In this feature, Thoreya Swage, Healthcare Consultant, examines the possible impact on the NHS of the outcome of the EU Referendum vote.
A month or so down the line from the EU Referendum vote the country is still coming to terms with, and assessing the impact of, the leave result.
Whatever promises were made by either side of the debate one issue is now very clear and that is that the “£350 million that the UK was paying to the EU every week” will not necessarily materialise and flood the NHS.
So what are the key issues and what sort of future does the NHS now face?
Simon Stevens, Chief Executive of NHS England, has noted that although the Brexit vote has divided the country it has also unified it in its desire to improve the funding of the NHS, and has commented that now there was an expectation that politicians would deliver on this promise. This was echoed by Dr Maureen Baker, Chair of the Royal College of General Practitioners, who said on 28 June in a message to GPs that “We must now hold those who stated that £350m a week could go to the NHS, instead of the EU, to account.”
In addition in early July, the finance ministers from the three devolved administrations in the UK (the Welsh Government, the Northern Ireland Assembly and the Scottish Government) have held discussions on the impact of the Brexit vote on public finances and their future funding streams, of which the local NHS is in receipt. The concerns of the devolved governments include securing their place and interests in Europe bearing in mind that Northern Ireland and Scotland voted to remain.
Mr Stevens announced, in a personal letter dated 4 July to all healthcare staff in England, that NHS England was setting up an NHS Europe Transition Team. This team will have a remit to engage with the health service, Department of Health, Cabinet Office and other agencies to enable as smooth a transition as possible ensuring that the NHS and patient voices were heard. The key “asks” would be put to the Health Select Committee on 19 July to clarify the path towards the new arrangements.
The immediate future
One of the first messages to go out from NHS leaders following the referendum result was a clear statement acknowledging that the 55,000 staff from the EU (and also others from elsewhere in the world) working within the health service were highly valued and played a vital role in delivering care to patients. Furthermore, the NHS was taking a zero tolerance approach to the intolerance and discrimination that arose in the aftermath of the leave vote.
One of the key assurances in the Brexit negotiations that will be sought from the new Prime Minister, Theresa May, who took office on 13 July will be that EU citizens currently resident in the UK should retain the right to do so following withdrawal from Europe.
In the meantime, work in the NHS will continue as before with a stronger focus in England on achieving the plan set out in the Five Year Forward View (FYFV) and now, at a faster rate. There are three main priorities identified by the FYFV.
Initiating the implementation of the seven national improvement programmes for urgent and emergency care, primary care, mental health, cancer, learning disability, diabetes prevention and maternity services.
Stabilising the NHS finance and operational performance at a local level.
Developing further the Sustainability and Transformation Plans (STPs) that were submitted at the end of June.
To this end the work on the 2016–2017 plan will accelerate from July 2016.
There will be further discussions with the local leaders of the 44 emerging STPs, bringing forward the annual planning timetable for 2017–2018 and possibly 2018–2019 and linking this in with the final STP submissions in October 2016.
There will be a focus on advancing the work on the mental health national clinical priority on Child and Adolescent Mental Health Services (CAMHS). On primary care, in line with the General Practice Forward View (GPFV), the new multispecialty community provider (MCP) voluntary GP contract will be published for consultation.
A series of “reset” measures will be published by NHS Improvement (NHSI) and NHS England for Clinical Commissioning Groups (CCGs), NHS Trusts and NHS Foundation Trusts to deliver on. These include measures to reduce the total provider deficit in England to less than approximately £250 million and to support CCGs that are struggling to achieve operational measures, eg waiting times.
Other measures include:
identifying new specialised tests and treatments that will be funded in 2016–2017
modifying the Cancer Drugs Fund to support the testing of “real world” outcomes for new cancer therapies that are most promising
identifying the centres that are best placed to provide the safest and most effective specialist services for children’s congenital heart disease.
Although there is an expectation that politicians should deliver more funding to the NHS, there is a greater risk that the Brexit vote could trigger a recession with the effect on reducing the tax revenues having a knock-on effect on public services. At the time of writing, the Chancellor has ruled out a surplus budget which potentially eases the pressure on the health service, although there are indications of greater reductions in public spending. Added to that is the underlying problem that the current NHS budgets are inadequate to meet the rising demand as evidenced by the increasing waiting times for access to primary care and urgent and emergency care.
The wider picture
Although the key decisions on how to run the NHS remain with the UK, there are a number of EU-connected issues which will require further examination including the movement and regulation of health professionals, rules of procurement, regulation on medicines and devices, cross-border patient entitlements and some public health measures.
Movement and regulation of health professionals
Both the General Medical Council (GMC) and Nursing and Midwifery Council (NMC) have stated that the vote to leave the EU should not have an impact on EU nationals already on the relevant professions register.
