• Trusts should boost their charging teams to collect fees from EU patients in the event of a no-deal, though this may be quickly reversed
  • NHS Brexit chief reveals top fears are loss of social care staff and “behavioural change”
  • Keith Willett says NHS better prepared than in March for no deal, but winter would make it more difficult
  • EU staff have not left the NHS as feared, he says

The NHS’ Brexit chief has said trusts should grow teams to be ready to charge some European Union patients in the event of a no-deal, as government ”will want to see a visible change”.

NHS England’s EU exit strategic commander Keith Willett said, in a wide-ranging update at the NHS Expo conference today, that in the event of a no-deal Brexit, trusts would be legally obliged to charge patients from EU countries who are not eligible for free healthcare.

UK residents originally from EU countries will continue to be eligible for free NHS care even under a no-deal, under current government plans, but non-resident visitors from the EU - will no longer be. 

Professor Willett said the NHS “doesn’t have a big charging structure” and carries out a “limited amount of activity”, meaning the legal obligation has historically not “always been implemented”. 

“Clearly this is a new shift and, from a government perspective, they will want to see a visible change around this,” he said.

“So what we’re saying to NHS organisations is you will need to beef up your overseas management teams in preparation for this.

“The slight awkwardness about it is that after a no-deal there’s an expectation that some countries – particularly those that have a large number of UK nationals living in them – will want reciprocal arrangements quite quickly. So this could be something we set up and have to do but then may need to take down again.”

Professor Willett also revealed at the event that his two main concerns were social care staffing, and “behaviour change” because of fears about a no-deal compromising NHS readiness.

He also said:

  • The NHS is better prepared for a no-deal Brexit than in March, although there will be “less headroom” going into winter;
  • Trusts’ plans are currently being assessed by the centre; and 
  • The NHS has not seen the “scare” of staff from EU countries leaving the health service.


While the NHS would start a no-deal scenario from the “difficult position” of a workforce shortage, Professor Willett said his greater concern was the knock-on effect of social care staff leaving the sector.

He estimated social care staff support up to 450,000 beds in domiciliary care and care homes, compared to the NHS’ 100,000 beds.

Professor Willett said the social care workforce, of which 7.5 per cent are EU nationals, was “vulnerable” because there is no salary structure such as Agenda for Change, staff on zero-hour contracts could be paid more by companies like Amazon and John Lewis, and a further decline in the pound’s value could lead to foreign staff moving to other countries to send part of their wages home to their families.

A “significant loss” of social care workforce would have an “immediate effect”, putting more demand pressure on the health service, he said.

He said NHS and social care providers should 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.

Around 6.5 per cent of staff in the NHS are EU nationals, and there are more EU nationals working in the NHS now than in June 2016 when the EU referendum was held, Professor Willett said.

He added that the number of EU nationals leaving the NHS in the last two years has been “more than compensated by applicants from the rest of the world”, but he accepted there were certain geographical areas and work groups that had been adversely affected by EU staff leaving.


Professor Willett said the biggest risk was posed by people changing their behaviour unnecessarily which could itself create problems.

“The NHS is all about managing this sort of thing,” he said.

“That’s what we do on a day-to-day basis, whether you’re at the bedside with a patient, the bed manager, or running an organisation…this is a broader version of those and the NHS has always managed this and stayed calm.

“Having lived this the last nine months, I think the fundamental difference right now is that there’s a much greater fear there will be no-deal in October. What we’re starting to see is behavioural changes in public, staff, organisations and industry that we didn’t actually see ahead of the March [exit] deadline.”

He said this was concerning because behavioural change, such as stockpiling, risked eroding the government’s mitigation plans.

“We need to remain calm and steady and make sure we get information to our frontline clinicians, managers and commissioners so they can reassure people they’re working with, and the right behaviour then follows,” he added.

Freight capacity

Ahead of the March deadline the government bought ferry tickets to ensure the NHS could access medicines and equipment if the ports in Kent were subjected to long traffic delays.

The process is similar this time but “smarter”, according to Professor Willett. This time the Department for Transport is procuring a framework which will allow for more flexibility, as last time too much capacity was purchased.

The emergency shipment channel is also in place again, though it is now called the “express channel”.

However, there is an “uplift” in the amount of freight capacity the NHS may require because winter is around the corner.

“Going into winter we know there will be less headroom in the system,” Professor Willett said.

“We know the impact on urgent and emergency care, we use more products during winter, plus there’s the potential for adverse weather and the seasonal impact of illness during winter.”

He said the NHS is “aligning” winter pressure plans with “any EU exit planning” at local and regional level, but stressed the need for trusts to keep their Brexit, emergency planning preparedness and response, and winter planning teams separate to ensure they have capacity to focus on each of the three areas.

Fresh government planning assumptions for the impact on ports and other updates is expected next week.


This year the UK will have more flu vaccines “than we’ve had in years”, Professor Willett said.

He said Public Health England is “comfortable” with the amount, although one of three tranches of Sanofi’s quadrivalent vaccine (for people aged under 65 with long term conditions) will arrive after 31 October due to a delay by the World Health Organisation – meaning it may have to transported to the UK through a different route. However, Professor Willett said: “We don’t anticipate it being a significant problem.”

Updated 5 September at 5.30pm to clarify that while some UK residents will no longer be eligible for free NHS care even under a no-deal, under current government plans, many will continue to be.