10. Education, science and healthcare
- Brexit brings material risks for science, education and healthcare
- Science and research: loss of funding; loss of influence over EU standards; loss of participation in science programmes; loss of talent
- Higher education: loss of academic staff and loss of EU27 international students due to uncertainty and new immigration controls; and, loss of funding from regional growth funds
- Healthcare and adult social care:
- Loss of EU workers leading to poor service delivery in health and social care; unfilled vacancies
- Loss of influence over EU regulation of medicines, loss of expertise and reduced participation in cross-border clinical trials
Click here for summary of Brexit FactBase.
Higher education in the UK is a world-class sector. UK universities rank amongst the best and produce highly-regarded research, making them attractive to international students and staff.
The higher education sector is valuable. In 2011–12, universities generated an annual output of £73 billion for the UK economy, contributed 2.8% of GDP and supported over 750,000 jobs.
Research by Oxford Economics for Universities UK found that, in 2014-15, through their payments to universities (for tuition fees and accommodation), international students:
- supported an additional £13.5 billion in gross output, and
- contributed £13.8 billion gross value added to GDP in the UK.
The UK higher education sector has strong ties to the EU. Collaboration and co-operation between UK universities and EU institutions are facilitated by:
- Free movement of students from the EU (127,000 non-UK EU students studied in the UK in 2015/16);
- Free movement of staff from the EU (31,600 EU academic staff make up 16% of the academic staff in higher education) and vice versa;
- Membership of EU research programmes, which provide significant funds to universities and facilitate collaboration;
- Membership of Erasmus+, which provides funding for work and study placements abroad to support student and staff mobility.
International students in UK higher education
In 2015/16, 428,000 international students studied in the UK in higher education (427,000 in 2014/15) – 19% of total (see Table 10.1).
Of these, 127,000 (5.6% of students in higher education and 29.1% of international students) from EU27 countries studied at UK universities in 2015/16
Non-UK EU students accounted for 14% of the economic impact (£1.9bn).
(EU students contribute less per capita than non-EU students because tuition fees for a non-EU student are higher. There are also more non-EU post-graduates).
Erasmus+ (European Region Action Scheme for the Mobility of University Students) is the EU’s programme to support education, training, youth and sport in Europe. The European Commission manages it, setting priorities and targets, and oversees delivery. These priorities link with the EU migration agenda, the EU security agenda and EU strategic investment in human capital. The UK joined Erasmus in 1987.
A budget of €14.7 billion (five years to 2020) provides opportunities for over four million Europeans to study, train, gain experience, and volunteer abroad. Annual budgets are increasing (see Figure 10.1).
- In 2016, 725,000 Europeans received Erasmus mobility grants.
- 44,741 participated in the UK in higher education, vocational education and training, school education, adult learning and youth.
- 2014 -16 budget was €2.1 billion – UK grants were €92 million in 2015-16.
- 15,786 UK students studied abroad under Erasmus.
- 31,362 Erasmus students studied in the UK.
- 2,919 UK staff worked abroad and UK received 4,406 staff.
- Non-EU countries in the programmes are: Macedonia FYR, Iceland, Liechtenstein, Norway and Turkey.
Sources: European Commission, December 2017, What is Erasmus+?; Erasmus+ UK factsheet for 2016; Erasmus results and statistics
In December 2017, the agreement reached in Phase 1 of the Brexit negotiations means that there will be no change to the UK’s status in Erasmus+ until 2021 at the earliest. The same applies to Horizon 2020.
In April 2017, House of Commons Education Committee made five recommendations in response to Brexit.
- Uncertainty over EU students and EU staff needs to be reduced immediately. For staff, the issue of their residency rights require speedy resolution. The Government should react to any delay in reaching a reciprocal agreement by unilaterally guaranteeing rights before the end of 2017.
- The immigration system after Brexit should cater more particularly for the needs of higher education. It should facilitate, rather than obstruct, movement of people from and to our universities. The best model for all international students, including from the EU, is an open approach with few barriers.
