The UK finds itself at the start of the negotiations to leave the European Union, and potentially at the start of seismic changes in the union between England and Scotland too. This is a sentence that a year ago it would have seemed impossible to be writing. But that is the stark reality. Assuming that the plans for Brexit continue, in five years we will be living in a different world. Whether you are a Remainer or a Brexiteer you might now be bracing yourself for the substantial changes that will unfold.
For healthcare these are, indeed, substantial. Unlike environment, agriculture or transport, health itself is not a core EU competency meaning that Brussels and Strasbourg do not have any direct legal jurisdiction over our health policy and how we deliver it. However there are so many elements of European legislation and investment that do impact - employment law, research and development, competition - they render that fact irrelevant. And, like any long term relationship, having been part of the 'ever closer Union' for over forty years, we take a lot for granted. We are closely entwined with the other countries in the EU, and unpicking things like reciprocal benefits and treatment approval processes, will be an important part of the negotiations.
There are five key issues that the healthcare sector needs to consider very carefully indeed: reciprocal healthcare; medicines regulation; competition and procurement law; workforce and funding.
The ongoing right of UK national visiting other EU countries or resident in them to access healthcare benefits must be negotiated. The European Health Insurance Card (EHIC scheme, or E111 in old language, has formed an important part of free movement for UK citizens: people can travel 'worry free' in terms of healthcare. If the UK cannot negotiate future involvement in the EHIC scheme we will need alternative arrangements. These are likely, by definition, to be more complex than applying for a health insurance card valid for five years, and will involve the same level of insurance that you would consider when travelling beyond the EU. We could also hazard a guess that it will be more expensive.
More importantly for the healthcare sector is how we then manage access to health services by non-UK citizens currently covered by the reciprocal arrangements. Following the excellent BBC documentary, Hospital, media and political activity focused on how non-EU citizens pay for healthcare. It is clear that the process is bureaucratically burdensome and also somewhat at odds with the 'care for all' ethos of those practising in the NHS. Although the NHS is now preparing for upfront charging for elective care, the resource implications of broadening this out to a larger population either resident in or visiting the UK could be considerable. We need to factor this very active monitoring in to our thinking.
There are five key issues that the healthcare sector needs to consider very carefully indeed: reciprocal healthcare; medicines regulation; competition and procurement law; workforce and funding.Director of policy and strategy
Recently media stories about timely access to life-saving medicines post-Brexit have been ramping up. A red line for the Government in any negotiation is that the UK will no longer be under the jurisdiction of the European Court of Justice. If this red line holds, it prevents our ongoing membership of the European Medicines Agency.
Currently as a member of the European Medicines Agency the UK (as part of the EU) enjoys 'tier 1' market status, which means that pharmaceutical and device companies launch their products here first, alongside other large markets such as the US and Japan. The intention is for our Medicines and Healthcare products Regulatory Agency (MHRA) to achieve regulatory equivalence with the EMA. But this is not guaranteed. The UK agency is a small player compared to the might of the EU. So outside of the EMA, our market reach will be small.
NHS patient access to new treatments could be delayed by a year or longer. This is bad for patients and it impacts the NHS's ability to provide cutting edge treatments which support its world leading healthcare system status.
Before the referendum last June NHS Providers surveyed NHS trusts about their views on the impact of leaving or remaining in a number of different areas. Competition and procurement law stood alone in being the area where trust leaderships felt that leaving would be beneficial. It would support greater efficiency and cut through the mass of red tape with which the EU is so closely associated.
Outside of the EU there is the opportunity for the UK to review the application of competition law and, perhaps, better align this with the collaborative approach to health and care delivery to which the NHS has moved in recent years.Director of policy and strategy
Outside of the EU there is the opportunity for the UK to review the application of competition law and, perhaps, better align this with the collaborative approach to health and care delivery to which the NHS has moved in recent years. Similarly there would be the potential to review procurement law and tailor its application to the NHS. The legislative burden of these changes would not be small but it could well have positive outcomes.
Healthcare is a people business - first and foremost. The most immediate response to Brexit in the NHS was about how we support and protect our workforce, a substantial part of which is made up of EU nationals. Their status is now unclear and this is problematic. Not only is it deeply unsettling for those affected but it also creates, practically, uncertainty in terms of retention and recruitment. We rely on EU workers but we can't repay that with guarantees; there is no clarity about status in the period between the 'cut off date' for UK resident EU nationals and the introduction of a new immigration system. This could be a deterrent.
Any new system must be flexible to ensure the health and social care system can recruit domestically, from our European neighbours and globally. The Government's aim is workforce self-sufficiency for the NHS. To achieve this in a reasonable timeframe needs a simple, unbureaucratic immigration system. There is common feeling across the health sector that the EU workforce must be protected. NHS Providers is a leading member of the Cavendish Coalition, which is campaigning for permanent leave to remain for all EU nationals resident in the UK as well as a future immigration system fit for purpose for the needs of the health and care system
We rely on EU workers but we can't repay that with guarantees; there is no clarity about status in the period between the 'cut off date' for UK resident EU nationals and the introduction of a new immigration system. This could be a deterrent.Director of policy and strategy
Finally we get to the money. This where one thing is clear: we really do not know the impact of Brexit on our economy and by extension on the budget available to support the NHS. The £350 million a week promised during the referendum campaign has disappeared into thin air, and our economic fortunes are likely to fluctuate during the two year negotiation period. Depending on the deal agreed with the EU upon the UK’s withdrawal, this could continue long beyond this. The prudence of the 2017 Budget demonstrates how much the Chancellor needs to give himself room to smooth the economic bumps – austerity will rule until the mid 2020’s.
NHS trusts are only just coping with rising demand now; the prospect of a sustained period of low investment will fundamentally challenge the viability of the NHS’s current model. Farmers who are direct recipients of CAP funding support, or regions of the country who relied on infrastructure funding from the EU, will be lobbying hard for replacement support. We in the NHS must make sure we beat the drum about the financial impact on healthcare of leaving the European Union.
Prediction is a fool’s game, but it is time to start preparing for what we know, and don’t know, is just around the corner.
This article was first published in PF Perspectives on 4 April 2017