Research report December 2020 Understanding the impact of Brexit on health in the UK Mark Dayan, Nick Fahy, Tamara Hervey, Martha McCarey, Holly Jarman and Scott Greer Contents Overview 2 Key points 4 1 Our approach 6 2 Overview of issues 12 3 Issues needing investigation and action 16 4 What would be needed for a sustainable impact tracking and monitoring mechanism beyond Brexit? 38 5 Conclusion 45 Glossary 49 References 50 About the authors 57 Understanding the impact of Brexit on health in the UK 1 1 2 3 4 5 Overview On 31 January 2020, the UK officially left the European Union (EU), although it remains a de facto member and beneficiary of its constituent structures until the end of the agreed transition period on 31 December 2020. From this date, the impacts of exiting European frameworks in practice will be momentous. Nowhere is this more relevant than health and the NHS, which is concurrently battling with the largest public health crisis in a century – the Covid-19 pandemic. Tracking these impacts, positive or negative, will be a vital task. This report, commissioned by The Health Foundation, maps out the health areas that will be affected by exiting the EU, identifies both well-known and often overlooked policy issues and dilemmas, lays out their possible impacts, and describes how they could be tracked over time. The project’s aim, both in this pilot phase and in the future, is to track, monitor, clarify and, where possible, anticipate impacts on health, and to help inform decision-making. In this first phase of the project, we held roundtables and interviewed key stakeholders to gather perspectives and intelligence, and analysed a range of data sources. We examined existing and potential health impacts in the following nine areas: • health systems delivery • health systems workforce • health systems financing • information systems • medical supplies • leadership and governance • communicable diseases • non-communicable diseases • public health capacity and governance. Understanding the impact of Brexit on health in the UK 2 1 2 3 4 5 We aim to look not only at the UK’s departure from the EU, but also, more widely, at resulting changes in trade and international relations, migration, scientific and regulatory frameworks, and political, economic and social indicators. Understanding the impact of Brexit on health in the UK 3 1 2 3 4 5 Key points Our research confirms the well-known issues Brexit raises in many areas, from medicine supplies to data flows. Most, though not all, are relevant whether or not an agreement on a future relationship is reached between the UK and EU at this late stage. It has also uncovered the following less widely discussed impacts, which deserve urgent attention: • The short-term supply of medicines and medical devices to the UK after the transition period is a serious concern, with levels of uncertainty very high. The UK government is preparing for disruption, but it is not clear which scenarios it is and is not ready for. Border closures in December due to coronavirus have introduced an unpredictable new element. Flows of data will also face blockages. • Beyond this short-term picture, our interviewees and roundtable participants believed the UK will face a lack of competitiveness in terms of investment in health-related industries, a permanent increase in the cost of supplies for health and social care, and difficulties in accessing them. Yet there seems to be no detailed plan for how the UK will regulate medicines and medical devices after we leave the single market and EU institutions. • The end of the free movement of labour is likely to make it more difficult for the NHS and social care to access the growing number of workers they need. Our data analysis shows that the Covid-19 pandemic has also slowed migration dramatically – from the EU and the rest of the world – even before Brexit changes take effect, with a 70% drop in migrants entering the labour market. The pandemic has therefore raised the bar still higher: the UK now needs to dramatically accelerate migration from 2021 to meet government commitments on nursing and on providing more social care. • Industry representatives and government officials described uncertainty around how medicines, supplies and staff will enter Northern Ireland after the transition period, and what this would mean for access to health services and medical products in the future. While the recent decision of the joint committee has set out short-term allowances, longer-term Understanding the impact of Brexit on health in the UK 4 1 2 3 4 5 decisions have yet to be taken and there is an expectation of widespread accidental failure to comply with the law. • While food safety issues such as chlorinated chicken have received significant media attention, the most important question for public health will be how the UK government regulates causes of ill-health such as poor air quality, tobacco and unhealthy food. There has been little discussion of plans for this after Brexit. • Slower economic growth and decreasing spending capacity following Brexit may worsen wider determinants of health, such as unemployment and access to health services. It will be possible to track indicators of these changes – such as healthy life expectancy or child poverty – over the long term. However, there will be a challenge in disentangling the impact of Brexit from the effects of the recession brought about by the Covid-19 pandemic. • There was significant uncertainty regarding powers returned and redistributed through the Internal Market Bill (IMB), with respect to the UK's four constituent nations. Officials in Scotland, Wales and Northern Ireland are concerned the Act could curtail their ability to regulate in the future to improve public health, tying them to unclear Westminster plans, and depriving the UK the opportunity to learn from regulatory experimentation, such as Scottish measures on smoking in public places and alcohol pricing. The Internal Market Act, approved on 17 December, partly addresses these fears, by including amendments that permit regulatory divergence from UK-wide rules, where the four constituent governments have agreed on a common approach. This mechanism has been set out in principle, but remains to be monitored in practice. Understanding the impact of Brexit on health in the UK 5 1 2 3 4 5 1 Our approach Scope of our report The frameworks underpinning the UK’s international trade and cooperation agreements will undergo fundamental change in the next few years, and health will be affected. The effects we investigate in this report will largely begin with, and be triggered by, the UK leaving the EU’s single market and customs union on 31 December 2020, bringing back to the UK powers to sign trade agreements with other countries. The report focuses on the direct impacts of exiting the EU and sets out a structure for a future project looking further into the changes to come. We examine how domestic policy parameters might change as powers are added to or subtracted from the UK, such as the ability to limit migration after the end of the transition period, or any conflict between Westminster and the devolved nations/administrations over the allocation of returning powers. We also aim to set a baseline to examine the potential and actual impact of the trade, migration, scientific and regulatory agreements that the UK now intends to seek with states including the United States, India and the Trans-Pacific Partnership countries.1 We also consider economic and social changes brought about by changing international agreements. In doing so, we are informed by considerable evidence showing that these factors affect population health, as much if not even more so than health delivery factors such as medicines and the NHS. Our project is centred on health. As a result, there is a risk that changes in other sectors – from agriculture to cybersecurity – might have an effect on health that we, and the sources we look at and speak to, did not anticipate. However, we will seek to expand and evolve the project wherever effects on health become significant. Understanding the impact of Brexit on health in the UK 6 1 2 3 4 5 The areas we looked at To make sure that we could identify all the ways in which exiting the EU would affect health, we mapped out nine areas of possible impact. These cover two broad segments: ‘health systems’, which looks at the services and industries that provide care and treatment (such as the NHS and medicines industries); and ‘public health’, which looks at the direct impact of economic, political and social change on the health of populations. We considered all areas of health service provision – from pharmacy to mental health – to be in scope for this report, as exiting the EU will have an impact on them. Our stakeholders accordingly cut across these areas. We used the World Health Organization’s ‘building blocks of health systems’ to structure our coverage of health systems.2 There are six of these: • health systems delivery – the international aspects of which include cross- border care and reciprocal health care initiatives such as the European Health Insurance Card (EHIC) • health systems workforce – where both migration and the rights of workers and employers are tied to international agreements • health systems financing – this may include impacts on public finances, and the loss or creation of international funding mechanisms • information systems – which involve the exchange and compatibility of data between countries and global bodies • medical supplies – in a UK context, branded and generic medicines, medical devices, equipment, consumables and even substances of human origin such as blood, which are frequently traded and moved on terms governed by international agreements • leadership and governance – this covers how policy, legislation and decisions are made at the highest level, who holds these powers and how they are scrutinised and limited, but it also covers the UK’s ‘soft power’ and informal connections and perceptions.