Brexit. The impact on health and healthcare in Wales.

Introduction

The AMRCW recognises that Brexit will impact on health and healthcare in Wales. We believe there are significant potential public health challenges that will need to be addressed. This briefing outlines some of the important issues that citizens and decision makers will need to be aware of.

Summary  

The UK’s future relationship with the EU will play a critical role in the health and well-being of Wales. Brexit will pose serious potential challenges to the NHS (both healthcare and public health) and social care in Wales including: longer waiting times, increased pressure on staffing levels, a reduction in rights when travelling and delays in the approvals of medicines.

The NHS already faces funding pressures, and these may increase as a result of the economic impact of leaving the EU – reducing the funds available for healthcare, which will have direct knock-on effects on waiting times, recovery rates and quality of care.

Around 200,000 EU nationals work in the health and social care sectors in the UK – facilitated by EU freedom of movement. They are pivotal to the NHS which is vulnerable to skills shortages and a consequent reduction in service quality.

Reciprocal rights for patients across the EU allow access to healthcare. UK nationals may need to take out private health insurance in the event of changes to the current regime. This could have particularly negative consequences for the elderly and those with chronic conditions.

EU rules on data protection laws enable the sharing of patient details and this is the bedrock of the sophisticated infectious disease surveillance systems which are the basis of systems to control the spread of disease. These systems replaced prior reliance upon quarantine and isolation.

The critical point here is that unless the UK is subject to the European Court of Justice (ECJ) – which underpins the legal operation of data sharing across Europe – then public health agencies in other EU Countries and also the European Centre for Disease Control in Stockholm will, under European data protection laws, be legally precluded from sharing patient identifiable public health surveillance information with UK bodies such as Public Health Wales. This would seriously undermine infectious disease control systems.

There are also serious implications for the markets for medicines, vaccines, medical devices, and radio-isotopes including:

  • The UK may lose access to EU monitoring and notification systems for pharmaceuticals
  • UK approved pharmaceuticals may not be approved by use across the EU
  • New drugs may be less likely to be launched in the UK, which may become a comparatively low priority market given its relative size to the EU.
  • Radio-isotopes (for cancer treatment) are supplied to the UK entirely from other EU countries – and their legal movement is entirely overseen by Euratom.

 

A new EU Clinical Trials Database, into which all clinical trial applications must be entered, has been set up. The UK would not have access to it unless a specific agreement is reached (though again this will likely require ECJ oversight), which could impact on UK researchers wanting to undertake cross-EU clinical trials.

UK organisations are the largest beneficiaries of EU health research funds. EU legal frameworks – for instance on data protection, human tissue regulation and safety of clinical trials – underpin cross-border collaboration.

Equally, The Rapid Alert System for Human Tissues and Cells (RATC) and the Rapid Alert System for Blood and Blood Components (RAB) enable information regarding adverse reactions to be shared quickly across member states.

The UK would not have access to these rapid alert and information systems unless there were specific sectoral agreements in place.

In Wales, the withdrawal of EU funding (such as Structural Funds for deprived regions and Common Agricultural Policy receipts which underpin rural economies) is likely have an adverse impact on the determinants of health.

Background

This briefing provides a high-level assessment of the potential implications that leaving the European Union (EU) will have on health in Wales aiming to make clear the potential challenges so they can be anticipated and appropriate action taken.

The EU has a significant impact on health and well-being in Wales, both directly and indirectly. The EU has little in the way of direct control over healthcare and social care policy – as healthcare is not a EU competence. Nonetheless, the NHS and social care services are indirectly affected very considerably by EU membership – because of single market competencies such as the European Working Time Directive, the recognition of specialist qualifications, the free movement of labour, the regulation of pharmaceuticals, medical devices and radio-isotopes to name just a few.

The situation is different with regard to public health policy and population health within Wales – including its wider determinants. Public health is directly subject to governance under EU competence – one in which the union has been very active and influential.

Membership and, by the same token, non-membership of the EU, make themselves felt via a variety of more or less indirect routes, whether the implications of free movement, or of European health regulations, or the general economic situation of the country as mediated by our relationship with our EU partners. And of course we remain unclear as to what form Brexit will take, which merely adds to the complexity of the task at hand.

