Brexit and the Irish Health System
Anthony Staines (Dublin City University)
Our nearest and dearest neighbours are engaged in leaving the European Union. For Ireland, the experience may be less like your neighbours moving, than them moving, taking their house, garden, the road outside, and possibly the party wall, as they head off to roam the world. As a result, like most other EU countries, Ireland is spending a lot of time on damage limitation. There has been a good deal of attention paid to key sectors of our economy, such as agriculture and finance, and our politics, notably the rights of Irish citizens in the UK post-Brexit and the Northern Ireland peace process. I suggest that we need to look at some other sectors of our society, and I’m going to explore some of the possible impacts of Brexit on health and social care.
As a starting point, let us look at existing research on the effect of Brexit on the UK health system. Nick Fahy and colleagues have written a paper in the Lancet which looks at three possible scenarios for Britain. They describe these as a ‘soft Brexit, hard Brexit, and failed Brexit’. These are, respectively, a deal similar to the EEA, a deal similar to CETA, and no deal, with WTO terms of trade. None of these scenarios is particularly optimistic. For their analysis, these authors use the WHO Health System Framework (and so have I – see below). This framework conceives of a health system as based on six “building blocks,” which go together to achieve four overall goals/outcomes (see chart below).
Applying this framework to the UK health system after Brexit, Fahy and his colleagues find little to cheer about. Working through each of the six building blocks, only two potential positives emerge: it might be possible to improve regulation of professionals, and it might be possible to improve working conditions for staff. I think it would be fair to say that the authors are by no means sure that these benefits will accrue.
For Ireland, things are more complex. Ireland is not leaving the EU, but it will be more distant from the UK than at present. Working through the likely impact of Brexit on each of the “building blocks” of the Irish health system, and following Table 2 in their paper, yields the following analysis:
Likely Impact of Brexit on the Building Blocks of the Irish Health System
|Workforce||Significant and adverse|
|Recruitment and retention of staff||This is likely to be harder, as Irish staff will be allowed to work freely in the UK, so demand will increase for Irish trained staff to replace other EU and non-EU staff members.|
|Mutual recognition of professional qualifications||This is unknown, as yet. It would likely be easy for the UK regulators to continue to recognize Irish qualifications. It may be much harder for the EU to recognize UK qualifications.|
|Employment rights for health workers||It may be much harder to employ UK trained staff until final rules are settled.|
|Financing||Uncertain impacts, but could be locally very severe.|
|Reciprocal health-care arrangements||It’s very unclear what the impact will be. At the moment Irish people resident in the UK can use the NHS on the same basis as UK citizens. UK citizens in Ireland are covered by reciprocal arrangements which predate the EU by many years. How these will be affected by Brexit is not known.|
|Capital financing for HSE||This depends on the impact of Brexit on the Irish economy.|
|Indirect impact on health service financing||This depends on the impact of Brexit on the Irish economy.|
|Medical products, vaccines, and technology||Substantial adverse effects, damaging the wider economy as well as the health economy.|
|Pharmaceuticals||There will be a serious impact on one of Ireland’s major exports. Some items are sourced only from the UK, and supply may be disrupted for a period of time. Many more items, from the EU and further abroad, are distributed from UK distributors, and these channels may be disrupted.|
|Other medical products||The effect on human products, such as blood and organ donations is unknown at present. There may be serious disruption of our medical device exports, and there could be major problems with contracts for maintenance of machinery, which is currently done by UK suppliers.|
|Information||There may be grave difficulties sharing electronic medical information with clinicians in the UK. The redeeming feature is that this is seldom done now, so the practical impact may be very small.|
|Service delivery||Potential for significant degradation of services|
|Working time legislation||No effect.|
|European Reference Networks||There will be a big loss to Ireland, which has many links for rare diseases with UK specialists and hospitals, which will need to be protected. The UK is very active in European rare disease care, and it will be very challenging to replace their inputs.|
|Cross-border care||There will be a big loss both to Northern Ireland and to the Republic. There is a network of joint services which will be very challenging and very costly to unpick. The impact may be very serious, especially in border areas, where sophisticated joint arrangements have been established. Some services are directly threatened, for example the joint HSE/NHS cancer service in Derry.|
|Leadership and governance|
|Public health||The impact may be significant, especially if there is a hard Brexit.|
|Competition and trade||The impacts are very substantial and mostly negative. It will cost more, be slower, and harder to trade with the UK, and the rest of Europe after Brexit.|
|Research||Very significant. Many of our closest and most effective research links are with UK partners.|
|Scrutiny and stakeholder engagement||Not applicable|
The economic impacts of Brexit have been well studied. Ireland’s physical exports include medicines and medical products, and the effect of Brexit on these will be significant. However, there are other health sector impacts of Brexit, and some of these have been discussed here. There are doubtless more.
These problems by not insuperable. The challenge is that health is nowhere near the top of anybody’s Brexit agenda. There is a risk that nothing will be done in time to mitigate these risks. Earlier this month, the ECB and the Bank of England set up a joint task force to keep the financial markets running, should there be a hard Brexit. Perhaps we need something similar for the health sector?
Anthony Staines is Chair of Health Systems, School of Nursing and Human Sciences, Dublin City University. He is a medical academic, a public health specialist, and an experienced director. Most recently he has worked on child public health, health information systems, the social costs of illness, blood transfusion policy, including stock management, multiple myeloma, and the financing of primary care.