The Romans had a word, decimation. Decimation meant that if a Legion rebelled, one in ten soldiers, regardless of guilt or innocence, would be taken out at random and put to the sword. I am a GP and by chance one in ten of my medical colleagues in the NHS are nationals of other EU countries. Hold that thought, I will come back to it.
Let me now tell you a story of Eva, not her real name. Eva is a ward sister who comes from an Eastern European country. She had been living and working in the UK for the past 20 years, was in fact educated here. She had been in a post of responsibility where her contract was renewed every five years until last year. She was then told this was no longer possible. She was still needed but because of uncertainty about the future she could be offered only a three month contract. Just imagine how she felt. Just imagine what would have happened if she had to apply for a mortgage. Do you think she will choose to stay on in the country after that? Multiply that story by many thousands, or indeed millions, and you may begin to understand what is going on.
I’ve been working in an NHS, which I’m convinced is potentially the best healthcare system in the world.
I spent most of my working life practicing in Cowley, in the largest practice in Oxford with a population drawn from no fewer than 173 countries. I’ve been working in an NHS, which I’m convinced is potentially the best healthcare system in the world. However the NHS is currently facing a perfect storm of problems. We are in a society with an ageing population, life expectancy is now over 80 and so far has been rising five years every generation. The corollary is that the proportion of UK born people of working age is falling. This means there are more and more people who rely on medical and social care. Both the NHS and social care are coping with the problems of austerity and in many areas are being forced to make major savings.
Simultaneously there are huge workforce problems in medicine, nursing and other caring professions. If your patients believe migrants are causing problems by joining the queue in front of them, just wait till the migrants who are serving them decide to go home, and 50% of our EU medical colleagues in the NHS have declared their intention to do just that. This is a time when the GP workforce has fallen by about 5% over two years, and when 40% of GPs are considering retirement in the next 5 years. There has already been a 94% drop in applications for UK nursing places from other EU countries. As we speak people from many health trusts in this country are running around the world looking for staff to replace the Europeans who are leaving, which of course has the added effect of depleting many developing countries of their precious medical and nursing staff.
Catastrophic as the effects of austerity and workforce depletion are on the NHS, they are only a part of the problem.
Think about European Medicines Agency, whose departure from London to Amsterdam is already a done deal because of Brexit. This is costing 900 jobs, but that is the tip of the iceberg, because the work done by the agency will have to be replaced within the UK, a long and tedious bureaucratic process which means that new drugs will take prospectively two years longer to reach the patients who need them, and British research on new drugs will wither on the vine.
Think about Euratom, which is not part of the EU but which the government has decided to leave because it wishes to exclude the European Court of Justice from any role in UK affairs (it has however conceded such a role in regard to citizens’ rights). Without Euratom we will struggle to get hold of many products necessary for diagnosis and treatment. On top of which of course there are major issues of nuclear safety.
Think about the opportunity costs, at a time when there is so much work for Parliament, the civil service, and indeed the judiciary to do in regard to important areas such as health, social care, security and defence, but so much of their time is now being taken up with delivering a so-called good Brexit, as if such a thing were possible.
Think of the implications for this country of losing trade with all our nearest neighbours, and having to replace it. Who can we rely on to fill the gap? Will we suddenly find ourselves at the mercy of an isolationist American government whose recent unthinking imposition of sanctions speaks for itself? In relation to the NHS, what is to stop the farming out of lucrative parts of healthcare to predatory and opportunistic multinationals whose object in life is to deliver on the American model? Is that really what we want?
The Government’s own impact assessments are damning, and all reputable economists agree.
But surely, some will say, it is a done deal, surely the Leavers won and to oppose them is to act against Democracy? Let me say two phrases that are key in our lives as doctors. Firstly evidence-based decision-making, and secondly informed consent. Both are sadly conspicuous by their absence in the whole process leading up to this chaotic and ill planned exit from the European union. We hear politicians speaking as if evidence did not matter. Believe me, it does.
The Government’s own impact assessments are damning, and all reputable economists agree – even Patrick Minford, the darling of the Leave campaign, admits Brexit will lead to the extinction of UK manufacturing industry, though he says that would be no bad thing. And there is no informed consent for Brexit and no consent of any kind for a hard Brexit, ie leaving the Single Market and European Customs Union. Much less for a no-deal Brexit. We all know that consent must be informed to be valid.
