“Reducing the ratio (of maternity staff in Surrey) to balance the books is the worst of all decisions.”

If Trust Boards and Directors are to be pilloried or dismissed for falling standards, then they have no option other than to close down services. The choice between quality and cost is no longer allowed, (By CQC or patients) so rationing has to increase… So lets make it ethical and explicit. The real risk in continuing denial of the need to ration, is that when it comes, it will be a knee-jerk co-payment system, across an NHS Region, and unfair to the poorest and most diabled.

Kate Gibbons in The Times reported 13 days ago: NHS cuts threaten hospital closures

James Watkins in GetSurrey reports  20th August: Royal Surrey plan to cut midwife numbers amid growing tensions over financial crisis 

and on 23rd August the BBC news reports: Debt-hit Royal Surrey hospital cuts maternity staffing

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Several midwife vacancies are to be left unfilled at a major hospital that is trying to save £22m.

The Royal Surrey County hospital in Guildford has warned of “some very difficult decisions and changes to working practice”.

It is cutting its midwife-to-mother ratio but insisted “patient safety, standards and care will not be affected”.

A former NHS trust chairman Roy Lilley said it “was a very bad idea”.

“They are sailing very close to the wind by reducing staffing levels. Unfortunately, finding extra midwives (when you need them) is very difficult, you have to resort to emergency agency arrangements which cost the earth or you simply do not get them.

“Reducing the ratio to balance the books is the worst of all decisions.”

The hospital trust said under the ratio, there would be one midwife per 30 mothers, rather than 29.

Retired NHS midwife Val Clarke, from Epsom, said: “It is very worrying. This can only impact on the mothers. When you are very busy, you are unable to give the level of care to each mother that they should be receiving.”

In a statement, Royal Surrey said: “The safety of our patients is our primary concern and as such we measure our midwife acuity levels on a daily basis.”

The trust said the ratio change was “not driven” by its need to make savings, but came from a “normal monthly process” of reviewing nursing and midwifery numbers.

But it also warned: “This year, the trust needs to save over £22m, which means… making some very difficult decisions and changes to working practice.”

Local hospital campaigner Karin Peluso told BBC Surrey: “If this continues at the Royal Surrey and they start slashing at the frontline services, key personnel like midwives, then the hospital could be on a very slippery slope.”

In April, regulator NHS Improvement began an inquiry after the trust recorded an annual deficit of £11m.

It said the trust has since agreed to develop long and short term plans to improve its finances “without impacting on patient care”.

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24/7? “Too few staff and too little money to deliver….. patients may not notice any difference even if it happens”.

Whilst three of the four UK Health jurisdictions are not attempting a 24/7 Health Service, England is persisting to say this is what it will achieve. The Guardian report indicates failure is predictable, but NHSreality predicts that denial will continue until Mr Hunt has to move on…. This is the result of prolonged rationing by undercapacity in training places, net emigration of overworked and undervalued doctors, overbearing performance targets, and an ideology which is patently failing to deliver compared to other G8 countries. Our politicians are running scared..

Dennis Campbell reports in The Guardian 23rd August 2016: Secret documents reveal official concerns over ‘seven-day NHS’ plans – Internal Department of Health papers drawn up for ministers detail string of dangers in implementing plan

The health service has too few staff and too little money to deliver the government’s promised “truly seven-day NHS” on time and patients may not notice any difference even if it happens, leaked Department of Health documents reveal.

Confidential internal DH papers drawn up for Jeremy Hunt and other ministers in late July show that senior civil servants trying to deliver what was a totemic Conservative pledge in last year’s general election have uncovered 13 major “risks” to it.

While Hunt has been insisting that the NHS reorganise around seven-day working, the documents show civil servants listing a string of dangers in implementing the plan – as summarised by a secret “risk register” of the controversial proposal that has prompted a bitter industrial dispute with junior doctors.The biggest danger, the officials said, is “workforce overload” – a lack of available GPs, hospital consultants and other health professionals “meaning the full service cannot be delivered”, they say in documents that have been obtained by the Guardian and Channel 4 News.

The risk register and other documents also show that the DH sees the NHS’s 1.5 million staff, especially doctors, as a “barrier” to the high-profile but controversial ambition of increasing patients’ access to hospitals and GP surgeries at weekends “because they do not believe in the case for change”.

Hunt has angered hospital consultants and junior doctors over the last year by ordering them to work more at weekends in order to help deliver the seven-day goal, even though both groups are often on duty on Saturday and Sunday.

