The referendum vote for the UK to leave the European Union in June 2016 marked a watershed in the country’s relations to its neighbours, changing relationships, rules, and the flow of goods and people.

This project, supported by the Health Foundation, monitors the ongoing effects of that EU exit on the health care system in the UK and the people, goods and resources that it relies on. Having previously looked at the issues following the UK’s fitful negotiation of exit and trade agreements with the European Union, this major 2022 update looks back to consider the impact of Brexit on health to date in total across three major areas: workforce, medicines, and the economy.

There is now significant evidence suggesting that Brexit is having negative effects in these areas. The worst-case scenarios have been ameliorated by agreements with the EU, planning and preparation for medicines disruption, and an easing of migration rules for non-EU staff. However, problems are distributed unevenly, with some medical specialties for example affected disproportionately by migration slowdowns. In most cases these problems seem likely to continue – potentially even being worsened if the exit and trade agreements are disrupted in the coming months.

Unfortunately, this has come just as the NHS has faced three of the most difficult years in its history. The service was struggling to secure enough key staff and failing to deliver on waiting lists even as the drama of the EU withdrawal agreement took place. Since then, it has faced by far the largest pandemic in its history, leaving it with a larger backlog of treatment, lower rates of health care activity and exhausted staff; and a war in Ukraine which has driven prices relentlessly upwards. The combination of these factors means Brexit has been another blow to resilience already stretched to breaking point.

Key points

• Across medicine, nursing and social care, there has been a decline in EU recruitment and registration since the EU referendum in 2016. This trend risks compounding widespread problems associated with the lack of workforce planning, unappealing conditions, and a need for a growing number of staff.
• For the total number of doctors and nurses, a rapid increase in recruitment from the rest of the world has compensated for the slowdown in EU workers. The number of nurses joining the UK register from the rest of the world has risen from 800 in 2012/13 to 18,000 in 2021/22. However, this is not sufficient to make up for ongoing shortages in nursing and cannot be a replacement for adequate workforce planning to recruit and retain staff domestically.
• Several essential specialties of medicine facing chronic shortages have seen EU and EFTA recruitment drop off without increases from other countries compensating for this. Cardiothoracic surgery's previous reliance on European staff has slowed to almost nothing, with no increase in rest-of-world recruitment. Anaesthetics, a large specialty with high numbers of European staff, has seen EU and EFTA recruitment drop from a rise of over 20% in the years before Brexit to just 5% in the following years. Non-EU recruitment has also fallen.
• The rate of EU and EFTA dentists joining the register has halved since the EU referendum, without a clear increase in rest-of-world registration. Social care has seen a drop in EU and EFTA nationals which has not been compensated by wider recruitment.
• The NHS is not supposed to actively recruit staff from ‘red list’ lower and middle-income countries experiencing workforce shortages, but recruitment from these countries has increased in many English NHS trusts since the UK exited the EU single market and introduced new migration rules. This poses important ethical issues related both to the damage incurred by health systems in staff’s country of training, and to potential abusive treatment of staff in the UK where recruitment is not adequately monitored.
• There is clear evidence that Brexit is likely to be reducing the incomes of people in the UK relative to a counterfactual of continued membership, through its impact on GDP, investment, and trade. The current economic situation means that this is likely to be an additional reduction on already falling real incomes, rather than slower growth. The link between health and income is well documented, and this is likely to lead to worse health outcomes and higher demands of the NHS.
• There have been unusual spikes in medicines shortages since the UK left the single market in 2021, and to some extent in the preceding years following the EU referendum. The number of price concessions granted by the government when medicines cannot be found at the usual price has jumped repeatedly since 2016 and has recently soared to record highs. The latest shifts illustrate how drops in the pound due to Brexit and the September 2022 Fiscal Statement appear to make it difficult for the NHS to obtain medicines under the cost controls it has relied on.
• For other G7 states, medicine imports have risen steadily in total value since 2016. For the UK, they have reversed and fallen back to where they were a decade ago. UK data shows that 2021 was a particularly slow year for imports. This will partly reflect previous stockpiling, but may also be associated with new trade barriers.