, there are now three fundamental threats to the NHS and health policy in the UK, says Martin McKee

Almost a year after the referendum, negotiations between the UK and EU have finally begun. There was a widespread expectation that the situation would become clearer as time went on. If anything, it has become more confused.

Ascertaining what is actually happening is difficult. The prime minister stated that she would not give a running commentary on negotiations. She hoped that they could be conducted away from the public gaze, perhaps drawing on her experience of agreeing a secret memorandum of understanding on security with Saudi Arabia, details of which she sought to withhold from parliament. In contrast, the EU was committed to full transparency, placing its negotiating documents on the internet, not least to avoid selective and misleading briefings by the British government. Unfortunately, the UK was not in a position to reciprocate. It failed to send anything on its position to the EU before the first day of negotiations, widely seen as an admission that there was nothing to send.

The reasons for this failure provoked much speculation, but several factors seemed relevant. Firstly, the prime minister has yet to reach agreement with the Northern Irish Democratic Unionist Party (DUP) about whether she could depend on their support in what is now a hung parliament. This is more important than it might seem as the EU has identified the Irish border as one of the three main priorities to resolve early in the negotiations. The DUP is seeking to be simultaneously outside the customs union while avoiding a hard border, a position that is clearly impossible. Secondly, the outcome of the election and, perhaps as importantly, her response to the fire at the Grenfell Tower, has weakened her greatly, emboldening those in her cabinet, such as the Chancellor of the Exchequer, who opposed to her approach to Brexit. Thirdly, as has been noted in my earlier BMJ Opinion pieces, the British government provided little evidence of having made any progress in developing its position, or even understanding the issues involved. The Brexit White Paper, with its many gaps, contradictions, and until corrected in later versions, factual mistakes, gave little encouragement. Fourthly, a few days before the negotiations began, the Department for exiting the EU lost two of its ministers, including Lord Bridges, whose resignation is widely believed to reflect his view that a workable Brexit is impossible to achieve. Finally, those in the rest of the EU were slowly concluding that the British approach was shaped by a fundamental misconception by the prime minister about the EU Treaties, based on her previous experience with provisions on justice and home affairs, where a completely different mechanism applies.

The negotiations got off to an amicable start although there was some surprise that, given the long list of issues to discuss, they were scheduled to last only one day this month. They might easily not have happened at all. The British side asked whether they could go ahead without a minister present. The EU, unsurprisingly, refused, saying that it was pointless to negotiate without someone who had the authority to agree anything. The concluding press conference showed evidence of progress. Both sides agreed that no talks of a free trade agreement could take place until sufficient progress had been made on the terms of the EU’s exit. This was not a surprise to anyone except sections of the British press. As late as the three days earlier, British ministers had said that there would be the “row of the summer” if the EU did not agree to take the two issues together, although informed commentators realised that this would never happen. As predicted, the UK government conceded at once.

Apart from this, the timetable, and that discussions would be conducted in English and in French, we learned little about the negotiations. The UK had still not produced any position papers, perhaps because it did not have any agreed positions on many key issues, although at least it now promises to publish one on reciprocal rights of citizens a week after the first talks. But we did learn something about domestic policies, when David Davies mentioned that he might talk to representatives of other UK parties on Privy Council terms, in other words in secret. This could herald the beginning of a process of cross-party discussions, at least once the Conservative Party has reached agreement with itself.

Meanwhile, the EU is watching political developments in London carefully, given the uncertainty about the prime minister’s own position. Newspapers abound with stories about plots to depose her, with the question mostly being about when rather than if. If she did go, however, it would almost certainly delay the negotiations even longer, with the EU unsure who would sign off any final agreement, if one could be reached. To add to the complications, David Davies is being touted as an interim replacement or even new leader, so the UK would need to find a new chief negotiator at short notice.

Given this situation, in which the British position can best be described as “chaos and confusion,” coupled with a hung parliament in which the prime minister can no longer count on support from her own MPs, a growing number of commentators, including the author of a scathing commentary in the leading German magazine Der Spiegel, now question whether the British government is actually capable of leaving the EU. The Financial Times quotes an unnamed minister as saying “In practical terms, Brexit is dead.”

We can only speculate as to the final outcome. But, regardless of what happens, there are now three fundamental threats to the NHS and health policy in the UK.

The first relates to the workforce, both in the NHS and social care. Numbers of nurses applying to come from the rest of the EU are in freefall. However, the problems go well beyond the NHS, affecting research, but also the financial services sector, and with it the tax revenues that it generates, as well as the agricultural sector, and our ability to feed ourselves at a time when our trading relations with the rest of the world are being put in jeopardy. Even before any restrictions come into force, large numbers of Europeans believe that the writing is on the wall for their future in the UK.

The second relates to the economy. The Office for Budget Responsibility estimates that Brexit will lead to a reduction of £15.2 billion in public finances by 2020/21 (equating to a cut of £2.4 billion to the NHS) while the Nuffield Trust estimates an additional cost of pensioners from other EU member states of approximately £0.5 billion per year net. However, even before some form of Brexit actually happens, there is likely to be the additional cost of recruiting staff to replace those EU citizens leaving and no longer coming (including an increased wage bill to make the jobs more attractive) and the higher cost of imported medicines and technology due to the lower value of the pound.

Thirdly, there is now a real risk of government failure. Lord Judge, the former Lord Chief Justice, predicted that Parliament would be unable to apply any meaningful scrutiny to the vast amount of legislation that would be needed should we leave. His prediction seems to be coming true, as Andrea Leadsom has just announced that there will be no Queen’s speech in 2018 because of the scale of the task involved in implementing Brexit. This is quite remarkable, given that King’s speeches continued throughout the Second World War. However, perhaps of greater concern is failure of the civil service. The Institute for Government estimates that the Department of Environment, Food, and Rural Affairs alone must enact 1,200 new laws.

The lamentable response to the Grenfell Tower fire revealed that central and local government have extremely limited capacity to respond to a crisis. This is a particular concern for public health, following deep cuts to the public health function in many local councils and, nationally, to Public Health England. Add the massive workload involved in preparing for Brexit and it becomes clear that the country is now extremely vulnerable.

Martin McKee is professor of European public health at the London School of Hygiene and Tropical Medicine.