The level of disruption that could be caused for the NHS by a no-deal Brexit was thrown into the spotlight last month when details from the Government’s Operation Yellowhammer were leaked.
The Government has now been forced to publish the documents in full by Parliament, and the Scottish Parliament has already published its own no deal briefing highlighting healthcare as one of 12 most at risk areas. Most worryingly, the now officially published documents confirm the risk of medicines shortages, along with at least three months of shortages of food and fuel as border crossing points struggle to deal with checks. Operation Yellowhammer also assumes the eventual return of a hard border between the Republic and Northern Ireland.
Despite losing his majority and control of Parliament, Prime Minister Boris Johnson has continued to repeat his pledge that the UK will leave the European Union on 31 October 2019, whether a deal has been agreed with the EU or not. So what challenges will the NHS have to deal with in the face of a no deal Brexit?
Medicines supply shortages
A recent media storm surrounded an on-air argument between Jacob Rees-Mogg MP and Dr David Nicholl, who had advised the Government on the risks of leaving the EU without a deal on patients and their medicine supply. Rees-Mogg suggested Nicholl was irresponsible for vocalising “the worst excess of Project Fear”, despite leaked Operation Yellowhammer documents warning delays at channel crossings would make medicines “particularly vulnerable to severe extended delays” “with significant disruption lasting up to six months” if unmitigated. These could impact as much as 40-60 per cent of imports from day one.
Medicines and medical supplies that required specific transport conditions, such as temperature controlled environments like insulin, or had short shelf-lives such as medical radio isotopes, would be particularly hard-hit, the documents warned. Heads of health bodies including the RCN, RCM and BMA warned at the end of August that agents necessary for cancer diagnosis and treatment were at risk in a no-deal scenario.
It is unclear what the impact of tariffs would be on exports, and it is hoped the World Trade Organisation (WTO) would agree to a WTO Pharmaceutical Tariff Elimination Agreement in the case of the UK leaving the EU without a deal. The pro Leave Institute of Economic Affairs (IEA) believe that tariffs would affect a limited number of pharma ingredients and devices but acknowledge that the NHS would have to absorb a rise in prices on some products. The cost of any tariffs would almost entirely be borne by the NHS the Institute of Economic Affairs has argued.
Royal Pharmaceutical Society Director of Pharmacy and Member Experience Robbie Turner said it was important to remember that global supply chain issues for medicines had been an issue for years, and “we will continue to see shortages for years to come and no deal Brexit could make that worse, but we have no indication that the global supply chain issues will be altered by Brexit.”
Staff shortages
There are already 100,000 vacancies in the NHS, a situation that is set to worsen in or out of the EU due to increased demands on our health services. The Kings Fund has calculated that the UK needs to recruit at least 5,000 new nurses each year from abroad to simply stop the situation worsening.
There are 116,000 EU nationals working in health care, meaning that any impact on them has the potential to significantly impact the health service, a joint letter by The Kings Fund, the Health Foundation and Nuffield Trust has warned. A BMA survey found that 45 per cent of doctors from the EU stated they were considering leaving the country and one fifth had made plans to leave. If a no deal Brexit caused a significant drop in the pound, then many NHS staff could leave if it makes working in the UK no longer a competitive option, The Kings Fund has also warned.
The reintroduction of a hard border between Northern Ireland and the Republic of Ireland could also cause a disproportionate impact locally due to a high vacancy rate in Northern Ireland, as NHS staff who reside in the Republic could struggle to get into work. This would be exacerbated by Home Secretary Priti Patel’s plans to remove freedom of movement for EU nationals on 31 October.
Economy
Office for Budget ResponsibilityThe Budget for Office Responsibility has claimed that a no deal scenario would likely require an extra £30 billion of borrowing each year. This is more money than was spent on adult social care and investment in NHS buildings and equipment in 2017/18 alone according to The Kings Fund.
Economically problematic is also the precarious nature of many of the companies that are now responsible for outsourced health and social care. Operation Yellowhammer documents warned: “An increase in inflation after the UK’s EU exit would affect providers of adult social care through increasing staff and supply costs, with smaller providers impacted within 2-3 months and larger providers 4-6 months after exit.”
Guy Collis, a Policy Officer at UNISON explains how this might have an impact on the NHS: “So many companies in social care are already in a very unstable financial position, and if there is the expected shock on the wider economy then numbers of providers could be exiting the sector or going bankrupt, and the likelihood is then there will be a fairly major knock on impact on the NHS.”
Though it is unclear what emergency support the NHS would be expected to provide, care homes going bust could see an increase in demand on A&E and community services which are already under significant pressure.
“Even if there was no Brexit whatsoever we would still see a number of care providers going under like Southern Cross a few years back. The problem is the services and staff usually transfer to another operator, but if they are all experiencing problems [following a no deal Brexit] then it is not clear how easy that would be,” Collis warns.
Rising costs and shortages
Looking outside of the health and social care system, it is also likely that the impact of leaving the EU without a deal on fuel and food availability could also affect the NHS practically and financially.
Even if “everyone will have the food they need” as promised by Michael Gove, increases in the cost of food and fuel could further squeeze NHS budgets. If the UK leaves the EU with no deal then it will be subject to World Trade Organisation tariffs on food and other products, such as a 35 per cent tariff on dairy. Skyrocketing hospital food bills aren’t going to help anyone.
Speaking at an Exiting the EU Select Committee hearing, Andrew Opie the British Retail Consortium director of food and sustainability said: “I think there’s been too little debate around the three, six, nine-month period [after Brexit],”
“For us, for example, we will [initially] have a temporary tariff on food, but how long will that temporary tariff last?”, reported Civil Service World. He also warned that late October would be the worst possible time for the UK to face a no deal Brexit as its fresh food import needs peak over the winter.
Dave Prentis warned ahead of the Trades Union Congress in Brighton this week that: “the catalogue of logistical nightmares goes on. The NHS serves more than 140 million meals to patients every year, with much of the food imported from Europe.
“Possible fuel shortages could have a severe impact on 6,500 emergency ambulances and their crews operating countrywide, especially those in areas with lorries queuing out of the ports.”
While it is not expected that the World Trade Organisation would implement tariffs for gas and electricity in the case of a no deal Brexit, industry experts do expect costs to rise, Bloomberg reported earlier this year.
NHS chronic underfunding has left it with a £991 million combined deficit according to the National Audit Office, making it unclear where any money will come from to pay for these rising costs of running NHS services.
While it would be incorrect to blame all of the NHS’s problems on a no deal Brexit, it is certainly the case that leaving the EU without a deal will significantly exacerbate a wide range of problems already afflicting our underfunded services.
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