Won't someone call a doctor?

The patient is bleeding out.

The UK, and its nations, are ill at ease. On that night, 23 June 2016, something broke in this country. A fragile bond snapped. 

Now, things had been going wrong for some time, certainly before the Brexit referendum. After all, the referendum on Scottish independence happened in 2014, after the SNP established a political stronghold north of the River Tweed. They continue to dominate Scottish political life and it would be surprising if pro-independence groups didn't win a convincing majority in next May's Scottish elections. 

No, this wasn't caused by the Brexit referendum. But there's little doubt that it accelerated it. It didn't create the political cultures in England, Scotland, Wales and Northern Ireland, but it did force them into new shapes. Increasingly our separate countries are going their different ways, becoming more at odds with each other in temperament and expectations. Not so much that we should become enemies, or anything so incredible, but perhaps enough that a political union run primarily out of London no longer appears to make much sense.

Northern Ireland is the most obvious example of this. It has a well-established alternative political system that looks essentially nothing like the rest of the country. It is deeply rooted in a sectarian split between nationalists and unionists, governed by a political infrastructure that was built to manage and guide this divide. At election time, parties from Great Britain barely make a showing in Northern Ireland. The odd attempt from the Conservatives or UKIP to run candidates in Northern Ireland have never met much success. 

Now Brexit has arrived to distance Northern Ireland's political life even further from that of the rest of the UK. The arrangement that the former Prime Minister said would be impossible for a British government to agree to will shortly become a reality: there will be controls between Northern Ireland and Great Britain. And not just for trade, but for other areas like movement of capital too. By contrast, the Irish government has intervened to ensure that citizens in Northern Ireland can still access the Erasmus student exchange scheme, which the UK government is leaving and will continue to have a strong involvement driven by deep (and ever deeper) ties between politics in the Republic and nationalist parties in Northern Ireland. 

In these circumstances, what is the future of Britain in Northern Ireland? Already most Westminster governments were wary of getting too involved with the region's infamously difficult politics. As Northern Ireland increasingly starts to follow different rules, managed by different parties and arguing over different debates, it will become ever easier for Westminster to simply let go. No one will say this out loud of course, but how many MPs ever think about affairs in Northern Ireland? How many even consider affairs in Northern Ireland to be their business?

Of course, Northern Ireland has its own particular circumstances that explain all of this. It would be quite easy, in fact, to give the rundown of Anglo-Irish relations and conclude that, ultimately, it would be a bit silly to try and read across from this particular part of the UK to any of the other constituent nations.

And yet - is that not where we are all drawn? When we widen our lens, what remains of a truly UK-wide political culture? Wales and England retain the most similarity - after all, the Conservatives and Labour are both prominent parties in each nation and both voted (if by different margins) in favour of Brexit. But there are cracks even here. The last UK elections notwithstanding, England is much more obviously aligned with the Conservatives and Wales with Labour, as reflected by the respective governments in Cardiff and London. And while support for Welsh independence remains low, it has been trending upwards for most of the past decade. If anything really keeps England and Wales together it is the UK as a whole. Were that to disappear, it would not be surprising if citizens and politicians on both sides decided to part ways, in the manner of the Czech Republic and Slovakia or Serbia and Montenegro, rather than to carry on as a union-of-two.

So we have to come back to Scotland, the nation teetering on the edge of leaving the UK. Polling averages show a clear lead in favour of independence, sustained in a way that surpasses the lead-up to the 2014 referendum. Scotland, for very different reasons, increasingly looks like a Northern Ireland - a place apart, with its own set of parties, its own debates and its own centre of gravity. Brexit was heavily opposed by Scotland (62% to 38%) and attempts by the Scottish government to push for closer relations with the EU were batted aside. To do this would be to oppose 'the will of the people', so the saying would go. 

Many Scots evidently now feel that they are no longer part of 'the people' the UK government represents. 

It is therefore inevitable that the first issue that a post-Brexit UK will face is a question mark over its very survival. The 2021 Scottish elections will provide an easy opportunity for the SNP to claim a new mandate in favour of independence, or at least in favour of a referendum. After all, why would 50+% of Scottish voters elect pro-independence representatives if not for the likely reality that a majority of Scottish voters want independence? 

