The Brexit predictions that came true, those that didn’t—and what we didn’t see comingBMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1870 (Published 03 August 2022) Cite this as: BMJ 2022;378:o1870
The battle over Brexit triggered extreme claims about its likely impact on UK healthcare, ranging from a collapse in staffing and drug supplies to a big funding increase and a bonfire of red tape. Then came the covid pandemic, which all but obscured any Brexit effect.
But, six years after the vote and 19 months after the UK finally separated from the EU, it’s possible to judge which predictions were accurate, which ones were not—and the things we didn’t see coming.
Predictions that came true
Nurse recruitment from Europe collapsed, although medical recruitment didn’t
The European supply of nurses plummeted, but it’s been made up by immigration from outside the European Economic Area (EEA). Mark Dayan, policy analyst and head of public affairs at the Nuffield Trust, says, “Before the vote to leave, there was heavy recruitment of nurses from the EEA—more than 10 000 a year at one point—and that was a fairly crucial way in which the health service was trying to fill the shortage of nurses.”
The migration of nurses from Europe “fell off a cliff in 2016, partly as a result of Brexit and partly as a result of a new language test that the Nursing and Midwifery Council imposed,” says Dayan. “Since then you see quite a rapid pick-up in non-EU nursing migration, especially after the liberalisation of migration rules in 2019. That’s gone back to delivering several thousand additional nurses recruited abroad every year.”
Layla McCay, director of policy at the NHS Confederation, says that the points based immigration system introduced since Brexit “has had the biggest impact because it allows doctors, nurses, and various allied health professionals to immigrate to the UK, but low paid health and social care workers cannot meet the salary threshold, and that’s probably contributing to their massive shortages.”
The addition of care workers to the “shortage occupation list” for 12 months from December 2021 could provide some short term relief. Although the new wave of migration has filled the gap left by nurses coming from the EU, the chronic shortage continues, with one in 10 nursing posts vacant.1
For doctors, the picture is different: the number of licensed doctors in the UK holding a primary medical qualification from the EEA and Switzerland dropped from around 23 700 in 2013 to 21 500 in 2016, before creeping up again to 23 900 in 2021.2
Robert Ede, head of health and social care at the Policy Exchange think tank, says that more rigour by the NHS in identifying EEA staff in recent years may have contributed to the increase. But it’s clear that there hasn’t been a stampede of EEA doctors leaving the NHS.
However, since 2014 there has been a marked fall in EEA doctors joining the specialist register. Specialties that are particularly dependent on European doctors include cardiothoracic surgery and neurosurgery, says Dayan.
Health tech, life science industries, and research have been hit
Brexit has affected research, health technology, and the life science industries. Specialist jobs have been lost, major research collaborations are in jeopardy, the import and export of supplies such as medical devices and pharmaceuticals is more complicated, and more problems lie ahead.
Symbolic of these harms was the European Medicines Agency (EMA) moving its 775 staff from London to Amsterdam.3 The Medicines and Healthcare Products Regulatory Agency (MHRA) suffered collateral damage, with a substantial cut to its budget.4 Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, says, “The MHRA is in a very difficult position because it was so dependent on the work for the EMA and European funding for research and other work. That’s going to be a challenge.”
He adds that the EMA’s departure has affected the pool of talent from which the MHRA can recruit. “It’s not just the fact that it doesn’t have the money,” he says. “It’s the ability to recruit expert staff, particularly when you get into areas like biologicals. There aren’t a lot of these people around.”
Layla McCay says that the main concern for industry is uncertainty about future regulation. She explains, “There’s been lots of talk about introducing some form of UK kitemark for medical devices, and there’s this ambition for the MHRA to accept global regulatory norms [while maintaining] sufficient alignment with the EU. But there’s a lot of complexity that’s still being thought through.”
Richard Phillips, director of strategy at the Association of British HealthTech Industries, highlights the difficulties of exporting to the EU, with different paperwork required by different countries. He says, “We’re not doing business with the EU any more, we are doing business with 27 individual jurisdictions. There are workarounds—but workarounds cost.”
Phillips explains that supplying Northern Ireland “has been difficult and slow. I’ve heard people saying they shipped to Germany, then from Germany to Dublin, and then across the land bridge because it’s quicker than trying to get it directly into Northern Ireland.”
Exports face the obstacle of no longer being in the single market. McCay says that “UK pharmaceutical exports have dropped by about a third since the referendum.”
The battle to save the UK’s membership of the Horizon Europe science network5 is totemic of the way Brexit is undermining research collaboration. Dayan says, “Horizon Europe is looking dicey and is basically being held hostage to the situation with the Northern Ireland protocol. The crucial thing is not the money, because the UK is a net contributor—the crucial thing is the chance to be part of these initiatives because they tend to be many of the most cutting edge and influential ones.”
Predictions that proved to be wrong
Brexit didn’t bring a cut or a jump in NHS funding
During the referendum campaign the Labour Party warned that Brexit would mean “brutal cuts” to the NHS,6 while Boris Johnson’s claim that the UK would take back control of £350m (€415m; $421m) a week that could be spent on the NHS was described by the UK Statistics Authority as “a clear misuse of official statistics.”7
The Office for Budget Responsibility has estimated that Brexit will reduce long term productivity by 4%,8 so it’s not going to unleash a funding bonanza for the NHS any time soon. At the moment NHS core funding—excluding funding for the pandemic—is continuing to rise in real terms,9 but the long term economic situation could cause problems.
