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:
- 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.
- 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.
- 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.
- 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.