The UK has historically been a global leader in life sciences innovation, but recent statistics paint a worrying picture for medicines access. The right policy can start to reverse this. We are living in a time where the intersection between breakthrough science, technology and data insights has the potential to transform treatment options for some of the toughest health conditions faced by patients in the UK. The UK has long played a central role in driving innovation when it comes to healthcare, and at Johnson & Johnson (J&J) we were pleased to see some positive signs from the Government at the end of 2025, illustrating an intent to reverse a decade of decline of investment in how the UK values innovative treatments. It was a positive first step, but now the real work begins to enable us to deliver the best possible outcomes for UK patients. To achieve this, our focus must be on ensuring our health system is set up to match the pace and gain the benefits of innovation that science provides. We need a supportive medicines environment that fully fosters growth, because even the most pioneering drugs and therapies are only valuable if they can be accessed by patients when they need them most. > even the most pioneering drugs and therapies are only valuable if they can be > accessed by patients when they need them most. At J&J, we are proud to have been part of the UK’s health innovation story for more than a century. We believe that turning ambition into delivery requires a clearer focus on the foundations that enable innovation to reach patients. We have had a substantial and long-term economic presence, with our expertise serving as the grounds for successful partnerships with patients, healthcare providers, clinical researchers and the NHS. Recent national developments are a step in the right direction The UK Government’s recent announcements on the life sciences industry are an important move to help address concerns around medicines access, innovation and the UK’s international standing. This includes a welcome planned increase to the baseline cost-effectiveness threshold (the first change to be made since its introduction in the early 2000s). While it is crucial to get this implemented properly, this seems like a step in the right direction — providing a starting point towards meaningful policy reform, industry partnership and progress for patients. The true impact of stifling medicine innovation in the UK compared with our peers These positive developments come at a critical time, but they do not fix everything. Over the past decade, spending on branded medicines has fallen in real terms, even as the NHS budget has grown by a third.[i] Years of cost-containment have left the UK health system ill-prepared for the health challenges of today, with short-term savings creating long-term consequences. Right now, access to innovative medicines in the UK lags behind almost every major European country[ii]; the UK ranks 16th and 18th among 19 comparable countries for preventable and treatable causes of mortality.[iii]These are conditions for which effective medicines already exist. Even when new medicines are approved, access is often restricted. One year after launch, usage of innovative treatments in England is just over half the average of comparator countries such as France, Germany and Spain.[iv] The effect is that people living with cancer, autoimmune conditions and rare diseases wait longer to access therapies that are already transforming lives elsewhere in Europe. And even at its new level, the UK’s Voluntary Scheme for Branded Medicines Pricing, Access and Growth (VPAG) clawback rate remains higher than in comparable countries.[v] J&J is committed to working together to develop a new pricing and access framework that is stable, predictable and internationally competitive — enabling the UK to regain its position as a leading destination for life sciences. Seeing the value of health and medicines investment as a catalyst for prosperity and growth Timely access to the right treatment achieves two things; it keeps people healthy and prevents disease worsening so they can participate in society and a thriving economy. New research from the WifOR Institute, funded by J&J, shows that countries that allocate more resources to health — especially when combined with a skilled workforce and strong infrastructure — consistently achieve better outcomes.[vi] > Timely access to the right treatment achieves two things; it keeps people > healthy and prevents disease worsening so they can participate in society and > a thriving economy. The UK Government’s recent recognition of the need for long-term change, setting out plans to increase investment in new medicines from 0.3 percent of GDP to 0.6 percent over the next 10 years is positive. It signals a move towards seeing health as one of our smartest long-term investments, underpinning the UK’s international competitiveness by beginning to bring us nearer to the levels in other major European countries. This mindset shift is critical to getting medicines to patients, and the life sciences ecosystem, including the pharmaceutical sector as a cornerstone, plays a pivotal role. It operates as a virtuous cycle — driven by the generation, production, investment in, access to and uptake of innovation. Exciting scientific developments and evolving treatment pathways mean that we have an opportunity to review the structures around medicines reimbursement to ensure they remain sustainable, competitive and responsive. At J&J, we have the knowledge and heritage to work hand-in-hand with the Government and all partners to achieve this. Together, we can realise the potential of medicine innovation in the UK Patients have the right to expect that science and innovation will reach them when they need it. Innovative treatments can be transformative for patients, meaning an improved quality of life or more precious time with loved ones. We fully support the Government’s ambitions for life sciences and the health of the nation. Now is the moment to deliver meaningful change — the NHS, Government and all system partners, including J&J, must look at what valuing innovation actually means when it comes to modernising the frameworks and mechanisms that support access and uptake. Practical ways to do this include: * Establishing a new pricing and access framework that is stable, predictable and internationally competitive. * Evolving medicines appraisal methods and processes, to deliver on the commitments of the UK-US Economic Prosperity Deal. * Adapting thresholds and value frameworks to ensure they are fit for the future — in the context of wider system pressures, including inflation, and the evolution of medical innovation requiring new approaches to assessment and access. > the NHS, Government and all system partners, including J&J, must look at what > valuing innovation actually means when it comes to modernising the frameworks > and mechanisms that support access and uptake. By truly recognising the value of health as an investment, rather than as a cost, we can return the UK to a more competitive position. The direction of travel is positive. At J&J, we stand ready to work in partnership to help ensure the UK is once again the best place in the world to research, develop and access medicines. Follow Johnson & Johnson Innovative Medicine UK on LinkedIn for updates on our business, our people and our community. CP-562703 | January 2026 -------------------------------------------------------------------------------- [i] House of Commons Library (2026). ‘NHS Funding and Expenditure’ Research Briefing. Available at: https://commonslibrary.parliament.uk/research-briefings/sn00724/ (Accessed January 2026). [ii] IQVIA & EFPIA (2025). EFPIA Patients W.A.I.T Indicator 2024 Survey. Available at: https://efpia.eu/media/oeganukm/efpia-patients-wait-indicator-2024-final-110425.pdf. (Accessed January 2026) [iii] The Kings Fund (2022). ‘How does the NHS compare to the health care systems of other countries?’ Available at: https://www.kingsfund.org.uk/insight-and-analysis/reports/nhs-compare-health-care-systems-other-countries (Accessed January 2026) [iv] Office for Life Sciences (2024). Life sciences competitiveness indicators 2024: summary. Available at: https://www.gov.uk/government/publications/life-sciences-sector-data-2024/life-sciences-competitiveness-indicators-2024-summary (Accessed January 2026). [v] ABPI. VPAG payment rate for newer medicines will be 14.5% in 2026. December 2025. Available at: https://www.abpi.org.uk/media/news/2025/december/vpag-payment-rate-for-newer-medicines-will-be-145-in-2026/. (Accessed January 2026). [vi] WifOR Institute (2025). Healthy Returns: A Catalyst for Economic Growth and Resilience. Available at: https://www.wifor.com/en/download/healthy-returns-a-catalyst-for-economic-growth-and-resilience/?wpdmdl=360794&refresh=6942abe7a7f511765977063. (Accessed January 2026).

