Will Brexit have a negative impact on patient safety?

The NHS was touted to be the biggest winner of a leave vote. But will patient safety prove the biggest loser of all?

Public opinion on Brexit remains divisive. A significant number of Remain voters are suffering from “Bregret”, resulting in several calls for a second referendum. ⁽²⁾ Some critics, on the other hand, call claims of economic and socio-political upheaval nothing more than scaremongering—a weapon of Project Fear. In the meantime, all number of fallouts continue to be discussed, from Hard Brexit to Soft Brexit, to a Brexit that is just right. Unsurprisingly, people and organisations have already started to prepare.

The concept of shortage and civil disorder is not new to Britain. Many people will remember the power cuts of the 1970s when work-to-rule strikes meant lengthy blackouts plagued the country. Some people will even recall rationing during World War II. The notion of empty shelves, spoiled food, and gridlock at ports, however, seems unthinkable in modern Britain. But while the government dismisses such pessimistic talk as nonsense, contingency plans for a no-deal Brexit exist, jobs in emergency planning have been advertised, and for the first time in over half a century, Britain has appointed a minister for food supplies. ⁽³⁾ Leaving the EU has arguably become the greatest peacetime challenge a UK government has ever faced.

Nowhere will the effects of Brexit be felt more viscerally than in the NHS. Once upon a time, the health service budget looked to do quite well out of Brexit. Indeed, the Leave campaign built an infamous fleet of buses to attest to that fact. ⁽⁴⁾ But as the eleventh hour of the negotiations approach, and another winter sets in, the NHS no longer appears the biggest winner out of a Leave vote. In fact, patient safety might be the biggest loser of all.

The most obvious impact of Brexit on the NHS and its patients stems from its economic effects. A 2016 Treasury analysis concluded that leaving the EU could lead to an annual net loss of income of circa £4,300 for each UK household. ⁽⁵⁾ Resulting tax receipts could be up to £36 billion lower a year. Effectively, this will leave the government with the politically unpalatable decision of either increased taxes or substantial cuts to spending on areas such as health and social care. Compulsory health insurance or large co-payments for NHS services could emerge. A rapid growth in these premiums or fees would likely dissuade patients from attending their doctor or continuing certain medication.

Staffing in the NHS is another key area that currently relies heavily on EU membership. Ironically, there is already a shortage in healthcare staff (with 278 doctors per 100,000 citizens compared to an EU average of 347). According to the NHS Confederation, there are approximately 144,000 EU healthcare workers in the UK, with one in ten doctors a European Economic Area (EEA) graduate. ⁽⁶⁾ Although the government has made a commitment to “protect and enhance the rights people have at work”, there is a very real chance that the legal entitlements of EU workers or their families could be undermined post-Brexit. If immigration is curtailed, and a hard line on existing EU migrants is followed, current evidence suggests the UK is in no position to fill these vacancies. Many home-grown doctors are opting to leave the NHS for a variety of reasons. Four out of five physicians-in-training, for instance, report excessive stress at work, while a staggering 95% claim poor staff morale negatively impacts patient safety. ⁽⁷⁾ Likewise, the Nursing and Midwifery Council (NMC) have attested to 24,000 vacancies. ⁽⁸⁾ Even with government intervention (notably, the Secretary of State for Health has pledged £100 million in medical student funding), it could take a decade or more to correct staffing shortages. In the meantime, patient care will suffer, and the population will be further disenfranchised from engaging with the NHS.

One of the biggest benefits provided by the EU to UK citizens is free movement. Yet, the safe movement of people within the EU is based on the social protection each member state mutually provides. In a situation where mutual recognition no longer exists, the UK government may not be in a position to reimburse EU countries, and thus the healthcare provided to UK citizens abroad will cease. This would not only affect the 27 million UK holders of European Health Insurance Cards, but also the thousands of UK expat pensioners residing in the EU. ⁽⁹⁾ The cost of travel insurance would be expected to rise and individuals with chronic disease could find themselves unable to pay. Although a deal on this issue is a high priority for both negotiating parties, no agreement has been reached yet.