Juniors have held eight days of strikes to protest against a new contract Hunt is imposing on them which they claim ignores the need for extra doctors to enable the expansion of care he wants – a claim that the BMA said was vindicated by the documents.

Dr Mark Porter, leader of the British Medical Association, said the papers proved that government had ignored warnings from healthcare organisations, especially that a lack of extra staff and more funding would hinder progress. That it has also “disregarded its own risk assessment’s warnings about the lack of staffing and funding needed to deliver further seven-day services, is both alarming and incredibly disappointing”, he added.

He also seized on the DH’s admission in the documents that it still has not worked out what No 10’s objectives were. In pushing ahead with implementing the plan, Porter said: “[It] only goes to show that this was nothing more than a headline-grabbing soundbite set to win votes rather than improve care for patients.”

Shortly after the May 2015 election, David Cameron, the then prime minister, made a speech in which he referred on 18 separate occasions to his “plan” for a seven-day NHS. Fourteen months later, the BMA added, that the documents show that there was still a painful lack of detail.

The papers also show that senior officials at the Department of Health:

Fear the seven day plan might fail to deliver its stated aims, which include improving the quality of hospital care at weekends and reducing death rates among those admitted for treatment as an emergency on Saturday or Sunday. “It is possible that the programme delivers the planned outputs, but this does not result in the desired change (delivering against the plan but missing the point),” one states.

Voice concern that there is also a risk that even if weekend services are successfully enhanced, that “patients do not report any difference/improvement in their experience [of] out of hours and at the weekend”.

Worry that Britain’s decision on 23 June to leave the European Union “may adversing (sic) impact upon the delivery of the 7 Day Services programme, particularly with regards to workforce and finances” because the NHS employs 55,000 staff from around the EU.

A DH spokesman said: “Over the past six years eight independent studies have set out the evidence for a ‘weekend effect’ – unacceptable variation in care across the week. This government is the first to tackle this, with a commitment to a safer, seven day NHS for patients and £10bn to fund the NHS’s own plan for the future, alongside thousands of extra doctors and nurses on our wards.”

A department source added: “A risk register by definition details all potential issues under a worst-case scenario to help the government develop robust plans to ensure we meet our promises to the electorate, but we are confident our programme for a safer seven-day NHS is on track‎, and will deliver real benefits for patients.”

Hunt has persistently championed the idea of a seven-day NHS. On 25 April the health secretary told MPs of “the government’s determination to be the first country in the world to offer a proper patient-focused seven-day health service”. In that speech he specifically rejected “the concern that a seven-day NHS might spread resources too thinly”.

That was unfounded, Hunt said, because the government has increased doctor numbers by 10,100 since 2010 and would add a further 11,420 to the headcount by 2020.

The documents also show that privately some of Hunt’s most senior civil servants worry that the pledge to increase the NHS budget by £10bn by 2020-21 will not be enough to deliver the promised NHS expansion by 2020. The risk register notes that much of the £10bn will not reach the NHS until near the end of this parliament and thus not be immediately available to fund the changes. “This could result in ‘back loaded’ delivery increasing the risk that deadlines for completing roll-out [between now and 2020] are missed,” they say.

Several of the risks reveal damaging internal disagreements among those taking forward the seven-day drive, including over what the purpose of the plan is. That included tension between the DH and Downing Street in May when Cameron was still in power. In a section of the risk register headed “scope creep”, which was last reviewed on 10 May, it says: “The planned objectives and scope of the programme do not meet the expectations of No10/Cabinet Office, meaning that they may continue to change. This could lead to an inability to deliver the desired outcomes to the agreed timescales.”

Prof Chris Ham, the chief executive of the King’s Fund, rejected Hunt’s insistence that the £10bn was enough to deliver a seven-day NHS by 2020.

“It is not credible to argue that it can continue to meet rising demand for services, maintain standards of care and deliver new commitments such as seven-day services within its current budget,” he said. “Implementing seven-day services is a laudable ambition but is not realistic unless additional funding becomes available and workforce challenges can be overcome.”.

The shadow health secretary, Diane Abbott, said: “This is a shocking indictment of the Tory government’s plans. They pressed ahead with their proposals even when campaigners and NHS staff argued they were unworkable. It has now been confirmed by the advice the government received from its own civil servants.”

