In launching the NHS Long Term Plan, Theresa May promised stability amidst all the instability. Key headlines include half a million lives over the next ten years to be saved through preventing diseases such as strokes and heart disease, and true efforts to bring parity to mental and physical health.

But with fears increasing that Theresa May is ‘thinking the unthinkable’ and seriously considering a no-deal Brexit, key policies within the Plan could be at risk before they’ve even begun. Here, we focus on four areas underpinning the Plan that are at risk from a no-deal Brexit:

1. The money behind the Plan

Before the Plan came the financial commitment: £20.5 billion more for the NHS over the next five years.

But as Bank of England Chair Mark Carney said last week, “A no-deal would be an economic shock for this country.” The UK economy expanded in 2018 at its slowest annual rate in six years, and a no-deal Brexit could continue, or even worsen this. Under World Trade Organisation Tariffs, the UK could have more expensive imports, less demand for exports and potentially cause a greater reticence from the government to borrow at what will inevitably be higher rates.

Simply put, no-deal is likely to give the Treasury less spending power and flexibility.

Due to a fortunately timed windfall from higher than expected tax income, the Plan’s funding is supposed to be guaranteed. But any major hit to Treasury revenue could mean that the designated budget must be drawn from elsewhere. It will have to be raised through increased taxation, borrowed, or moved from other departmental budgets – highly contentious when other public services will inevitably have to undergo (further) cuts.

2. Relieving pressure on hospitals by increasing care in community settings

A major pillar of the Plan is for more patients to receive care in primary and community settings, rather than in hospitals. This has been a longstanding ambition of this and previous governments but has been notoriously hard to deliver.

An extra £4.5 billion a year has been ringfenced for the increase in primary care capacity and shift to a more integrated approach. But reducing hospital care also relies on effective and complementary social care services, the often-ignored, yet critical part of the puzzle. As Simon Stevens has reiterated many times, a failure to deliver on social care will lead to a failure to achieve on the Long Term Plan.

Yet the long-awaited social care green paper has been delayed because of Brexit. Current thought is that it will land in April. But a no-deal will inevitably change the scope once again or even delay the Green Paper indefinitely.

Ideas rumoured to be considered for inclusion, such as tax incentives for young people to save for their social care, will have to be reconsidered against what will be politically palatable and financially necessary following a hard Brexit. With this further delay, the risks grow that social care reform will once again be kicked down the road.

3. Increasing the NHS workforce

There has already been plenty of criticism at the Plan’s lack of focus on workforce, which is understandably seen as a critical tenet of its successful delivery.

The BMA has repeatedly highlighted the risks of the high level of vacancies in the NHS’s workforce. Ruth May, NHS England’s new Chief Nursing Officer, reiterated the point in her first interview. For a sector already struggling to cope, a no-deal exit would make this challenge even more acute.

At almost 70,000 individuals, the current number of EU nationals working in the NHS is staggering. Any reduction in this number would hit services hard, and undoubtedly reduce the ability to deliver appropriate, and necessary levels of care.

Under pressure from NHS leaders, a workaround has been agreed. In the event of a no-deal, EU citizens coming to the UK will be permitted ‘temporary leave to remain’, giving them the same rights they have now.

But note the ‘temporary’ aspect, which is crucial. It grants permission to stay for just three years and with no extension ability. Applying for Indefinite Leave to Remain or a Tier 2 Visa are the only other routes, undoubtedly acting as a deterrent to many.

Even if a deal is agreed, the workforce questions are likely to remain. All eyes are on the Workforce Implementation Plan proposals, expected in early April, and the eventual full Plan within two months of the Comprehensive Spending Review.

4. Improving outcomes for all major conditions

While improving outcomes for major conditions relies on multiple, complex factors, a key factor is to ensure patients receive the right care at the right time.

This necessitates uninterrupted access to treatments and therapies. The Department of Health and Social Care (DHSC) and NHS England have been keen to reassure the public that there will be no interruption to medical supply, no matter the exit scenario. Huge sums have been spent testing scenarios and creating contingencies by industry and government to ensure continued access to medicines. But questions remain over the ability to maintain supplies in a volatile, hard Brexit scenario.

Diabetes UK and JDRF last week published a joint statement calling on the Government to provide more detail on access to insulin in the event of a no-deal. And today, HSJ has a splash from the Royal College of Radiotherapists, saying that if a no-deal Brexit delays the import of radioisotopes NHS trusts will have to prioritise which patients receive cancer treatment, meaning some cancer treatments may be delayed.

While the necessary customs forms and transport arrangements will undoubtedly be prioritised and agreed relatively swiftly, this is unchartered territory and a no-deal Brexit will test the preparedness to the limit. The potential impact on patients in the meantime is highly concerning.

The Long Term Plan has been one of the few glimmers of domestic policy success for Theresa May’s battered government. While considered challenging to deliver, there is optimism in and across the health sector that progress can be made. However, there are growing concerns that a no-deal Brexit risks destabilising many of the Plan’s core ambitions, potentially undermining it from the offset. Providing stability amongst the instability may not be straightforward after all.

