Healthcare and the National Health Service (NHS) budget were a key element of the Brexit referendum narrative: Vote Leave infamously promised that savings from paying into the EU budget could be spent on health, a pledge from which campaigners have since disassociated themselves. Indeed, the NHS is unlikely to benefit from Brexit – very much the contrary. Indeed, Brexit weakens the financial sustainability of the NHS.

According to estimates from the King’s Fund, in 2015–16 the NHS had the largest deficit in its history. NHS funding has been unable to keep pace with a growing demand for services. These financial constrains come at a time of staff shortages in most British hospitals, which have had to rely, as is common practice, on private temporary contract agencies and, more generally, on private providers who already make up 18% of the NHS spend on community health services.

Leaving the European Union in such a context creates a conundrum for English hospitals. How can they square their need for cost savings with maintaining quality? Better-quality services inevitably mean extra resources, which are not available without extra funding. So Brexit raises questions about the financial sustainability of an unreformed NHS – that is, an NHS without additional money. Leaving the EU will lead to significant restrictions on labour mobility, which can shift labour costs upwards – for example, higher wages will be required to incentivise a declining medical workforce, and more vacancies might need to be covered by temporary staff. In addition, we can expect higher transaction costs for intermediary goods. Brexit is estimated to lead to a reduction of 6.3–9.5 % of national income which will mean even less revenues to fund the NHS.

Effect on the workforce

Even before Brexit, the NHS has struggled to recruit and retain permanent staff. In 2014, there was a shortfall of 5.9%, and in social care 5.4%, rising to 7.7% in care services in the home, and about one-third of all UK nurses are due to retire in the next ten years. The problem is even more alarming when one looks at the GP workforce. A recent report of the Royal College of Physicians suggests that, in 2016, 86% of physicians experienced shortages across clinical teams.

Reducing EU immigration would increase wages on both ends of the wage distribution. In such a scenario, the options available include incentivising EU immigration or expanding health and social care spending in an attempt to transform it into a higher-wage sector, with the aim to increase its productivity. Therefore, the trade-off is between saving NHS funds by hiring health professionals from overseas, or expanding health investment further to incentivise local recruits (with some delay as they are trained).

Brexit may offer an opportunity to get rid of the contentious European Working Time Directive  which limits the maximum amount of time that employees in any sector can work to 48 hours each week. In turn, raising working time limits is likely to cause a deterioration in the quality of NHS employment and make working for the NHS less attractive.  

Effects on patients

The balance of payments associated with free patient mobility seems to have traditionally benefited the UK, given that British expats (who stop using the NHS) tend, overall, to be older than EU residents in the UK – who are on average younger, healthier and more highly skilled. After Brexit, UK citizens are unlikely to have the right to travel to the EU for treatment and therefore will enjoy less control over their healthcare. Furthermore, British tourists might be excluded from the European Health Insurance Card  programme. The only advantage, from a welfare perspective, of restricting mobility is that discouraging it reduces competition between health systems. Hence it could be argued that mobility deters a ‘race to the bottom’ in healthcare investment.

Brexit almost certainly means higher costs for the NHS, especially labour, as I argue in more detail in a recent article in the Journal of Social Policy. As a consequence of Brexit, it will become more difficult to attract qualified staff and other inputs affected by non-tariff barriers (e.g. rules of origin checks, regulatory barriers, border controls etc.), and procurement will become more expensive. Certainly, Brexit does bring some opportunities too – including the possibility of redefining the NHS in new directions. Nonetheless, it takes place in the midst of a process of fiscal consolidation (leading to longer waiting lists, waiting times etc) and will create additional and unnecessary financial pressures.

This was first published on the  British Politics and Policy blog

The triggering of article 50 starts a period of uncertainty in our NHS. The decision is momentous, but after seven years of neglect from successive Tory governments the prime minister and health secretary must finally give the NHS and patients the certainty needed through the Brexit process.

So far the complacency in government is astounding. Last week, Jeremy Hunt published the department of health’s “mandate to NHS England” to set “the government’s objectives and any requirements for NHS England”. Amazingly the 24 page document made no mention of Brexit whatsoever.

And during the prime minister’s statement yesterday confirming the triggering of article 50, she failed to mention the NHS even once. Neglecting our health and social care system during the most significant period of political and economic uncertainty in decades is completely unacceptable.

The prime minister has already turned her back on the clear promise of £350 million a week for our NHS, but perhaps it shouldn’t come as much of a surprise that the NHS isn’t taken seriously as a Brexit priority for the government. Indeed, the health secretary isn’t even a member of the relevant cabinet committees managing the exit strategy.

