Mark Dayan assesses the impact of Brexit on the health service, looking at the effect on funding, the workforce and medicine supplies.
The NHS is the UK’s largest and perhaps most well-loved institution – so it is unsurprising that it played a prominent role in the great political drama of our time – the Brexit referendum.
The Leave campaign claimed Brexit would free up more funds to put into the NHS, whereas Remain claimed Brexit risked creating staffing and medicine shortages.
For the first time, we are now far enough away from the referendum, and actual withdrawal from the EU, to stop speculating and start measuring the results. The latest report from our Health and International Relations Monitor project funded by the Health Foundation aims to begin describing what Brexit has meant for the health service so far.
During the EU referendum, the Leave campaign famously claimed that ‘We send the EU £350 million a week – let’s fund our NHS instead’. But fact checkers concluded that the real figure of the UK net transfer to Brussels was much smaller, and that projections showed any savings being more than cancelled out by the economic hit of a hard Brexit.
The NHS budget (in England alone) has in fact risen by more than £350m a week since 2016. In fact, between 2015-16, the year before the referendum, and 2019-20, the year before the Covid-19 pandemic, it rose by £400 million a week in real terms.
This increase in the budget owed nothing to diverting savings from leaving the EU (though it may have owed something to Brexit’s political ramifications). Brexit has had an economic impact roughly as severe as was predicted: spending has had to come from taxes, borrowing and squeezing other departments.
Although this may seem like a significant boost in funding, the NHS budget is so vast that this is actually far from an unusual rate of increase, and in fact barely kept pace with a growing and aging population. The service remains strapped for cash, and through much of this period invested a strikingly low amount in equipment and buildings compared to other systems globally. If the public hoped for a transformative sum post-Brexit which would arrest problems in healthcare, they did not receive it.
Another major question is how Brexit affects the NHS workforce. New nurses arriving from the EU and EFTA states slowed to near zero immediately and dental recruitment entered a prolonged slowdown, exacerbated in both cases by a new language testing regime.
As with funding, both the politics and the actual impact of this were based on a longstanding problem caused by domestic short-termism: many key staff groups were in serious shortage seven years ago, and many still are. The reaction of successive governments has been to repeatedly reform visa rules to enable a very high rate of recruitment from Africa and Asia.
The scale is remarkable: the outright majority of newly registered doctors in 2021 qualified outside the UK, EU or EFTA. This is delivering enough trained and qualified doctors and nurses to significantly boost numbers despite a continuing total lack of workforce planning for the English NHS, and a rate of staff leaving which has only increased. The number of non-EU doctors licensed in the UK has risen from 72,000 to 112,000 in the six years since the referendum: the number of non-EU nurses has risen from 67,000 to 124,000.
Unfortunately, this response has its drawbacks and its limits. Unlike with free movement in the EU, these visas come with skill and salary requirements. This worsened the situation for the chronically underpaid, understaffed and underfunded social care sector, which had been drawing on migrant recruits. Even with the recent declaration of care workers as a ‘shortage occupation’, a minimum salary of £20,480 to be eligible for a Health and Care Worker Visa is well above average pay for the sector in many parts of England. The proportion of EU social care workers fell from 8% to 7% between 2019/20 and 2021/22: the overall workforce did not grow across these years.
Meanwhile, in some crucial medical specialties, previously highly dependent on EU migration, we found that following a slowdown in recruitment within the single market no sufficient alternative had been found, with shortages still outstanding. The affected specialties included heart and lung surgeons, anaesthetists, and psychiatrists.
The UK avoided a no-deal Brexit, and civil servants and suppliers managed to avoid a sudden crunch in medicine supplies when a more organised exit from the single market occurred at the start of 2021. Yet we nonetheless found clear signs that the UK has faced elevated shortages to some extent since 2016.
The number of medicines for which the Department of Health and Social Care has had to agree to pay higher than the previous going rate in order to maintain supply has risen from around 20 a month before the referendum to consistently over 100. Multiple ‘Serious Shortage Protocols’, allowing pharmacists to rewrite GP prescriptions because the intended drug is running out, have been in force.
Some of this is a global phenomenon which we also see in the EU. But the UK’s problems in ensuring consistent supply of medicines seem to be especially consistent and to have started earlier. While we intend to look further into the different factors, the anomalous drop in UK imports of medicines – which has risen in other countries – suggests post-Brexit trade may be a factor.
Meanwhile, despite high profile decisions around vaccines, the possibility that Brexit could have allowed for faster access to new medicines seems to have been missed. When we looked at recent approvals in Autumn 2022, we found 9 of the last 20 drugs approved by the EU had yet to reach UK markets. In a similar timeframe, there were no clear recent examples of faster UK approval – though this has happened on some occasions. Research tracking total innovative approvals also shows the UK lagging behind the EU and USA.
Leaving the European Union dealt unfortunate blows to structural weak points which already existed in staffing and financing, and created a new weakness which would later be exacerbated by global shortages in medicine supplies.
Most of these problems could be addressed domestically or through negotiations with the EU – for example, by tackling the poor retention of existing staff, or achieving more mutual recognition agreements to make it easier to trade medicines with the continent. But this has not happened.
The near future will bring further Brexit difficulties for health in the UK, from pharmaceutical negotiations and investment trends to global trade deals. They need to be dealt with by strengthening the health service and the bodies which regulate medicine and plan the workforce, and by facing up to tough trade-offs. Continuing to drift may mean towing our Brexit and healthcare dramas along for years to come.
By Mark Dayan, Policy Analyst and Head of Public Affairs, Nuffield Trust.