Both the UK Government and the Welsh Government must ensure that the health and social care needs of the population of Wales are not negatively impacted by the UK’s exit from the European Union (EU). Wales’ relationship with the EU has had a substantial direct and indirect impact on delivery of health and social care within the UK. It is critical that patient safety standards, public health, quality of care, and the workforce supply chain are not adversely affected by the forthcoming process of change or resulting outcomes.
Nursing staff, and the wider health and care community, are central to the successful delivery of health and social care in Wales. Their needs and the needs of the future workforce should be considered carefully. The UK’s exit from the EU is likely to have a profound impact on the existing and future nursing community in a wide range of areas, ranging from workforce strategy and planning, regulation, standards, public health, research, employment and social law and cross-border exchange.
The following issues should be considered as part of the inquiry into Wales’ future relationship with the EU:
The sustainability and stability of the nursing workforce in health and social care is crucial to the delivery of health and social care services in Wales. Any impacts on the recruitment or retention of the nursing workforce must be monitored closely.
The exact figures for the number of EU nurses and the healthcare workers in Wales is not known, although it is understood that around 1000 EU nurses currently work in the NHS in Wales. The Royal College of Nursing Wales would welcome this data being collected and being published, including for the independent sector where the picture is particularly unclear. If the Welsh Government has conducted its own assessment of these figures then this information should be shared widely.
At a UK-wide level we have already seen a significant impact in terms of numbers of European Economic Area (EEA) nationals leaving the UK and a huge drop in numbers of EEA nationals applying to work in the UK. Figures from the Health Foundation in December 2017 showed there has already been a 96 per cent reduction in the number of EU nurses coming to the UK, post Brexit. This sharp fall has coincided with a sudden increase in qualified EU professionals leaving the NMC register: from 2,435 in 2015-16 to 4,067 for 2016-17 – a rise of 67%.
The EU currently sets the minimum training standards that nurses responsible for general care (adult nursing in the UK) and midwives must meet to be eligible to register and practise in their home member state and across the EU. These standards are set out in Directive 2005/36/EC on the Recognition of Professional Qualifications (the Directive). This means that many EU educated nurses can easily register with the UK regulator of nurses and midwives and thus able to practice in Wales. The future of this directive is unclear. Any movement away from this directive may reduce the quantity of skilled nurses and midwives readily, and will restrict the freedom of UK residents to pursue their chosen careers across the EU. Indirectly there is a potential impact on the UK’s higher education and training system more generally.
It is important that a coherent workforce strategy is developed in Wales and UK-wide which aims to maintain and grow the domestic health and social care workforce, as well as preserves the rights of EEA nationals currently working in the sector.
A substantial proportion of UK employment law originates from the EU and provides important protections for nurses and healthcare support workers. In particular, these protections cover things such as health and safety at work, working time, consultation on collective redundancies and safeguarding employment rights in the event of transfers of undertakings (TUPE).
The EU’s key health and safety related directives have been proven to significantly reduce the risks for nurses and patients. They provide a legal framework for employers to reduce the risks of musculoskeletal disorders (MSDs), biological hazards, stress and violence to health care staff.
The Working Time Directive provides important safeguards to reduce fatigue within the nursing workforce, such as compensatory rest and controls on working time to address the health and safety effects of shift work and long working hours. Fatigue, long working hours, lack of rest breaks and poorly managed shift rotas are a risk to the health of nursing staff, and patients. The EU’s TUPE legislation has been a cornerstone in providing legal protection to staff when reconfigurations in the provision of public health and social care take place. It is important that nurses and other staff, who continue to ensure continuity of care and service provision during these reforms, are not disadvantaged in terms of working conditions and employment benefits if their employer changes.
We are encouraged by the commitment for full transposition of all of the above legislation into UK law through the EU (Withdrawal) Bill and would be very concerned were any changes sought which would undermine the standards of existing legislation.
Retaining existing reciprocal healthcare arrangements, or the agreement of comparable alternatives, should be an important consideration for the UK government as negotiations continue with the EU. The impact on the NHS would be significant if access to reciprocal healthcare schemes is not retained or suitably replaced, and if the rights of EEA and UK citizens living abroad are compromised.
The EU’s public health remit includes cross-border health threats, such as infectious diseases and the threat of antimicrobial resistance. Regardless of the future settlement, there will continue to be cross-border societal health challenges, relevant to the UK population and its nurses.
