Brexit and the NHS: Just the Facts. Part 3: We, The People

In a multi-part series looks in-depth at the potential impact a No Deal Brexit will have on the NHS. In Part 1, we looked at the potential disruption to the supply of vital medicines, and in Part 2 we examined the barriers to importing nuclear isotopes essential in many treatments including cancer.

In this part we look closely at the largest and arguably most important resource the NHS has, the staff.

What’s going on with NHS staffing in 2018?

The NHS is the world’s fifth largest organisation, in England alone it employs 1.2million people. Since 2010 staff numbers across multiple areas have fallen, leaving large gaps. To maintain current services we need 40,000 more nurses, 10,000 more GPs, 11,000 more hospital doctors and 7000 more mental health nurses.

What has the government done about this so far?

Short answer: A lot of words and little else.

Long answer: During the coalition years the government cut nursing training numbers and nursing staff posts in hospitals, as well as cutting 6000 mental health nurse positions. Meanwhile demand and activity in the NHS relentlessly grew every year by ~3%, increasing the pressure on the remaining staff and creating a situation where more staff are leaving than joining.

Despite promises of “5000 more GPs by 2020”, the number of GPs have actually fallen by over a thousand. Growth in nursing numbers is equally negative, as more leave the NHS than join. Despite proposing 15,000 more nursing places to train “homegrown” staff, so far those extra places have not been filled. Funding for places may have increased but bodies have not followed; applications fell by ~10,000 in England last year, meaning the number of nurses in training actually dropped. This is due to the government cutting nursing bursaries and charging full tuition fees from 2016. Similarly, the government has announced an expansion of doctor training places by 1500 per year from 2020, but these new doctors won’t be on the shop floor until 2025, and won’t be new GPs until 2030 or new hospital consultants until 2033.

What has that got to do with Brexit?

We have a worsening staff crisis coupled with a failure to train our own staff to deal with it. We are therefore 100% reliant on recruiting trained staff from abroad to fill the gaps, in recent years from the EU especially. Of the NHS 1.2 million staff, approximately 5% are currently from the EU, 10% of doctors and 7% of nurses.

How have things changed since the Brexit vote?

The official number of self-reported EEA staff has actually risen slightly from 58,698 to 61,974 between 2016 – 2017. This is partly because 10,000 “unknown” nationality staff members in 2016 became “known” in 2017. In specific groups, such as nursing, there has been an 89% drop in the number of new EU nurses, and a 67% rise in those leaving.

Are EU staff leaving?

Short answer: Yes

Long answer:

Staff in the NHS come and go as with any very large organisation, it’s the relative balance that is important. The total percentage of EU staff leaving has increased, and the percentage of EU staff joining has decreased. 10,000 EU staff left the NHS last year, an increase of 42% on the year before.

The BMA surveyed 1700 EEA doctors this year- 50% were considering relocating, and 20% had already made concrete plans to leave. Although this is bad, the major issue is recruitment.

Since 2016 EU recruitment has flatlined, for nurses especially. In addition to new language tests, new EU nurses also face a falling exchange rate, dropping the effective starting salary by 12%, and prolonged uncertainty about their working conditions and residential status. Applications for EU entrants into nursing have dropped 96% since Brexit began. Where 6400 new EU nurses joined in 2016, only 800 joined in 2017, a loss of 5400 nurses we sorely needed. The number of doctors also joining the register from the EU declined by 1000 between 2016-8.

Overall since 2009 there has been a steady rise in nursing and medical staff from the EU, a rise which levelled off after the EU referendum and hasn’t resumed. The balance of recruitment to resignations has shifted dramatically, so as a source of manpower to solve our staffing crisis the EU has dried up.

Why is this a big deal? What’s a few less nurses?

Statistically there is a direct correlation between staff numbers to patient ratios and the chance of survival. For example, the higher the number of nurses per patient the more likely stroke patients are to survive. Less staff = more deaths and more patient harm. The NHS recruits in large drives to plug these gaps from the EU; Spain, Portugal and Ireland in particular, but no longer. That shortfall will undoubtedly lead to patient harm.

How does No Deal change any of this?

