NHS Risk Register: West Midlands SHA Briefing 8

A look at the DH’s ‘secret’ risk analysis of the NHS changes, and why Lansley blocked its publication

From the West Midlands Socialist Health Association, May 2012

The Health & Social Care Act – the missing Risk Register

The Health & Social Care Bill is now an Act, thanks to the failure of LibDem peers to listen to the pleas of their remaining supporters.  Before it passed, Labour made strenuous efforts to secure publication of the Department of Health (DH) official Risk Register, so that legislators would know the risks the Government was taking.  Andrew Lansley refused publication, claiming it would undermine advice given to Ministers by making civil servants pull their punches.  But apart from the slur on civil service professionalism – would the outcome have been any different if Labour had won the case?  The Risk Register has leaked [1], so now is your chance to find out.

What is in the Risk Register?

The Register is only 7 pages, but lists 42 major risk headings, rating each in terms of immediacy, likelihood and impact – with a brief note about how the impact might be mitigated.  One third of the risks were rated as both highly likely and high impact, and in half these cases the danger was described (in September 2010) as ‘imminent’.  To give just a few of the more striking examples:

1. Costs and where they will fall are not known, so the new system could be unaffordable: eg GP consortia could add to costs by using private sector organisations or staff.
2. Implementation will begin without knowing how the transition is to work, making accountability unclear. Who is responsible for funding when outgoing Strategic Health Authorities and incoming National Commissioning Board are running in parallel? Or for commissioning with both outgoing PCTs and incoming GP Commissioners in place?
3. A transition managed by people who are themselves at risk will lead to worse performance, delays and losses of key staff.
4. NHS changes will overtake changes to DH, public health and social care, so the parts of the system do not work properly together. Good people will be lost from PCTs and then have to re-recruited, while PCTs pass their roles to GPCs before their functions and budgets are clear (this, incidentally, is regarded as only a medium impact outcome).

The Risk Register is just about the process of transition, but the problems that were identified in October 2010 may have been serious enough to give Ministers a shock, particularly as the mitigation measures are generally unconvincing.  This may be one reason why they agreed to a ‘pause’ in April 2011, though some of the risks (eg the diversion of GPs from clinical work to managing £20bn cost savings) have come to pass, unmitigated.  Moreover, although begun well ahead of Parliamentary approval, the transition still has a long way to go.

However, several of these ‘transition risks’ are also implicit criticisms of the new system, which we turn to next.

What is not in the Risk Register?

The complexity of the new structure will, in itself, make it more difficult to improve productivity and quality or to reduce health inequalities.  Further major risks resulting include:

1. As there is no equivalent half-managed, half-regulated structure anywhere else in the world to use as a model or benchmark, the risks are unknown and impossible to mitigate;
2. In undergoing marketisation the NHS riks the same fate as the rail network and water utilities, where the resulting chaos led to restoration of partial Government control through further structural change and regulation.  It might also lead to introduction of privatised intermediaries on the US model with massive cost increases (see Briefing No 6 on the Americanisation of the NHS, and further comments below);
3. Unbridled localisation makes it difficult to tackle inequalities, driving unsustainable increases in costs because inequality is itself a major cause of increasing ill-health;
4. Longer term ‘outcome’ targets may be a good idea, but the risk of simply doing away with ‘process’ targets (because they are unpopular) means the end of Labour’s steady gains in productivity, quality and safety.  These are even more vital when resources are short.

Why was the Register not published?

The refusal by Andrew Lansley to publish the Risk Register has been severely criticised in a report this month by the Information Commissioner (http://www.bbc.co.uk/news/health-18071681).  The law permits Ministers to refuse publication only in ‘exceptional circumstances’: this is only the third occasion on which this power has been used, and the Commissioner does not believe the test has been met. There are two possible reasons for such an extraordinary decision, not mutually exclusive:

1. This government has been characterised by gung-ho actions by Ministers keen to burnish their right-wing credentials (as well as Lansley, Gove and Pickles come to mind).  Authoritative risk analysis from Departmental officials would cramp their style, risking rebellion by LibDems and other doubters.
2. Their aim of extending privatisation of the NHS in due course will require further acts of concealment from the public, so Ministers are testing the instruments of secrecy.  It is notable that although they have been criticised in this case, they have nevertheless succeeded in getting the legislation passed in the meantime.

How should Labour respond?

Moving onwards from marketisation to privatisation is the right’s hidden agenda.  The crucial step would be a move from a single-payer system (like the NHS, and other cost-effective national health services) to a multi-payer system (as in the US, where 10,000 insurance-based players generate enormous profits, add hugely to costs, and deny access to healthcare for nearly a third of the population).  This would effectively end the concept of universal national standard of care based on need, replacing it with one based upon provider profitability.

Commissioning by GP-run CCGs was supposedly the whole point of the legislation.  But Commissioning Support Units (CSUs) are already in place, and in the process of taking over the commissioning function.  Because CSUs are non statutory they are free of public accountability or public duties.  The privatisation of the first CSU would thus signal a tipping point.  Labour must work hard to alert the public to this danger, fight any such move – and continue to demand that relevant information is placed in the public domain, so that debate can be informed.