The European Centre for Disease Control (ECDC), in collaboration with the World Health Organisation (WHO), manages disease surveillance and response for detecting emerging health threats, such as pandemic influenza and Middle East Respiratory Syndrome Coronavirus. It is essential that the UK seeks a close working relationship with the ECDC following exit from the EU, to mitigate the risk stemming from being outside these European coordination measures on disease threats. As there are a number of associative models available, this should be a relatively easy process. The UK must retain the ability to contribute to, and compare, surveillance data to ensure UK health systems are prepared as the epidemiology of resistant organisms develops. It is paramount that Brexit does not negatively affect this.
International collaboration and exchange increases the speed and likelihood of finding the solutions to global societal challenges, as well as adopting insight and innovation at faster rates. For example, through collaborative research and academic exchange, it is well evidenced that international research collaboration increases research excellence and mobility increases researcher productivity. Research opportunities can also play a significant role in terms of recruiting and retaining the workforce.
Whilst many of these activities take place internationally beyond Europe, the EU has developed frameworks to ease collaboration and make it more effective, it also funds collaborative activities through its various programmes. There is a risk of loss of access to the research funding and student exchange programmes (Horizon 2020 and Erasmus+) for nursing faculties in higher education, and to the wider policy exchange mechanisms that European Commission initiates and funds.
The UK currently has operates under a well-functioning medicines and medical devices regulatory system, working with the European Medicines Agency, underpinned by EU regulations and directives. The common framework for monitoring and assessing drug safety has also operated to the benefit of patients across the EU. If the Welsh Government has already carried out work to look at the associated risks in these areas after we have left the European Union then these should be shared and made accessible.
Any new trade deals the UK may negotiate outside the EU must exclude health services to avoid detrimental impact on patient care and health workers’ employment conditions. The RCN has been very clear about this during the negotiation of the Transatlantic Trade and Investment Partnership (TTIP) and would be very concerned were any new UK trade deals considering this.
Whilst it may be appropriate for some areas of policy, such as serious cross-border threats to health for instance or the professional regulation, to be dealt with at a UK level, it is right that any EU laws that currently fall within the Assembly’s competency, should be transposed into Welsh law.
EU Structural Funds have seen significant benefits for Wales, with significant amounts of money used to support projects across Wales, many of which are aimed at reducing poverty and thereby reducing health inequality. The Welsh Government have confirmed that Wales will continue to benefit from these funds until 2020 but beyond that time there is uncertainty around whether or not similar or equivalent funding will be available from elsewhere. The Royal College of Nursing would like to see the Welsh Government continue to prioritise tackling poverty and health inequality beyond 2020, and for all alternative funding streams to be considered.
The Committee may also want to be aware that the Royal College of Nursing is a member of the Cavendish Coalition which is a group of 37 health and social care organisations united in their commitment to provide the best care to communities, patients and residents. The coalition acts as a shared voice which influences and lobbies on post-EU referendum matters. It also provides those leading the negotiations with expertise and knowledge on the issues affecting the health and social care workforce.
As a part of the coalition, we are committed to working together to ensure a continued domestic and international pipeline of high calibre professionals and trainees in health and social care. More information about the Cavendish Coalition can be found here - http://www.nhsemployers.org/your-workforce/need-toknow/brexit-and-the-nhs-eu-workforce/the-cavendish-coalition
Whilst, in the context of Brexit, it is understandable that much of the focus at Government level is on areas of legislation and policy such as the economy, trade and agriculture, all areas of Welsh Government work need to be considered individually and in an appropriate level of detail. We would therefore welcome further conversation and scrutiny on the issues covered in this paper and in the wider health and care context. While the Royal College of Nursing is in a key position to engage and inform these conversations, much of the detailed information and data will be held by other agencies such as the NHS. As such, we would welcome engagement from the Committee and Welsh Government with a wide range of organisations across the sector in order to inform and enlighten the debate.
The RCN is the world’s largest professional union of nurses, representing over 450,000 nurses, midwives, health visitors and nursing students, including over 25,000 members in Wales. The majority of RCN members work in the NHS with around a quarter working in the independent sector. The RCN works locally, nationally and internationally to promote standards of care and the interests of patients and nurses, and of nursing as a profession. The RCN is a UK-wide organisation, with its own National Boards for Wales, Scotland and Northern Ireland. The RCN is a major contributor to nursing practice, standards of care, and public policy as it affects health and nursing.
The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies.