Brexit and health – 4 years on

From a health perspective, Brexit has been a dismal failure.

Jan 31, 2024, the anniversary of the UK formally exiting the EU, is an opportunity to take stock and reflect. In 2016 the Vote Leave campaign placed the UK National Health Service (NHS) at the heart of its campaign to exit the EU, with its slogan “We send the EU £350 million a week. Let’s fund our NHS instead”, defying the Chair of the UK Statistics Authority who pointed out that this amount for the UK contribution to the EU was wrong. But the Vote Remain campaign, which had plenty of evidence that Brexit posed a severe risk to the NHS, decided to focus on other issues that could seem distant from the harsh realities of life experienced by those who would vote to leave. In 2016, disparities in access to opportunity and health were widening, leaving many people feeling left behind and disillusioned, but those supporting the Vote Remain campaign seemed generally disinterested in their plight. Indeed, the vote to exit the EU was greatest in those communities whose health had suffered most in the years running up to the referendum. 4 years on from the UK’s formal withdrawal from the EU on Jan 31, 2020, is it possible to say whether Brexit helped or harmed the NHS?

There are two answers, one easy and one difficult. The easy one is that there is no credible evidence that leaving the EU helped the NHS or improved health in the UK. But an absence of benefit does not necessarily mean harm. So the difficult answer involves quantifying how much damage Brexit has caused. Economists often invoke the term ceteris paribus, or all other things being equal. Yet all else has not been equal. Brexit was followed by the devastating Covid-19 pandemic, Russia’s illegal reinvasion of Ukraine, and intensifying conflicts in other regions of the world, with resulting disruption of global supply chains. Advocates of Brexit are spoilt for choice when they seek alternative explanations for why the UK is doing so much worse on many economic measures than many other countries.

Separating out these factors is particularly challenging when considering the NHS and health more broadly. The health of the population in the UK is getting worse, as measured by life expectancy. However, this decrease in life expectancy partly reflects a trend that began in the early 2010s and has been associated with the imposition of austerity. Less money to invest in public services during the 2010s had a detrimental effect on the social determinants of health. The dampening effect Brexit has had on the economy indirectly affects population health through less funding for social and health services. But there are also effects from the loss of things such as the EU structural funds, some of which were allocated for investment in life sciences and helped to address regional inequalities; these funds have been replaced by much smaller amounts of domestic funding.

The NHS is doing worse than before Brexit, but how much Brexit has contributed to this situation is complicated. The number of people waiting for NHS hospital treatment reached 7.71 million people in October, 2023, double that on the eve of the 2016 EU membership referendum. Doctors are on strike, which is always a marker of deep system failings in a health system, and funding remains inadequate to improve health facilities and equipment in need of urgent maintenance.

Perhaps the most obvious impact Brexit has had is on the NHS workforce, which is a function of both recruitment and retention. Brexit has made recruitment more difficult. Since 2016, numbers of health workers coming from the EU to work in the NHS have fallen precipitously. From September, 2016, to September, 2021, the number of nurses who trained in the European Economic Area and were registered in the UK fell by 28 percent, from 38,992 to 28,007.

However, there has also been an increase in health workers coming from the rest of the world, who now make up the majority of newly registered doctors in some specialties. For example, the number of international medical graduates joining the General Practitioner Register almost tripled from 2018 to 2022, whereas the number of UK graduates becoming general practitioners fell by 4 percent. Yet while pivoting recruitment of staff from Europe to the rest of the world has avoided a more disastrous short-term crisis, the current UK Government’s determination to reduce net migration threatens future recruitment. Although NHS workers can get cheaper visas than others and can claim back the cost of the NHS surcharge that visa holders must pay on top of their taxes to access NHS services, constant changes to the rules have created uncertainty and health workers considering moving to the UK can have little confidence in their long-term future. Brexit has had a less direct role in staff retention, which has been more severely impacted by health-care professionals choosing to leave a system in which they do not feel valued to emigrate or retire prematurely. But the adverse impact of Brexit on economic performance in the UK also makes it more difficult to find money for competitive salaries for a health workforce and investment in working environments.

Harder to unpick is Brexit’s contribution to shortages of medicines. In January, 2024, it was reported that shortages of medicines had doubled since January, 2022. Here the conflict in Ukraine, the impacts of the Covid-19 pandemic, and disruptions to production in China have all compounded the situation. Expert reports document rises in drug shortages in the UK that seem to be more severe than in EU countries that have experienced the same global pressures. This situation has been partly attributed to regulatory divergence, resulting in extra costs and paperwork and the UK now being outside major European supply chains. It is likely that the situation will get worse as the EU implements a programme to stockpile medicines from which the UK is excluded. Furthermore, the UK’s Medicines and Healthcare products Regulatory Agency previously benefited from EU funding and with its loss approvals by the agency have slowed.

On medical science and research funding the UK’s eventual decision to rejoin many parts of the Horizon Europe research programme is welcome, but as an associate member the UK will have limited input into its research agenda and the delay in rejoining has been a hindrance for researchers, funders, and regulators. However, divergence from EU rules could make it more difficult to run global clinical trials in the UK than before Brexit. Regrettably, the UK has declined to rejoin the ERASMUS+ scheme that provided opportunities for young British researchers to gain experience abroad, replacing it with its own inferior Turing Scheme that has struggled with complex and inefficient bureaucratic procedures, a single-year funding model, and the absence of two-way exchanges. Healthcare professionals and researchers can try to overcome these enforced barriers to European partnerships by working harder to collaborate with European counterparts, but without greater political support there are limits to what individuals can do.

Ultimately, Brexit has been a failure from a health perspective. Some of the damage from Brexit to health can be limited—for example, by signing a phytosanitary agreement that would ease some, but far from all, of the barriers to trade with the EU, a move proposed by the Labour Party, and by avoiding pointless regulatory divergence. However, the damage to health and the economy in the UK continues to accumulate. Regrettably, few politicians are willing to admit this situation, perhaps because of their reluctance to refight old battles and because they fear the reaction of a predominantly pro-Brexit British media. This puts health in the UK in a precarious position. A major lesson from the vote to withdraw from the EU was that an increasingly unfair and unequal UK makes those whose health is most negatively affected by such inequality more susceptible to polarisation and populism. To strengthen health in the UK and the NHS, the UK must move closer to the EU. But this will not happen in a vacuum. Policies that will make for a fairer society, including taxing the super-rich, tackling the inverse care law, listening to communities that feel left behind, and investing in health infrastructure and regulation that will protect people’s health, are the only way forward. Unfortunately, these policies are not high on any political party’s agenda.

Authored by Jessamy Bagenal, Senior Executive Editor at The Lancet and Martin McKee, Research Director of the European Observatory on Health Systems and Policies.