January 2026 I GB-73006 Disclaimer  POLITICAL ADVERTISEMENT  * This is sponsored content from AstraZeneca.  * The advertisement is linked to public policy debates on the future of cardiovascular care in the UK.  * This content has been paid for and developed by AstraZeneca UK  Cardiovascular disease (CVD) has shaped the nation’s health for generations. It remains a leading cause of death and a major driver of long-term sickness, yet it is also one of the most preventable. Today, 8 million people in the U.K. live with CVD, and early deaths from CVD in England have reached a 14-year high.1,2 The reality is stark: without urgent action, one million more could live with CVD by 2030 — and two million by 2040.1  Tackling CVD is not only a moral imperative, it’s an economic necessity. In the U.K., 2.5 million working-age people are economically inactive due to long-term sickness, and CVD contributes to long-term sickness at unprecedented levels3 Each year, CVD costs the U.K. economy an estimated £24 billion, straining public finances, dampening productivity and widening inequalities.4  In July 2023, AstraZeneca convened the CVD-risk coalition — with charities, clinical organizations and patient groups — to shape a coordinated response to these trends.   Today, the coalition has published Getting to the heart of the matter: A national action plan for tackling cardiovascular disease5 — a blueprint for decisive action and a call for the government and the NHS to confront CVD head on. It has a clear message: the tools exist to tackle this challenge, but we need leadership, investment, and a focus on prevention and early intervention to unlock meaningful change.  > the tools exist to tackle this challenge, but we need leadership, investment, > and a focus on prevention and early intervention to unlock meaningful change. Diagnosis and prevention gaps we cannot afford   CVD often arises from detectable and treatable conditions: hypertension, high cholesterol, diabetes, chronic kidney disease. Yet millions remain undiagnosed. Six million people in the U.K. don’t know they have high blood pressure — a silent driver of heart attacks, strokes and kidney disease.6,7   This systemic diagnosis gap is not the result of a lack of evidence or clinical consensus; rather, the longstanding pressure on primary and community care, fragmentation across services, and declining investment in public health. Between 2015/16 and 2023/24, funding for key preventative services — including smoking cessation and adult obesity support — fell sharply in real terms.8  Additionally, secondary prevention remains patchy across England. Despite clear treatment guidance from NICE, less than half of patients with CVD meet recommended cholesterol levels. Almost 30 percent of hypertension patients are not meeting recommended blood pressure targets or don’t have a recent blood pressure measurement in their records.9   The consequences are clear: progress on CVD outcomes has stalled, premature deaths are rising and those in England’s most deprived areas are four times more likely to die prematurely from CVD than those in the least deprived.10  > progress on CVD outcomes has stalled, premature deaths are rising and those in > England’s most deprived areas are four times more likely to die prematurely > from CVD than those in the least deprived We must place prevention at the heart of our health system.  A vision for proactive, personalized cardiovascular care  Early CVD prevention and treatment save lives and money. It benefits patients, reduces NHS pressure and strengthens the UK’s economic resilience.   A 20 percent reduction in CVD incidence could save the NHS £1.1 billion annually within five years and place 60-70,000 more people into work.11 Recent CVDACTION modeling suggests that even modest near-term improvements in treatment could prevent approximately 61,000 events of heart attack, stroke, heart failure admission and end-stage kidney disease in three years.12   This is not theoretical. We know what integrated, proactive models can do.   Unlocking the power of data and digital tools  Platforms like CVDPREVENT and CVDACTION already demonstrate how data-driven insights from GP records can flag undiagnosed or undertreated patients — enabling clinicians to prioritize, optimize treatment and thus prevent avoidable heart attacks and strokes every year.13,14  Additionally, as the NHS App becomes a digital ‘front door’, there is an opportunity to deliver personalized risk information, lifestyle guidance and seamless access to services.  But digital transformation requires investment in workforce capability, interoperability between systems and national procurement frameworks that can scale at pace.  Tom Keith Roach A neighborhood approach to prevention  Joined-up neighborhood services — across community pharmacies, general practice, specialist teams and local authorities — could identify risk earlier, manage long-term conditions holistically and reduce avoidable admissions.   Community pharmacy hypertension screening has delivered over two million blood pressure checks in a single year, identifying thousands previously unaware of their risk.15    The LUCID program, developed as part of a joint working initiative between AstraZeneca and University Hospitals Leicester, has shown that integrated care across nephrology specialists and primary care can identify high-risk chronic kidney disease patients and optimize their treatment, reducing emergency admissions and long-term NHS costs.16    But to truly deliver change, resources must be rebalanced toward primary and community care. Cardiovascular prevention cannot be driven from hospitals alone. The neighborhood service must be properly resourced, with contracts and incentives aligned to prevention and outcomes, not activity.  A whole-system effort to transform lives and the economy  The forthcoming Modern Service Framework for CVD, promised within the Government’s 10 Year Health Plan, presents a critical opportunity. This framework must: * Embed prevention into every level of care  * Enable earlier diagnosis using digital and community-based tools  * Support optimal treatment through data and workforce innovation  * Define clear national priorities backed by accountability  CVD is a health challenge and a national prosperity challenge. We cannot afford rising sickness, worsening inequalities, and an NHS stretched by late-stage, preventable disease. The link between health and wealth has never been clearer: investing in CVD prevention will deliver both immediate and long-term returns.  > The link between health and wealth has never been clearer: investing in CVD > prevention will deliver both immediate and long-term returns. The action plan published today provides a clear, evidence-based roadmap.5 It calls for:  * National clinical and political leadership  * Ambitious targets, including a 20 percent reduction in incidence  * Investment in prevention and the expansion of Health Checks  * Improved uptake of effective treatments, guided by data  * Digital and diagnostic excellence across neighborhoods  * Partnership working at every level  A call to action  CVD has affected too many lives for too long. But progress is within reach. The decisions we make today will determine whether the next decade is defined by a widening crisis or a renewed national effort to prevent avoidable illness.  AstraZeneca stands ready to support the government, the NHS and partners to deliver the change our country needs. The time to act is now.  Find out more at astrazeneca.co.uk   References [1] British Heart Foundation. UK factsheet. January 2026. Available at: https://www.bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-uk-factsheet-jan26.pdf.Last accessed: January 2026. [2] British Medical Journal. Early deaths from cardiovascular disease reach 14 year high in England. British Medical Journal. January 2024. Available at: https://www.bmj.com/content/384/bmj.q176. Last accessed: December 2025.   [3] Rising ill-health and economic inactivity because of long-term sickness, UK: 2019 to 2023. Office for National Statistics. Available at: https://www.ons.gov.uk/employmentandlabourmarket/peoplenotinwork/economicinactivity/articles/risingillhealthandeconomicinactivitybecauseoflongtermsicknessuk/2019to2023. Last accessed: December 2025.   [4] UK Government. UIN HL5942. March 2025. Available at: https://questions-statements.parliament.uk/written-questions/detail/2025-03-18/hl5942. Last accessed: December 2025. [5] Getting to the heart of the matter. A national action plan for tackling cardiovascular disease. AstraZeneca. 2025. Available at: https://qr.short.az/r/Getting-to-the-heart-of-the-matter. Last accessed: January 2026. [6] Blood Pressure UK. Why is know your numbers! needed?. Available at: https://www.bloodpressureuk.org/know-your-numbers/why-is-know-your-numbers-needed/. Last accessed: December 2025.   [7] Department of Health and Social Care. Get your blood pressure checked. March 2024. Available at: https://www.gov.uk/government/news/get-your-blood-pressure-checked. Last accessed: December 2025. [8] The Health Foundation. Investing in the public health grant. February 2025. Available at: https://www.health.org.uk/reports-and-analysis/analysis/investing-in-the-public-health-grant. Last Accessed January 2026.  [9] CVDPREVENT. CVDP Annual Audit Report 2025. March 2025. Available at: https://static1.squarespace.com/static/65eafc36395e4d64e18a3232/t/6937fb8666a6d23761182c05/1765276550824/CVDPREVENT+Fifth+Annual+Report.pdf Last Accessed: January 2026. [10] Public Health England. Health matters: preventing cardiovascular disease. February 2019. Available at: https://www.gov.uk/government/publications/health-matters-preventing-cardiovascular-disease/health-matters-preventing-cardiovascular-disease. Last accessed: December 2025. [11] Tony Blair Institute for Global Change. The economic case for Protect Britain, a preventative health care delivery programme. July 2024. Available at: https://assets.ctfassets.net/75ila1cntaeh/7CcuI38C3mxgps6lC9O2iA/825bf2a41f933cf719459087c1599190/Tony_Blair_Institute_for_Global_Change__The_Economic_Case_for_Protect_Britain__July_2024.pdf Last accessed January 2026 [12] Into-Action.Health. Powering the prevention shift – The CVDACTION impact model.  