![\"mcKee_martin\"](\"https:\/\/blogs.bmj.com\/bmj\/files\/2012\/12\/mcKee_martin.jpg\")
<\/a>As 2018 draws to a close and politicians in London and Brussels get ready for a much needed break, we have an opportunity to take stock of where the Brexit process has got to and what the implications might be for health. <\/span><\/p>\nTo recap, the UK and EU negotiating teams agreed a <\/span>draft text<\/span><\/a> of the agreement for the UK\u2019s withdrawal from the EU. This was strictly limited to getting the UK to the next stage of the process, the negotiations of the future relationship. With some minor exceptions it covered only three areas, citizens\u2019 rights, the financial settlement, and the Irish border. Negotiations on a long term relationship would only begin in April 2019 and, given the length of time to reach the withdrawal agreement, it seems reasonable to assume this could take many years. <\/span><\/p>\n Previously, and extremely reluctantly, Theresa May had been forced to concede that any agreement with the EU would be put to a \u201c<\/span>meaningful vote<\/span><\/a>\u201d in the House of Commons. However, it soon became clear that there was no chance of the vote supporting it, with opposition from all of the other parties, including her supporters in the Northern Irish Democratic Unionist Party, but also a substantial number of Conservatives, including those supporting Brexit and Remain. It was clear that the prime minister would be unable to get it through Parliament so she pulled the vote.<\/span><\/p>\n So where now? Amid scenes that parliamentary sketch writers likened to a <\/span>pantomime<\/span><\/a>, and with cabinet ministers publicly making <\/span>completely incompatible statements<\/span><\/a>, the prime minister maintains that she can somehow overcome the opposition within Parliament to get agreement on her deal. Few find this remotely plausible. The EU has already made major concessions to allow the UK to sign up to it, <\/span>too many<\/span><\/a> in the view of some member states. Heads of EU27 governments, by now tired of having their schedules disrupted by meetings called at short notice that go nowhere, have made it abundantly clear that the deal on offer is the <\/span>best one possible<\/span><\/a>. Of course, it is much worse than staying in the EU, but that is the UK\u2019s choice. It is up to it to find a solution to its domestic political problems. But is this possible?<\/span><\/p>\n At a time of national crisis, one might think that the political parties could work together in the common good. Yet, rarely have British politics been so polarised. Moreover, throughout the entire Brexit process the prime minister has been determined to limit any discussion to a small inner circle. This excludes not only opposition parties and devolved administrations, but also her party, much of her cabinet, and even apparently, successive Brexit secretaries. It seems very unlikely that she will now change. <\/span><\/p>\n Nor is it clear who she would talk to in the Labour Party. The party\u2019s official policy is to seek a general election and, if that fails, to consider a second referendum. Yet, although it is now obvious that it cannot achieve the first objective, by winning a confidence vote, Jeremy Corbyn does everything possible to avoid moving to the second option. Labour is as divided as the Conservatives and, by all accounts, is also led by someone who is locked inside a tiny circle of advisers. Claims that Labour could somehow negotiate a better deal, while maintaining restrictions on freedom of movement are, to say the least, implausible, given the steadfast commitment of the EU to the integrity of the single market, which includes free movement. Those searching for an explanation of what is happening ask whether, just as there are those in the Conservative Party who see Brexit as an opportunity to create a free market state, free of \u201cred tape\u201d, in the form of workers\u2019 rights, food safety regulations and the like, there are some around the Labour leader who would welcome Brexit as an opportunity to create a <\/span>socialist revolution<\/span><\/a>. There are also some politicians, in both of the main parties, who talk of a \u201cWTO deal\u201d, although no such thing exists. Trade experts are agreed that reverting to World Trade Organisation arrangements would be catastrophic, and would ignore the many other issues related to EU membership. This proposal also ignores how President Trump\u2019s <\/span>refusal to reappoint WTO judges<\/span><\/a> is bringing the organisation to the brink of a crisis.