What Implications Will Brexit Have for Integrated Care Provision? Ltd Teresa Burdett, Lee-Ann Fenge Policy of Delivering Integrated Health and Social Care Provision

BREXIT AND HEALTH

What implications will Brexit have for integrated care provision? Ltd Teresa Burdett, Lee-Ann Fenge policy of delivering integrated health and social care provision. A move towards integrated health and social care provision has been a key policy driver in the UK since 2010, underpinned by a On 14 November 2018, the belief that this is essential to provide holistic, person-centred care proposed withdrawal agreement while transforming service provision. Progress towards achieving for the UK to leave the EU integrated care has been slow, and now Brexit poses a further was published, and alongside challenge, as attention is focused on preparations for a ‘no-deal’ Cabinet resignations resulting scenario. Ensuring that the NHS and social care systems are able from its overall focus, it has been to continue to function after March 2019 is now a key concern criticised for its lack of detail on for those leading and managing frontline services, and measures the future of health care across are being put in place to deal with potential disruptions caused the EU. The European Federation by a no-deal Brexit. This includes dealing with issues related to of Pharmaceutical Industries the recruitment and retention of European economic area (EEA) and Associations has expressed staff into the NHS, disruptions in the supply of medicines across concerns about its lack of specific European Union (EU) borders, challenges to the recognition details addressing ‘health issues of professional qualifications and patient safety, and health important to patients and the protection and health security within the UK post-Brexit. The wider public health’ (Andalo, 2018). imperative to prepare for a worse-case scenario diverts attention away from other key policy drivers, such as integrated care PeopleAt the time of writing, the provision. It may also serve to reinforce a view of integration as Prime Minister, Teresa May, is a cost-cutting exercise, rather than as an approach to promote facing opposition from both better care for patients. A move towards the transformation of care within and outside her party as through integrated provision offers real potential for improved she attempts to gain approval for patient outcomes in the future, and a revitalised health service. the draft withdrawal agreement. However, Brexit has the potential to disrupt the integration With possible challenges to her agenda as financial resources and staff time become focused on leadership, the potential of a dealing with the fall-out from Brexit, rather than on frontline no-deal Brexit is growing. The patient care. Community and practice-based nurses and staff are government is already making in the frontline of integrated service provision, and in the next contingency plans for the event of few months may be some of the first staff to witness the negative a no-deal Brexit, and, in August impact of Brexit preparations on the provision of integrated care. 2018, the Secretary of State for Health and Social Care wrote to all KEYWORDS: health and social care  Brexit  Integrated care  Workforce development organisations to inform them about  Implications for practice the government’s preparations for this eventuality. These considerations include measures ince the publication of to ensure the ongoing supply the authors’ paper on the of medicines, the regulation of Spotential impact of Brexit medicines and clinical supplies, on community health services the quality and safety of blood (Burdett and Fenge, 2018), little supplies, and employment has changed regarding firm protection for members of the Teresa Burdett, senior lecturer in information on the terms of Brexit workforce from the EU (NHS integrated health care, professional lead for for the UK. With less than five European Office, 2018). interprofessional learning and education, unit lead for foundations of integrated care months to go until the UK leaves and person-centred services; Lee-Ann Fenge, the EU, there is still uncertainty This paper explores the impact professor of social care and director of the around the implications of of Brexit on the integration agenda Centre for Seldom Heard Voices, both at Faculty of Health and Social Science, Brexit for health and social care for health and social care, and Bournemouth University provision, and its impact on the considers what the implications Woundcare JCN 2018, Vol 32, No 6 57 BREXIT AND HEALTH

