Last week the Lancet Public Health published a comment piece by me about the challenges it faces in the near future. This comment was linked to a research article that found a huge increase in elderly people with care needs in the UK population over the next 10 years. This article predicted that 10 years from now there will be a 25% increase in the number of people aged over 65 who have care needs, which corresponds to a numerical increase of 560,000 people. The largest growth will be in dementia-related disability, which may perhaps have been a slightly stinging finding for the government given that Prime Minister May had released a deeply unpopular policy for paying for dementia care in the same week. The article and my comment received some media coverage (see e.g. here), focusing on the impending massive increase in care needs and the risks to the NHS. My article made the point that this growth in elderly people needing care comes at a time when a unique combination of policy challenges confronts the incoming government: an underfunded social care service, an NHS in crisis, a looming workforce shortage, and the risk that Brexit will lead to an immediate loss of staff and a long term reduction in the number of staff entering the NHS. I made the simple point that the British health and social care system needs more money and a commitment to expand the local workforce to make up for the looming drop off in European staff. This is particularly pressing for the social care sector, which unlike the NHS employs large numbers of very low paid staff who have a very high turnover rate and are very often European. Once Brexit hits that turnover is going to bite, because new staff simply won’t be there to replace the high churn rate. There is no solution to this problem except to increase pay and improve working conditions to ensure this sector of the economy can attract British workers and retain them.
The problem is not limited to social care, however: something between 5-10% of staff in the NHS are recruited from Europe, which means that even if the final Brexit deal allows existing staff to stay, over the medium term natural attrition will mean that the NHS needs to increase local recruitment to cover that 5-10% of new staff who are not being recruited from Europe. Worse still, Brexit will hit just as the health workforce hits a wave of retirements of staff recruited from the baby boomer generation, and as junior doctors show increasing signs of burnout and the nurses association is talking about striking to preserve pay and conditions (the strikes themselves will not necessarily be a crisis – though I’m sure Jeremy Hunt can turn them into one! – but the underlying problems they signify will be). It takes 10 years to make a new doctor and about 7 years to make a new nurse, so the entire workforce planning system in the UK needs to be restructured and enhanced rapidly in the next 1-2 years if the UK health and social care system is to be ready to handle this. To be clear the issues are huge: A rapid increase in disability and health risks in elderly British people occurring after a decade of leakage of staff back to the EU, as a generation of older staff retire, and just as the cut to the nurse’s bursary and NHS funding leads to a shortfall in new staff, with no way to make it up through EU recruitment. This will affect every aspect of coverage, quality of care, equality of access, and timeliness of access in a system that is already struggling to handle basic pressures.
Today the Nuffield Trust released a report that adds to the pressures revealed by the article I was commenting on, by discussing additional health system pressures that will arise from leaving the EU. This report finds that:
- If the Brexit agreement does not properly support UK citizens abroad and the welfare sharing arrangements they benefit from, 190,000 elderly Britons will return home and cost the government an extra 500 million pounds a year
- If these elderly Britons return home they will require hospital beds equivalent to two new hospitals to care for them
- If the NHS cannot continue to recruit nurses from the EU there will be a shortfall of 20,000 by 2025
- The 350 million pounds a week that can be saved by leaving the EU was a myth, but in the first two years after leaving there may be more money to pay for health and social care – if the government is willing to spend it
The publication I commented on predicted an extra 560,000 people with care needs by 2027; this Nuffield Trust finds 190,000 more elderly people the study didn’t cover, and suggests they will have significant care needs currently being (basically) paid for by Europe, and it quantifies the shortfall in staff I identified. It’s worth noting that the NHS employs 320,000 nurses, so the 20,000 shortfall is about 6% of the workforce, but this 6% shortfall comes also when a large number of nurses will be retiring, and about the same time as the current reduced nursing student cohort hits the workforce. A lot of these numerical details are very hard to predict, but it appears likely that there is going to be a major reduction in a nursing workforce that is already not well stocked by OECD standards. Nurses are the bedrock of a functioning health system, and although there is no international evidence on the best nursing levels, a rapid decrease in numbers is only a bad thing, especially if combined with a rapid increase in health care demand.
