Welcome to the ‘About that bus…?’ weekly newsletter – giving you the inside track on how the fallout from Brexit is affecting the NHS at national and local level, edited by James Illman. Contact me in confidence.

The NHS must ignore the political mayhem and remain geared up for a no-deal Brexit. But here’s our bitesize guide to what Boris Johnson’s proposals would mean for the NHS if he can get them through parliament, by James Illman.

The Brexit process was thrown into fresh chaos last week after the government’s attempts to bulldoze its deal through parliament were thwarted.

As this briefing was written on Friday, MPs were scheduled to vote today on the government’s demand for an election on 12 December and the EU was deciding if they would sanction an extension to the 31 October deadline.

If the UK is to leave the EU without any further significant twists (yes, I know), it will therefore do so either with no deal, or with the deal agreed by Boris Johnson.

NHS England chief executive Simon Stevens has long told local leaders to ignore the politics as much as possible, and simply focus on ensuring they are prepared for a no-deal Brexit. And that remains the advice.

But, as first reported by HSJ, if the government does get the Withdrawal Agreement relatively unammended through parliament, experts have warned the deal would expose the service to more risk than Theresa May’s original agreement.

Before delving into why this is the case, it is worth noting two things. Firstly, many NHS leaders viewed the May deal as doing a good job of shielding the NHS from the risk of being unable to import its medical and non-medical supplies.

A second point of note is that even if the government can get the deal over the line, the UK would not have fully Brexit-ed, but would first go into a “transition period” during which the UK would remain fully aligned to EU laws  This is due to run until December 2020, but a one or two-year extension is possible if the UK and EU are unable to agree a trade treaty and a whole host of other issues on which the deal agrees the direction of travel but not the finer details.

The impact of the new PM’s deal can be split into four broad categories: economic; trade and continuity of NHS supplies; workforce; and continued uncertainty and the threat of a future no-deal Brexit cliff-edge.

Economic impact

The government has not published an economic impact assessment of the deal, a move roundly criticised by sensible people. 

The most credible study on the matter has been carried out by The UK in a Changing Europe research group. It forecasts the public finances would be worse off by between £19 and £49bn per year under the Johnson deal as opposed to between £13bn and £39bn under the May deal. 

This would leave far less fiscal headroom to address areas like social care reform. The potential knock-on effects of any economic downturn on other areas of public spending like education, housing and the welfare system would also negatively influence demand for NHS services

Impact on trade and continuity of supply of medicines

One of the NHS’s biggest areas of concern about Brexit is the continuity of supply of medicines, clinical and non-clinical goods.

Brexiteers were vehemently opposed to the Northern Ireland backstop in the May deal because it would have tied the UK into the EU customs union and take away the UK’s chance of striking new trade deals. But for the NHS it was an insurance policy which would have ensured continuity of supply. This isn’t the case with the so-called front-stop arrangement within the Johnson agreeement, which involves a customs border down the Irish Sea (See explainer in this article). 

The Nuffield Trust’s Brexit expert Mark Dayan told me this week: “The [front-stop] seems to set a course for more trade friction than the old backstop. Under the new ‘front-stop’ arrangement, there is no all-UK customs union with the EU.”

This verdict was supported by the UK in a Changing Europe’s modelling. It forecast barriers to trade would rise by 3 per cent under the Johnson deal. They would increase by 8 per cent under a no deal scenario.

There are also concerns that being out of the European single market could push up the costs of importing medicines. The Nuffield Trust estimated this could mean extra costs of around £400m a year for the NHS. Again, it should be stressed that this is better than a no-deal Brexit, for which the Trust estimated extra costs of around £2.3bn annually.


The impact on the NHS and the social care workforce is one of the biggest risks posed by Brexit. The King’s Fund estimates there are 116,000 EU nationals working in the NHS, and around 104,000 in social care.

The Withdrawal Agreement secures the rights of EU citizens in the UK, but the government has been clear Freedom of Movement will stop after Brexit. The workforce issue is not necessarily one which will explode on the first day after Brexit, but it could build quite quickly.

Senior NHS figures have expressed concerns to me over the last few months that some EU workers, especially low-paid carers, may go back to their country of origin over Christmas and then not return to the UK.

Continued uncertainty and cliff edges

As mentioned earlier, if the UK does leave the EU under an unammended Johnson deal, we will enter a transition period which could last years. This means the no-deal Brexit cliff edge still looms in the future if a trade deal cannot be agreed before the end of the transition period.

Three years sounds like a long time, but some major international trade deals have taken up to a decade to complete, so it is far from guaranteed a deal will get done.

NHS remains braced for no-deal

The NHS has been gearing up for a no-deal Brexit for about a year now. The previous March deadline conveniently served as a good dress rehearsal.

The NHS is far better prepared now then it was then. This conclusion is backed by the National Audit Office, and various impartial think-tanks, albeit with the huge caveat that you cannot fully prepare for events don’t know about, and Brexit will likely throw many of them at the health service.

But remaining on high alert comes at great cost to the NHS in terms of hard to quantify staff hours and focus. It is also affecting the pharmaceutical industry, which will eventually pass the costs it is incurring onto its customers.

The last About that bus…? explored the concerns that the NHS is already suffering from a heavy bout of Brexit fatigue. The NHS Confederation’s latest Brexit Thermometer Check found the NHS was “generally well-prepared”, but it identified seven key areas of concern for local leaders preparing for a no-deal Brexit, from continuity of medical supplies to transport problems. The lobby group’s head of international relations Layla McCay analyses the results further in an exclusive HSJ piece here.

This week’s further essential Brexit listening and reading: