By World Healthcare Journal-
The impact of Brexit on the globalisation of health and social care.
The UK Government has requested and been granted a short extension of time until 31 October 2019 by the European Union in order to agree a Brexit deal. In the event no agreement is reached then it is set to leave the European Union on October 31. Currently, there is disarray over how that might happen. Among the issues causing greatest division between “remain” and “leave” supporters is the future of health and social care.
Those opposing BREXIT believe that the international agreements under which the UK currently trades with global partners provide vital protection to the NHS, safeguard the UK’s right to regulate in the interest of public health, sets high health and safety standards on imported products, and maintain open border arrangements with free movement of much needed healthcare and medical research staff. Leavers – and especially those pushing for a “no-deal” departure – argue that the UK’s future lies ina more global environment, and that a significant number of trade agreements can be negotiated that will increase access to markets and limit the economic cost of BREXIT.
They say the UK’s expertise in sectors such as healthcare can not only generate more investment and resources for the NHS, but can also be leveraged as a valuable global trade commodity in an increasingly interconnected world.
At time of publication, there is still considerable uncertainty over BREXIT, because the UK Parliament hasn’t made key decisions about how the country will leave – and what its future relationship with the EU27 and other jurisdictions will be.
Currently, the Government is trying to win Parliamentary approval for a Withdrawal Agreement,but it faces strong opposition and has already been defeated in three previous votes brought to parliament in respect of this. Talks between the government and the main opposition party have failed to resolve the current impasse. Unless agreed, The UK Government has requested and been granted a short extension of time until 31 October 2019 by the European Union in order to agree a Brexit deal. In theevent no agreement is reached then it is set to leave the European Union on October 31. Currently, there is disarray over how that might happen. Among the issues causing greatest division between “remain”and “leave” supporters is the future of health and social care.Those opposing BREXIT believe that the international agreements under which the UK currently trades with global partners provide vital protectionto the NHS, safeguard the UK’s right to regulate in the interest of public health, sets high health and safetystandards on imported products, and maintain open border arrangements with free movement of much needed healthcare and medical research staff. Leavers – and especially those pushing for a “no-deal” departure – argue that the UK’s future lies ina more global environment, and that a significant number of trade agreements can be negotiatedit raises the prospect of the UK leaving on a “no deal” basis and exiting without a transition period on 31 October 2019.
There is likely to be a series of key votes in the UK Parliament in June and possibly in September or October 2019 on whether the UK Parliament will allow the UK Government to sign the current Withdrawal Agreement, categorically rule out the UK leaving without any deal negotiated (the so called “No Deal” BREXIT scenario) or whether a further formal extension to Article 50 that would delay any departure will be sought. Whilst some commentators have mentioned the possibility of a second referendum that could reverse the 2016 vote to leave, there appears at the present time to be insufficient numbers within the UK Parliament for such prospect to succeed.
The current gridlock means there are no immediate prospects of talks starting on free trade agreements(‘FTAs’) to decide the UK’s future relationship with the EU or many other countries with whom there are often strong relationships based on shared histories.
Global mobility and immigration
When the UK Government made clear that ending freedom of movement between countries is a red line BREXIT commitment, there was naturally concern among health providers.
The majority of NHS staff in England are British – but a substantial minority are not. Around 144,000 out of 1.2m staff report a non-British nationality. This is 12.7 percent of all staff for whom a nationality is known, or one in every eight. Between them, these staff hold 200 different non-British nationalities. Around 63,000 are nationals of other EU countries - 5.6 percent of NHS staff in England. Around 49,000 staff members are Asian nationals. (source: UK House of Commons Library).
In common with other countries, the UK has an ageing population that places increasing demands on health and social care services. It therefore competes with other countries such as Australia, the United States and Canada for the same global pool of workforce resources – including India and the Philippines.
The World Health Organisation estimates the world will be short of 12.9m health-care workers by 2035, a problem made worse as populations rise.
To provide greater clarity for employers (and in particular health organisations) needing to recruit from within the EU and elsewhere, the Government recently launched a White Paper on Immigration with the aim of creating a post-BREXIT system that will prioritise skilled workers under a single immigration system rather the current dual system which distinguishes European Economic Area (EEA) citizens and their dependants from Non-EEA nationals.
The Paper proposes to end the cap on skilled workers, and scrap the requirement for employers to carry out a resident labour market test before hiring a worker from overseas.
Home Secretary Sajid Javid says this will place the focus on “talent and expertise, rather than where people come from”. Individuals meeting the criteria will be entitled to bring their dependants to the UK, to switch to other immigration routes and, in some cases, to settle in the UK permanently.
From an immigration perspective, the proposed changes are likely to make it easier for UK healthcare providers to seek skilled workers from overseas, but this will depend on the exact salary levels at which such skilled workers are considered.
At present, non-EU migrants (not eligible to be engaged at graduate level for roles) must earn more than GBP 30,000 a year to work in the UK. The government – under pressure from employers in the health, social care and other sectors - will consult on whether or not this threshold should be retained for all overseas workers.
There have also been indicative proposals on the introduction of an intermediate skills route allowing the recruitment of individuals to roles requiring skills at a lower level than that of a University degree. This may result in such roles having a lower salary requirement but the detail of such proposals is still be provided by the UK government.
Equally, a transitory measure up until 2025 of a short term visa requiring no sponsorship for what are deemed “lower skilled” roles has been suggested for periods of no more than 12 months to support organisations in the short term as they adjust their staffing requirements post Brexit to reflect the new system.
As a first priority, organisations wanting to hire non-UK workers should register now as sponsors(and thereafter issue certificates of sponsorship to their employees). This could take at least four months to secure, and will also involve substantial record keeping and reporting obligations, with the added worry that any non-compliance risks employers losing their licence and ability to recruit overseas staff.
The Government has also introduced a settlement scheme for EU citizens wanting to live in the UK. Under the scheme, EU citizens can apply for 'settled' or 'pre-settled' status:
- Settled status - EU citizens and their family members who have been continuously resident in the UK for five years, by 31 December 31 2020, will be eligible for settled status, enabling them to stay in the UK indefinitely
- Pre-settled status - EU citizens and their family members who arrive in the UK by December 31 2020, but will not yet have been continuously resident here for five years as at that date, will be eligible for pre-settled status, enabling them to stay until they have reached the five-year threshold. They can then apply for settled status
Both public and private sector organisations can’t get enough skilled people they need both now and for future investment, and are worried that BREXIT will increase difficulties in retaining workers from EEA and other countries particularly as the numbers of net migration of EEA nationals into the UK is falling substantially in the run up to Brexit.
Consequently, a substantial burden will remain on employers trying to manage complexity and compliance, amid concerns that recruitment and hiring difficulties in the UK have now reached critical levels.
New health systems
There is a rapidly changing global landscape of health provision that requires fresh thinking and innovation. In this context, “necessity may be the mother of invention” as UK organisations may be at the forefront of having to adapt to these challenges even sooner than would have been the case if BREXIT had not become an issue.
The UK already “exports” its expertise in healthcare. Its knowledge of how technology platforms can deliver care via new models - and frequently on a remote and cross-border basis – are likely to be an important feature in future FTAs the UK may seek to make with other countries.
Such opportunities may make it easier, therefore, for UK organisations to market their existing capabilities and experience in delivering innovative solutions to meet burgeoning healthcare and social care demands.
Currently, efforts are being made in the UK for better cross integration between social and healthcare provision - as well as more integration between primary and secondary healthcare services.
Given the relative maturity of the UK healthcare market and the mix of public and independent healthcare providers already providing services, there are likely to be opportunities for organisations globally that have experience in delivering such services innovatively to consider such opportunities in the UK.
We have advised on a number of partnership ventures between UK healthcare organisations and third/Middle East countries in recent years, and this trend is likely to continue in the future as UK organisations look to build on marketing their expertise globally.
A key requirement will be training the right number of people … with the right skills to deliver health and social care … in the right place.
Leading health economies now acknowledge that greater integration of services, more community based care and digital solutions – all of which are receiving substantial investment now in the UK – will be critical in delivering the advanced public health and disease protection models their citizens need.
The UK is well-placed in contributing to training and education, particularly for non-EU countries as they seek to develop their own healthcare systems. In the UAE’s fast developing healthcare sector, for example, the UK already holds a prominent position in the market with world-class UK NHS brands such as Imperial College, Moorfields, King’s College Hospital and Maudsley Hospital delivering high quality clinical services.
The increase in new-build hospitals and medical centres offers joint opportunities for filling gaps in provision such as oncology, paediatrics, mental health, primary care, trauma, emergency services and long term rehabilitation – and delivering high quality training and education programmes for medical staff.
Global health regulation
The UK’s likely decoupling from the EU will disrupt a well-understood global regulatory framework for health product development, licensing and ongoing monitoring, including pharmaceuticals and medical devices.
