NO MATTER WHAT Brexit we get, the UK’s health service – the NHS – will be negatively affected, according to a health policy review published in The Lancet.

The review says that a no-deal Brexit is the worst scenario for the health service, impacting the workforce, financing, availability of medicines and vaccines, sharing of information and medical research.

The authors also warned that there’s “little evidence” that the UK is prepared for any of the eventualities set out in their analysis, which include a no-deal Brexit and British PM Theresa May’s rejected Withdrawal Agreement.

For instance, the recently published NHS 10-year plan is 136-pages long, with only two mentions of Brexit, neither of which offered any detail on how any threats would be handled.

The four scenarios analysed are a no-deal Brexit; the Withdrawal Agreement; the Irish backstop; and the political declaration, which outlines what a future UK-EU trade agreement could look like. 

While the review says that Theresa May’s Withdrawal Agreement offers “a more positive” scenario compared to a no-deal Brexit, there are still concerns about the longterm negative impact any Brexit could have on the NHS.

Under either the backstop or political-declaration scenarios, the impact of Brexit on the NHS is only slightly less harmful than a no-deal, though the exact impacts vary and are based on current UK and EU documents available to the study’s authors.

What are the problems?

In this new analysis, leading experts in public health and law assessed the likely impact on 15 specific aspects of the UK health service to try to predict the effect Brexit would have on those crucial services. 

A caveat for this lies with every Brexit analysis: this that is based on what is the current situation – which, as we know by know, is subject to change from day to day.

Among the problems exacerbated by Brexit is the recruitment and retention of healthcare workers, according to the review. The Withdrawal Agreement provides for mutual recognition of professional qualifications up to 2020, the end of the transition period.

But no provisions for healthcare workers have been made in the backstop or political declaration, which could follow after that (the transition period would run from 29 March until 31 December 2020, although it can be extended beyond that).

Under a no-deal Brexit, the Immigration White Paper proposes a minimum salary threshold of £30,000 per year which could seriously limit immigration of many health workers to the UK.

Under the Withdrawal Agreement, reciprocal healthcare arrangements (eg, via the European Health Insurance Card) would remain but only until 2020 as there is no mechanism to continue them subsequently, although some limited bilateral agreements may be possible eventually.

For example last week, the Irish government provided legislation in its omnibus Brexit bill, will allow for Common Travel Area healthcare arrangements so that patients in the North can access healthcare services in Dublin, and vice versa.

But in continental Europe, all reciprocal health care arrangements would cease in 2019 under a no-deal scenario. This would be particularly harmful to older UK residents and people with pre-existing conditions for whom health insurance cover in the EU would be particularly expensive.

As one of the largest areas of public expenditure, any negative impact in the UK economy will put additional pressure on NHS financing, and the UK has already seen a slower rate of economic growth than if it had remained in the EU.

In the build up to the 2016 Brexit vote, it was claimed that if the UK left the EU, that fees being paid into the European Union pot would be redirected to the NHS. A slogan on the side of a bus claimed that an extra £350 million a year would go to the NHS; Ukip founder and Brexiteer NIgel Farage clarified that this wasn’t possible after the referendum result was announced.

The review emphasised that the suggestion that Brexit will bring a “deal dividend” was described as not credible by the Treasury Select Committee. Given looming crises in several other sectors, including welfare and the criminal justice system, the authors note that concerns about whether the government can maintain its funding commitments for the NHS are warranted.

Under the Withdrawal Agreement, the continuity of legal provisions will secure supply chains for medicines, vaccines, medical devices and equipment until 2020. Under a no-deal Brexit, the absence of a legal framework for imports and exports would have an immediate and drastic effect on supply chains.

Despite government reassurance of contingency plans in place, shortages are likely because stockpiling arrangements can’t last more than a few weeks, proposals that doctors offer “best alternative medication” can be distressing for patients, and some products can’t be stockpiled.

Brexit has also drained the energy of the British civil service, as government and the House of Commons is required to pass several major pieces of legislation and up to 600 statutory instruments within a month. Meanwhile important legislation, such as social care, has suffered prolonged delays.

Under any form of Brexit, the UK will no longer be part of the European Medicines Agency, and while the UK’s Medicines and Health products Regulatory Agency will continue to licence medicines, without laws in place to secure regulatory alignment, the UK would become less attractive for global pharma to launch new medicines, potentially meaning launch dates up to 24 months later.

Additionally, UK laws on air pollution, workplace health and safety, and tobacco trade derive from EU law. With the UK having failed to meet standards on air quality, there is concern that the UK might use Brexit to roll back some of these measures.

Author’s analysis

Professor Martin McKee, co-author from the London School of Hygiene & Tropical Medicine said that some people “will dismiss our analysis as Project Fear”.

“But with just over a month to go to Brexit, we need to move beyond slogans. We have set out the problems in detail, based on the best available evidence.

If others disagree, then they owe it to the British people to say why. It just isn’t good enough to keep saying that ‘something will work out’ without any details of exactly how.

Professor Tamara Hervey, co-author from the School of Law, University of Sheffield said that it was “critical to be clear about the practical effects of disentangling over 40 years of legal integration”.

This is not something that can be done hastily without potentially jeopardising people’s health. 

Dr Nick Fahy, co-author from the Department of Primary Care, University of Oxford, said that the “NHS is at the heart of our national life; it is vital to understand the impact Brexit will have on it”.

The authors note that their analysis is based on the most up-to-date available legal texts, but is inherently limited by the lack of transparency about the British government’s preparations, the lack of detail in the political declaration, and the unprecedented nature of a member state leaving the EU.