Mark Dayan: Follow the signs to the nearest Brexit

Whatever the outcome of Brexit, there are some clear themes that the NHS needs to prepare for

Predictions about Brexit are a dangerous game. Even if parliament and the Government settle on an outcome in the coming weeks, at most this will only take us to another stage of negotiations where almost everything remains on the crowded proverbial table. But the specifics are another matter. Under the noise we now know enough about most forms of Brexit to be fairly sure of the likely impact on the NHS.

No deal

Nobody knows what a no deal Brexit would truly bring, but the direction of travel is not in doubt. NHS supplies imported from the EU would be hit with a battery of new checks, and delays caused as public and private sector customs officials and systems struggle to cope with the massive increase in their workload. Medicines are especially exposed because they are both heavily regulated and heavily traded.

In the longer term, all this would push up costs to a total I have estimated at £2.3bn a year across the UK. Meanwhile, reciprocal healthcare initiatives like the European Health Insurance Card would cease to function until they could be replaced, something so far only arranged with Spain. The UK would be ejected from shared arrangements in clinical trials, data sharing, and science funding.

A plummeting pound and the rapid introduction of what is set to be a tough new migration system would risk layering on top of these problems a sharp exacerbation of the workforce crisis.

An orderly divorce

Until leaving without a deal became a real possibility, a “hard Brexit” meant leaving the single market with a trade agreement. That still remains possible, either through something akin to what is outlined in Theresa May’s joint Declaration with the EU, or through a customs union.

The Withdrawal Agreement that would form the basis of any such departure includes a standstill transition period of up to four years, providing some respite. Northern Ireland’s NHS would be spared the problems of a hard border. Beyond that, looking at the EU’s trade deals with other partners gives us some sense of what could and could not be secured.

Agreements with Australia, for example, give its regulators the right to sign off medical devices for the EU market and vice versa. The EU’s flagship science funding programmes have a well-established route to associate membership.

But no country outside the single market is part of the EU’s system of medicine authorisation and oversight. This would mean the UK splits off into a separate market for medicines. We would tend to get new products later, and be a less attractive place to invest in trials and research. Reciprocal healthcare programmes like EHIC seem unlikely to survive.

For staff migration, the proposed new immigration system would again loom on the horizon. Our analysis with the King’s Fund and Health Foundation has catalogued the problems this could cause for nursing and social care—unless it is revised, which it would be entirely within the UK’s power to do.

Gently does it

The “Common Market 2.0” and “Norway” options promoted by some MPs and commentators present a very different future: one where the UK leaves the EU, but stays in the single market. This would mean that medicines regulation, clinical trials, migration and reciprocal healthcare continue just as today. Some costs may still rise, though, as there would still be additional friction unless we also entered a close customs union with the EU.

These models do, of course, mean that the UK is largely bound to follow EU rules without much formal role in shaping them, with only limited and politically dramatic ways to opt out.

The constant factors

Across these scenarios are running themes: effects that people in the NHS may want to prepare for, whatever the Brexit weather. The first is pressure on the costs of supplies—especially medicines, and especially generic medicines, where prices float more freely. Pressures on costs, of course, is synonymous with shortage.

The sensitivity of the finely tuned logistical machine behind medical imports can be in no doubt. Even today, before Brexit has led to the slightest regulatory change, uncertainty and perhaps stockpiling appear to have led to a steady climb in the number of medicines recognised by the Government as being in shortage—from twenty to thirty before the referendum, to more than twice that.

The second is increased pressure on staffing as migration is at best deterred by uncertainty, or at worst barred by new rules. Again, the ramifications are already making themselves felt, with EU migration slowing or falling for many groups. This has been partly balanced by an increase in migrants from outside the EU, but this trend might not survive contact with the new Immigration Bill.

In short, the NHS should brace itself for an impact whether large or small—but also recognise that there is still all to play for in influencing and responding to the course of Brexit.


Mark Dayan is a policy analyst and head of public affairs at the Nuffield Trust