Abbott said she would be contacting Hunt to see if he had misled parliament.

Hospital doctors ‘miss signs of illness’ because of chronic staff shortages – Survey reveals widespread concern that widening gaps in rotas are risking patient safety and leave ‘pressurised’ medics in tears

These leaks show Jeremy Hunt’s deception over the seven-day NHS

NHS weekend-working risk management document – Leaked document shows what NHS officials perceive to be main risks in rolling out weekend working in health service

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Yet another trust bites the dust.. and the media fail to recognise the overall implications..

This post chronicling the demise of standards in East Sussex will not surprise any of the employees. The decline was sustained before the fall, and as yet another trust bites the dust, politicians will remain in denial about the cause. Local mismanagement will be blamed when it is impossible for any management team to meet both the quality/access, and financial imperatives. (With apologies to the Argus for full reproduction). The media seem unable to take the argument beyond the specific to the general..

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On Friday 15th August Frank le Duc reported in the Brighton and Hove News: Brighton hospital trust in crisis

3 days later the ITV News reported: ‘Racism is endemic’ at Sussex NHS Trust placed in special measures

The day before, 17th August, Flora Thompson in The Sussex Argus reported: Hospital will be put into special measures, sources confirm

PATIENT safety has been put at risk due to a catalogue of failings at a major hospital trust which has been placed in special measures.

A damning report published today by the Care Quality Commission (CQC) brands Brighton and Sussex University Hospitals NHS Trust inadequate and makes the recommendation that it needs support to improve.

The main areas of concern include:

  • Patients being treated in a corridor in A&E at the Royal Sussex County Hospital in Brighton, compromising their dignity and confidentiality and risking infection
  •  The old buildings at the Royal Sussex being overcrowded and cluttered with narrow corridors and inaccessible fire exits
  • Staff from black and ethnic minority backgrounds saying bullying, harassment and discrimination were rife
  • Staffing levels and the skill mix in emergency departments, medical wards, critical care and midwifery were too low
  • Some emergency patients using beds in the operating theatre’s recovery area for up to three days with no appropriate toilets
  • The trust reported seven “never events” in 2015 – including four incidents where surgeons operated on the wrong part of a patient’s body

The trust – which also looks after the Princess Royal hospital in Haywards Heath – was placed in special measures yesterday.Going into special measures will normally mean the trust would partner with a successful trust and an action plan for improvements put in place. A trouble shooter is normally brought in.

The trust board was criticised for its lack of ownership to resolve the issues and inspectors said there was a “disconnect” between the board and staff.

The report also highlighted the trust’s failure to hit its targets for A&E waiting times and for outpatient appointments.

The trust was said to be inadequate for safety, responsiveness and leadership, while its effectiveness and care needed to improve.

However its services for children and young people at the Royal Alexandra Children’s Hospital were rated as outstanding.

Patients also said they were treated with compassion and care.

Trust chief executive Gillian Fairfield said the failures were unacceptable and apologised unreservedly.

The issues raised have partly been due to the condition of some of the buildings at the Royal Sussex along with an increase in demand for services and delays in discharging patients ready to leave hospital.

Dr Fairfield said changes had already been made to improve services and significant progress had been made in many areas since she arrived in April.

She said: “There is a lot more to do and some of the improvements will take time and a lot of hard work to achieve, but we are determined to continue the improvement process we have started to get to a place where we are providing our patients with a standard of care that they rightly expect and deserve.”

CQC deputy chief inspector of hospitals, Edward Baker, said: “There was a distinct disconnect between the trust board and staff working in clinical areas, with very little insight by the board into the main safety and risk issues, and seemingly little appetite to resolve them.”Royal College of Nursing senior regional officer Sue Huggins said: “The nursing team will be devastated to receive this report and yet they remain dedicated to providing the best care they can as they are professionals.

“No patient should ever have to receive care in a corridor and patients deserve dignified care at all times.

“This isn’t a problem unique to Brighton but it is an indication that unsafe staffing levels mean the appropriate standards can’t always be met.”

SAFETY AND LEADERSHIP ARE INADEQUATE WHILE CARE NEEDS IMPROVEMENT

AMONG services looked at by CQC inspectors were accident and emergency, medical care, surgery and critical care, end-of-life care and outpatients.

Overall the Brighton and Sussex University Hospitals NHS Trust, which runs the Royal Sussex County Hospital and Princess Royal Hospital, was given an inadequate rating.

