Statement in the Welsh Assembly on preparing the health and care services for a 'no deal' Brexit

Thank you, Llywydd. I have set out the significant potential impacts of a 'no deal' Brexit for our NHS and social care services in Wales in this Chamber on a number of occasions. My position remains crystal clear: a 'no-deal' Brexit poses significant risks to services in Wales and the public that they serve.304

In an environment of historic uncertainty, my focus has been on working with all partners to limit, as far as possible, the damage that a 'no deal' Brexit would have on our NHS and social care services. Together, we are ensuring that robust arrangements are in place to prepare for the impact of leaving the European Union, and to respond quickly to issues and impacts as they arise if we do leave. These arrangements have been repeatedly tested, rehearsed and, as far as possible, assured. But let me be absolutely clear: whilst we are doing everything we can to prepare, no amount of planning can guarantee a disruption-free Brexit. To suggest otherwise is deeply misleading and irresponsible.305

Leaving the EU will have an impact over the short, medium and long term. Our priority has been to ensure the continuity of essential supplies, so that services can be maintained, as far as possible, on a business-as-usual basis. This will allow professionals to work properly and with confidence, ensuring the public and patients, as far as possible, are not adversely affected. The last thing that we should do is introduce additional complexity and uncertainty for the public and our staff, especially as we head into winter.306

We have looked for opportunities to strengthen capacity within the sector beyond the immediate context of Brexit. Members will know that I approved the purchase and stocking of an additional storage facility to ensure that supplies of medical equipment and essential items are not disrupted. This £11 million investment was made necessary and urgent by the prospect of a 'no deal' Brexit in March. To put that in context, the £11 million warehouse funding could instead have paid for seven replacement magnetic resonance imaging scanners.307

Many of the essential 'no deal' Brexit responses are UK Government responsibilities. We continue to press for assurance on matters such as the flow of goods through ports, settled status for EU citizens, and provide robust challenge in areas where Welsh interests need to be protected.308

On medicines, we participate in UK-wide arrangements to maintain supplies, working closely with the industry. There are established processes to manage medicines shortages, and these will apply to any shortage caused by Brexit. They will be informed by detailed analysis of medicines that are potentially at risk. There are similar UK-wide arrangements in place for radioisotopes, supported by dedicated express freight channels into airports. These arrangements, again, have been tested and rehearsed recently in response to widely reported concerns raised by clinicians and professional groups.309

In addition to medicines, there are hundreds of thousands of products that the NHS relies upon each day. These include everything from dressings and bandages to gloves, syringes, needles and much more. For these medical devices and clinical consumables, we continue to work closely with NHS Wales to increase the amount of stock that we hold. From the start, our planning has included provision for key items used by social care providers too, as well as the national health service. So far, this overall additional stock holding has cost over £5 million.310

There is no evidence to suggest, as Lesley Griffiths has said, that there will be an overall shortage of food, but a 'no deal' Brexit will lead to a reduction in the choice and availability of some foods imported from the EU. The British Retail Consortium have been very clear on this point. To prepare, we've asked health and social care organisations to consider how meals could be adapted if the availability of some ingredients is limited, without, of course, compromising on nutritional standards.311

A major concern for me has always been the potential impact of Brexit on our workforce, not just in the provision of services, but this goes to the heart of who we are as a nation. We could not deliver our health and care services without staff from Europe and across the world. I place the same value on all of our staff, regardless of their country of origin, and I continue to reinforce this message in public and to the UK Government. It is a source of unbelievable frustration to me that the UK Government continues to promote restrictions on recruiting staff that would do undeniable harm to health and care services and, of course, to the vulnerable people who rely upon them.312

We have not yet seen a significant departure of EU nationals from employment in health and social care here in Wales, but other parts of the UK have. We're seeing a reduction in overseas recruitment, which will have a serious effect in the medium term if it continues. We may also see health and care staff moving to jobs in other sectors, some of which have already seen significant losses of EU nationals.313

