A bad deal on Brexit would be “a disaster” for the NHS, Jeremy Hunt has said, as he accused the European commission of deliberately interfering in the general election to undermine the Conservatives.
Ramping up the rhetoric of Theresa May, who last week accused the commission of leaking an unflattering account of talks at Downing Street to disrupt the election, the health secretary warned that a good Brexit negotiation was vital for the NHS.
“We’ve got 27 countries lined up against us,” Hunt told BBC1’s Andrew Marr show. “Some of them appear to think that for the EU to survive, Britain must fail.”
He said of the impact on the health service: “If we don’t get a good Brexit outcome, and we don’t protect the economic recovery, the jobs that so many people depend on, whose taxes pay for the NHS, if we get a bad Brexit outcome, that would be a disaster for the NHS.”
However, pressed on the issue, Hunt refused to specify what sort of bad deal this might involve, or to say whether the UK leaving the UK with no deal and defaulting to World Trade Organisation tariffs, would also affect the NHS.
“We’ve been very clear that no deal is better than a bad deal,” he said, adding: “I’m saying that a good deal would be best for the NHS, but obviously, a bad deal would be the worst possible outcome for all our public services. It would be bad for the country.”
On Wednesday, May used an address outside Downing Street launching the election campaign to accuse the European commission of seeking to influence the election.
“The European commission’s negotiating stance has hardened. Threats against Britain have been issued by European politicians and officials. All of these acts have been deliberately timed to affect the result of the general election which will take place on 8 June,” she said.
May did not specify who this interference was intended to assist. But pushed on the matter, Hunt said he assumed the commission wanted to undermine the Conservatives and help Jeremy Corbyn’s Labour party.
“Well, you’ll have to ask them why they chose to do that, but I think the answer is very clear, that they are trying to leak reports that undermine Theresa May’s position,” he said, when asked who the commission favoured.
Asked specifically if the aim had been to harm the Conservatives, he said: “That must be the presumption, and what we’re saying is that they should not be doing that, because it’s an election for the British people to decide.”
May’s accusation baffled Brussels, where the European commission’s chief spokesman, Margaritis Schinas, dismissed the allegations as electioneering.
“We here in Brussels are very busy, rather busy, with our policy work,” he said. “We have enough on our plate.”
The European council president, Donald Tusk, said the stakes of the Brexit talks were “too high to let our emotions get out of hand”.
He added: “We must keep in mind that, in order to succeed, we need today discretion, moderation, mutual respect and a maximum of goodwill.”
Millions of Britons could have their access to free health insurance taken away after Brexit, a parliamentary report has said.
MPs on the health select committee urged the government to offer more guarantees for Britons visiting the continent after hearing evidence that without the right to receive treatment in countries that are part of the European Economic Area, people with cancer could find it too expensive to go to Europe.
In a strongly worded report on the effect of Brexit on health and social care, the committee said the challenges created by losing reciprocal health arrangements should not be underestimated.
British travellers can currently use the European health insurance card, which guarantees access to healthcare free or at a reduced cost in Europe. The EU member state providing treatment is able to claim back costs from the patient’s home country. Some estimates suggest that up to 27 million Britons have the cards.
The inquiry heard evidence that losing this agreement could create challenges for many travellers, including disabled people and those with mental or physical health conditions. Prof Martin McKee of the London School of Hygiene and Tropical Medicine said a week’s full private health insurance for a holiday in France for someone with diabetes or mild depression would cost between £800 and £2,500.
The report also noted that hundreds of thousands of expats living abroad could lose reciprocal healthcare rights, leaving some facing hardship. McKee, a professor of European public health, said many Britons in Spain have properties that are now worth little. “Many will come back in a state of poverty because they bought properties in Andalusia and other places … They will be throwing themselves on the mercy of the state when they come back,” he said.
Christopher Chantery, a British resident in France, told the committee many pensioners moved to the country “in good faith on the implicit promise that these arrangements would continue. Suddenly, something happens that brings those arrangements to an end. It is absolutely terrible for many people”.
British nationals living abroad have to get an S1 form, which gives them health cover, paid for by the UK, within Europe.
The committee, which includes Labour and Conservative MPs, called on the government to preserve the existing system as opposed to seeking a new arrangement. What was currently in place offered taxpayers good value for money, it said.
In the same report, the committee warned that the Brexit vote could lead to a brain drain, with morale among EU nationals in the NHS low due to uncertainty about their future. It called for more reassurances and said the government should continue to be able to recruit the “brightest and best from all parts of the globe” after Britain leaves the EU.
The Department of Health could not comment due to general election purdah rules. But when asked about reciprocal healthcare at the start of the year, the health secretary, Jeremy Hunt, said it was one of the rights of those who retired to Spain or France and he wanted to secure it early on in negotiations, but could not guarantee this.
Speaking to the Guardian, Prof Jean McHale, the director of the Centre for Health Law, Science and Policy at the University of Birmingham, said: “If questions of healthcare provision and patient mobility are not included in the negotiations, if there is not a transitional period and we move to hard Brexit, there will be major practical questions. What happens at midnight on Brexit D day to the person in hospital in another EU member state who has been in a car accident?”
The government’s statement that there are 11,200 more doctors and 2,100 more nurses on the wards since 2010 (Hospitals offer doctors £95 an hour as staffing crisis grows, 15 April) is not the experience of those of us in frontline NHS work. Last year 30% of foundation doctors (those who have finished medical school and are at the point of choosing the specialty to train in up to consultant level) chose not to apply for specialist training straight away and went off to do something else. Many will come back, but many won’t. This year the reluctance to carry on rose to 50%. It appears Jeremy Hunt has been the best recruiter for the Australian and New Zealand medical services. People who chose to train as doctors are clearly reviewing their options.
Why this has happened is plain to see. An underfunded NHS, a new contract imposed on the junior medical workforce, increased tuition fees at medical schools and subsequent debt have, together with Brexit, produced a perfect storm of unhappiness and uncertainty about the future in the NHS and in the country. The fallout from Brexit is that there are 10,000 NHS doctors who qualified in the European Economic Area – and a recent British Medical Association survey found that 42% plan to leave.
The UK already has fewer doctors per person than other leading European economies at 2.8 per 1,000 people: Germany has 4.1, France 3.3 and Italy 4.2. If you think that waiting two weeks for a GP appointment or more than four hours in A&E is unacceptable at the moment, then just wait for 2019 when we finally do Brexit. There will be no extra £350m a week for the NHS as promised on the side of a bus. Dr Michael Maier London
• The junior doctor contract reforms had their roots in providing a “seven-day service” – a reasonable idea given many hospitals run a skeleton staff over the weekend. A smaller hospital with a staff of 10 or 15 junior doctors for 150 inpatients would cut down to three or four at the weekend. I dreaded the weekend ward cover: patients and nurses clamouring for attention and emergencies requiring you to be in several places simultaneously.
This laudable idea has been mangled into a catastrophe. Alterations of weekend pay rates and caps on maximum number of days worked means staffing now suffers globally and continuity of patient care becomes a casualty of doctors being shoved from one post to another. The gaps reduce quality of life, meaning jobs are unfilled and the situation worsens.
