The impact of Brexit on the health industry in the UK is likely to be deep and far-reaching. Most changes are unlikely to happen immediately, and indeed depend on when Article 50 is triggered and the deal Britain is able to negotiate for its relationship with the EU as a non-member state.
However, June’s referendum has created huge uncertainty for the healthcare industry in the UK, as well as the medical research that underpins innovation in its diverse fields.
This article examines four distinct areas likely to be impacted by Brexit; staffing, regulation, access to healthcare and medical research/the life science industry.
Staffing
A total of 55,000 of the 1.2 million staff in the NHS in England are citizens of other EU countries — equivalent to 5 per cent of NHS workers. The EU’s central tenet of the freedom of movement of workers, and the parallel obligation of mutual recognition of professional qualifications, has been hugely significant to the healthcare industry in the UK. According to the Nuffield Trust, 10 per cent of physicians and 4 per cent of nurses are from other EU countries.
It is well known that the NHS is facing huge problems in recruiting and retaining permanent staff – in 2014 there was a shortfall of approximately 50,000 full time staff. A similar problem exists in the social care sector. Although both the head of NHS England and the Secretary of State for Health have sought to reassure EU workers in the wake of the result, the problems of recruitment are likely to worsen.
While the freedom of movement of EU citizens is unchanged at this time, the uncertainty Brexit has created over the security of their ability to live and work in the UK in the future will exacerbate the existing shortfall in staffing in health and social care. Though the government is likely to encourage healthcare professionals from the EU to remain even if the Brexit goes ahead, the increased amount of bureaucracy and the difficulties of working in a system outside of the EU may force many to seek employment elsewhere.
Regulation to enable common professional standards and medical education between EEA countries and cross border co-operation
Linked with staffing is the issue of ensuring common professional standards across borders. A new directive on Mutual Recognition of Professional Qualifications (MRPQ), agreed at European level at the end of 2013, was enacted in member states on 18 January 2016. The directive covers all professions, for example vets and architects, and not just healthcare. The EU directive already includes provisions on:
- Knowledge of languages
- Minimum standards of training
- Temporary service provision
- Conditions for recognition
- Recognition of professional traineeships
- Compensation measures
A consultation on the directive was commissioned in order to obtain views on the new elements being introduced that would apply to doctors, dentists, general care nurses, midwives and pharmacists from January 2016. Overall it was clear that the new measures would assist appropriately qualified EU citizens to move between the EU with ease. It is possible that all these developments will be prejudiced.
Likewise, it is unclear whether the new Europe-wide alert mechanism aimed at enhancing patient safety across the EU will now benefit Britain. The alert provides professional regulators in host states, with a faster and more reliable system for identifying certain professionals who have been restricted or prohibited from practising in another EEA state. It obliges professional regulators to notify their counterparts in other states within three calendar days (not working days) of any decision to restrict or prohibit that individual from certain practising rights. There is a risk that, with Brexit, England will miss out on the benefits from this proposed mechanism, allowing rogue professionals to escape detection here.
Language control is another key topic. In 2014 regulators were empowered to carry out proportionate checks on professionals where there is a concern about their English language capability. The Government had also been considering introducing new legislation requiring all public sector organisations to ensure that all staff in public-facing roles can communicate effectively, to what is expected to be at least "level 2" (equivalent to a C or above at GCSE). The changes were to be implemented through the new Immigration Bill which is anticipated to come into force in Autumn 2016. Now that the government’s focus is elsewhere, achieving effective regulation might be delayed.
In terms of co-operation, recent examples of cross border collaboration include the H1N1 pandemic and efforts to tackle anti-microbial resistance (AMR).
Collaboration across the EU has also enabled the UK to further its scientific research agenda, through our ability to access both European research talent and important sources of funding. For example, between 2007 and 2013 the UK contributed €5.4 billion to EU research and development (Office for National Statistics 2015) but also received €8.8 billion for research, development and innovation activities (European Commission). There are also other formal and informal networks across Europe – for example for some rare diseases, where the low numbers affected make it beneficial to work across the EU – that may be affected. There are concerns that this type of collaboration will be negatively impacted by Brexit.
