Brexit three years on: Health and the NHS are still sufferingBMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p232 (Published 31 January 2023) Cite this as: BMJ 2023;380:p232
- Martin McKee, professor of European public health
Three years ago, on 31 January 2020, the British flags that had flown outside European Union buildings for over 40 years were lowered. The then prime minister Boris Johnson had “got Brexit done.” Except he hadn’t. As we now know, he had agreed to a withdrawal agreement, covering the rights of EU citizens in the UK, the UK’s financial obligations, and arrangements on the island of Ireland. He did so in the knowledge that, at least with respect to Ireland, he had no intention of adhering to the agreement and the quest for an alternative solution remains as elusive as ever.1
Meanwhile, there is growing recognition among those who voted for Brexit that they were lied to and the promised “sunlit uplands” are nowhere to be seen.2 The “opportunities,” such as trade deals with other parts of the world, have revealed just how powerless the UK now is.3 A clear majority of the British public, 62% as of January 2023, now think that Brexit was a mistake.4 And this is before many of the provisions of the Trade and Cooperation Agreement, such as incoming border checks, have even been implemented by the UK; some arrangements, such as on financial services, that have been given a few years grace period, will eventually expire.5 New provisions that will create new trade barriers, including those related to energy intensive industries, will be introduced.6
Those most impacted by these problems, such as researchers working on European projects7 or small businesses that once exported to the EU, are well aware of them. The scale of the damage inflicted by Brexit is less widely appreciated. British politicians, bolstered by large sections of the media, have consistently blamed global events for the UK’s woes. But the pandemic and the Russian invasion of Ukraine have affected all countries—in some cases, such as those adjacent to Ukraine, to a much greater extent—yet the UK has fared much worse on almost all measures than its European neighbours.8
What does this mean for health and the NHS? We can look to two new reports that analyse the situation in detail. One report, from the Centre for European Reform, asks how much Brexit has damaged the economy.9 It used a technique that creates a “synthetic UK” as a model, based on a weighted average of similar countries pre-Brexit and compares its subsequent performance with what actually happened. This isolates the effect of Brexit from all the global factors. The findings are stark. In the final quarter of 2021, the UK’s gross domestic product was 5.2%, or £3bn, smaller than it would have been if the UK had remained in the EU. Clearly this limits the financial headroom that the government has to increase NHS funding, even if it wished to, constraining its capacity to respond to the current crisis. This also exacerbates the financial pressures of the cost of living crisis on many people who are already facing hard choices between heating and eating that will inevitably worsen their health, placing added pressure on the NHS. By the end of 2021 it was estimated that Brexit had added £210 to the average annual food bill.10
The second report is from the Nuffield Trust.11 It looks specifically at the impact of Brexit on the NHS. From the outset, one of the greatest concerns was about the UK’s dependence on health workers from abroad—especially the European Economic Area (EEA). We can now see that this concern was justified. Numbers of nurses coming from the EEA fell dramatically after the referendum and have not recovered. The report also notes how growing hostility to foreigners drove some to leave. The effect was a 28% reduction in nurses and health visitors on the UK register who qualified in the EEA, a net loss of over 10,000. This was compensated for by a marked increase in recruitment from the rest of the world, although this raises questions about the ethics of recruiting from countries that are themselves facing often critical shortages of health workers. Importantly, the increase was nowhere near enough to meet the NHS’s needs.
The problems are greater when we look beyond the overall figures, as some specialties were especially dependent on EEA staff. This is adding to already severe shortages in specialist staff including dentists, anaesthetists, and cardiothoracic surgeons. In these cases, the fall in recruitment from the EEA has not been compensated by increases from elsewhere. These shortages have knock on effects, placing greater pressure on remaining staff and exacerbating problems with morale and retention.
There have also been shortages of drugs, illustrated by a rapid rise in waivers that allow pharmacists to pay more when they cannot find a drug at the usual price. The authors attribute this in part to the decreased value of the pound and the falling value of imports of drugs since 2016, in marked contrast with the increases in every other G7 country.
These problems were obvious from the outset to those who understood the EU but were dismissed by Brexit supporters as “Project Fear.”12 There is some scope for mitigation by a future government that can show the EU that it can be trusted, but there is no escape from the fact that Brexit will continue to damage health and the NHS for the foreseeable future. The tragedy is that neither of the two main English political parties is willing to do anything about it.