- Research collaboration with Europe is essential to higher education. The Government should commit to Horizon 2020 and future research frameworks to ensure ongoing research collaboration with the EU
- Erasmus+ is an important programme for student and staff mobility and continued membership should be a Government target. If this looks unlikely, we recommend a home-grown replacement that could include mobility beyond Europe.
- The Government should establish a new regional growth fund to replace, and exceed, the investment from European structural funding.
Science and research
The EU leads the world in science output:
- The EU produces over a third of the world’s scientific output. It produces 34% more than the US and that gap has grown by 4% over the last six years (according to the latest UNESCO data).
- Oral evidence given at the ongoing Lords’ inquiry into EU membership and UK science repeatedly stated that the EU had overtaken the US as the home of “big science”.
- The EU puts 8% of its budget into Horizon 2020, the multinational science programme. This was over €11billion a year for the 2014-20 financial plan. The EU science budget has tripled over the last decade.
Figure 10.2 shows how the intensity of science activity (measured by the number of researchers as a percentage of the population) in a country correlates with public funding of science. Source: UNESCO Science Report, Towards 2030, 2015.
Benefits of EU for UK science
EU membership benefited UK science in three main ways:
- International collaboration within the EU. Working together across borders is becoming an increasingly common and effective way to solve major challenges. UK researchers can work with the best partners across the EU. Freedom of movement of people and a common legislative framework make cross-border collaboration within the EU much easier than with the rest of the world.
- Global networking and productivity. European-led projects attract laboratories from around the world as secondary partners, increasing the global networking power of UK science. From 2007-2013, the EU science programme involved 170 countries worldwide. The latest UNESCO data show that 62% of the UK’s research outputs are now international collaborations (compared to 39.6% for the US). According to a 2013 UK government report, the UK’s increasing internationalisation has put the UK ahead of the US for science productivity.
- Funding. EU funds now make up 17% of the total science research grants in UK Higher Education Institutes (HEIs). But, most importantly, 73% of the increase in HEI science funding from 2007-14 came from EU sources. Meanwhile, UK government spending on research and development (R&D) in the UK has been declining, falling from 0.56% of GDP in 2009 to 0.49% of GDP in 2013 (according to Campaign for Science & Engineering (CaSE) figures). The average spending on R&D in OECD countries in 2012 was 0.7% of GDP, while the EU average was 0.64%.
Brexit has implications for science and research in three main areas: people and collaboration; policy and regulation; and, funding. UK and EU science are interlinked closely, as the President of the Royal Society observed:
“In the past, UK science has been well supported by EU funding. This has been an essential supplement to UK research funds. In the upcoming negotiations we must make sure that research, which is the bedrock of a sustainable economy, is not short changed, and the Government ensures that the overall funding level of science is maintained.
“One of the great strengths of UK research has always been its international nature, and we need to continue to welcome researchers and students from abroad. Any failure to maintain the free exchange of people and ideas between the UK and the international community including Europe could seriously harm UK science.
“Finally, many global challenges can only be tackled by countries working together and it is easier to work together when policy and regulation are consistent. In negotiating a new relationship with the EU we must ensure that we do not put unnecessary barriers in place that will inhibit collaborations.”
Venki Ramakrishnan, President of the Royal Society
The agreement reached in Phase 1 of the Brexit negotiations means that there were no changes to the UK’s status in Horizon 2020 until 1 January 2021. Subsequent changes depend on whether the UK reaches agreement with the EU for UK participation in new Horizon programmes after the end of the transition period. At the moment the UK may participate in Horizon 2020 programmes which run after 31 December 2020, but there is not yet an agreement for the UK to participate in the next Horizon programme which will run from 2021 to 2027.
