Our submission highlights the joint concern from the Academy of Medical Royal Colleges and the Academy of Medical Royal Colleges Wales about what needs to happen to maintain the quality and standards of health and social care in the UK following the decision to withdraw from the EU.
Please note that this is a consensus view from Academy membership through discussion and may not fully represent the expressed views of individual member colleges and faculties.
· The Academy of Medical Royal Colleges Wales (Wales Academy) brings together the voices of its member colleges and Faculties for overarching generic issues around healthcare.
· The Wales Academy role is to promote, facilitate and at times, coordinate the work of the
· The Wales Academy is an independent committee accountable to the Academy of Medical Royal Colleges (AoMRC) board of trustees. We aim to work collaboratively with the AoMRC and be the Welsh voice within that but responding to the unique needs and systems of Wales.
1. Whatever the views of member organisations or individuals on the merits or otherwise of the decision to leave the EU, the joint concern of both the AoMRC and the Wales Academy is about what needs to happen to maintain the quality and standards of health and social care in the UK following the decision to withdraw from the EU.
2. It is our joint hope that the best aspirations of the Leave campaign can be delivered and the worst predictions of the Remain campaign are avoided.
3. Royal Colleges have identified a number of areas which must be addressed as part of the Brexit negotiations (highlighted in Question One). These include:
· Recognition of medical qualifications
· Maintaining medical research links and funding
· Continued cooperation on public health issues
· Reciprocal healthcare arrangements and
· Regulation of medical devices.
4. These, however, are technical issues. The Wales Academy believes the greatest challenge will be the likely impact on the size and skills base in both health and social care. All levels of the health and social care system rely heavily on staff from the EU and could not operate effectively without them. This concern should also be considered in the context of current staff shortages which affects all specialties.
5. Overall, there has been a long-held belief within Colleges that the UK must train more doctors and healthcare staff. Following the referendum result, the need for the UK to train more health and social care staff has become critical.
What are the main issues facing your sector as a result of the UK’s withdrawal from the European Union, and how should the Welsh Government respond to these?
6. Following consultation with its member organisations the AoMRC has agreed:
· A set of principles that should be followed to maintain quality and standards in the NHS, healthcare and public health following the decision to leave the EU
· Specific issues that will need to be addressed by Government or other national bodies in negotiations on withdrawal from the EU.
7. The AoMRC has agreed the following overarching principles which should both guide Government negotiators and be used as a benchmark to judge proposals from Government:
· Health is international
· Ensuring the continued protection of the public’s health in terms of both communicable diseases and environmental standards
· Ensuring that the health inequalities gap is not widened and indeed addressed through economic development targeted at highest need areas
· Support for the continued free movement of clinical and academic medical and health workforce staff (subject to appropriate standards) needed to resource the NHS from medical school to consultant and GP
· Ensuring academic and research links including medical science and funding streams remain open and are maintained as part of a competitive programme
· Ensuring the unencumbered flow of scientific and academic data
· Ensuring there is a clear route for national and international medical opinion to UK Government and devolved nations
· Ensuring involvement for key UK and devolved nation health agencies with European and linked International bodies e.g. medicine regulation, specialty bodies
· Maintenance of uniform, agreed clinical and educational standards instituted by the medical royal colleges and faculties
· Protecting safeguards for worker health currently enshrined in EU regulatory framework Issues for Government and national agencies to address
The AoMRC has identified the following specific issues will require action by Government or other national bodies.
8. An estimated 144,000 EU nationals work in health and social care in England with additional staff working in services in Northern Ireland, Wales and Scotland.
9. Clearly the system could not be sustained if that workforce was lost and we believe it is essential that commitments are given to them in terms of their future. We believe action is vital to reassure EU staff of their value, to stop significant departure of staff and to maintain services.
10. In the longer term we believe that the NHS will continue to need EU and other overseas staff in clinical and non-clinical posts at all levels to maintain services. Specifically in terms of medicine, the AoMRC believes the availability of medical staff from the EU should not be restricted.
11. The UK scientific community is concerned about the impact of leaving the EU on UK science and research and this is particularly applicable in relation to medical science. The UK's success in attracting EU research funding reflects its acknowledged position as a leader in research and innovation which Brexit potentially puts at risk to the detriment not only of the UK but also the rest of the EU.
12. The Academy of Medical Sciences has identified three threats. Firstly funding – the UK has hugely benefited from EU research funding, receiving €8.8 billion between 2007-2013 despite only contributing €5.4 billion to the EU research budget over the same period and it has also been hugely influential in how funding is allocated. Secondly, the potential restrictions to the free movement of talent undermining the benefits of collaboration. Thirdly, the value of EU research regulations on issues such as clinical trials, data sharing and animal testing etc. The Brexit negotiations must develop clear and coherent plans to safeguard scientific research in the UK.
13. The regulation of medicines (including medical devices and in vitro diagnostic testing)both for those under development and as approved products in the UK is heavily reliant on the Regulations and Directives that come from the EC via the European Medicines Agency (EMA).
14. Should the EMA move from London, as seems probable, we believe this would diminish the UK’s influence in regulation, research and innovation. The UK will have to re-write much of its own legislation to cover this following withdrawal.
15. If not part of the EMA we would be unable to participate in the European wide approval system for new medicines and the revisions to already approved products, to participate in the Orphan Drug Designation and the Small to Medium Sized Enterprise schemes that the EMA operate or to participate in the specific centralised approval process for paediatric drugs and the process that supports new medicines development for children. We would also lose access to the EU wide Pharmacovigilance networks and the EU Clinical Trials
16. The European Union Organ Donation Directive (EUODD) sets minimum standards that must be met across all Member States in the EU, ensuring the quality and safety of human organs for transplantation. NHS Blood and Transplant implements the EU rules on the procurement, storage, use and monitoring of all human tissue and blood in the UK. Decisions will need to be made about future arrangements.
17. Our specific concerns are around health scourges that don’t respect international boundaries. These include disease epidemics and infection as well as antimicrobial resistance. It will be essential to ensure that the UK can continue to participate in the European Centre for Disease Prevention and Control.
18. We are concerned to protect the regulation that has maintained food safety, air, water and environmental quality and maintained health workplaces and employment conditions
19.The European Working Time regulations have been a matter of controversy and the lack of flexibility a cause for concern for some groups. Withdrawal gives the opportunity to develop proposals which explicitly suit the needs of the UK health service. But whilst some people would welcome greater liberalisation of the regulations there are many who would be very concerned to see the current protections lost. Other safeguards to worker health that have been established through EU regulations
20. Requirements for health and safety in the workplace and the promotion of health employment need to be retained.
21. In terms of NHS staff, under the framework directives the requirements to strengthen assessment of and protection from exposure to chemical agents (e.g. Latex, glutaraldehyde, cytotoxic), biological agents (blood borne pathogens, viruses etc.), physical agents (radiation) have been considerably strengthened in the EU.
22. There are a range of issues relating to the regulation and education of health professionals which will need to be addressed. These include transferability and recognition of European qualifications for doctors, routes of access to the specialty register (CESR/CEGPR and CCT), and requirements for language testing. It is recognised that in some instances Brexit may provide the opportunity for a more flexible approach which suits UK requirements which has been called for on a number of issues. There will, however, be issues where Colleges would want to see consistency maintained on a UK-wide basis.
23. Infrastructure projects affecting communities such as transport links, leisure facilities, community enterprises and support to businesses leading to threats to employment and wellbeing. These are more likely to affect areas of higher deprivation and increase the risk of greater inequalities.
24. At present there are EU wide rules regarding procurement of public projects through open tender through OJEU (Official Journal of the European Union). Whilst this is obviously not an issue exclusive to healthcare the NHS will need clarity over the rules for public project procurement in the future.
25. There are approximately 2 million UK citizens currently living, working and travelling in the EU, with 380,000 living in Spain alone. Currently, EU membership entitles our citizens access to the host country's public healthcare system on the same basis as the indigenous population. There has to be clarification if current EHIC arrangements would continue to operate. Post-Brexit, it remains to be seen what the impact on the NHS would be of large numbers of ex-pats returning to the UK to access healthcare, particularly as many will be older people with more complex needs. Emphasising the requirement for continued full involvement in EU activity until departure.
26. It is important for so long as the UK remains a member of the EU it continues to be included in current decision making processes. There has been anecdotal evidence of people being excluded from participation in meetings or events as a result of the referendum decision.
27. The AoMRC has identified three potential categories into which we think solutions will fall.
These would seem to be
· Continued access to current arrangements. Non EU countries are participants in various current arrangements for example in the public health field. This may, however, depend on the wider issue of whether the UK remains part of the EEA
· Replication of current desired arrangements or requirements at UK level
· Replacement of undesired current arrangement with better and more appropriate UK alternatives or indeed simply abandoning of undesired measures.
28. The AoMRC, Wales Academy and colleges do not claim to have solutions to all the issues raised and there may, indeed, be additional issues that come to light. Most are highly complex with no simple or single solution although it would appear that remaining part of the single market would address a number of issues. However all will need to be addressed and solutions found if the quality of the UK’s health and care system is to be maintained and the health of the public protected.
