Why are so many doctors and scientists in favour of Remain?

No-one takes much notice of doctors, least of all politicians, but all the doctors MD has spoken to are in favour of the UK staying in the EU. Indeed, MD cannot trace one prominent national medical, research, or health organisation that has sided with Brexit. This is partly because of the un-evidence based fantasy bollocks of the Brexit camp and partly because, on balance, doctors and scientists overwhelmingly believe the UK is better off, healthier and safer in Europe.

The best guess of the net saving of withdrawing from Europe if there was no pursuant economic crash is £27 million a week. Even if every penny was spent on the NHS it wouldn’t even wipe out the current deficit. If there was an economic crash, it would wipe out any saving and make the NHS funding crisis even worse. The EU is not a prominent threat to the NHS as Article 168 clearly states that the organisation and delivery of health services is a national responsibility. A far greater threat to the NHS is the current UK government’s creeping privatisation and outsourcing of vital services, and a lurch to the right from Brexit is likely to accelerate this.

National health services are not included in the trans-Atlantic trade and investment partnership trade deal. (TTIP). The UK government has stated that it has no intention to broaden the scope of the deal to include the NHS at any point in the future, but a change of leadership and personnel in the Tory party post Brexit could well signal a change of intention and a new trade partnership with the US, with a ‘Privatise the World’ agenda that further opens up a £130 billion NHS market to American buyers.

Migration is more complex, and clearly puts strain on public services. However, EU migrants tend to be of working age, use the NHS less and pay taxes to fund it. The failures in NHS provision come from poor capacity and workforce planning, not because EU migrants aren’t paying taxes. Some even return home for healthcare because they can get quicker access to specialists than in the UK. There are 135,000 non-British European citizens working in the NHS and social care, about 10 per cent of the total, at all levels of the service from consultants to carers. There are also widespread staff vacancies at every level, and a current shortage of 50,000 staff in the NHS alone. How many would be able to stay or take up jobs post Brexit is unclear, as is how many of the 2 million British people living in other EU countries – including about 650,000 British pensioners – who would return home particularly for health reasons, as they lose eligibility for EU citizen health services.

As for the impact on research, Brexit would sacrifice our right to participate in the European Medicines Agency. We would have to pay to keep access to the centralised authorisation system, but have no influence on policy. The National Institute for Health and Care Excellence (NICE) would lose its vital European health technology assessments. To date, the UK has been the most successful country at winning competitively awarded EU funding for research and development in life sciences. After Brexit, the UK would have to pay to keep access to funding but have no influence in setting priorities in research and development.

As for the wider implications, a sense of belonging and connection is fundamental to mental health. Many NHS staff want to feel part of a Europe where compassionate collaboration triumphs over profiteering and virulent nationalism. Some people will do very nicely out of Brexit, and their health may even improve because of it, but it won’t be the people who depend most on the health and social care system, or those who work in it.

To believe that the UK can be a gated community, immune to consequences of millions of displaced citizens and a resurgence in right wing nationalism in Poland, Hungary, Austria, and beyond is fantasy. The refugee crisis has created a public health disaster, as has civil unrest and war in Ukraine, with a resurgence in multidrug resistant tuberculosis. Clearly the EU can be a wasteful, bureaucratic nightmare and needs continuous improvement. But denial and refusal to engage in Europe-wide solutions to such urgent and dangerous problems will not keep the UK secure or healthy for long.

References:

Policy briefing report jointly published by the Institute of Global Health Innovation and the LSE Health. The original briefing report is available here.