Ede says, “Where we see potential issues is the wider economic impact of Brexit still starting to be felt. It does mean that we are in a more constrained environment for public sector investment. In terms of the £350m a week pledge . . . Brexit has not improved the supply of resources into the NHS.”
No crisis was seen in medicine supplies
A collapse of medicine supplies didn’t materialise, as the government and the NHS acted on warnings and put in years of preparation.
McCay says, “The Department of Health and Social Care, NHS England, and the MHRA worked really hard to sort out preparedness. So, whether it was stockpiling, sorting out alternative routes, or working with industry to make sure they were going to be prepared, that’s been pretty successful.”
Dayan says that the risk of a collapse in medicine supplies was headed off by detailed planning: “going through medicines [line by line] and trying to ensure that each one had a plan for getting into the UK.”
But there have still been shortages of individual medicines. A Nuffield Trust analysis of HM Revenue and Customs data shows that the introduction of customs controls and transport requirements meant that medicine imports from the EU, which have historically made up two thirds of the NHS supply, fell to their lowest level in years.10
Procurement rules are no simpler—yet
In the run-up to the referendum, cutting “procurement red tape”11 seemed to be one of the easier promises to deliver.
The Health and Care Act 2022 gives ministers powers to introduce new procurement rules, while the Procurement Bill12 going through parliament aims to simplify the rules, such as making it easier to roll over a contract with an existing provider. But new rules don’t necessarily make life simpler. With legislation that has yet to be tested in the courts, it could open up new avenues for legal challenge.
Aris Georgopoulos, assistant professor in European and public law at Nottingham University, gives the example of seven procedures being reduced to three, with new definitions. He says, “Some people may say OK, that is more flexible, but from the eyes of a lawyer that gives an opportunity for clarification, so there are a lot of question marks, even after the [government determines] the details.”
For managers charged with taking procurement decisions, the move towards greater use of judgment rather than rigid application of rules brings its own perils. Georgopoulos asks, “Would you like to face the music if something goes wrong or if a commotion starts about your decision which was exercised with maximum flexibility, or would you prefer a much more straightforward set of rules?”
What most people didn’t see coming
Devolved powers over public health have weakened
An indirect consequence of Brexit has been a weakening of the devolved administrations’ control of policy on food, tobacco, and alcohol. This is a consequence of the Internal Market Act 2020—how the UK government has implemented Brexit here. Ironically, “taking back control” for the UK has resulted in a loss of control for Scotland, Wales, and Northern Ireland.
Dayan says, “Within the EU, there are certain restrictions on the controls that could be imposed [on food, tobacco, and alcohol], to maintain an internal market, and those occasionally caused trouble with the devolved administrations: you might remember the back-and-forth over the minimum unit pricing for alcohol in Scotland.
“The UK is replacing that with the Internal Market Act, and there is certainly a body of opinion that feels it’s quite a backward step. It’s administered by the Competition and Markets Authority, which has quite a strong competition remit, and it doesn’t have the kinds of overarching duties towards health that the EU does.”
What most people have forgotten
The European Working Time Directive keeps going
The European Working Time Directive has long divided medical opinion, with the BMA arguing that restricting doctors’ hours is essential for patient safety,13 while others contend that it undermines training in some medical specialties.14 But, despite the UK leaving the EU, there seems little desire to change or scrap the directive, and it’s far from clear that the UK is able to do so.
Dayan says, “It’s an open question about whether the UK can diverge on the Working Time Directive, because maintaining a degree of labour protection is part of the agreement with the EU.” These are the rules that aim to avoid the UK becoming a low regulation competitor on the shores of the EU.
The bigger picture
While it’s crucial to examine the individual policy areas affected by Brexit, it’s also important to see the big picture of how leaving the EU has affected UK healthcare, particularly through the lens of the pandemic.
May van Schalkwyk, doctoral fellow at the London School of Hygiene and Tropical Medicine, says that Brexit “undermines those key structures, and resilience in resources and systems, that you want to be as robust as possible when you have unforeseen crises.
“Brexit was a shock to all the systems. We didn’t know covid was going to happen, but we always know there’s a risk of crises, so during times of stability you should be building your systems, not undermining them. Brexit is almost a complete contradiction to being prepared for a pandemic.”
23 June 2016—The majority of people who vote in the referendum choose for the UK to leave the EU
29 March 2017—The UK triggers article 50 and begins a two year countdown to formally leaving the EU
2019—With EU agreement, Brexit is repeatedly delayed. Parties eventually settle on a date of 31 January 2020
12 December 2019—Boris Johnson wins a majority in the UK general election with a promise to “get Brexit done”
23 January 2020—The European Union (Withdrawal Agreement) Act 2020 receives royal assent
31 January 2020—The UK leaves the EU and enters a transition period
31 December 2020—The transition period ends
Competing interests: None declared.
Provenance and peer review: Commissioned, not peer reviewed.