Can you blame someone wanting high rates to cover a shift with massive responsibility, no breaks and the risk of GMC suspension and lawsuits if they slip up in an impossible workload? The NHS, in trying to iron out gaps and make staffing cheaper, is paying out more in danger money to those brave or foolish enough to take it. Dr William Watson Cambridge
• Katie Johnston is right (How to start a social care revolution in seven easy steps, 10 April). If we want value for money in the NHS, to continue spending more and more on hospitals – the most expensive component of the service – to the relative exclusion of other, more widely used parts, is doomed to failure. Hospitals need help, but a key way to do that is to invest elsewhere. That requires a change in strategic approach far greater than the initiatives currently being pursued by NHS England.
It means using digital technology to allow people to be more involved in accessing and managing services without leaving home. It means investment in expanding general practice and other primary care facilities. And it means building intermediate care and social care facilities as a matter of urgency, not least to reduce demand on hospitals and to allow the timely discharge of patients. Currently, our acute hospitals are receptacles into which we tip ever more medical and social care. And then we wonder that hospitals cannot cope.
These changes would reduce demand on hospitals, provide better value for money and offer a greatly improved service for us all, whether or not we need hospital care. Most patients do not. Andrew Willis Chester
• Perhaps Jeremy Hunt would like to explain why he picked a fight with junior doctors over the imposition of a new contract, ostensibly to allow safer staffing at weekends, when hospitals are now increasingly unable to fill rota gaps without resorting to imploring doctors to provide additional cover at exorbitant pay rates.
Labour has gained plaudits for its proposal on provision of free school meals. Is it not time for a comparable initiative on health? The party should cease its internecine warfare, remind the electorate that the last Labour government increased NHS spending five times faster than the coalition and set up a commission to gain general agreement on a bold plan for a permanent solution to the NHS funding crisis. Dr Anthony Isaacs London
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Ever since Theresa May set out her vision to govern for everyone and not just the privileged few last July, those in the charity sector who work to reduce poverty and inequality have waited patiently. Campbell Robb, the chief executive of the Joseph Rowntree Foundation, was one of many charity leaders who hoped for progress. He wanted to see a revamp of the government’s much-criticised “troubled families” programme, a £1bn scheme set up by David Cameron in 2011 and billed as the Tories’ flagship social policy initiative.
But when the Department for Communities and Local Government issued its first annual report on the programme , the charity sector was hugely disappointed. Robb described the document that emerged as “thin” and a “testament to the vacuum” that exists where we need to see “big political and social change”. It was barely noted in the media, which focused instead on a range of austerity-driven changes to the tax and benefit system, announced originally by George Osborne, which came into effect at the beginning of the new tax year. The changes hit the poorest hardest, while helping millions of the better off. The view increasingly held by thinktanks, and across the public sector, is that May’s government – even if well intentioned in wanting to reduce inequality and enhance opportunity for all – is too distracted and too constrained by the state of the public finances to do so.
“There is a danger that Brexit could suck the oxygen out of attempts to implement a sweeping programme of social and economic reform that is badly needed at home,” Robb said.
Even within parts of the Tory party, MPs and others worry that Brexit is now the only show in Whitehall, one so all-consuming, so draining of civil service and ministerial energies that everything else – the May agenda included – is on the back burner.
“David Cameron came into office with a new social vision of Conservatism and promptly sacrificed it on the altar of austerity,” says Phillip Blond, director of the ResPublica thinktank. “It is vital Theresa May does not let her one-nation Conservatism experience a similar sacrifice at the behest of Brexit. The trouble with Brexit is that those who voted against the EU as a proxy for globalisation and its general destruction of working-class security, risk finding May’s ‘global Britain’ to be far, far worse for them.”
Ryan Shorthouse, director of the liberal conservative thinktank Bright Blue, says he always suspected Brexit would syphon the energy out of Whitehall and voted against it partly for that reason: “A persuasive argument for voting Remain, I thought, was the lengthy and disproportionate focus that would be required of politicians and policy-makers to undertake the process of Brexit, which is indeed what we are now experiencing. There are other important and pressing issues that urgently require deeper thinking and discussion: the affordability and quality of social care, the upskilling of those on the lowest incomes, the financial sustainability of the NHS, and decarbonising our economy.” The green agenda, once central to May’s predecessor, hardly registers these days.
When the financial crisis broke in 2008, Nick Pearce, now professor of public policy at the University of Bath, was in charge of the No 10 policy unit under Gordon Brown. “It was the biggest economic shock the UK had faced since the second world war,” he says. But it did not preoccupy every government department as Brexit does. “It was largely dealt with by the prime minister, his advisers, the chancellor and Treasury officials, and the Bank of England. It was not like Brexit. Most of Whitehall now has Brexit at the top of the in-tray.”
It has already been decided that the next Queen’s Speech will be dominated by Brexit-related bills. Ministers have been told to limit their bids for domestic legislation so the way is clear for parliament to focus on the “great repeal bill”, which will incorporate the mass of EU law into UK law, and on other Brexit-related bills including one on immigration. A recent report by the National Audit Office says the civil service has already created more than 1,000 extra roles in the two new Brexit departments – for International Trade and for Exiting the EU.
‘Lego bricks and boiled eggs’: the three Brexiteers explain everything
And that is just the start, as the search for trade experts – outsourced over the last four decades to Brussels – intensifies. Many civil servants have shifted from domestic roles to Brexit posts in a huge, destabilising, but necessary, reconfiguration of Whitehall. Jeremy Heywood, the cabinet secretary, has described the task of managing his Brexit troops in Whitehall as “the biggest, most complex challenge facing the civil service in our peacetime history”. The NAO says new skills have to be learnt and found – a process which inevitably means less use of expertise gathered over decades by senior mandarins.
The poorest third of households are faring even worse than they did after the 2008 crash
Its report says: “Departments which have had large amounts of EU-derived funding and legislation, for example, will need legal, economic and sector experts to deal with the implications of leaving the European Union, and will have to do so using their remaining staff while also seeking to achieve pre-existing priorities.” Lord Kerslake, a former head of the civil service, says it is entirely right that the focus is on delivering a successful Brexit, but he fears problems will develop down the line in unrelated but vitally important areas as eyes are taken off the ball. “Nobody has quite got the measure of this because of the dominance of Brexit,” Kerslake says.
“Of course there is a need to equip government for Brexit but there is also a need to carry on with the rest of the business of government. There is a risk for the government in this: that things that would have surfaced through being debated and being challenged in normal times will now not surface early, and not until they become crises.”
The Angel of the North statue. The fate of English devolution – formerly a priority – is in question. Photograph: Christopher Thomond for the Guardian
Emma Norris, programme director at the Institute for Government, says the repercussions are already being felt on issues of critical importance. “After trailing a big decision on airports, a parliamentary vote on Heathrow was pushed to late 2017. Key social reform policies in education have been delayed too, like the national funding formula, which was originally due to be implemented this year, but will be delivered at least 12 months late.
