Today, a leaked copy of the first draft of a risk register (PDF) assessing the damage that could follow the Tory-led coalition government’s reckless plans to reform the NHS (which involve devolving 60% of the NHS’s £100bn budget to new GP-led consortia, and introducing more competition into the NHS), was published by the Guardian.
As the axe fell on the NHS last week, with the passage of Andrew Lansley’s wretched NHS reform bill, last minute calls for delays until the risks could be assessed were ignored by the Tories and the Liberal Democrats, even though a freedom of information tribunal had twice ordered Lansley to release the Transition Risk Register, in which civil servants advised ministers about what could go wrong with their plans. Traditionally, risk registers are for internal use only, as they provide “worst case scenarios” that could lead to scaremongering if made public, but there has been such uproar over the NHS plans, which were so potentially damaging and ill-conceived that the legislation took 14 months, and involved hundreds of amendments, that the release of the risk register was justifiable.
Lansley is still refusing to release the final version of the risk register, which was drawn up on November 10, 2010, for reasons that were made clear on February 2 by the pro-NHS campaigner Dr. Éoin Clarkeon his blog The Green Benches, just after Lansley refused to acknowledge the second ruling regarding the risk register. Dr. Clarke wrote:
Andrew Lansley has concealed a ‘risk report’ that has examined the potential dangers of his NHS Bill. He simply refuses to publish it. I am told that the reason for this is that the report contains a very serious warning about the long term damage the bill will do to the NHS. The chief warning in the report is that Lansley’s reforms will spark a surge in health care costs and that the NHS will become unaffordable as private profiteers siphon off money for their own benefit. The report specifically warns that GPs have no experience or skills to manage costs effectively. The profit element contained in Lansley’s reforms is the chief reason for the report citing these worries. This is the reason Lansley refuses to publish the report, because he has claimed that his bill will make costs in the NHS more affordable. This flaw in the bill if exposed would undermine his entire argument and it is the reason the report will not be published until the bill becomes law.
The draft of the risk register released today is dated September 28, 2010, and was leaked to the health writer Roy Lilley. As the Independent explained, it identifies “43 separate areas of potential risk,” and “rates each on a scale of one to five, where a rating of one means little likelihood and very low impact and five means almost certain to occur and very high impact.”
Noting also that “[t]he likelihood and impact figures are multiplied together to give an overall risk rating, with a maximum score of 25,” the Independent explained that there were 13 areas with a risk rating of 16 — in other words, those where the likelihood and impact were each assessed at four out of five (“near nigh certain,” in Dr. Clarke’s words). These included:
- Parliamentary amendments creating “unforeseen consequences for the system”
- Costs being driven up by GP consortia using private sector organisations and staff
- Implementation beginning before adequate planning has been done (“One example of area where system could be more costly is if GP Consortia makes use of private sector organisations/staff which adds costs to the overall system”)
- Loss of financial control (“Financial control is lost due to the restructuring of budgets distributed between or allocated to organisations within the system [to be clarified]“)
- Unhelpful conflict” between the NHS commissioning board and regulator Monitor
- GP consortia going bust or having to cut services for financial reasons
- GP leaders being drawn into managerial processes which end up driving clinical behaviour
The Guardian also noted that other risks (with a rating of less than 16) involved emergencies — specifically, that “[t]he NHS role in emergency preparedness/responsiveness is more difficult to manage through a more devolved organisation, and so emergencies are less well managed/ mitigated” — and what it described as “[u]nfavourable media coverage.” The risk register stated, “Public reputation. There is a risk that the transition will be presented in a negative light via the media. Two of the biggest risks which have already surfaced in the media are i) that the reforms will continue to be characterised through the prism of privatisation and ii) financial cuts.”
The Independent also noted that the risk register advised that “[s]taff concerns and union action over the reforms could lead to ‘deterioration in relations, lower productivity in the Department of Health/NHS and delays in programme,’” and warned that “strategic health authorities and primary care trusts might lose ‘good people’ who then have to be re-employed to run the new system.”
