The risk of a “no deal” Brexit is now extremely high and, if May’s plan goes wrong, it will be the NHS and its patients that bear the brunt of her gamble

European press coverage of the Brexit debate in the UK Parliament on Tuesday 29 January was savage. The consensus was that Theresa May had placed a fragile unity of the Conservative Party above the national interest, making it impossible to negotiate a new deal with the EU27. Worse, an op-ed in the Spanish newspaper El Pais bluntly stated that she simply could not be trusted. A few weeks previously she had agreed a draft withdrawal agreement with EU negotiators and, when she presented it to Parliament, suffered the largest defeat ever recorded in a parliamentary vote. She had repeatedly said that this was the best deal available, given the “red lines” that she had chosen to define her version of Brexit. Yet now she was encouraging an amendment that would change it so fundamentally that she would have to go back and try to renegotiate it.

The response from the EU was swift. Within minutes of the vote, the President of the European Council simply reiterated what Theresa May had been saying only a few days previously, that this was the best deal available and it would not be renegotiated. And even if there was an alternative, it was clearly too late to find it now. EU heads of government have grown tired of rearranging their diaries to fit in emergency summits, only to see the UK turn up unprepared, lacking feasible suggestions. And anyway, the UK has enough to do, trying to enact six major legislative acts and about 600 statutory instruments, some hundreds of pages long, and all before the end of March.

So what is the problem? Attention has focused on what is termed the “backstop”, although it is clear that supporters of Brexit have many other concerns that are likely to re-emerge should any withdrawal agreement be reached. Here it is important to recall that what is being argued over is only how the UK extracts itself from the EU with the least possible damage, including a transition period where many things stay as they are now. The real problems will come when discussions start on any future arrangements, which few serious commentators believe could be concluded by the end of the transition period in December 2020.

The backstop was agreed as a means to address the conundrum of how to reconcile the commitments in the Good Friday Agreement, the basis of peace in Ireland, with Brexit. In essence, if the UK insists on leaving the customs union and diverging from the rules of the single market, which it does, it is necessary to place inspection posts on any frontiers it shares with the EU27. There are three such borders, between Gibraltar and Spain, the Sovereign Base Areas and Republic of Cyprus, and on the island of Ireland. It is the last of these where the problems arise because of the widespread agreement that any infrastructure on this border risks inciting a return to the violence that left over 3,000 people dead at the end of the 20th century. The explosion of a car bomb in Derry/Londonderry (community divisions have prevented agreement on what the city should be called) served as a reminder of the recent past.

Brexit supporters argue that there is no need for border infrastructure as any checks could be done electronically, yet as the current industry minister has noted, “There is currently no border in the world, outside a customs union, that has eliminated border infrastructure”. Some look to the French Swiss border as something to emulate, even when pictured with very solid concrete customs buildings behind them. Given the high priority placed by the EU27 on peace in Ireland, a process in which the EU has invested heavily, it was willing to explore imaginative solutions. One was to allow Northern Ireland to remain in the customs union and single market. However, this would have required the necessary checks to be moved to the sea border between Great Britain and Ireland. This was unacceptable to the Northern Irish Democratic Unionist Party, on which Theresa May depends for a majority in the House of Commons, as well as many within her own party.

The EU then made a major concession, agreeing that the entire UK could remain in the customs union until an “alternative arrangement” was agreed. Given that any alternative arrangement would require that the UK remained in something very like the customs union, many Brexit supporters were appalled. The whole point of Brexit was to be able to forge new trade deals with countries like the USA (most of the others they cite, such as Singapore, Canada and New Zealand, either have, or soon will have, such agreements with the EU, so it is unclear why they want to be excluded from them). But remaining in a customs union, even if only partial, would require them to accept whatever the EU decided in its negotiations, as is the situation now with Turkey.