Individually, the Royal Sussex in Brighton was found to be inadequate and the Princess Royal in Haywards Heath requires improvement.

Safety, responsiveness and leadership at the trust were all found to be inadequate, while its effectiveness and care required improvement.When it came to safety, inspectors said the trust had reported seven serious incidents over a one-year period, which was attributed to surgery. Four of these were related incidents, where surgeons operated on the wrong part of the body.

Not all areas of the hospital met cleaning standards and the fabric of areas like the Barry and Jubilee buildings were was poor and posed a risk to patients, particularly with regard to fire safety.

Both buildings were overpopulated, overcrowded and cluttered with narrow corridors and inaccessible fire exits and flammable oxygen cylinders were found stored in fire exit corridors.

Patients waiting in a corridor area of the emergency department at the Royal Sussex, known as the cohort area, were not assessed appropriately and there was a risk of cross infection.

Inspectors said there was a lack of clinical oversight of these patients and a lack of ownership by the trust board to resolve the issues.

Although the trust had an up-to-date infection-control policy, there was an inconsistent approach to hand hygiene practice in some areas.

Inspectors also criticised the trust’s use of balcony areas to create additional bed spaces.

The operating theatre’s recovery area at the Royal Sussex was being used for emergency patients due to having to reduce the pressure in A&E.

Some patients had stayed there for up to three days, despite no appropriate toilet facilities or access for visitors and carers.

Patients’ privacy, dignity and confidentiality were compromised in the outpatients department, medical wards and emergency department, where inspectors found frail elderly patients without call bells, patients being examined without the use of privacy screens and medical history discussions in close proximity to other people.

Inspectors said staffing levels and the skill mix in emergency departments, medical wards, critical care and midwifery were too low to ensure patients received the care they needed.

Nurse staffing levels in the emergency department at the Royal Sussex fell below safe levels on more than 60 per cent of shifts.

In some areas the trust had systematically failed to respond to staff concerns about this.

When inspectors looked at effectiveness, they found staff generally followed national guidance for care and treatment and patient’s nutritional needs were generally met.

The percentage of patients whose operations were cancelled was consistently higher than the national average, and over the course of a year, 71 people waited more than 12 hours in A&E for a bed to become available on a ward, In some areas, like the cohort area in the Royal Sussex, patients did not always have easy access to food and water.The trust’s care also requires improvement, although staff were found to be caring and compassionate to patients’ needs and patients said they felt well looked after.

Children and young people at the end of their lives received care from staff who consistently went out of their way to ensure both patients and families were emotionally supported and their needs met.

The trust was also found to be inadequate over its leadership.

Staff in general reported a culture of bullying and harassment and a lack of equal opportunity and longstanding problems faced by black and ethnic minority staff did not receive effective board action.Inspectors said there was a clear disconnect between the trust board and staff working in clinical areas, with very little insight by the board into the key safety and risk issues of the trust and little appetite to resolve them.

The culture at the Royal Sussex was one where poor performance in some areas was tolerated and there was a problem with stability of leadership and several long-term vacancies of key staff.

Ward managers and senior staff reported they received little support from the trust’s human resources department in managing difficult consultants or with staff disciplinary and capability issues.

The relocation of neurosurgery intensive care from Haywards Heath to Brighton in June 2015 had been managed without appropriate planning and risk assessment and also lacked evidence of robust staff consultation.

The executive team failed on multiple occasions to provide resources or support clinical staff in critical care to improve safety and working conditions.

There were several areas of outstanding practice, including services for children and young people at the Royal Alexandra Children’s Hospital.

The play centre has an under-the-sea themed room with a bubble tank and interactive floor.

A virtual fracture clinic, where patients with simple breaks in their bones are given advice over the phone instead of having to come in was praised, and the care provided for patients who had suffered a stroke was said to be outstanding.

The trust says it has already made significant improvements since the inspection in April, including sorting out fire risks and redesigning the A&E area to include a new assessment unit for patients coming in by ambulance.

New ways to better manage emergency patients during periods of high demand have been drawn up and a 24/7 surgical assessment unit has been opened for patients referred by GPs, which has increased the number of patients that can be seen and critical care nurse staffing numbers have been increased.

IT WILL TAKE TIME FOR THE TRUST TO GET ITSELF BACK ON RIGHT TRACK

TODAY’S CQC report makes difficult reading for Brighton and Sussex University Hospitals NHS Trust but many of these findings cannot be described as surprising.

Issues about overcrowding and long waits in A&E, missed targets, concerns about patient safety, staffing levels and allegations of bullying and harassment, especially for people from black and ethnic minority groups, have been well documented.

However, the depth and scale of the trust’s problems and the enormity of the task ahead means it is going to take a while to get it back on track.

The trust has been in a state of flux for nearly a year with several changes at the top following the departure of former chief executive Matthew Kershaw at the end of last year to take up a position at another trust.

Amanda Fadero took over as interim chief executive for a couple of months before Gillian Fairfield arrived in April.

Since April it has seen a new interim chairman and other board members have also been replaced and it is hoped the new team will be able to repair the distinct disconnect the CQC found between the board and staff.

Some of the issues raised are an indication of cuts in NHS investment in general, with staff struggling to provide the best service possible for an ever-growing number of patients in an atmosphere of cost cutting and cuts in bed numbers.

Part of the problem are the delays in patients being discharged from hospital when they are ready to leave because of issues providing community beds and support in their own homes.

This has a severe knock-on effect on departments like A&E and can lead to cancelled operations and long waits for appointments.

The NHS in general is also suffering a national recruitment crisis, something which the trust is not responsible for, but this is also adding to its problems.

There are plans for the future, the £480 million redevelopment of the Royal Sussex will lead to a better environment for patients but that will not be finished for several years and improvements need to be made now.

Dr Fairfield has already brought in several changes and it is hoped the trust will be out of special measures as soon as possible.

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Video clips of NHS (England) rationing

Here are some recent news clips with evidence for NHS (England) rationing, and some views. Charlie Cooper in The Independent sums it up on 21st June: Doctors’ leader warns of more NHS rationing unless funding freeze ends. This implies a simplistic short term suggestion of more money, and NHSreality agrees that more is needed, but not from direct taxation. We need overt co-payments related to means and income….. This needs time and debate to organise and agree, and we are not yet beginning the debate because of political fear and denial. Gagged politicians with perverse incentives….The conspirators in this are the media: constantly short term themselves, and easily distracted, they rarely sustain a debate on any ideology.

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Exclusive: Government accused of ‘dishonesty’ in expecting health service to match increasing need without more cash

Videos of nhs rationing newsview on BBC

Divided we fall. The “Mutual” of health care gets another body blow… Explicit division into a two tier system begins..

GPs are told to refer to private sector in a bid to cut local trusts’s waiting times.

Divided we fall. The “Mutual” of health care gets another body blow… Explicit division into a two tier system begins.. It is not the job of the Commissioning Groups to consider the ideology, rather to balance the books. It will be interesting to see if conservative politicians address this explicit rationing by wealth.

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Exclusive GPs in Hertfordshire have been told to not refer patients to the local NHS trust but instead refer to alternatives providers, including ‘independent sector providers’.

NHS Herts Valley CCG has told GPs to refrain from referring patients to West Hertfordshire NHS Trust (WHHT) for non-urgent appointments wherever possible, and has put a bar on all referrals for certain specialties, including cardiology, ENT, urology, pain, and general surgery.

Instead GPs have been told to refer patients to alternative hospitals, including local private providers, while the Trust is in the process transferring existing referrals to the private hospitals. The referrals will be funded by the NHS.

This is in a bid to cut waiting times at the trust, which has failed to meet national 18-week referral to treatment targets.

It follows the proposal by NHS St Helens CCG to defer all non-urgent referrals over a four-month period this winter – from which it later backtracked

NHS Herts Valley CCG has asked GPs ‘wherever possible to refer to alternative NHS and independent sector providers’ in a letter sent earlier this month headed ‘urgent for action’

In addition they have been told not to refer any patients at all to eight specific specialties ‘for the next three months in the first instance’.

The letter explains that WHHT is failing to meet the 18-week referral to treatment standard ‘in a number of specialties’ and that the hospital is ‘performing at a rate of 89% against a target of 92%’.

The eight specialties with a complete bar on referrals are cardiology, ENT, urology, pain, general surgery, ophthalmology, trauma and orthopaedics and rheumatology.

In addition, the letter says that WHHT is ‘seeking additional capacity from the independent sector and transferring patients for treatment’.

The CCG adds that it is also reviewing referral thresholds ‘as we need to ensure these remain within the overall funds available to the CCG’.