Later this week health bosses will publish the updated five year forward view. NHS chief executive, Simon Stevens, must ensure it includes the NHS’s plan for Brexit and not duck its responsibility to staff and patients.

After all, Britain’s health and social care system is dependent for its success on tens of thousands of European staff. Many of them have settled and built lives here while caring for our sick and elderly: safeguarding their futures should be an absolute priority in the Brexit negotiations.

So our first test of the government plans will be whether they deliver a right of remain for the 140,000 European Union nationals working in the NHS and social care system.

Secondly, on funding we know that the EU’s horizon 2020 scheme is due to invest £7.5 billion in health research across the EU over the next five years, and Britain will be by far the largest recipient of those funds. This long-term funding is crucial for our medical institutions and universities planning major research projects. So we need to know whether access to these funding streams will continue after Brexit, and if not, how does the government propose to make up the shortfall?

Our third test is on reciprocal healthcare arrangements. It is a key principle that British citizens can obtain free healthcare elsewhere in Europe, just as they would here at home from the NHS. Therefore, we want a guarantee that British citizens travelling and living abroad in Europe will continue to receive healthcare.

Finally, our fourth test is on EU healthcare collaboration. Effective joint working with our European partners has been vital for the NHS over recent years on everything from infectious disease control and the licensing, sale and regulation of medicines. The government must clarify whether the UK will continue to participate in the centralised marketing authorisation procedure for medicines governed by the European Medicines Agency. And how will Brexit will affect the UK pharmaceutical industry when exporting medicines to other member states in future?

These are of course difficult and complex questions to answer, but they are all of absolute importance to the future of our health service and of our medical research sectors.

The NHS is already in crisis over funding and staffing. But without a proper plan Brexit has the potential to tip those crises into unprecedented disasters. Patients and NHS staff should not be bargaining chips, and, at the very least, the public deserves clarify and certainty from the government.

First published on Labour List

Everyone knows that after seven years of neglect from the Conservative government, the NHS is undergoing a serious crisis of funding and staffing. The last thing needed is more uncertainty. That is exactly what the NHS faces with Brexit.

On Wednesday Theresa May will trigger article 50 and later this week health bosses publish the updated Five Year Forward View. It is time for the prime minister and the health secretary, Jeremy Hunt, to give the NHS and its patients the certainty needed through the Brexit process. May has already turned her back on the promise of £350m a week for our NHS and now she is walking away from her responsibilities to protect the health service through a turbulent Brexit process that will hit it hard.

The complacency in government is astounding. Last week Hunt published the department of health’s Mandate to NHS England to set “the government’s objectives and any requirements for NHS England”. Amazingly, the 24-page document made no mention of Brexit whatsoever.

Will health professionals from other EU countries be able to come to work in our NHS after Brexit, or will there be a cap on their numbers? As long as the issue is left unclear, more and more EU workers are voting with their feet and leaving on their own terms. In a recent survey, 42% of European health staff working here said they are now thinking of leaving the UK. Almost 5,500 have left since the Brexit vote according to NHS Digital, a 25% increase on the 2015 figures. And others are being put off from coming here at all: only 96 European nurses registered to work in the UK in December – that figure was 1,304 for last July.

This long-term funding is vital in giving security to those medical institutions and universities planning major research projects. They cannot just wait and see what will happen after 2019. So we need to know whether access to these funding streams will continue after Brexit. If not, how do the government propose to make up the shortfall?

Our third test is on reciprocal healthcare arrangements. It is a key principle that British citizens can obtain free healthcare elsewhere in Europe, just as they would at home. That is an important safety net for British holidaymakers, and for UK citizens living elsewhere in Europe. Does the government intend to maintain those arrangements? If not, how will it address the increased insurance costs for UK holidaymakers?

These are difficult and detailed questions, but they are all of absolute importance to the future of our health service and of our medical research sectors. There is no reason why May should refuse to give us the answers. That will allow us to understand with greater clarity what the impact of Brexit will be on the NHS – and most importantly, it will allow patients and staff the opportunity to scrutinise the government’s plans closely over the next two years.

The NHS is already in crisis over funding and staffing. But Brexit has the potential to tip those crises into disasters. Patients and NHS staff should not be bargaining chips in May’s hard Brexit negotiations. They want a world-class NHS delivering the best quality healthcare. As article 50 is triggered, the very least the public deserves is clarity and certainty from its government.

First published by The Guardian