The No Deal Brexit papers specifically do not mention EU citizens status in the event of No Deal. Whether a tactical omission or a political misstep, the lack of concrete reassurances for EU staff is deeply troubling. Bear in mind many of our EU NHS staff have lived here for years, have children in schools, support dependent relatives and have long-term careers. The looming threat of uprooting and even deporting, however distant or vague, should not be underestimated. If you were in the same position of uncertainty, unsure if you might have to pack up your whole life in six months time, would you buy a house? Would you move to a new job? It seems unlikely you’d come to a country that was so unsettled currently.

The additional predicted further drop in the value of the pound, the uncertainty over basics like pensions and healthcare access in the event of No Deal, will only compound that. As a father with a young family I certainly would not move here if I were in that position, and I can’t say I wouldn’t be thinking of leaving myself. Would you?

Is the government doing anything about this?

Dominic Raab, the current Brexit Secretary, has “reassured” EU residents no one will be “turfed out” in the event of No Deal. However, as already mentioned, they haven’t published anything tangible on this as yet.

There is a pilot programme in the North West for up to 4000 EU students and NHS staff to apply for Settled Status, initially for those in 12 NHS trusts. Although a digital process this pilot will require a face to face Home Office appointment. The Home Office has already stated it does not have sufficient staff currently to process 3,000,000 applications, and the initial launch of the “app” in June did not function on half of smartphones, so it remains to be seen how the remaining 60,000 NHS staff will be settled in this way. Whether these terms will change in the event of No Deal is another question hanging over everything.

What about future EU recruitment for the NHS?

The drop in recruitment due to Brexit is creating a worsening shortfall in key departments, increasing the pressure on existing staff and exacerbating increased numbers from all groups leaving the profession or retiring early.

In a No Deal Brexit the U.K. remains a less attractive destination: relatively less pay, new barriers to the immigration process including visa caps as a third country and uncertain settled status.

So in summary the NHS is already in an understaffing crisis, created by under-resourcing and poor workforce planning, exacerbated by cuts to posts and bursaries for recruitment, meaning hopes of new “homegrown” staff to plug the gaps are a decade away. EU staff have been invaluable to maintaining a functioning service but since the Brexit referendum recruitment has dropped off a cliff. A No Deal scenario will only compound the haemorrhaging of staff, in a system where staff numbers are a literal matter of life and death.

With a shortage of medicines, diagnostic isotopes and vital staff, we will require a massive influx of resources and funding to keep the service going.

Resources and funding we do not currently have. If you’re still with us, read on to Brexit and the NHS: Just the Facts. Part 4: Show Me the Money. (coming soon).



Brexit and the NHS: Just the Facts. Part 2: Going Nuclear

In a multi-part series looks in-depth at the potential impact a No Deal Brexit will have on the NHS.

UPDATED with the latest No Deal planning paper from Govt. “Civilian Nuclear regulation if there’s no Brexit Deal”.

In Part 1, we looked at the potential disruption to the supply of vital medicines. In this part, we will look closely at the use and supply of radioactive isotopes in the NHS, and how a No Deal Brexit specifically will impact this.

What do you mean radioactive?

We use radiation a lot in medicine. The term conjures images of radiation burns and nuclear warfare, or perhaps super-powered arachnids, but in controlled doses for the right reasons radioactive substances are a vital part of many types of healthcare. We can use radioactive therapies to diagnose conditions, monitor treatment, and even as treatment itself. From breast cancer to heart disease to thyroid cancer there are dozens of uses for nuclear derived radioactive material.

Where does it come from?

Nearly all nuclear material for medicinal use is imported. The commonest, Technetium-99m, is made in several reactors in Europe. We perform over 600,000 radioactive imaging procedures a year involving Tech-99m alone. The production, transport and storage of radioactive material is obviously very heavily regulated. The agency responsible in Europe is called EURATOM.

What is Euratom?

The European Atomic Energy Community is responsible for the safe use and distribution of all nuclear material- from the tiny diagnostic isotopes we use, to the nuclear reactors that generate power for cities. Unlike the European Medicines Agency, we currently do not have a local equivalent in the U.K.

Why is that important?

Well, in a No Deal scenario we have no equivalent agency of infrastructure to manufacture, import and export, distribute and store, radioactive isotopes.