of this might be for community and social care system provide However, there are also challenges healthcare provision in the UK. accessible, comprehensive and to integrated care (Goodwin et al, co-ordinated services to a 2013; Liberati et al, 2016; Burdett, The integration of health and population in the community. 2018), including tensions around social care has been a policy new ways of working, resource initiative since 2010 (Department implications and partnership of Health [DH], 2012; NHS changes. Brexit has now thrown England, 2014). In the past decade, ‘In 2017, a survey found that a curveball into this maelstrom funding has been applied to the 61% of doctors from the EEA of change, posing immediateLtd integration agenda in the form of were contemplating leaving challenges to those who lead and Better Care funding to support a the UK... 91% declared that develop health and social care move towards improved integrated Brexit had played a part in provision within the UK. practice and working together. their decision.’ Concerns about the implications There are a number definitions of Brexit are being voiced by a of integrated care, but the variety of different sectors in definition by the National This definition incorporating society. In September 2018, the Collaboration for Integrated Care a comprehensive service clearly British Medical Association (BMA) and Support (2013) resonates with resonates with community issued a stark warning about the nurses and care staff: practitioners’ desires for the potential challenges posed by a Integrated care... is the means individuals they provide care for. no-deal Brexit and the uncertainty to achieving high-quality, it creates regarding the migration compassionate care resulting The move towards integration and qualification status of future in better health and wellbeing, has been ongoing, and in 2017, EU nationals wanting to come and and a better experience for NHS England published its aim work in the NHS or social care patients, service users, their to ‘use the next several years to sector. In 2017, a survey found that carers and families. make the biggest national move 61% of doctors from the EEA were to integrated care of any major contemplating leaving the UK, However, Valentijn et al (2015) western country’ (NHS England, and a staggering 91% declared that defined integrated care in the 2017: 31). This has resulted in new Brexit had played a part in their community arena as: models of care emerging, includingPeople decision (General Medical A network of multiple the integrated care systems, which Council, 2017). professionals across the health signify a significant and deep- seated change to the way the NHS The uncertainties surrounding currently and historically works, rights to work and live in the UK ▼ Practice point including a move away from have resulted in the UK appearing competition to co-operation and a less attractive option to health The integration agenda has the collaboration (NHS England, 2014). workers from the EU (Fahy et al, potential to positively impact upon 2017). If, following Brexit, medical the health and social care arena It is believed that integrated qualifications gained in the EEA in a variety of ways, including care can bring many benefits to are not automatically recognised in the evolution of new care models the UK health and social care the UK, and vice-versa, this would (King’s Fund, 2018) and integrated landscape (Ham and Curry, further disrupt the UK’s health care systems (Charles et al, 2018), 2011; National Collaboration for workforce. In turn, such disruption which result in improved Integrated Care and Support, to the current and potential patient outcomes. 2013; Burdett, 2018). These include workforce may undermine enhanced person-centred care integrated working. This may The community nurse and care where the uniqueness of the be exacerbated if social care worker are at the heart of this individual is valued and they are employment is perceived as less process, often witnessing first- situated at the centre of their attractive than similar employment hand the beneficial impact that own care (Manley et al, 2011; in the healthcare sector due to integration has on the lived Parish, 2012). These features different pay and conditions. experience of those they care are particularly important for for. More than ever before, it is vulnerable patient groups who A recent study by Read and important for those on the front are increasingly being cared for in Fenge (2018) found that the private line of integrated service provision community settings. nursing/residential care sector, to be vigilant about the impact of which requires qualified nurses Brexit on health and social care Integrated working also enables in its workforce, is particularly provision, and to advocate for better use of existing resources, concerned that it will be unable their patients during this time of including nursing and care staff, to compete for migrant workers significant change. finances, and equipment, which if the pay and conditions offered can help to reduce duplication. by the NHS are more attractive. 58 JCNWoundcare 2018, Vol 32, No 6 BREXIT AND HEALTH