Whilst the direct implications of Brexit—and particularly a 'no deal' Brexit—are already significant and wide-reaching, there are other more indirect impacts that could have direct, serious consequences for health and care providers. For example, the cost of food, fuel and medicines are likely to increase in a 'no deal' scenario as a result of reduced supply and a weaker pound. This would impact especially on organisations in the social care sector. Across Wales, 1,275 care home providers deliver care and support to more than 26,000 people. A third of those providers are small businesses with fewer than six beds. Many would find price rises difficult to absorb, and these increases would affect other services that play a crucial role in meeting people’s care and support needs, such as meals on wheels and day centres.314

Price rises would, of course, hit some parts of our workforce particularly hard, for example domiciliary care staff. This would be a real and unjust example of how a 'no deal' would disproportionately impact on people in lower income groups and more vulnerable groups. That, of course, is set out clearly in the Yellowhammer document that was released by the UK Government.315

If we see the scale of job losses predicted following a 'no deal' Brexit, this would lead to an increased demand for health and care services, particularly mental health support. Whilst it is difficult to quantify, we can expect an increase in cost and time to access treatment as we simply don’t have the number of professionals needed to respond to the anticipated level of demand.316

It is a continuing source of further frustration to me that Brexit preparations are diverting so much energy and resource from other important areas. Our estimate is that there are the equivalent of between 50 and 100 full-time posts dedicated to 'no deal' readiness across health and care in Wales—enough to run a significant number of medium-sized general practices in Wales instead. Brexit preparedness draws heavily on the time of leaders and managers at all levels of our organisations. These people should be working on other priorities to improve the services we provide for the people of Wales, instead of preparing for the potential of a 'no deal' Brexit, which, as I've said, is the worst possible Brexit outcome and the Brexit outcome that will cause the greatest amount of harm. I am, however, grateful to all of the staff working in health and care services for their professionalism and commitment in preparing for the possibility of a 'no deal' Brexit. We have worked hard to protect the interests of the public and patients in Wales and we'll continue to do all that we can to assess the impacts of leaving the EU and to ensure that we are as prepared as we reasonably can be. We'll continue to do all that we can to prevent the UK Government from leading us to a disastrous 'no deal' Brexit, which will inevitably hit Wales harder than other parts of the UK.317

I'm pleased to receive this update from you, Minister, because, whether it's a deal or no deal, we need to get Brexit done.318

Now, the Welsh Conservatives support the result of the referendum. People in Wales voted overwhelmingly to leave, and it is incumbent on Welsh Government to make the requisite preparations. And, let's be frank, leaving without a deal is a direct result of Labour in Westminster voting against Brexit deal proposals again and again. They voted against it on every occasion, Minister, and, to be fair, or to be honest, or just to be frank, again, Jeremy Corbyn is showing zero leadership on this.319

The e-mails and telephone calls that I receive from people right across the political spectrum, and from people who have no political allegiance whatsoever—there's frustration; they want it done, they want it out of the way. They want to get Brexit done. And it needs to be done whilst protecting our NHS and our social care services. And, Minister, given that protecting our NHS is vital, will you welcome the £1.2 billion investment that the UK Government will be able to realise, which should be able to come to Wales? And will you commit to ensuring that that £1.2 billion over the next three years will be spent on our NHS and our social care? Because, after 20 years of your Government in charge here in Wales, we are behind in our NHS. Four out of our seven health boards are now in targeted intervention or special measures. Betsi Cadwaladr's mental health services have been in special measures longer than any other health board anywhere in the UK. In Wales, a 95 per cent target for patients spending less than four hours in A&E hasn't been met since it was introduced in 2008. And NHS Wales last met its cancer waiting times in 2008. This is compounded by the fact that the Welsh ambulance service has the longest delays of any NHS trust in the UK. So, will you commit, Minister, here and now, to ensuring that any additional money, that this £1.2 billion, as a result of consequentials in health, is spent on our NHS?320

You mention, in your statement, drug shortages. Now, the Welsh NHS Confederation are very clear on this: they said that shortages of medicine are standard in the NHS and the challenge is how to manage it. And I have confidence that the UK Government is working with the pharma industry to ensure that supplies are not affected and that increased costs are minimised. I think the scaremongering about this issue is very dangerous. It must be terrifying to people watching what's going on, and it can only have a negative effect, both on prices, stockpiling and public perception. And I reiterate again, the NHS Confederation themselves state: 'Our members inform us that there are currently no issues with the availability of medicines as a result of Brexit'.321

Now, the English NHS has outlined the following contingencies: they've recommended that suppliers of medicines build up at least six weeks of extra stock above their usual buffer levels. Can you tell me, Minister, if you've done the same to suppliers to us here in Wales? I was really pleased to see in your statement that you have committed to extra warehousing and storage facilities for medical necessities and medical equipment. But, obviously, it can also be used for some of these medicines. Have you been involved in trying to push through things like buying extra space on ferries so that medicines and medical products will be able to come into the UK? Have you been involved in encouraging the re-routing of medicines into the UK? Have you been party to the discussions, or been involved in, promoting that medicines, devices and clinical trials licensed or tested in the EU can continue to be used in the UK in the event of a 'no deal' Brexit by amending those regulations? So, I'd be really grateful if you would be able to give us an update on those particular issues.322

You mentioned food supplies, as did the Minister for the Environment and Rural Affairs. Again, I don't wish to scaremonger to people out there who may be worrying that, if they were to go into hospital, they wouldn't be able to have any food, because, of course, it's going to be just some things that are out of kilter—that could be out of kilter. Because the reality is nobody actually knows what is going to happen. So, can you please confirm—I know that you've said that you have asked health boards to look at this, but can you confirm that the health boards themselves have actually engaged with their staff and have issued the instructions that you spoke about?323

You mentioned recruitment issues. Now, of course, we know, don't we, here in Wales, we have a special set, a unique set, of problems with recruitment, and it's not just Brexit—to Brexit or not to Brexit. We've had issues with people wanting to come into Wales; we've had issues with people about whether or not they believe that the hospital they might go to work for is stable enough and strong enough; we've had issues with historic under-investment in training places and difficulty in providing training specialisms. So, if you could perhaps give us an update on how those kinds of issues might be affected by a 'no deal' Brexit, I think that that would, again, go some way to setting the record in a very, perhaps, clear way.324

I'm delighted to see, as per your statement, that, despite Brexit, the number of EU nationals employed by the Welsh NHS has actually increased. In fact, Llywydd, we've seen a staggering 42 per cent increase in EU nationals working in the Welsh NHS since 2015, and each and every one of them is extremely welcome here. And it is good to see that we're still a world leader in the UK in the innovation of new medicines. Now, we talk about investment and investment happening in the NHS, but we need to remember that, here in Wales, for example, ReNeuron have just struck an £80 million deal with the Chinese firm Fosun Pharma in April this year for the development of stroke-related and human retinal progenitor cell line blindness therapy programmes. Now, that's no sign of uncertainty and that's really good, and that's the kind of business we need to go out there and get.325

Research and development spending in Wales is still strong, in the UK is strong. It's expected to increase by 3 per cent in the longer term. And, of course, the corporation tax cuts will benefit UK pharma companies. But can you tell me what effect Labour's hard left proposals under 'Medicines for the Many' will have on the UK's world-leading reputation in research and development for medicines? Taking China and Cuba as his examples, the leader of the opposition, Jeremy Corbyn, said that a Labour Government would use compulsory licensing to secure generic versions of patented medicines, and hold pharma to ransom by telling them that, if they want public research funding, then they'll have to make their drugs affordable for all. And you and I know how important it is to have affordable drugs in the NHS, because we have an ever-tightening budget and ever greater needs. But the Association of the British Pharmaceutical Industry have said that compulsory licensing amounts to the seizure of new research and would undermine this amazing research and development that we have here in Wales, particularly in Cardiff and Swansea universities. So, your clarification on this matter and on the effect that that would have on us—Brexit or no Brexit—would be very, very worthwhile listening to.326

Thank you for the series of comments and a few questions in there. I congratulate you on a straight-faced attempt to spend as much time diverting attention away from preparations for a 'no deal' Brexit. I'm not going to get sent down the rabbit hole of talking about things that have nothing to do with the statement I have made on the preparations on a 'no deal' Brexit.327