“The fate of English devolution – formerly a major priority – is also in question. Adult social care and hospitals are being pushed to breaking point and, in the case of prisons, beyond it. Ambitions to reduce demand, make better use of technology and find new ways of working have yet to be realised. Without action, within the next two years the government could face a disastrous combination of failing public services and breached spending controls against the backdrop of Brexit.”
She adds: “Even the prime minister’s personal priorities are moving slowly. David Cameron’s life chances strategy was scrapped in favour of a new focus on social mobility. But many of the details of this are yet to come and, as the Social Mobility Commission recently reported, inequality is rising.”
The Resolution Foundation maintains that the need to address stagnating living standards and rising inequality is “the non-Brexit challenge of this parliament”. It points out that typical incomes are set to grow by 3% over this parliament – barely any faster than during the Blair/Brown Labour governments, which coincided with the financial crisis and its aftermath. The thinktank says May’s priority, the “just managing families”, are doing worst of all, with the poorest third of households faring even worse than they did after the 2008 crash. This, it predicts, means we are heading for the “biggest rise in inequality since Margaret Thatcher was in Downing Street”.
Pearce points out that Brexit will also skew spending priorities, creating new pressures on finite resources for a government struggling to keep public finances on a tight rein. “Economic priorities – such as R&D, skills and infrastructure spending – will get higher priority in public spending. Brexit will also create powerful new lobbies, such as farmers, universities and key business sectors, who will be arguing for funding to replace lost European Union resources. These lobbies will find themselves competing with the public services that have lost most from austerity, such as social care. And they will also be up against a neo-Thatcherite wing of the Conservative party that wants to use Brexit to cut corporate taxes and public spending even further.”
Torsten Bell, the Resolution Foundation director, says May cannot afford to overlook problems at home as she conducts her Brexit battles with the EU. “The living standards outlook is bleak and risks giving us the inequality rises of the 1980s, without the feelgood factor of rising incomes. But it can and should change. After all, Theresa May knows her record will be judged as much on the Britain she builds as the Brexit she delivers.”
The government is under intense cross-party pressure to guarantee that EU nationals will still be able to work in the NHS, as concern grows that Brexit will cause a critical shortage of nurses and doctors.
Tory, Labour and Liberal Democrat MPs said ministers must not only guarantee that EU staff already working in the NHS can stay, but also that recruitment from EU countries can continue.
The calls for NHS workers from the EU to be given special status as Britain heads towards Brexit were echoed by former Tory health minister Dr Dan Poulter, who now combines his role as an MP with work as an NHS psychiatrist. Poulter told the Observer that unless action were to be taken on both fronts – to reassure those already here and to ensure a future flow from the EU – services to patients would be soon be seriously affected.
“The NHS is heavily reliant on the contributions made by many dedicated EU healthcare professionals, and without them, our health and care system simply wouldn’t be able to cope,” Poulter said.
“Protecting the rights of EU nationals to continue to live in the UK and care for patients is essential, but it is also important that we look after the best interests of the patients of tomorrow. Having the right work visa rules to ensure that in future, healthcare professionals from within the EU can continue to contribute to the NHS and care for patients, must be a priority.”
Poulter said he knew of many colleagues from EU countries who were concerned and of two fellow doctors who were planning to return to Spain by the end of the year. Fears that there could be a mass exodus from the NHS are growing as evidence mounts that EU nationals are already beginning to leave. Some 17,197 EU staff, including nurses and doctors, left their posts last year, compared with 11,222 for 11 months in 2014.
Merkel calls on all sides to protect everyday lives of EU citizens in UK – video
The supply of doctors is already a serious worry. A total of 10,363 – nearly 10% – of those working in England’s NHS Hospital and Community Health Services (HCHS) last year were from other member states.
Labour’s health spokesman, Jon Ashworth, highlighted NHS data showing that there are 22,081 EU nationals working as nurses in an NHS which is struggling to fill 26,000 vacancies.
Ashworth said: “This NHS crisis will be compounded if the 140,000 EU nationals working in the NHS and social care sector walk away. It’s time for an ‘NHS guarantee’ for these workers ensuring their rights – offering these workers who care for our sick and elderly the certainty that they deserve.
“What’s more, we need urgent guarantees that the NHS will be able to continue recruiting from the EU as it currently does. Yet we have no clarity whatsoever from the prime minister. Will health professionals from the EU be able to come to work in the UK after Brexit, will there be a cap on their numbers? The government need to tell us their plans and quickly.”
The Liberal Democrats are also demanding that the government grant an urgent “NHS passport” to every EU citizen working in our health service to encourage them to stay.
Theresa May has so far refused to guarantee that EU nationals will be allowed to stay after Britain leaves the EU. The prime minister reiterated last week when article 50 was triggered that she would not do so unless the rights of UK citizens living in other EU states were also guaranteed.
A total of 2,348 doctors from the 27 other EU states left NHS England between July and September 2016 compared with 1,281 in the same period in 2015. That is a rise of 83%.
There were also warnings yesterday that a potential exodus of EU workers could hit other sectors. A spokesman for the CBI said: “Since the referendum, we have heard from members in sectors who depend on EU workers to fill local shortages that they are having difficulties filling.”
As the growing season approaches for Britain’s £3bn horticulture industry, recruiters warned that it would be hit particularly hard by staff shortages. The head of the largest Romanian employment agency for temporary workers in the UK called on the Brexit secretary, David Davis, to be clear that EU workers still enjoyed the same rights.
“There was a lot of talk about restricting the rights of Romanians on the day article 50 was triggered but that did not happen in the end. For the next two years of negotiations there should be clear messages,” said Alexandru Barbacaru of Est-Vest Services.
NHS England is to launch a new nursing training programme to help plug the gap created by the record number of Europeans leaving the service in the wake of Britain’s vote to leave the European Union.
Simon Stevens, the chief executive of NHS England, acknowledged that the service relies on international staff, including more than 12,000 nurses who are EU nationals out of the 315,000 nurses on its payroll.
Speaking on the BBC Radio 4’s Today programme before the launch of a five-year plan for the NHS, he announced a training programme to “grow the workforce from within this country”.
The moves comes after new figures revealed that a record 17,197 EU nationals, including doctors and nurses, left the NHS last year.
Asked if he was worried about the impact of Brexit, Stevens said: “The NHS has always relied on international staff as well as staff from this country. It is about 4% of our nurses who come from the rest of the European Union. We are grateful for the work that they do.”
But he suggested newly trained British nurses could help fill the gap left by EU nationals once Britain leaves the bloc.
Stevens said: “We have got a curious situation where many more people in this country would like to train to be nurses than we have nurse training places. So we want to expand the number of nurse training places and the routes into nursing so that we can grow the work force from within this country as well.”
He said the new training programme would be modelled on an initiative to recruit more teachers.
“We are announcing a new programme called Nurse First, which is the equivalent of the Teach First programme, whereby new graduates can fast-track into nursing alongside other apprenticeship routes … so that we can expand the number of nurses we have.”
The programme will boost the number of newly qualified nurses by up to 2,200 more a year in 2019 when the UK is due to leave the EU.
