Welcome to the ‘About that bus…?’ weekly newsletter – giving you the inside track on how the fallout from Brexit is affecting the NHS at national and local level, edited by James Illman Contact me in confidence.

The Yellowhammer documents released last week should focus NHS minds on the need to ratchet up lobbying efforts. Avoiding the social care crisis likely to materialise after a no-deal Brexit – which will need improved funding and policy change – is the most pressing issue, writes James Illman.

The Operation Yellowhammer documents published by ministers last week contained no new revelations for those who have been watching the Brexit process closely. However, the publication of the short but highly controversial five-page document on the possible impact of a no-deal Brexit, Operation Yellowhammer HMG reasonable worst case planning assumptionsis still a highly significant moment.

There can be no pretense now that the warning of potential public disorder, food, energy and medicines shortages are “out of date” – as the government claimed when the Sunday Times published a leaked version of the document – or exaggerated.

It’s all there in black and white – even if the government did try and downgrade the document from a “base scenario” as reported by the newspaper, to a “worst case scenario” as the published copy purported to be.

The specific NHS-related issues are listed under point 6 (medical supplies shortages and disease outbreaks). Transport chaos at ports and on major roads, power outages, rioting, and fresh food shortages would also all impact the NHS.

However, it is point 20 (social care fragility) which perhaps poses the greatest single threat to the NHS. It is certainly the issue which is causing senior policymakers most concern.

On directly-related healthcare issues, preparations have been reasonably robust. As the NHS Confederation’s Brexit expert Layla McCay told HSJ last week, the Department of Health and Social Care “has probably done as much as it can do to make sure there won’t be [drugs] shortages”.

This is simply not the case for social care. The post-no-deal Brexit social care system, already reeling after years of local government funding cuts, faces a triple threat.

First, there is the risk large numbers of the circa 104,000 EU nationals working in the sector will leave their jobs, if not the country altogether. There are concerns care workers could take similarly paid but far less stressful warehouse-type jobs in the run up to Christmas, or they may go home for Christmas then not return.

Second, as Yellowhammer rightly highlights, the sector’s already financially fragile providers could be pushed over the edge if inflation rises and pushes up the costs of staff and supplies. 

Third, it also faces the same issues around medicines shortages, which are a major concern for the NHS. 

So, what can the NHS do about it?

As HSJ reported this month, NHS England’s Brexit chief Keith Willett has told NHS and social care providers to work together to mitigate the risk, and suggested staff-sharing arrangements would help.

“As a trust if you’re going to lose the nursing bed element of a care home because they can’t retain nurses then it would be in your interest to support them so those beds stay open and your delayed transfers of care are not compromised,” Professor Willett said.

This is sound advice but, with the NHS itself struggling with huge staff shortages, it is unlikely trusts will have much spare capacity to share.

There may therefore be a limited amount the service can do in practical terms. But the NHS does have considerable powers of political persuasion and the ability to impact government policy beyond its bailiwick.

In June 2016 – the same month the UK voted to leave the European Union – NHS England chief executive Simon Stevens publicly made the case ministers should prioritise social care over the NHS in the Budget, as reported by HSJ.

Mr Stevens continued to press this point and, the following March, then chancellor Philip Hammond allocated an extra £2bn into adult social care spending as the health and social care sectors went about trying to address delayed discharges.

With team Johnson-Cummings declaring the NHS their number one domestic priority, Mr Stevens et al have the scope to exercise influence on behalf of social care’s much less powerful lobby.

More than 90 per cent of care workers earn below the proposed £30,000 salary threshold that could be required to obtain a visa after Brexit and 8 per cent of staff are of EU nationality. Of course, that ratio is much higher in certain areas of the country, such as the South East.

There remains considerable confusion around the deadline for settled status applications, and the very large proportion of EU nationals yet to apply.

These low earners are also exactly what a certain Brexit-promoting Tory faction, who demand we “take back control of our borders”, would classify as “the wrong kind of immigrants”, taking jobs from British workers.

Think tanks the King’s Fund, the Nuffield Trust and the Health Foundation warned this month the social care workforce already has 110,000 vacancies and that, if even a small number of the EU nationals working in the sector leave, the stress will become even more intolerable.

The £30,000 salary threshold is, however, under review. Business and education bodies have this summer been calling for it to be lowered to £20,000, a proposal set out in the Home Office’s immigration white paper, published in December 2018 and still out for consultation.

Campaign group Migration Watch predictably said such a move would be “shocking”.

The NHS must make sure it has a decisive say in this debate, not least because it also has 100,000 vacancies, many of which are in pay bands below £30,000.

Prime minister Boris Johnson’s government has already acknowledged the parlous state of the social care sector with a £1.5bn boost for 2020-21 in the one-year spending review this month.

Extra money next year will, however, be of no little comfort should the social care system completely buckle this winter, taking the NHS down with it.

Plans for some form of Brexit pressures war chest to support social care providers and a cut in the salary threshold are the least the government should be drawing up in preparation for what is going to be a beastly winter if the UK crashes out without a deal on 31 October.