I do, though, want to go back to some of the points that you made about Brexit. You said that Brexit must get done, one way or another. You talked about an overwhelming result here in Wales; it was not an overwhelming result. And you talked about 'no deal' has to get done, but protecting—'no deal' being a potential way forward for this, and yet, at the same time, about protecting our NHS and social care. And, actually, the worst possible outcome for health and social care, for our staff and the public who rely upon it, is a 'no deal'. This isn't complicated. It isn't difficult. The Government's own reports on Yellowhammer acknowledge this; Conservative colleagues around the country acknowledge the harm that a 'no deal' Brexit would do to health and social care. And, just to be absolutely clear, we are not in this position because of the way that Labour Members of Parliament have voted in response to deals put here by the UK Government. And if the Members—[Interruption.] If the Members want to look at where they were before the general election—having a Conservative majority, the deal done with the DUP, the fact that you lost members of the European research group, who acted as a party within a party—they may well have taken over the rest of the Tory party now, but, actually, there are plenty of Conservatives who would not bring themselves to support the deal provided. This has nothing to do with the way that Labour Members of Parliament have voted and everything to do with the Government's inability to meet the promises that it has made.328

I recognise also the points that were mentioned about the sums of money. The fantasy sums of money that are being described are not considered real by this or any other part of the national health service. We have a year's worth of money for us to plan a budget for. The idea that I should commit to three years of expenditure on the basis of promises that not even the service believe is fanciful in the extreme.329

On your point about food supplies in the NHS, we have had regular engagement with this. We, of course, have the ability to provide food within the national health service. The point that I made in the statement is about the potential for needing to substitute or change some of that, but not to compromise on nutritional standards. It is more difficult for some of our social care providers to do so, particularly those smaller concerns that exist, and, as I say, there is a straightforward point that the choice in food will definitely be affected, but we commit to maintaining nutritional standards.330

On staff recruitment, now, we have seen a significant challenge in staff recruitment, in particular, the Nursing and Midwifery Council register. We have been relatively insulated from that, compared to England. There's been a catastrophic fall-off in the number of new registrations on the NMC register from people from across Europe, and it's a real cause of concern. If you had this conversation with the Royal College of Midwives or the Royal College of Nursing or Unison, then they would tell you about the reality of people making a choice to leave England, in particular, because not only of the policy choices, but of the environment and the language used to describe them. I am proud that here in Wales—and in Scotland too, to be fair—we have constantly reiterated the value that we place upon our staff in wanting people to stay, and that will continue.331

I do, though, need to point out the immigration cap proposals are an act of wanton vandalism to health and social care services in every part of the United Kingdom. The average pay in the social care sector is under £17,000 in Wales. Having a salary cap of £30,000 would be disastrous for social care, and it would have a serious impact on the health service. It is not too late for Conservatives in the UK Government to recognise common sense and to end those proposals, or they will do serious and significant harm to health and care services.332

I'll deal with your points about medicines. In terms of the increased costs being minimised and the points you make about buffer supplies, these are UK-wide arrangements that are being put in place. This is not the Government acting simply for England, and this is part of the responsibilities that the UK has. It's a UK responsibility to deliver medicine supply into the United Kingdom, and there are arrangements involving the chief medical officers and the chief pharmaceutical officers to oversee how shortages would be addressed in terms of making sure there is equitable distribution of medicines across the country.333

In terms of transport arrangements, again, this is part of UK-wide responsibilities. About a third of the pharmaceutical industry have made their own arrangements and spent significant amounts of sums in doing so. About two thirds are relying on the transport arrangements provided by the UK Government. And, on this, I will acknowledge there's been an improvement in 'no deal' Brexit preparation by the UK Government from March. You will remember it was farcical, that we had ferry-less ferry companies winning contracts, and moneys had to be paid both to ferry companies and to Eurotunnel for arrangements that were put in place. I acknowledge the UK Government is in a better place now. Having learnt from the mistakes and the significant waste of money that took place, they are now in a better position, but the challenge will be, if two thirds of supply rely on the up-to-date ferry arrangements, we then run into the very real challenges set out in the Yellowhammer document about HGV backlogs.334

