On the 23rd of June 2016 Scotland voted to stay within the European Union (EU) by an almost two to one majority. But this was a UK-wide vote and, as a consequence, Scotland now faces the very real prospect of leaving the EU by the end of 2018.

Sadly it became almost immediately apparent after the EU referendum result was announced that the Leave side didn’t actually understand what the implications of victory would be for so many aspects of our society nor had they any real plans to deal with them.
One of those aspects is the possible effects of Brexit on the NHS. Writing in his blog on 30th June Mark Porter, Chair of the British Medical Association’s UK Council said ”Whatever your view of the outcome of the EU referendum, there is no doubt of the profoundly destabilising force it has exerted upon the country… we have been dragged into a situation that may compromise our ability to practise in a number of highly significant ways, and which has raised fundamental questions about the funding and workforce of a service already in crisis”

Two weeks after the result the NHS Confederation issued this statement: “The influence and impact of EU affairs on the NHS has significantly increased over time, with various aspects of domestic health policy now being intrinsically linked with EU policy. The Leave vote will therefore certainly have far reaching implications for the NHS despite at this stage it being impossible to predict the level of impact, as we do not know which type of new relationship the UK Government would seek, how long negotiations with the EU would last and which outcome there will ultimately be”

But the warnings were already out there for those prepared to look.

NHS2One of the biggest areas of concern is in relation to the NHS workforce. In Scotland almost 10% of doctors employed in the NHS are EU migrants and for nurses and other health and social care providers the figure is as many as 5%. These numbers may be smaller than for non-EU migrants but still account for over 500 senior doctors, over 3000 nurses and perhaps as many as 8000 workers in adult social care. In recent years the numbers of EU migrant health workers in the NHS has been rising rapidly to fill shortfalls in training numbers here and without this immigration overall numbers of nurses and doctors working in NHS Scotland would have fallen. Even before Brexit became a reality the NHS in Scotland has been struggling to recruit and retain health and social care staff.

The new Prime Minister Theresa May has so far refused to give any guarantee that any existing EU citizens working in the UK will be allowed to remain once the UK pulls out. In May 2016, in the run up to the EU referendum, the Nuffield Trust issued this warning: “If EU immigrants are simply treated in the same way as non-EU immigrants after exiting the EU…the tightening of the rules for non-EU immigrants in 2010…suggest that it has been politically feasible to introduce laws which meaningfully restrict NHS migrant staff, and that the effect of this has been substantial”

Speaking to the British Medical Journal, Kieran Walshe, Professor of Health Policy and Management at Manchester Business School said “If Brexit threatens the freedom of movement, or makes the UK a less attractive place to live and work, it will have a profound effect on health services and research. The best and the brightest are likely to vote with their feet and leave the UK”.

And of course immigration is a two-way street. There are currently over one million UK citizens living in other parts of the EU. At present they are entitled to access the health services in the countries where they live on the same terms as the citizens of those countries. The use of health services by EU citizens living in the UK is less than that of people born here largely because these EU migrants are younger. In contrast many of the UK citizens living in other EU countries are pensioners. If they can no longer access the health services of the countries in which they now live on favourable terms they may choose to return to the UK placing additional pressures on already over-stretched health and social care services.

The relative lack of borders within the EU also plays an important role in the larger public health picture. Institutions such as the European Centre for Disease Prevention and Control coordinate surveillance systems for communicable diseases such as influenza or HIV and are intimately involved in helping tackle challenges such as antimicrobial resistance.

Such “cross-border cooperation” is also vital to medical and scientific research. Sir Paul Nurse, the Nobel Prize winner and former President of the Royal Society, has warned that Brexit amounted to “the biggest threat” facing UK research in living memory which could “jeopardise” the world-class medical research for which Scotland is renowned. Scotland’s Auditor General Caroline Gardner has suggested that Brexit could cost medical research in Scotland millions of pounds in funding.

Rustam Al-Shahi Salman, Professor of Clinical Neurology at Edinburgh University, has warned that “Brexit will immediately destabilise our ongoing EU funded multi-centre studies”

At present almost one in four research scientists working in the UK is from another EU country. Brexit could make the UK a far less attractive place for these scientists to work. In addition, the loss of EU wide collaboration may see vital clinical research trials pulled out of the UK.

As Simon Wessely, President of the Royal College of Psychiatrists put it: “There will be less money for the NHS and for science. I cannot hide my anger – there never was £350 million a week for the NHS. Will we be able to attract the best doctors and scientists in the future?”
Another major area of concern for health and social care workers is what will happen to the European Working Time Directive (WTD). Whilst some EU rules and regulations may seem meddlesome, time-consuming and largely unnecessary there have been many which have enhanced the protection of both workers and the public. It’s not surprising that major trade unions came out for Remain.

In the 1980s junior doctors were working an average of about 90 hours per week. A new contract for junior doctors introduced in 1991 brought this figure down to about 72 hours per week. Whilst such long working hours almost certainly improved the continuity of care this came at the expense of exhausted doctors and increased risks to patient safety.

The WTD sought to ensure maximum working hours of 48 hours per week as well as regular breaks between shifts. If Brexit leads to an “opting out” of the WTD it will have massive implications for contracts and initiatives like Agenda for Change as well as risking a return to the dark days of exhausted young doctors with patients being harmed as a consequence.NHS1

At a more profound level Brexit may affect the health and well-being of our society across the board. According to Professor Sir Michael Marmot of the UCL Institute of Health Equity “around 90% of economists predict that, in the case of Brexit, we would be a poorer country in the short and medium term. A poorer country will have less money to spend on social services, healthcare, education and research. This will damage health.”

So we have to accept that if Brexit occurs and Scotland is pulled out of the EU and the warnings for the provision of health and social care come to pass this will have profound implications for the health and well-being of us all.

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