UPDATED: in the latest government technical paper on civilian nuclear material, responsibility will move to the Office for Nuclear Regulation. Importing nuclear materials, as with medical isotopes, still has no plan at this time. Under the relevant header the paper reads: “importers may need to obtain an import license” and will “provide further guidance” at an undisclosed interval. So, still no plan as yet.

The Lords voted to stop our withdrawal from EURATOM in 2018, but a No Deal scenario would leave us out regardless. The rationale for leaving EURATOM as its “legally joined” to the EU has been derided as dubious as best. Currently it’s unclear what will happen in any Brexit scenario.

To illustrate the potential impact on the individual let us look at a specific example: the use of Technetium-99m in breast cancer, in a technique called Sentinel Lymph Node Biopsy. When diagnosing breast cancer we need to know several things: is there a tumour there, how far advanced are the cells in the cancer process, how far it’s spread in the breast itself and how far it’s spread to other places, firstly the lymph nodes in the armpit. These ‘sentinel’ nodes play a huge part in prognosis, and determining the need for chemotherapy and radiotherapy. Sentinel Lymph Node Biopsy uses radioactive isotopes to very accurately diagnose cancer spread to the armpit, determining the need for chemotherapy and radiotherapy. Without the isotope the potential to miss spread to the armpit skyrockets, as the next best diagnostic test is far more likely to make a misdiagnosis. Missing spread and reducing treatment means a curable cancer could become an advanced one, or even a deadly one. These are the stakes at play here.

Have these isotopes ever run out before?

Yes. There was a series of reactor maintenance stops in 2008-9. At the time there was sufficient supply for most units to delay or borrow isotopes from other hospitals. There is also a predicted shortage from 2016-2020.

Why is No Deal Brexit different?

The scale of the issue this time has never occurred before. Additionally the new requirement for customs infrastructure will have major implications as these isotopes cannot be stockpiled- they decay to become non-useable after a number of weeks. Procedures such as thyroid cancer treatment, palliative treatment for bone pain and heart scans would all be halted, temporarily or even long-term while inferior alternates are used.

in summary, leaving EURATOM does indeed appear to be the nuclear option: it’s needlessly extreme with no legal basis and will have widespread and long-lasting ramifications. There’s a high probability you will personally know someone who will be negatively affected. As a doctor, I have to admit I didn’t know most of this a year ago. I’m flummoxed how anyone outside of the industry could have. None of us were “informed”. Until now.

With less medicine and no isotopes we face a rocky future in the NHS. None of that will matter however without any staff.

See Part 3: We, The People (Coming soon)


Brexit and the NHS: Just the Facts. Part 1: Medicine

In a multi-part series looks at the No Deal Brexit scenario and its direct and indirect impact on the National Health Service.

Informed consent is the bedrock of medical ethics. It means I cannot legally do anything to you without your express permission, and for anything you do allow, or “consent to”, you have to know why you need it, the risks, benefits and all the alternatives. Such are the legal ramifications of this, if I were to perform a procedure without properly informed consent I could be jailed for the crime of battery.

The absolute irony of the EU referendum, arguably the most important vote in a generation, was the completely backward approach to the decision. The further from the time of “consent” the more informed the conversation has become. In this first part asks, how will a No Deal scenario affect our supply of drugs and medicines?

Will we still be able to import medicine?

Short answer: Yes, but costs will likely rise, and some supply chains will be threatened or may breakdown entirely.

Long answer:

Currently there are no tariffs or border checks within the EU for medicines. Tariffs are additional duties charged at the border for moving medicines between countries.

In the event of No Deal we would leave the EU and become an individual state within the World Trade Organisation, an internationally agreed baseline for trading.

The WTO has its own issues:

1. Although we are currently members our membership is within the EU bloc. We don’t have individual membership yet.

2. The WTO court for settling disputes is currently non-functioning due to a dispute with the USA. If any aspect of our joining or terms is disputed, there isn’t currently a way to settle it within the WTO.