The sum total of EU influence upon the healthcare and public health is fundamental and the implications of Brexit upon the NHS and upon the health of the population is significant.

Health and Social Care Financing

The NHS is approaching a crisis point, and social care is suffering from chronic under-funding, and there are many important concerns for each relating to the UK’s exit from the EU. Brexit is forecast to mean less money for public services generally, including the NHS, due to lower economic growth and lower trade with our nearest neighbours. This of course comes on top of existing funding pressures. Should these pressures become more acute after Brexit, there will be direct knock-on effects on waiting times, and thus recovery rates, as well as the quality of care that can be delivered.

Health and Social Care Workforce

For the NHS and wider health and social care sector in Wales, there will be significant workforce implications due to difficulty in recruiting and retaining talent from the EU.

An EU Directive currently enables automatic recognition of professional experience across the EU, providing free movement of professionals such as doctors.

Health and social care rely heavily on non-UK staff, of which a significant percentage are from the EU. EU nationals thus play a crucial role in the health service. The NHS, and social care, face the dual challenge of retaining skilled staff already in place and attracting sufficient numbers in future to fill vacancies.

Given this, it is concerning to already see a change in recruitment and retention of NHS and social care staff coming from the EU. For example, the number of EU nurses and midwives leaving the Nursing and Midwifery Council’s register between October 2016 and September 2017 increased by 67% compared to the 12 months before, while the number joining it fell by 89%. Moreover, a recent British Medical Association survey of EU doctors working in the UK has found that 45% are considering leaving following the EU referendum result, with 18% already having plans to relocate elsewhere.

It’s clear that Government needs to be doing much more to reassure EU citizens that their rights to live and work in the UK will be protected after Brexit.

The health and social care sectors could face a considerable loss of staff if EU migration is limited after Brexit. Modelling from Department of Health projects a shortage in the UK of between 26,000 to 42,000 nurses by 2025/26. Estimates from the Nuffield Trust suggest a shortfall in England of as many as 70,000 social care workers by the same date.

For the NHS, this presents a short-term challenge in filling key posts and a longer-term challenge in training sufficient numbers within Wales – particularly for those groups not on the UK Shortage Occupation List.

If the withdrawal agreement enters into force, an immediate staffing crisis for the NHS and social care is likely to be avoided. Future rights for EU27 citizens already working in the UK were agreed in principle in mid-March. But the NHS has never trained enough doctors for its own needs: NHS England alone depends on 10,000 doctors and 20,000 nurses from the EU27.

Even if these staff remain in the UK, there is currently insufficient capacity planning for the future. The end of free movement after the transition period may mean fewer NHS and social care staff from EU27 countries.

The EU (Withdrawal) Bill provides some legal continuity. An Immigration Bill could recognise the needs of the health and social care sector. But the UK is committed to ending free movement. It envisages that EU27 citizens resident in the UK will be required to apply for a new residence status. The original proposal of a two-year grace period has been cut significantly to just six months in the draft withdrawal agreement. And a promised white paper on immigration has been delayed. This lack of clarity is already affecting health professionals.

Depending on its design, a new immigration system could have deeply damaging effects on the NHS. Free movement between the UK and the EU27 has been highly advantageous to the health sector. The operation of the NHS and related life sciences research are predicated on career-long fluidity of movement, protected by EU rights enforceable by law.

The government could decide to fund more training places for staff in the UK, but this will not be a quick fix and will face similar constraints from the public finances.

Another issue is the loss of access to the EU health professional alert system which allows authorities of all Member States to rapidly warn each other if health professionals have been prohibited / restricted from practicing, allowing professional mobility without impacting on patient safety and care quality.

Access to healthcare (including for British ex-pats)

The draft withdrawal agreement (as yet un-agreed) stipulates that the reciprocal healthcare arrangements covering the 190,000 British pensioners living in the EU27 are to be continued.

However, it is of concern that a large proportion of UK nationals living in Spain, in particular, have legally declared themselves as “non-resident” there – so that they do not have to pay local taxes. They are thus ineligible for coverage by the EU’s S1 Healthcare Insurance System intended for long term residents and have instead been using their European Health Insurance Card (EHIC) which is intended for short term tourist and business visits to secure care.