In a wide-ranging interview, Stevens denied he was abandoning the 18-week waiting time target for non-urgent operations by relaxing the deadline for hospitals to meet the deadline.
He said: “Fifteen years ago you might be waiting 18 months for your hip or your knee operation, now for nine out of 10 people it’s 18 weeks. The average wait for an operation is 10 weeks. Over the next couple of years we want to have more funded operations on the NHS, but we recognise that the rate of growth is probably going to have to be a little bit slower than it has at points in the past, because we also want to make big improvements in cancer care, in GP services and in mental health services as well.”
The Royal College of Surgeons said the new guidelines amounted to “waving the white flag on the 18-week target”.
Asked if the target had been jettisoned, Stevens said: “It hasn’t. The reality is that there are pressures right across the health service. Under those circumstances we have to make a start on sorting out particularly those pressures in A&E departments which we have seen over the course of the last winter. But over the course of the next several years we want to continue to expand the amount of surgery that is being done, so that waiting times stay low.”
He also announced that all major A&E hospital departments will have to provide GP services to help emergency medics focus on the sickest patients. Steven said: “You can find about 60 hospitals right now that have got this arrangement. This is going to be rolled out to all major A&Es.”
Stevens confirmed that the NHS wanted to stamp out an estimated £4m spent on homeopathic medicine. He dismissed homeopathy as a “placebo at best” and said it was a “classic example of what we want to see less of”.
Everyone knows that after seven years of neglect from the Conservative government, the NHS is undergoing a serious crisis of funding and staffing. The last thing needed is more uncertainty. That is exactly what the NHS faces with Brexit.
On Wednesday Theresa May will trigger article 50 and later this week health bosses publish the updated Five Year Forward View. It is time for the prime minister and the health secretary, Jeremy Hunt, to give the NHS and its patients the certainty needed through the Brexit process. May has already turned her back on the promise of £350m a week for our NHS and now she is walking away from her responsibilities to protect the health service through a turbulent Brexit process that will hit it hard.
The complacency in government is astounding. Last week Hunt published the department of health’s Mandate to NHS England to set “the government’s objectives and any requirements for NHS England”. Amazingly, the 24-page document made no mention of Brexit whatsoever.
It should come as no surprise that the NHS is not a priority for the government. Hunt isn’t even a member of the cabinet committees managing the exit strategy. Yet Britain’s health and social care system is dependent on tens of thousands of European staff, many of whom have settled and built lives here while caring for our sick and elderly. Safeguarding the future of these staff should be an absolute priority in the Brexit negotiations. But in the House of Commons last week Hunt failed to offer any reassurance that he’s prepared to stand up for this essential section of the workforce he oversees.
Will health professionals from other EU countries be able to come to work in our NHS after Brexit, or will there be a cap on their numbers? As long as the issue is left unclear, more and more EU workers are voting with their feet and leaving on their own terms. In a recent survey, 42% of European health staff working here said they are now thinking of leaving the UK. Almost 5,500 have left since the Brexit vote according to NHS Digital, a 25% increase on the 2015 figures. And others are being put off from coming here at all: only 96 European nurses registered to work in the UK in December – that figure was 1,304 for last July.
So our first test of the government plans will be whether they deliver a right of remain for the 140,000 EU nationals working in the NHS and social care system. Secondly, on funding, we know that the EU’s Horizon 2020 scheme is due to invest £7.5bn in health research across the EU over the next five years, and the UK will be by far the largest recipient of those funds. We also receive EU funding from the Innovative Medicines Initiative, the European Cooperation in Science and Technology programme, and the Active and Assisted Living programme for older people.
This long-term funding is vital in giving security to those medical institutions and universities planning major research projects. They cannot just wait and see what will happen after 2019. So we need to know whether access to these funding streams will continue after Brexit. If not, how do the government propose to make up the shortfall?
Our third test is on reciprocal healthcare arrangements. It is a key principle that British citizens can obtain free healthcare elsewhere in Europe, just as they would at home. That is an important safety net for British holidaymakers, and for UK citizens living elsewhere in Europe. Does the government intend to maintain those arrangements? If not, how will it address the increased insurance costs for UK holidaymakers?
Our fourth test is on EU healthcare collaboration. Working effectively with our European partners, on everything from infectious disease control to the licensing and regulation of medicines, has been vital for the NHS in recent years. The sector desperately needs to know whether it’s the government’s intention to maintain the UK’s participation in pan-European public health initiatives after Brexit. Will the UK continue to participate in the centralised marketing authorisation procedure for the licensing, sale and regulation of medicines, governed by the European Medicines Agency? The government needs to be clear about how Brexit will affect the UK pharmaceutical industry when exporting medicines to other member states in future.
These are difficult and detailed questions, but they are all of absolute importance to the future of our health service and of our medical research sectors. There is no reason why May should refuse to give us the answers. That will allow us to understand with greater clarity what the impact of Brexit will be on the NHS – and most importantly, it will allow patients and staff the opportunity to scrutinise the government’s plans closely over the next two years.
The NHS is already in crisis over funding and staffing. But Brexit has the potential to tip those crises into disasters. Patients and NHS staff should not be bargaining chips in May’s hard Brexit negotiations. They want a world-class NHS delivering the best quality healthcare. As article 50 is triggered, the very least the public deserves is clarity and certainty from its government.
How will Brexit impact the NHS? It already has. Nurses from the EU are much less keen to come and work here. Today the Times reported that in the last four months of 2015, an average of 797 EU nurses per month signed up to work in the UK; over the same period last year, that number fell to 194 a month. We currently have a huge shortage of nurses, with 24,000 jobs unfilled in England alone.
You can see this shortfall any time you go into a hospital. There is pressure on beds, on doctors and on nurses. Often there just aren’t enough of them, and they are overstretched. Some A&E departments that used to have 20 nurses are now down to half that number, and staff feel at breaking point. The five Cs that nurses are taught in their training – commitment, conscience, competence, compassion and confidence – are impossible to practise properly in the circumstances many are working in.
There have long been warnings of these shortages but a complete lack of long-term planning, now combined with Brexit, is bringing the situation to a head. We have an ageing population with complex needs. One in three nurses is set to retire in the next decade. The introduction of loans instead of bursaries for training means a 23% drop in applications for nursing and midwifery. Anyone could have predicted that taking away bursaries would prompt this result. No one goes into nursing for the money, so why did George Osborne decide to make it even harder? Why, when we need more nurses, are we not reinvesting in training?
This shortage had been plugged by about 7% of our nurses coming from the EU. If we fail to train nurses that’s how it has to be. This is where so much Brexit rhetoric falls apart. While Theresa May talks tough, refusing to guarantee EU nationals a right to stay, these nurses feel neither wanted nor welcome and will understandably go elsewhere. As Janet Davies, chief executive and general secretary of the Royal College of Nursing, has said: “The government is turning off the supply of qualified nurses from around the world at the very moment the health service is in a staffing crisis like never before.”
