Brooding Over Brexit: Cardiologists Voice Uncertainty About Effects on Collaboration, Research Funding

 

Politicians are raging, currencies are tumbling, and, in the hallways of hospitals around the United Kingdom, cardiovascular specialists are reacting with disappointment and dismay to last week’s Brexit vote.

Many, speaking with TCTMD, said they have mounting concerns about how the current political climate might affect research funding, drug and device regulation, and pan-European collaboration.

“I personally am very disappointed with the results of the referendum. I think that that feeling is probably mirrored by a substantial majority of the cardiology community,” Rod Stables, MD (Liverpool Heart and Chest Hospital, England), told TCTMD. “I and many of my colleagues have enjoyed the collaboration with continental Europe, and we have profited from the close association with European cardiology for the developments of clinical practice and research.”

Researchers in Europe have long-benefitted from combining cohorts within various countries to create more heterogeneous study populations, which in turn lead to stronger trial findings. Recent examples include MATRIX, WIN-TAVI, and EUROMAX. The United Kingdom leaving the EU does not mean that this collaboration would stop, but already “the sentiment is bad,” Justin Davies, MD, PhD (Imperial College London, England), said in an interview.

At minimum, the Brexit “changes the tone of our interaction” with colleagues in other European countries because they “will hear that this country has made a majority decision that will turn us back a little bit,” Alan Fraser, MBChB (Cardiff University, Wales), commented.

The same concern applies to non-residents who come to the UK for work. “Any threat over their heads with regard to residency or migration is really bad,” Davies said. “If you’re that young person in Poland who was thinking of coming, you may choose to go somewhere else because you may feel that there is a long term threat.”

Less than a week after the Brexit vote, interventional cardiology trainee Sukhinder Nijjer, MBChB, PhD (Hammersmith Hospital, London, England), told TCTMD that it’s affecting staff morale. “There’s already been stories of people being told that they need to leave the country and go home,” he said, adding that several hospitals have sent out letters to staff reinforcing support and appreciation for them, regardless of their nationality.

“Most of our cath lab staff are almost entirely non-UK born,” Nijjer noted, but despite the goodwill being circulated by hospital administrations, “we’ve had several Polish nursing staff say they are quitting and leaving the country.”

Money at the Forefront

Among all of the uncertainty, research funding is likely to be affected by the Brexit, according to Robert Henderson, MD (Nottingham University Hospitals, England), who serves as the Honorary Secretary of the British Cardiovascular Society (BCS). “Grants that are already in existence I would hope would be continued, but . . . I suspect that the outcome of this would be that we will no longer have access to that source of funding for research in the UK.”

Those lost resources will either lead to less UK research overall “or it will have to be made up for by the government, and of course that depends on the state of the economy and whether we can afford to do that or not,” he commented.

HORIZON 2020, which is the EU’s largest program for sponsoring research and innovation, has the budget to award nearly €80 billion to European researchers by 2020. In its first round of applications, researchers from the United Kingdom submitted more than 14,000 proposals—more than any other EU nation. Of those funded, UK researchers received just under 15% of the HORIZON 2020 pot, or about €825 million, in the first round of awards.

Given that researchers from non-EU member countries like Switzerland, Norway, Israel, and Turkey are allowed to apply for HORIZONS 2020 funding under “associated country” status, those in the United Kingdom will likely still have access, Anthony Gershlick, MD (Glenfield Hospital, Leicester, England), told TCTMD. “But the bottom line is nobody really knows.”

Either way, Vinayak Bapat, MD (Guy's and St. Thomas' Hospital, London, England), noted that a Brexit would definitely have a “negative effect” on large research projects within the United Kingdom. “With the pound dropping and doubts about economic stability and [the National Health Service] already in deficit, I think there will be no money for groundbreaking research,” he said in an email to TCTMD.

Then there is the issue of paying for expensive drugs, devices, and procedures within the National Health Service (NHS)—a contentious matter for cardiologists in the United Kingdom given that, for example, many TAVR candidates remain on long waiting lists before being able to have their procedures.

One of the main arguments made by those who campaigned in favor of a Brexit was that £350 million a week once sent to the EU could instead be used to directly fund the NHS. In a matter of hours after the results of the vote were announced, UK Independence Party leader Nigel Farage backtracked on this claim.