Specifically in regards to moving medicines back and forth between the EU from the WTO, the EU is signed up to the Pharmaceutical Tariff Elimination Agreement, an Agreement to eliminate tariffs on a set list of medications with other WTO countries. We could continue to import tariff free medicines on this list from the EU under this agreement. However, this list hasn’t been updated since 2010- the US are again disputing it and holding up a revision. This leaves many new medicines off, meaning we would have to pay new tariffs on importing those from the EU. Which is a lot. We import 37 million packets of medicines every MONTH from the EU worth £18.3billion. The EU are our largest source of medicines (73% of all our imports), likely due to the frictionless movement and lack of tariffs. Estimated WTO tariff rates would add 5-6% of cost to these medicines. We also leave all the EU-WTO countries Free Trade Agreements we also had access to, e.g Japan, and any agreed medicines tariff reductions included in them.

Worse, UK based companies produce medicines in supply chains that often cross borders multiple times – each import potentially adding an additional tariff without an agreement. This will add significantly to the current £16bn medicines bill for the NHS.

That’s just the additional taxes. The costs and practicalities of physically moving medicines across customs borders will be a huge barrier to importing medicines, so-called “non-tariff barriers”. These govern how medicine is checked, regulated and transported – essentially guaranteeing the drug that’s injected to you has for example been refrigerated across the entire supply chain so it remains safe. Or is actually the drug on the bottle and not a knock-off imported elsewhere.

If we leave with No Deal we also leave the Customs Union, meaning we will require infrastructure at our border and at every exporting countries border to facilitate movement of medicines between our countries.

Not only will this disrupt and delay the import of finished medicines to our hospitals, it will also disrupt our ability to make medicine in U.K. based pharmaceutical companies like AstraZeneca and GSK. Many of these supply chains are time and temperature sensitive. Delays at borders may break the chain entirely and strategies to circumvent these issues, such as building additional storage space, additional supply routes or moving manufacturers, will only add to the final cost of the medicines passed on to the NHS.

Many drugs we also can’t stockpile for very long to prepare for a No Deal scenario. Insulin is a good example. We only make 1-2000 patients worth of insulin in the U.K. each year, while the national need for the medicine is 400,000 patients, the vast majority imported from Europe. We can’t stockpile insulin for very long, and it requires refrigeration and very careful regulated transport.

So, back to our short answer, availability of medicines will be reduced due to customs delays and supply chain issues, while the cost of these new barriers will be added to the medicines alongside any new tariffs for medicines off the list of WTO traded drugs. If this adds even a conservative 8% to the cost of medicines, that means an additional cost to the U.K. of £1.4bn every year.

What about importing future medicines?

Short answer: Leaving the European Medicines Agency will add to the cost of introducing new medicines to the U.K., deprioritising the U.K. for new drugs and delaying the introduction of state of the art therapies, such as in cancer.

Long answer:

Even if we can secure the supply line for our existing medication, in the short to mid-term we will face difficulties bringing new medications to the U.K. We were previously a key member of the European Medicines Agency, an organisation governed by the European Court of Justice. This Government decided Brexit should include leaving the EMA as it’s under the jurisdiction of the ECJ, although passed a motion this summer to include negotiating to stay in the EMA as a non-member. Obviously in the event of No Deal we are out of this entirely.

Why does this matter?

The process to develop new drugs and medicines is unbelievably expensive and time consuming. New medicines have to first be synthesised, tested on cells, then animal models and then a dose and formulation needs to decided upon. That process alone can take a decade and often doesn’t go anywhere at all. Once a drug is stable and theoretically beneficial to humans it has to go through several phases of trials before it can be approved for routine use by any doctor for a patient. Firstly it’s tested for safety in healthy people- unforeseen severe side effects in humans sometimes occur, for example see the “Elephant Man” trial at Northwick Park Hospital in 2006, where six healthy adults took an experimental drug at this phase of testing and all become critically unwell. Once it passes this safety benchmark the drug is then tested in a small group of people who actually have the disease. This is to demonstrate benefit and look at side effects- again, in the real world this may not work at all. If it passes this stage a much larger trial is organised, usually testing the drug against a placebo or the current best treatment in the strictest conditions possible to avoid any possible corruption of the results. These large trials take years to organise and perform and then publish, cost millions of pounds and again, often don’t go anywhere at all. Even once a drug is in the market we have a phase 4, where data is continuously collected from reported side effects. Sometimes it takes two or more of these trials to prove something actually works.