When in hospital we are at our most dependent. There may be those who complain about immigration but most people have experience of being cared for by someone who has come here to work. Our NHS could not function otherwise. Is May going to further exacerbate the nursing shortage by making the UK so hostile and unwelcoming to EU nurses they will go elsewhere? Well, this is already happening; people won’t take jobs here in such uncertain times. Yet we continue not to train enough nurses and have made it more financially difficult for them. Where is the joined-up thinking on this? The toxic discourse about “foreigners” stealing jobs may not have been intended for the nurse who washes you after your operation, but that’s how it pans out. We can choose to make people feel welcome or not, but it turns out we need them more than they need us.
Naomi Alderman is the only novelist to make it on to the longlist for the 2017 Orwell prize for outstanding political writing, in a year when George Orwell’s Nineteen Eighty-Four is once again troubling the bestseller lists.
Alderman’s The Power heads a 14-strong list of books that span anthropology, politics, memoir and history for an accolade considered Britain’s most prestigious for political writing, which comes with a cash award of £3,000. Described as The Hunger Games crossed with The Handmaid’s Tale, Alderman’s dystopian novel examines the roots and impact of misogyny by reversing the gender roles in a future society ruled by women. The novel has also been longlisted for the 2017 Bailey’s prize for women’s fiction, and shortlisted for the Wellcome Trust science writing prize.
No overall theme emerges from the longlist, which includes four books by women. Helen Pearson, whose The Life Project is an account of the UK’s pioneering cohort studies run since 1946, is listed beside Somali FGM campaigner Hibo Wardere for her memoir Cut, co-written with Anna Wharton. Irish revisionist historian Ruth Dudley Edwards is longlisted for The Seven, one of four of history books on the list. It tells the story of the seven founding fathers of the Irish state.
FGM campaigner … Hibo Wardere, co-author of Cut with Anna Wharton. Photograph: Alicia Canter for the Guardian
Other history books on the list are Easternisation, by the chief foreign affairs commentator of the Financial Times, Gideon Rachman – the winner of the Orwell prize for political journalism last year – who documents the shift of global power to Asia; John Bew’s biography of the postwar Labour prime minister Clement Attlee, Citizen Clem; along with And The Sun Shines Now, a vivid account by Hillsborough survivor Adrian Tempany of the football disaster’s impact on the game and wider society.
Joining them on the longlist is Black and British: A Forgotten History, David Olusoga’s landmark history of Britain’s black community, which has also been shortlisted for the inaugural Jhalak prize for writers of colour.
Fellow Jhalak nominee and Guardian editor-at-large Gary Younge is also longlisted for Another Day in the Death of America, which documents the lives of 10 people killed by guns in the US on 23 November 2013. Author Gillian Slovo described the book as “a gripping account of the conditions that turn so many of America’s powerless into victims”.
Hisham Matar, the Libyan writer who was shortlisted for the Baillie Gifford prize for non-fiction, is again nominated with The Return, his account of his father’s kidnapping at the hands of Muammar Gaddafi’s government.
Tour de force … nominee Rory Stewart beside Hadrian’s Wall. Photograph: Murdo MacLeod for the Guardian
More recent politics is also documented in the books All Out War, Tim Shipman’s account of the 2016 EU referendum; Island Story, Londoner JD Taylor’s story of biking around Britain to discover other sides to UK identity; Enough Said, a look at the evolution of political language by the former BBC director-general Mark Thompson; and The Marches by Rory Stewart, Tory MP and son of a spy, who reflects on his relationship with his father and its political contexts as he walks along Hadrian’s Wall.
Announcing the longlist, the judges – Financial Times comment editor Jonathan Derbyshire, playwright and author Bonnie Greer, writer and broadcaster Mark Lawson and critic Erica Wagner – praised the list for offering “a clear and calm perspective on Britain and its place in the world”.
“The books reflect many aspects of Orwell’s literary character and interests: fiction, journalism, football, language and landscape,” the judges added.
The shortlist will be announced on 15 May, with a winner revealed at a ceremony during University College London’s festival of culture on 8 June.
The Orwell Prize for Books 2017 longlist
The Power by Naomi Alderman (Viking)
Citizen Clem by John Bew (Quercus)
The Seven by Ruth Dudley Edwards (Oneworld)
The Return by Hisham Matar (Viking)
Black and British by David Olusoga (Macmillan)
The Life Project by Helen Pearson (Allen Lane)
Easternisation by Gideon Rachman (The Bodley Head)
All Out War by Tim Shipman (HarperCollins UK)
The Marches by Rory Stewart (Vintage, Jonathan Cape)
Island Story by JD Taylor (Repeater)
And the Sun Shines Now by Adrian Tempany (Faber & Faber)
Enough Said by Mark Thompson (The Bodley Head)
Cut by Hibo Wardere, in collaboration with Anna Wharton (Simon & Schuster)
Another Day in the Death of America by Gary Younge (Guardian Faber)
The warning that children with cancer risk missing out on drug trials (Report, 9 March) highlights an issue that has been largely overlooked in the Brexit debate. I led work on the EU clinical trials regulation, which will come into force in 2018. By harmonising EU law and creating a single application portal, this will make it easier to carry out clinical trials in more than one country. Cross-border trials are particularly important for paediatric cancers because there are usually not enough cases in one country to make a trial viable. Once outside the EU, it will be harder for UK patients to participate in these trials.
Although cancer in children is relatively rare, more than 1,700 children are diagnosed and 257 die from cancer every year in the UK. Due to the lack of treatments available, a clinical trial may represent the only chance of survival for a child with cancer. Children are already missing out on access to innovative treatments because drug companies are reluctant to carry out paediatric testing due to the small anticipated profit margins; if children in the UK no longer have access to EU trials, this situation could become much worse. Withdrawing from the European Medicines Agency (EMA) could further impact the time it takes for new medicines to be available to patients in the UK.
Theresa May seems determined to cut all ties with the EU, even where there are obvious advantages from continued cooperation. It would certainly benefit patients in the UK, and children with cancer in particular, if we seek to remain part of the EMA and the EU clinical trials framework. Dame Glenis Willmott MEP Labour’s European parliament spokesperson on health
Leading doctors are warning that British children with cancer could suffer if they are no longer able to join Europe-wide trials of innovative new medicines as a result of the Brexit deal.
The Institute of Cancer Research (ICR) and the Royal Marsden NHS Foundation Trust say the best hope for some children with cancer is a clinical trial where a new drug is being tested. But because of the small number of children with the same cancers, the trials have to be run in many hospitals, often across Europe.
If the UK leaves the European Union and withdraws from the currently London-based European Medicines Agency which licenses new drugs, as expected, then pharmaceutical companies may choose to trial drugs just for children from countries in the EU. Children in the UK would lose out, and it could take years before they could get access to the newest treatments.
The ICR and the Marsden say EU regulations governing the way medicines are tested in children badly need reform to make companies trial more drugs in children, but the UK would be worse off without them.
“It is imperfect but it is all we have,” said Prof Louis Chesler, a consultant in paediatric oncology at the Marsden.
Children’s cancer is a very small field, he said. “The most effective way to run a clinical trial is to run a big one. If the regulations change and stop us working across European sites, that is a big problem for us,” he said.