September 2025. Available at: https://www.into-action.health/_files/ugd/ee4262_81e75612f13e403aab6594727b338771.pdf. Last Accessed January 2026. [13]Data & Improvement Tool. CVDPREVENT. Available at: https://www.cvdprevent.nhs.uk/. Last accessed: December 2025.   [14] Transforming the prevention of CVD. CVDACTION. Health Innovation Network. Available at: https://thehealthinnovationnetwork.co.uk/case_studies/transforming-the-prevention-of-cvd/. Last accessed: December 2025. [15] NHS Business Services Authority. Dispensing contractors’ data. Available at: https://www.nhsbsa.nhs.uk/prescription-data/dispensing-data/dispensing-contractors-data . Last Accessed January 2026 [16] AstraZeneca UK. Executive summary of Joint Working outputs. Pan Leicester Integrated Chronic Kidney Disease (CKD) Transformation Project: a quality improvement project to identify CKD patients in primary care suitable for virtual management to improve patient outcomes. (LUCID). July 2024. Available at: https://www.astrazeneca.co.uk/content/dam/intelligentcontent/unbranded/astrazeneca/uk/en/pdf/work-with-nhs-uk/Executive_Summary_of_Joint_Working_Outputs_Pan_Leicester.pdf. Last Accessed: January 2026

This article is presented by EFPIA with the support of AbbVie I made a trip back to Europe recently, where I spent the vast majority of my pharmaceutical career, to share my perspectives on competitiveness at the European Health Summit. Now that I work in a role responsible for supporting patient access to medicine globally, I view Europe, and how it compares internationally, through a new lens, and I have been reflecting further on why the choices made today will have such a critical impact on where medicines are developed tomorrow. Today, many patients around the world benefit from medicines built on European science and breakthroughs of the last 20 years. Europeans, like me, can be proud of this contribution. As I look forward, my concern is that we may not be able to make the same claim in the next 20 years. It’s clear that Europe has a choice. Investing in sustainable medicines growth and other enabling policies will, I believe, bring significant benefits. Not doing so risks diminishing global influence. > Today, many patients around the world benefit from medicines built on European > science and breakthroughs of the last 20 years I reflect on three important points: 1) investment in healthcare benefits individuals, healthcare and society, but the scale of this benefit remains underappreciated; 2) connected to this, the underpinning science for future innovation is increasingly happening elsewhere; and 3) this means the choices we make today must address both of these trends. First, let’s use the example of migraine. As I have heard a patient say, “Migraine will not kill you but neither [will they] let you live.”[1] Individuals can face being under a migraine attack for more than half of every month, unable to leave home, maintain a job and engage in society.[2] It is the second biggest cause of disability globally and the first among young women.[3] It affects the quality of life of millions of Europeans.[4] From 2011-21 the economic burden of migraine in Europe due to the loss of working days ranged from €35-557 billion, depending on the country, representing 1-2 percent of gross domestic product (GDP).[5]   Overall socioeconomic burden of migraine as percentage of the country’s GDP in 2021 Source: WifOR, The socioeconomic burden of migraine. The case of 6 European Countries.5 Access to effective therapies could radically improve individuals’ lives and their ability to return to work.[6] Yet, despite the staggering economic and personal impacts, in some member states the latest medicines are either not reimbursed or only available after several treatment failures.[7] Imagine if Europe shifted its perspective on these conditions, investing to improve not only health but unlocking the potential for workforce and economic productivity? Moving to my second point, against this backdrop of underinvestment, where are scientific advances now happening in our sector? In recent years it is impressive to see China has become the second-largest drug developer in the world,[8] and within five years it may lead the innovative antibodies therapeutics sector,[9] which is particularly promising for complex areas like oncology. Cancer is projected to become the leading cause of death in Europe by 2035,[10] yet the continent’s share of the number of oncology trials dropped from 41 percent in 2013 to 21 percent in 2023.10 Today, antibody-drug conjugates are bringing new hope in hard-to-treat tumor types,[11] like ovarian,[12] lung[13] and colorectal[14] cancer, and we hope to see more of these advances in the future. Unfortunately, Europe is no longer at the forefront of the development of these innovations. This geographical shift could impact high-quality jobs, the vitality of Europe’s biotech sector and, most importantly, patients’ outcomes. [15] > This is why I encourage choices to be made that clearly signal the value > Europe attaches to medicines This is why I encourage choices to be made that clearly signal the value Europe attaches to medicines. This can be done by removing national cost-containment measures, like clawbacks, that are increasingly eroding the ability of companies to invest in European R&D. To provide a sense of their impact, between 2012 and 2023, clawbacks and price controls reduced manufacturer revenues by over €1.2 billion across five major EU markets, corresponding to a loss of 4.7 percent in countries like Spain.[16] Moreover, we should address health technology assessment approaches in Europe, or mandatory discount policies, which are simply not adequately accounting for the wider societal value of medicines, such as in the migraine example, and promoting a short-term approach to investment. By broadening horizons and choosing a long-term investment strategy for medicines and the life science sector, Europe will not only enable this strategic industry to drive global competitiveness but, more importantly, bring hope to Europeans suffering from health conditions. AbbVie SA/NV – BE-ABBV-250177 (V1.0) – December 2025 -------------------------------------------------------------------------------- [1] The Parliament Magazine, https://www.theparliamentmagazine.eu/partner/article/unmet-medical-needs-and-migraine-assessing-the-added-value-for-patients-and-society, Last accessed December 2025. [2] The Migraine Trust; https://migrainetrust.org/understand-migraine/types-of-migraine/chronic-migraine/, Last accessed December 2025. [3] Steiner TJ, et al; Lifting The Burden: the Global Campaign against Headache. Migraine remains second among the world’s causes of disability, and first among young women: findings from GBD2019. J Headache Pain. 2020 Dec 2;21(1):137 [4] Coppola G, Brown JD, Mercadante AR, Drakeley S, Sternbach N, Jenkins A, Blakeman KH, Gendolla A. The epidemiology and unmet need of migraine in five european countries: results from the national health and wellness survey. BMC Public Health. 2025 Jan 21;25(1):254. doi: 10.1186/s12889-024-21244-8. [5] WifOR. Calculating the Socioeconomic Burden of Migraine: The Case of 6 European Countries. Available at: [https://www.wifor.com/en/download/the-socioeconomic-burden-of-migraine-the-case-of-6-eu­ropean-countries/?wpdmdl=358249&refresh=687823f915e751752703993]. Accessed June 2025. [6] Seddik AH, Schiener C, Ostwald DA, Schramm S, Huels J, Katsarava Z. Social Impact of Prophylactic Migraine Treatments in Germany: A State-Transition and Open Cohort Approach. Value Health. 2021 Oct;24(10):1446-1453. doi: 10.1016/j.jval.2021.04.1281 [7] Moisset X, Demarquay G, et al., Migraine treatment: Position paper of the French Headache Society. Rev Neurol (Paris). 2024 Dec;180(10):1087-1099. doi: 10.1016/j.neurol.2024.09.008. [8] The Economist, https://www.economist.com/china/2025/11/23/chinese-pharma-is-on-the-cusp-of-going-global, Last accessed December 2025. [9] Crescioli S, Reichert JM. Innovative antibody therapeutic development in China compared with the USA and Europe. Nat Rev Drug Discov. Published online November 7, 2025. [10] Manzano A., Svedman C., Hofmarcher T., Wilking N.. Comparator Report on Cancer in Europe 2025 – Disease Burden, Costs and Access to Medicines and Molecular Diagnostics. EFPIA, 2025. [IHE REPORT 2025:2, page 20] [11] Armstrong GB, Graham H, Cheung A, Montaseri H, Burley GA, Karagiannis SN, Rattray Z. Antibody-drug conjugates as multimodal therapies against hard-to-treat cancers. Adv Drug Deliv Rev. 2025 Sep;224:115648. doi: 10.1016/j.addr.2025.115648. Epub 2025 Jul 11. PMID: 40653109.. [12] Narayana, R.V.L., Gupta, R. Exploring the therapeutic use and outcome of antibody-drug conjugates in ovarian cancer treatment. Oncogene 44, 2343–2356 (2025). https://doi.org/10.1038/s41388-025-03448-3 [13] Coleman, N., Yap, T.A., Heymach, J.V. et al. Antibody-drug conjugates in lung cancer: dawn of a new era?. npj Precis. Onc. 7, 5 (2023). https://doi.org/10.1038/s41698-022-00338-9 [14] Wang Y, Lu K, Xu Y, Xu S, Chu H, Fang X. Antibody-drug conjugates as immuno-oncology agents in colorectal cancer: targets, payloads, and therapeutic synergies. Front Immunol. 2025 Nov 3;16:1678907. doi: 10.3389/fimmu.2025.1678907. PMID: 41256852; PMCID: PMC12620403. [15] EFPIA, Improving EU Clinical Trials: Proposals to Overcome Current Challenges and Strengthen the Ecosystem, efpias-list-of-proposals-clinical-trials-15-apr-2025.pdf, Last accessed December 2025. [16] The EU General Pharmaceutical Legislation & Clawbacks, © Vital Transformation BVBA, 2024.