An October 2020 research paper has found that UK firms have decreased their international research collaborations by about 50% while other European firms increased international partnerships during the same time. This is a useful barometer that indicates that Brexit has made the UK less attractive as a collaboration partner. Although the study did not analyse causes, this are likely to include concerns about the implications of ending freedom of movement and regulatory divergence.
HMG, Horizon 2020: what it is and how to apply for funding, 31 January 2020
Osswald and Pierk, Brexit! The Effect of Political Risk on International Research Collaborations of Firms and Research Institutions, 2 October 2020
Loss of talent
As an EU member and during the transition period, the UK could hire effortlessly from a population of 500m. By losing freedom of movement with the EU, the UK would be hiring from the EU27 in the same way as from the rest of the world. Currently, non-EU science workers go through extensive bureaucracy from the UK Home Office.
If the UK puts restrictions on EU scientists and their families, the EU is likely to put restrictions on UK scientists in the EU. The free-flow of talent and easy collaboration is being replaced in the UK by the uncertain, stressful and costly red-tape of the Home Office.
In the “science and maths” higher education workforce in the UK, 21% are from the EU27 who play a key role in UK science education. For more information on EU citizens in the UK workforce please see the section on immigration.
Loss of participation
Future UK participation in the EU science programme and all the associated multinational collaborations and talent exchanges is not guaranteed. Some countries (e.g. Switzerland, Norway, Israel) buy into the EU science programme from outside.
However, participation is not an entitlement, it needs to be negotiated. When Switzerland cancelled its freedom of movement agreement with the EU, it was limited to partial access to the science programme. As a result, Swiss involvement reduced by 40%. It seems likely and natural that the EU27 will cherry-pick parts of the programme away from the UK to best serve its own institutions and researchers.
Lost influence over EU science policy
The UK will no longer have input to EU science policy (e.g. patient data, clinical trials, stem cell research, climate change). Similarly, the UK will lose input to the development of the EU science programme or the EU laws that the UK would have to adopt to work across borders effectively.
There is a risk that European science infrastructure and science-based companies would leave the UK to be based in EU member states or establish centres based inside the EU. As a result, the UK could become less attractive to science-based companies. Some have already put in place contingency plans, such as moving parts of their business activity out of the UK to ensure seamless activity with EU collaborators regardless of Brexit deal
Loss of funding
The loss of EU funding to UK science and higher education would have a substantial effect. However, the government’s target (2.4% of GDP) of growing public and private investment to nearer the level of the UK’s international peers from a low base should mitigate this risk.
The Treasury has encouraged UK organisations to apply for funding under EU schemes. It has also stated that it intends to underwrite funding of all awards made while the UK is still a member of the EU.
Royal Society’s aspirations for post-Brexit science
The Royal Society identified three principal aspirations for UK government policy to mitigate the effects of Brexit.
- People – mobility and collaboration. Mobility of talent is crucial to the conduct of cutting-edge research and innovation. The UK must continue to be able to access easily the EU-wide talent pool that provides 17% of our university staff and over two thirds of the founders of UK based start-ups. We must also ensure that the UK continues to collaborate with European partners, and that individuals with skills essential to the research endeavour can travel with ease and maintain and build the international networks that are central to its progress.
- Policy and regulation. It is critical that we identify areas of regulation where continued alignment with EU rules is most important for the UK. Where we choose to do so, UK experts should continue to be able to influence EU policy development. We should take the opportunity to pioneer new regulatory approaches on emerging technologies, and to take a leading position on international markets.
- Funding. Investment is crucial to maintaining a successful research and innovation system. Leaving the EU must not lead to any reduction in funding for UK research. EU programmes currently provide about one sixth of the UK’s funding for research.
In February 2018, CaSE provided further detail on each of these three areas in its evidence to the Science and Technology Committee Enquiry. See the CaSE evidence base and the submission to the House of Commons Select Committee on Science and Technology.