The ICR and the Marsden, in their response to a European commission consultation on the future of drug regulation for children, are calling for changes so that drug companies cannot so easily obtain a waiver and duck the obligation to do trials in children once they have shown a drug works in adults.
A new analysis by the ICR shows that over the past five years (2012-2016) pharmaceutical companies were granted waivers from having to trial cancer drugs in children for 33 of 53 approved cancer treatments.
“By allowing pharmaceutical companies to use waivers to avoid trials in children so they can focus on adult treatments, the regulation is stifling progress and could be stopping children receiving a treatment that could save their lives,” said Chesler.
Prof Paul Workman, the chief executive of the ICR, said: “Children with cancer are currently missing out on the kind of innovative cancer treatments that are becoming increasingly common in adults because of outdated European rules that have failed to keep up with advances in science.
“We’ve been urging decision-makers to change the regulation for several years now, so that adult cancer drugs are tested in children whenever their mechanism of action suggests they could be effective.
“This is a real chance for reform to prevent the current out-of-date approach from being cemented for a decade. It could also be the last chance to make meaningful changes that apply across Europe, including the UK, before we leave the EU. It’s vital that whatever deal the UK does preserves access to Europe-wide clinical trials for children with cancer and avoids creating even longer delays in children accessing the latest cancer medicines.”
Dr Lynley Marshall, a consultant in child and adult cancer drug development at the Marsden, said families who are going through the trauma of caring for a child with cancer should not be alarmed. She pointed out that children with cancer in countries outside the EU, as far away as Israel and Australia, participate in some of the big treatment trials because of the difficulties of getting enough children with the same condition in one place.
She did not think fewer children in the UK with cancer would be included in trials. “I think it would be difficult to be categorical about it, but we will all be working very hard to ensure that there wouldn’t be,” she said.
The NHS faces a severe nursing shortage. An ageing population has pushed up demand, while an ageing nursing workforce – with one in three nurses set to retire in the next 10 years – is reducing supply. The shortage is particularly acute in mental health, with specialist nurse numbers falling more than 10% in the past five years.
And the Brexit vote may make it even worse. A July 2016 Institute for Employment Studies (IES) report reveals about 4.5% of NHS nurses in 2015 were from EU countries excluding Ireland, a steep rise from the 1% of 2009. In some trusts in London and the east of England, the proportion is as high as 20%.
Nurses who have been here more than five years will be eligible to remain. But what will happen to the others? Helen McKenna, senior policy adviser at the King’s Fund thinktank, believes that the government “urgently needs to clarify its position on the status of nationals who are already here in the UK working in health and social care roles”. While the prime minister has said she would like to guarantee the rights of EU citizens already living here, that is by no means certain. McKenna says: “Her position is likely to be dependent on reciprocal agreements for UK citizens living elsewhere in Europe.”
Rachel Marangozov, IES senior research fellow and report co-author, notes that the uncertainty and perceived hostility towards migrants may put some EU nurses off: “What are you going to say? ‘Come and work in London or the east of England – we can’t guarantee your future status, but come and work for us.’ It’s a very difficult sell.”
Janet Davies, Royal College of Nursing chief executive and general secretary, says that nurses from the “wider” EU are already losing interest in coming here and warns: “It’s to be expected as an immediate reaction, but what we don’t know is whether it’s a trend that will be sustained and become a serious problem.”
Both Marangozov and McKenna think the problem could be partially addressed by naming nurses as a priority occupation. But it may be difficult, says Marangozov, to devise a set of criteria that would allow in nurses but not other occupations in shortage areas.
An alternative is to ramp up recruitment from outside the EU. This will also need a change in policy, but, according to Marangozov, the very reason recruitment from EU countries has increased so dramatically is because of tighter immigration controls on countries outside the EU. The only realistic solution, she argues, is better workforce planning at a national level. Given the global shortage of nurses, dependence on immigrant nurses can only be a temporary measure: “We just rely on them as a stopgap because nobody has bothered to plan these issues in the workforce properly.”
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British cancer patients could be left “significantly disadvantaged” by the UK’s departure from the EU, leading oncologists have said, as collaboration with European scientists has been vital to making breakthroughs in the field.
In an editorial published on Friday in the ecancermedicalscience journal, six doctors, representing cancer physicians, patient advocacy groups and genomics researchers, said the UK government must be prepared to fill in the gaps in law, regulation and resource allocation that would open up after Brexit.
“It’s important that the UK’s cancer researchers and cancer care providers watch the ‘Brexit space’ very closely,” they wrote. “We need to take every opportunity to remind the UK government that cancer patients and cancer research could be significantly disadvantaged, unless great care is deployed in the negotiations of the legal and economic frameworks which will govern the UK’s relationship with the EU beyond Brexit.”
The authors are the Nobel prize winner Sir Paul Nurse, CEO of the Francis Crick Institute; Peter Selby, the president of the Association of Cancer Physicians UK; Mark Lawler, the chair of transnational cancer genomics at Queens University Belfast’s Centre for Cancer Research and Cell Biology; Richard Baird, a consultant at the Cambridge Breast Cancer Research Institute; Ian Banks, vice-president for patient advocacy at the European Cancer Concord; and Patrick Johnston, vice-chancellor of Queens University Belfast.
Lawler said: “It is vital that UK researchers continue to perform high-quality science that leads to new diagnostic tests and therapies for cancer patients. Research is no longer an ivory tower silo-type pursuit – collaboration is the key.
“UK scientists contribute greatly to the European research effort while having scientists from different countries working within our research institutions and hospitals contributes greatly to our battle against cancer.”
The authors, who in May argued the case for voting remain, said the consequences of the Brexit vote were unlcear, but expressed a lack of confidence over current regulatory structures being replaced by the UK government.
“There are widely held concerns among the cancer community,” they wrote. “Brexit would mean that the EU directive no longer applied in the UK, which is of concern to the manufacturers of devices and tests unless the EU and the UK share regulatory frameworks in future to allow ready import and export of devices/tests.”
Another complication is the fact that the headquarters of the European Medicines Agency is in London. “It is also possible that the EMA would not feel it appropriate to have its headquarters in a country not fully part of the EU,” Lawler said.
“If the EMA was to move to another jurisdiction, then the Medicines and Healthcare products Regulatory Agency (MHRA) would have to step up to take over certain regulatory activities and conduct cooperations with other global regulators.”
The uncertainty about funding, Lawler said, could discourage senior researchers from relocating to the UK, particularly if they felt that prestigious funding such as European council grants were no longer available to them.
“Anecdotally, a number of UK institutions have already indicated that pre-Brexit recruits have turned down positions due to uncertainties related to continued EU funding,” he said.
Genetic analysis of tumour samples can help decide what course of treatment is best for individual patients, and help researchers fully understand the mutations behind many cancers. One recently announced international project, Harmony, seeks to centralise and make better use of genetic data from blood cancer patients across Europe. But a key issue is how sensitive patient data is handled.
“There would be considerable uncertainty about the movement of personal research data between the EU and the UK,” Lawler said. “Data protection regulations would influence UK companies wishing to trade in services to individuals within the EU. All of this is likely to be the subject of complex negotiations.