My biggest concern on medicine supply is actually getting goods around the United Kingdom. The evidence provided in the August release from Yellowhammer is sobering, and no-one should be sanguine about it and simply claim we must get on with 'no deal' if that's all we're left to, because that sets out the real and significant harm that would be caused, and the up to six months' severe disruption that would be faced across the narrow straits. So, this is no matter to trivialise. Medicines are category 1 items; they will have first call on the capacity that exists. We then need to get those goods around the country, and, on that, we are engaged at both official level and in ministerial conversations about those very issues.335

I want to make the other final point about medicines, and that is that none of us should be sanguine about the potential shortages caused. There are normal shortages that are managed within the health service, that is true. But the times that we are in are quite extraordinary, and we have never deliberately chosen to do something that we know will risk medicine supplies. For all of the analysis that we have on the arrangements now being put in place, if one single medicine is affected because of a 'no deal' Brexit, then every single person who relies on that medicine will understandably look to us and say, 'Why did you do this? Why did you demand that Brexit happened if you knew that this was a risk to me and my health?' I will comfortably look those people in the eye and say, 'We have done the right thing in raising these issues.' Other Members from whatever party need to think carefully on their position on a 'no deal' Brexit and the risks that that entails to the health and well-being of people in Wales.336

Diolch, Dirprwy Lywydd. Can I thank the Minister for his latest statement on 'no deal' Brexit preparations in health and social services? In the part of your statement on page 2, you say that there are similar UK-wide arrangements in place for radioisotopes, supported by dedicated express freight channels into airports. Obviously, medical radioisotopes are hugely important, and this is an area of huge concern. The Minister will know that these isotopes—radioactive isotopes—are essential for our high-tech medical scanning kits in all of our larger hospitals, and some hospitals that are not so large, in fact. Also, these medical radioisotopes are used in high-end cancer treatments and various investigations that we carry out. So, they are absolutely vital.338

You also know that radioisotopes like technetium and molybdenum have a half-life of six hours only. Half of it disappears in six hours, in other words. Another half disappears in another six hours, and so it goes on. We get these from the European mainland at the moment. So, two questions follow specifically as regards medical radioisotopes. Has the Welsh Government obtained legal clarification on whether EU suppliers will even be able to sell us these radioisotopes without an agreement, as this is classed as nuclear material? The second question is: is the Welsh Government satisfied that the plan of flying radioisotopes into Coventry Airport for distribution to bypass queues in ports will work, and that there will be no delays for checks on either the EU or the UK side, given that every hour of delay means that the materials are less likely to work, particularly for hospitals far away in Wales, and that the M42, M5 and M6 routes into Wales are frequently jammed?  339

Thank you. The position on radioisotopes and other medicines has been a significant concern for me, and I have mentioned this in the Chamber before. It's a good example of products that we use within the health service in a normal way that do have a short shelf life, and so we can't stockpile everything. In terms of the issue of potentially leaving Euratom—which we don't need to leave, but that's the position that the UK Government has previously adopted—then yes, that is potentially an issue.340

We haven't taken independent legal advice, because we've had direct assurances from suppliers that they will continue to supply the UK. But I recognise that it's a real risk, and members of the BMA in particular have expressed concern about whether those items can be lawfully provided. But all of the current suppliers say that they are prepared to go through new arrangements to fly into East Midlands Airport, as you mentioned.341

Again, this goes back to my concerns about medicines and supplies. It is not so much my concern about getting goods onto ferries or into an aeroplane. It's about getting them around the whole of the UK. Whether you are in Pembrokeshire, County Durham or Cornwall, actually, that's quite a long way from East Midlands Airport. So, if you are a clinician in the Truro hospital, or a clinician in Bangor, you would be understandably concerned: 'Is this going to get to me in time?' You are right; six hours is not a long time.342

