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Pre-Brexit situation
The UK government had responsibility for healthcare in the UK. The EU provided support, but had little direct influence over UK policy or legislation. Indirectly, the Single Market and the customs union played important roles in facilitating the delivery of UK health services, via access to workforce as well as free-flowing goods and services.
EU regulations with a direct impact on health and care included: 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 meant that many health and social care professionals working in the UK had come from EU countries.
The proportion of EU workers in both the NHS and the social care sector had been growing over time. Both sectors increasingly relied on EU migrants and would continue to need them in the future.
In 2019, around 180,000 EU nationals worked in health and social care in England. This was 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 were 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
Benefits of EU membership
UK organisations are the largest beneficiary of EU health research funds, which provided over €300m to them since 2014. EU collaborative research opportunities help the NHS speed up translation of medical discoveries into healthcare provision.
UK citizens benefited from access to health and care in the EU, and EU citizens’ benefited from access to UK services.
- 27 million Britons had European Health Insurance Cards (EHIC), facilitating immediate access to healthcare when in the EU.
- Over 1.2 million UK citizens living in the EU, including pensioners, are entitled to healthcare abroad.
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. See the Euratom section for a deep dive into medical isotopes
The single EU medical regulation system enabled new health technologies to be brought to market sooner for the benefit of patients. The NHS led a quarter of the new European Reference Networks, which improve diagnosis and treatment for rare and complex diseases.
Clinical trials and market access
EU legislation provides a harmonised approach to medicines regulation and clinical trials across the EU member states.
As an EU member, the UK was part of the centralised authorisation system operated by the European Medicines Agency (EMA). Under those arrangements:
- companies could submit a single application to the EMA to obtain a marketing authorisation that was valid in EU, EEA and European Free Trade Association (EFTA) countries;
- EMA membership meant that pharmaceutical and device companies prioritised the UK as a market for launching their products;
- the revised EU Clinical Trials Directive took effect in 2017/18
- harmonises arrangements across the EU top create a single entry point for companies that wish to carry out trials of new drugs on participants in different countries.
- UK had its own Medicines and Healthcare products Regulatory Agency (MHRA) which provided expertise for a large proportion of EU licences.
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. Pre-Brexit examples of collaboration include managing the H1N1 ‘swine flu’ pandemic and efforts to tackle anti-microbial resistance.
Health spend: UK’s EU ranking
The UK’s spend on health relative to other EU countries provides context in assessing the implications of Brexit.
The UK ranked ninth in the EU at 9.9% of GDP spent on healthcare in 2014 (see Figure 10.3). France and Sweden (both at 11.1 %) ranked the highest, with Germany and Netherlands close behind (both at 10.9 %).
After adjusting for price differences, the UK ranked 11th on healthcare spend/head in 2014 (expressed in purchasing power standards, or PPS):
- The top three EU healthcare expenditures per head in PPS were:
- Luxembourg (€4.1k per inhabitant)
- Germany (€3.9k per inhabitant)
- the Netherlands (€3.8k per inhabitant)
- The UK’s spend at €2.8k per inhabitant was over 25% less than that of Germany or the Netherlands.
In 2018, the UK ranked 13th on PPS per head (according to Eurostat.
Figure 10.3: EU expenditure on healthcare (spend/head and % of GDP) – 2014
Source: Eurostat, Healthcare expenditure statistics (now archived)
Expected Brexit impacts
The Brexit vote created significant economic and political uncertainty at a time when the NHS and social care were facing huge financial and operational pressures. Reduced economic growth would put pressure on tax revenues and the public funding of health and social care.
For details of the funding pressures please the sections on overall Brexit impacts.
In addition to the major funding risks, other areas of risk to healthcare included:
- workforce
- accessing treatment
- regulation.
For an authoritative summary of the expected 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.
(i) Workforce
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 was likely to be severe. (The NHS needs low-skilled migrant workers in health and social care as well as skilled medical practitioners).
The health and social care sectors would face a considerable shortfall in staff in future if EU migration was limited after Brexit. The Department of Health projected (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.
(ii) Accessing treatment
The government will need to negotiate arrangements with the EU as to how both ‘ordinarily resident’ UK citizens and citizens from elsewhere in the EU will access health care services in future.
(iii) Regulation
Brexit 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. From March 2019, the EU divided up the work that the MHRA used to do between agencies in the EU27.
This departure represented a loss of influence and expertise from the UK. The UK would 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.
As the UK would no longer be part of the harmonised EU procedure for clinical trials, some in the pharmaceutical industry were concerned the UK would 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.
Source: The Kings Fund, Five big issues for health and social care after the Brexit vote. 30 June 2016
Actual Brexit impacts
The NHS budget for England alone has risen by more than £350m a week since 2016. Between 2015-16, and 2019-20, the year before Covid-19, it rose by about £400 million a week in cash terms. However, this was a ‘business as usual‘ increase to the NHS budget to meet growing demand.
In 2015-16, the NHS spend for England was £117.2. billion (about £2.3 billion a week) and in 2019-20 £138.5 billion (about £2.7 billion/week). In real terms this was an increase of over 11% (about 2% a year), but, despite this, the budget was struggling to keep pace with the needs of the UK’s aging population, repairs to old buildings and updates to medical equipment.
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