More fundamentally, as they have registered as “non-resident” then they will not legally be covered by the UK’s Withdrawal Agreement and will not therefore secure their residency and healthcare insurance rights – unless they register soon as resident and agree to pay local taxes. Many of the pensioners concerned are not wealthy and they may instead decide to return to the UK – so that they can rely instead upon the NHS. This is likely to place additional demand upon the NHS.

More broadly, as things stand, the eligibility of all UK nationals to the EHIC Card – which is intended for short stay heath care insurance cover – will cease at the end of transition. This is despite the UK’s avowed commitment to retain the current system of reciprocal healthcare, this has now been left to the next phase of the negotiations, where agreement will be procedurally more difficult.

Medicines, vaccines, medical devices and biotechnology products

The European Medicines Agency (EMA) underpins the Europe wide regulatory system that ensures that medicines are safe, effective and of a high quality. EMA supports cross-border collaboration and provides a common framework for assessing and monitoring drug safety and efficacy, providing timely access to new therapies and technologies.

If the UK were to develop a divergent approach to licensing, this could lead to:

  • delayed access (potentially up to 12 to 24 months) to new medicines and medical devices. For example, in Switzerland, medicines typically reach the market six months later than in the EU
  • weakened post-approval regulation and pharmacovigilance
  • loss of expertise in regulatory processes and pharmacovigilance.

In addition, any breaking of trade networks could cause availability and supply chain problems for medicines used by UK patients.

Without special agreements on issues such as regulatory alignment and marketing approvals, the UK will lose access to many of the networks, approval systems and databases that allow these goods to flow freely between the UK and the rest of the EU. There is also a risk that the UK could become a lower priority market when it comes to the launch of new drugs. The result may be a delay in the ability of UK patients to access these products.

Regulatory change, and a loss of international regulatory sway, also promise to be problematic for the NHS. While the government has recently conceded that shared regulatory standards are highly advantageous to market access, the combination of its ongoing commitment to ‘taking control of our own laws’ and the removal of legally automatic mutual recognition of standards unless divergence is justified means that this political position remains highly uncertain.

As the Health Secretary put it, ‘the right to choose to diverge’ from the EU post-Brexit remains. Divergence would raise significant problems in a host of areas relevant for the NHS, including medical devices; pharmaceuticals; blood, tissues and organs; clinical trials; and data protection (see below).

The UK’s influence on future regulation is also at risk. The European Medicines Agency (EMA) is relocating from London to Amsterdam as a result of Brexit. As its seat is only currently secured as part of the EU delegation, the UK may lose its voice in the International Conference on Harmonisation (for pharmaceuticals) and the International Medical Device Regulators Forum (for medical devices).

Radio-isotopes

The UK is a member of Euratom, which facilitates a secure and consistent supply of radioisotopes (all of which are imported into the UK from other EU countries) that are widely used in medicine e.g. diagnosis through nuclear medicine imaging techniques, radiotherapy treatment.

If the UK were to work outside of Euratom, it would need to source radioisotopes outside of this framework, potentially causing delays in diagnosis and treatment, reduced opportunities for sharing expertise in radiation research (Euratom funds research through the Horizon 2020 programme), and issues with radiation protection and the disposal of radioactive waste.

Like other non-EU countries, the UK could develop an associate agreement with Euratom.

Infectious Disease Control

The European Centre for Disease Control (ECDC) supports a co-ordinated response to hazards and threats by facilitating sharing of data, expertise and national strategies. The ECDC manages the:

  • European Surveillance System – routine, regular data reporting
  • Epidemic Intelligence Information System – immediate reporting of events or outbreaks
  • Threat Tracking Tool – used to detect and assess emerging threats
  • Early Warning Response System (EWRS) – for outbreak management and communication of control measures.

Any reduced level of collaboration with the ECDC could lead to delays in reporting and disease tracking, hampering outbreak response. Alerting systems such as EWRS will need to be replaced with World Health Organization (WHO) equivalents which may not perform in the same way. It would also reduce the effectiveness of pandemic preparedness planning and response. Loss of access to ECDC would create significant intelligence gaps for infectious diseases.