One of the more publicised effects of Brexit on patient safety is the potential for medication shortages because of a disruption in trade. Currently, 45 million medication packs are exported from the UK to the EU monthly, with 37 million shipped the other way. ⁽¹⁰⁾ Already, pharmaceutical companies have been instructed to stockpile an extra six weeks supply of the drug to buffer any impact of a no-deal. Britain’s biggest Insulin supplier, Novo Nordisk, has gone one step further, building up to four months reserve. ⁽¹¹⁾ At a community level, the Royal Pharmaceutical Society (RPS) has called on the government to extend pharmacists emergency powers. This would allow pharmacists to switch patient medication without consulting doctors in the event of drug shortages. Outside of medication, concerns also remain around the supply of medical devices, clinical consumables, vaccines, and blood products. The EU patient population will be similarly affected, as companies such as AstraZeneca have their manufacturing basis in the UK. ⁽¹²⁾

At the moment, the UK Medicines and Healthcare products Regulatory Agency (MHRA) and the EMA are working under the shared understanding that, after Brexit, all existing marketing authorisations will be recognised by the MHRA, meaning no legal barriers to accessing over nine hundred medications. Issues will arise, however, with the authorisation of new therapies. As the UK only represents 2-3% of the global market, it will find itself down the pecking order in terms of new medication approval. In Switzerland and Canada, which also have separate approval systems, new therapies typically reach the market six months later than in the EU. ⁽¹⁰⁾ Some medications never reach these markets at all. As a result, smaller patient populations such as sick children and those with rare “orphan” diseases could find themselves without access to life-saving therapies. Although the Leave campaign was keen to take back sovereignty, the MHRA may have to forego it to the FDA or EMA in order to establish quicker access to new therapies.

Arguably, the only thing more essential than staff and stock to healthcare provision is good information. A series of pan-EU networks will be seriously affected by Brexit, including systems to monitor infections, pharmacovigilance, counterfeit medications, and cancer outcomes. ⁽⁹⁾ While in theory cooperation on these issues can continue, oftentimes these programs depend on sustained financing and collaboration, to which the UK’s non-EU status may act as a hindrance. As a result, any data gathered may be increasingly difficult to apply to UK patients.

European-wide research programs are also vital to healthcare and patient wellbeing. Direct EU funding accounted for almost three-quarters of the growth in UK research funding in the last ten years. ⁽⁹⁾ Beyond cost alone, British institutions also rely heavily on access to EU networks, infrastructure, and research personnel. Approximately 15% of the UK academic workforce comes from other parts of the EU through programs such as the Marie Curie scheme. While the government has offered to guarantee funding for existing EU projects, such as Horizon 2020, no promise for long-term support has been made. In some ways, this lack of commitment reflects a wider issue in post-Brexit health research. For one, the UK is a net beneficiary of EU research funding, attracting substantially more funds than it contributes to the common pool. Furthermore, patients may miss out on clinical trials and the innovative products that stem from collaborative research.

Finally, it is important to note that the EU regulations affect public health at large, on matters as wide-ranging as road infrastructure, food safety, air and water quality and workplace health and safety. As a leader in public health, the UK may look to develop a competitive advantage in trade. With the loss of EU standards, however, the UK may also be targeted by certain industries, including alcohol and tobacco. This could have potentially disastrous consequences for patient well-being and public health.

Overall, there lies the potential for negative impact of Brexit on patient safety and health. With the challenges, however, also come the opportunities. The UK could become an attractive pharmaceutical market, with a more streamlined regulatory process than its European counterpart. Potential improvements in hospital staff working time legislation could also be made. Thirdly, public health measures could be redrafted, with possible benefits for the public at large.

Truly, it is this last point—the future health of a nation—that needs to be reckoned with as the Brexit negotiations draw to a close. In every permutation of the UK leaving the EU, the shockwaves felt by the economy will be immediate. In most, they will be lasting. As a result, the wider determinants of health—from housing to education to income and pensions—could take decades to recover. Perhaps the aggregate effect will never be tallied. And so, it falls to politicians, in collaboration with regulators and healthcare staff, to strike a deal. With health and wellbeing on the line, we must ensure Brexit works for the most vulnerable people of all.

Will Humphries is the marketing Director of Pharmapod.

References

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