Brexit is one of the biggest issues facing public policy in the UK. The Royal College of Physicians (RCP) has answered some of the frequently asked questions from our members about how Brexit will impact on them and their patients.
In the short term the EWTD will still apply to the UK, and is written into British law as the ‘working time regulations’ (WTR). The bill currently passing through parliament, the European Withdrawal Bill, transforms EU directives and regulation from EU law into UK law. This means that the same rules will apply from the point the UK leaves the EU. Technically this could apply to the EWTD, but this is moot, due to the existing WTR. However, at a later date the UK parliament may decide to amend WTR rules. With specific regard to doctors, however, the limitation on working hours as outlined in the WTR (and thus EWTD) are written into junior doctors’ contracts, as negotiated by the BMA and NHS Employers. This means that any changes to doctors’ working hours will have to be agreed through the formal contract negotiations process, rather than through a decision of parliament.
In December 2017 the RCP was a signatory on a letter to the prime minister raising concerns about the potential removal of the working time directive from UK law after Brexit.
The joint report from the negotiators of the EU and the UK on progress made during phase one of the negotiations has confirmed that qualifications achieved prior to the specified date will be recognised. However, the recognition of qualifications in the future has not been agreed.
It is currently very difficult to assess how Brexit could potentially affect the recruitment and retention of not only doctors but wider staff in the NHS and social care. The UK has heavily relied on staff from EU countries to work in the NHS and support the delivery of services. It is estimated that 10% of doctors and 7% of nurses working in the NHS are originally from EU countries. The exact arrangement that will be reached at the end of the Brexit negotiations is unclear, and it is not known whether the UK will continue to recruit staff from the 27 EU countries following Brexit.
During the 2017 Conservative party conference Jeremy Hunt, secretary of state for health, stated:
Let me say to them this [EU nationals working in the NHS and social care]: you do a fantastic job, we want you to stay and we’re confident you will be able to stay with the same rights you have now – so you can continue being a highly valued part of our NHS and social care family.
On Monday 11 December the prime minister told the House of Commons:
More than 3 million EU citizens make an extraordinary contribution to every part of our economy, our society, our culture and our national life, and I know that EU member states similarly value the contribution of the 1 million UK nationals living in their communities, so from the outset I have made protecting citizens' rights my first priority. But for these rights to be truly reciprocal, they need to be interpreted consistently in both the UK and the EU.
The prime minister also stated:
One issue for EU citizens here has been the ease of the process of applying for settled status. The Home Office is developing that process and will bring it forward. It is very clear that it will be a very easy and light-touch process, so that nobody need have fears about the arrangements they will have to go through.
In addition to the Brexit negotiations, the government has also committed to increasing the number of medical school places by 1,500 places a year to try to resolve some of the gaps in the doctor workforce. However it is unclear whether this will meet the current need and fill gaps within the medical workforce.
It is very unclear what the UK’s approach will be to international recruitment and immigration following Brexit. The UK has worked with partners from across the health and care sector to make recommendations for the future of the NHS after Brexit, in terms of international recruitment and immigration, to support high-quality care.
While the detail of future of immigration and priorities are unclear, the government has outlined that it wants a change. During her Lancaster House speech the prime minister outlined the UK’s priorities for the Brexit negations. These included a commitment that the number of people allowed to enter the UK may be restricted following the UK’s departure from the EU. The prime minister stated:
Britain is an open and tolerant country. We will always want immigration, especially high-skilled immigration, we will always want immigration from Europe, and we will always welcome individual migrants as friends. But the message from the public before and during the referendum campaign was clear: Brexit must mean control of the number of people who come to Britain from Europe. And that is what we will deliver.
The government is currently working on a white paper that will set out the proposed approach to immigration after Brexit. On 5 February 2018 immigration minister Caroline Nokes stated in parliament: 'We will publish a white paper in the coming months, when the time is right, and of course we will consider how we can update the House as negotiations progress.'
Since the referendum there has not been any money ‘reallocated’ from the EU budget to the NHS. However, in the autumn statement the NHS did receive additional funding (£6.3 billion over the course of this parliament).
Negotiations are still ongoing and, although some matters have been mutually agreed, unless there is a complete package of decisions there will be a ‘no deal’ scenario and individual agreements will not be valid. Both the European Commission and UK parliament have to vote to agree the final deal. The RCP therefore continues to make recommendations to support patients and doctors until a final deal is made.
