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Guest editorial Thursday 26 January 2012: Risks? What risks? Reasons not to publish and be damned.

This guest editorial from Irwin Brown of the Socialist Health Association raises an eyebrow laconically at the refusal to publish the Risk Register for the Health And Social Care Bill.

The spectacular chaos that surrounds the Health & Social Care Bill is increased by the Government’s refusal to provide the Risk Register for the transition programme – the programme of activities which will deliver The Nicholson Challenge and the Bill ‘reforms’ (the Health and Care Reform Transition Programme).

A sensible approach would have been to provide a redacted version of the Register as it was at the time it was requested – all names and identifiers removed.  Even if nasty questions had been asked, they could have said that it was a snapshot at a point in time and that things had moved on – or some other deflecting remark.

But no - they have turned this into a fight with the Lords on almost constitutional grounds. This has served to elevate a risk into an issue.


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Programmes must manage risk. Most guidance on methodologies for managing large or high-risk programmes expect sophisticated methods for identifying risks, setting out mitigating actions, indicating assurance mechanisms and then assessing levels of likelihood and impact – in some form or other.

Regular high-level review of key risks is fundamental but so too is a risk management process which involves all stakeholders and shares widely the identification and mitigation of risk.  This idea of a risk register as part of stakeholder communications has escaped them.

In case they missed it the OGC developed standard programme management methodology (MSP) sets out how risk management should be established on a support structure with a culture of trust where participants are not afraid to raise concerns about risks and the ideas for managing the risk are openly shared. Obviously, this does not apply to the biggest and most complex programme ever undertaken by the NHS (and probably anywhere else)!

We are able to see some of the risks as they are set out in the Impact Assessment (a document notable for its poor quality, as assessed by the independent Regulatory Policy Committee). We also have a list from the Minister of what the broad issues are – see the footnote below.

We know NHS London – overseeing about one-sixth of our NHS - happily published its register, even though it had a number of apparently alarming risks identified – and the sky did not fall.

We know many public bodies, including local authorities, regularly publish risk registers and see it as part of being open and transparent – and not as a risk to good management.

So what could possibly be secret to the point that it is now a cross-government constitutional issue?

The register must contain a list of the major risks (which are hardly very secret) and the mitigation steps that are being taken (which are observable facts). What steps are being taken to obtain assurance around mitigation might lead to requests for details which might be embarrassing - but hardly threaten national security or the stability of the system.  The names of those who flagged up the risk and who is responsible for managing it can be redacted: entirely fair enough.

The assessment of the level of risk in terms of relative likelihood and the impact (both post mitigation) again might be a bit embarrassing if for example there were more than one or two risks with “red” ratings.

But just what is so secret about that lot?

If the register was rewritten into the format adopted by NHS London and names were removed, what on earth can be the problem?  Nothing in the actual Register can be as bad as what people are assuming is in it.  It might even show more “grip” than is apparent.

Perhaps the real fear is that the register will cast doubt on assurances provided to Parliament such as by Lord Howe that the list below encompasses all the key risks. For example, perhaps it fails to flag up the very clear risk that the changes, even if approved by Parliament, will be undermined during implementation because of the total lack of any support. Perahps it mentions financial control twice, but does not flag up the tension between the Nicholson Challenge and the reforms – an issue highlighted very clearly by the Health Committee – etc.  

In all honesty, if this programme had good support and a robust plan (and it has neither), then the biggest risks would be the lack of any credible leadership and the inept nature of the management of the programme.

But we know that.

‘Publish and be damned’ is about right. But they won’t publish. Because they would be damned.

Irwin Brown
Socialist Health Association
January 2012

Earl Howe answered in the Lords that the broad areas covered by the risk register are:
•  how best to manage the parliamentary passage of the Bill and the potential impact of Royal Assent being delayed on the transition in the NHS;
• how to co-ordinate planning so that changes happen in a co-ordinated fashion while maintaining financial control;
• how to ensure that the NHS takes appropriate steps during organisational change to maintain and improve quality;
• how to ensure that lines of accountability are clear in the new system and that different bodies work together effectively, including the risk of replicating what we already have;
• how to minimise disruption for staff and maintain morale during transition;
• how best to ensure financial control during transition, to minimise the costs of moving to a new system, and to ensure that the new system delivers future efficiencies;
• how to ensure that future commissioning plans are robust, and to maximise the capability of the future NHS Commissioning Board;
• how stakeholders should be engaged in developing and implementing the reforms; and finally,
• how to properly resource the teams responsible for implementing the changes.