We need to talk about Brexit

Nick Goldstein is a service user

The implications of this political turmoil are dangerous for service users says Nick Goldstein. Read the full article in DDN magazine.

Ha! Brexit!! I can imagine eyes rolling out there, but bear with me – I promise to avoid commenting on Brexit itself or the ideology and tribal politics that propel it.

This article will just be a gentle ramble through some of the plausible short- and long-term implications of Brexit on substance misuse.

I’m afraid there will much supposition, conjecture and flat-out guess work because when it comes to Brexit there are very few definites and a mountain of intangibles. This is certainly the cause of much political uncertainty, but the coup de grace is an uninterested silence from the state, political parties, NGOs, charities and, more forgivably, from drug users themselves. More on this silence and its meaning later.

There are significant implications for substance misuse and substance misuse treatment that come from the wide variety of Brexits still possible. These range from our potentially leaving Europol with its knock-on effect on policing influencing how much and even what drugs are available, to our potentially leaving the EMCDDA – an agency that provides key data used by policy makers, which would obviously have a knock-on effect on any future politico-legal change.

Of rather more concern would be the loss of the European Convention on Human Rights and access to the European Court of Human Rights in Strasbourg. These rights (ironically put together mainly by David Maxwell Fyfe at Churchill’s behest and based on English law) are limited but offer invaluable protection to many vulnerable groups – including drug users.

One example of their worth is that they were used successfully as the legal basis of a case brought by prisoners to ensure maintenance treatment in the prison estate. I can’t prove it, but I have a feeling that it was fear of Strasbourg that curtailed many of the coalition government’s more extreme plans for substance misuse treatment, including time-limiting it – something that might become of interest to some in government again after Brexit.

In the longer term it would take a brave human to bet against the economic and social cost of a Brexit which could be a negative influence for 50 years, increasing both numbers of drug users and those seeking treatment.

A treatment system that has struggled with the removal of ring-fenced budgets and is now funded as part of public health through local authorities can only suffer as the economy struggles and business rates fall. So, there will potentially be more service users and less money for services – a turbo charging of the double whammy that has hit treatment services since 2010 and has resulted in an orgy of ‘salami slicing’.

A further worry is that there isn’t much salami left to slice, and a brave new, post-Brexit world could provide the impetus for a significant change in the structure of treatment. And while change is subjective, it would take a very brave man to see Brexit as an opportunity for positive change.

Most of these outcomes lie in the future, but drug shortages and supply chain problems are of more immediate concern. Considering the complex supply system of modern drug production, it’s distinctly possible that there will be temporary problems with the availability of some drugs. Of even more concern is the government’s response to this possibility, which amounts to quietly passing the power to pharmacists to alter both the amount of drug and even the drug itself, via an amendment to the Human Medicines Regulations.

Granted, ministers have to specifically give pharmacists this power on a drug by drug basis, despite a lack of medical training or a full assessment of the patient’s needs. Absolutely nothing in my experience suggests the unique maintenance prescribing that predominates substance misuse treatment would receive any consideration. The amendment, which takes power away from doctors and gives it to pharmacists, is a worrying sign of the government’s approach and values.

Obviously much of the above is guess work. Brexit and its impact is highly fluid with many variables and possibilities, but its impact on substance misuse is particularly hard to evaluate because an aura of silence exists around the subject and now, at the eleventh hour, we’re surrounded by what Dick Cheney would refer to as ‘known unknowns’ and ‘unknown unknowns’. Or to put it another way, we know sod all about the short- or long-term impact of any form of Brexit on substance misuse due to the state’s lack of interest or inability to research the area. After years of cuts, services are reactive and lack the ability to enact a proactive approach.

Uncertainty clouds most areas of life post-Brexit, but attempts have been made to assess risk, from Operation Yellowhammer to specific sector analysis. As an example, there are several pieces of research on Brexit’s impact on the fishing industry. Research has been done, maps have been drawn – some thought has been put into fishing post-Brexit and there are 10,000 fulltime fishermen in the UK. So the fact that so little has been done to evaluate the possible impacts of Brexit on substance misuse and substance misuse treatment – fields that have a direct impact on around 270,000 people in treatment and a damn sight more out of treatment – a little larger cohort than the fishing industry, not to mention a more vulnerable cohort, is sad if not surprising.

It’s hard to see much positive in Brexit for substance misusers. The good people at The King’s Fund have done some actual research on the impact of Brexit on general public health and social care, and although substance misuse is a unique field there are enough commonalities to make their findings disturbing. Most likely, Brexit will lead to poorer services and more suffering, but one positive outcome is that it’s highlighted the indifference of the state to the whole subject.

Brexit has made it clear that the state’s primary aim is to protect wider society from substance misusers, not help substance misusers themselves. Accepting we’re an afterthought in policy makers minds is a valuable realisation, and the gaping hole where the state’s Brexit preparation should be is a timely reminder of our role in their scheme of things.

In an open letter to MPs, The King’s Fund, the Health Foundation and Nuffield Trust summarised the four major areas where the impact of a no-deal Brexit could be felt most sharply in health and care.

Richard Murray, chief executive of The King’s Fund

1. A risk of intensifying the staffing crisis

The NHS has serious workforce shortages, with nearly 100,000 vacancies in English NHS trusts and a further 110,000 in social care. With 116,000 EU nationals working in health care and 104,000 in social care, even a small trend towards European migrants leaving the United Kingdom due to a fall in the pound or uncertainty around being granted settled status will worsen this situation.

2. Shortages and price rises for vital supplies

Despite plans for stockpiling and creating new supply routes, the large amount of new paperwork and regulatory hurdles that a no deal Brexit would create for imports is likely to increase shortages of medicines and medical devices. Although it is difficult to judge the magnitude of the problem, the leaked Operation Yellowhammer document emphasised the vulnerability of supply chains in the sector. We can be certain that these additional burdens will mean companies face higher costs to get their products into the UK – costs that will ultimately be passed on to the NHS.

3. The need to care for returning emigrants

A no deal Brexit will mean UK emigrants to the European Union do not have guaranteed rights, and they may have to return to the United Kingdom to live and receive treatment if they become ill. Around 200,000 people using the special EU scheme that guarantees health care rights to retirees abroad would face losing that protection. It is unclear how many of the roughly 800,000 other UK nationals in Europe might also be unable to access or afford care. While we would have a duty to help these individuals, it would add considerably to the already high demand pressures on the NHS and social care.

4. Funding shortfalls at a time when health and care need it most

Although an extra £20.5bn has been pledged to the day-to-day budget of the NHS in England, this does not cover other areas of spending such as investment in buildings, equipment and staff training budgets, which have been reduced in recent years. Creating real improvements for patients will also require repairs and upgrades to buildings and equipment, increased public health funding, and a stable social care system. In particular, analysis by the Health Foundation estimates that £1.0bn extra in 2020-21 and £2.1bn in 2021-22 are needed just to stabilise the adult social care system. Yet the Office for Budget Responsibility’s assessment is that the United Kingdom’s public finances would be around £30bn worse off each year in a no deal scenario of medium disruptiveness. This sum is more than the total spent on adult social care plus investment in NHS buildings and equipment across the whole of the United Kingdom in 2017-18.

Health and care services are already struggling to meet rising demand for services and maintain standards of care, not least in advance of an expected difficult winter. The potential consequences of a no deal Brexit could significantly impede services’ ability to meet the needs of the individual patients and service users who rely on them.

The impact of a no deal Brexit on health and care: an open letter to MPs at www.kingsfund.org.uk

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