Attitudes to Brexit: A survey of nursing and midwifery students.

Abstract

Brexit has delivered a political earthquake, the tremors of which will be felt for generations to come. (Goodwin (2016a, 2016b)) In a referendum on 23 June 2016, the people of the UK voted to leave the European Union (EU). The phenomenon known as Brexit did not come out of nowhere: according to Clarke, Goodwin, and Whiteley (2017), it marked a culmination of social and political trends emerging over many years. Moreover, there is resonance far beyond the UK, with tensions between an increasingly globalized society and national autonomy, between young and old, and between “liberals” and “authoritarians” (Ford & Goodwin, 2014). Such forces underlie not just Brexit, and also, in different context and in different forms, the election of Donald Trump and the rise of populist parties in Europe. The referendum was called in response to a surge in support for the UK Independence Party (UKIP), which led to Prime Minister David Cameron promising a plebiscite on EU membership in the 2015 General Election campaign. The verdict humiliated the political establishment, immediately resulting in Cameron's resignation (Shipman, 2016). However, the margin was narrow (52% to 48%) and Brexit continues to stir controversy and animosity. Negotiations for the terms of departure have been difficult, due to disagreements between the British government and the EU, and conflict between and within Leave and Remain sides. Opinion polls show that the majority of the British electorate want the referendum decision to be implemented, although a considerable minority would like the referendum result to be overruled or overturned (ComRes, 2018). In 2017, there was further political upheaval in Britain, when Prime Minister Theresa May sought and expected to gain a larger majority that would strengthen her hand in the process of leaving the EU. However, the General Election produced a remarkable result, with the Labour Party led by veteran socialist Jeremy Corbyn achieving 40% of the vote. The General Election was not dominated by Brexit, as initially expected, but by domestic policy. Although the Conservative Party held on to power, gaining over 42% of the vote, it lost its parliamentary majority and has since relied on support of the Northern Irish Democratic Unionist Party. Views on both the EU and domestic politics appear to contrast sharply between the generations, with younger voters (particularly students and graduates) more drawn to Remain and the Labour Party, and the over-50 age group more likely to have voted Leave and Conservative. Described as a “youthquake”, a reported 16% surge in voting by younger people was believed to have significantly influenced the General Election (Whiteley, Clarke, & Goodwin, 2017). Yet there is no straightforward overlap of Labour Party policy and the Remain case, and this has created interesting and unpredictable dynamics at a crucial time in Britain's political evolution. Patterns in EU Referendum voting do not align to traditional political loyalties. Areas voting most strongly to Leave were typically poorer. Of the 20 local authority constituencies with the highest Remain vote, 45% of the electorate had a degree and 42% had a professional occupation; in the 20 areas with highest Leave vote these figures were 16% and 23% respectively. Leave voters, according to Goodwin (2016a, 2016b) “hold a more socially conservative outlook on Europe, immigration and national identity”. These were more important factors in voting than economic warnings, which opponents dubbed “Project Fear”. While the government committed to implementing the Brexit vote (albeit with internal divisions about the leaving arrangements), the Labour Party issued mixed messages. While Labour did particularly well in the General Election in university towns and metropolitan areas with high concentrations of Remain-voting younger people, Corbyn had promised to honour the referendum result. This contrasted with the avowedly anti-Brexit stance of the Liberal Democrats and Green Party, who failed to make an impact in the General Election. However, Corbyn's long record of Euroscepticism is at odds with most of the parliamentary Labour Party, which was overwhelmingly for Remain, including Shadow Brexit Secretary Keir Starmer. The party recently declared a change of policy to stay in the Customs Union. However, some figures on the left of the party and some left-wing academics (e.g. Bickerton & Tuck, 2017) argue that Brexit will allow a Labour government to pursue a transformative agenda, particularly in economic policy. Some Members of Parliament representing northern seats that voted to Leave, such as Caroline Flint, believe that ending free movement is essential for the party to regain credibility in “left-behind” areas. The present and potential impact of Brexit on the National Health Service is contested. Alastair Campbell, former press secretary to Tony Blair (British Prime Minister from 1997 to 2007), argued (New European, 11 November 2017): “You can have Brexit or the NHS. We can't have both.” Campbell argued that the NHS would suffer from a severe deterioration in the British economy and a decline in recruitment and retention of staff of European origin. About 5% of the NHS workforce is of other EU nationalities, but in recent years they have accounted for a much higher proportion of new recruits. Reports of an exodus of European doctors and nurses have therefore raised concerns (Financial Times, 2017), although NHS data showed a small increase of NHS workers from other EU countries since the Brexit vote (Tinsley, 2017). Whether due to perceived or actual barriers, Brexit has the potential to worsen staffing problems in an already pressurized service (Menon, 2017). This complicated picture suggests dissonance in the views of the younger generation in relation to Brexit and domestic politics, raising several interesting questions: what influenced younger people in their attitudes towards the EU and Brexit; how did such views relate to political preferences in the General Election; and how do they see the prospects for the country and people's livelihood on leaving the EU? Therefore, we undertook a survey of attitudes to Brexit and domestic politics in a sample of university students, to contribute to understanding this key segment of the electorate at a time of significant political change. We designed the Attitudes to Brexit Questionnaire (Appendix 1). The 19 items of this instrument are neutrally posed, with a balance of positive and negative options. In most items respondents could choose a maximum of three options, with an “other” category allowing free-text entries. The target population was current nursing and midwifery preregistration students at King's College London. Such students are not representative of the UK electorate, being predominantly young, well-educated UK residents, and over 90% female. The survey was not exclusive to British nationality or voting eligibility: we were interested in attitudes rather than citizenship. The tool was designed for generic use, providing opportunity for respondents to state what is most important for them. Therefore, any responses related to health care arose from the respondent's viewpoint rather than being guided by the questionnaire. Following approval by King's College London Research Ethics Committee, the online questionnaire was accessible from 4 December 2017 to 31 January 2018. The full set of results is in Appendix 2. The online questionnaire was completed by 162 of the eligible 1783 students (9.1%). By birthplace, 80.1% were British and 11.2% were born in Europe. For ethnicity, 74.5% selected “White/White British”, considerably higher than their frequency in the study population (1063 students, 60%). There were 5.0% “Asian/Asian British” and 6.2% “Black/Black British”, plus 6 other British/part-British ethnicities entered in free text. For the EU referendum, 83.9% were eligible to vote. A great majority favoured Remain over Leave (80.5–19.5%), in contrast with the overall referendum result (48.1–51.9%), as shown in Figure 1. Free movement was the most frequently perceived benefit of EU membership, with 75.2% of the sample selecting this item. Over half of respondents chose human rights and employment rights (56.9% and 53.7% respectively), with 46.3% opting for European identity/citizenship and 43.8% for the Single Market. Among other benefits stated in free text were “easy European travel”, “environmental laws” and “protection from our own Tory government”. Three respondents used the “other” option for negative judgements, one stating: “None of these. Britain will not abolish human rights or employment rights. All the others have downsides”. The most frequently selected disadvantage of the EU was bureaucracy (52.5%), with 33.3% choosing contributions to the EU budget. Free-text responses mentioned strain on housing and the NHS. One stated “forced to keep terrorists for the sake of their human rights”. Eight respondents denied any adverse effects of being in the EU; for example, “I love it and find it hard to see any disadvantages”. On perceived benefits of leaving the EU, 40.7% chose ending payments to Brussels. Of the 38 responses using the “other” category, 30 were negative; for example: “I can see no benefits apart from honouring the democratic decision”. Another respondent remarked: “I think sovereignty is a bit of a myth that is sold to us as something great, when in reality it doesn't mean much anymore”. On the disadvantages of leaving, 71.8% saw nationalism and racism as corollaries of Brexit. Loss of free movement was selected by 60.5%. In free text, three respondents mentioned the NHS; for example, “skilled workers (e.g. health professionals) potentially deterred from working in the UK”. One saw no adversities, arguing: “The problem with all these options is that they are not real negative outcomes…Leave voters are not bigots, our economy won't collapse and we won't be trapped on our island unable to move, nor will we close it to skilled migrants”. Another respondent feared “a bad deal negotiated by our Remain-dominated government”. Respondents were asked about the reasons for the Brexit vote. The demographic variable perceived as most important was age (73.9%). Social class (54.9%) and education (51.2%) were also seen as major influences. In free text, respondents made comments combining several factors; one stating: “Lots of older people, and quite a few less educated seemed to vote out of hatred for the bogeyman of Brussels or from xenophobia”. Another remarked: “I wonder how many healthcare and social