EWRS access is restricted to EU and EEA member states, with countries such as Switzerland not having routine access to the system.

From a microbiology perspective we will lose membership of a number of specialist organism/syndrome networks such as the:

  • Emerging Viral Diseases-expert Laboratory Network
  • European Reference Laboratory Network for Human influenza (ERLi-Net)
  • Healthcare-associated infections surveillance Network – supporting capacity building for the surveillance of Clostridium difficile infections
  • European Antimicrobial Resistance Surveillance Network (EARS-Net)

Through these networks, we have access to the latest intelligence, tools for surveillance and materials for the development and quality assurance of laboratory tests.

The Faculty of Public Health has recently launched a ‘blueprint’ for the UK’s future relationship with the ECDC.

Non-Communicable Disease Surveillance and Control

Wales participates in EU disease surveillance registries such as Eurocat, the European network of population-based registries for the epidemiologic surveillance of congenital anomalies. The Welsh congenital anomaly register and information service (CARIS) is a member of Eurocat, with membership contributing to our surveillance function through the analysis of CARIS data along with those of other registers. Through Eurocat, CARIS participates in EU funded research (for example, EurolinkCAT).

The Welsh Cancer Intelligence and Surveillance Unit (WCISU) benefits from the European Network of Cancer Registries (ENCR). Cancer registry data has also been shared in ongoing European studies of cancer survival, helping to inform cancer policy in Wales. WCISU is also a member of the UK and Ireland Association of Cancer Registries, an important forum allowing collaboration, harmonisation and peer review of cancer registry data quality and statistical method development. Such a network may not be feasible post Brexit.

Organ Donation

The UK currently imports and exports organs for transplant with other EU member states. It is important that steps are taken to maintain such exchange systems, after the UK leaves the EU, so that achieving the closest matches in compatibility between donor and recipient can be maintained.

Research and Development

The EU provides research networks, infrastructure, legal frameworks, research standards and policies that underpin scientific research. Replacements will be needed if continued access is not available after Brexit.

The EU enables medical research collaboration by supporting the sharing of research staff and expertise, cross border trials, and the development of research facilities. The EU provides funding through programmes such Horizon 2020 and the European Investment Bank has invested in UK research facilities including in Swansea and Bangor Universities.

Following exit from the EU, Wales can continue to collaborate on research, although there are concerns about the potential loss of access to EU health-related research funding programmes; difficulties in sharing expertise, facilities and datasets; an increased burden of conducting multi-centre clinical trials and issues recruiting high calibre researchers from Europe and reduced training and career opportunities. If the UK establishes a separate regulatory framework, this could impact on research in areas such as medical devices, rare diseases and clinical trials for children.

Following the most recent UK Government position (March 2018), we do not expect any current activities with EU Member State/European partners to change in the near future. Our understanding is that the UK can still participate in Horizon 2020 funding opportunities. We are unsure whether access to research funding streams would change after the UK leaves the EU. If this should be the case, this could be an opportunity for more collaborative working between the four nations, although this will require funding from Government. If research funding becomes reliant on UK funding streams, these will become even more competitive, and some research proposals that could have significant benefits to population health may not be funded.

Laboratory Standards

Whilst laboratory standards are devolved to Wales, standards are all underpinned by European law and are assured by a European system.

UK International Trade Deals and the future of the NHS

UK trade policy will also pose questions for the future of the NHS. What happens in trade negotiations with the EU and other countries will indicate what to expect for the post-Brexit health sector. Negotiation of these agreements will be very telling in terms of what the UK government values.

For example, it will demonstrate the level of its commitment to preserving shared regulation, and the free movement of professional and research staff. More broadly, it will illustrate how much value the government places on the NHS as a public entity, still largely not open to private investors.

For some people, the ‘best possible deal for the United Kingdom’ in such trade agreements may include changes to NHS England to allow access for foreign investors. The need for explicit reservations to prevent this was recognised by the EU and member states during negotiations with the US over the Transatlantic Trade and Investment Partnership (TTIP), but it is unclear whether the UK will be able to or want to negotiate similar terms.

Future capacity planning will have to take place within those as yet uncertain rules. UK trade deals with other countries may involve elements that affect the NHS, or the NHS may be explicitly excluded from their effects.

Broader Population Health Implications of EU Regulations

The following are high level reflections on the potential broader population health implications of EU regulations that will fall away after leaving the EU.

It is of interest that the UK Faculty of Public Health has been campaigning for the introduction of a ‘Do no harm’ clause into the Withdrawal Bill, so that the Bill’s powers do not reverse or amend regulations critical to the health of the population.

Food Standards

The Food Standards Agency (FSA) works with the European Food Safety Authority (EFSA) to ensure UK standards are in line with EU regulations, ensuring that imported products (either from within or outside the EU) meet robust standards to protect health.

To enforce standards, the FSA conducts food supply chain inspection at a domestic level. The European Commission provides supply chain surveillance for food products imported into the EU from countries with a free trade agreement. This is also important when considering the transmission of infectious disease through food.

Potential impacts of leaving the EU include:

  • weaker regulation and market surveillance of imports and exports. The EU has previously rejected imported products on the grounds of public health safety.
  • Any divergence from EU standards would require the UK to establish a food inspection regime to replicate the function provided by the EU for food products from non-EU countries. Failure to do so would potentially introduce public health threats into the supply chain.
  • Any weakening of domestic standards would raise concerns about UK products exported to the EU, with impacts on business.
  • Withdrawing from the EU legal framework on food could potentially offer opportunities such as helping consumers make healthy choices.

Tobacco and Alcohol

Wales is pursuing policy around Minimum Unit Pricing and tobacco regulations. This needs to be considered in future, in the context of the EU Withdrawal Bill and the potential centralisation of powers.

In relation to smoking, the EU has enabled a cross border approach to anti-smoking measures through the Tobacco Products Directive. The Directive regulates a range of matters, including tobacco advertising and nicotine levels in tobacco and addresses issues related to trade in illicit tobacco. Post Brexit, it is vital that the UK’s commitment to tobacco control does not become weakened.

Transition and Mental Well-being

The period of uncertainty related to Brexit is likely to impact the mental health and well-being of the population and may disproportionately affect specific groups such as farming communities. Economic and investment decisions made before Brexit is complete will add to the uncertainty and concerns of the population relating to financial and employment uncertainty. We believe that it is important to understand the impacts on health during negotiation and transition.

Wider Determinants of Health

Wales receives a disproportionately larger amount of EU funding compared with other parts of the UK. Any loss of funding could negatively impact on well-being (and inequalities) in Wales. EU structural funds have supported initiatives to close inequalities in health and tackle poverty, with Wales being a net recipient.

Any decline in the economy will mean that socioeconomic inequalities increase, with a likely increase in health inequalities.

There is also concern about potential future trade agreements, such as the Transatlantic Trade and Investment Partnership (TTIP), which may negatively impact on health. Of note, the Faculty of Public Health is advocating for health focused post-Brexit trade agreements that support the UK’s ability to regulate to improve health in areas such as food, alcohol and tobacco.

Farming

Welsh farmers currently benefit from EU market access. For example, 30% of Welsh lamb and 90% of landed catch is exported to Europe and any loss of such markets or imposition of tariffs will have a significant impact on Welsh farming. There are also concerns about loss of funding for agriculture and rural development as part of Common Agricultural Policy support.

In July 2016, the Faculty of Public Health, along with 80 other organisations, called on the UK Government to adopt common-sense food, farming and fishing policies that benefited jobs, health and the environment. Improved food, farming and trade policies could contribute to cutting greenhouse gas emissions from farming and food industries by 80% by 2050, promote healthier diets and support a vibrant economy with good jobs.

Social Cohesion

It has been noted that some areas of Wales that supported Brexit are those that have had significant support from the EU. This needs to be better understood, but indicates that community involvement is needed with funding and support programmes.

Education Funding

Education is a key determinant for health and well-being. In Wales, EU funding has supported further education college buildings and skills funding and programmes such as Erasmus+. In addition, universities have been recipients of EU structural funds, helping to target the poorest areas and support the local economy.

 

 

 

 

 

 

 

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