It's a dangerously straightforward argument for the British government to try and counter. Organising a binding referendum is the decision of the UK government so a flat refusal is always an option but there's no guarantee it would make the issue go away. Indeed, it could make it much worse. Civic disagreement could quickly turn to anger if Westminster is seen to be denying the democratic will of Scottish citizens. 

Wouldn't it be ironic if, after Brexit, it turned out that the UK was the involuntary union, abolishing the national identity of its members and trapping them against their will?

With the wind in their sails, we know that the Scottish government will try every route open to them, including passing legislation for a referendum (or a referendum by another name) directly through the Scottish Parliament. This could force the debate into the courts, with unpredictable consequences as both sides try to leverage the ambiguity of the UK's uncodified constitution. Even if the British government shuts down these legislative expeditions, it may not come out of this contest with the same union that it started with.

Against this backdrop, where is England? As by far the largest nation in the UK, England holds most of the power to determine the fate of the union as a whole. But England and the English persist in a general indifference towards Scotland, Northern Ireland and Wales. Sure, there is some love and there is some hostility, but for the most part English politics is detached from what happens elsewhere, driven by English priorities and English votes. Hardly surprising when one considers that the nations in the UK have no power at the national level save for their seats in Parliament. Specifically, the 533 seats for England, 59 for Scotland, 40 for Wales and 18 for Northern Ireland. You can do the maths. 

So the inward turn of England continues. Contrary to the name, the idea of 'Global Britain' itself represents this - it is a global vision that is first and foremost about transactions, the exchange of goods and money, extracting resources and neutering them of any cultural or political context before they are in sight of the white cliffs of Dover. 

Meanwhile, the global politics of people, the shared bonds of international solidarity, of joint political endeavours and shared sovereignty for the greater good - what we'd typically call cosmopolitanism - these are maligned, even reviled, on the front pages of the same daily newspapers who regularly extol our post-Brexit excursion out of Europe. Far from a desire to deeply engage with the rest of the world, Global Britain is England's (greatly misnamed) fallback to avoid any need to change. England may stride out into the world but the world may not stride into England. So long as England's material needs can be serviced, the world need not call back. 

In spite of these evident and growing differences, perhaps some new unity in the UK can be forged? A notable part of the split in the UK is driven by the divergent economic fortunes of its different members. Wales and Northern Ireland are substantially worse off in terms of GDP per capita than much of England and Scotland (which both cover the entire range from poorest to richest). A programme of 'levelling up', driven by the central government, could convince people that the UK is able to deliver a fairer outcome than would be possible if everyone went it alone. 

It's certainly not impossible. But just as likely is that we will see a new group of 'left behind' communities, those populations who have been considered essential in driving the Brexit votes and Boris Johnson's victory. 

Outside of the EU Single Market and Customs Union, UK businesses will face significant new barriers to trade with their nearest market, regardless of the UK-EU free trade agreement. Free trade deals with the rest of the world have only just been keeping pace with the standard already set by the EU - a year-long exercise in copying and pasting deals the UK already had as an EU member. The potential for growth from new deals with countries like the US is very small, while others, like Australia and New Zealand, have already opened up negotiations for free trade agreements with the EU. In this environment, UK businesses will struggle to build a competitive advantage relative to EU counterparts. And with the UK now torn out of EU-wide Free Movement, those simple pleasures of life, in easily travelling around the continent, in making new connections and discoveries, in retiring to a sunny idyll, which had all previously been enjoyed as rights for all, will return to being the privilege of the few who have the means to jump over the barbed wire hurdle course of international borders. Many communities will likely see business prospects dwindle just as individual see their opportunities shrink.

An alternative idea is that, even if UK economic policy doesn't enjoy a great revival, people will at least feel more connected to their political leaders - either because the EU really was a drain on accountability or because it served as a convenient excuse for shifty national politicians, depending on who you talk to. This hope is misplaced. 

Lies abounded in the Brexit referendum and regardless of your view of the EU, it's a verifiable fact that UK politicians were able to get away with wrongly blaming things on Brussels because the media let them get away with it. This is the real problem - there will always be another EU, always another entity or group that some political leader will try to blame when things go wrong and there's little reason to believe that the media will stop being complicit. This phenomenon did not start with the EU and it won't end now. Brexit cannot cure the British disease of weak standards in public life. 

Even if there were a miracle here, the hard truth is that many MPs never have to worry about the electorate anyway. In recent elections almost half of parliamentary seats could be easily predicted before the vote because they are so uncompetitive. Thanks to our voting system, First Past the Post, which stifles electoral competition in favour of the two main parties, many UK MPs are pretty well immune to the changes and shifts in national public opinion. For the many people in these constituencies who don't back the eventual winner, their votes are practically worthless. How can citizens be expected to engage with a political system that effectively disenfranchises millions from the outset?

Given these bleak assessments, it's not surprising that some feel the end of the UK is a virtual certainty. What was seen as an unlikely outcome, put to bed for some time in 2014, has been revitalised since 2016. A perfect storm of economic and political upheaval, stretching bonds that were already weakened past their breaking point, could spell the end of the UK.

But we need not ring the coroner yet. 

In spite of the dark clouds gathering around the UK's future, there is still some small amount of time to correct course. But it will require a bold proposal to reform the UK's democracy. In concrete terms this would mean the creation six devolved entities in the UK: Northern Ireland, Wales, Scotland, London, Northern England and Southern England. 

The last proposal may seem strange as in these discussions England normally either remains whole or is split into smaller regions (often along the lines of the NUTS 1 division). But while England in its entirety is too big to function well in a new UK, the usual regional divisions do not have much hold on ordinary people. By contrast, the split between North and South, for good or ill, is something that is widely recognised, has been true for many centuries and is the kind of division that people could actually identify with. Most English citizens are more or less brought up on this division and can relate to it and understand it while still at school. 

Each of these entities would have its own parliament, with substantive powers over tax and spend. All elections at every level would use a system of proportional representation (possibly the Additional Member System used in Scotland, which preserves individual member constituencies). Finally the UK Parliament, retaining exclusive right over areas like defence and foreign policy, would integrate representation for each of these entities directly. This could be done using the US model of a Senate, with each entity electing its own representatives directly, or it could be done in the way of the German Bundesrat, where the upper chamber is simply composed of representatives from the state parliaments, with no additional elections needed.

In any case, the most important aspect of this is speed. While there is time to save the union, there is no time for more debates and conventions. We can be fairly sure of this because we have been here before. In the early 20th century there were similar debates and ideas around how to ensure that the nations of the UK could stay together, amid rising and consistent nationalist sentiment in Ireland. 'Home rule all round', the idea of giving each nation its own parliamentary assembly with meaningful powers, was considered as one of the solutions. But even home rule for Ireland was interrupted by the First World War and these plans never made the necessary progress. By the end of the war it was already too late and the Irish War of Independence began in 1919, settled with the peace treaty and the emergence of the Irish Free State in 1921/22. 

It is unlikely that a major war will prevent us from dealing with our constitutional pangs today but this cautionary tale shows us that we cannot delay this conversation forever. If the UK is to survive then these reforms must become a top priority and a part of official policy for all UK parties.

But will any of them do so? Unfortunately, as we close this piece we have to return to pessimism because the problems the UK faces are also the same forces that prevent solutions emerging. Political parties, when successful, can be imagined as vote-maximising machines: they try to adopt policies and positions which gain them as many votes as possible from supporters of those ideas, without losing too many from critics. As the political spaces of the different parts of the UK take on their own characters, this equation becomes harder to balance for UK-wide parties. This was plainly in evidence during the Brexit negotiations when, time and again, Labour and the Conservatives prioritised retaining English and Welsh votes over trying to win back votes in Scotland (and Northern Ireland only had a brief moment in the sun because of the DUP-Conservative alliance during Theresa May's premiership). 

Essentially we're caught in a loop. As the UK's nations drift apart, it becomes more and more logical for the main UK parties to double down on Welsh and, especially, English votes. As they double down on those votes, the other parts of the UK are less represented and so continue to drift apart, and so forth. In other words, the country has arrived at the strange conclusion that UK parties have little to gain in actually trying to save the UK - there aren't enough votes in unionism for its own sake. Even Labour, which has a history of being more attentive to the needs of the Celtic fringe of the UK, today is timid, leaning towards Leave voters in English seats and only presenting forums for discussion on constitutional reform. 

And so there our patient lies, bleeding out, a steady drip on the floor. Not dead yet - will the doctor arrive in time?