In the past three weeks, Theresa May has made two major speeches, of which the first failed of its intended effect and the second was a disaster. Boris has drawn provocative red lines in places that were not his business, and made an ass of himself in places which were. The Cabinet has skidded from one crisis to another and is trying to avoid unintentional suicide. The European Parliament has voted that not enough progress has been made in the Brexit negotiations for talks to proceed to the next stage, which renders largely pointless the Prime Minister’s speech in Florence.  Official figures showed the UK at the bottom of the G7 growth table; productivity has fallen for two consecutive months. And The Lancet has published a nine-page paper on the effect Brexit will have on the NHS.

The most important of these is the last.

Of all the facets of British life that Brexit will affect, the NHS is unique. It arouses not just passion, but unanimity. On immigration the nation is divided; on sovereignty there is room for endless argument. There is no room for argument about the NHS. It has to be protected. Even people who in their hearts would like to dismantle it dare not say so. During the referendum campaign an emotional voter told the BBC she would “literally go mad” if Boris Johnson’s £350 million per week for the NHS did not materialise. Her husband needed complex medication. I do not know what her mental state is now.

The Lancet’s paper, “How will Brexit affect health and health services in the UK?” (http://dx.doi.org/10.1016/S0141-6736(17)31926-8), surveys the risk to health-related issues in the UK of three scenarios: soft Brexit, hard Brexit and failed Brexit (no deal).  Its bleak conclusion is that each scenario poses substantial threats, that failed Brexit would be the riskiest outcome, and that the greatest threat facing the NHS will come from the impact of Brexit on the national economy.

Starting with the recruitment problem, it says it will be very difficult for the UK to be self-sufficient in the NHS or social care workforce in the foreseeable future. “Over 6,000 people from non-UK EU countries work in the NHS and 90,000 work in adult social care. One in ten doctors in the UK is a European graduate…” Moreover, “EU membership greatly enhances the attractiveness of the UK as a place to build a career in research and clinical roles.”

Or it did. The authors go on to discuss the ways in which Brexit would make the UK less attractive to these workers by undermining their legal entitlements.  Already in March, the Guardian  reported a 92% drop in the number of EU nationals registering as nurses in England, which the Royal College of Nursing blamed on the Government’s failure to provide them with any security about their future.

About 190,000 people who receive British pensions live in the EU and depend for health care on reciprocal UK/EU arrangements. The authors note that “the post-Brexit deal could continue this system and the UK Government appears to want to do so, although how this system can be reconciled with leaving the future jurisdiction of the European Court of Justice is unclear…The summary of negotiating positions on citizens’ rights shows no agreement on this crucial issue.”

It is indeed crucial, although the British Government did not at first think so and did not include it in plans for the talks. It also represents a bargain for the taxpayer: the UK pays about £650 million per year for care provided to British people in EU countries (about £500 million is for pensioners) and receives about £50 million for the care provided to EU-insured nationals in the UK. The amount paid by the UK is less than 0.5% of the total NHS budget and is “good value for money, because the average cost of treating pensioners elsewhere in the EU under these arrangements is about half the cost of similar treatment within the UK.”

Does Boris know this, one wonders?

The fall in sterling is already making imported medicines more expensive. “Events that affect the UK economy are likely to have a substantial impact on NHS finances,” the report notes. The Economist Intelligence Unit estimates that NHS costs will increase by £7.5 billion a year. It adds that “The overwhelming consensus of economic forecasts… is that Brexit will have a substantial long-term negative impact on the UK economy.”

As part of Brexit, we are leaving the European Medicines Agency, which had its offices at Canary Wharf, and which authorises and standardises medicines across the EU. This seamless system makes it possible to bring new medical products to the market more quickly and cheaply than would otherwise be possible. “In Switzerland and Canada, which have separate approval systems, medicines typically reach the market six months later than in the UK.” Perhaps we could pay to continue participating in it, but we will lose any power to influence it. (And how many other things will we have to pay to participate in, and why don’t we just stay where we are?)

The UK has its own Medicines and Healthcare Products Regulatory Agency, which at present is incorporated in the EMA. It will need to be beefed up, the report says, but “this process will be challenging, as the agency derives a substantial proportion of its income from the EU… and…it is likely to face difficulties in attracting specialised staff from other parts of Europe.” (My italics.)

Boris?

Furthermore, “A failed Brexit” (which would throw us on to WTO trade rules) “would cause immediate disruptions to importing health products whose trade is not governed by WTO rules. There is a major threat to the availability of radioisotopes for diagnosis and for cancer therapy, which the UK imports mainly from the Netherlands.”

Moving on to public health, the report casts a caustic eye on the UK government’s record on air quality. In 2015, only two London boroughs met EU standards for nitrogen dioxide concentrations. It’s not too good on water quality, either, although, prodded by the EU, it has improved. “This trend suggests that, in the absence of EU legislation, UK environmental standards could slip further.” There is a risk that the UK could become a prime target for the tobacco industry post Brexit, “as is the case in Switzerland.”

Did we know that the UK lags behind comparable economies in investing in research and development? The report tells us so. “It is a net beneficiary of EU research funding, attracting substantially more funds than it contributes to the common pool, and the loss of this funding would have severe consequences.” (My italics).

Why has it been left to a paper in a medical journal to say things that should have been on every billboard in the referendum campaign?

Whatever the form of Brexit, “vast areas of EU legislation will need to be adopted and adapted into national law and then potentially revised; the harder the Brexit, the greater the volume of legislation needed.” This task, say the authors, “risks overwhelming parliament and the civil service,” and they have grave concerns about the lack of scrutiny that is likely to result.

They are talking about the Withdrawal (or Repeal) Bill. Health is only one small part of the huge body of legislation involved. And health is something to which the Government seems to have given little consideration. It excluded the Department of Health from the negotiating process.

What hope in that case that, staggering under a mountain of directives and regulations about workers’ rights, safety of shipping, anti-competitive practices, farming, waste disposal and countless other matters, MPs will be able to give their minds to the importing of isotopes?

For the NHS workforce and EU/UK citizens who find themselves in the wrong place when Brexit strikes, “the impacts will be… potentially devastating,” the report believes. “However, the largest impact on the health system is likely to come from Brexit’s impact on the wider economy, on the ability of the state to function, and thus on the ability of the UK to finance the health service.

“Given the apparent lack of capacity of the government to rise to this challenge, we argue that the wider health community within the UK must work together to address these issues.” (My italics.)

Those last two sentences are extraordinary. When was something like this last said in a professional journal by scientists? It amounts to saying that the Government is not capable of protecting society from a grave harm and that the people must take charge.

The rest of the world seems to know this. Confidence in the UK economy is dropping like a stone. Inanimate objects know it: letters drop off the set behind the Prime Minister as, coughing convulsively, she attempts to “reset” her premiership. The psyche of our leading politicians knows it – hence the increasing inappropriateness of Boris Johnson’s antics, the Edwardian pastiche of contender-in-waiting-for-the-crown Jacob Rees-Mogg, and that self-immolating cough.

All of them point in the same direction: the sun is setting on the UK.

It doesn’t have to.

In Catalonia the people are in the streets. They know what they want and what it is worth to them.

What is the NHS worth to us?

 

 

 

 

 

 

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