The plan and the assurance provided says that that should still be possible and that it should still happen. But it's my concern that we have never done this before. We have never deliberately tried to interrupt the supply of goods into the United Kingdom in this way. This is part of the reason why I say that these are plans that are in place, there is a level of assurance about them, but there is uncertainty about the real impact. Because if we do see the kind of transport disruption that is predicted and has been modelled for, then we will see challenges along the way, and that could have a direct impact on the healthcare and experience of people right across the United Kingdom. So I'm far from sanguine and far from positive about it, and I don't share the view of others that everything will be well.343

Just a simple factual reflection here: the sad fact is that this huge and sustained effort, like that that the Minister has referred to of the diverted army of civil servants, policy officials, legal experts and others, is at the direct cost of turning their attention away from other urgent matters of social and economic reform. Brexit has cost Wales and the UK already, but it continues to cost us in that diverted energy and missed opportunities.345

But could I ask you, Minister, about any discussions you may have had with the UK Government? You've made clear, quite rightly, that the issue of medicines is very much a UK responsibility. But it's specifically on the preparation in the case of a 'no deal' for the issue of parallel exports from the UK to the EU and wider overseas, where we could find, quite remarkably, but we can anticipate this, the situation where sterling dips in the run-up to a 'no deal'—and the Prime Minister at the moment keeps reminding us that if all else fails, we are heading for a 'no deal'—but sterling dips, and because of the change in the exchange rate, as we have seen before without Brexit even happening, parallel exporters take the opportunity to raid the wholesalers, raid individual pharmacists who have trading licenses, and we suddenly find that, in the situation of taking our country back, we find that medicines for patients here in the UK that are part of 'no deal' preparations, part of that preparation to avoid a situation of shortages, are being sold overseas.346

Now, that would be preposterous, and I don't think anybody would want to see it. It's not something within the gift of the Welsh Government, I know, but I'd be grateful if he could reassure us that he's raising those concerns with UK Ministers so that every possible signal is being sent to those parallel traders that they should not do that in anticipation of a 'no deal'—that their commercial imperatives should not override the moral imperative to put UK citizens and UK patients first.347

Could I also ask you what you've made of the British Medical Association's brief that has been sent round, I think, to all Assembly Members? In their words, it tells of the catastrophic consequences for health services of a 'no deal'—on patient safety, on winter pressures, on medical research, on recognition of professional qualifications, reciprocal healthcare arrangements, international co-operation on rare diseases, the health and care workforce and immigration, as the Minister has mentioned, and much more. Does the Minister regard this very clear message from the BMA as a simple rerun of project fear, or the genuine fears of people who have the concerns of their patients, of our social services and health service, at the forefront of their minds, about what could happen in the case of a 'no deal'? And if that is the case, and these are genuine fears, isn't that once again why a 'no deal' should be simply ruled out?348

Thank you for the two main points. On the one on parallel trading, you're right that with a weaker pound it does change different incentives to move goods around between different parts of the European Union. That's a consequence of the weakening of the pound now, and, if we are still headed towards the end of October with a serving Prime Minister threatening to break the law and to try to leave without a deal, then that is not likely to see the pound strengthen in force. There's a challenge here: with branded medicines, there are price controls, but with generic ones less so. It is something that's been raised in conversations between the Governments, and so there is awareness of that. We still think that the potential and significance of this—it's unlikely to be the case before we leave, but the challenge is that, potentially, if we leave the European Union without a deal, then we may find that generic medicines, which are typically less expensive, may actually rise in cost, particularly if there are additional checks, and additional barriers to goods, and that will be reflected in the price. So, it is a real concern. And given the significance of the drugs bill, even a small rise has a significant consequence for the finances of the health service in every part of the United Kingdom.349

I recognise your point about BMA members and the briefing that they've circulated. BMA members have been very clear to me about their view and their concerns. This is project reality. This is what we are faced with dealing with. Don't take my word for it, don't take what the BMA say for it, take a look at what the Yellowhammer document released actually says. No-one should be sanguine about this. It recognises the real and significant impact. The concerns are genuine. And that is why we're spending so much time, energy and effort within the Government and within our health and care services in preparing for a 'no deal' Brexit, which I completely agree with the Member should be ruled out as a wholly unacceptable outcome for any and all of us.