Leaving the European Union - briefing

As paediatricians we need to know that children and young people are placed at the centre of Brexit preparedness. It is also critical that people who work at the heart of our NHS are protected and reassured. While the political situation intensifies, this briefing document highlights our concerns and recommendations around three core priorities: continuity of access to medicines, a strong workforce, and preserving our vital research strengths. We also have particular concerns in relation to Northern Ireland.
Last modified
19 September 2019

Supply of medicines, devices and the delivery of care

Registration and supply

There are potential challenges to supplies of medicines if the UK leaves the EU without a deal. The Health and Social Care Secretary has written to suppliers of medical devices and clinical consumables to say that contingency plans are being developed and that stock holding at a national level will be increased to a six weeks supply. The Government has confirmed that the supply of medicines will be prioritised in the event of delays or disruption at the border, which is particularly critical to ensure access to this year’s flu vaccine. The Government has also secured additional roll-on, roll-off ferry capacity between the UK and EU, including air freight routes for suppliers of critical goods such as radioisotopes.

The UK does not have access to a domestic supply of radioisotopes, close to the point of use, and so relies on imports from Europe and beyond. Leaving Euratom (European Atomic Energy Community) will risk supply issues. Breaks in supply can lead to delayed diagnosis and treatment, as occurred in 2009 and 2013 when maintenance of reactors resulted in facilities going offline temporarily. 

The Department for Health and Social Care is having ongoing, frequent engagement with key suppliers of medical devices. Should we leave the EU without a deal, the UK’s current participation in the European regulatory network for medical devices will end, and the Medicines and Healthcare products Regulatory Agency (MHRA) will take on the responsibilities for the UK market currently undertaken through the EU system.

It is important that the MHRA continues to work closely with and align their practices with the European Medicines Agency (EMA) to ensure that children have access to the best medicines needed for their care. Pharmaceutical companies are less likely to want to negotiate with two separate licensing and regulatory bodies, and harmonising processes between the MHRA and EMA will help to mitigate this risk. 

Reciprocal healthcare arrangements

In the event of a no-deal Brexit, the European Health Insurance Card (EHIC) card will not be valid and UK citizens travelling to the EU will need private travel insurance. Guidance published by the Government on 28 January 2019 for UK nationals living in the EU/EEA and Switzerland confirms that their existing access to healthcare may change if the UK leaves the EU without a deal.

The Government has indicated that the S1 certificate (providing access to free healthcare for those resident in the EU) may not be valid in a no-deal Brexit. In this case, the Government would seek bilateral agreements with individual member states to protect current rights to reciprocal healthcare, though nothing has been determined. Agreements have been reached with EFTA states (Switzerland, Norway, Iceland and Liechtenstein), which will protect the healthcare rights of UK nationals resident in those countries even in a no-deal scenario. 

It is expected that the loss of reciprocal healthcare rights could increase demand for NHS care if large numbers of UK expats move back from the EU.

We are calling on the Government to: 

  • Publish detailed reassurance for patients and people who use medication that supplies will be maintained
  • Publish and communicate measures to ensure the consistent supply of radioisotopes
  • Discourage trusts and health boards, patients, and members of the public from stockpiling medicines in preparation for a no-deal Brexit
  • Urgently undertake a full assessment of the impact of losing reciprocal arrangements on the NHS and other healthcare systems in EU/EEA members for children accessing health services.

Workforce

Freedom of movement

The NHS currently employs around 30,000 doctors whose primary qualification is from an EU or EEA (European Economic Area) country. This is 11% of the total number of doctors working in the NHS1. In paediatrics, 6% of consultants and 7.2% of specialty and associate specialist (SAS) grade doctors qualified in EU countries2.

NHS England has reported that the number of EU doctors has not fallen over the past six months, which is encouraging. However, there is now a possibility of a sudden end to free movement if the UK leaves the EU without an agreement.

Uncertainty may have a deeply negative effect on an already squeezed NHS workforce. We are concerned that recruitment and retention figures will continue to fall as the UK begins the process to leave the EU. Prospective trainees may be hesitant to join an already pressurised workforce and EU citizens may put plans to join the NHS on hold due to the high degree of political uncertainty.

Working hours

One fifth to one quarter of the paediatric workforce are working less than full time (LTFT). 22% of paediatric trainees were working LTFT in 2018 and 24% of paediatric consultants were working LTFT in 20173. Many paediatricians working or training less than full time do so for family reasons.

The European Working Time Directive was enshrined in UK law as the Working Time Regulations 1998 resulted in the 48 hour week for junior doctors. It is believed there is some appetite among MPs to use a no-deal Brexit scenario to amend regulations like this and the Parental Leave Directive which gives both mothers and fathers the right to take 13 weeks unpaid leave per child before their fifth birthday.

We are calling on the Government to: 

  • Provide immediate reassurance regarding maintenance of terms and conditions of employment, and migrant status, to EU nationals working in the NHS 
  • Enact the recommendation from the Migration Advisory Committee to place paediatrics (along with other medical specialties) on the shortage occupation list, with exemption from the resident labour market test 
  • Develop short stay career development opportunities in the UK for non-training grade healthcare professionals from abroad and identify a responsible body for national coordination 
  • Ensure immigration rules allow entry to the UK of healthcare professionals whose clinical skills will benefit the NHS
  • Ensure any future points-based system does not include a wage-based metric which would bar many essential NHS workers
  • Commit to maintaining the European Working Time Directive and Parental Leave Directive into UK law.