Why doctors should vote to remain in the EU on 23 June: BMJ 2016; 353 doi: http://dx.doi.org/10.1136/bmj.i3302 (Published 14 June 2016) Cite this as: BMJ 2016;353:i3302

The Brexit debate. www.bmj.com/brexit

80k workers in social care (Source: Skills for Care, September 2015: https://www.nmds-sc-online.org.uk/reportengine/GuestDashboard.aspx?type=Nationality

55k workers in NHS (Source: Health and Social Care Information Centre, September 2015: http://www.hscic.gov.uk/media/20194/All-staff-by-staff-group-nationality-and-HEE-region—full-time-equivalents-and-headcount—Sep-2015/xls/Staff_groups_by_nationality_and_HEE_region_FTE_and_HC_-_Sep_2015_-_Final.xlsx)

“Academics across Europe join ‘Brexit’ debate” Nature 530, 15, 2016 http://www.nature.com/news/academics-across-europe-join-brexit-debate-1.19282

“The EU: what’s best for UK cancer research and patients?” Lancet Oncology Volume 17, No. 5, p556–557 http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(16)30063-8/abstract

“If Mark Carney is right, then that is a severe concern for the National Health Service, because it would be very dangerous if at precisely the moment the NHS is going to need extra funding, actually the economy goes into a tailspin and that funding is not there.” Simon Stevens, CEO of NHS England http://www.bbc.co.uk/news/uk-politics-eu-referendum-36353145

“HM Treasury analysis: the immediate economic impact of leaving the EU” https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/524967/hm_treasury_analysis_the_immediate_economic_impact_of_leaving_the_eu_web.pdf

Governor of the Bank gave evident to the Treasury Select Committee that leaving the EU carried the risk of a “technical recession” http://www.independent.co.uk/pugpig/7026821

Letter from 200 health professionals to The Times April 4, 2016 http://www.thetimes.co.uk/article/the-benefits-to-the-nhs-of-staying-in-the-eu-dnjnp8b82

“Paediatric research and the Brexit debate” Letter from six doctors at Great Ormond Street to The Times June 11, 2016 http://www.thetimes.co.uk/past-six-days/2016-06-11/comment/paediatric-research-and-the-brexit-debate-njtgztr6k

“EU boost to science” Letter from 150 members of the Royal Society to The Times, March 9, 2016 http://www.thetimes.co.uk/tto/opinion/letters/article4709281.ece

Torjesen I. EU exit would have a detrimental effect on the NHS, academics warn. BMJ2016;353:i2953.http://www.bmj.com/content/353/bmj.i2953?trendmd-shared=0doi:10.1136/bmj.i2953 pmid:27220718.

EU members. UK cannot be an island in science. Guardian 2016 Feb 27. http://www.theguardian.com/politics/2016/feb/27/eu-membership-uk-cannot-be-an-island-in-science

Wessely S. Why health of NHS will be at risk if UK leaves EU. Yorkshire Post 2016 Apr 8. http://www.yorkshirepost.co.uk/news/opinion/professor-simon-wessely-why-health-of-nhs-will-be-at-risk-if-britain-leaves-eu-1-7840583

Wollaston S. Brexit should come with a health warning for the NHS, public health, and research. BMJ2016;353:i3295.

A response to the RCP’s ‘call for views’ on the EU referendum, 2 Jun 2016. https://www.rcplondon.ac.uk/news/response-rcps-call-views-eu-referendum

Why should we Vote Leave on 23 June? http://d3n8a8pro7vhmx.cloudfront.net/themes/55fd82d8ebad646cec000001/attachments/original/1463496002/Why_Vote_Leave.pdf?1463496002

Dilnot A. Letter to Dominic Cummings, 27 May 2016. https://www.statisticsauthority.gov.uk/wp-content/uploads/2016/05/Letter-from-Sir-Andrew-Dilnot-to-Dominic-Cummings.pdf

Institute for Fiscal Studies. Brexit and the UK’s public finances. 2016. www.ifs.org.uk/publications/8296.

