What does the Chequers plan mean for the NHS?

Originally published in Prospect magazine on 5 October, this blog from Mark Dayan takes a closer look at the Prime Minister’s preferred Brexit plan and what its implications might be for the health service.

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Published: 17/10/2018

Conservative Party conference was dominated by firm views on the government’s Chequers plan for the UK’s future relationship with the EU. Boris Johnson called it “humiliating”, “dangerous” and “unstable”: the Prime Minister responded by saying his alternatives tore up guarantees to the people of Northern Ireland.

All this can seem a long way from the nuts and bolts of what Brexit means for the NHS and life sciences in the UK. But the Chequers plan is a detailed and complicated compromise between factions in government, published as a white paper in July. We can actually look in some detail at the pros and cons for health care in the UK – and, crucially, how likely they are to make it through negotiations.

The proposals laid out in the Chequers white paper are far from perfect from the point of view of health and social care. Above all, by ending the free movement of people, the plan would allow measures that worsen staffing problems.

But future leaders could always decide to keep the door open. And taken in isolation, other proposals in the white paper would in fact solve at least two of the major problems patients would face under harder forms of Brexit.

Medicines approval and reciprocal health care

The first is the prospect of leaving the European system of medicines approval. This would mean new drugs being introduced later in the UK, practical difficulties and costs from setting up two regulatory systems in place of one, and disruption to the processes of the medicines industry. Closely related is UK involvement in the streamlined new EU system of clinical trials: fear about departure from this appears already to have led to the cancellation of at least one trial in Scotland.

The Chequers plan answers this by setting out an aim that the UK will continue to “participate” in the European Medicines Agency, and to access “all the current routes to market” that it oversees. It also implies a degree of further alignment on clinical trials, and aims for the UK still being considered by the body in charge of overseeing supplies of radioisotopes, where we depend on EU imports for the most often used substance.

The second is the prospect of losing access to the EU’s reciprocal health care schemes that facilitate care across borders. This would mean no more European Health Insurance Cards that provide cover to travellers, valued especially by those with long-term illness who would otherwise find insurance difficult to secure. It would also end the S1 scheme that provides for people to settle abroad and access health care.

In the UK, most people who use this are pensioners who want to retire abroad. It gives them additional options and means they do not require the capacity of the NHS. Again, Chequers is unequivocal in pledging to seek continued access – not just for those already using these initiatives, but for future generations as well.

The problem is that Chequers represents not a settled agreement but a proposal for negotiation. And these benefits to the NHS fall into what appears to be the crumple zone of the UK’s propositions: a part of the plan that almost nobody expects the other side to simply accept.

The white paper’s model for regulation after Brexit is based on the principle that the UK will continue to follow the same rules as the EU for goods (including medicines) and for some other areas. This will enable it to continue to trade without regulatory checks, and provide a legal basis for taking part in EU agencies and programmes. But it will not be bound by EU rules for services like banking, or by rules for the free movement of people.

The four freedoms

Leaders of EU institutions and large member states have repeatedly objected to this idea. They do not want to divide the EU’s “four freedoms” – goods, capital, labour and services.

Voices in the UK may point out that this principle has not been absolute in the past: the EU has signed agreements with other countries that split the four freedoms. But ultimately this is not a legal debate, but a negotiation where the EU is the larger party. And every indication is that the “integrity of the single market” is a strong priority. The EU’s formal negotiating guidelines for the future relationship state simply that “the four freedoms are indivisible”. European Commission President Donald Tusk said all member state leaders had agreed at the Salzburg summit last month that the economic element of Chequers “will not work – not least because it risks undermining the single market”.

On a practical note, some EU leaders also fear that this sort of cherry-picking would allow UK companies an unfair advantage: dodging some of the rules that bind their counterparts, while still having the right to export freely.

Of course, if splitting out goods from services is a tricky sell, opting into the reciprocal health care system while being exempt from wider rules on people and services risks looking like cherry-picking squared. We appear to be looking at a situation where the broad positions laid out in the Chequers plan could preclude specific solutions that are best for health care.

Is there still time to come to an agreement?

Of course, it is not yet too late to reach a compromise that could put these back on the table. Key proposals in the coming days from London and Brussels should give us some sense of what would be required. For the UK government, it would probably mean agreeing to alignment in more areas, perhaps many more: something that would also help with several other difficulties Brexit brings for the NHS. Securing the benefits of Chequers would also require compromise on the part of the various EU bodies and, perhaps most of all, the British parliament.

If these parties put the interests of patients first, there is nothing fundamentally impossible about the proposals in Chequers on medicines, medical devices and reciprocal health care. Sadly, we cannot be certain that this is the spirit in which the final stage of negotiations will be approached.

*This article first appeared in Prospect on 5 October (“What the Chequers Brexit plan means for the NHS”) and is reproduced here with permission. Read the original article.

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