Science and research

EU Horizon Funding 2020

Horizon 2020 is the biggest EU Research and Innovation programme worth nearly €80 billion, which the UK has been particularly successful at securing research in the past.

A search was carried out of the European Commission’s Community Research and Development Information Service website to ascertain the amount of funding received by the UK from the EU for child health research. The search was limited to all Horizon 2020 projects which were either Coordinating Actions or Research Innovation Actions, using the search terms “paediatr*” and “child*”, from 1 January 2012 to 23 January 2018. The search identified 40 child health related projects with funding contributions from the EU, of which 32 had UK involvement. The total EU contribution to the 32 projects was just over €200 million with €64 million (32%) directed to the UK. The UK is the coordinator for 14 of the 32 projects.

A lack of access to this funding in future will limit the ability of UK paediatricians to lead in child health research.

At the end of 2017, the Government confirmed that UK institutions could continue to bid for EU Horizon 2020 funding post-Brexit4. However, it is unclear whether the UK will be able to participate in the framework programme that will succeed Horizon 2020.

Pharmaceuticals market

The UK has 2% of the global pharmaceutical market, while the EU has 28%. A no-deal exit from the EU and non-translation of EU regulations and policies to UK systems may negatively affect the UK’s desirability as a place for clinical research. This will have a knock-on impact for the UK economy, science research reputation and higher education sector.

We are calling on the Government to:

  • Ensure the UK can continue to participate in EU-wide clinical trials in the event of a no-deal Brexit
  • Guarantee funding from EU research programmes in the event of a no-deal Brexit.

Northern Ireland

Border

RCPCH estimates that approximately 15% of the paediatric medical workforce in Northern Ireland gained their primary medical qualification in the EEA. Among this group, we estimate that approximately 72% gained their primary medical qualification in the Republic of Ireland.

The border issue also presents serious practical concerns. Doctors and healthcare workers, who are often in possession of medication, would need assurances that they are covered legally to possess medication in an EU country and to drive in an EU member state.

The effective delivery of paediatric services in Northern Ireland and the Republic of Ireland is dependent on paediatricians working together on an all-island basis to maximise resources and deliver the highest quality healthcare for children on both sides of the border.

Specialised services

A number of paediatric specialised services are delivered on an all-island basis dependent on cross border cooperation. One notable example is the All-island Congenital Heart Disease Network, which operates on an all-island basis. Paediatric cardiac surgery ceased in Belfast in 2015 and there is currently ongoing implementation of surgical patient transfer to Our Lady’s Children’s Hospital Crumlin, Dublin. It has been reported that between January and September 2017, 23 children travelled to Dublin for cardiac surgery5 and it is estimated that overall, during 2017 approximately 100 children from NI were treated in Dublin who otherwise would have had to journey to Britain6.

Moreover, adolescent patients from the Republic of Ireland have been able to access treatment in Belfast.

We are calling on the Government to:

  • Publish a clear strategy outlining how all-island healthcare services can be retained after Brexit
  • Establish the rights of freedom of movement and mutual recognition of professional qualifications retained
  • Restore the executive in Northern Ireland to allow for better responsiveness in the event of a no-deal Brexit.

Wider impacts

NHS finances

The Office for Budget Responsibility has forecast a hit to the economy after Brexit. The impact will clearly be more serious in the event of a no-deal Brexit. Coupled with the expectation that costs for running the NHS will rise post-Brexit, we can expect finances to be squeezed both ways. The Nuffield Trust has forecast that a no-deal Brexit will result in up to £2.3 billion in extra costs by 2019-2020. It is likely that this will make it harder to deliver on education and training, capital, public health and social care commitments.

Public health

This year’s flu vaccine will be distributed from north west France. In the event of a no-deal Brexit, cross-channel trade will face significant disruption. It is not possible to stockpile prior to 31 October as production has only just begun.

We are calling on the Government to: 

  • Commit to delivering the spend on health and social care as set out in the 2019 Spending Review
  • Publish information on contingency planning in relation to this year’s flu vaccine.

Engagement

RCPCH has had the opportunity to feed into a number of stakeholder roundtables at the Department for Health and Social Care and will continue to do so over the coming months. In addition, we have written to the UK Government to press the importance of developing robust plans that are communicated with patients in good time. We have highlighted as a priority the urgent need for the development of clear, public-facing information to be shared with clinicians in order to help them provide advice to patients.

Call to Government

Professor Russell Viner, President of the Royal College of Paediatrics and Child Health said:

I call upon the Government and all MPs to place the best interests of our children and young people at the heart of decisions on the future of our country.

I am increasingly concerned about the effects of such chronic political uncertainty on our doctors, patients and parents. Those working at the heart of our NHS deserve reassurance and peace of mind so they can get on with looking after patients. It is difficult to provide vital reassurance in such a profoundly uncertain environment.

We must not, in leaving the European Union, harm the very thing on which our future depends – the health and wellbeing of today’s children and young people. The politics are divisive but the details of what must be done for young people and children need not be. We must have clarity and certainty on the maintenance of our NHS workforce, the supply of medicines and how to protect our research base from the effects of leaving the EU.

An abrupt severance of the vast web of connections we have built over the past 40 years will inevitably disrupt the health of children and young people. It is essential to do all we can to protect children and young people and those who care for them. For the UK to be successful, no matter what our future relationship with the EU, the health and wellbeing of our children is key.