Ten weeks before Brexit, vital questions are still unanswered

This week Number 10 sent out a script for public bodies to use when responding to media queries about Brexit, as revealed by HSJ.  It was duly forwarded on by the Department of Health and Social Care to NHS organisations with a promise that it would be updated weekly.

In the event of a no-deal Brexit, “all necessary funding will be made available” to support the NHS, health services bosses have been ordered to say.

It puts the vast majority of NHS leaders in the depressing position of perceiving Brexit – and especially a no-deal Brexit – to be really bad news for the NHS but being effectively banned from saying so and having to appear supportive of it.

This bitter pill would perhaps be a little easier to swallow if the DHSC had been as efficient in providing guidance on issues which are literally life and death (public health, staff recruitment, reciprocal healthcare arrangements) as it has been on passing on PR lines.

But, with just 10 weeks to go before the 31 October Brexit deadline, many of these fundamental questions remain unanswered. And some healthcare leaders who have spoken to HSJ are growing increasingly concerned and are questioning the centre’s leadership.

The DHSC would dispute this narrative. The Department insists “robust preparations” are under way. Health and social care secretary Matt Hancock said earlier this month: “I guarantee that we now have all plans in place to make sure that the NHS will be prepared whatever the Brexit scenario.”

And, let’s be clear, there has been some progress.

Ministers have of course made a significant amount of noise around procuring freight and storage to ensure vital drugs and medical devices can still arrive from Europe – an issue at the top of the list of concerns for the NHS.

But we do not know whether they will pull this off, and even so, it remains the tip of the iceberg of known challenges, and that’s before all the unknowns crop up post exit.

Other unanswered questions include: 

• How would the UK coordinate with European partners in the event of a cross-border public health emergency, like a pandemic, after a no-deal Brexit?
• What NHS services will EU citizens have access to after exit day and how will trusts be supported to recover any costs from newly ineligible patients?
• What additional capacity will trusts have to take on the wide range of administrative burdens created by Brexit?

Health secretary’s absence from the top table

One senior NHS source, who has followed the Brexit process closely, told HSJ ministers were underestimating the pain coming the NHS’ way under a no-deal scenario and that health had been sidelined in negotiations.

“Since the referendum, health has not been regarded as a central to informing the government strategy on Brexit, despite the very significant potential risks that various Brexit scenarios post,” the source told HSJ.

They argued a worrying symbol of health’s standing in the government pecking order when it comes to Brexit planning was evidenced by the health and social care secretary’s omission from the prime minister’s powerful EU exit strategy committee, under both Theresa May and Boris Johnson.

The key committee under Ms May had 11 cabinet members with secretaries of state for business, the environment and the Cabinet Office all included while the health secretary (first Jeremy Hunt and then Mr Hancock) was not.

The committee has been pared down by Mr Johnson to include the foreign secretary, chancellor, secretary of state for EU exit and the attorney general. But the absence of the health and social care secretary at the top table is concerning for the NHS.

The concern was this week backed by 17 royal colleges and health charities. They called for Mr Hancock to be put on the committee, now chaired by Michael Gove, in a letter coordinated by the Royal College of Physicians, first reported by the BBC.

“Opaque” leadership and guidance

The government produced guidance for the NHS in December 2018 before the original March Brexit deadline.

NHS chiefs raised concerns at the time that the guidelines did not address several core issues around public health, reciprocal healthcare, cost recovery from EU citizens accessing NHS services and mutual recognition of professional qualifications. NHS England has updated the guidance through a series of letters but trust bosses told HSJ many of the outstanding issues have not been addressed.

One major trust chief executive echoed the sentiments of many when they told HSJ that NHS England’s central support had been conducted in an “opaque” manner, and that they had expected far more direct instruction.

NHS Providers also has fundamental concerns about the state of no-deal preparations.

Deputy chief Saffron Cordery told HSJ: “We need more clarity and reassurance from the government that [the no-deal plans] will be ready for exit day at a time when trusts will be in the middle of steeling themselves for a busy winter.”

Ms Cordery cited supply of medicines, particularly those that cannot be stockpiled, and medical devices as an area of major concern.

But she added: “We also need greater certainty on what services EU citizens will have access to after exit day and how trusts will be supported to recover these costs. This risks placing a significant and immediate additional administrative burden on trusts.”

Confed optimistic

The NHS Confederation, however, struck a more optimistic tone. “We have done what we can and healthcare now seems to be one of the most prepared sectors for a no-deal Brexit,” it said.

Chief executive Niall Dickson added: “The [DHSC] and the NHS have been working well together, and NHS organisations have thought through the implications as best they can.”

Many will find it hard to share the optimism. There will doubtless be unknown challenges under a no-deal Brexit. So, with even the known challenges not squared off, the system looks increasingly vulnerable, especially as winter pressures will be cranking up at exactly the same time. The last thing the NHS needs is a load of guidance dumped on it at the 11^th hour, so if further advice is to be issued, it needs to be done so promptly.