After nearly five years of negotiation, delay, and drama, there are now less than 100 days until the UK leaves the EU’s single market and Brexit becomes a reality for many areas of healthcare, social care, and science. With the deadline for extension now passed, these changes will wait for no pandemic. They will be felt primarily in the areas of supplies, workforce, and finances.

Clog in the channel

Leaving the EU customs union and single market will mean many checks and declarations are needed at currently frictionless borders, with a huge leap in overall bureaucracy involved in importing items into and out of the UK. For example, the number of customs declarations made is expected to increase fivefold from 55 million to around 255 million.

Ahead of a no deal Brexit last year, the Government believed that the public and private sector would struggle to cope to the point where there would be disruption to supplies for up to six months, at its “most severe” for the first three. Recently published plans for dealing with medicines and devices disruption are largely identical to last year’s, which suggests the underlying prognosis is similar. They include new routes to ship medical supplies into the UK, and a six week stockpile. Whether these are enough remains to be seen: given the striking fluctuations we have already seen in medicines supply over recent years, it seems unlikely that there will be absolutely no effect.

Regulate to accumulate

Leaving the single market also means that we are no longer part of its shared regulatory system for medicines and devices. This will present health policymakers in the UK with a dilemma. 

The immediate temporary plan is to keep recognising most EU regulatory processes, from the release of individual medicine batches to the certification of devices. This will partly head off the hundreds of millions in extra costs and likely delays to new products reaching the UK market which would result if we insist suppliers go through separate processes.

But it will also mean that pharmaceutical firms will have less incentive to invest in the UK, and that we have no control at all over medicines and devices policy or standards. Eventually, the incentives will point towards using the new powers in the Medicines and Devices Bill to set up a different UK regulatory system offering faster or smoother approvals—but even if it attracts business, any duplication will increase costs.

In some areas, a trade deal could improve the situation by obtaining mutual recognition in either direction, something the UK has asked for. However, the EU appears to have refused. This is not in the interests of European health systems, who will have less competitive pressure driving down the costs they pay, but has seen little public pushback from the UK side compared to issues of state aid and fisheries.

Can’t get the staff

From 1st January, the UK will also be free to impose its own migration system on all those coming here. The Home Office’s policy statement lays out an approach that would let in nearly any doctor, and nearly any nurse for at least as long as they remain a “shortage occupation”. But yet again, social care receives short shrift. Despite a shortfall of well over 100,000 in England alone which has been growing despite sizeable recruitment from the EU, the new rules would make it impossible to migrate to take up the vast majority of frontline roles in the sector.

There is no money left

Economic assessments unanimously conclude that leaving the single market will mean less growth in GDP, and therefore a slower increase in tax revenue. The implications for the NHS need to be understood alongside the crash caused by coronavirus, and the laundry list of large spending commitments that the government has already pledged in health and social care—from guaranteed growth in the NHS England budget, to forty new hospitals, to comprehensive social care reform.

The result is likely to be that even though the health services ended 2019 struggling to keep a lid on their finances across the UK, with areas like public health and training having seen years of cuts, further pleas for funding will fall on even deafer Treasury ears than usual.

The end of an era

Following these major effects are many smaller, but potentially consequential changes in how healthcare in the UK relates to its counterparts in Europe. The Nuffield Trust is part of a new initiative funded by the Health Foundation which will aim to map all the ways Brexit may affect health in the UK and how to monitor them. For example, the future of European Health Insurance Cards is under negotiation, as is the UK’s continued access to the institutions that share data and connect countries to deal with pandemics. Major changes will happen in areas such as chemicals regulation, air quality standards, and state aid, any one of which may turn out to have important ramifications for peoples’ health and for organisations providing healthcare.

2020 will stand out in the history of the NHS for decades to come. The most momentous event in infectious disease for a hundred years is still ongoing: the most momentous event in its international position for seventy years is impending. Leaders, policymakers and ordinary staff at every level from care homes to the Brussels negotiating chamber will need to go to exceptional lengths to keep decent healthcare freely available to people in the UK.

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

Competing interests: None declared