BERLIN — The leaders of German Chancellor Friedrich Merz’s conservative-led coalition on Friday announced accords on key issues that had divided his government in recent weeks. The internal disagreements — over pension reforms and a phaseout of the combustion engine — had turned into a test of the viability of Merz’s relatively weak and ideologically divergent coalition government. The new agreements, reached after a night of long negotiations, may have staved off a larger crisis of confidence in Merz’s government. Members of Merz’s coalition sought to portray the agreements as evidence that the government is functioning smoothly. “Sometimes the image that people paint — saying that everything is stuck and so on — doesn’t match what I experienced yesterday,” said Lars Klingbeil, the leader of the center-left Social Democratic Party (SPD), which governs in coalition with Merz’s conservative alliance. “We really did push forward far-reaching changes for this country in constructive debates.” The agreements announced Friday revolve around a pension package lawmakers are set to vote on in December that a faction of Merz’s own conservatives had railed against, as well as a deal on Germany’s position on the EU’s push to phase out the combustion engine. In the case of the pension reform, Merz sought to placate conservative rebels by vowing to take on a second, more far-reaching set of pension system reforms that would involve implementing the recommendations of an expert commission as early as next year. Previously, the coalition had agreed on a lengthier timeframe. “There is now a firm agreement,” Merz said in view of the immediate pension reform package set to go for a vote. “We will come to a decision next week, and it is not just a gut feeling, but a well-founded hope, based on the discussions we had this morning, that our colleagues now see that we are really serious about these reforms and that we are now going down this path together.” With regard to EU plans to ban carbon-emitting engines from 2035, Merz said he would write a letter to European Commission President Ursula von der Leyen on Friday to urge Brussels to apply extensive exemptions — including on dual-motor vehicles, plug-in hybrids, electric vehicles with range extenders and “highly efficient” combustion engines. That announcement signaled that the SPD has effectively backed off its previous support for EU green regulations for cars. “We ask the Commission, in a comprehensive sense, to adapt and correct the regulations for mobility,” said Merz. “This concerns in particular the compatibility of competitiveness — the industrial competitiveness of the European automotive industry — with the demands we place on climate protection.” Merz’s coalition has a majority of just 12 votes in the Bundestag, making his government vulnerable to even modest defections in the ranks. Conservative Bavarian premier Markus Söder on Friday signaled satisfaction with the agreements. “Everything we did yesterday is good for Germany, good for the economy, and bad for radicals,” he said in view of the surging far-right Alternative for Germany (AfD) party. “They are waiting outside the door for us to fail together. That is their great hope, that we will fail.”

The mastermind of President Donald Trump’s effort to downsize the federal workforce, Russ Vought, promised to use the government shutdown to advance his goal of “shuttering the bureaucracy.” Presented with a layoff plan that would have moved in that direction, officials at the Department of Health and Human Services scaled it way back, POLITICO has learned. It was another example, like several during the layoffs led by Elon Musk’s Department of Government Efficiency this spring, in which Trump’s agency heads have pushed back successfully against top-down cuts they viewed as reckless. POLITICO obtained an HHS document from late September, the shutdown’s eve, that said the department wanted to cut nearly 8,000 jobs, based on guidance from Vought’s budget office. On Oct. 10, HHS only went ahead with 1,760. In the two weeks since, the number has dwindled to 954, as the department has rescinded nearly half of the total, blaming a coding error. The disorganized handling of the layoffs is reminiscent of Musk’s DOGE effort, in which employees were rehired after being fired, sometimes on court orders, sometimes because agency officials objected. In each case, the layoffs rattled agency managers and traumatized employees, as Vought wanted, but haven’t gone nearly as far in downsizing the government as forecast. While the nearly 8,000-person layoff plan this month was largely scuttled by top agency officials who intervened before the cuts could be made, the whiplash manner in which it was proposed and then scaled back shows that the administration is still following the DOGE playbook. “These appear to be leftovers from DOGE. I don’t know anyone — including in the White House — who supports such cuts,” a senior administration official told POLITICO in explaining the pullback from the promised mass layoffs. The official, granted anonymity to discuss confidential matters, pointed to the involvement of a staffer who was part of the DOGE effort in producing the administration document. That document came to its initial tally of 7,885 layoffs at HHS by adding employees who would be furloughed during the shutdown, as well as workers in divisions that would be shuttered if Congress passed Trump’s fiscal 2026 budget proposal. Trump’s May budget plan called for a 25 percent cut to HHS, but lawmakers have rejected it in the appropriations bills now in process. HHS spokesperson Emily Hilliard told POLITICO in a statement that HHS made its layoff list “based upon positions designated as non-essential prior to the Democrat-led government shutdown.” She added: “Due to a recent court order, HHS is not currently taking actions to implement or administer the reduction-in-force notices.” According to the document reviewed by POLITICO, the National Institutes of Health was to take the hardest hit among HHS agencies, 4,545 layoffs, or roughly a quarter of its workforce. It ended up firing no one. A federal judge in San Francisco blocked the firing of 362 of the 954 HHS employees who did receive the October layoff notices. More will be shielded after additional federal employee unions joined the lawsuit on Wednesday. In congressional testimony earlier this year, Health Secretary Robert F. Kennedy Jr. said he had downsized his department’s staff to 62,000 from 82,000 when he took office. He’s nowhere close. An HHS contingency plan produced in advance of the shutdown said the department still employed 79,717. Employees who took a Sept. 30 buyout offer from Musk would bring that lower, though the number who did is unknown because the White House has not released agency-by-agency totals and has stopped publishing agency employment updates. It’s unclear who within the Trump administration came up with the initial plan for the shutdown layoffs. Hilliard did not respond to POLITICO’s question about who within HHS was responsible. Thomas Nagy, the HHS deputy assistant secretary for human resources, has been the one updating the judge, Susan Illston of the U.S. District Court for the Northern District of California, about the layoffs. The experience of the fired 954, whose last work day is scheduled for early December, mirrors the chaos of DOGE’s spring layoffs, in which employees were left wondering whether they still had jobs amidst lawsuits and officials were forced to backtrack and rehire fired workers. In one such instance, Kennedy told a House panel in June that he had appealed directly to Vought to make sure Head Start funding was protected after the early education and health care program was left out of the president’s budget proposal. In another case, HHS fired and then rehired an award-winning Parkinson’s researcher. Kennedy also told senators that he brought back hundreds of staffers at the National Institute for Occupational Safety and Health. That came after West Virginia Republican Sen. Shelley Moore Capito and others protested. Now many HHS employees are having déjà vu. The situation is reminiscent of the experience some former employees of the U.S. Agency for International Development had during the Trump administration dismantling of the foreign aid agency early this year. Some furloughed employees at HHS, for example, didn’t have access to their work emails to receive notices informing them they were laid off this month. “There were individuals who didn’t even know if they were in RIF status until they got the hard copy packet in the mail two days ago,” a laid-off employee at the Centers for Disease Control and Prevention said, using the acronym for “reduction-in-force.” A similar situation played out at HHS’ Office of Population Affairs, where nearly all of the roughly 50 employees were laid off two weeks ago, according to one person with knowledge of the situation speaking anonymously for fear of retribution. The office, which is congressionally mandated, manages hundreds of millions of dollars in funding for family planning and teen pregnancy prevention programs. Three fired employees from the Substance Abuse and Mental Health Services Administration — granted anonymity to provide details about the firings without fear of retribution — said that many of the roughly 170 employees cut from the agency earlier this month are getting physical copies of their termination notices mailed to them because they’re shut out of their email accounts. “DOGE never really left, it just looks different now,” one of the SAMHSA employees said. Amanda Friedman and Sophie Gardner contributed reporting. Tim Röhn is a global reporter at Axel Springer and head of investigations for WELT, POLITICO Germany and Business Insider Germany.

