Health...What are the Brexit issues?

1. Workforce

The healthcare workforce on the island of Ireland is essentially one workforce. The existing open border arrangements on the island enable medical professionals based on both side of the border to travel freely to provide healthcare to their patients. This needs to continue both for the benefit of patients and for the service on which they so heavily rely on and to safeguard the sustainability of vital health services in North and South of the border. If after Brexit only the Common Travel Area rules apply, then only UK and Irish nationals will remain protected by this freedom. This would mean that separate arrangements may need to be put in place for EU nationals.

Brexit will have major impacts on the recruitment and retention of EU nationals within the NHS and social care. Brexit may make the UK less attractive to health workers from the rest of the EU because it could undermine their legal entitlements for EU nationals and those of their families such as residency rights, the right not to be discriminated against, the right for social security and welfare and many others that are currently enjoyed.

The healthcare sector in Northern Ireland is one of many sectors in Northern Ireland that is reliant on EU nationals. Migrants are key to filling vacancies here in order to meet skill shortages, including in rural areas. The 2011 census revealed that 9.5% of healthcare professionals, health and social care associate professionals and care staff are from outside the UK. There are concerns about an ensuring adequate supply of safe and qualified healthcare staff after Brexit due to difficulty retaining and recruiting new EU/EEA nationals to work in the healthcare sector here. This could leave a gap in an already under pressure health and social care sector.

2. Qualifications

EU legislation currently exists which concerns the mutual recognition of professional qualifications. This enables health professionals from EU countries to work in other EU member states. Even if the residency status of EU healthcare workers here is confirmed post Brexit, there are still concerns that it may be difficult to retain staff and attract new recruits from the EU due to uncertainty which rights they and their family will be entitled to. This is at a time when health and social care services are already under pressure.

One in ten doctors in the UK is a EEA graduate. Data from the General Medical Council on licensed EEA graduates by country reveals NI has a relatively high reliance on EEA graduates (8.8% of registered doctors). GMC data on EEA graduates by country of qualification and are of practice shows that the highest numbers of licensed doctors from within the EEA graduate in Ireland, with 3196 doctors with a UK licence graduating from Ireland. In contrast to the other nations of the UK nearly three quarters of the EEA graduates working in NI obtained their primary medical qualification in ROI. A high proportion of these doctors are likely UK citizens from NI who went to medical school in the ROI.

3. Employment Rights

Health and Social care staff are protected by many employment rights under EU law. The Working Time Directive protects workers health and safety including a limit to working hours and ensuring appropriate breaks for workers. If the UK government decided to appeal/amend these regulations this would have implications for HSC employment contracts and change to the Agenda for Change pay framework. These EU laws also provide equality protections and maternity leave rights.

4. Cross border workers and healthcare

Anyone requiring healthcare in a different EU country is treated as if they live there, with their home country reimbursing the country where the care was provided.

Cross border workers are entitled to access health services both where they live and where they work. However, this right does not extend to dependants who are only covered under the legislation of the state in which they reside. In ROI, under EU regulations, cross border workers and their dependants are automatically entitled to an Irish medical card without a means test, provided they don’t have additional income in ROI.

Cross border workers are also entitled to access maternity services in either jurisdiction. For example, a woman working in NI and living in ROI is entitled to access NHS maternity services and post-natal care in NI, she is able to choose which side of the border she will have her baby. However, after appropriate post-natal care, the child will not be able to access NHS services.

Cross border workers living in NI and working in the South may be entitled to a medical card but this is means tested. However, these workers will also be eligible to access NHS service in NI.

Cross border workers who retire in ROI due to ‘old age or invalidity’ are entitled to access continuing medical treatment for a condition for which they are already receiving services from NI. However, all other health services must be accessed in ROI. Brexit could have implications for this which will be unknown until the outcome of the negotiations.

5. Reciprocal Healthcare

Anyone requiring healthcare in a different EU country is treated as if they live there, with their home country reimbursing the country where the care was provided.

5.1 The Directive 2011/24/EU on cross border healthcare

The cross-border healthcare route is one where an individual seeks access to treatment in another EEA country in either the state or private sectors. The HSCB considers applications for cross border healthcare when the treatment is available locally or within the rest of the UK within a medically/clinically appropriate time-period but nonetheless the patient has opted to seek treatment elsewhere. Where treatment is opted for under the provision of this directive, the HSCB will reimburse the patient directly. Depending on the outcome of Brexit negotiations, patients may no longer have access to necessary treatment and care outside the UK.

5.2 Extra Contractual Referral

This is when the HSCB transfers a patient to a provider outside NI for assessment or treatment, but can also be outside the UK. The board pays approved treatment costs direct to the provider, books flights/ferries, reimburse accommodation expenses up to a max amount, provides subsistence allowance for meals, provide assistance towards other transport expenses. There are concerns about the impact of Brexit on these Extra Contractual referrals which are to other EEA countries especially the Republic of Ireland.

5.3 Treatment under S2 or E112

An individual can seek access to state-funded planned treatment in another EU/EEA country (outside UK) or Switzerland if they require the treatment and it is not available locally or within a reasonable time period. It is not suitable for treatment in other parts of the UK. The HSCB will book flights or ferries, reimburse other reasonable travelling expenses up to a maximum allowance, reimburse accommodation expenses up to a maximum allowance, provide subsistence allowance o meals, provide assistance towards other transport expenses. The cost of treatment is paid at national level through the overseas healthcare team in Newcastle. The impact on this will be determined by the outcome of the negotiations. Potentially patients will no longer have access to necessary treatment and care outside the UK.

