The Brexit referendum five years on: what has it meant for the NHS?

Today marks five years since the UK’s vote to leave the European Union – a sharp change of course with far-reaching impacts on health that continue to emerge. It followed a campaign in which the NHS was widely cited in arguments by all sides. So who has been proven right and wrong – and what can we learn from that today?

Fact-free finances

Taking centre stage was the Leave campaign’s claim that “we send the EU £350 million a week – let’s fund our NHS instead”. This was indisputably wrong, as reflected in public finances since, which have never shown a net saving from Brexit. The amount the UK sent the EU was considerably lower, and every official forecast has always shown that savings would be outweighed by the medium-term economic cost.

Yet polling, even well after the referendum, showed that a plurality of British voters believed the £350 million claim. Vote Leave campaign director Dominic Cummings believed that the argument was so successful as to “neutralise” economic arguments for a decisive proportion. By the end of the campaign most people believed Brexit would be bad for the economy, but good for the NHS.

One lesson, very relevant to the Nuffield Trust and those like us, is that fact-checking can actually keep an incorrect narrative in the foreground, rather than presenting a different one. Cummings notes that his campaign had actively hoped for widespread pushback on the claim, which helped raise its prominence.

The Remain campaign warned that a vote to leave would cause NHS budgets to fall. Labour warned that Brexit “would mean brutal cuts to the Department of Health”. The Trade Union Congress, Liberal Democrats and Conservative spokespeople produced figures of up to £10 billion in predicted cuts.

These predictions were wrong. The NHS budget has actually risen more rapidly since the vote to leave than it did in the few years before, and will continue to rise.

Brexit has indeed damaged public finances. The Office for Budget Responsibility, official forecaster of a government led by prominent Brexiteers, today believes that leaving the EU will result in 4% lower economic growth than would otherwise have been the case. If translated proportionately onto the NHS budget this would have meant less spending – though not actual cuts.

But in reality, public spending is a political choice, not a direct consequence of economic trends – a point that is relevant in the current debate on both health and social care.

Migration

The second major theme of the health debate during the referendum campaign was migration. Here Vote Leave pointed to rising waiting times, and stated that “current levels of migration are causing unsustainable pressures on our public services and we can see that the NHS is creaking under the strain. It's time to take back control.”

These claims have aged poorly. Brexit has in fact resulted in a fall in EU migration, but this has not alleviated pressure on services: waiting times have worsened. This is unsurprising. As we pointed out ahead of the referendum, the evidence suggested that EU migrants – typically quite young and healthy – used services at a low rate and were not responsible for increased pressure on the NHS.

The Remain campaign, meanwhile, warned of the risks of no longer having access to EU staff. This was well founded: previously high levels of recruitment from the continent entered a historic downturn after the referendum, dramatically so for nurses. The prominence of this in Remain campaigning was quite low. While the NHS Confederation and Simon Stevens, Chief Executive of NHS England, both raised the issue, I could not find an instance of it being mentioned by Prime Minister David Cameron, or his Chancellor George Osborne.

Several major trends in migration around Brexit were not anticipated or highlighted by either side. Migration from outside the EU has risen sharply, especially for nurses, as politicians blanched at the risks of shortages and softened the rules. Meanwhile, the Oxford Migration Observatory says that UK public opinion towards migration has softened consistently since the referendum, with even Leave voters now less opposed to EU arrivals. The referendum in fact took place close to a historic peak in concern about migration: it is relevant to policy debates around issues like social care migration today that public views appear quite changeable.

Minor skirmishes

More specific health issues were also occasionally dragged into the fray, as enumerated by Politico at the time. Some prominent Leave campaigners pointed to the EU’s endlessly delayed trade deal with the USA, warning that it might lock in privatisation of the NHS. Identical issues, of course, have since arisen as the UK charts a separate trade policy with Washington.

On the Remain side, campaigners at times warned that Brexit would mean an end to EHIC cards for travellers accessing health care in the EU. While a genuine possibility, this proved to be essentially incorrect: the 2019 Trade and Cooperation Agreement retained UK membership of the scheme in all but name.

Sound and fury

The overriding impression in retrospect is of an immature debate around health and the EU. Migrant staff in health and social care were discussed little, though later evidence suggests they hold a distinct place in public opinion. The issues of medicine supply and life sciences were barely mentioned, despite subsequently topping government risk registers around a possible no deal exit in 2019, and in Northern Ireland currently.

Before 2016, the international dimensions of health simply were not paid enough attention. We ourselves at the Nuffield Trust probably did less work on the EU referendum than its subsequent importance for health merited. We hope that our new health and international relations initiative, funded by the Health Foundation, will help support a better informed debate as we approach new trade deals and begin decades of continued negotiation with the EU.

As the UK government, policy-makers and media grapple with the complexities of trade deals that can aid or hinder the movement of goods, services and money across borders, there is much still to understand about how we make the new reality work for patients. Their need for secure medicines supply, prompt access to new drugs and a stable, well-qualified clinical workforce remains as pressing as ever.