In an AI-first era, where AI is becoming an integral part of everything we do, its applications spanning across different sectors and facilitating various parts of our daily routines, healthcare should be no exception. In an ideal world, this is what healthcare should look like: a patient goes to an app to book an appointment, AI directs them to the doctor with the best expertise, knows which equipment is available, and which location makes most sense, and puts the appointment in their respective diaries. The complexity with healthcare is that this isn’t just a system, but three interconnected worlds that must work together seamlessly. Patients rightly want care when and where they need it. Clinicians want to ensure their expert resource is directed as impactfully and efficiently as possible. And medical assets, from MRI scanners to life-saving medications, must be available when and where required. This is where investing in technology becomes key. The good news is that the AI revolution in healthcare is already beginning, and the early results are encouraging. Some GP practices have cut waiting times by 73 percent using smart triaging systems, reducing waits from 11 to three days. AI can help tackle the dreaded ‘8am rush’ when phone lines jam with appointment requests. In the same study, GP practices using these systems reduced phone-based contacts from 88 percent to 18 percent and saw a 30 percent drop in missed appointments — potentially saving £350 million annually from reduced non-attendance. Through ServiceNow’s work with NHS Trusts, we’ve identified five areas where change can make an immediate difference, as outlined in ServiceNow’s NHS Digital Transformation white paper: * improving the staff experience; * joining up corporate services; * protecting against cyber threats; * streamlining patient journeys; and * harnessing AI. The reward for getting this right? We could see £35 billion in productivity savings by 2030. That’s money that could be reinvested directly into patient care. Better staff systems could save £750 million annually — not through cuts, but by giving critical NHS workers back the 29 million hours currently lost to bureaucracy. Right now, it takes up to 120 days to get a new NHS employee properly started. In some trusts we have cut that to 25-40 days. Imagine the impact if this was rolled out across the whole NHS. When you’re trying to grow the workforce from 1.5 to 2.4 million people by 2036, every day matters. Joining up corporate services could save another £1.6 billion each year. This is especially urgent given that Integrated Care Systems are facing combined deficits and have been told to slash running costs by 50 percent. The NHS 10 Year Health Plan for England talks about rebuilding the NHS in working-class communities; areas that currently get 10 percent less funding per person. Digital transformation isn’t just about efficiency; it’s about equity. When systems work properly, everyone benefits, but the biggest gains go to those who currently struggle most to access care. The problem is these parts barely speak to each other. The white paper reveals just how costly this disconnection has become: 13.5 million hours wasted annually due to inadequate IT, a 7.5 million case waiting list, and nearly £3 billion spent each year compensating for care failures. Behind every statistic is a person. Someone facing a delayed diagnosis, a cancelled operation or simply not receiving the care they deserve. This fragmentation isn’t just inefficient, it has a direct effect on patients and clinicians too. We’re spending £15.5 billion annually, 6.5 percent of the entire NHS budget, on corporate services that don’t talk to each other. Nurses are spending over a quarter of their time on paperwork instead of caring for patients. GP practices are drowning in 240 million calls annually from frustrated patients who can’t get through. We have a patchwork of systems where crucial information gets lost in translation.  When it takes 20 separate manual processes just to say goodbye to a leaving employee, you know there’s room for improvement. In addition to internal challenges, there’s the cyber threat affecting the NHS. Healthcare cyberattacks doubled between 2022 and 2023. A single ransomware attack forced over 10,000 patients to have their appointments cancelled at just two trusts. Without proper digital defenses and monitoring, we’re one attack away from regional healthcare paralysis. But here’s the thing, AI is only as good as the systems it connects to. That’s where we need to be honest about the infrastructure challenge. You can’t build tomorrow’s healthcare on yesterday’s technology. We need systems that talk to each other, share information securely and put the right information in the right hands at the right moment. The truth is, the NHS can’t do this transformation alone. The scale is too big, the timeline too tight and the technical challenges too complex. It’s about partnership — because the best outcomes happen when public sector insight combines with private sector innovation and speed. We need genuine partnerships focused on outcomes, not just products. At ServiceNow, we’ve seen what’s possible when this approach works: connected systems, freed-up time and better patient experiences. We’re at a crossroads, and the path we choose in the next two to three years will determine the NHS our children inherit. We can keep tinkering around the edges, managing decline through small improvements or we can be bold and build the digital foundation that healthcare needs. This isn’t a distant dream; it’s an immediate opportunity. Patients have waited long enough. NHS staff have endured enough frustration with systems that make their jobs harder, not easier. The cost of inaction isn’t just measured in pounds, it’s measured in lives. The technology exists, the knowledge is there and the legal framework is in place. What we need now is to act on what we already know works for this transformation to happen.

Donald Trump this spring dubbed himself the “fertilization president.” But some conservative family policy advocates say he’s done little so far to publicly back that up and are pushing to get the White House in the remaining months of the year to prioritize family policy — and help Americans make more babies. A top priority is a pronatalist or family policy summit that spotlights the U.S.’s declining fertility rate. Other asks, which typically run through the White House’s Domestic Policy Council, include loosening regulations on day cares and child car seats, further increasing the child tax credit and requiring insurers to cover birth as well as pre- and post-natal care at no out-of-pocket cost. While the Trump administration has advanced a handful of policies explicitly billed as “pro-family,” some conservative advocates are dismayed that the president has not done more on one of his campaign’s most animating issues. The lack of movement threatens to dampen enthusiasm among parts of the Republican Party’s big tent coalition, including New Right populists, who worry about the erosion of the U.S. workforce, and techno-natalists, who advocate using reproductive technology to boost population growth, as the GOP stares down a challenging midterm election. “I think there are people, including the [vice president] and people in the White House, who really want to push pro-family stuff,” said Tim Carney, a senior fellow at the American Enterprise Institute who recently wrote “Family Unfriendly,” a book that has become popular in conservative circles. But “it hasn’t risen to the forefront of the actual decision-making tree in the White House, the people who can put some velocity on things.” “It’s all nascent,” Carney added, but “it is going to be something that Republicans want to talk about in the midterms.” White House aides acknowledge advocates’ restlessness, but argue that even as it has yet to take action on the suite of explicitly pro-family proposals advocates want, they have taken a whole-of-government approach to family policy. Privately, the White House is deliberating its next moves now that the GOP’s tax and policy bill passed. It’s taking a two-pronged approach: addressing financial pressures and infertility issues that prevent people from having children; and helping couples raise kids in alignment with their values. That latter bucket includes bolstering school choice and parental rights, promoting kin- and faith-based child care, and other actions that can help with the costs of raising children, including health care and housing. “You saw what we were able to accomplish in 200 days. It was a lot. Just wait for the next three-and-a-half years,” said a White House official, who was granted anonymity to discuss internal strategy. “There’s a lot of opportunity to accomplish a lot through pure administrative action, through the bully pulpit and, of course, if we need to, through working with Congress.” The official couldn’t rule out a family policy event hosted by the White House in the future. “Look, the president loves to convene stakeholders and thought leaders and policy leaders,” the official added. While they understand the White House has had its attention fixed on other issues, like foreign policy, immigration, and trade, pronatalists are anxious for the administration to do something about the declining birth rate. They see it as, quite literally, an existential crisis. “Demographic collapse has become the global warming of the New Right,” said Malcolm Collins, who along with his wife Simone, are two of the most outspoken techno-natalists and have pitched the White House on several policies. “And this is true, not just for me, but for many individuals within the administration, and many individuals within the think tanks that are informing the administration.” The Trump administration has advanced a handful of policies that conservatives argue will support families and, they hope, encourage people to have children. The president’s so-called One Big Beautiful Bill made permanent the child tax credit first passed as part of Trump’s first-term Tax Cuts and Jobs Act, increased the rate and adjusted it for inflation on