Brexit: the clock is ticking
BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k4057 (Published 27 September 2018) Cite this as: BMJ 2018;362:k4057
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Brexit might benefit the NHS by improving staff morale: while it is often argued that diversity is right for everyone and is a good thing (indeed, it has practically become political dogma), there is a downside and the possibility that other things may be lost should be considered.
For example, I think there are quite strong arguments to suggest that people feel most comfortable with those who share their background and I believe that groups which share a common language and culture are the most productive. While this does not preclude cooperative work from disparate groups, an appropriate mix may need to be found, benefitting all concerned.
I suspect a lot of resistance to EU migrants stems from the insecurity that people feel when they feel their way of life is being threatened - and is actually a form of self-defence. Recognition that there is a problem and collaborative discussion to find solutions must be the way ahead – while attacking people and accusing them of being stupid or racist (or both) will only encourage hostility, cause unnecessary unhappiness and, ultimately, be counterproductive.
Competing interests: No competing interests
The British media, economists, and medical community have focused largely on the implications for health British citizens will wake up to on Saturday morning, 30 March 2019, after shutting the door behind them on more than 45 years of membership in the largest and most successful economic and political union in modern history. What will be the impact of Brexit on the British citizen’s access to medicines and other medical interventions? What will be the impact on the availability of qualified medical personnel? What will be the impact on the National Health Service and on private healthcare? What will be the impact on health-related research? What will be the impact on the British citizen’s access to healthcare – in the United Kingdom and in the European Union?
Be it a ‘good deal’, be it a ‘bad deal’, be it a ‘no deal’, undoubtedly all the above aspects of public health will be impacted. And given the fact that Downing Street has yet to address these questions with concrete and public analyses alongside clear policy approaches, few would argue the impact on British patients will, regardless of which ‘deal’, be in anyway positive for the following 3 months, 3 years, 5 years. Trading access to good and reliable healthcare for Westminster’s autonomy may be a price some are willing to pay if the consequence of ‘being a few pills short’ is only for a relatively short period.
In Brussels, however, while we are concerned for British patients in the short term, believing any curtailing of access to the full range of health services is unacceptable, our larger worry is that British patients are so willingly foregoing their place at the European discussion table. When President Obama stood beside Prime Minister Cameron and threatened (unwisely) the British people with ‘the back of the line’ (one Obama policy President Trump appears in no hurry to rescind), President Obama missed what was most important to British patients: having their voice heard in all matters concerning their complaints and having the necessary and sufficient resources (medical, scientific, economic) employed to expediently address their ailments.
The exodus of the UK from the EU will likely not entirely stymie the voice of British patients on the continent, but it will surely result in a weakened voice outside vital decision-making – and this not only in the short term. The British patients' access to medicines, access to science and innovation, and even access to hospital care will suffer even more in the long term than in the short term.
Why would British patients trade their place at the European table for decisions made solely in London rather than jointly with their European partners: those suffering the same complaints, the same diseases? We in Brussels are looking also to the long term for British patients, and we are at a loss to understand their coming absence from our discussion table following all we achieved together. For us this is a hard pill to swallow (if swallow we must).
Competing interests: Francis P. Crawley has worked for more than 25 years at the intersection of patients, science, and ethics with patient organisations and researchers on both sides of the Channel, including several European-funded projects to build patient consortia and ensure their voice at the European discussion table. He is an active member of the Faculty of Pharmaceutical Medicine, Royal Colleges of Physicians, London.
"The uncertainty is unacceptable to patients, who are alarmed at the looming deadline of 29 March 2019, writes patients’ advocate Jeremy Taylor": I assume the majority of these patients (52%) voted in favour of Brexit, of course. So this groups is actually responsible of their own worries, and our sympathy for them could be somehow affected. Anyway, for those and the 48% who have no responsibility in this sorry state of affairs, they could gather together and ask the Governement to keep the Brexiteers' promise of £350 million a week more for the NHS. It was written on the back of a bus, remember? That's £18 billion per year, an increase of almost 15% on the yearly NSH budget (which is approximately £124.7 billion in 2017/18). It may not help to recruit sufficient staff, but it might stave off other rationing.
Competing interests: No competing interests
Language, Truth and Logic
Language
“Perhaps tellingly, it wasn’t easy finding someone to argue for the benefits to health in leaving the EU, but Graham Gudgin agreed.” Crisp, punchy copy; but misleading and factually incorrect.
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Richard Hurley, the BMJ’s features and debates editor, offered me the 600 word debate on the 24th July. We agreed that my response would wait until I returned from holiday. On the 14th August, for reasons outlined below, I declined, instead suggesting Dr Graham Gudgin. He was approached on the 17th August and accepted on the 19th.
Tellingly or not, ‘finding’ doesn’t come much easier than that.
The offer of a debate followed my criticism of an editorial (1) which put only one side of a case. I bemoaned, not for the first time (2), the lack of external refereeing in editorials and commentaries where the BMJ gave advice on matters of health. My complaint was that the Journal was breaking many of its own rules on the handling of evidence (evidence-based medicine; open data; partnering with patients) and included a predominance of confirmation-biased references (3).