The UK government has responsibility for healthcare in the UK. The EU provides support, but has little direct influence over UK policy or legislation. Indirectly, the Single Market and the customs union play important roles in facilitating the delivery of UK health services, via access to workforce as well as free-flowing goods and services.
EU regulations that have a direct impact on health and care include: regulation of medicines and devices; procurement and competition law; and, the Working Time Directive.
The policy of freedom of movement and mutual recognition of professional qualifications within the EU means that many health and social care professionals working in the UK have come from EU27 countries.
The proportion of EU workers in both the NHS and the social care sector has been growing over time. Both sectors increasingly rely on EU migrants and will continue to need them in the future.
In 2019, around 180,000 EU nationals work in health and social care in England. This is made up of 115,000 in adult social care (9% of the 1.3 million workforce), 65,000 in the NHS (5.5% of the 1.2 million workforce). In the NHS, around 9.5% of doctors and 6.4% of nurses are from the EU.
See the section on immigration for details of EU citizens working in the UK in other industry sectors.
Sources: House of Commons Library, NHS staff from overseas: statistics, July 8, 2019
The King’s Fund, Brexit: the implications for health and social care, October 2019
UK organisations are the largest beneficiary of EU health research funds, providing over €300m since 2014. EU collaborative research opportunities help the NHS speed up translation of medical discoveries into healthcare provision.
EU rules govern UK citizens’ access to health and care in the EU, and EU citizens’ access to UK services.
- 27 million Britons have European Health Insurance Cards (EHIC), facilitating immediate access to healthcare when in the EU27.
- Over 1.2 million UK citizens living in the EU, including pensioners, are entitled to healthcare abroad.
The single EU medical regulation system has enabled new health technologies to be brought to market sooner for the benefit of patients. The NHS leads a quarter of the new European Reference Networks, which improve diagnosis and treatment for rare and complex diseases.
Regulation and clinical trials
EU legislation provides a harmonised approach to medicines regulation and clinical trials across the EU member states.
As an EU member, the UK is part of the centralised authorisation system operated by the European Medicines Agency (EMA). Under current arrangements, companies can submit a single application to the EMA to obtain a marketing authorisation that is valid in EU, EEA and European Free Trade Association (EFTA) countries. Being a member of the EMA means that pharmaceutical and device companies prioritise the UK as a market for launching their products.
The revised EU Clinical Trials Directive took effect in 2017/18. It harmonises arrangements across the EU with the aim of creating a single entry point for companies that wish to carry out trials of new drugs on participants in different countries.
The UK has its own Medicines and Healthcare products Regulatory Agency (MHRA) which provides expertise for a large proportion of EU licences.
Cross-border health threats
The EU operates systems for the early warning of communicable diseases, managed by the European Centre for Disease Prevention and Control (ECDC). These share information and technical expertise in response to potential pandemics, communicable diseases and other cross-border health threats. Recent examples of collaboration include managing the H1N1 ‘swine flu’ pandemic and efforts to tackle anti-microbial resistance.
As a member of Euratom, the UK has quick and safe access to nuclear materials produced in other countries that are essential for the diagnosis and treatment of cancer. In 2016/17 the NHS performed more than 592,000 diagnostic procedures that rely on radioactive material.
UK ranking in terms of health spend
As part of the context of assessing the implications of Brexit for healthcare, it’s useful to look at the UK’s spend on health relative to other EU countries.
In terms of % of GDP spent on healthcare in 2014, the UK ranked ninth at 9.9% in the EU28 (see Figure 10.3). France and Sweden (both at 11.1 %) ranked the highest with Germany and Netherlands close behind (both at 10.9 %). The UK was at 10.0% of GDP in 2018 and ranked 10th according to Eurostat.
The UK ranked 11th on healthcare spend/head in 2014 after adjusting for price differences (by expressing expenditure in purchasing power standards, or PPS):
- The top three healthcare expenditures per head are in the Netherlands (PPS of €3.8k per inhabitant), Germany (€3.9k per inhabitant) and Luxembourg (€4.1k per inhabitant).