House of Commons Treasury Select Committee. The economic and financial costs and benefits of the UK’s EU membership. 2016. http://www.publications.parliament.uk/pa/cm201617/cmselect/cmtreasy/122/122.pdf

Centre for Economic Performance. Brexit and the impact of immigration and the UK. 2016. http://cep.lse.ac.uk/pubs/download/brexit05.pdf

National Institute for Economic and Social Research. Impact of migration on the consumption of education and children’s services and the consumption of health services, social care and social services. 2011. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/257236/impact-of-migration.pdf

Mason R. John Major: NHS at risk from Brexit pythons Johnson and Gove. Guardian 2016 Jun 5. http://www.theguardian.com/politics/2016/jun/05/john-major-nhs-risk-brexit-pythons-johnson-and-gove

Economist Intelligence Unit. Healthcare markets in Europe: what would be the impact of Brexit? 2016. http://www.eiu.com/public/topical_report.aspx?campaignid=BrexitHealth

Dearden L. “A dark day for Europe”: EU reaches agreement to send refugees back to Turkey despite legal concerns. Independent 2016 Mar 18. http://www.independent.co.uk/news/world/europe/eu-turkey-refugee-deal-what-is-it-erdogan-a6939156.html.

Who wants to be leader?

Whatever the result of junior doctors’ July ballot on their proposed new contract, they will continue work shifts and hours that wouldn’t be tolerated in any other safety critical industry. The central issue was always that we don’t have enough junior doctors to staff the NHS safely, but then we don’t have enough at any level. NHS Employers produced a tactless report with the Nuffield Trust last week, inviting senior nurses and others to ‘fill in the gaps in the medical workforce’. Quite where theses senior ‘medical infill’ nurses would come from is unclear. From September 2009 to January 2016, the NHS dispensed with 2,293 nurse consultants and matrons.

On June 8, High Court action by the junior doctor group Justice for Health was due to start to determine whether health secretary Jeremy Hunt can legally impose the latest version of the new contract, as he has repeatedly threatened, if junior doctors and medical students vote to reject it. This has now been postponed until after the junior doctors ballot result is announced on July 6. Any contract is only as safe as the staff available to work it, and we’ll find out in August how many rota gaps need to be filled by imaginary nurses. Junior doctor campaigners have at least been given a good taste of how NHS politics work, how unpleasant, inaccurate and unaccountable the top of their organisation can be, and whether they want to be part of it.

Many NHS chief executives are pondering precisely those questions. One described the current state of the NHS in England as ‘the last days of the Roman empire. NHS England and the army of regulators brutally demand accountability, compliance with targets and ever more savings, and yet are completely unaccountable themselves. Try complaining about them and they make your life even worse. As for all Vanguard sites and all those bloody stupid new models of care they keep imagining, it would be far quicker to just burn the money At least with Jeremy Hunt, you can vote him out.’

The King’s Fund recently produced a report based on interviews with NHS CEOs at or near the end of their careers. It is not pretty reading. The mean tenure of an NHS CEO is less than three years, and the job is so unpalatable that many posts are either vacant or filled by interims. This lack of interest in being an NHS leader means that some truly shocking and incompetent CEOs are still in post, as well as some truly outstanding ones who have somehow managed to survive. Despite Hunt’s claims to the contrary, the NHS is going through by far the longest period of restrained growth in its history. Since 2010, allowing for population growth, spending has risen by 0.1% per annum and is likely to be stuck there until 2021. In 2009, we spent 8.8% of our GDP on health, now we spend 6.3%, and you get what you pay for. Social care services have collapsed, and there is still huge variability in access to, and quality of, NHS services. Try finding emergency dental or mental health care.

All this would be bad enough were in not for the Health and Social Care Act on top of the austerity. As the King’s Fund report observed; ‘There was barely a good word said for the 2013 reorganisation of health and social care…. The changes were ‘disastrous’ and ‘catastrophic’. Tim Smart, former chief executive of King’s College Hospital NHS Foundation Trust declared; ‘I think the system was broken by the Health and Social Care Act. And that’s a real shame.’

When MD first met Jeremy Hunt on January 8, 2013, he said ‘When I look under the bonnet of Lansley’s reforms, I’m pretty impressed with what I see.’ Hunt is now the longest serving health secretary in the history of the NHS, and yet not nearly enough good leaders want to work under him, in a chaotic competitive market where no-one understands how the system works, no one is overall charge and too many organizations are concerned with their own survival, rather than the survival of patients. For thirty years, the NHS has been run like a business and failed spectacularly. In the NHS, the more business you attract, the more likely you are to go bankrupt because there is no money to pay for it. And yet you aren’t allowed to close for business, and the regulators and commissioners can punish you for treating too many patients, especially the sick ones. Time to admit commissioning has failed and ditch the market. That alone would attract good clinical leaders to stay in the NHS.

