On Wednesday (March 29) the Prime Minister will trigger Britain's departure from the European Union. This will undoubtedly leave the estimated 57,000 EU nationals who work in the NHS feeling even more unsettled and anxious than they have been since June.
We know that Brexit is already having an impact on the NHS. During 2016 2,700 EU nurses left the NHS - compared to the 1,600 EU nurses who left in 2014. And only 96 nurses joined the NHS from other EU countries in December 2016 - compared to 1,304 who joined last July.
A morning spent at the Wiltshire Clinical Commissioning Group (CCG) board meeting offers ample evidence of the way the NHS is already, in pre-Brexit times, struggling with recruitment - and the shortage of staff is also hitting social care which in turn affects the NHS.
1) It was the impossibility of recruiting two GPs to the Marlborough and Pewsey GP surgeries that has caused their merger. Now, "due to unforeseen GP shortages", the Smallbrook surgery based in the Warminster Community Hospital has collapsed - leaving its 4,300 patients unsettled and anxious.
This surgery - which in December had been rated 'Good' by the regulator - lost one GP to maternity leave and then two partners suddenly left. Recruiting one doctor - let alone three doctors - in a hurry proved, understandably, impossible. The surgery has now been 'integrated' - temporarily? - with the Westbury Group Practice.
Smallbrook is still open for three hours a day with priority for appointments given to those who cannot travel to Westbury. The CCG are working on more permanent plans to make sure those 4,300 people have a full and local GP service.
2) The Avon and Wiltshire Partnership (AWP), which provides the county's adult mental health services, shows a scary example of the endemic recruitment shortfall. Their teams in Wiltshire have 117 vacancies - a vacancy rate of about 22 per cent.
3) There was some wry laughter during discussions on the ongoing 'crisis' in A&E and the missed four-hour-wait target. The CCG Board heard that capital money was available to meet NHS's insistence that GPs should be placed at A&E 'front doors' to act as a first line of triage. The elephant stalking that room was simply: "Where are they going to find all those doctors?"
4) The CCG and Wiltshire Council's Better Care Plan work to keep the elderly out of hospital and, if they do have to go into hospital, to get them back home faster, will be supported from April 1 by an experimental scheme involving 30 Rehab Support Workers - a new role.
The plan is for them to help people during their first ten days at home and, over a year, should effect 1,091 timely discharges from hospital. In the first year they will be costing £1.2million.
Seven of those thirty recruits have come from Wiltshire's Help to Live at Home providers - leaving them, in turn, short of seven staff who should also be helping patients get home from hospital - and at a time when their work is getting harder.
A report to the CCG Board stated: "Help to live at Home providers are experiencing increased acuity and are delivering more hours of care, supporting the same number of clients".
As one CCG director put it, when it comes to recruitment "We are all fishing in the same pond."
5) Virgin Care which last April took over community health services for Wiltshire's 110,000 nought-to-eighteen year-olds, is also having recruitment problems. In January their nursing vacancy rate rose by eleven per cent.
In the last quarter of 2016 they were short of six whole-time-equivalent school and community nurses and currently have clinical vacancies equivalent to 22 whole-time-equivalent posts.
That is probably enough examples to show how great a problem Wiltshire faces. Why is Wiltshire affected so much by these shortages? Recruitment plans and staff retention plans abound. To some extent it is true that "We are at the mercy of the market." But it may be much more of a cultural issue.
AWP appears to have no problems of recruitment for its services in the Bath and North East Somerset area. Presumably the cultural and night-life of Bath solves their problem.
Facing the closure of Smallbrook Surgery, one Warminster town councillor was quoted as saying: “The town council doesn’t have much on a say on healthcare, but what we can do is do our best to make the town a more attractive place to live - to encourage more GPs to want to come and work here.”
Locally these staff shortages may be partly due to cultural and partly to housing costs. The problem may be partly a matter of rates of pay and, more generally, of government imposed pay restraint.
But as Brexit proceeds and EU nurses, doctors and surgeons (and for that matter those from beyond the EU) feel even less welcome in Britain than they have been made to feel since the EU referendum, then recruitment and staff retention could well become the next great problem that threatens to break the NHS.