Access to healthcare at home and abroad
How about the care itself? Currently UK citizens can hold a European Health Insurance Card (EHIC), which allows them to receive treatment in another member state during a temporary stay. Thanks to reciprocal agreements, these costs can then be recouped from the visitor’s home country. Post-Brexit this arrangement will need to be discussed and we will look with interest at how the issue is worked through as it seems unlikely that a situation will be allowed to develop whereby the costs of care available under reciprocal arrangements are increased. For example, nationals of EU member states are currently entitled to access health care on the same basis as citizens of that country. If this were no longer to apply to the considerable numbers of UK citizens currently resident in other EU member states, many of whom are pensioners, it could mean that many will instead return to the UK for treatment, which will impact on the demand for healthcare provision in the UK, and in turn on the costs of providing such healthcare. Equally, the NHS will likely no longer be under the current obligation to provide healthcare to EU citizens resident in the UK. We expect to see constructive efforts to reach a mutually beneficial arrangement to deal with these issues.
Medical research and the life sciences industry
Related to costs is the question of funding and development. Leading figures from the life sciences industry recently expressed their fears that Brexit could jeopardise the UK's central role in the European pharmaceutical industry and call into question the country's access to innovative medicines. EU law allows for a cooperative and harmonised approach to the regulation of medicines. Similar regulations were due to be applied to clinical trials across the UK in 2018. When Britain leaves the EU, in the absence of arrangements that mirror existing arrangements it is likely that European pharmaceutical companies would have to apply separately to the UK’s regulatory agency for authorisation to supply medicines in the UK. Again, uncertainty surrounds how leaving these regulatory agreements will impact upon UK citizens’ access to 1) medicines and 2) the benefits that result from the clinical trials that are currently being undertaken.
There are also concerns that Brexit will have consequences for British science. Nobel Laureate Sir Paul Nurse, director of the UK’s flagship biomedical research centre due to open this month, the Francis Crick Institute, regrets the grave impact any limits on mobility will have on Britain’s ability to continue the ground-breaking research it has built up a reputation for: “Science thrives on the permeability of ideas and people, and flourishes in environments that pool intelligence, minimises barriers and are open to free exchange and collaboration.” Head of the Royal Society, Venki Ramakrishnan, has similarly warned that “any failure to maintain the free exchange of people and ideas between the UK and the international community including Europe could seriously harm UK science.”
Immediate concerns for medical research in the UK centre on the twin issues of funding and personnel. The EU has for decades played a crucial role in funding world-leading medical research in the UK. As the Royal Society recently reported, more than 31,000 scientific researchers at British universities come from EU member states. There is now uncertainty as to whether the government will be able to fill the financial gulf left by the retraction of EU funding from its research budget, Horizon 2020, which was launched in 2014 and is worth nearly £67 billion.
What next?
An overused word is the description of dealing with uncertainties as a “challenge”. Clearly there will be challenges ahead as the Government defines its objectives around a new relationship with the EU and its member states. Politically, some will point to the future of the NHS as a public service available to all, being put at risk. Despite those siren voices the fact is that the development of healthcare provision in the UK, whether in the public or independent sector rarely stands still but evolves constantly. To add to the dynamic pace of change and evolution is now the uncertainty that Brexit highlights.
Any reduction in the provision of publicly-funded health care could lead to an increase in the provision by the independent sector. That would offer different challenges to for example investors and healthcare insurers.
Quite apart from a weakened pound, the UK remains a location where high quality healthcare provision exists and may in future be seen as a market for export, perhaps alongside the idea of UK PLC that came to prominence following the 2012 Olympic Games.
Health professionals and those in the health insurance market would be well advised to keep abreast of developments with Brexit as they happen, as key issues such as staffing, regulation, access to healthcare and funding for medical research and life sciences are put under the spotlight.