The Brexit paradox: why Britons’ health will suffer consequences
Laetitia@Work #5
Hi everyone,
There are now more than 1,000 of you following Laetitia@Work, which is spurring me on to write my fifth newsletter with increased enthusiasm. 🙏
As Brexit is nearing (it’s due tomorrow!), I’ve chosen to share a few thoughts about some of Brexit’s likely consequences on the National Health Service (NHS) and Britons’ health.
I moved to the UK in the first half of 2015, more than one year before the Brexit referendum, fully incapable of anticipating that the Brexit referendum would yield such earth-shattering results. Like (almost) everyone else, I was fed the idea that the status quo bias would prevail at the polling booths, that Britons were “pragmatists” after all. Also, let’s not forget this was before Trump’s election and we hadn’t gotten used to crazy being the new norm.
Then for two years after the June 2016 referendum I had Brexit nightmares. I had enough conversations with people in law, finance and the administration to realise Brexit was first and foremost a bureaucratic ordeal that would create a lot of business for lawyers and cost the UK state billions of pounds. But I couldn’t help but think about what it meant for people, future inflation, further cuts in public services, further liberalisation of the labour market, increased inequalities, a possible future trade deal with the US that would bring hormone-treated beef and chlorine-soaked chicken to UK supermarkets, etc.
I eventually came to terms with Brexit the way I’ve come to terms with Trump’s election: by switching off mentally, and building a sort of wall of indifference to the fate of people who I can do nothing to help. It’s not something I’m proud of, but the only sane thing I could do was to flee, mentally if not physically. You realise that you and your family will be ok, that you can avoid chlorine-soaked chicken by going to expensive organic stores (or going vegan), and that you can even leave the country and pursue better opportunities elsewhere. It’s a deplorable every-woman-for-herself mentality that takes hold of you 😢
But to mark this special Brexit date, I’ll make an exception and go back to being my normal, non indifferent self to reflect on the paradox that is at the heart of Brexit. One of the main reasons so many people were convinced to vote against the status quo was the National Health Service. They were told the millions of pounds sent to the EU could serve the NHS instead (let’s not even get into the details of why this argument is utterly fallacious). Remember Johnson’s big red Brexit bus that read, “We send the EU £350 million. Let’s fund our NHS instead”? It played a huge part in Brexit. Yet Brexit is likely to lead to further weakening and dismantling of the NHS. Let me explain why.
The NHS is Britain’s jewel but it’s not what it used to be
On the European continent, the UK is sometimes seen as this free-market every-man-to-himself island with less redistribution of wealth, reduced public services, and a safety net that pales in comparison to the rest of Europe. The French, for example, often put the UK in the same category as the US and tend to completely forget the UK invented the modern Welfare state. They forget the NHS is a uniquely centralised, ‘socialist’ health system in which doctors and nurses are civil servants and people have access to medical visits and most treatments, free of charge. Here in the UK, delivering a healthy baby will cost you nada. So will being treated for cancer.
After World War Two, when Clement Attlee’s Labour Party won a majority in Parliament against all odds (how could Churchill, the victor of WWII, possibly lose his majority?), Labour’s first majority government brought about a revolution. The dominant sentiment was “enough with wartime (and prewar) austerity”. Britons were ready for William Beveridge’s system of social insurance, a cradle-to-grave welfare state. They were ready for a better future in which healthcare is a human right.
And so the NHS became the country’s favourite jewel, and the world’s most democratic healthcare system. In July 1948, Minister of Health Aneurin Bevan launched the NHS, which had three core principles at its heart: it was meant to meet the needs of everyone, to be free at the point of delivery, and to be based on clinical need, rather than ability to pay. Nostalgia for post-war NHS can be seen in TV series like Call the Midwife, a BBC period drama series about a group of heroic NHS midwives working in the East End of London in the late 1950s and early 1960s.
Today the NHS is the UK’s biggest employer (and one of the largest employers globally): in England alone, it employs 1.5 million people! It is still essentially funded by general taxation and national insurance contributions (about 10% of GDP). Its cost has grown together with the needs of the population and inflation, even though for roughly 40 years, both Conservative and Labour governments have attempted to curtail NHS spendings.