“We need to break down data silos not build them up. It is vital for cancer research and most importantly for our patients that we share information that can help to identify new targets for cancer therapy.”
After Brexit, the group wrote, the UK will have to establish its regulations for clinical trials with a view to achieving the minimum necessary bureaucracy, as well as compatibility with other European countries for multinational trials.
They noted that some assurances have been offered: it has been agreed that current EU funding held by UK individuals and institutions will be honoured, and the government is talking about increasing the total spend available for research, within which cancer might figure significantly.
“But will they continue to fund researchers who compete successfully for European grants? That is the key question that needs to be answered,” Lawler said.
The Guardian has contacted the Department of Health for comment.
About 12,000 doctors trained in European countries could quit the UK because they feel less welcome following the Brexit vote, according to a survey of overseas medics.
About two in five doctors who qualified in European Economic Area countries are considering leaving the UK in light of the referendum result, research by the British Medical Association reveals.
The findings prompted alarm about an impending “disaster” in medical staffing and fears that an exodus of EEA doctors could exacerbate already significant personnel shortages in NHS hospitals.
The BMA’s findings are based on a survey it undertook of 1,193 EEA doctors working in the UK. When asked if they were thinking about leaving the UK following last year’s referendum vote, 500 (42%) said yes, 309 (26%) said no, 278 (23%) were unsure, while the other 106 did not answer.
“These are the people who staff our hospitals and GP surgeries, look after vulnerable patients in the community, and conduct vital medical research to help save lives. Many have dedicated years of service to healthcare in the UK, so it’s extremely concerning that so many are considering leaving,” said Dr Mark Porter, the BMA’s council chair.
“At a time when the NHS is already at breaking point and facing crippling staff shortages, this would be a disaster and threaten the delivery of high-quality patient care. But this isn’t just about numbers. The quality of patient care is improved where doctors have diverse experiences and expertise,” he added.
The EEA includes the 28 members of the European Union plus Norway, Iceland and Liechtenstein.
Figures from the General Medical Council, which regulates the medical profession, show that there are 280,932 doctors on the medical register. Of those, 177,912 (63%) were trained in the UK, 30,733 (11%) qualified in another EEA country and 72,287 (26%) are from elsewhere in the world.
“While thousands of overseas and EU doctors work across the UK to provide the best possible care for patients, many from the EU are left feeling unwelcome and uncertain about whether they and their families will have the right to live and work in the UK after Brexit,” said Porter.
European doctors feel significantly less appreciated by the UK government now than before the referendum. Their average rating on that score has fallen from seven out of ten before the vote to leave the EU to less than four out of ten now.
Similarly, they also feel a lot less committed to working in the UK since the Brexit vote. Their average rating on that question has fallen from nine out of ten before the referendum to six out of ten.
“Since the result of the EU referendum I feel increasingly uncertain about my future here, and am considering returning to Germany. It is unsettling that in a country that I have contributed to for 20 years and consider home, I am now seen as a foreigner and have to prove that I deserve to live and work here,” said Dr Birgit Woolley, a German-born GP who has worked in Britain for 20 years.
“I feel supported by my patients, with even those that voted leave telling me: ‘You can stay because you’re a doctor. We like you. We didn’t mean you.’ But the reality is that the government does not appreciate what EU nationals like me have contributed to the UK, and only sees us as bargaining chips.”
Luciana Berger, a Labour member of the Commons health select committee, said: “These extremely worrying BMA figures show the huge contribution made by doctors from the EU, and the severe risk that hundreds will leave the UK as a direct result of Brexit.”
A Department of Health spokesman said: “As the government has repeatedly made clear, overseas workers form a crucial part of our NHS and we value their contribution immensely.
“We want to see the outstanding work of doctors and nurses who are already trained overseas continue, but at the same time we have been very clear that we want to give more domestic students the chance to be doctors, given the enduring popularity of this as a career.”
Jeremy Corbyn has criticised Tony Blair’s call for pro-Europeans to form a new cross-party movement to oppose Brexit, urging the former prime minister to “respect the result” of the referendum and to put his energy towards building relations in Europe.
Corbyn, who was questioned on the comments after addressing Labour’s local government conference at Warwick University, said: “Well, it’s not helpful. I would ask those to think about this – the referendum gave a result, gave a very clear decision on this, and we have to respect that decision, that’s why we didn’t block article 50.
“But we are going to be part of all this campaigning, all these negotiations about the kind of relationship we have in Europe in the future.. The referendum happened, let’s respect the result. Democracy happened, respect the result.”
Earlier Corbyn said people were dying at the hands of the government’s austerity policies in a scathing attack on the prime minister days before two crucial byelections.
The Labour leader blamed ministers for an “emergency” in local services and a social care crisis caused by “disgraceful neglect” as he urged voters in Copeland and Stoke-on-Trent to “send a message” to Theresa May on 23 February that they had had enough of cuts.
In a speech to Labour councillors at Warwick University, Corbyn said: “We have a state of emergency in our social care system and the worst crisis in the history of our NHS.”
He added that the situation in social care was an “absolute scandal that leaves 1.2 million elderly people without the care they need”.
Corbyn cited a report in the Journal of the Royal Society of Medicine that said the crisis was linked to 30,000 excess deaths in 2015. “People are dying because of the choices made by this government,” he said. “Councils are at breaking point on social care. Our social care system has been privatised, outsourced and cut. It has dehumanised our parents, grandparents and neighbours.”
Corbyn vowed a Labour government would provide the NHS and social care with adequate funds while accusing May of leading a government that gives billions away in tax breaks to big business and the richest in society while cutting services for the most vulnerable.
He said: “It is this callousness, even brutality, that has put local services in a state of emergency.”
The twin byelections, caused by the resignation of Labour MPs Jamie Reed and Tristram Hunt, represent Corbyn’s toughest electoral challenge yet. The Conservatives are hoping to win Copeland from Labour, who are trailing in the polls. Corbyn’s past opposition to nuclear power is viewed with suspicion among many voters in the Cumbrian constituency, which is economically reliant on the Sellafield nuclear processing facility.
The party’s battle to retain the two seats suffered a further blow after Corbyn’s campaigns chief, Simon Fletcher, quit on Friday over an apparent clash with Labour’s inner team over the direction of the party.
The sudden resignation of one of his closest aides follows the resignations of four shadow cabinet members over Corbyn’s support for the article 50 bill.
Corbyn said on Saturday that Fletcher would continue working with Labour. “Simon and I are great friends and will remain great friends. We had a good chat last night. I’ve known Simon for 25 years, he’s a great friend of mind and he is going to do other things, but will continue working with us.”
In Stoke, which voted strongly in favour of Brexit in last year’s referendum, the main challenge is expected to come from Ukip, where party leader Paul Nuttall is standing.
Corbyn, who is expected to campaign in the constituency on Saturday, claimed Labour would “defeat Ukip’s politics of hate”.
