So what happens next? And what are the implications for the NHS? Martin McKee unpicks the latest developments on Brexit

The cliff edge has been averted, for now. The UK will not crash out of the European Union without a deal on 29 March 2019. And there is a plan to move forward. It is not, however, the plan chosen by the UK, but rather one that has been chosen for it by the EU 27. Two defeats, by some of the largest margins in parliamentary history, coupled with the reminder by the Speaker of rules, dating from 1604, that she could not keep bringing the same proposal back until she got through, meant that Theresa May had run out of time. She had to ask for an extension to the Article 50 process at the March meeting of the European Council. Before she arrived, it had been made crystal clear that she had two options on timing, a short delay, going up to the start of the European Parliament elections, or a longer one of up to two years. The first would allow the UK to avoid holding the elections; the second would require it to. A member state cannot remain part of the EU while its citizens are unrepresented in the Parliament. Faced with these two choices, the prime minister proposed a third, to extend the process to 30 June, just before the first sitting of the new Parliament. To almost no one’s surprise, it was not taken seriously.

Given the almost universal desire to avoid a “no deal” scenario, with the notable exception of substantial parts of the British Conservative party and some speculators, or “disaster capitalists” who appear to welcome it, the assembled heads of governments did everything possible to help the prime minister. But there is only so much that anyone can do. Accounts of the discussions make clear that, two years on from triggering Article 50, she lacked any credible plan to leave the EU. One source is reported as saying it was 90 minutes of nothing… Evasive even by her standards.” Asked three times about what she would do if her proposal failed to pass parliament the following week, “she very much dodged these questions.” Indeed, she could not even confirm whether she would move a third vote. At this point, it was clear that the EU 27 would have to come up with their own plan, which they did. The UK can remain a member state until 12th April. If, by then, she has secured approval for the existing Withdrawal Agreement, she will have until 22nd May to enact the necessary legislation to leave. Otherwise, she can ask for a longer period, providing she has a clear plan for how to proceed.

So what happens next? Everything hinges on whether Parliament will approve the Withdrawal Agreement. There are several reasons why this may not happen. First, the Speaker may not agree for it to be debated again. Given that Mrs May has not shifted on her “red lines” of remaining outside the single market and customs union, there is no further scope for negotiation with the EU27. He has made clear that any new motion must be substantially different. Even if he did, her speech in which she appealed to the British people while representing their elected representatives as the barrier to achieving Brexit has alienated some of those who had shifted to support her and others who were considering it. Her portray of MPs as, in effect, “enemies of the people”, even if she did not use that wording was seen as especially ill-judged as it led to MPs being advised to take extra security precautions. And even if she did succeed in scraping together sufficient support in a third “meaningful vote,” there is no guarantee that she would be able to pass the necessary legislation to give its provisions legal force.

In these confused circumstances, prediction is extremely hazardous and can easily be overtaken by events. Assuming Theresa May remains prime minister, it is difficult to see how she could agree to a longer delay in April. This means that crashing out with “no deal” remains a real possibility. Already, central and local government bodies are putting in place the necessary provisions. Authorities in Kent, the county likely to be worst affected, is putting its schools on an emergency footing, including advising on measures to protect children who may be exposed to additional pollution from idling lorries stuck in traffic jams and caring for children whose parents are caught in those jams or on duty as emergency workers. The Ministry of Defence has activated an emergency team in a nuclear bunker in Whitehall. Ferry contracts to import vital supplies, including medicines, are being activated. Yet, faced with a two week delay, what are they to do? It is very difficult to halt these processes once they have started. Even before the European Council decision, many financial corporations had started to move an estimated £1 trillion and many of their operations away from London, despite recognising the possibility of a delay. These developments recall the events leading up to the First World War, when a series of measures that would lead to catastrophe were driven less by individual political decisions and more by railway timetables.

And what are the implications for the NHS? The Health Secretary continues to offer reassurance. We are told that all will be okay “if everyone does what they are meant to do”. The obvious problem is that this requires that they know what this is. Throughout the Brexit process, the UK approach has been based on secrecy while the EU27 approach has been characterised by transparency. Planning has been handicapped by delays in providing civil servants with security clearance. The now notorious “impact assessments”, deemed so secret that even MPs were denied access to them and, when eventually the government was forced to allow them to be read, it was in sealed rooms without any means of recording what was written. When eventually released, they were found to contain such insights as how fishing mainly took place in coastal communities and banks were generally situated where people lived. It is now reported that the Department of Health and Social Care has signed 24 non-disclosure agreements, although we are not allowed to know with whom. Other reports describe how NHS Trusts have been advised not to release their Brexit risk assessments. Meanwhile, NHS staff who are EU27 citizens remain deeply uncertain about their future, quite reasonably taking little assurance from ministerial statements.

Yet, even if Parliament does somehow take back control and reaches an agreement about how to proceed, it will only be the beginning. There is no consensus whatsoever about the nature of the UK’s future relationship with the EU27 and very little possibility that the necessary legislation could be enacted by the Commons. Then there is the problem of the House of Lords, largely ignored in the debate so far, which has already shown itself willing to vote down a number of key measures. The Irish border issue continues to defy a solution. It is simply impossible to identify anything that retains free movement between Ireland and the continent, required by the EU Treaties, Ireland and Northern Ireland, required by the Good Friday Agreement, and Northern Ireland and Great Britain, required by the effective veto held by the Democratic Unionist Party, while preventing it between Great Britain and the continent. The term “alternative mechanisms” is understood in quite different ways by the UK and the EU27. The former envisages some sort of technological solution that simply does not, and cannot in the foreseeable future, exist (despite the debunked arguments of Brexit supporters). The EU27 is referring to a deep alignment of policies on trade, rejected by the UK. It is simply not possible to reconcile these views.

If it is to avoid a “no deal” scenario (although there are some suggestions that Theresa May would now be willing to allow it), at some stage, the UK will have to shift its “red lines”. This seems unlikely that this will happen as long as she is in charge. When it does, it will have to restart the negotiations with the EU. Yet this time it will be much more difficult. So far, there has been a determined effort to respond positively to the UK’s demands, even while recognising that many were impossible to reconcile with the EU Treaties. The arrangements for the Irish backstop, which would allow the entire UK to remain in a customs union and not just Northern Ireland, was a major concession, allowing a degree of cherry picking that would otherwise be unacceptable. Now, however, the mood has changed. EU27 leaders have spent many long hours trying to help the UK find a solution to its self-imposed constraints. This has prevented them getting on with other important issues. And they are now fed up. Even though many leaders are strongly Anglophilic, they despair for the UK and, often very reluctantly, have concluded that the UK is beyond saving from itself. They will continue to do everything possible for UK citizens in their country, even while being aware of the risk to EU27 citizens from the UK’s “hostile environment”. And this view is not limited to the EU27. While some MPs have advocated a “Norway model”, in which the UK aligns with, or even joins EFTA, it is increasingly clear that the governments concerned, especially Norway and Iceland, are questioning whether they actually want such a disruptive and difficult member.

And of course there is another possibility. For several months, polling has shown a consistent majority in favour of remaining in the EU. Demographic shifts alone, as older “leave” supporters die and are replaced by younger voters who are strongly supportive of remaining can be expected to widen this gap further. A petition calling on the government to revoke Article 50 gained almost 3 million signatures in under 48 hours. Although the Prime Minister has firmly rejected this option, at some point it may be the only one remaining that is actually feasible without doing long lasting damage to the country.

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

Competing interests: None declared.