The first phase of negotiations ended in December 2017 with an ‘agreement in principle’ that focused on
For more information read the RCP's Brexit briefing: What does it mean for patients and doctors?
The government has agreed to underwrite already agreed funding, and has recently agreed to continue to contribute to the EU budget until 2020. This means that researchers can still apply for EU funding until 2020, however is dependent on a complete deal being reached. No agreement has been reached over the long-term impact on researchers’ access to funding after 2020.
The UK has historically been very successful at medical research, with notable successes such as producing the top 25 out of 100 drugs in the world, and discovering DNA. However, successful research has not been done in isolation, and a significant number of international researchers come to the UK to contribute expertise, along with funding from the EU. Evidence has shown that citations that are collaborations between UK and EU authors increases a study’s impact, leading to more citations. The UK collaborates on medical research with the EU in a variety of ways, whether through funding, data sharing, facilities such as the European Bioinformatics Institute or pan-European trials for rare diseases, where there are not enough suitable patients within one country’s population.
Horizon 2020 is one of the research funding and collaboration initiatives from the EU. It funds a wide range of research, including medical research and the UK has been particularly successful at securing funding in the past. As the name suggests the pot of money is currently available until 2020, however after this point a new research pot called Framework Programme 9 (FP9) will be open for applications, with a new budget and strategy. It is unclear whether the UK will be able to participate in FP9, however other countries outside of the EU do eg Switzerland, by contributing to the overall pot of money available. The benefits of this funding programme to not only extend to financial support but collaboration and resource sharing. Therefore the RCP has recommended that the UK remains a part of these initiatives or finds additional replacement funding. The government has underwritten any funding until the UK leaves the EU in March 2019, so researchers can still apply until 2020 based on current negotiations. If there is no deal then researchers cannot apply for funding after March 2019.
The Innovative Medicines Initiative (IMI2) is a partnership between the European Commission and European Federation of Pharmaceutical Industries and Associations to support the development of new medicines and the development of best practice. It co-funds between public (EU) and private partners to support medical research.
According to a recent report by the Campaign for Science and Engineering, since the referendum the UK has fallen from being the second-highest recipient of Horizon 2020 funding to the fifth.
The Department for Business, Energy and Industrial Strategy has issued a report outlining its position on the next EU Framework Programme after Horizon 2020 and has also issued guidance for those applying under the current framework.
There is concern that once the UK leaves the EU it will slow down the system to approve medicines. However the RCP urges collaboration between the MHRA and EMA to ensure that this is not the case, ensuring patients are not adversely impacted.
The Academy of Medical Royal Colleges recently coordinated a cross-college response to the House of Commons Health Select Committee inquiry into the effect of Brexit on medicines, medical devices and substances of human origin. This urged the UK to ensure it remains an attractive place to conduct clinical trials through cooperation with the European Medicines Agency and by ensuring that costs for approving and running clinical trials are competitive.
For more information read the RCP's Brexit briefing: What does it mean for medical research?
A number of EU directives relevant to air quality have been transposed into UK law through the Air Quality Standard Regulations 2010, including the Ambient Air Quality Directive 2008 (2008/50/EC) which sets legally binding limits for concentrations in outdoor air of major pollutants that impact public health such as particulate matter (PM10 and PM2.5) and nitrogen dioxide (NO2). These limits require a significant reduction of air pollution in towns and cities across the UK, many of which currently exceed the EU's pollution limits, particularly for nitrogen dioxide, which is linked to thousands of deaths across the UK.
Air pollution limits set by the EU will technically remain in UK law after Brexit, having been enshrined through the Air Quality Standards Regulation. However, the RCP is concerned that the EU will no longer have a role in enforcement and the UK government would therefore be free to repeal the existing limits and introduce weaker air quality rules, and review any deadlines for meeting them.
Brexit could also be used as an opportunity to strengthen air quality standards in the UK by adopting revised limits based on World Health Organization guidelines which are driven solely by the available health evidence and set much tighter standards for a number of pollutants. It is also important to note that the UK is a signatory to a number of international agreements including the Gothenburg Protocol, and is bound to meet its international obligations following Brexit. Therefore certain standards may not change.
For more information read the RCP's Brexit briefing: What does it mean for air quality?