You can see already what a time-consuming and data-heavy undertaking this is. The EMA’s job is essentially to check every stage of this process, to take into consideration of practicalities like how the drug is given and how much it costs, and then to approve and regulate the medicine for use in EU patients.

Without this function there would be no checks on the drug development process, a process already hugely driven by the need for pharmaceuticals to recoup the money they’ve spent on development.

The EMA streamlines this process for the U.K. by allowing a single member state to undertake the approvals process and then applying that approval to all other members. So a drug approved in France is then licensed for the U.K.

Our subdivision, the Medicines and Healthcare products Regulatory Agency, was a leading part of the EMA. EMA HQ was formerly in London, and employed 900 people, but has already moved away post-Brexit vote. Once we are out of the EMA we will have to approve and license every new drug ourselves. As a much smaller market for drug companies than the EU we will be deprioritised for new drug launches. State of the art developments for conditions like cancer will take longer to come here. This might seem a trivial concern; what possible difference could a year or two make for a single drug?

In the 1960s an accidental discovery created an entirely new cancer drug called Cisplatin. Based on platinum, Cisplatin was found to be revolutionary for the treatment of testicular cancer, a condition that was once fatal in nearly all patients, but is now cured in 90%.

Imagine you have been given a terminal diagnosis, perhaps a year to live, when a new game-changing medicine like Cisplatin is discovered. Those few years delay will make the difference between life or death for you. That’s the reality of the unforeseen consequences of such a colossal decision; the knock-on effects domino everywhere, and real people may actually die as a result.

So, leaving the EMA will add to our own development costs and time requirements to approve medicines and delay state of the art treatment in conditions like cancer, where time can make all the difference.

What about future medicines?

Short answer: We are pulling out of research funding and EU-wide scientific collaborations on health and medicine products, which may hamper potentially life saving medical advances.

The long answer:

In the mid to long term, threatening to pull out of the EU with No Deal has already dropped many U.K. applicants from the EU research fund, Horizon 2020. A half a billion pound fund backing health science and technology, we may never know what good that could’ve done, what avoidable harm will now happen as a result.

So a No Deal scenario will have far reaching and damaging effects across nearly every aspect of current and future medicines in the NHS?

Short answer: Yes

Long answer: Very much so. But it only get worse. See Brexit and the NHS Part 2: Going nuclear.


“You are having a heart attack but we will fix it”. If only everything was so simple.

I’m working my second stretch of nights in a week (due to a missing EU doctor, ironically) on the heart attack service. At 3am my bleep rattles next to me and then shouts “Primary Angioplasty. Inferior MI. 10 minutes”.

This means someone is flying towards us in the dead of night with a major heart attack. Inside, a vessel supplying the heart muscle is completely blocked, the muscle beyond literally dying by the second. Needless to say these patients are very unwell.

The patient arrives and her ECG confirms all our fears: a major heart attack. My 3am brain tries to simultaneously take her history, listen to the ambulance handover, scan her heart muscle and consent her for the procedure all at once. She’s looking very unwell and I’m very conscious of how short time we have. “Time is muscle” in cardiology land, and her heart and possibly life is slipping away by the minute. 

I end up simply saying “You are having a heart attack, but we will fix it”. We rush her into the lab and fifteen minutes later we have indeed fixed it. She’s looking much better and is very thankful. I love cardiology.

Simple eh? From the patient’s perspective she’s had some chest pain, called an ambulance, been told she’s having a major heart attack, and then told it’s been fixed. What could be easier?

Well, pretty much everything. The procedure actually takes at least five people to perform properly, all highly skilled and trained and working together seamlessly. Every bit of equipment we use has been developed over decades, rigorously tested in trials involving 100,000s patients, each part carefully evaluated, checked, stored and audited. The techniques we use, even the pathway itself, has been researched and tried and rejected and trialled again. When this technique was first pioneered many thought it ludicrous. Now it saves thousands of lives every year. Even the basic physiology is incredibly complex.

Which is not to say nothing ever goes wrong- far from it. We routinely have patients who we can’t make better, or don’t get there in time, or need even more advanced therapies: pumps inside the heart, artificial lung and heart machines, emergency bypass surgery, even transplants. There is an entire world behind the curtain that very few members of the public will ever glimpse. And even those who do so directly as our patient do so with only the limited and reassuring perspective of a problem that has been “fixed”. With only a tiny cut 1mm long in their wrist, who can blame them?

