In a multi-part series juniordoctorblog.com looks in-depth at the potential impact a No Deal Brexit will have on the NHS. In Part 1, we looked at the potential disruption to the supply of vital medicines, and in Part 2 we examined the barriers to importing nuclear isotopes essential in many treatments including cancer.
In this part we look closely at the largest and arguably most important resource the NHS has, the staff.
What’s going on with NHS staffing in 2018?
The NHS is the world’s fifth largest organisation, in England alone it employs 1.2million people. Since 2010 staff numbers across multiple areas have fallen, leaving large gaps. To maintain current services we need 40,000 more nurses, 10,000 more GPs, 11,000 more hospital doctors and 7000 more mental health nurses.
What has the government done about this so far?
Short answer: A lot of words and little else.
Long answer: During the coalition years the government cut nursing training numbers and nursing staff posts in hospitals, as well as cutting 6000 mental health nurse positions. Meanwhile demand and activity in the NHS relentlessly grew every year by ~3%, increasing the pressure on the remaining staff and creating a situation where more staff are leaving than joining.
Despite promises of “5000 more GPs by 2020”, the number of GPs have actually fallen by over a thousand. Growth in nursing numbers is equally negative, as more leave the NHS than join. Despite proposing 15,000 more nursing places to train “homegrown” staff, so far those extra places have not been filled. Funding for places may have increased but bodies have not followed; applications fell by ~10,000 in England last year, meaning the number of nurses in training actually dropped. This is due to the government cutting nursing bursaries and charging full tuition fees from 2016. Similarly, the government has announced an expansion of doctor training places by 1500 per year from 2020, but these new doctors won’t be on the shop floor until 2025, and won’t be new GPs until 2030 or new hospital consultants until 2033.
What has that got to do with Brexit?
We have a worsening staff crisis coupled with a failure to train our own staff to deal with it. We are therefore 100% reliant on recruiting trained staff from abroad to fill the gaps, in recent years from the EU especially. Of the NHS 1.2 million staff, approximately 5% are currently from the EU, 10% of doctors and 7% of nurses.
How have things changed since the Brexit vote?
The official number of self-reported EEA staff has actually risen slightly from 58,698 to 61,974 between 2016 – 2017. This is partly because 10,000 “unknown” nationality staff members in 2016 became “known” in 2017. In specific groups, such as nursing, there has been an 89% drop in the number of new EU nurses, and a 67% rise in those leaving.
Are EU staff leaving?
Short answer: Yes
Staff in the NHS come and go as with any very large organisation, it’s the relative balance that is important. The total percentage of EU staff leaving has increased, and the percentage of EU staff joining has decreased. 10,000 EU staff left the NHS last year, an increase of 42% on the year before.
The BMA surveyed 1700 EEA doctors this year- 50% were considering relocating, and 20% had already made concrete plans to leave. Although this is bad, the major issue is recruitment.
Since 2016 EU recruitment has flatlined, for nurses especially. In addition to new language tests, new EU nurses also face a falling exchange rate, dropping the effective starting salary by 12%, and prolonged uncertainty about their working conditions and residential status. Applications for EU entrants into nursing have dropped 96% since Brexit began. Where 6400 new EU nurses joined in 2016, only 800 joined in 2017, a loss of 5400 nurses we sorely needed. The number of doctors also joining the register from the EU declined by 1000 between 2016-8.
Overall since 2009 there has been a steady rise in nursing and medical staff from the EU, a rise which levelled off after the EU referendum and hasn’t resumed. The balance of recruitment to resignations has shifted dramatically, so as a source of manpower to solve our staffing crisis the EU has dried up.
Why is this a big deal? What’s a few less nurses?
Statistically there is a direct correlation between staff numbers to patient ratios and the chance of survival. For example, the higher the number of nurses per patient the more likely stroke patients are to survive. Less staff = more deaths and more patient harm. The NHS recruits in large drives to plug these gaps from the EU; Spain, Portugal and Ireland in particular, but no longer. That shortfall will undoubtedly lead to patient harm.
How does No Deal change any of this?
The No Deal Brexit papers specifically do not mention EU citizens status in the event of No Deal. Whether a tactical omission or a political misstep, the lack of concrete reassurances for EU staff is deeply troubling. Bear in mind many of our EU NHS staff have lived here for years, have children in schools, support dependent relatives and have long-term careers. The looming threat of uprooting and even deporting, however distant or vague, should not be underestimated. If you were in the same position of uncertainty, unsure if you might have to pack up your whole life in six months time, would you buy a house? Would you move to a new job? It seems unlikely you’d come to a country that was so unsettled currently.
The additional predicted further drop in the value of the pound, the uncertainty over basics like pensions and healthcare access in the event of No Deal, will only compound that. As a father with a young family I certainly would not move here if I were in that position, and I can’t say I wouldn’t be thinking of leaving myself. Would you?
Is the government doing anything about this?
Dominic Raab, the current Brexit Secretary, has “reassured” EU residents no one will be “turfed out” in the event of No Deal. However, as already mentioned, they haven’t published anything tangible on this as yet.
There is a pilot programme in the North West for up to 4000 EU students and NHS staff to apply for Settled Status, initially for those in 12 NHS trusts. Although a digital process this pilot will require a face to face Home Office appointment. The Home Office has already stated it does not have sufficient staff currently to process 3,000,000 applications, and the initial launch of the “app” in June did not function on half of smartphones, so it remains to be seen how the remaining 60,000 NHS staff will be settled in this way. Whether these terms will change in the event of No Deal is another question hanging over everything.
What about future EU recruitment for the NHS?
The drop in recruitment due to Brexit is creating a worsening shortfall in key departments, increasing the pressure on existing staff and exacerbating increased numbers from all groups leaving the profession or retiring early.
In a No Deal Brexit the U.K. remains a less attractive destination: relatively less pay, new barriers to the immigration process including visa caps as a third country and uncertain settled status.
So in summary the NHS is already in an understaffing crisis, created by under-resourcing and poor workforce planning, exacerbated by cuts to posts and bursaries for recruitment, meaning hopes of new “homegrown” staff to plug the gaps are a decade away. EU staff have been invaluable to maintaining a functioning service but since the Brexit referendum recruitment has dropped off a cliff. A No Deal scenario will only compound the haemorrhaging of staff, in a system where staff numbers are a literal matter of life and death.
With a shortage of medicines, diagnostic isotopes and vital staff, we will require a massive influx of resources and funding to keep the service going.
Resources and funding we do not currently have. If you’re still with us, read on to Brexit and the NHS: Just the Facts. Part 4: Show Me the Money. (coming soon).