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It’s the Capacity, Stupid

It’s painfully clear to anyone works in or needs the NHS or social care services that we don’t have the capacity – equipment, technology, beds, staff – to cope with the demands placed on us. This is down both to lack of investment – the UK spends less of its GDP on health and social care than other Western European countries –, an ageing and expanding population, and massive waste, particularly on political reorganisations and reforms that are not evidence-led, cost a vast amount in time, money, effort and goodwill – and end up making little or no difference to the length or quality of people’s lives, and may even cause harm.

90% of consultations in the NHS occur in general practice, for a fraction of the funding. If general practice fails, the NHS fails. The belated bung now promised for GPs – £2.4 billion extra a year by 2020-21 – is not new money and may not stop the service collapsing. Sadly, much of it is likely to be wasted on non-evidence based political vanity projects such as opening surgeries for 12 hours on a Sunday when no one wants to be there, useless well person checks which only serve to make well people anxious, and ill thought out screening that doesn’t have a proper evidence base and hasn’t been approved by the National Screening Committee. Money will be thrown at faddish technological fancies that haven’t been properly evaluated, all GPs will be ‘accelerated towards a paper free environment’ and if there’s any money left over, it might be used to treat people who are genuinely ill. It might also be too late.

Research from the King’s Fund has found that the number of GP consultations has increased by 15% in 5 years, three times the rate of increase in the number of GPs. Consultations among the over-85’s were up 28% and many were too complex to be completed in ten minutes. The job is so stressful that five years after qualifying, only 1 in 10 new GP trainees plan to be working full time. Between 2009 and 2014, 46 per cent of GPs leaving the profession were under 50; between 2005 and 2014 the proportion of GPs aged between 55 and 64 leaving doubled. In addition to the stress of seeing more complex, demanding patients, GPs also have to cope with an absurd administrative burden. As well as individual appraisals and revalidations with the GMC, GP practices have to be inspected by the CQC which – driven by the fear of missing the next Harold Shipman – impose a hugely bureaucratic and stressful inspection procedure with little evidence base that it improves the quality of care.

Ruling the NHS by fear and bullying is a highly corrosive error that all governments make. Under Labour, access targets were brutally imposed and fear of failure was so great that figures were fiddled and patients were ignored, most notably in Mid Staffs hospital. Hospital inspections and targets are not in themselves a bad thing – inspections could focus on learning and development, targets could help provide quicker care for many patients but allow enough leeway to prioritise sicker patients at busier times. And yet both tend to be inflexibly enforced with no evidence or empathy

Nearly Four years ago, MD referred Dame Barbara Hakin – National Director of Commissioning Operations at NHS England – to the GMC for unilaterally raising the 4 hour casualty waiting time target from 98% to 100%, and insisting that it had to be met ‘whatever the demand’. In Hakin’s fantasy world, every single patient who turns up to an emergency department must be seen, treated, admitted or discharged within 4 hours no matter how busy it is. That the GMC is still considering whether this impossible imposition was unsafe suggests either a very limited understanding of patient safety or a chance for the second most senior doctor in the NHS to retire safely before reaching a decision. The fact that record numbers of hospitals are now missing a reduced 95% target shows what an unworkable demand it was. There will always be patients who can’t be seen within four hours when an emergency department lacks the capacity to deal with the demand, and there will always be patients who need to be kept longer than 4 hours because it is not safe to transfer or discharge them. Brutal imposition of such non-evidence based nonsense costs money, lives and careers in the NHS. Jeremy Hunt risks repeating the error by imposing an untested junior doctors’ contract without evidence he has enough doctors to cover extra shifts across seven days. Whatever way the vote goes on the junior doctors’ contract, many will continue to work dangerous hours and shifts come August, and there aren’t enough consultants to safely extend seven day services either. Does Hunt have the capacity to understand capacity? Or is he wilfully blind?

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