This maneuver “was highly misleading,” according to Fraser, because nothing had been promised and “there was no reason why the conservative government could not have increased funding irrespective of the vote.”

Brexit or not, the president of the British Junior Cardiologists Association, Jubin Joseph, BMBCh (St Thomas’ Hospital, London), told TCTMD in an email that the “already underfunded” NHS is facing the “potential for quality failure.” If Brexit does ensue, “there is no reason to believe that cardiology will be spared from any adverse fallout,” he said.

“Fundamentally, the details of ‘Brexit’ need to be carefully negotiated between the UK government and the European Union,” Joseph continued. “It is difficult to see terms negotiated that will improve NHS cardiac services in the near future.”

Drug, Device Regulation Up in the Air

There’s also the question of what might happen for European drug regulation in the event of a Brexit if the European Medicines Agency—currently headquartered in London—has to move. Whether or not the United Kingdom would be able to piggyback off of how EU regulators continue to work or if Britain will have to develop its own process for supervising homegrown drugs and devices is unclear.

“It doesn’t make any sense that each individual country might have to have its own system for approving each medical device and each new drug that comes along. That’s been the benefit of developing systems in Europe to share these mechanisms,” said Fraser, who serves as the chair of the European Society of Cardiology’s regulatory affairs committee. “The UK should certainly try and remain a part of [the EU process], though it may have to do more itself.”

Reflecting on the carefully achieved harmony that regulatory bodies within Europe “have worked hard for the last decade,” Bapat said the future poses a “challenge” for those working in a changed UK environment. “I do not see the UK to be attractive for device companies to come to for first-in-man or pivotal trials if the outcome and approval is not accepted on the continent,” he noted.

‘Complex’ Impact on Training

A Brexit’s potential to affect UK training opportunities is “complex” but certain, said Joseph.

“The Brexit must be viewed alongside the downward pressure on wages, the desire for the current government to deliver a ‘7-day NHS’ service, the junior doctors’ contract disputes in this regard, and the ‘Shape of Training’ reforms,” he said. “Losing the European Working Time Directive in this environment will inevitably lead to pressure for longer hours at lower wages, reducing the attractiveness of and recruitment to cardiology training.”

Nijjer added that it is “very common” for UK medical trainees to work abroad, often within Europe, for a year and receive a more well-rounded education. “That movement will be affected” by a Brexit, he said. “It won’t make it impossible, but it will make it a little bit harder.”

Additionally, Nijjer said that he works with several trainees from other European countries within his hospital. “They have equal footing with us,” he said, adding that a Brexit would affect the desires and abilities of competent individuals to train in the United Kingdom. Not only will this potentially mean less trainees overall, “but it may mean that training is diminished,” Nijjer noted.

Bapat also pointed out that presently an EU trainee needs only to pass a language proficiency test to secure a General Medical Council license to practice in the United Kingdom. Post-Brexit, they might have to take a more intensive exam, similar to the USMLE, which would make the process more cumbersome, he said.

Additionally, Bapat said that since candidates from outside the EU “have been sidelined as EU doctors get preference” for training slots within the United Kingdom, there will likely “be a reversal of this situation.”

Meeting Attendance Also a Question Mark

The last pressing question on everyone’s mind has to do with conference attendance.

“Educational meetings have always been nonpolitical and not limited by geographic boundaries. Hence, I do not see any issues with meeting attendance,” Bapat said. However, if EU citizens, need to apply for visas to enter the United Kingdom for meetings, for example, “then the attendance will drop without doubt,” he added.

Gershlick made the point that cardiologists willingly travel all over the world for meetings, and not merely within Europe. So a Brexit would not make “any difference at all,” he stressed.

Taking a broader view, Fraser pointed out that while there are only 28 member countries within the EU, the European Society of Cardiology includes 56 national cardiac societies. He therefore expects that the BCS will continue to be a member of ESC. Adding on, Henderson said “we would hope that [BCS’ relationship with ESC] would not be affected by this changing relationship with the economic community.”

Going forward, physicians “need to be aware of the things that may unbalance what we are already doing” with regard to the implications of a Brexit, Gershlick said.

Davies predicted a second referendum given the economic implications of the first vote and the general disappointment felt within the country. “The key thing is in the short term not much will change, and in the long term there’s a lot of uncertainty,” he said.

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