Today the NHS is chronically undersourced: there are fewer doctors and nurses per patient than in other EU countries. According to a YouGov poll, 74% of the UK public is worried there are too few nurses. The NHS performs below average in preventing deaths from cancer and heart disease. And Brexit will aggravate the problem.
Britain’s health service will be up for grabs and healthcare will be more unevenly distributed
Britain’s health service used to be democratic and universal (“meet the needs of everyone, free at the point of delivery, and based on clinical need, not ability to pay”). Yet healthcare in the UK is becoming increasingly unequal, and Brexit will make it more and more so.
In the early 1970s non NHS healthcare was almost non existent. In 1976, it was 3% of total healthcare expenditure. But in order to “extend the choice of providers available to patients”, the Thatcher government offered tax relief to expand private medical insurance.
The UK private healthcare market is forecast to grow exponentially over the next few years. The Tories make no secret of their plan to expand it. In theory private healthcare can serve the public (and be paid for by the NHS). In reality, it undermines the whole system. As explained in this Guardian article, “the number of NHS patients having surgery in private hospitals has nearly trebled since 2010, sparking accusations that for-profit companies are benefitting from an ‘enfeebled’ health system under the Conservatives.”
After Brexit, the UK will turn to the US for a trade deal and it’s likely the NHS will be up for grabs. US pharmaceutical firms would love to be given freer access to the British market (drug bills could soar as a consequence). So would US healthcare giants. Blogger Umair Haque is adamant that “the price of Brexit is the NHS”: “the diminishment and eventual loss of the NHS is an inevitable consequence of Brexit. American capital has already demanded it as the first condition of trade. That demand isn’t going to change — it’s only going to harden and grow. British politicians can say noble things like “Our NHS isn’t for sale!!” — but the truth is that they will have no power, none, to keep that a reality.”
Umair Haque’s (invariably dark) explanation of why a trade deal with the US would necessarily jeopardise the NHS’s three core principles is that US healthcare companies need “total market access” to British healthcare because they’ve already “literally left the average American penniless. (...) America is a nation of paupers. American capital knows it has bled Americans dry. (...) it needs people who still have money to drive into poverty and bankruptcy.”
As private healthcare expands, it’s likely healthcare will become increasingly unequally distributed. And those who flee the NHS will no longer care for its fate, which will weaken its political support. Little by little, there will be on-demand personalised private healthcare for the rich and minimalist public healthcare for the poor.
The main issue: recruiting nurses and doctors
Most Leavers voted to stem the flow of migrations from the EU (and elsewhere), but this flow is what keeps the NHS afloat. Without EU workers, and workers from all around the world, the NHS would not have enough nurses and doctors to offer Britons proper healthcare. Like many UK businesses, the NHS is facing severe workforce shortages. As far as other businesses are concerned, one might think it could give UK workers more leverage to possibly ask for higher wages (low wages and poverty are understandable reasons for Britons’ anger), but the most likely outcome is more companies will be understaffed and Britons’ health will suffer from lack of nurses and doctors.
Even before Brexit there is a severe shortfall of staff in the NHS: “there were nearly 94,000 full-time equivalent advertised vacancies in hospital and community services alone between July and September 2018. This equates to an estimated shortfall of 8%. (...) The highest numbers of advertised vacancies are in ‘nursing and midwifery’—at nearly 40,000—and ‘administrative and clerical’ (20,000).”
Staffing pressures will increase severely with Brexit: falling numbers of nurses and increasing vacancy rates for clinical and non-clinical roles are to be expected. Some key hospitals in England depend on the EU for up to one in five staff (with even higher proportions of doctors and nurses). Waiting times could increase dramatically after Brexit.
Today 10% of doctors and 7% of nurses come from EU countries. (And almost as many come from India, the Philippines, or Africa). Since the 2010s the percentage of new workers from EU countries has been significantly higher. In social care, the percentage is even bigger: over 100,000 staff are EU nationals. But because a report from the migration advisory committee recommended no preferential treatment for EU citizens after Brexit, all future lower skilled workers (those needed in social care) may expect to have their visas cut.
