HealthManagement, Volume 19 - Issue 5, 2019

The date is set (we think!) - on October 31st the United Kingdom is to leave the European Union (EU). Since the 2016 referendum on membership of the EU bloc, when 51.9% of British voters opted for an exit from the European Union, the Brexit negotiations have been erratic and dramatic with no resolution about the form the exit will take. Trade deals, immigration and the impact on the UK and bloc-wide economy have dominated the agenda since the vote but what about the effect Brexit will have on the UK National Health Service (NHS), patient rights and medical research? Healthcare experts from across a spectrum of disciplines gave their views.

Mark Dayan

It’s impossible to predict what Brexit will mean for the NHS since how or even if it will happen remains undecided. But, if we look separately at each possible path out of the EU, the picture is clearer.

A no-deal Brexit would be a real shock to the healthcare system. The aligned laws that support access to medicines, devices, and science cooperation programmes would vanish, causing friction and disruption. We would lose European Health Insurance Cards (EHIC) and other reciprocal healthcare schemes. And under new controls on migration from the EEA as laid out by the last government, a slump in the numbers coming in would worsen the staffing crisis. A Brexit with a deal but which involved leaving the Single Market would still mean being shut out of the EU medicine regulation system eventually, and reciprocal healthcare too. But the impact would at least be padded by a transition period and better wider terms of trade. A competent government should be able to negotiate continued access to science programmes, and aligned regulation for medical devices.

A “soft” Brexit where the UK stayed in the Single Market would mean very little change from what we have now. But the UK would lose its voice in the institutions that make the rules, potentially leading to science and medicine regulations that would suit the country less in the future.

Markus Frischut

EU citizens currently enjoy certain rights under EU law concerning health treatment abroad, both in planned and unplanned situations. While it is true that EU Member States are, in principle, responsible “for the definition of their health policy and for the organisation and delivery of health services and medical care." EU law has a huge impact on various stakeholders and in various ways. Depending on the type of Brexit (soft, hard, or no agreement), this will have huge consequences on EU27 citizens and UK citizens, seeking healthcare in either direction. Hence, we don’t have a “bright future," but a dismantling of existing rights.

While the Withdrawal Agreement does not mention EU rules on patients’ rights detailed under the relevant EU Directive, it provides for some complex rules for the coordination of social security systems.

However, if the Withdrawal Agreement is rejected by the UK, the EU27, or the European Parliament, such a no-deal will have consequences in both directions; for cross-border healthcare at the island of Ireland, for British pensioners in the EU, to name but a few examples of direct effects. This doesn’t event touch on indirect effects with regard to EU rules on public health and research.

Michael Johnson Ellis

There are a number of current potential threats to the NHS that could be exacerbated by Brexit. For example, the current recruitment and retention crisis will potentially provide a huge challenge to the sector. In fact, Brexit has already had an effect in the UK, with applications from EU nurses down 96% since the 2016 vote.

To mitigate this, decision-makers need to ensure they are reducing spend on temporary staff and directing their focus to securing permanent workers. With the huge amount of money that can be saved from cutting spiralling agency costs, Trusts can then create more favourable workplace conditions, reducing the likelihood of a staffing exodus. In addition to this, with a concerted effort at creating strategic workforce plans aimed at pipelining future talent, Trusts can prepare as best as possible for future externalities.

While Brexit will undoubtedly pose a large test, it’s important to not pay too much attention to fear mongering. Despite what many may say, there will be more than enough high-quality talent available to staff the NHS post Brexit – but only if workforces are managed efficiently.

Martina Axmin & Titti Mattsson

European integration has led to increased mobility in healthcare. Over the years, a great number of people around Europe have been able to take advantage of the right, established under EU rules of coordination, to obtain healthcare during a temporary stay in another state participating in the scheme. The EHIC was introduced in 2003. Its aim is to facilitate access to healthcare for residents of the participating states when they visit another such state, and to simplify the procedures in such a situation. The card replaced the forms that such persons had needed earlier in order to gain access to healthcare during a temporary stay in another participating state. Since then, this card has been the sole document with which said persons can verify their entitlement to healthcare in another participating state. It also entitles the state in question to reimbursement for costs thereby incurred. The card can be used in any situation during a temporary stay – irrespective of the purpose of the stay – should medical treatment be needed. It thus proves the entitlement of the card holder to such treatment. The card guarantees the same treatment to its holder as that received by a person covered by the social-security system of that state. The same procedures must be followed; the same charges (if any) are to apply.

This health-card scheme, then, is a powerful factor facilitating free movement among the participating states. The impact of Brexit is highly uncertain in many areas, especially if it takes a ‘hard’ form. There is no uncertainty, however, about its effects on the British when it comes to their access to healthcare during visits abroad. In the absence of a formal agreement stating otherwise, namely, they will no longer be able to use the EHIC. Instead, they will need to return home to receive the care they require, or they will have pay for it up front. Nor, unfortunately, will residents of the participating countries be able to use the EHIC when visiting the UK. Should a hard Brexit take place, this will be the harsh reality.

Vassilios Papalois

With Brexit, the first concern I have is about the patients. We must not forget there are many people from continental Europe living in the United Kingdom. There are many people from the United Kingdom living in continental Europe. These people have well-established lives, either in the UK or in Europe spanning many years. As they are human, they will eventually face health problems. At the moment we have no clarity as to how these people are going to be treated.

When you are a doctor, politics is one element of it- but your main care is about the patient. In this situation, we have no clarity whatsoever of what type of care we will be able to offer our patients and this is a major issue and my biggest concern.

Parallel to this falls the issue about health professionals, because there are many professionals who have moved to both sides of the English Channel. Again, they have well-established professional lives and they don’t know what the status of their employment, the status of progression, or the status of their family in the years ahead will be. So, again, this lack of clarity is detrimental for the practice of those people, not only for radiology but also for all specialities.

Nick Fahy

Although health is primarily a national issue, decades of European integration mean that Brexit would have wide-ranging impacts on the NHS. Obvious examples include the free movement of the healthcare workforce, access to medicines and medical devices licensed through European mechanisms, and reciprocal healthcare arrangements. Less obvious examples include cross-border European Reference Networks for rare diseases, EU investment in NHS infrastructure, and integration in Europe-wide health research.

The effects of Brexit on healthcare could thus be widespread and overwhelmingly negative. The precise effects depend on the type of Brexit – the harder the Brexit, the worse the effects, with no deal being the worst of all.

The Withdrawal Agreement at least provides continuity while the long-term future relationship is negotiated. The Northern Ireland backstop has varying effects, with continuity in some areas, such as health products, but no continuity in others. The Political Declaration on the Future Relationship envisages a relationship that is centred around a free-trade agreement, in which wider health-related issues are largely absent. In the long run, though, the largest impact on the health system is likely to come from Brexit’s impact on the wider economy, and thus on the ability of the UK to finance the NHS.