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It seems a long time since the Referendum campaign and the Big Red Bus with £350 million on its side but the NHS has remained very much at the heart of the Brexit debates. The impact of Brexit on the NHS across the devolved jurisdictions has been something which has not been extensively explored to date. As part of our ESRC Funded project “Health Law Outside the EU: Immediate, Intermediate and Long Term Impacts” we are undertaking a series of semi-structured interviews with stakeholders and our findings from the first stage of our interviews were launched at the Houses of Parliament on Tuesday 4 December.

Northern Ireland is the place where our interviews to date indicate that there is a key geographical challenge in relation to staffing and delivery of patient care. Recent years have seen increasingly integrated healthcare provision in the island of Ireland. Much of this has been driven by economies of scale and has led to a considerable degree of integrated care provision with some services supported by EU InterReg funds, some under the North-South Ministerial Agreement and others via bi-lateral arrangements.

Children’s cardiac surgery stopped being provided at Belfast Royal Victoria Hospital in 2015 and children from Northern Ireland and Republic are treated in Our Lady Children’s Hospital in Dublin. The Irish Government has contributed funds to the Radiotherapy unit at Altnagelvin which is the main hospital for the North West of Northern Ireland situated in Derry near Londonderry which provides treatment for cancer patients from both Northern Ireland and Donegal. There is cross-border provision of emergency ambulances.

Our interview respondents expressed great concern at anything which would hinder the provision of such services in the future. Patients from Northern Ireland use the EU Patients’ Rights Directive to bypass large waiting lists and obtain treatment abroad funded by the NHS. Access to medicines and drugs in the case of a No Deal Brexit is a particular concern with the Government already taking steps to order a 6 week stockpile of essential medicines. Our respondents also raised the prospect of the shortage of consumables, such as needles and syringes, and what they saw as the very fragile nature of existing supply chains.

Staffing was raised as a concern by respondents and any prospect of limited access to health professionals trained in another member state was seen as a major issue. In Northern Ireland, the majority of their clinicians from another EU member state come from the Republic of Ireland. Respondents noted how existing staffing shortages could be seriously exacerbated due to the adverse impact of Brexit on recruitment.

Under EU law, there is a system in place for the mutual recognition of professional qualifications. Here there were differences in stakeholder responses. There were suggestions that the current EU recognition of qualifications was not sufficiently rigorous and this could be seen as an opportunity to tighten professional qualification requirements for those from other member states. Others saw any change and tightening of requirements as having a particularly adverse impact on recruitment particularly in the context of nursing.

Our research found that public health is an area where the EU has had a considerable impact on health policy. Respondents raised smoking control as a particular issue. The EU has driven forward regulation in relation to e-cigarettes in response to public health concerns. Some in public health see e-cigarettes as a gateway into smoking, particularly by the young and a major health risk, others see it as a way to wean people off nicotine. Here there were differences in approach from our respondents between Wales where there was strong resistance to any change on the policy on e-cigarettes to England where this was seen an area where regulation might be reduced in the future.

The impact of Brexit on patient safety also remains a significant concern. A no-deal Brexit would remove the UK from a range of cross-border safety and vigilance systems operated by the EU such as those in relation to serious adverse reactions in relation to pharmaceuticals, blood and tissue safety and the safety of health care practitioners.

Others raised the potential impact of Brexit on the socio-economic determinants of health. Health is underpinned by socio-economic factors and poverty and deprivation can have a corresponding devastating impact on health. Any major damage to the economy could have an adverse impact on health and this was particularly flagged by respondents in Wales and Northern Ireland. In Wales, the prospect of “mass unemployment events” and the long term impacts of the loss of EU structural funds and their impact on health was seen as a serious risk.

As the Prime Minister has delayed the meaningful vote, the clock is ticking down to 11pm on the 29th March 2019. Our research demonstrates that the impact of a No Deal Brexit on the NHS across the UK could be very sharp and painful unless there is extremely careful management of the contingencies and myriad of factors which impact on the regulation of the provision of healthcare.

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Professor Jean McHale, Director of the Centre for Health Law, Science and Policy, Birmingham Law School, University of Birmingham.