This has created an impasse. It is very difficult to envisage the British Parliament signing up to any permanent agreement that would keep the UK in a customs union. But as long as it also rejects a border in the Irish Sea, it will have to remain in one to avoid a hard border on the island of Ireland. And this cannot be time limited. Quite simply, a backstop is an insurance policy against the UK failing to live up to its stated commitment to avoid a hard border in Ireland. Given the lack of trust in assurances from the British government, EU27 governments insist that it must be included in a legally binding treaty, in other words the Withdrawal Agreement.  

So now the prime minister has said that she will return to Brussels, her hand strengthened by the vote in Parliament. But what can she possibly hope to achieve? The backstop cannot be negotiated away so she is bound to fail. Slogans such as “they need us more than we need them” are still being used, despite the evidence to the contrary. And the pro-Brexit wing of her own party has vowed to reject her deal when it returns to Parliament unless the backstop is removed. But failure to achieve a workable agreement in Parliament that is acceptable to the EU means that the UK will automatically leave on 29 March. The EU may be willing to agree a delay, but not if it is simply to allow more time for bloodletting within the Conservative Party.

Given these developments, major companies and EU27 governments are activating their “no deal” planning. The UK is also taking action although there is little evidence that its effort begins to approach the scale of the challenge. Indeed, many of its plans have attracted ridicule, such as its contract with a ferry company with no ferries that borrowed its terms and conditions from a fast food company. Its efforts to test truck movements in Kent, involving less than 1% of the daily flow, was seen as a “waste of time.”

Rather late in the day, the NHS has begun to prepare for this eventuality. As a recent report for The BMJ noted, even a few months ago most NHS Trusts had done little or nothing. But now that they are staring into the abyss, reliance on ministerial assurances is no longer tenable. Already, staff from EU27 countries are leaving in large numbers and not being replaced, in some cases threatening the viability of existing services. The Health Secretary has said that medicines will be prioritised over food, which is hardly reassuring given estimates of the grave impact of Brexit on food supply, especially as the UK will leave the EU at a time of year when it is most dependent on imports. Reports of drugs shortages and price hikes are already accumulating and the government has also proposed allowing pharmacists to substitute medicines for others that are unavailable. This is scant reassurance to those with rare diseases needing specific treatments or others, such as people with epilepsy, whose treatment is carefully adapted to their condition. The problem is that it is very difficult to know what to do. Philippa Whitford, a breast surgeon turned SNP MP, has tirelessly sought reassurance about supplies of medical isotopes but described a Brexit minister’s response, in December 2018, as “vacuous.” The Health Secretary repeatedly says that all will be well “if everyone does what they are meant to do”, but fails to say what this is.

For months, the food industry has been warning the government in private of threats to supplies but has finally spoken out publicly. A few senior NHS managers are doing so too, with one warning that “In the event of a chaotic, no-deal exit, many NHS trusts could quickly run out of vital medical supplies” and his memo suggested that, while it was believed that the Department of Health and Social Care had identified vulnerabilities, it had not shared the information with Trusts. The new President of the Royal College of Physicians has also spoken out, stating that “it’s just not possible to reassure patients that their care won’t be negatively impacted by the UK exit from the EU.”

Theresa May is clearly hoping that, by going up to the wire, MPs will support her deal rather than a catastrophic no deal. But she faces several problems. Firstly, she has spent two years telling the public that “no deal is better than a bad deal”, a message reinforced by pro-Brexit politicians displaying, to varying degrees, ignorance, confusion, and dishonesty. Secondly, it assumes that all MPs actually want to avoid the resulting chaos and, worryingly, this is far from certain. The slogan “Never waste a crisis” has attractions for some on the left and the right, with the terrible twins of Disaster Capitalism and Socialism offering scope to create either an unfettered free market or a communist utopia. And there are other opportunities, with many unanswered questions about the massive profits made by some Brexit backers who speculated on the referendum result. Thirdly, as the recent votes showed, it seems impossible to achieve a cross-party consensus on anything, not least because of the reluctance of many MPs to place the national interest above a façade of party unity. The risks are now extremely high and, if her plan goes wrong, it will be the NHS and its patients that bear the brunt of her gamble.

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

Competing interests: None declared.