Steve Fouch

NHS staffing, funding and culture after ‘Brexit’ – Christian reflections

Steve Fouch is CMF Head of Nursing, and formerly worked in community nursing, HIV & AIDS and palliative care. He serves on the International and European regional boards of Nurses Christian Fellowship International.
The views expressed do not necessarily reflect those of CMF.

MedicalA week is a long time in politics, it is said. But few weeks could have been quite as momentous or eventful for the citizens of the United Kingdom as this last one. Whether you awoke to the news on 24 June with joy or dismay (or indifference), it is hard to deny that a massive change is taking place as a result of the referendum vote to leave the European Union.

A lot of emotions have been stirred up, with some unpleasant words spilled on social media between the ‘Leave’ and ‘Remain’ camps and their supporters. More worrying has been a 57% increase in reports of racist abuse against migrant communities and ethnic minorities in the last week. Meanwhile the political leadership of the country is in turmoil with three party leadership campaigns triggered by the results, and currency and stock markets have undergone considerable turbulence.

Where does this change leave our health service, and how should Christians in the health professions be responding?

An International NHS

Firstly, we all know that we work in an internationally diverse nation and an even more diverse health service. 11% of all staff working in the NHS are not British nationals, but that is not the full picture. 14% of clinical staff are from outside the UK, and 26% of all doctors are expatriates. When the BMA said the NHS could not work without migrants, they were not exaggerating.

However, while the European Union has provided a significant proportion of these, the biggest expatriate nationalities working in the NHS are from outside the EU. Doctors from India make up 7% of the medical workforce, and nurses from the Philippines nearly 3% of NHS nurses. In fact, after British nationals, Indians and Filipinos make up the two largest groups of NHS workers. Ireland has the fourth highest number of staff in the NHS, followed by Poland, Nigeria, Zimbabwe, Portugal, Pakistan, Spain and Germany.

The reasons why we have recruited so actively outside of the UK and the EU are fairly straightforward – India, Pakistan, The Philippines, Zimbabwe and Nigeria train their medical and nursing staff in systems very similar to our own, and in English. But also, we are not training enough clinical staff of our own – especially not nurses. As a Norwegian counterpart of mine recently said, nursing is the spine of healthcare – without nurses, the system collapses, and yet we have a growing recruitment problem.

We need well-trained migrant staff in the NHS and it is very unlikely that any government would change migration rules to put those currently working in the health service at risk of not being able to stay and continue in their posts. Post-EU however, it may be harder to recruit and retain staff from Europe. At the same time, while we can recruit from many other parts of the world, we have to be mindful of the ‘brain-drain’ impact of taking health professionals from developing nations, and continue to work creatively at supporting the development of health services and professional development in those nations.

Migrant health workers are vital members of our teams; they are our colleagues, friends and neighbours, and we need to be encouraging and supportive of them, especially in the current climate. I have heard some Europeans working in the UK say that they feel the ‘Brexit’ vote was a personal attack – they need to know that this is not the case. Initiatives like the Safety Pin campaign can be a simple way of saying to them that they are welcomed and valued, and to stand against a vocal minority who have viewed the vote as a chance to air their intolerance.

The NHS and the Brexit Economy

But staffing is not the only issue. The economic impact of Brexit is an unknown quantity.

The initial falls in currency and stock markets may well resolve over time, but could well remain volatile until the next steps in the process of leaving the EU are clearer. The real issue will be just how costly the disentangling of British and European institutions will be, the impact of new trade and immigration deals, and so forth. The likely scenarios that most economists have put forward suggest that we will be looking at an economic downturn, at least for the short-term.

With a growing number of NHS Trusts falling into deficit, and with a recognised £30 billion funding gap facing the NHS by 2020, it was already clear that the NHS was facing a financial crisis long before the referendum. Where the vote to exit the EU leaves the situation is less clear.

One of the most controversial claims in the ‘Leave’ campaign was that an extra £350 million a week would be available for the NHS if Britain voted out. The figure was disputed widely, and there has been some back-tracking since the result was announced. In reality, we do not know how much money will be saved after the two year exit negotiations come to an end – we may have more or less available, depending on the state of the economy and trade deals that have been struck. Furthermore the government may have other priorities for any savings made by that stage.

This means that there will almost certainly be no new money for the NHS in the foreseeable future, unless there is a recovery in the economy or the new government substantially changes its spending priorities. We do not yet know what priority health spending will have in the new government that will be formed in September. The long term impact is even harder to predict, but it is clear that the future funding of the NHS will continue to be huge political and economic challenge.

Furthermore the fall in the pound may well have an impact on the value of the remittances that expatriate health workers are able to send to their families overseas, especially if they come from stronger currency areas.

Wider reform and reorganisation of the NHS is very unlikely in the medium to long-term, simply because every civil servant in the UK will be tied up with dealing with ‘Brexit’ at some level or another for at least the next two years.

However, many in the health service unions and professional bodies are concerned that the loss of the EU Working Time Directive might have an impact on NHS staff. While the new Junior Doctors contract has working time safeguards built in, the ‘Agenda for Change’ contracts for non-clinical staff do not have any such provision, and would need to be renegotiated, along with a number of other workplace rights and protections that come from EU law.

A Challenge for Christians

Whatever our views, this will be an uncertain time of change. Scripture reminds us that, even when the social and political system around us is in turmoil, God remains in control and is working out his plans (e.g. Psalm 75:3). So while it is right that we should be concerned about what is going on around us, we should also retain confidence in God, and not be fearful.

Christians are being urged to be unifiers and peacemakers in this situation – to support one another regardless of how we voted, to care for and support our migrant neighbours and colleagues, to avoid the class, generational and geographical factionalism that has opened up between ‘Leave’ and ‘Remain’ voters, and to work together to make a post-EU United Kingdom into a nation that has justice, kindness, tolerance of difference and welcome at the heart of its values.

I would go further, and say this is also an opportunity to see that Good News of the Kingdom of Heaven shared and lived out by the church in this land as never before. We need to be living out that gracious good news in our workplaces and neighbourhoods and bringing together those who this vote has torn asunder. We need a deeper resolution to these divisions than a purely political or economic one, because the divisions that have emerged after the vote have been there all along, only they have been hidden or unacknowledged for a long time. First and foremost we need the spiritual transformation of individuals, communities and the whole nation that only the Gospel can bring.

If our health service is to flourish and continue to be a world leader in providing universal health coverage, we also need to stand up for these values in our NHS. Justice, fairness, accountability, compassion and equity must not and need not be lost just because we have left the EU – they are there in the bedrock of our nation and our health system, their roots to be found in the Christian foundations of British society. However they need to be defended and not taken for granted through all the changes that are to come.

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