workers voted Leave because we see daily the problems of overcrowding and a lack of opportunity to those at the bottom”. On perceived motives of Leave voters, 68.9% saw immigration as the biggest concern. No other option reached 10%. The view that Leave voters were primarily motivated by hostility to immigration was reinforced by free-text comments: “a sense of superiority over other Europeans”, “misinformed idiots”, “xenophobia and Islamophobia” and “lack of understanding that leaving the EU only impacts on EU migration”. Propaganda was also blamed; for example, “NHS funding featured heavily even though it was a lie”. One respondent considered that “people felt disempowered and wanted a change”. Respondents were asked for three terms symbolizing the EU to them. Of a total of 371 entries, 324 were positive, 43 negative and four ambiguous (e.g. “neoliberalism”). Five respondents presented both positive and negative terms; for example, one student chose “partnership” and “potential monster”. These terms were classified into themes. Most common were unity (91), freedom (57) and inclusiveness (50). The most frequent negative theme was controlling (16). Similarly, three terms were sought that symbolized Brexit. Of a total of 360, 52 were positive, 302 negative and six ambiguous. Four respondents presented both positive and negative terms; for example, one student chose “independence”, “expensive” and “complicated”. The most common themes were division and xenophobia (91), general concerns (81, including uncertainty and fear) and ignorance (39). The most common positive theme was sovereignty and democracy (28). Some extreme terms appeared such as “fascism” and “stupidity”. The term “fear” appeared to refer to either Brexit voters or the respondent's reaction. For the General Election, 89.5% were eligible to vote. The most favoured party was Labour, with 70.7% of the votes, followed distantly by Conservative (19.3%). Again, this voting pattern differed markedly from the national result (Figure 2). Party policy on Brexit was considered very important by 28.9% of respondents, but quite important by 48.7% (totalling 77.6%). Of the 99 respondents who voted for Labour, 75 had voted to stay in the EU. Excluding voters who were ineligible or did not vote in the EU referendum, the Remain share among Labour voters was 91.4%, considerably higher than the 80.5% Remain vote across the whole sample. A large proportion of Labour voters saw Brexit policy as quite (57.2%) important, with 20.2% as very important. There was much variation in how such policy was perceived, with 52.3% believing that Labour wanted a “soft” Brexit, while 26.6% thought a second referendum would be offered. A relatively high proportion of Labour voters (14.6%) was unsure of the party's stance. Of the 27 Conservative voters, 25 were eligible to vote in the EU referendum, with 12 voting for Brexit. On future voting intentions, respondents would strongly support a party committed to a second referendum (74.2% for; 25.8% against), but some who voted Remain would vote for a party committed to implementing the result of the referendum irrespective of any negotiated terms (25.9% for; 74.5% against). Labour voters were more strongly opposed to a party that commits to Brexit with or without a negotiated deal (81.4 against; 18.6% for), and more strongly in favour of voting for a party pledging a second referendum (82.1% for; 17.9% against). Reviewing the survey results, most striking is the prominence of values: our sample tended to regard the EU as a paragon of virtue: tolerance and freedom, with a sense of common European identity. Tangible benefits of EU membership mostly related to identity and rights (free movement, employment law and human rights), while the economic impact of leaving the EU, including the Single Market and Customs Union, was relatively neglected. This contrasts sharply with both the Remain argument in the referendum (in which the supposed economic benefits of EU membership and costs of Brexit were the most important element, as emphasized by the Stronger In campaign) and public discourse (Lord Ashcroft Polls, 2017). Evidently, our respondents have very different perceptions of EU membership to those of the general population, although possibly representative of the younger generation (particularly university students). There was similar divergence on the disadvantages of EU membership. Free movement (and perceived lack of control over immigration) was clearly the most unpopular feature of EU membership in the electorate, including among Remain voters, with polls showing 70% want controls on immigration from the EU (e.g. Guardian, 2016). This was a central theme in the referendum campaign, but in our survey, five times as many respondents regarded free movement as an important benefit of EU membership as perceived it as a significant concern. Perceived demographic factors for the referendum verdict were fairly accurate: age and education were indeed key factors. Nationally, education was the clearest dividing factor, greater than age or income (Goodwin, 2016a, 2016b). Immigration was indeed a major factor in the Brexit vote; despite evidence (Lord Ashcroft Polls, 2017) that Leave voters’ primary motive was sovereignty and opposition to the supposed ambition of a federal “super-state”. There