According to Dr Jonathan Adams the UK is now in the 'fourth age of research', suggesting that it is now an international pursuit (whereas traditionally it was individual, institutional or national). The EU itself currently has international collaboration agreements with 20 other countries. The UK already collaborates globally on a range of health issues, but Brexit does provide an opportunity to assess whether the UK can collaborate to a greater extent with international partners. Further information on collaboration in research is available from the British Council, Royal Society or Cancer Research UK.
The intent of both the EU and UK is to ensure that there is no hard border between Northern Ireland and the Republic of Ireland, however the exact future arrangements remain unclear. Many patients and care staff regularly travel across the border between Northern Ireland and Republic of Ireland, to deliver care and access treatments. The RCP has stated that it is important not only for doctors, but patients who need to access treatment, that the cross-border healthcare collaboration is able to continue.
Euratom (European Atomic Energy Community) is perhaps best known for its oversight of nuclear power and nuclear research but it also regulates the safe use of nuclear materials in medicine, which can be used for treatments such as radiotherapy. Although not part of the EU, it is governed by the European Court of Justice, which the UK has stated will no longer have power over parliament. Current negotiations indicate that the UK seeks to set up its own version of Euratom, however it is unclear how this will work in practice. For further information you can visit the Royal College of Radiologists’ website.
There is significant collaboration between the EU and UK in healthcare around research as part of the European Research Area. UK-EU collaboration also extends to public health – for example through the European Centre for Disease Prevention and Control and terms of ensuring safety through the European Medicines Agency.
The EU supported 3,539 UK-based researchers to access 1,055 European research facilities between 2007 and 2013. In addition, 107 UK national research facilities received support from the EU to grant access to international researchers, fostering collaborations and exchange of ideas.
For further information on collaboration, see the collaboration briefing from the RCP or for details on collaboration in research, see Cancer Research UK’s report on the Impact of collaboration: the value of UK medical research to EU science and health.
The European Medicines Agency (EMA) is a central place for drug and medical device approvals in Europe, which seeks to ensure that drugs have been robustly assessed, and once approved, can be licenced across Europe. The Medicines and Healthcare Regulatory Agency is the UK authority for enforcing law and ensuring devices and drugs in the UK are safe to use. The two bodies have very similar remits and work closely together, particularly as, until now, the EMA has been based in London and the MHRA provided significant expertise to support its work.
In November 2017, the decision was made to move the EMA to Amsterdam, as the UK would no longer be in the EU after 2019. Whether the UK continues to support and collaborate with the EMA is still up for negotiation. The RCP recommends that this continues as far as possible to ensure that patients do not experience delays in accessing new drugs and treatments. It is more attractive for industry to only undergo one licencing process, and it is beneficial for both the EU and UK to pool their expertise and resource to ensure patient safety.
This is important not just for drugs but devices too. The CE system applies to a vast array of products and it shows that the device is fit for its purpose and meets safety regulations. For medicine this includes devices and equipment including surgical instruments, scanners and even a wooden tongue depressor. The CE system is currently managed by the European Commission and provides peace of mind for consumers and marketability for business.
In a speech in March 2018 the prime minister stated the government was exploring the possibility of securing ‘associate’ membership of the EMA post-Brexit. The EMA has also recently announced that it has completed the reallocation of medicines for which the UK is currently the rapporteur or co-rapporteur.
For more information read the RCP's Brexit briefing: What does it mean for collaboration?
This depends on whether the UK and EU come to a ‘deal’ before the deadline and whether a transition period is implemented. It would be best to ensure that if you are planning a trip abroad and further advice has not been issued by government, that you seek medical insurance before travelling.
If negotiations are agreed, there will be a transition period likely in place until 31 December 2020 which means that the UK will still be part of the customs union and single market but not a decision-making member state. A recent House of Lords report on reciprocal healthcare outlines that there has also been an agreement in principle that those on holiday at a specified date may continue to access healthcare.
As part of the ongoing negotiations the UK has confirmed that the EU and the UK have agreed reciprocal healthcare arrangements. This means that citizens from the EU and UK will still have access to healthcare when travelling. This will then be charged back to the person’s country origin, in line with the arrangements of that country.
However the prime minister has stated that ‘nothing is agreed until everything is agreed’. This means that no agreement achieved during the Brexit negotiations can be guaranteed until there is agreement on every issue.
For more information read the RCP's Brexit briefing: What does it mean for reciprocal healthcare arrangements?