The impact of Brexit on Health in Northern Ireland…

Mr Jacob Rees-Mogg was on Nick Ferrari’s LBC show on Monday 2 September; he was taking phone calls. Dr David Nicholl, a consultant neurologist, called to ask what mortality rates could be expected in the event of a no-deal Brexit. Dr Nicholl wrote the relevant mitigation part in the
Operation Yellowhammer document.

Rees-Mogg has been characterised in the past as having quite exquisite politeness, extreme almost to farce. He wasn’t at all polite to the caller, saying that this was the worst excess of “Project Fear”, and was surprised that a doctor would be fear mongering in that way. Rest-Mogg indicated that Dr Nicholl’s mitigation plans weren’t very good, and that it was fortunate that they were being now written by people who are serious, rather than “Remoaners”. He thought it deeply irresponsible of Dr Nicholl to try to spread fear across the country. He thought Dr Nicholl should be “quite ashamed”. There is a video of the conversation, with sub-titles,
here.

Unsurprisingly, Dr Nicholl wasn’t happy about this, and responded daring Rees-Mogg to refer him to the General Medical Council. The Guardian has a report on this, and the exchange,
here.

Are there really causes for such concern around health issues in a no-deal Brexit?

The British Medical Journal published an article on Assessing the health effects of a “no deal” Brexit on 29 August. It’s an overview of the situation; it’s sober, but not technical and is easy to read. As is typical of medical articles, it is much more ‘information dense’ than you might be used to.  It’s available
here. The key messages from the authors are:

• Leaving the EU without a deal threatens health and the NHS in many ways, but the scale of the threat remains unclear
• We propose a framework that could be the basis for the comprehensive health impact assessment to inform politicians and the public
• The government’s claims that it is prepared for no deal are implausible and, at best, might mitigate some of the worst consequences

They then suggest the areas and mechanisms that need to be considered in such an assessment. There will be a loss of finance, of people, of European access etc. They illustrate this with a conceptual framework which shows existing and new problems:

Larger version of infographic here…

Don’t get too hung up on the complexity of the diagram; just observe how much is included, how many areas have to be considered in a health impact; this very obviously is not a simple back-of-a-fag-packet exercise.

The diagram doesn’t include a third dimension, the geography. The authors are quite clear that the effects of Brexit will be most obvious between GB and N Ireland.

They expand on the new problems, and again in the ‘law and order’ paragraph they are clear about the threats of civil unrest here, and the need for ‘direct rule’.

They discuss some of the government’s contingency plans; these include the medicines Dr Nicholl referred to, above. The emphasise that the government has instructed Health Trusts not to release assessments to the public; that much of the planning is secret, and that non-disclosure agreements have been imposed. I find this lack of transparency, this enforced secrecy, very troubling; it suggests a government which is not ‘on top’ of all the problems, which recognises just how damaging a no-deal Brexit will be, and is frightened of scaring the population. That wasn’t quite what Rees-Mogg was saying.

There are two Linked Opinion pieces, both by Prof Martin McKee from the London School of Hygiene and Tropical Health. The first is about
Operation Yellowhammer, the leaked “secret” document about the effects of a no-deal Brexit. McKee concentrates on the supply of medicines.

The document is reported to predict significant disruption of medicines lasting up to six months, with HGVs facing a delay of up to 1.5 to 2.5 days at the border. This seems entirely plausible…

Medicines have several characteristics that make them especially vulnerable to supply chain threats. These can be fatal, something that is observed every day in many low income countries where procurement, transport, and supply problems allow sub-standard medicines to reach the market, for example because of breaks in cold chains. They also encourage the activities of organised crime syndicates, diverting genuine medicines to the black market or introducing counterfeits…

The fundamental problem with medicines is that, in an increasing number of cases, one cannot be substituted for another. The pharmacogenomics revolution has seen a transformation of cancer care. The first drugs, some derived from chemical weapons, were based on a scorched earth approach. Now they are targeted to individual molecules that can vary widely within what appears to be the same type of cancer meaning the wrong drug is useless. In some cases, even a small change in formulation can have serious effects, as with epilepsy. David Nicholl, a neurologist who was shown Brexit planning documents, was so alarmed that he felt obliged to speak out. His concerns have not been assuaged.