was a strong tendency in our sample not only to attribute the Brexit vote to immigration but also to regard such attitudes as xenophobic. This suggests that, rather than the EU and Brexit being primarily about economics, trade, and political and regulatory structures, respondents perceive a cultural schism, with Remain on the liberal side and Leave on the illiberal side. Remain voters in this sample, while promoting values of tolerance and inclusivity, tended to see Brexit voters as inward-looking or racist. Arguably, casting such aspersions is itself divisive, and likely to contribute to ongoing distrust and conflict. Brexit voters have persistently complained of being ostracized, as academic group Briefings for Brexit described in a letter to the Times (2018). This presents an interesting counterpoint to much public discussion of the Brexit vote, often portrayed as a conflict between the rational, economics-based arguments for Remain (trade and investment), and the identity or values-based (sovereignty and democratic control) arguments for Leave. Brexiteers have been analogized as Cavaliers, in contrast to Remainer Roundheads (Times, 2016). Our analysis suggests that in this heavily Remain sample, values trump economics. This ascent of identity and values-based motives over practical concerns is a significant challenge for those (on either side) who frame Brexit as primarily an economic or structural concern, and for those who hope that divisions within British society exposed by Brexit can be bridged in the years ahead. Another finding is that those who were firmly against Brexit and would like its reversal largely voted for Labour, despite this party's ambiguity on Brexit and despite the presence of definitively anti-Brexit parties. It is unclear whether this was because they hoped that Labour would shift its stance (which it has done to a limited extent since the election) or because they saw no other viable option (the Liberal Democrats lost popularity among students following that party's agreement to raise tuition fees in the coalition government of 2010–2015). Younger voters were not necessarily fooled into voting for a pro-Brexit party: Labour policy, as most of our sample discerned, is to negotiate a “soft” Brexit. Despite its prominence in the campaign and the postreferendum debate, there was little evidence in our survey that respondents related Brexit directly to the NHS. There was no direct mention of the Vote Leave campaign pledge to spend money saved from the UK's current EU budget contributions on the NHS. While Brexit might pose risks to recruitment and retention of workers from the EU, our sample's attitude to free movement appears to convey a general principle rather than a NHS-specific problem. It is notable that bureaucracy was regarded as the biggest disadvantage of EU membership; this may be influenced to nurses’ general concerns about administrative burden, seeing government and the raft of management policies as obstacles to their caring role. The EU working time directive, although not specifically mentioned, may be a factor here, as it constrains nurses’ potential earnings. Our results should be treated with caution, given the low response rate and the specific population sampled. Although the proportions voting for Remain and for Labour in our sample followed national voting patterns for the younger age group, they are obviously unrepresentative of the wider electorate. Internal validity is also questionable due to the disproportionately White British participation, and the 91% who did not respond. However, the purpose of the study was not to produce generalizable results but rather an exploratory study of interplay between EU sentiment and domestic politics among a population of particular interest in the context of debate on Brexit and the NHS. Niall McCrae (Florence Nightingale Faculty of Nursing & Midwifery, King's College London) & Jonathan Portes (UK in a Changing Europe and King's College London) Who most influences your views on the relationship between the UK and EU? Please rank 1 for most influence, 2 for next most, and so on. Leave blank any options that have no influence. How do you see the general opinion of fellow students on the best outcome for Brexit negotiations? Tick one. As the UK is currently a member of the EU, what do you see as the main benefits? Please rank 1 for most beneficial, 2 for next most, and so on. Leave blank any options that are not beneficial. What do you see as the main disadvantages of EU membership? Please rank 1 for most disadvantageous, 2 for next most, and so on. Leave blank any options that are not disadvantageous. What would you see as the main benefits of the UK leaving the EU? Please rank 1 for most beneficial, 2 for next most, and so on. Leave blank any options that are not beneficial. What would you see as the main disadvantages of the UK leaving the EU? Please rank 1 for most disadvantageous, 2 for next most, and so on. Leave blank any options that are not disadvantageous. When casting your vote, how did you perceive your party's policy on Brexit? Tick one. Which of the following do you believe was the most important demographic factor in how people voted in the EU referendum? Please rank 1 for most important, 2 for next most, and so on. Leave blank any options that were unimportant.