<\/span><\/p>\n The prime minister\u2019s strategy now seems to be to threaten that, if the House of Commons rejects her deal, there will be no deal. To reinforce this message she has ordered the civil service to step up planning for such an eventuality, while cabinet ministers even suggest that the UK could <\/span>\u201cflourish and prosper\u201d<\/span><\/a> in such an event. <\/span><\/p>\n This view is not shared by those who would have to try to keep the system working, with those involved in getting food on the shelves of British supermarkets using terms such as \u201c<\/span>Armageddon<\/span><\/a>\u201d. Their concerns are not allayed by the absence of any detail in the documents produced so far by the UK government, which continue to express a hope that something will work out. This contrasts starkly with the <\/span>European Commission\u2019s documents<\/span><\/a>, which spell out in precise detail the measures that it will take. Recognising that competence for many of the issues affected by Brexit are shared between the EU and Member States, the Commission calls on national governments to do everything possible to support both UK and EU27 citizens who are at risk. It has not, however, gone unnoticed that the spirit of generosity in the EU\u2019s approach, and that of national governments such as <\/span>the French<\/span><\/a>, is not reciprocated in the UK\u2019s Immigration White Paper. Crucially, the EU makes very clear that these measures will be adopted unilaterally, to protect the EU 27. If the UK government is determined to pursue a \u201cno deal\u201d situation, it must make its own arrangements. <\/span><\/p>\n But is the UK really serious about planning for \u201cno deal\u201d. Many are sceptical. The health secretary Matt Hancock says that the plans will work \u201cif everybody does everything they need to do\u201d. We can assume this is core to the plans as he repeated the phrase five times when giving evidence to the Commons <\/span>Health and Social Care Committee<\/span><\/a>. The government\u2019s published advice is based largely on the assumption that the EU will agree to provisions to alleviate its problems. This would involve what has been termed a \u201cmanaged no deal\u201d, although the government (but not every <\/span>minister<\/span><\/a>) rejects that term. Yet that will not happen, for many reasons, including that it would resemble some aspects of the existing situation with Switzerland. The EU and Swiss government have been negotiating a single overarching agreement since 2014, but having finally reached one in principle, the Swiss Federal Council has been unable to agree and has initiated a <\/span>public consultation<\/span><\/a> to break the deadlock. <\/span><\/p>\n There is some evidence that the government is taking planning seriously. It has committed to increase spending on \u201cno deal\u201d preparations to \u00a34.2 billion, a substantial sum from a government that invokes the lack of a \u201c<\/span>magic money tree<\/span><\/a>\u201d to refuse claims to address the many other challenges facing the country. As others have noted, this money could usefully <\/span>be spent elsewhere<\/span><\/a>. Yet \u00a32 billion of this will not be spent until after March 2019 and there are serious doubts about whether the sums already committed can be spent, given the time it will take to recruit and train new staff and to create completely <\/span>new organisations and IT systems<\/span><\/a>. Similarly, the announcement that <\/span>3,500 troops<\/span><\/a> would be placed on standby has inspired little confidence, given that the government deployed <\/span>18,200 during the 2012 Olympics<\/span><\/a>. <\/span><\/p>\n But beyond the rhetoric, is anything actually happening. Not much, it seems. The health secretary reports that he is buying up fridges, but an analysis undertaken by this journal found that NHS Trusts are <\/span>almost totally unprepared<\/span><\/a>, lacking any central guidance. And time is running out. The Pharmaceutical Services Negotiating Committee, representing community pharmacies, reports <\/span>shortages and rising prices<\/span><\/a>, which it believes may be related to Brexit. The government is planning to allow pharmacists to <\/span>change prescriptions<\/span><\/a> if the drug is unavailable, without contacting the prescriber. GPs in <\/span>Wales<\/span><\/a> and <\/span>Cornwall<\/span><\/a> are already reporting shortages of medicines, thought to be due to stockpiling, while others have warned that, even without Brexit, the pharmaceutical supply chain in the UK is <\/span>more precarious than is often realised<\/span><\/a>.<\/span><\/p>\n