Currently there are about 19,000 doctors from the European Economic Area (ie the EU plus Iceland, Liechtenstein and Norway) working in the UK. This represents around 8% of doctors that are licensed to practise in Britain.
With regard to the movement of doctors, the GMC has highlighted a need to clarify how doctors from the EU will be able to register with the Council, how information is shared across countries and the implications for British doctors who wish to work in Europe once the UK is no longer a Member State.
Rules of procurement
The NHS procurement process currently follows a number of EU treaty principles when tendering and awarding contracts for clinical and non-clinical services. This includes the requirement to advertise any contract that is worth over €750,000 and to ensure that the principles of transparency, proportionality, equality of treatment and non-discrimination are maintained. Although different conditions may be negotiated with other countries including the EU, it is likely that the NHS would still want to demonstrate open, fair and transparent procurement.
Medicines and devices development and regulation
By leaving the EU the process of regulation of drug development, approvals, intellectual property and investment will be made more complex for pharmaceutical companies in Britain.
Similarly, any influence the UK has on a centralised authorisation system with regard to drug development and approvals by no longer being a member of the European Medicines Agency will probably diminish. While drugs and devices marketed in the UK are regulated by the Medicines and Healthcare Regulatory Agency (MHRA), any extra processes placed upon it as a result of leaving the EU may slow down access to medicines by patients in the UK.
In addition, British pharmaceutical companies may no longer have access to EU funds such as the European Investment Fund.
Cross-border patient entitlements and access to healthcare
Currently the health systems of European countries have a reciprocal arrangement with the UK for the provision of medically necessary healthcare for their citizens when travelling abroad using the European Health Insurance Card (EHIC). Although no changes have been proposed as yet this may do so as negotiations proceed.
UK residents can also decide to have operations abroad for certain procedures by paying upfront and then claiming the costs from the NHS. In some cases, prior authorisation is required from NHS England before proceeding. This arrangement may also be subject to change post-Brexit.
EU rules permit EU nationals to have access to healthcare within the EU on an equal basis as their country of origin. There are estimated to be around 1.2 million British nationals living in other EU countries. It is possible that following the referendum result UK pensioners may return placing extra pressures on health care services.
NHS research and development
The UK has contributed €5.4 billion to EU research and development between 2007–2013 and has received €8.8 billion for research, development and innovation activities.
Britain has a track record of winning EU funding for research and development in the life sciences sector, amounting to about 20% of the total awards granted despite being 12.7% of the EU population. If Britain wanted to retain access to this funding the UK would still need to make a contribution to the fund but have no influence in determining priorities or setting the agenda.
The National Institute for Health and Care Excellence (NICE) currently leads in European health technology assessments. This may diminish.
In addition, restrictions on freedom of movement may have a negative impact on the movement of researchers and academics across Europe.
Public health measures
The European Centre for Disease Prevention and Control manages the systems of surveillance and early warning of communicable diseases facilitating the quick sharing of information and technical expertise in response to communicable diseases, potential pandemics and other cross-border risks. Examples include management of the H1N1 pandemic and initiatives to address anti-microbial resistance.
So what does this mean for primary care?
The number one issue for primary care as highlighted in the GPFV is the impact on the numbers of GPs in the country. The GPFV plans to increase the numbers of GPs by 5000 by 2020, a key element of which is a major recruitment campaign overseas to attract up to an extra 500 doctors who are appropriately qualified and trained.
There are similar aims to increase other members of the primary care workforce such as practice nurses, physician associates, primary care mental health therapists and pharmacists, some of which could potentially be recruited from the EU.
These healthcare workers are needed to play a part in the implementation of the rest of the primary care strategy outlined in the GPFV to improve access, enhance information technology, improve the real estate and developing new care models such as MCP.
The NHS was already struggling to recruit enough staff to meet demand before the vote and this situation may be exacerbated by EU staff deciding to relocate to other countries.
The possible change in rules on access to healthcare may mean the return of older British nationals to the UK from the EU and placing a further burden on stretched primary care services.
The new climate for approving and regulating drugs would have the impact of possibly reducing access to new effective drugs as well as potentially increasing the practice drug budgets.
The success of the GPFV will be predicated on the flow of funds that were promised year on year to build-up primary care.
We Must Ensure a Strong General Practice in Post Brexit Britain, Royal College of General Practitioners, publication date 28 June 2016.
Personal message from Simon Stevens to all NHS England staff: The NHS after the Referendum, NHS England, 4 July 2016.
Five Big Issues for Health and Social Care after the Brexit Vote, King’s Fund, 30 June 2016.
Last reviewed 20 July 2016