Brexit brings serious issues at an already difficult time for NHS

● But there are things that can be done either by the Scottish or UK governments to improve matters Mark Dayan

what we are in danger of doing”

The NHS is not among the sectors most obviously affected by Brexit. Whereas industries like car manufacturing are closely regulated from Brussels and trade across Europe, health care mostly happens in one country and the EU has left much of the task of regulating it to its member states.

But there are many indirect effects, where the NHS interacts with fields like migration and trade where EU involvement is extensive.

So what are these, when can we expect them, and what can be done about them? And can things be different in Scotland?

The Leave campaign’s famous bus was, of course, entirely wrong that £350 million a week could be freed up for the NHS by cancelling our EU membership fees.

But there is a grain of truth that the NHS’S financial health depends on public finances generally – and we do send the EU more money than we get out, to the tune of several billion a year.

On the other hand Brexit is likely to mean less coming in as barriers arise to trade with our major partners.

The UK government calculates that this effect will swamp savings on our payments to the EU, so the overall impact will be £20 billion to £80bn a year less in public coffers by the mid 2030s.

The more dramatic forms of Brexit would cost more. This is equivalent to anywhere from a seventh to a half of today’s NHS spending of £149bn a year.

This is likely to have a proportional impact on Scottish public finances.

The impact of Brexit on migration will also be crucial for the NHS, which has been struggling to find enough staff in recent years. Importing staff from Asia and Africa has been made more difficult by restrictions and policy changes, so EU migration was a godsend – supplying as much as a third of extra nurses and social care workers each year.

But it is already tailing off, and hard restrictions after the Brexit transition period ends in 2021 could mean the tap is turned off for good.

Several thousand EEA staff work in health and care in Scotland, although a precise breakdown is unfortunately not available.

In the long run Scottish Tory peer Lord Patten discussing the House of Lords amending the Brexit Bill.

“The Leave campaign’s famous bus was, of course, entirely wrong that £350m a week could be freed up for the NHS by cancelling our EU membership fees” “Liam Fox must be joking if he thinks investing

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0 From financial regulation to the Irish border, by way of fishing quotas and farm subsidies, negotiators face a busy few months ahead politicians and NHS leaders could head off this problem by increasing training places for doctors and nurses. There are already plans coming through to do this for some crucial groups.

However, this will take time and it would help much less in social care, where many staff are drawn from a more general pool of labour. In the medium term, we will continue to need migration and gaps could open up quickly without it. My estimates suggest England could be 70,000 social care workers short by the middle of next decade. Scotland is unlikely to be immune.

Could Scotland go its own way on migration?

Quebec, the Frenchspeaking part of Canada, has an agreement with the federal government to run its own skilled migration policy with its own standards. The Scottish government has been lobbying for something similar. This would be well worth exploring.

Then there are EU regulations which govern elements of staffing, trades and industries linked to healthcare, and science.

The approval of medicines is currently done through a co-ordinated EU system, with the advantages that both the NHS as buyer of medicines, and pharmaceutical companies as the sellers, have access to a very large market. The UK Government has rated pharmaceuticals as the sector where open trade with the EU is most important. It adds billions of pounds to the Scottish economy.

Recognising this, the UK government has specifically indicated it would like to stay in the system built around the European Medicines Agency.

But the EU finds this kind of picking and choosing politically and legally undesirable. Whether it can happen will depend on how hard a Brexit the UK opts for overall.

Similar considerations apply to clinical trials and to blood and organs used for healthcare – where again, shared regulation has encouraged co-operation across Europe.

The industries which make medical equipment would also like to stay under EU rules. Here precedents are more promising: agencies in many countries are able to grant approvals under the EU system without being members of the union itself. Customs barriers to trade, though, could still prove an obstruction.

There are other regulations where some in the NHS would like to move away from European rules. The Royal College of Physicians of Edinburgh, among others, has called for a debate about whether rules on the hours doctors work should be tweaked after Brexit.

With much debate over which powers return to Edinburgh as opposed to London, could there be new roles here for the Scottish government? Blood and organ regulation could now be a devolved matter, but it makes sense to keep standards similar across the UK. On the other hand, if the EHIC system where European visitors enjoy healthcare coverage in different countries no longer applies to the UK, the Scottish Government could look at taking its own approach in deciding whether and how much to charge them.

Overall, Brexit presents some serious issues for health services across the UK at an already difficult time. But for almost every area, there are things that could be done either by NHS leaders or the Scottish or UK governments to improve matters. The complicated impact of Brexit on health care was not well reflected in the referendum campaign.

We should make sure it gets more of an airing as we approach Brexit itself. ● Mark Dayan is policy & public affairs analyst with independent health think tank Nuffield Trust