NHS Herts Valley CCG told Pulse in a statement: ‘Currently WHHT is experiencing some pressures on its ability to deliver the required waiting time of 18 weeks from referral to treatment in a number of specialities.

‘We have advised GPs that they can suggest alternative non-urgent referrals to their patients away from WHHT for a short period of time (initially three months) to allow the trust to clear the backlog of patients waiting.’

Pulse reported last week that NHS St Helens CCG proposed to suspend all non-urgent GP referrals for four months over the winter in a bid to tackle a £12.5 million funding gap for the year.

It later backed down, after GPs has said the move was ‘unacceptable’ and warned it would lead to missed diagnoses and cost the health system more in the long run.

Another cost-cutting scheme in Devon saw GPs having to devise management plans and treatment for one-third of all patients they had referred to urology specialists.

Last year, NHS Redditch and Bromsgrove CCG asked GPs to not refer to a local acute trust for at least three months to allow the hospital to clear up its backlog of operations.

Smith warns of ‘secret Tory NHS privatisation’: The Health services are like a sacred cow – with rabies.

Like a sacred cow in the Hindu culture, even if it has rabies the health system ideology cannot be touched.

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BBC News reports 15th August 2016: Smith warns of ‘secret Tory NHS privatisation’

Labour leadership contender Owen Smith has accused the government of having “a secret plan to privatise the NHS” in England.

In a speech, Mr Smith said NHS spending on the private sector has doubled to £8.7bn during the six years the Conservatives have been in power.

The Department of Health said his analysis was “simply wrong”.

Meanwhile, leader Jeremy Corbyn has said he wants a “National Education Service” based on NHS principles.

3 days ago in the Express: Tories ‘have secret plan to privatise NHS’ says Owen Smith

3 days ago BBC: Reality Check: Has private contracting in the NHS doubled?

2 days ago in the Guardian Dennis Campbell reportds: How much is the government really privatising the NHS? = Figures show privatisation to be less of the explosion that Owen Smith warns about and more a gradual, inexorable rise in the outsourcing of services

1 day ago: Co-operation, collaboration and competition – inside the mindset of NHS managers

Peter Hill reports in the express 16th August: The NHS is sacred and politicians are scared of it,   – THE NHS lurches from crisis to worse. Hospitals openly admit they can’t cope, operations are cancelled, patients lie on trolleys for 12 hours, drugs are denied, it’s even harder to see your local doctor and don’t bother to try A&E instead.

Doctors are leaving for EU already, health chiefs warn

Chris Smyth warns us in The Times 16th August 2016, on the reduction in EU trained doctors threatening staffing levels further. So even more medical student places need funding…

Doctors are leaving for EU already, health chiefs warn

Medical expertise in areas from cancer treatment to brain surgery will be damaged by an exodus of European staff following Brexit, leading hospitals have warned.

Some European doctors and nurses are already leaving the NHS, threatening specialist care that relies on them, hospitals say. A quarter of the doctors in some specialist hospitals come from the EU and because they have rare skills they cannot be replaced by British staff. NHS officials say that patients would be at risk if they left.

In a letter to The Times the Federation of Specialist Hospitals has urged the government to guarantee European staff that their future in the NHS is secure so that patients do not suffer.

The chief executives of Royal Brompton Hospital, which specialises in cancer care, Papworth Hospital, the leading heart transplant unit, Walton Centre, a major neurology hospital, and Moorfields Eye Hospital are those warning of the threat posed by the departure of EU staff.

“Our ability to provide exceptional care to patients hinges on recruiting and retaining the best clinical talent from the UK and further afield,” they write. “Crucially, this includes the European Union, where up to a quarter of doctors in a given specialist hospital trust may come from other member states, with even higher proportions for some clinical teams.

“In the wake of the EU referendum result our greatly valued European colleagues are understandably feeling uncertain about what the future holds for them in this country. Indeed, one or two have already left and, as things stand, more will be heading in the same direction with little return traffic.”

Rob Hurd, head of Royal National Orthopaedic Hospital, which treats complex hip and spine problems, said that with the NHS already under pressure “we don’t want this to be the thing that breaks us”.

Theresa May, however, has declined to offer guarantees, while uncertainty remains over the status of millions of Britons living in Europe.

• Patients are at risk because of European doctors’ poor English, the Royal College of Surgeons has warned. EU doctors attract a disproportionate number of complaints about their ability to speak English and must be subject to the same stringent tests as other foreign medics, the college says.