Almost exactly a year ago I visited a Harley Street address, notebook in hand, to interview a plastic surgeon, a number of his staff and a few of his satisfied clients. The story was simple: business was good. The place was high-ceilinged and expensively decorated. In the UK the number of cosmetic surgical procedures had increased to record levels, by a whopping 13% year on year, in line with a decade-long upward trend.
What a difference a year makes. Figures just released by the British Association of Aesthetic Plastic Surgeons (Baaps) show that procedures actually dropped by 40% in 2016. A total of 31,000 cosmetic surgeries were performed in the UK last year, fewer than in 2007. It’s one of those statistics that seems to indicate – in contrast to all the other evidence – that sometime last year people started to see sense.
In a press statement Baaps cited several possible explanations for the decline, from uncertainty surrounding the EU referendum to “global fragility”. It’s also been suggested that larger cultural forces – mainly Instagram – have left us with less rigid ideas about beauty.
The thing about such a surprising reversal is that no one knows exactly what’s behind it. It makes sense that in times of upheaval people are reluctant to make life-changing decisions or commit to big purchases, but there was no corresponding drop in first-time mortgages or foreign holidays. It’s true that more people are opting for non-surgical cosmetic procedures, which are cheaper and less invasive, but that’s been the case for some time.
I’d love to believe that the public has begun to seen the light regarding the often illusory benefits of cosmetic surgery, but if I had to guess I’d say it was plastic surgeons themselves who are driving this shift. Non-surgical procedures are cheaper for them too, and they can do lots more of them. The practice I visited last year had already thoroughly diversified into Botox, thread-lifting, and proprietorial anti-ageing ointments.
Non-surgical clients require no hospital stay, and they have to keep coming back because the treatments wear off. Plastic surgery remains risky, and comes with tiresome ethical obligations on the part of the surgeon. It’s estimated that about half of plastic surgeons turn away 10% of all patients, and that one in five surgeons turns away a third. You don’t have to tell a patient they may be having Botox for the wrong reasons.
‘I arrived to find that two freezer cabinets had been moved to the spot where the newspapers used to be.’ Photograph: Dan Kitwood/Getty Images
Corner shop chaos
The other day I went to buy milk and a newspaper from the corner shop. I’ve done the same thing every day, at roughly the same time, for about 15 years, more or less on autopilot.. On this occasion I arrived to find that two freezer cabinets had been moved to the spot where the newspapers used to be. I like to think of myself as a rational and perceptive being, quick to adapt to small adjustments in my immediate surroundings, but that doesn’t quite square with my behaviour in this instance: I stared at the freezers in total incomprehension for about 20 seconds, my jaw hanging open.
The first conclusion I drew was that I’d walked into the wrong shop, or maybe a different universe. It wasn’t until another customer came in and experienced the same bafflement alongside me that I figured out what was going on. I found the newspapers on another shelf, bought one and left, forgetting the milk.
Dumb and dumberer
I spent the rest of that day appraising the world around me with renewed suspicion, which made me realise how important it is to have one’s environment disrupted from time to time; if you don’t notice something is amiss, chances are you won’t notice anything. I wish I could say this heightened sense of awareness stayed with me, but I went back to the shop the next day and performed the whole dumbshow of stupidity all over again, although I did at least remember the milk. It’s amazing we’re allowed to drive.
With growing unease I read the story about fellow EU citizen Monique Hawkins, whose application for a document certifying permanent residency was rejected by the Home Office even though she seems to have fully complied with the rules when submitting her application (Report, 29 December). I am German, 61 years old, married to a British husband and 16 years in the UK. Throughout these years I did my best to integrate. I worked, never claimed any benefit and participated in community life through voluntary work. The people around me never let me feel “foreign” or unwelcome and genuinely treat me like a fellow citizen. Like Mrs Hawkins, I never thought it was necessary to have my immigration status certified. This changed after the Brexit vote, because the life my husband and I have built together entirely depends on my right to remain in the UK. Consequently, I also decided to apply for British citizenship, which requires certification of permanent residency.
Like Mrs Hawkins, we discovered that our marriage is treated differently to non-EU/UK marriages and that it is discounted as a reason for certifying my status because I am an EU national. So I ploughed through the 85 pages of the application form and submitted it, together with the required evidence as advised in the guidance notes, feeling confident that I had done everything right. But after reading Mrs Hawkins’ story, I began to think that decisions made by the Home Office involve more unspoken rules and processes than can possibly be foreseen by applicants. My application is still being processed and I will let you how I get on. Regina Erich Stonehaven, Aberdeenshire
• My wife is Swedish and has lived in the UK for 60 years, while proudly retaining her Swedish citizenship. She has been married to me for 57 years, is as English in her social and cultural experience as any English person and probably speaks our language more correctly than most native English speakers. She now suffers from dementia and is physically more or less immobile. She would be unable to conduct the defence of her right to be here herself, but if I were to write to the Home Office on her behalf would we receive a similarly disgraceful and insensitive letter as others, whose experiences you have reported, have done? Or maybe, even, immigration officers would turn up on our doorstep at 5am and cart my wife off to the nearest detention centre. Name and address supplied
• The case of the Dutch mother of English children being advised by the Home Office to leave Britain after living here for 24 years perfectly legally, is not going to be an isolated one. Either in the UK or the rest of Europe. Significant numbers of internal refugees will be created because people are resident by virtue of EU citizenship while not necessarily meeting local residency rules. Many of these people will also fail to qualify for services, such as health, if they return to their country of origin.
A typical example would be a UK citizen who has spent modest life savings on an apartment in the Spanish Costas and has been surviving there on the British state pension for a year or two. Registering for Spanish residence can be daunting without the language skills and resources to pay for advice. Some like the Dutch mum would not be eligible and, should they be asked to leave once the protection of EU citizenship is removed, would arrive in Britain without the right to use the NHS and would also be ineligible for the house benefits needed to secure accommodation. The number of people displaced across Britain and Europe could run into millions. HMG and the EU negotiators will have to find a way of preventing what could become a significant internal refugee crisis among their own citizenship. Olly Cooper Cambridge and Algarrobo, Spain
• Re EU citizens applying for British citizenship and the long processing times, the Home Office’s pathetic response was to say that they had launched an express passport check-in service. They failed to say that the cost of nationalisation is over £1,000 plus all the add-ons, eg biometric residences permit, medical checks etc, and the process takes six months or more. A super premium service is £8,750. Margaret King Polegate, East Sussex
• It would seem that some EU citizens when applying for permanent residence in the UK are being subjected to requirements concerning comprehensive health insurance that the NHS clearly states they do not need to have (Call to scrap rule barring some EU citizens from the UK, 31 December). If a person from the EU, EEA or Switzerland is moving to England, a quick check of the NHS website reveals that: “Provision of free NHS treatment is on the basis of being ordinarily resident and is not dependent upon nationality, payment of UK taxes, national insurance (NI) contributions, being registered with a GP, having an NHS number or owning property in the UK.” Furthermore, “ordinarily resident means, broadly speaking, living in the UK on a lawful and properly settled basis for the time being.”
Is the Home Office trying to take away the rights of some EU citizens that the Department of Health states that they are entitled to? Paul Tattam High Peak, Derbyshire
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