As far as doctors and nurses are concerned, the UK is all the more dependent on EU talent as UK applications to study nursing are down because new fees were introduced that make becoming a nurse much more expensive. The country was quite happy to outsource the training of nurses (and doctors) to other EU countries! It meant it didn’t have to invest as much to train them.
In other words the regular flows of migrant workers from the EU (and the rest of the world) have made it possible for the UK government to invest less and less in nurse and doctor training. It’s also made it possible for the NHS to control wage inflation: had it not been for immigrants, wages would have had to be higher. As a result NHS jobs have progressively been made less attractive to UK workers. In places where real estate prices have soared (particularly London), wages have not kept up. (See my previous newsletter titled “Employability vs attractiveness: why companies complain they can’t recruit”). After Brexit, it will become increasingly hard to staff the NHS as UK citizens will likely be ever more reluctant to fill the gaps.
All in all, Brexit will accelerate a trend that started more than three decades ago: the NHS will continue to decline, and private alternatives will develop to serve the high end of the market. Like income, health and life expectancy will be more and more unevenly distributed. What’s really sad is how Britons were convinced to vote for Brexit with the argument that it would help improve the NHS. It adds an element of Greek tragedy to the whole story.
This week I’m proofreading the manuscript of the HR book I wrote with Welcome to the Jungle CEO Jérémy Clédat that’s to be published in March by Vuibert: Welcome to the Jungle. 100 idées innovantes pour recruter des talents et les faire grandir. An English version of the book will be published by Welcome to the Jungle shortly after.
New Welcome to the Jungle “must-read” article about Ben Horowitz’s new book, What You Do Is Who You Are: “Your culture is how your company makes decisions when you’re not there. (…) It’s how they behave when no one is looking. If you don’t methodically set your culture, then two-thirds of it will end up being accidental, and the rest will be a mistake.” This is already my 26th article about the “must-read” books on the future of work. (The article was also translated into French). Discover all the other “must-reads” here.
Content related to this week’s newsletter:
🗞️ “NHS reliance on EU staff in numbers – full scale of Brexit risk revealed”, Karen Bloor, The Conversation, October 2018.
🗞️ “Why the true price of Brexit will be the NHS”, Umair Haque, Medium, December 2019.
🗞️ “NHS winter crisis fears grow after thousands of EU staff quit”, Michael Savage, The Guardian, November 2019.
🗞️ “US wants access to NHS in post-Brexit deal, says Trump ally”, Jessica Elgot, The Guardian, June 2019.
🗞️ “Brexit: the implications for health and social care”, Jonathon Holmes, Beccy Baird, Helen McKenna, The King’s Fund, October 2019.
🎥 “Brexit: The Uncivil War”: a 2019 British TV film directed by Toby Haynes that centres on a key figure of the Brexit referendum campaign, Dominic Cummings, and how his use of the NHS as an argument for Brexit made all the difference.
📚 Middle England: Jonathan Coe’s 2018 novel is THE fiction book to understand why Brexit happened. It’s brilliant!
Miscellaneous:
🗞️ “My Time With the British Aristocracy”, K.A. Dilday, The Atlantic, January 2020: “What I found more distinct in the U.K. was the collective acquiescence—physical and psychological—to dominance by birthright". A fascinating account of her years in Britain by an African-American writer.
🗞️ “The case for ... making low-tech 'dumb' cities instead of 'smart' ones”, Amy Fleming, The Guardian, January 2020: this article makes the case for “dumb” cities vs. smart cities; there are many ancient technologies that should be embraced.
🗞️ “The Key to Lifelong Fitness is Inefficiency”, Emily Kingsley, Medium, January 2020: forget the gym, all you need to remain fit is to be a bit more inefficient in your everyday life.
🗞️ “The psychology of Silicon Valley”: Katy Cook, the author of an eponymous book, wrote Azeem Azhar’s January 19 Exponential View newsletter, and it made me want to buy her book (more about it in a future newsletter!).
🎙️ Exponential View Podcast: very interesting conversation with David Runciman. “We've already been living with artificial decision-making machines for hundreds of years -- we call them corporations and states.” (Runciman is professor of politics at Cambridge University and host of the “Talking Politics” podcast which I’ve already mentioned several times in my newsletters).
That’s all for now. I hope you have a good week! Please share this newsletter with your friends and colleagues 🙏