This problem will face whoever wins the election in two weeks, since a lot of these pressures are the result of a Brexit decision we are supposed to believe is set in stone, and population ageing. But any party that does not have a plan to increase the health workforce, to restore funding to social care, and to improve payment, retention, credentialling and work conditions for the workers at the bottom of the social care heirarchy, is not serious about the depth and seriousness of the crisis the NHS faces. Although the Tories like to talk about working better rather than increasing funding, the reality is that the NHS desperately needs more money; and so long as Labour continue to dance around the issue of exactly how they will handle free movement, they present no serious plans to handle the looming workforce crisis. The British people voted for Brexit without having any clear information about what it would mean for the social care sector, while Boris Johnson flounced around the country in a bus that was advertising a clear lie. Now the election looms, and both parties have to come up with policies to handle this unavoidable crisis on a 10 year deadline. I think from a brutally practical standpoint, the real winner of this election will be the party that loses it, because whoever wins is going to be held responsible not just for Brexit’s short term economic damage, but for the long-term health and social care crisis that neither party is properly prepared to deal with.
The NHS needs more money and more staff. Without it, unless the winning party can deliver a truly miraculous Brexit deal, the UK health and social care system is heading for two decades of increasing and unavoidable crisis. I’m not confident that anyone in British politics is ready to deal with this problem, or even listening to the warnings. Let’s hope, for the sake of Britain’s elderly population, that I’m wrong.
Compromise and Conceit 
May 31, 2017 at 7:28 pm
You say that the staffing shortfalls will have “no way to make it up through EU recruitment”, but the UK will still have the option of using immigration to make up any shortfall it just wouldn’t be facilitated by having people move there directly from the EU.
That means it’d have a higher transaction cost (because of the bureaucracy) and may need higher wages (to attract people), but it remains an option.
The main differences are 1) it’s more likely that the people coming in will be from places like Africa or India and 2) the UK will be importing them on schemes that allow for UK citizenship.
So that means that any racist Brexit supporters have actually voted for more non-white citizens coming into the country – more generous of them than you’d expect…
May 31, 2017 at 9:49 pm
You’re right, Commonwealth citizens could provide an alternative to EU citizens, though as you say they will come with a transaction and possibly financial cost that some parties may not be willing to support. I remember Farage was talking a good game about how the UK has more in common with the Commonwealth than the EU, but as soon as it looked like he was going to lose the Brexit referendum he unveiled the infamous poster of non-EU refugees; today we see Theresa May accusing the Labour party of supporting “uncontrolled immigration” because Corbyn said he thought there was still a role for immigration. It’s pretty clear that immigration is not considered a solution to post-Brexit issues by the party that is most likely to win the election, or by the media and political organizations (Daily Mail and UKIP) that are driving their Brexit agenda.
There is another issue here too which Commonwealth immigration likely won’t solve, at least not easily. A lot of the coming problem is in social care staffing levels, particularly in the basic care providers, and these people are paid at or near minimum wage and work in typical grinding conditions. There are a lot of them and the turnover is high. The EU offers an ideal way for the social care system to continue operating under this model, since there is a regular flow of temporary care workers, but it will be very hard to support this industrial model based on Commonwealth immigration unless similar borderless arrangements can be put in place. Without a regular supply of transient labour this industry is going to need a change in employment model, more along the lines of Japan or some other EU countries where low level care work staff are credentialled, offered permanent positions, paid the proper value of their labour, and offered a career structure. There will still be a place for temporary and part time workers but without a large pool of easily-replaced staff it’s impossible to run the current model. The alternative model will require a lot of money, at a time when the councils (which fund social care) are suffering significant cutbacks. To be clear, I think the current model is terrible – it means that elderly people are being cared for by unskilled, underpaid people – but changing to a better model is going to be expensive. (For a discussion of care home employment practices see this Guardian article, which seems well sourced).
I can’t see any way the care home sector can continue to function if they can’t recruit staff and don’t have the money to pay more. But you’re right, an open borders arrangement with a couple of developing Commonwealth countries would do the job … I’m sure Little England is all for such an idea!
June 1, 2017 at 8:50 pm
And then there’s the other way out – loosen prescriptions on opioids, turn a blind eye to alcohol and problem solved as death rates rise. Worked in the ex Soviet Union, is working in the US, why not Britain?
June 4, 2017 at 6:20 pm
I’ll be coming back to a discussion of opiates in a few weeks, I think … I don’t see it as a conspiracy but I do think if people are not getting the health care they need because they can’t afford it, it’s natural for doctors to want to give them pain relief as a kind of work around for their problems. In America given the health insurance problems they have this likely means a lot of people seeing non-specialist doctors infrequently while taking opioids for chronic pain, even though opioids are known to be bad in that situation. This could explain some portion of the problems they have seen growing in the past few years. I also think though that there must have been changes to drug access laws, though I’ve seen nothing about that yet.
The NHS is now starting to ration things like hip replacements. That is surely going to lead to increased use of drugs to manage chronic pain in people who are waiting very long periods for quality care. The results of that will potentially lead to the same problems as the US is seeing.