Ultimately, challenges in recruiting countries capitalise on this and also suggests that the government staff into the social care sector recruit UK-based nursing staff. plans to introduce caps for low- will undermine ‘integrated care’, skilled workers from the EU and Brexit has increased existing While reading around this post-Brexit, which could result in workforce challenges (Marangozov subject, the authors have seen a devastating consequences for the et al, 2016), particularly for number of adverts encouraging social care sector. employers who have become nursing and social care workers increasingly reliant on EU staff to to move abroad, including to There is also governmental fill workforce vacancies (Bungeroth countries not previously viewed discussion about limiting residencyLtd and Fennell, 2018). as the obvious choice, such as to two years. This will further Norway and Sweden. Other groups heighten recruitment issues Staffing issues cross all borders. may well be affected, including and increase challenges for the In April 2018, the DH revealed physiotherapists — 9.7% of social care sector, which already that it could be hit by a severe which currently come from EEA faces severe workforce shortages shortage if immigration laws are countries (Dolton et al, 2018) — resulting from long-term issues altered (Harrold, 2017). The Royal who may well choose to seek their around low pay and low status, College of Nursing (RCN) has opportunities elsewhere. which can act as disincentives for also warned that Brexit poses an care-sector employment (Skills for immediate risk to the provision of Care, 2011). safe and effective care for patients ‘Other countries may in the UK and requests a second now offer more attractive A projected shortfall of 250,000 referendum on the final Brexit deal healthcare staff by 2030 (Health (RCN, 2018). employment opportunities Foundation et al, 2018) cannot be to migrant staff, and the ignored, and the indecision around In the community, there has UK may lose out as other Brexit only serves to exacerbate been a reduction in nurses who countries capitalise on this the potential staff loss that will have qualified to become district and recruit UK-based continue to undermine the drive nurses, with numbers decreasing for integration. by more than 10% in 2017 nursing staff.’ (Queen’s Nursing Institute [QNI], Staffing challenges across the 2018). This negatively impacts on Peoplehealth and social care sectors frontline staff and the vulnerable Even in a scenario where the require a holistic response that patients that they care for. UK’s Brexit deal results in minimal addresses the long-term lack risks to the future recruitment of of parity in pay and working Brexit has resulted in staff EEA staff, the NHS already faces conditions across the two sectors. from the EU/EEA feeling massive workforce challenges as a Developing integrated care unsettled at a time when global result of ongoing staff shortages. requires vision to deal with the demand for nurses is increasing. In the authors’ opinion, these may staffing challenges and an ability Other countries may now offer undermine person-centred service to engage a wide range of provider more attractive employment delivery and moves towards joined- organisations in the development opportunities to migrant staff, up integrated service provision of innovative joined-up provision. and the UK may lose out as other across health and social care. Failure to do this will undermine the potential of truly integrated A recent report by the Health service provision, resulting in ‘ring- Foundation et al (2018) suggests fenced monopolies’ where NHS Staffing that staff shortages in the NHS providers attempt to do everything ▼ challenges now present a greater threat than themselves (Hare, 2018). funding challenges. Integrated The NHS already faces massive provision is reliant on partnerships Another challenge to the workforce challenges as a result across health and social care successful implementation of of ongoing staff shortages. agencies, and staff shortages in integrated care is the potential The Health Foundation et al both these sectors can undermine funding deficit in NHS budgets (2018) projected a shortfall of innovative ways of working that resulting from extra costs 250,000 healthcare staff by promote seamless person-centred associated with a no-deal Brexit. 2030. Developing integrated care provision. Indeed, the Health This may well lead to less spending requires vision to deal with Foundation report stresses that, in the NHS (Portes, 2018) at a time staffing challenges and an ‘the NHS workforce cannot be when there is increasing demand ability to engage a wide range viewed in isolation from the for health and social care provision of provider organisations in the challenges facing the social care (Dolton, 2017). The Nuffield Trust development of an innovative, workforce’ (Health Foundation et has recently suggested that the joined-up provision. al, 2018: 12). A recent report in the NHS is facing up to £2.3bn in extra Independent (Matthews-King, 2018) annual costs by the end of 2019/20 Woundcare JCN 2018, Vol 32, No 6 59 BREXIT AND HEALTH

owing to a sharp rise in red tape care has massive implications for and trade barriers if the UK has community healthcare provision, KEY POINTS a no-deal Brexit (Dayan, 2018). but the current uncertainty about Funding deficits have the potential the implications of Brexit may  Integrated care can bring many to derail progress towards undermine integrated policy aimed benefits to the UK health and improved integrated provision at improving seamless integrated social care landscape. and ultimately undermine person- provision for patients. centred provision.  Preparation for worse-case Community and practice-based scenarios surrounding BrexitLtd IMPLICATIONS OF BREXIT nurses are placed centre stage diverts attention away from ON INTEGRATED CARE in the move towards integrated key policy drivers, including provision and may witness integrated care provision. As we move towards the first-hand the consequences of integration of health and social Brexit on the integration agenda. care provision, recruitment issues Community nurses are important  Uncertainties surrounding within the social care workforce advocates for frail and vulnerable rights to live and work in the may prove particularly challenging patients and need to remain UK have resulted in the UK for community and practice- vigilant to the ways in which Brexit appearing a less attractive based staff whose patients rely might undermine both integrated option to EU workers. on packages of care. Current provision and person-centred debate around Brexit continues practice. As we continue in a period  The NHS could experience to polarise society and exacerbate of uncertainty and confusion, it is a severe staff shortage if the differences at a time when vital that community practitioners immigration laws are altered. individuals, professional bodies uphold their professional values, and organisations need to integrate which have the patient at the  Staff shortages may result and work together further. centre of practice. JCN in inadequate social care packages being provided The current disarray in the community. surrounding Brexit and the UK’s withdrawal from the EU is resulting REFERENCES  As we continue in a period in a paralysis of action, which is People of uncertainty and confusion, impinging on the development, Andalo D (2018) Dismay at lack of detail it is vital that community formation and improvement of on healthcare in Brexit withdrawal practitioners uphold their integrated care in the UK in a document. 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Int J Integr Care-Social-Care/standing-at-a- National Collaboration for Integrated Care Care 15(4): 1–18 Woundcare JCN 2018, Vol 32, No 6 61 Copyright of Journal of Community Nursing is the property of Wound Care People Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.