Consistently, and purposely, I have made no case for or against Brexit. For that reason, suggesting I should debate in favour of Brexit was inappropriate. In the lengthy published to-and-fro (and additionally with Richard Hurley and Fiona Godlee), I have repeatedly stressed that I was urging the use of an independent referee (I spare the dates and quotes for any of you who are still awake); I was NOT arguing for or against leaving the EU (I happen to be for). I suggested that, since the original editorial had relied on questionable and unreliable financial data and conclusions, an economist would be better suited; Dr Gudgin was easily found.
Truth
As far as statistics go, we are all familiar with their relationship to lies and damned lies:
Of the 46,500,001 UK electorate in 2016, 29,089,259 (62.6%) did not vote to leave (4).
Equally truthfully, 30,358760 (65.3%) did not vote to remain. Both quotes are needed for balance.
“Around 2500 EU nationals (net) joined the NHS in the quarter before the referendum. Between March and December 2017 the figure was just over 200”. (5)
Rebecca Coombes was partial when she chose to repeat Anand Menon’s numbers which “plummeted” from 2,500 to 200, while ignoring Graham Gudgin’s 7,000 (actually 6,888) increase in new EU recruits in the two years to January 2018 (6). Both Menon’s and Coombes’ links (7, 8) are opaque (even NHS Digital (9) were unable to replicate Coombes’ figures), but Gudgin’s (10) are easy to verify (pace A J Ayer). What is clear is that Menon, apart from using different denominators for his figures (3 and 10 months), is selective in his choice.
I did, eventually, find a source with quarterly figures (11). Access them and see that Menon prefers his 200 (actually, 365 (62,299 – 61,934), and actually not March, but April to December), to the 1,916 (net) increase for the calendar year 2017 and the rather less doom-laden 957 increase in the first three months of 2018. Apart from debatable arithmetic and English, cherry-picked numbers have been used to advance his argument.
Suppose a statin’s formulation had been changed in June 2016, and identical figures to the above were offered demonstrating the diminution in side-effects before and after. The BMJ would have rightly examined the figures minutely and lambasted the drug company for crooked, dishonest dealing.
Logic
There is no consistency in the BMJ’s approach to data and evidence; and no logic in having a stringent set of guidelines for the original research section which are then ignored in the early pages. I suggest again that, when editorials involve medical decisions, external referees would improve both content and credibility. Obviously the large majority of news and views need only be scanned in-house but I do expect a balanced and scientific argument in both research pieces and editorials.
In this instance, why use ‘tellingly’ (OED = significantly) when a brief word with an office colleague would have revealed the facts? Why, when Menon’s link to NHS Digital was so obscure, did Coombes repeat this opaque link while misquoting him – his denominator for 200 was 10 months not three? The importance of authors checking their references and sources has been emphasised by the BMJ (12). Did the author access the tables and, if so, why not use a clearer link (10) or even check the numbers herself? Did anybody in the Office read the references?
I feel uncomfortable prolonging this squabble and happily emphasise that correspondence has at all times been polite and gracious but at no time has anyone addressed my original complaint that, without independent refereeing, the BMJ puts at risk its hard earned reputation in dealing with evidence.
References
1. Gill M, McKee M, Malloch Brown M, Godlee F. Brexit is bad for our health. BMJ2018;361:k2235 . doi:10.1136/bmj.k2235 pmid:29794034
2. Barlow D. Bias in medical literature on health outcomes; bias in commentary?
BMJ 2016; 355 doi: http://dx.doi.org/10.1136/bmj.i6634 (Published 16 December 2016)
3. Barlow D. Brexit - an impartial view? BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2743
4. Electoral Commission https://www.electoralcommission.org.uk/find-information-by-subject/elect...
5. Menon A. Could Brexit harm the NHS? Yes! https://doi.org/10.1136/bmj.k4014
6. Gudgin G. Could Brexit harm the NHS? No! https://doi.org/10.1136/bmj.k4014
7. NHS Digital. NHS workforce statistics, December 2017. https://digital.nhs.uk/data-and-information/publications/statistical/nhs...
8. http://bit.ly/2DtW7jM
9. NHS Digital Contact Team/Workforce Analysis Team. Personal communication Oct 29. ref NIC-241581-D9Q6P
10. https://digital.nhs.uk/data-and-information/find-data-and-publications/s...
11. https://files.digital.nhs.uk/3C/F5CB38/HCHS%20staff%20in%20NHS%20Trusts%... (published 21 June)
12. Godlee F, Smith Jane, Marcovich H. Wakefield’s article linking MMR vaccine and autism was fraudulent; BMJ 2011;342:c7452
Competing interests: My long-standing, happy, and continuing connections with Europe are detailed elsewhere (3). I voted to leave the EU. In 2015 my name was added to the BMJ’s panel of doctors prepared to work on conflict of interest.