Add to that the fact that there are 48 million people in this country who did not vote for Brexit, including many of the major stakeholders, some 2 million plus of whom were EU27 citizens and UK taxpayers who were denied the right to vote. Add also what we now know about illegal activity on the leave side. Add the fact that in a democracy it is not acceptable for one citizen to vote to take away arbitrarily the civil rights of another (ie the right to European Citizenship). How can anybody argue in such circumstances that the outcome of an advisory referendum is ethically or legally binding on the Government? Conversely if the Government chooses to push ahead in the face of all the evidence, it cannot blame the ‘Will of the People’, rather it must bear the responsibility for the consequences.
It is hard to believe now that the referendum is almost 2½ years ago. It is astounding both to think how much has changed in the world in the meantime, and how little has been achieved in negotiations. At the very least we now know how difficult these negotiations are when it is one against 27. I do not want to re-fight the referendum. You may have voted remain or you may have voted leave. If you voted remain, in common with over 70% of doctors, you have a right to feel angry that you were not listened to. Indeed whenever Mrs May says “the people have spoken” she is talking as if you did not exist. What right has she to do that? You may be tempted to say, with some of our politicians, “I was a remainer”. Please do not. If you vote Labour and the Tories win, or vice versa, it does not mean you suddenly change your political allegiance and have to do all you can to help the party in power to implement its policies. Say “I am a remainer” and be proud of it.
Or you may have been one of those who voted leave. If so you have a right to feel angry because the Government is not delivering on what you thought you were voting for, control of borders. Speaking as an Irish person I can say this with feeling. The government has repeatedly promised control of borders, as if that were inherently a good thing. Yet it has simultaneously promised, and agreed in subsequent negotiations from the phase 1 deal in December onwards, that there would be an open border in Ireland, i.e. free movement of people, goods and services between North and South.
Simultaneously the political arithmetic is that a border in the Irish Sea is impossible, given that the DUP now holds the balance of power. Therefore, I do not just argue that the kind of Brexit Mrs May is promising is undesirable – that speaks for itself. I argue that it is impossible. All the profound economic and social sacrifices we are facing will prove to be in vain because they will fail to achieve their primary objective, which is to create barriers to migration.
The Irish border issue – something which was not even considered by either side in the run up to the referendum – is insoluble without breaking one or more solemn promises given by the Government. The solutions put forward at Chequers will not be accepted either by the EU27 heads of Government or by the UK parliament, and have the support of under 20% of the electorate (so much for ‘the Will of the People’). There is no workable plan B. And sadly, despite the positive mutterings currently emerging, the forthcoming EU summit will change none of that.
You may simply be fed up with the whole thing, you might want to bury your head in the sand and hope it will go away (it won’t). Or you may be worried about being too ‘political’. All I can say to you is that to do nothing is a political act, because it implies acquiescence. And time is running out.
Do we really have to resign ourselves to the decimation of the NHS?
So, to finish, is it a done deal? How can it be when, with 5 months to go, we know so little about what is ahead? Do you ever put down a deposit on a house and commit to going ahead with the sale regardless of what unpleasant things come to light in the survey? No, of course not. Is the best we can do really just an exercise in damage limitation? Can we not recognise that much of the prosperity and success of our society over the past 40 years has been as part of the world’s largest trading bloc, and we would throw this out as our peril?
To come back to where I started, do we really have to resign ourselves to the decimation of the NHS? Can we do better than that? Yes we can. We can come out of the closet, say the survey is disastrous, and put it back to the people, with an option to remain in the EU. A Vote on the Deal now has majority support in survey after survey. It has the full support of the BMA among many others. Let us have one.
[Footnote: There was a march in London to support a People’s Vote on 20 October 2018, see: https://www.peoples-vote.uk/march]
Born in Dublin, graduate of UCD. Currently portfolio GP in Oxford. MRCGP CSA assessor. GP Appraiser. Honorary Senior Clinical Lecturer in primary medical care at Oxford university. Formerly partner at St. Bartholomew’s Medical Centre, Oxford. Interests in communication skills teaching, ENT, child health, and staying in the European Union
Declarations of interest: I am on committee of South East Oxfordshire Liberal Democrats, Oxford for Europe, European Movement (Oxford Branch)