an ongoing basis. The legislation also established a one-time $1,000 so-called baby bonus for children born in 2025 through 2028. Transportation Secretary Sean Duffy instructed his agency to give preference in competitive grants to communities with higher-than-average birth and marriage rates. Critics of the administration note that the megalaw will make it harder for people to keep their Medicaid insurance, the president’s proposed 2026 budget eliminates childcare subsidies for parents in college, and Trump’s CDC eliminated a research team responsible for collecting national data on IVF success rates. But family policy advocates say on the whole they see progress, though not nearly enough to reverse the trend of declining birth rates. “From my conversations with folks in the administration, there is definitely interest in doing something visible on the family stuff. They feel like they’re going down the list — homelessness, crime, obviously immigration — of different things and families’ time will come,” said Patrick Brown, a fellow at the conservative Ethics and Public Policy Center who focuses on family policy. The U.S. birth rate has been declining since the Baby Boom ended in the early 1960s, falling from 3.65 births per woman in 1960 to 1.599 in 2024, according to the CDC’s National Center for Health Statistics. There are similar trends across high-income nations, in part the result of easier access to contraception, changing societal values favoring careers over having children and high costs of living. The issue came to the fore during the campaign when Trump promised government-funded in vitro fertilization in an effort to allay concerns over his anti-abortion stance. A few months later, then-Sen. JD Vance doubled down on controversial comments about the country being run by “a bunch of childless cat ladies” and argued for more babies in the U.S. Elon Musk, perhaps the most prominent pronatalist, was Trump’s biggest financial booster during the campaign and a key adviser in the early days of the administration. There is no agreed-upon solution to the problem of a declining birth rate. Hungary is held up as a model by pronatalists for its family friendly policies but its birth rate remains low, despite exempting women with four or more children from paying income tax, among other incentives. The birth rate also remains low in Nordic countries like Sweden, Norway and Finland that have generous paid parental leave and heavily subsidized childcare. Still, advocates in the U.S. have a list for the Trump administration they believe will make a difference, arguing that even if they fail to increase the birth rate, they would support families. Some policies that pronatalists hope the Trump administration will pursue are more typically associated with the left, such as expanding child tax credits, which Trump did in the GOP megalaw, and reducing the costs of child care. But others have a home in the libertarian wing of the GOP, such as cutting regulations on day care and curbing car seat rules. Some of these proposals, pronatalists acknowledge, come with more risk but would overall result in more births. For decades, social conservatives led the GOP’s charge on families, arguing in support of policies that promote two-parent, heterosexual families. But declining birth rates, coupled with a broadening of the GOP coalition, has broadened the lens to focus on increasing the birth rate, a new pronatalist tinge. In an effort to keep their nascent and fragile coalition unified, neither social conservatives nor the techno-natalists are pushing policies at the extremes — like banning IVF or creating genetically modified super soldiers. That helps explain why the president has not taken action on one of his most concrete promises, making IVF free, despite receiving a report on it in May. A second White House official, granted anonymity to discuss internal deliberations, said expanding IVF access for families remains “a key priority,” but declined to offer specifics on the status of any policy moves. “This issue is a winner for the Republican Party, it’s a winner for women, it’s a pro-life issue,” said Kaylen Silverberg, a fertility doctor in Texas who has consulted with the White House on IVF. “This will result in more babies, period.” But social conservatives are morally opposed to IVF both because of a belief life begins at conception and because they don’t think that science should interfere with the natural act of procreation. The proposal would also be quite costly. Instead, they want the White House to support something called reproductive restorative medicine, which can include supplements and hormone therapy, that they say will help women naturally improve their fertility. “The point of President Trump’s campaign pledge was to help couples with infertility have children. There’s a way to do that that’s cheaper, faster, less painful and more preferable to couples,” said Katelyn Shelton, a visiting fellow at the Ethics and Public Policy Center’s Bioethics, Technology and Human Flourishing Program who worked at the Department of Health and Human Services during the first Trump administration. While most of the family policy conversation has been concentrated on the right, it’s also starting to grow on the left, alongside the so-called “abundance” movement focused on reducing government bureaucracy. Both the National Conservative Conference and the Abundance Conference this week in Washington hosted panels on family policy. Reducing barriers to building housing is “good for families,” said Leah Libresco Sargeant, a senior policy analyst at the Niskanen Center, a think tank that describes itself as supporting free markets and effective government, who co-moderated the Abundance Conference’s family policy panel. “That’s not kind of a family centered policy per se, [but] it’s a good policy that’s good for families.” Ultimately, many conservative family policy advocates argue there is only so much government can do to address what they see as a fundamentally cultural and religious problem. It’s a posture that the GOP’s historically small-government contingent takes as it pushes back on their new populist bedfellows. “I do not think that the problem of people not having enough kids is a problem of economics. I think that is very often a line that is used in order to promote a larger government populism,” said conservative commentator Ben Shapiro. “This is a predominantly religious problem, it’s a cultural problem.” Pronatalists have a lot of hope in the future of the GOP in part because of Vance, the administration’s most prominent and ideologically committed proponent of family policies, to carry the mantle, either during Trump’s presidency or as part of his own 2028 presidential bid. They love that Vance brings his children on official trips and is open about carving out time during the day to spend with them. “Our political leaders are inherently cultural leaders,” Carney said. “Bringing his kids with him to Europe and at the inauguration — where the little one, she was sucking on her fingers, so they had put Band-Aids on some of them so she wasn’t sucking all of them at once — all of those things that show a loving family and that kind of stuff, I think that can be culturally really productive.”

LONDON — Unions founded Britain’s governing Labour Party. But that doesn’t mean they’ll always have its back. A year into Keir Starmer’s government, union reps can point to some big wins, including a dedicated workers’ rights bill and the cooling of several pay disputes that had simmered under the previous Conservative government. Yet unions are still pressing Labour for more, and ministers are quickly discovering that a flurry of above-inflation pay hikes is not enough to satiate them. A Labour MP on the left of the party, granted anonymity to speak candidly, said relations between Labour and the unions were now “strained to a degree” because of the stagnant state of the British economy. “There’s a fairly widespread sense of unhappiness about the direction of the country, and that obviously reads on to the Labour Party,” they said of the current union mood. STRIKING A BARGAIN  Labour won the July 2024 elections by a landslide, running on a ticket of “change”. On labor relations, the need for a shift was obvious. Under the Conservatives, millions of working days were lost as train drivers, doctors and teachers all walked out over pay and terms, while the government, citing concerns about Britain’s shaky public finances, resisted. Labour wanted to show swift action — and a jolt to straining public services — by settling pay claims with numerous public sector workers who were demanding the restoration of their pay to historic levels. Teachers received a 5.5 percent pay award, train drivers were handed a 15 percent multi-year uplift, and resident doctors got a 22.3 percent rise over two years on average. “It was an important signal of intent from the government,” reflects Trades Union Congress General Secretary Paul Nowak. His body represents 48 affiliated unions and roughly 5.5 million workers. “It was good for our members, but more importantly, it was good for public services and the people that rely on them.” A much-hyped Employment Rights Bill is also going through parliament. It promises to end some of the more insecure forms of work, ban “fire and rehire” schemes, and grant workers the right to challenge unfair dismissal from the day they start employment. Unions have welcomed involvement with the legislation, although some critics remain. The Labour MP cited above said the bill was far from perfect: “It doesn’t really deal with the collective rights which workers need to protect themselves fully.” TIGHTEN THE PURSE STRINGS  Union reps say that Labour has been much better at communicating with unions than its predecessors, although they argue this was a low bar to clear. “It’s been night and day in comparison to our relationship with the previous Conservative governments,” says Nowak. “This is clearly a government that actually sees a positive role for unions in a modern economy and sees us as part of the solution.”  