With some distance now since the first peak of Covid-19 and two years after the UK left the EU single market, Nuffield Trust was keen to explore the impact of Brexit. Our report Health and Brexit: six years looks at how Brexit has influenced various aspects of health in the UK. And it found the clearest evidence yet that Brexit has exacerbated the challenges facing health and social care in the UK across several areas, such as NHS and social care staffing, the supply of medicines, and living standards.
Between 2016 and 2021, the NHS lost around 11,000 European nurses and gained around 30,000 from the rest of the world. However, this shift is not set to meet government targets to address shortages in England and across the UK.
In social care, the number of vacancies has actually increased to an estimated 165,000 full-time equivalent roles in England. With pay and working conditions significantly lower than in the NHS, loosening immigration rules has not generated overseas applications to improve this figure. Similarly, the number of EU dentists joining the register has fallen and has not been compensated by arrivals from the rest of the world.
In individual medical specialities where reliance on EU staff was high and shortages were ongoing – such as anaesthetics, cardio-thoracic surgery, psychiatry or paediatrics – EU numbers have also plateaued. The shortage has not been offset so far by increases in doctors from the rest of the world.
Meanwhile, the NHS in England is hiring high numbers of staff from ‘red list’ lower-income countries, such as Nigeria or Pakistan. This directly contradicts its adoption of WHO guidance, which discourages such a policy as it compromises the health systems of those countries. In addition, we heard of abusive recruitment practices by UK private agencies because of poor monitoring and enforcement of these rules.
Pursuing recruitment drives from abroad rather than robust strategies for recruitment and pay at home is unlikely to be a sustainable solution to create a health system that attracts and retains domestic or international employees.
In the immediate aftermath of the UK exiting the single market, the government avoided medicine shortages that would seriously impair patient care through contingency planning.
However, medicine shortages have increased since the referendum and spiked in the last two years. For example, at least five serious shortage protocols – emergency measures whereby a substitute medicine can be offered to patients if their prescription is unavailable – have been in place consistently since 2021. These have been for medicines such as fluoxetine or hormone replacement therapy.
Similarly, the number of price concessions granted by the Department of Health and Social Care increased five-fold (to 100) between 2019 and early 2022. Price concessions are given when medicines are unavailable at their usual price – indicating pressure on supply. These shortages also appear in peer EU economies but are more consistent in the UK.
A number of factors will have influenced these trends. Most obviously, Covid-19 caused an upheaval in demands for specific drugs. And in 2022, the price of materials used for medicines shot up with the war in Ukraine, lockdowns in China, and increases in worldwide demand for drugs as lockdowns eased elsewhere.
But Brexit also played a role. For instance, there was a sharp fall in the value of the pound after the referendum. There was also a rise in costly administrative checks on goods between the UK and EU and regulatory differences arising between those two entities. And there has been a shortage of British HGV drivers with EU-free movement no longer including the UK.
Under its Protocol, Northern Ireland remains in the single market. As a result, goods crossing to and from Great Britain from Northern Ireland are subject to additional checks. Brexit negotiations and continuing disagreement around the Protocol generated uncertainty for business planning. Due to the cost involved in observing two regulatory regimes for drug manufacturing, an increasing number of drugs are being supplied in Great Britain or Northern Ireland, but not in both. This effectively splits the British and Northern Irish market for medicines.
Finally, there is increasing evidence of an adverse impact of Brexit on the economy. That is through a fall in the value of the sterling, decreases in economic output, inflation and declining real wages. These effects are likely to be particularly marked in the UK regions and occupations more affected by trade barriers, typically tied to manufacturing jobs. There is an established link between poverty and health, as shown through the impact of austerity on health inequalities.
The UK health and care system has experienced exceptional pressures in recent years, as a pandemic further exposed long-standing issues with staffing, and health and income inequalities. Brexit seems to have exacerbated these issues. It has brought about shifts in migration rules that provide no real solution to a severe domestic staffing crisis. It has raised barriers affecting the production and supply of medicines across the UK. And it has caused an economic downturn that coincides with the war in Ukraine and a related cost-of-living crisis. A serious and evidenced discussion is necessary to address these challenges.
By Martha McCarey, a researcher at Nuffield Trust and author of the Nuffield Trust report Health and Brexit: six years