29. It is essential that the health community and those with specific expertise are actively involved and listened to before and during the negotiation process. The AoMRC is part of the Cavendish Coalition of health and social care employers, professional bodies and trades unions which can provide a common and coherent voice on workforce issues and we would hope the Government would ensure it engages with this important grouping.
30. Medical royal colleges, faculties and the Wales Academy would wish to engage directly with Welsh Government and other appropriate agencies to discuss what would provide the best solutions for healthcare, patients and citizens in Wales.
What advice, support, or assistance have you received from the Welsh Government to date in preparation for Brexit?
31. To date we have received nothing; we would of course welcome advice, support, or assistance from Welsh Government. The Wales Academy provide a unique voice in Wales, we would welcome engagement with Welsh Government in preparation for Brexit and other appropriate agencies to discuss what would provide the best solutions for healthcare, patients and citizens in Wales.
What financial considerations have arisen as a result of UK’s withdrawal from the European Union and what should be done to prepare for these?
32. The AoMRC outlined position on financial considerations in our ‘Brexit Position Statement’ (July 2017).
“Whilst not an issue for Brexit negotiations the implications for the funding of the NHS and other public services post Brexit are crucial. The promised Brexit funding bonanza does not seem likely. A potential influx of UK citizens living in Europe (300,000 alone in Spain) seeking NHS treatment if there are no reciprocal arrangements will place additional strain on services.” [1]
33. In relation to healthcare services, the UK is a net beneficiary for research grants and one of the most successful countries at securing funding from the EC. The EU research and innovation budget for 2014-2020 is around €120bn [2]. A lack of access to EU-wide clinical trial research projects will have a direct impact on our ability to secure good patient outcomes, particularly for rare conditions. Projects funded by the EU have enrolled over 340,000 patients [3] to clinical trials so far with the UK leading the way in Europe for conducting clinical trials. [4]
34. Major clinical centres are now questioning whether they should participate in global clinical studies at phase II and phase III if there is no guarantee of NHS funding post-study and if reimbursement timelines become prohibitively long. This will have a significant impact on patients with rare or serious, life-threatening disease for whom novel therapies might be transformational.
35. Additionally, In submission to the Parliamentary Review into Health and Social Care in Wales, The Wales Academy outlined a need to fund social care services in order to relieve pressures in primary care and work towards more integrated services. [5] Any potential negative impacts to NHS funding to social care post Brexit would greatly affect the longer term vision outlined in the review.
What advice or support would you like to see from the Welsh Government that will help you and your sector to prepare for Brexit?
36. Royal Colleges have identified a number of areas which must be addressed as part of the Brexit negotiations (highlighted and detailed in Question One). These include:
· Recognition of medical qualifications
· Maintaining medical research links and funding
· Continued cooperation on public health issues
· Reciprocal healthcare arrangements and
· Regulation of medical devices.
37. These, however, are technical issues. The Wales Academy believes the greatest challenge will be the likely impact on the size and skills base in both health and social care. All levels of the health and social care system rely heavily on staff from the EU and could not operate effectively without them. This concern should also be considered in the context of current staff shortages which affects all specialities.
38. The exact shortfall of any given speciality faces changes from year to year, but, the current problem is particularly prevalent in General Practice and acute medicine. This problem is exacerbated by a general lack of ‘boots on the ground’, provided by nurses and allied healthcare professionals, which could be worsened by the threat Brexit poses to freedom of movement of people, if not sufficiently addressed in negotiations.
39. Overall, there has been a long-held belief within Colleges that the UK must train more doctors and healthcare staff. Following the referendum result, the need for the UK to train more health and social care staff has become critical.
40. The Wales Academy would hope for a plan B if the effect on our Health and Social Care workforce is going to be detrimental:
· Train and retain more
· Recruit from other parts of the world
· Different roles for Health Care providers like Advanced Nurse Practitioners etc.
41. Medical royal colleges, faculties and the Wales Academy would wish to engage directly with Welsh Government and other appropriate agencies to discuss what would provide the best solutions for healthcare, patients and citizens in Wales.
‘Priorities for health and social care in the negotiations on the UK's withdrawal from the European Union’, House of Commons Health Select Committee Inquiry, AoMRC, October 2016 http://www.aomrc.org.uk/wp-content/uploads/2016/10/Brexit_Health_Social_Care_Inquiry_251016.pdf
‘Brexit - Position Statement’, AoMRC, July 2017
http://www.aomrc.org.uk/wp-content/uploads/2017/08/2017-07-26_Brexit.pdf