If that wasn’t bad enough, his second opinion piece is
Healthcare has brought people together across the Irish border—now Brexit threatens what has been achieved. 
McKee was educated at Inst, Queen’s and trained in the City Hospital. He describes the history of the border, the Good Friday Agreement, and the effects of Brexit. His opinion is very worthwhile reading in full.

The Co-operation and Working Together programme, largely funded by the European Union, promoted numerous cross-border care initiatives. However, the money came not from the EU’s health programme (reflecting the Treaty provisions that health services are a matter for member states) but from its peace and reconciliation budget. Health services were seen as a way of bringing people together, with the added benefit of making it much easier for many people to obtain care in a sparsely populated rural area, where the nearest facility was across the border.

He spells out what the freedom of movement of people, of goods, and of  services (including data) means locally:

While people were always able to cross the border, thanks to the common travel area, the Treaty provisions on free movement of people allowed them to live in one jurisdiction and work in another, to accumulate pension entitlements, and to obtain healthcare. Free movement of services allowed an ambulance in one jurisdiction to transport a patient in another, while free movement of goods allowed it to carry morphine without falling foul of international law on trafficking narcotics and to administer a transfusion, without infringing rules on moving blood products, imposed by other countries in large part because of the UK’s role in the BSE affair. Treaty provisions on services also enabled the transfer of data, which underpins many aspects of cross border care.

An early suggestion was for NI to remain in both the Single Market and the Customs Union; the DUP could not accept a ‘hard border’ between NI and GB. But:

Contrary to what is often alleged, it is simply impossible to have two territories, one inside either the Single Market and Customs Union, and the other outside it, and not have border infrastructure. This is for many reasons, and not as is sometimes suggested only for tariffs. Other checks include product regulation, VAT, and phytosanitary protection. Again, contrary to what is often alleged, there is no example of such a border without infrastructure anywhere in the world. Also, and for completeness, again contrary to what the DUP and others often allege, such an internal border would not be a precedent. There are many, including between EU and other states, for example in an Italian and a German enclave in Switzerland, the island of Heligoland. The “alternative arrangements” suggested by some as a means to avoid a hard border in Ireland are an archetypal example of what have been described as Brexit unicorns, or fantasies that don’t exist anywhere.

Those who understand the recent history of Ireland are virtually unanimous in believing that the inevitable border checks with a no-deal Brexit are incompatible with the Good Friday Agreement. Even if British politicians say they will not build border infrastructure, this is incompatible with their obligations under international law.

Finally:

Any prediction about Brexit now risks becoming out of date within minutes, but what is clear is that anything that creates a hard border on the island of Ireland, and that includes any Brexit that takes Northern Ireland out of the Single Market and Customs Union, is a threat to health.

What we can say is that, first, and most immediately, it will reduce access to healthcare for those living along the Irish border. Second, it will affect those on the island of Ireland who depend on specialised care, including paediatric cardiac surgery, provided as an all-Ireland service. Third, any upsurge in violence will almost inevitably cost more lives, with a recent bomb attack near the border highlighting the reality of the threat. But that is only the start. A no deal Brexit presents an enormous and possibly existential threat to Northern Ireland’s important agri-food sector. In a province with few other employment opportunities, it will be difficult to give a sense of hope to those affected, with potentially
tragic consequences.

The ’tragic consequences’ are suicides in farmers.

Meanwhile, the Prime Minister continues to insist that the UK will leave the EU on 31 October, ‘no ifs, no buts’, and with or without a deal. Any Brexit will harm the health of all of us in Ireland, north and south; a no-deal Brexit will be a disaster.

Photo by Kevin Grieve is licensed under CC0