The launch of the NHS Long-Term Plan is intended to set the direction for NHS policymaking for the next 10 years. The 134-page report signals a shift in priorities and an evolution of focus. As always, this means winners and losers.

As the dust begins to settle on yesterday’s plan, we take an early look at the beneficiaries of this plan, and areas left out in the cold.

Winners:

Primary and community care networks – the new poster child of the NHS?

In line with Matt Hancock’s own priorities, prevention was the buzzword in advance of the official launch, and the expanded role of community care was borne out in the detail. One of the centrepieces of the plan is the roll out of primary care networks (an evolution of the GP Federations) backed by £4.5bn of funding by 2023/24 to deliver meaningful integration at the community-level. Out-of-hospital care is once again the name of the game for NHS planners – although this longstanding ambition is notoriously hard to deliver on the ground.

Mental health services – big on ambition, but challenges remain

As heavily trailed, mental health services for both adults and children figure significantly in the NHS Long Term Plan. Parity of esteem may finally be turning from words into action. Well known to be one of Theresa May’s pet policy areas, a number of eye-catching initiatives – such as mental health ambulances and services for 0-25 year olds – make it into the plan, alongside the renewed commitment for faster growth in mental health services funding against the overall NHS budget. However, realising the ambitions the plan sets out for the sector is unlikely to be plain sailing, given funding earmarked for mental health has failed to reach the frontline in the past and deep-rooted workforce and capacity issues remain.

Theresa May – an NHS plan a day keeps Brexit away

Yesterday’s announcement was – for once – a relative success for the Prime Minister. Having had to postpone publication from 2018, this was May’s opportunity to set the news agenda with important and ambitious domestic policy. Rather than another day solely dominated by a Brexit back-and-forth, she was able to come out with a proactive and positive message which, on the whole, has gone down pretty well.

Digitised GP consultations – the gardens of Babylon

Under the Long-Term Plan, digital-first primary care will become a new option for every patient within five years, drastically increasing the availability and uptake of services such as GP-at-hand. Good news for providers, but these services are not without controversy, and this move will not go unnoticed by the small army of clinicians on Twitter who describe them as untested and unsafe. As a vocal proponent of the digital approach, the inclusion of this measure is a win for the Health Secretary.

Global health recruiters – looking further afield for NHS talent

The workforce implementation plan, due to be published later this year, will have a major focus on recruiting NHS staff from overseas. An expansion of the Medical Training Initiative to ensure clinical trainees from around the world can learn in the NHS is being considered, while the government’s Immigration White Paper also gives the NHS more opportunities to bring in new talent from outside of the EU. However, the gaps are significant and growing, and there remain major question marks around the nursing and social care workforce when it comes to international recruitment.

Losers:

NHS managers – what’s another strategy among friends?

Nigel Edwards, CEO of the Nuffield Trust, reiterated his concerns about the capacity for rolling out such wide-ranging changes in an already stretched and reorganisation-fatigued organisation. For NHS managers, the Long-Term Plan represents yet another document to be implemented, in some cases with additional checklists and bureaucracy, at a time when the integrated care systems programme was just beginning to bed in. A new set of responsibilities and targets, alongside new uncertainty over the statutory role of CCGs, does little to ease the headaches of front-line planners and commissioners.

Local authority funding – the elephant in the room

Few in local government would have been under any illusion that the NHS plan would equate to a spending bonanza on social care and public health, but for all its warm words, the document gave scant comfort. Decisions over social care and public health funding have been deferred until the spending review expected in the spring, while services are desperately struggling to cope with demand. For a plan so focused on prevention, commentators have been quick to point out that local authority public health budgets continue to be cut. Floating a possible solution of reabsorbing some public health services – such as sexual health – back into the NHS is likely to irritate rather than comfort.

The life sciences sector – limited language on innovation in treatment

The Long-Term Plan launched with two clear messages – that decreasing demand is the aim and that prevention is better than cure. Primary prevention and earlier diagnosis has taken precedent over world-class treatment, with medicines featuring sparingly in the document. Pharma is well aware that the battles on pricing and access will take place elsewhere, but for industry already feeling under pressure in the UK market, mentions of the role of innovative treatment would not have gone amiss. Still, there are green shoots for anyone involved in genomics, and nods to the growing importance of precision medicines.

2012 Health and Social Care Act – another nail in the coffin?

The NHS plan represents another step towards unpicking the Health and Social Care Act. As requested, Simon Stevens (in consultation of course) spells out exactly which parts he would most like to remove through primary legislation, should the opportunity become available. The plan describes primary legislation as having the potential to ‘rapidly accelerate’ the progress on service integration as well as cut out counter-productive and bureaucratic competition and compulsory tendering processes. In truth, a Brexit dominated 2019 makes it very unlikely that MPs will have the chance to get their teeth into a health bill, so the existing fudge will have to do.