Yet consulting is not the same as acting, and last year’s pay settlements may have already set a precedent. Chancellor Rachel Reeves’ tight fiscal rules mean this is an expectation the government is unlikely to meet. “We know how tight the fiscal position is, but we also know we’ve got a crisis in our public services that have been underfunded,” argues Nowak, who points to problems in recruiting and retaining staff. Britain has a series of independent pay review bodies tasked with examining the economic picture and recommending salary hikes for many public sector workers. Still, it is ministers who ultimately decide who receives the increases. This year, the body for resident doctors recommended a far more modest 5.4 percent increase for 2025-2026. Health Secretary Wes Streeting backed that call — and faced an immediate backlash. The British Medical Association, which represents doctors, branded the hike inadequate as it did not restore real-terms pay to 2008 levels. They’re already balloting members for strike action that could last at least six months, at a time when the government doesn’t need the headache. “The bedside manner is much better, but the NHS is still really sick,” says Emma Runswick, deputy chair of council at the BMA. “We have an NHS which is hemorrhaging staff because it’s eroded their pay so badly and it treats them so poorly.” Streeting, who is expected to unveil a 10-year reform plan for the publicly funded National Health Service this week, is urging doctors not to strike and instead to “work with the government.” But unions shouldn’t expect much. Although the health secretary says his door is open, Streeting has stressed there are no further funds for pay increases. “If you’re going to base yourself as the party who founded the NHS … where’s the action to back that up?” Runswick asks. A summer of strikes could make the growth Reeves desperately covets even harder to achieve. | Andy Rain/EPA-EFE For Labour MPs with a union background, this kind of punchy approach isn’t too surprising. “I don’t think that kind of rhetoric is uncommon in the trade union movement,” says Labour MP Steve Witherden, a former teacher who remains in a teaching union. “They’re obviously setting themselves up for a negotiating position.” “Even a trade union leader [who] might want to be able to be favorable to the Labour government … will be feeling the breath of their members down their necks,” says the Labour MP quoted at the top of this article. The Labour government, by standing firm against union demands, is betting that public opinion has shifted since past disputes. A YouGov poll of 4,100 adults in May found that 48 percent somewhat or strongly opposed resident doctors striking, compared to 39 percent somewhat or strongly supporting them. That’s a fall in support since a comparable YouGov poll was conducted last year. “If it’s a profession they admire and like and think makes a significant contribution, they tend to be favorable toward strike action,” says YouGov’s Head of European Political and Social Research Anthony Wells. But he adds: “While people hugely value doctors, doctors are also already seen as being relatively well paid, so they get far less support for strikes than nurses do.” “There’s an awful lot more that needs to be done,” said left-wing Labour MP Ian Lavery, a former National Union of Mineworkers president, regarding union discontent. “They’ve got to get their heads together.” It’s not just healthcare staff getting antsy. Refuse workers in the city of Birmingham have been on strike for over 100 days due to pay disputes, and the Unite union recently extended that strike mandate until December. National Education Union members also rejected the government’s 2.8 percent pay offer for teachers and leaders in April, with 83.4 percent of respondents saying they would be willing to take strike action. Labour is also treading a fine line with its workers’ rights package, as firms that are already smarting from increased taxes warn the bill’s measures could further dent the government’s growth agenda. The opposition Tories have promised to scrap the package if they return to power in the next election. SUMMER OF DISCONTENT? A summer of strikes could make the growth Reeves desperately covets even harder to achieve — and draw unfavorable historical comparisons. In the 1970s, Labour was effectively toppled for a generation by what became known as the “Winter of Discontent.” Garbage piled up on the streets, bodies weren’t buried, and health, rail and haulage workers made their anger known.  To avert a similar fate, some in the party say keeping unions on side is essential. “The most important thing about relations is that you always keep those channels of dialogue open,” Witherden argues. Garbage workers in Birmingham have been on strike for over 100 days due to pay disputes. | Andy Rain/EPA-EFE Nowak, who has been publicly supportive of much of the government’s agenda, argues that sorting out pay won’t be enough, particularly in the public sector. “There needs to be a longer-term, more strategic discussion … about what’s the future of the public sector workforce” on issues like flexible working and artificial intelligence, he says. “That’s the missing piece of the jigsaw for me.”  However, for a government already struggling to put out multiple fires, keeping the unions sweet will be easier said than done. “The fiscal framework which the government’s working to is incredibly tight,” said the anonymous Labour MP. “It’s difficult to see how they’re going to fund further pay rises that can meet people’s expectations.”

EUROPE’S FRONTIER COUNTRIES READY THEIR HOSPITALS FOR WAR From stockpiling trauma kits for mass casualties to kitting out medics with body armor, wartime health planning is no longer hypothetical on NATO’s eastern flank. By GIEDRĖ PESECKYTĖ Illustration by Wayne Brezinka for POLITICO Speeding along Fabriko Street in an ambulance toward Lietavos school, Martyna Veronika Noreikaitė felt unprepared. She could feel her heart pounding. It was a sunny Tuesday morning in mid-May when Noreikaitė was radioed about an explosion in Jonava, a city of 30,000 people in central Lithuania. In her three years as a paramedic, her calls would, on a normal day, involve high blood pressure or chest pains. This was Noreikaitė’s first mass casualty event. As they pulled up to the school, sirens wailing, the building was obscured by smoke. “People were running around, lying on the ground, screaming,” Noreikaitė said, recalling the chaos at the school’s stadium. Police, firefighters and military personnel were already on site. Noreikaitė and her colleague were the first paramedics to arrive.“When you see what happened — the panic, the screams — you don’t know what to do, or where to go. You forget everything. It throws you off balance.” The novelty of such a disaster in a peaceful European state was precisely why the Lithuanian authorities had set up the two-day “Iron Wolf” (“Geležinis Vilkas”) military exercises. The goal was to steel the military, police, firefighters, hospitals and paramedics to operate under exceptional circumstances — as Lithuania braces for the worst-case scenario: an attack on NATO’s eastern flank. Since Russia’s full-scale invasion of Ukraine, the threat of military conflict has loomed large. “When the media reported the war had started in Ukraine, it was terrifying,” Noreikaitė said. “It was frightening at work because we didn’t know if we had enough resources or if we were prepared if it happened here.”  Noreikaitė now feels calmer. She focuses on training and mastering triage protocols. Exercises, like the one in Jonava, help. Indeed, she believes they “should happen more often.” Lithuania is no outlier: All NATO’s eastern flank countries are revisiting crisis response protocols for health-care facilities, organizing training exercises, investing in ballistic helmets and vests, and shifting operating theaters underground. Since the conflict in Ukraine has shattered the illusion that Europe is safe from war. “It’s not a question of if [Russia] will attack,” said Ragnar Vaiknemets, deputy director general of the Estonian Health Board, which oversees preparedness for crises from pandemics to war. “It’s a question about when.” Ukrainian medical personnel transport a wounded soldier to a medical evacuation (Medevac) airplane, in Rzeszow, Poland. | Petter Bernsten/AFP via Getty Images Formerly under Soviet occupation, the countries on Europe’s eastern frontier know only too well how quickly troops can arrive. “We have bad neighbors here: Russia and Belarus,” Daniel Naumovas, Lithuania’s deputy health minister, said at an event in February. His country links NATO to the Baltics via the Suwałki Gap — a narrow, vulnerable corridor seen as one of the likeliest targets of a future Russian attack. While all EU countries are “in the same boat,” some are in the vanguard “where the water is cold,” Naumovas said. “Water is splashing on our face; water of war.” For countries on NATO’s east, war readiness isn’t optional — it’s urgent. “Few EU countries are frontline countries,” said Katarzyna Kacperczyk, undersecretary of state at Poland’s health ministry. “For them the issue is more pertinent.”  Poland has elevated the issue of health security during times of conflict throughout its rotating presidency of the Council of the EU, where Europe’s security has been the central theme. “We cannot prepare a contingency or strategic plan for the military sector or economic sector or energy sector, and exclude the health sector,” Kacperczyk said.  