There are many “third countries” whose own regulations refer to the EU’s regulations as part of their own quality assurance framework. By way of example, in the Kingdom of Saudi Arabia, the Saudi Food and Drug Authority (‘SFDA’) issues a broad sweep of guidance on the regulation, licensing, importation, batch testing and marketing of pharmaceuticals, biological products and medical devices.
Whilst there remain some verylimited references to British standards, these appear vestigial and given the pre-eminence of organisations such as the European Medicines Agency (‘EMA’), of limited application in any event.
For UK manufacturers, this position presents a serious challenge. The EMA is moving from London to the Netherlands. There has been something of a stampede for UK manufacturers to establish branches or subsidiaries in the Netherlands to facilitate seamless licensing of existing product and future simultaneous releases in the UK and the EU.
With a “hard” BREXIT, the UK will lose the right to have its laws presumed equivalent to those of the Union, though we should expect some sensible “work-arounds” together with a great deal of goodwill and commonality of purpose within the sector.
In jurisdictions less familiar with BREXIT issues, the position will differ markedly. In 1988, the EU and the Gulf Cooperation Council (‘GCC’) entered into a Cooperation Agreement that provides reciprocally for “most favoured nation” (‘MFN’) status as regards the regulation of trade.
In effect for the UK it sets the high water mark in terms of how its goods will be treated (i.e. it will not get any better treatment than that accorded to the EU). What the Cooperation Agreement does not provide for is the position where a member state of a signatory organisation secedes from such membership.
So what is likely to happen?
From a Gulf perspective, much depends on the common sense of regulators in the GCC. Soundings indicate that they are adopting a “wait-and-see” position (in common with the rest of the world) as regards the outcome of the BREXIT deliberations in the UK Parliament.
However, it should be noted that the issue is simply not that important to some countries in the region. There appears to be an assumption that a sensible way through whatever regulatory hurdles present themselves will be found. No measures have yet been announced as regards stockpiling against a worst-case scenario.
There is ground level evidence in the Middle East that the UK Government is working hard at consolidating existing relationships and setting ambitious targets to improve trading relationships.
The United Arab Emirates is the UK’s largest export market in the Middle East, the 13th biggest globally and also the UK’s fourth largest export market outside the EU (source: UK Department for International Trade).
In the provision of services, BREXIT thereforerepresents a significant opportunity for UK health operators to secure lucrative contracts in the Middle East, with the timing being perfectly aligned with the region reducing public spending on healthcare and hoping to attract private sector investment and operators of facilitates.
There is substantial demand in the region for specialist clinical services in which the UK excels. Success stories include the Imperial College London Diabetes Center in Abu Dhabi, and the new King’s College London hospital and clinic in Dubai, along-with UK interest in other projects in the Kingdom of Saudi Arabia and in Kuwait.
It seems likely that once more is known about the ultimate shape of the BREXIT deal, more detailed guidance will issued to the relevant authorities regarding the status of UK-origin products and their interim status.
Longer term, much will depend on new trade arrangements put in place by the UK and the GCC (or constituent members). However, whether the finer trade terms promised by leave supporters in the UK are actually possible - given the most favoured nation status provisions in most existing EU agreements - remains to be seen.
In the short term, and with an end to freedom of movement, BREXIT may result in a system that is flexible enough to meet resourcing needs for skilled and intermediate skill levels - but this does not change the short term likelihood of more administration resource needed to comply with any new system once Freedom of Movement ends.
The increased demand for such health services globally not only means competing for a limited global pool of resource, but also means that there is greater pressure upon UK organisations within healthcare and social provision to look at improved productivity and innovation solutions to meeting challenges ahead, with increased use of technology and digitisation.
The UK government has high hopes that FTAs with non-EU countries, will result in greater trade liberalisation in both goods and services, and many third countries have announced they are willing to sign-up to new deals.
However, based on other countries’ experiences, it is likely the UK will face some significant challenges and complexities in negotiating services agreements. The UK’s bargaining power could be limited by the MFN clauses for services that exist in several of the EU’s existing FTAs.
But, given the limited global pool of labour and resources to meet ballooning healthcare needs, capability in delivering innovative solutions to healthcare and social care provision is likely to be a precious asset.
BREXIT or no BREXIT, changing demographics and rising demand for better healthcare and social care - together with the need to deliver those services at sustainable cost - means there are many opportunities for providers to market their healthcare know-how globally.
The specific opportunity for the UK is not only to showcase its particular range of expertise, but also for other third country healthcare providers to explore potential opportunities to meet the considerable health and social care challenges in the UK.
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