Which, by a rather roundabout way, leads me to Brexit. Obviously. This week the NHS and Brexit have been in the news on multiple fronts, mostly raising concerns about the implications of No Deal on the NHS and then some unbelievable absurdity about shortening doctors training times after Brexit to “plug staff shortages”.

The issue we seem to have is one of perspective. There’s too little scrutiny, too much wilful acceptance of “I can fix it”, and not enough people asking “how?”. And especially not enough detail for those of us behind the curtain that can see the vast monstrosity of interlocking gears and cogs that makes up the NHS machine. For those of us that worry Brexit, especially No Deal, will be a sledgehammer to a system already straining under pressure.

Take for example the No Deal scenario. Overnight we will leave the Customs Union and European Medicines Agency, meaning importing medication will require new licenses and tariffs, infrastructure we don’t currently have. Insulin has been the much lauded example– used by nearly half a million patients in the U.K., only one small factory in the U.K. makes any at all, enough for 1500-2000 patients a year. The rest (99.9%) is imported from France, Denmark and Germany. On day 1, with No Deal, there would need to be additional customs infrastructure to even EXPORT to us. In places like Germany where there wasn’t before. The new Health Secretary, Matt Hancock, has assured us they are stockpiling for contingency planning for this event. But insulin needs to be refrigerated, and we are talking about half a millions patients a year. I want to see the detail, I want to see the benefits of this plan, I want to see the mechanics of the machine before I accept this is even possible. So far I have yet to be convinced.

Similarly, Steve Barclay, Tory Health Minister, made headlines on Friday claiming that Brexit will be good for the NHS, claiming the EU forces U.K. doctors to qualify in five years minimum and we could shorten this to “plug staff shortages”. But behind the curtain we know nearly all U.K. medical courses are five years already, some graduate entry courses are four years (although some have switched to five now) and count the first year of work as qualification to meet the EU technical requirement. We know we can’t shorten medical school beyond four years due to the sheer breadth and intensity of work, and the reason most U.K. medical schools opted for five years in the first place. This suggestion will have no practical impact on doctor numbers, but might make undergraduate medicine overly pressured or dumbed down, and will only affect <25% of graduates regardless. And no mention of the 10% of U.K. doctors from the EU who already risk losing their right to work, to healthcare and to pensions here in the event of No Deal. It’s this nonchalant and worse, unchallenged, Brexit commentary that doesn’t inspire confidence amongst medical professionals. We doubt that our government understands the dangerous and complex machine they are tinkering with. 

Similarly Theresa May proposed a welcomed £20bn injection of funds into the NHS, but then predicated that on a “Brexit Dividend”, a dividend nearly every single economist agrees doesn’t exist, a dividend for which no legitimate cases has been made. It’s hard to trust a government that seems to speak to us without any substance. No wonder a majority of U.K. doctors support a referendum on the final terms. 

In the healthcare profession we have a pathological abhorrence to unsubstantiated claims. To b******t. Colleagues that say they will do something and then do not are unreliable, and unreliability is dangerous. Bald-faced lying is even worse, and the GMC hold us to a standard far higher than any politician. A lack of basic probity will get you suspended or struck off, such is the bedrock of trust that the practice of medicine requires. Trust between ourselves and our patients, and trust with each other. And the highest sin of misinformation? Wasting the most precious resource we have; time. Time is muscle. Time is life. Time I waste with you I could infuse into someone else, time that could make all the difference. And for Brexit time is running out. 

Despite occasional appearances suggesting otherwise, medicine teaches you a universal truth: nothing is simple. Absolutely nothing worth doing is easy. The Brexiteers waving away the potential healthcare disasters ahead think they are riding a tricycle down a garden path, that they can flick a wrist and change direction on a whim, when really they are aboard a runaway freight train, heading for a cliff.

We need to start hearing some practicality, we need to start seeing some understanding of the complexity of the machine, of the extraordinary stakes ahead. We need less of the perception “everything is simple”, and more of the reality: this is complicated, this really matters, lives are literally in the balance.

Please fix it.