Following the EU leave vote healthcare is evermore under threat. From a workforce crisis to funding deficits, NHS workers are noticing a multitude of issues encroaching on medicine. Tim Tonkin reports
Nearly a year has passed since British voters went to the polls to decide whether the UK should be in the EU.
The decision to leave, followed by prime minister Theresa May’s triggering of article 50 at the end of March this year, spells a period of political, social and constitutional upheaval not witnessed in decades.
While the full impact of Brexit may not be known for a number of years, what is clear are the implications it has for healthcare in the UK and Europe.
With British voters set to go to the polls again in a general election, the BMA published its manifesto – A Vote for Health – outlining a number of issues, including Brexit, which will prove decisive to an NHS at breaking point.
In its recommendations for protecting healthcare post-Brexit is a need for a guarantee of permanent residence to all EU health workers and medical researchers.
The association is also calling for reciprocal arrangements such as mutual recognition of professional qualifications and patient-safety measures to be in place between the UK and EU post-Brexit.
More than 10,000 doctors working in the NHS gained their primary medical qualifications in other EEA (European Economic Area) states, while the UK’s health and social care workforces are bolstered by around 135,000 EU nationals.
Following last year’s vote health secretary Jeremy Hunt, despite pledging at the 2016 Conservative Party conference that the UK would become self-sufficient in doctors, conceded that the NHS would ‘fall over’ without the ‘extraordinary contributions’ of overseas staff, with another 35,000 doctors working in the NHS who are from outside the EEA.
However, a survey of EU doctors carried out earlier this year by the BMA found that 42 per cent admitted to considering leaving the UK as a result of the Brexit vote.
Aberdeen-based specialty trainee 5 in trauma and orthopaedics Anna Riemen is one of many EU doctors facing an uncertain future.
Coming to the UK from Germany 17 years ago to study biochemistry, Miss Riemen completed her medical degree in 2004 and has since worked in the NHS in Scotland.
Although eager to remain in the UK, events of the past 12 months have meant she is having to consider complex decisions about her future while still having no clear idea about what might happen following Brexit negotiations.
‘It [the outcome of the referendum] was quite disconcerting at the time, even though I sort of saw it coming,’
‘A year on, as a German citizen, I still have no clear idea what the plan is for me. I would like to stay, complete my training and work in the NHS but we [EU staff] do not know what we will get from the negotiations.’
Rights at risk
Immigration status once the UK leaves the EU has long been the primary concern for EU nationals such as Miss Riemen, who, following the 2016 vote, has looked into a number of residency options.
‘I did consider applying for dual nationality but ultimately decided against this.’ She explains: ‘I have applied for permanent residency which took two months for me to get a confirmation of my application and may take another six months for a decision to be made.’
In spite of Mr Hunt’s promises of staffing self-sufficiency, Miss Riemen says she had little confidence that a future government would be able to safeguard the health service.
‘The NHS relies on dedicated nursing staff and doctors from the UK and many EU countries – [in Scotland] we can barely recruit to rural places and cities such as Aberdeen.
‘Reducing this talent pool further would be very dangerous for the health service. Progress and excellence is supported by staff with different and new experiences.
‘It takes five years to train a doctor, even longer to get specialists. Workforce planning is notoriously difficult – the Government has not managed to get it right so far – why should this time be different?’
Without these assurances, Miss Riemen says that she would have serious concerns as to how her EU colleagues might respond and what this might mean for the NHS and patients.
The BMA has warned that ensuring a flexible approach to EU immigration post-Brexit is as vital to medical research collaboration as to frontline NHS care, as is continued access to the funding the EU provides.
According to figures published by the Royal Society, the UK received an estimated €8.8m from the EU between 2007 and 2013, while contributing around €5.4bn during the same period.
With more than half of UK research in 2015 the result of international collaboration, the society noted that 60 per cent of this work included EU partners, with EU nationals accounting for 16 per cent of all academic staff in UK universities.
Despite the Government’s announcement in August 2016 that it would guarantee EU grant funding post-Brexit, finance is only part of the wider picture, with freedom of movement and the ability for UK and EU staff to collaborate vital to research.
Funds in question
Anaesthesia specialty trainee Harriet Kemp is a currently completing a PhD as a clinical fellow at the pain research group at Imperial College.