HOSPITALS UNDER FIRE Russia’s invasion of Ukraine has shown that modern conflicts no longer spare health services — or the civilians they serve. Eastern European countries are taking note. Located just 50 kilometers from the EU’s external border with Belarus, Vilnius University Hospital Santaros Clinics is developing underground infrastructure, shelters, helicopter landing sites and autonomous systems that would allow it to function even if electricity or water supplies were cut off. Santaros is not unusual. In Estonia, in addition to body armor for ambulance crews, satellite phones would be distributed to maintain communications if traditional networks fail. Plans are even in place to generate an independent internet network if necessary. European countries average 11.5 intensive care beds per 100,000 population. | Omar Marques/Getty Images Electrical generators are being installed across the health-care system, following Ukraine’s experience with Russian strikes that routinely cut off civilian power. “We know for certain that Russia targets the civilian infrastructure and energy structures, and that means that you cannot have these kinds of situations where the hospital doesn’t work because there are some power plant problems,” Vaiknemets said. Many hospitals in Eastern Europe — relics of the Soviet era — are particularly vulnerable. “We have high buildings, we have large buildings. They are in one complex, one area,” Vaiknemets said. Hospitals are now looking at how to repurpose basements to be operating theaters in case of need. “I can’t imagine working on a top level … of the hospital just waiting to get hit,” he said.  Estonia is procuring mobile medical units — pop-up treatment facilities deployable in emergencies — which should help address the currently limited critical care capacity in Europe. While European countries average 11.5 intensive care beds per 100,000 population, “wartime needs could require three to five times this capacity,” said Bjørn Guldvog, special adviser at the Norwegian Directorate of Health, at a health security event in April. Sustaining a high volume of operations for weeks or months would also be challenging: “Most facilities can sustain maybe 120-150 percent of normal surgical volume for 24 to 48 hours,” he said. Blood and oxygen supplies would also become critical. STOCKPILES AND SUPPLY CHAINS Even the best-prepared hospitals can’t function without medicines, supplies and equipment, and the Baltic countries are stocking up in preparation for mass casualties. Estonia, for example, has allocated €25 million for mass casualty supplies, including orthopedic gear, tourniquets and trauma kits — “the only heavy investment we have made,” Health Minister Riina Sikkut said at an event in February. Stockpiles would ensure that hospitals can run until supplies from allies reach them, Vaiknemets said, adding that NATO is crucial to securing supply routes.  In Latvia, health-care institutions have been required since Covid-19 to maintain a three-month supply of medicines. “I have never thought that I would say thanks to Covid, but thanks to Covid … we found financial resources,” said Agnese Vaļuliene, health ministry state secretary. The country is also working on national stockpiles. But the Baltics are too close to the front lines to keep emergency supplies safe, said Jos Joosten, a medical adviser at the European External Action Service, the EU’s diplomatic corps. As a result, other EU countries must “identify the things that are scarce, that are very difficult to organize, specifically for the small nations,” Joosten said. “And then we should give [up] some sovereignty, give it to the European Union to make decisions” on distributing what is needed. Stockpiles from the Red Cross, national reserves and rescEU, the EU’s emergency service, must all be ready to reach the front line — and civilian patients. “We have to have good crisis plans,” Sikkut said. STAFFING THE WAR EFFORT War readiness goes beyond policy — it needs people. Workforce shortages are a fundamental challenge for the Baltics, where day-to-day health staff are already stretched thin. Estonia, with a population of 1.3 million, has nearly half the health-care workforce per capita of Germany.  A Lithuanian survey found that over a quarter of health workers would likely flee during war, while fewer than 40 percent would stay and a third were unsure. | Mykhailov Dmytro/Global Images Ukraine via Getty Images As a result, patients “from the front lines” cannot expect the same care they would receive in times of peace, Vaiknemets said, which is “the main and underlying principle of our crisis-measure planning.”  But there’s another problem: Not everyone is prepared to stay. When Russia invaded Ukraine, Noreikaitė, like all paramedics, had to sign a declaration saying if war broke out in Lithuania she would stay on and work. “But how it would really be — who would come and who wouldn’t — I don’t know. Personally, I don’t have children or a family yet, so I think I would stay,” she said.  A Lithuanian survey found that over a quarter of health workers would likely flee during war, while fewer than 40 percent would stay and a third were unsure. Estonia anticipates similar patterns: “There are patriots, the first responders, the people that we know without question will stay,” Vaiknemets said. “Of course, there are naysayers that talk about going to Spain straight away.” He said around 50 percent to 60 percent of the population don’t yet know how they would respond. While he’s confident that most doctors and nurses would remain, Estonia’s authorities are working to ease concerns, especially about family safety. “It is very human: If I don’t feel safe, if I don’t have the confidence that my family is safe, I will not do it,” Vaiknemets said. In Latvia, pulmonologist Rūdolfs Vilde said some doctors he spoke to were considering fleeing if war breaks out — especially parents who “don’t see how it would be suitable for them to ditch the children somewhere and be in the hospital in times of military crisis,” he said.  Just a week before the interview, Vilde and his colleagues at Pauls Stradiņš Clinical University Hospital were also asked to sign a document acknowledging they are critical personnel required to report to work if sirens sound.    Vilde himself plans to stay but stressed that he needs more information to feel confident should the worst happen.  “Should I be prepared … to provide some kind of military medicine, or should I be just prepared to come into my regular work and just have a bigger flow of patients?” Vilde asked. “Because those are two very different things and probably both of them would have to function during the wartime.” And Vilde doesn’t mind spending extra hours on top of his doctors’ job for training “because … I see this as a way to keep things the way they are.” A Ukrainian soldier being evacuated to Poland. | Petter Bernsten/AFP via Getty Images “If I want to be able to do my pulmonology job and maybe to try to develop things in Latvia, then there should be Latvian existence, right?” His hospital in Riga has also begun war-training sessions, Vilde said. Other hospitals and countries have begun ramping up war-readiness drills, too. Estonia is reinforcing its system-wide training. Hospitals, ambulance crews and health workers are instructed on how to switch to “crisis mode,” in which they must deal with large influxes of patients and treat wartime injuries — including blast wounds, gunshot trauma, burns, amputations and spinal or head injuries — that are rare in civilian settings. At Lithuania’s Vilnius University Hospital, “evacuation drills and preparedness exercises for receiving a large number of casualties are conducted for hospital staff” alongside the Lithuanian Armed Forces and Riflemen’s Union, hospital chief Tomas Jovaiša said. This year alone, Lithuania is planning seven exercises with the army and over 10 civil-security drills for medical professionals, according to health ministry spokesperson Julijanas Gališanskis. Lithuania is also forming an emergency medical team, and junior doctors last month hosted a forum dedicated to wartime health-care readiness. Some medics travel to Ukraine to learn firsthand how hospitals deal with missile strikes, mass casualties and power outages.  Vaiva Jankienė, a nurse and coordinator at Blue/Yellow Medical, which provides medical care to civilians close to Ukraine’s front line with Russia, has volunteered over 20 times in Ukraine since April 2022 — including in the atrocity-stricken town of Bucha shortly after its liberation. She said the best way to prepare health-care specialists is by volunteering in Ukraine.  She described the scale of injuries and illnesses in Ukraine as “difficult to comprehend” — many wounds are unlike anything seen before, owing to new wartime tactics. “After the drone attacks, the consequences are hard to imagine,” Jankienė said. “Injuries like these,” she sighed, “every single medical professional who saw them said the same thing: We couldn’t have imagined it would look like this.” While a trauma doctor in Lithuania might perform one amputation a year, in Ukraine, entire hospital wards are filled with patients suffering amputations of one, two, three, or even four limbs — plus a range of other severe injuries. “We have very little experience treating such complex, multiple traumas,” she said.  THE REFUGEE SURGE RISK The impact of war wouldn’t stop at national borders. Because of the use of advanced weaponry in Ukraine — including long-range missiles and military drones — the front line is no longer a fixed boundary. Attacks can now reach targets hundreds of kilometers away, endangering hospitals and civilian infrastructure far from combat zones and making evacuation plans essential.  Illustration by Wayne Brezinka for POLITICO As a result, countries further from the front lines must prepare to receive patients and refugees, Joosten said, warning that EU solidarity will be tested. “If Lithuania is overrun, who’s responsible for Lithuanians, because there’s no Lithuania anymore? But the European Union is (still there),” he said.  Joosten urged EU institutions to create funds to handle civilian and military casualties, as well as displaced populations. He added that casualties could be dramatically higher than in Ukraine. “Those 4,000 patients we moved away from Ukraine, that’s nothing, 4,000 in three years,” he said. “Let’s talk about 4,000 in two weeks, and then the next two weeks again, and the next two weeks … the numbers are so different when the real war starts.” No one knows when — or if — war will come. But as Vaiknemets put it: “Crisis never shouts when it’s coming.” That’s why the Poles and the Baltics “have to prepare for the worst,” Vaļuliene said. “But we hope it will not come.”