- The UK’s spend at €2.8k per inhabitant was over 25% less than the corresponding spend in Germany or the Netherlands.
In 2018, the UK ranked 13th on PPS per head (according to Eurostat – follow links in 2021 report and create your own analysis).
Figure 10.3: EU 28 expenditure on healthcare (spend/head and % of GDP)
The implications of Brexit for the health and care sectors are likely to be far-reaching.
The Brexit vote has created significant economic and political uncertainty at a time when the NHS and social care are facing huge financial and operational pressures. If Brexit leads to sustained, reduced economic growth (as predicted by most economists), this will put pressure on public finances with a knock-on effect for public funding of health and social care.
In addition to funding risks, there are five main areas of risk: workforce, regulation, clinical trials, Euratom, trade deals.
For an excellent and authoritative summary of the implications of Brexit for health services, please see “How will Brexit affect health services in the UK? An updated evaluation” published in the Lancet on 1 March 2019. The article covers Brexit options, ‘no deal’, the Withdrawal Agreement, the Backstop and the Political Declaration.
The Kings Fund also has an excellent web-based summary of the material impacts of Brexit on health and social care (October 2019).
Given the reliance of UK healthcare on overseas workers, the damage to the NHS due to EU health-workers deciding to leave the UK and others deciding not to come is likely to be severe. (The NHS will continue to need low-skilled migrant workers in health and social care as well as skilled medical practitioners).
The health and social care sectors will face a considerable shortfall in staff in future if EU migration is limited after Brexit. The Department of Health projects (under a worst case scenario) a shortage of between 26,000 to 42,000 nurses by 2025/26. Projections from the Nuffield Trust suggest a shortfall in England of as many as 70,000 social care workers by the same date.
In October 2019, there were 100,000 vacancies in the NHS (9% of workforce) and 122,000 vacancies in adult social care (9% of workforce).
See the immigration section for more information on EU citizens in the UK workforce and migration trends.
Brexit has led to the relocation of the European Medicines Agency (EMA) from London to Amsterdam and withdrawal of the UK from the centralised EMA system for the approval of new medicines. This departure represents a loss of influence and expertise from the UK. The UK will need to design and establish a replacement regulatory system centred on the MHRA, which will need to interface with the EMA and other international regulatory bodies.
As a result, the UK may end up at the back of the queue for new medicines. For example, in Switzerland and Canada, which have separate approval systems, medicines typically reach the market six months later than in the EU.
From March 2019, the EU divided up the work that the MHRA used to do between agencies in the EU27.
(iii) Clinical trials
As the UK would no longer be part of the harmonised EU procedure for clinical trials, some in the pharmaceutical industry are concerned the UK will lose out on multi-country trials that benefit UK patients. Multi-country trials are particularly important for rare diseases and personalised medicine, as they give researchers access to the large populations required.
The government has stated that the UK’s exit from Euratom (see section 12 for more details) will not have an impact on the availability of radioactive materials. Nevertheless, many are concerned about the impact on future supply, including increased costs and risks to patients should access be disrupted.
(v) Trade deals
Negotiation of new trade deals with countries outside the EU is likely to have implications for the NHS. The terms of these agreements could have consequences for public health. Consider, for example, the controversy over the implications for health standards over the EU-US FTA negotiations (TTIP).
Against these risks, there may be opportunities to reshape regulation (such as on competition and the Working Time Directive) to allow greater speed and flexibility in the delivery of health and social care. However, revisions to regulation would need to avoid weakening existing protections and safeguards.
Source: The main source for this section is The King’s Fund, Brexit: the implications for health and social care, December 2017. This source refers to several other sources.
How will Brexit affect health services in the UK? An updated evaluation
Nick Fahy, Tamara Hervey, Scott Greer, Holly Jarman, David Stuckler, Mike Galsworthy, Martin McKee , March 2019