The 2016 Brexit referendum created widespread political and economic uncertainty across the United Kingdom, with one of the most immediate and tangible effects emerging in the health sector. The National Health Service (NHS), long dependent on foreign-trained staff to meet its operational needs, faced a significant challenge as the referendum result signalled a tightening of immigration policy and a decline in the attractiveness of the UK to European healthcare workers. The resulting labour supply shock disrupted workforce composition in English hospitals, raising concerns about the implications for patient care. Recent research using detailed administrative data has demonstrated that these changes were not without consequence. Hospitals that previously employed a higher share of EU nurses saw a measurable decline in care quality, including higher patient mortality and emergency readmission rates.
Workforce Substitution Following the Referendum
Before the referendum, EU nurses played a vital role in staffing NHS hospitals, often filling gaps created by a persistent shortage of domestic healthcare professionals. In some hospitals, EU nationals made up more than a fifth of the nursing staff. After the referendum, the anticipated end of free movement and the broader political climate made the UK a less attractive destination for European nurses. Although immigration rules for EU citizens remained unchanged until 2021, the uncertainty alone was sufficient to reduce the number of new EU joiners. Hospitals responded to this shortfall by hiring more non-EU nurses, particularly from Asia, as visa restrictions for healthcare workers from outside the EU were eased in 2018. While this strategy helped maintain overall staffing numbers, it introduced a new problem.
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The qualifications and experience of new hires differed markedly from those of the departing EU nurses. Data from the NHS Electronic Staff Records showed that post-referendum recruits were often hired into lower salary bands, indicating lower skill levels or less experience. This pattern was not observed among medical doctors, whose higher pay likely insulated them from the effects of Brexit-induced uncertainty. As a result, while the absolute number of nurses did not decline significantly, the average level of skill within the workforce did.
Consequences for Patient Care
The quality of hospital care is closely linked to the competence and experience of clinical staff. In the case of NHS hospitals, a drop in workforce skill levels translated into poorer outcomes for patients. The most affected were emergency patients, who typically do not choose their hospital and rely on timely, high-quality intervention during acute episodes. Hospitals with a higher pre-referendum share of EU nurses experienced a statistically significant increase in in-hospital mortality rates and unplanned readmissions. The estimated effect on mortality was a 5.31 percent increase, equivalent to roughly 1,485 additional deaths per year across England. Similarly, unplanned readmissions rose by over two percent, adding nearly 8,800 extra cases in the three years following the referendum.
These figures underscore the human cost of a seemingly abstract policy decision. The impact was not limited to specific patient groups. Both men and women, across age ranges and income brackets, experienced higher risks. However, elderly patients were particularly affected, with their mortality risk increasing at a rate nearly three times higher than that of younger cohorts. Importantly, the analysis showed that these changes were not driven by shifts in patient volume, hospital funding or broader demographic changes. The decline in care quality was directly linked to workforce changes, not external pressures on the NHS system.
Economic and Policy Implications
The findings have important implications for policymakers, particularly in countries where health systems depend heavily on skilled migrant labour. In the case of the NHS, the financial burden of increased readmissions alone totalled more than £18 million. These funds, if available under different circumstances, could have been used to hire over 800 additional nurses at standard pay rates. When the estimated years of life lost due to higher mortality are considered, the cost becomes even more substantial, approaching £650 million in lost human value. Such outcomes highlight the unintended consequences of abrupt or poorly managed immigration policy changes.
The NHS case also provides a broader lesson on the importance of maintaining a stable and skilled workforce in sectors that are both labour-intensive and socially essential. It reveals that policy signals alone—even without immediate regulatory change—can influence the behaviour of prospective migrants. The Brexit vote, despite being consultative and not legally binding at the time, was sufficient to alter the perceptions and decisions of skilled workers. This sensitivity underscores the need for careful communication and transition planning when reforming immigration systems, especially in sectors like healthcare, where staffing disruptions can quickly affect service quality and patient safety.
The Brexit referendum had a clear and measurable effect on the composition of the NHS nursing workforce and, by extension, on patient outcomes in English hospitals. While staffing numbers remained stable, the decline in skill levels among new recruits led to a deterioration in hospital care, particularly for emergency patients. The findings suggest that the NHS’s dependence on foreign-trained nurses, especially those from the EU, is not easily offset by substitutions from other labour markets. More broadly, the experience highlights the risks of policy shifts that fail to account for the complexity of workforce dynamics in critical public services. The NHS case offers a stark reminder of the real-world consequences that can follow from disrupting the flow of skilled labour.
Source: IZA: Institute of Labor Economics
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