5.4 European Health Insurance Card (EHIC)

This card enables people from the UK to access emergency healthcare whilst on a temporary stay in another EU/EEA member state or in Switzerland at a reduced cost or sometimes for free. The removal of this access will have impacts on the emergency treatment for UK citizens when travelling in EU member states. UK and Irish authorities have an agreement where UK residents do not need their EHIC card to access healthcare services if they are on a temporary stay in Ireland.

6. Cross border care

The existing open border arrangements between NI and ROI under the Common Travel Area have provided a number of benefits for patients, health services and health professionals which are at risk of being lost if restrictions are introduced following Brexit.

10.1 Co-operation and Working Together programme (CAWT)

This is a body that was formed in 1992 to improve the health and wellbeing of the population of Northern Ireland and the Republic of Ireland and has enhanced service provision in many rural and peripheral areas. CAWT managed a range of health and social care projects funded by £24million from EU INTERREG funding up to 2014/15.  Substantial proportion of services funded by the EU INTERREG IVA programme have continued after the conclusion of EU funding as planned. Under the overarching programme called ‘Putting Patients, Clients and Families First,’ 12 cross border health and social care services projects were able to be delivered:

  1. Cross Border acute hospital services

  2. Additional and new sexual health/GUM clinics (1.95m euros from EU INTERREG IVA programme, 7195 patients treated by the end of 2014)

  3. Alcohol abuse prevention and intervention

  4. Eating disorder services

  5. Improving outcomes for Children and Families

  6. Diabetes Education and Clinics

  7. Prevention and management of childhood obesity

  8. Health inequalities

  9. Support for Older people

  10. Citizenship for people with disabilities

  11. Cross Border Workforce Mobility

  12. Autism Support

Current CAWT Strategic Plan 2014-2019 asserts continued partnership between both jurisdictions to support the change agenda (TYC in NI and Future Health in ROI). EU wide policies such as Europe 202 (EU’s growth strategy) will provide direction for future actives).

10.2 North South Ministerial Programmes

This body manages many cross-border health projects, whilst it is not subject to EU funding it relies on cross border cooperation between NI and ROI. Programmes include:

  • Emergency Planning

  • Accident and Emergency

  • Co-operation on high end technology

  • Cancer Research

  • Health Promotion  

Examples of cross-border projects:

Radiotherapy Unit at Altnagelvin Hospital: This is a cross-border treatment that will treat cancer patients from both NI and ROI. This has provided radiotherapy services to more than half a million people living in the Western Trust and in County Donegal.

All island congenital heart disease clinical network: This is a new all-island children’s heart surgery network which has received an investment of £42million. This is the first integrated clinical network to operate on an island wide basis.

The existing open border arrangements enable medical professionals based on both side of the border to currently travel freely to provide healthcare to their patients. This needs to continue both for the benefit of patients and for the service on which they so heavily rely and safeguard the sustainability of vital health services in both countries.

7. Pensions and Healthcare

There are about 190000 people receiving British pensions who live in other EU countries and depend on these arrangements for healthcare. Many are UK nationals who worked their whole lives in the UK but chose to retire in another country. Others are not British but have worked in the UK for most of their lives before retiring in their home country. The UK pays about £650million per year for care provided to British people in EU countries (about £500m is pensions). This represents good value for money as the average cost of treating pensioners elsewhere in the EU under these arrangements in about half the cost of similar treatment within the UK.

8. Financing

7.1 Capital financing of the NHS

The European Investment Bank has provided over 3.5 billion euro in low cost capital to the UK since 2001.

7.2 Indirect impact on NHS financing

The NHS is the largest discretionary part of UK public expenditure o vents that affect the UK economy are likely to have a substantial impact on NHS financing.

9. Medical licensing and regulation

EU law governs nearly every aspect of medicine licensing including medical products. Legislation from the EU also provides for a harmonized approach to medicine regulation across member states as well as common rules for carrying out clinical trials. It also promotes the functioning of the internal market including innovation. There are concerns that Brexit will result in the loss of benefit to UK patients from certain drug trials.

10. Information

Comparable information at EU level has been a substantial force for improvement in health care. For example, European comparative data on cancer outcomes generated by the EU-funded EUROCARE studies have had a profound impact on cancer care in the UK.

11. Public Health

There have been a number of EU directives aimed at improving public health such as directives around air quality, beaches, tobacco and participation in specialised agencies such as European Food Standards Agency and the European Centre for Disease Prevention and Control.  These EU directives and co-operation has contributed to improving public health here.

  1. Research and innovation

The EU have provided funding for research and innovation here and the area of health and social care has benefited greatly from this. This funding includes the participation of NI universities in Horizon 2020 which involves £80billion funding over 7 years. There are concerns that Brexit will make it difficult for academic researchers in the UK to collaborate with experts in the EU and will result in the loss of this important funding, the impact coming from any impingement on the free movement of people and the standards that underpin research.

Areas of Horizon 2020 funding include:

  • Food

  • Health promotion

  • Social sciences

  • Biotechnology

  • Wellbeing



Malene Bratlie