2016 was a year of historic turmoil and change. While the NHS faced workforce shortages, growing demand and very tight funding, Brexit and the subsequent change of government have transformed British politics. Where does this leave the health service going into a new year?
As Martin McKee described in his BMJ blog, Brexit means uncertainty and a high level of confusion for the UK and the NHS. Much has been written about the impact on the significant number of EU clinicians and other staff who make a vital contribution both to health services and social care. Those who are here now face uncertainty over whether they can remain, while those who are needed to fill gaps in the workforce have seen their potential salary devalued by over 15 per cent with the fall in the value of the pound.
Some of the rhetoric from prominent politicians has not helped here. This comes at a time of serious staff shortages in certain fields and unprecedented reliance on European migration, which now accounts for a third of all newly registered nurses, to keep up with demand. There are already a number of reasons to be concerned about the workforce: this could be the last straw.
There are also growing concerns about the impact on research, as well as a number of longer-term concerns about public health, disease control and reciprocal arrangements for health care. If this last issue is not resolved, we could see the return of many pensioners to the UK just at the point when the system is short of staff and when we are excluding tax-paying migrants.
The economic shock from Brexit, while less immediately severe than predicted, nevertheless will be very negative in the longer term. Growth is likely to slow and inflation to rise. The OBR forecasts a £20 billion deterioration in the public finances by 2020, with other studies being even more pessimistic.
The few potential upsides of Brexit for the NHS, which include the scope to change aspects of working time rules and the legislation that requires competitive procurement, are a long way off. In the short term these will simply be converted into UK law, and they may still be required under post-Brexit treaties. The record of the Department of Health in representing the interests of the NHS in matters relating to Europe is not impressive.
There are implications for the NHS too from the fall of David Cameron’s government. The first, unexpected, one is that the unwritten deal between No.10 and 11 and NHS England, which seemed to promise a further look at health and social care spending to get through the very lean years of 2018/19 and 2019/20, now appears to be off the table. The strong connection between NHS England and the Prime Minister and Chancellor has been lost. The new incumbents see the last few years very differently. They feel that while they made huge cuts to the police and Ministry of Defence, the NHS failed to reform and has become inefficient. Any evidence offered to the contrary is treated as special pleading.
Meanwhile the continuing divisions in the Labour party, its poor showing in the polls and its lack of a coherent position on Brexit or free movement of people means that there may be relatively little scrutiny and pressure on the government even as NHS performance deteriorates.
All this sums up to a more fundamental risk: that the attention of politicians and the civil service will be consumed by Brexit and its consequences in 2017 and beyond, and they will be reluctant to engage with issues in health and social care. Whether the growing problems in the NHS will intrude into this bubble with sufficient force, and whether this will lead to helpful and creative solutions, remains to be seen.