The project, which focuses on HIV associated sensory neuropathy benefitted from more than €500,000 in EU funding and has allowed Dr Kemp to collaborate with fellow medical academics from across Europe.
With funding for the project secured before last June’s EU referendum, Dr Kemp says that she had no fears about impediments to her research, but that leaving the EU raises a question mark over future initiatives.
‘Being in the EU means we get to work with research groups from all over Europe and within this network gain the opportunity to learn about what they’re doing and take part in joint projects. The collaborative side is as important as the funding side,’ she says.
‘While leaving the EU does not stop us collaborating it does make it that much more difficult. There are many aspects of pain research that are at more advanced stages in countries such as France and Germany, so having the opportunity to benefit from their experience is crucial.’
An often overlooked aspect of the healthcare implications posed by Brexit are those affecting Northern Ireland.
With healthcare in the country facing acute pressure, at general practice and secondary care levels, the BMA has urged politicians to ‘pay particular attention’ to the unique impacts Brexit may have.
These include issues around the recognition of EU medical qualifications, with significant numbers of doctors practising in Northern Ireland having gained their medical qualifications in the Republic of Ireland.
Damage to cross-border collaboration is also a concern, with a paper published last December by the Northern Ireland Assembly highlighting the risk to initiatives such as CAWT (Cooperation and Working Together).
Funded by the EU, the CAWT project has facilitated a variety of health and social care services jointly overseen by authorities in both Northern Ireland and the Republic, benefiting patients from both countries.
Finally, and perhaps above all else, there is the issue of border controls between what will be EU and non-EU territory and a return to a pre-1993 ‘hard border’ between the two countries.
Newry-based consultant anaesthetist Peter Maguire is one of a number of Northern Ireland doctors who regularly travel south of the border as part of their work.
Holding dual nationality and having qualified in Dublin, Dr Maguire – who is normally based at Daisy Hill Hospital in Newry, Northern Ireland – has, since May 2016, also worked at Monaghan General Hospital in the Republic.
He said that the UK’s exit from the EU presented a number of challenges to the health service in Northern Ireland, not least the potential for a return to hard borders. He asks: ‘How onerous will this be? How long will the process take?
‘If we get hard borders [as a result of Brexit] I am going to leave the NHS and move to the Republic of Ireland, and there’s no question that other doctors in Northern Ireland feel the same way.’
As well as placing new restrictions on cross-border movement, he says that he was concerned that trade between the Republic of Ireland and a post-Brexit UK could also face new challenges.
He says: ‘54 per cent of the exports from Ireland are pharmaceuticals, additionally huge amounts of medical equipment are made and come from Ireland. What will happen if there are tariffs? What will happen to the cost of drugs with the change in the [value of the] euro? Euro salaries will make it much more attractive to work in Ireland. Medication that I already have to make a business case for to access in Northern Ireland will potentially become even less available.’
The NHS is at breaking point
Public health faces increasing uncertainty
The BMA manifesto has urged that an exit from the EU does not hinder the UK’s ability to take a lead in European and global public health threats.
By leaving the EU, the UK will need to define a new relationship with those organisations responsible for regulating safety standards in health, or develop a new approach.
These include the European Medicines Agency, which evaluates the safety of pharmaceutical treatments for people and animals, and Euratom, whose remit would include areas such as nuclear medicine.
While public health services in the UK have already borne the brunt of significant funding cuts, exiting the EU could see new regulatory responsibilities, or at least more complex arrangements, for public health being heaped on to a future UK government.
London School of Hygiene and Tropical Medicine professor of European public health Martin McKee expressed his concerns about what impact Brexit might have.
Professor McKee, who is also director of research policy at the European Observatory on Health Systems and Policies, says that the sheer scale of the undertaking facing the Government made it unlikely that complex areas such as public health, could be given sufficient regard.
‘Brexit is the biggest event our government and civil service has had to face since the D-Day landings,’ he says.
‘The main challenges will be the Government’s inability to function and secondly the shortfall in money that leaving the EU will entail. Both of these will have a huge impact on the NHS. We [the UK] import all our radioisotopes from the Netherlands, and we import our food from all over the world.
'The EU has Euratom and [food safety] inspectors in 130 countries. The UK could, on some basis, choose to continue to buy into these EU regulatory structures, otherwise we will have to establish our own systems.’
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