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.

A large hospital trust which will likely encounter severe challenges if there is a no-deal Brexit later this month has identified “EU exit fatigue” as one of the key risks facing its organisation. Brexit fatigue is no joke for the health service and treating it will require an early down payment on the NHS People Plan by system leaders, writes James Illman.

Ahead of attending the NHS Providers conference in Manchester last week, I noticed there was not one session on Brexit. On first thought, it appeared strange that no time had been earmarked to discuss the biggest, most unprecedented threat the system has faced in a generation.

But these programmes are, of course, organised long in advance, and perhaps it was felt planning such a session when we know so little about how the cards will fall wasn’t worth the candle.

The beastly Brexit subject naturally reared its head at times, but few of the keynote speakers wanted to dwell on it for too long.

NHS chief executive Simon Stevens dedicated very little time to it in his speech, telling delegates they should simply ignore the politics and focus on their readiness plans, which seemed sensible advice.

The word “Brexit” did not appear once in health and social care secretary Matt Hancock’s speech, and the only reference he really made to it during a Q&A was on his faith the UK could still get a deal, which was hardly a surprise line.

Of course, plenty of Brexit planning, war gaming, unwieldy conference calling and much else rumbles on relentlessly behind the scenes, occupying the minds of a small army of NHS employees and gobbling up increasing amounts of public funding.

It is understandable to some degree why officials want to keep preparations behind closed doors. Little good will come from the general public getting spooked, although the almost sinister levels of secrecy may well prove as equally unnerving.

Another potential reason for the lack of desire for conference producers to have much on Brexit was that everyone, Leavers and Remainers alike, is so bored and tired out by Brexit that appetite for even more debate was minimal.

And here lies a huge potential risk for the NHS, and doubtless to other key sectors of the UK society and economy.

Indeed, Maidstone and Tunbridge Wells Foundation Trust in Kent, which faces significant risk should there be a no-deal Brexit on 31 October, has astutely highlighted “EU exit fatigue” as one of the major risks facing the trust.

A paper on its Brexit preparations discussed at its last board meeting set out four risks: winter, flu season, half term and “EU exit fatigue”. “The repeat of preparations means it is possible that people underestimate the importance or impact of the risks,” it added.

So, what’s the cure for Brexit fatigue? If you find out, do let me know, because I’m suffering a bout myself. Like many complex conditions, the treatment will vary for different patients.

But for the NHS, treatment will largely centre around the fact the service will be hugely reliant on the goodwill of its staff to survive this winter – even more so than normal – so it will need to reciprocate that goodwill… And then some.

The first issue is not in the control of the NHS: resolving, to use Simon Stevens’ choice of phrase in his address to the NHS Providers conference last week, the “pensions crisis”.

The impact of this has been widely covered, so I won’t re-rehearse the argument here, and it is also hugely demoralising for staff that the issue still has not been resolved nearly two years since it was first raised by pay negotiators in early 2018.

As NHS Providers chief executive Chris Hopson pointed out in his conference speech last week, while the focus has been on consultants, other staff groups, including managers and those at the bottom of the payscale struggling to have a decent quality of life, were also being penalised.

On top of addressing the pensions fiasco, the service must turbo-charge efforts to deliver the kind of cultural overhaul Baroness Dido Harding has repeatedly talked about since becoming NHS Improvement chair in 2017.

Staff heading into winter are already being threatened at some trusts by being denied annual leave, particularly around the 31 October deadline.

There may be circumstances when there is no alternative to such a move, but, again, its demoralising impact needs baking into the decision-making process.

And, of course, it is not simply a case of changing culture from board to ward within trusts, but also how system leaders treat local leaders.

As Mr Hopson also pointed out in his HSJ interview last week, changing the NHS’ culture from “aggressive command and control” to “support and improvement first” will be a “clear test” for NHS England and Improvement, particularly this winter.

The NHS People Plan is due later this year and may well provide some of the longer-term answers, but system leaders will need to start walking the walk as well as talking the talk this winter to help mitigate the inevitable winter burnout exacerbated by Brexit fatigue.