Providing an overview, the Guardian noted:
Health secretary Andrew Lansley’s reforms were built on demolishing a layer of management — the primary care trusts which currently purchase care on behalf of patients. But the document highlights the risk that the reforms would sow confusion between rival bodies on the ground during the transition to Lansley’s new look NHS. Civil servants also rate highly the danger that the £20bn savings may not materialise as managers lose focus and that the quality of patient care suffers.
The Department of Health refused to comment, but the Guardian explained that it was “understood that the leaked document looked familiar to officials.”
In response to the publication, critics were swift to attack the government for its ideologically driven recklessness. Clare Gerada, the chair of the Royal College of General Practitioners, who was a staunch critic of the reforms, commented on Twitter that the risk register was “very scary reading & should have been disclosed long ago.”
Andy Burnham, the shadow health secretary, whose last-minute intervention in the House of Commons to delay the passage of the bill until the risk register was published, was defeated last Tuesday in the House of Commons, said, “Now we know why David Cameron refused to publish the risk register before the bill was through Parliament — it’s because civil servants were telling him his reorganisation was likely to cause major damage to the NHS. David Cameron will never be forgiven for knowingly taking these risks with the country’s best-loved institution.”
John Healey, the MP who first pushed for the release of the risk register, said, “This is exactly the type of information that the public and parliament lacked while the bill was being debated. This shows how unprepared the NHS and civil service were for this huge NHS reorganisation.”
Unfortunately, although the risk assessment is indeed “very scary reading,” its publication — and, if it ever happens, the publication of final version that Andrew Lansley is sitting on because of its dire warnings about the future of the NHS — will not, in and of themselves, constitute the smoking gun that brings down the government’s malignant reforms.
As the Guardian explained, “Ministers are likely to argue that the document is an early draft drawn up four months before the publication of the health and social care bill. Since then the bill has undergone two major changes during the government’s ‘listening exercise’ last spring and in a series of parliamentary amendments. Ministers will also say that a report to be published on Tuesday shows that the NHS is on course to meet the so called ‘Nicholson challenge’ to save £20bn over the course of this parliament.”
Similar concerns were expressed by Dr. Éoin Clarke. Although he described the risk register as “horrific,” and specifically noted that it “talks of catastrophic financial failure with no management to deal with it,” and advised that “[t]o allow any bill to proceed with those level of risks would border upon negligence and open up the government to criminal charges should resultant deaths transpire,” he also worries that if Andrew Lansley “actually releases the final Risk Register he will be able to juxtapose it with the horror show that was the first Risk Register and claim the credit for having improved the bill.”
This may or may not be true, but I admire what Dr. Clarke wrote following up on this analysis. The truth, he wrote, is that the NHS Bill “still carries the risks of financial meltdown,” and explained that the local risk register for London from January this year (which he published here) “still recorded the risk of financial meltdown or bankruptcy for CCGs [the Clinical Commissioning Groups, which will replace Primary Care Trusts in April 2013, and will be responsible for buying healthcare] as extreme.” He added, “So I am calling on Andrew Lansley to stop ignoring the courts, the Information Commissioner and Tribunal and to release the final draft of the Risk Register before this ‘peep show’ version becomes sensationalised. Show the world what we already know, there were serious risks still not mitigated before this bill finally went onto the statute book. You played fast and loose with our national treasure that is the NHS and no amount of expectation management can hide that.”
I agree that Andrew Lansley should publish the risk register, but on the basis that none of us know what shifts people’s perceptions to such an extent that government become popular or fall out of favour, I’m happy that the millionaires’ budget and the Crudgate scandal of cash-for-access has been followed by the sound of alarm bells ringing for the NHS in a risk register that, back in September 2010, should have sunk the NHS reform bill before it saw the light of day.
Put simply, the 2012 Health and Social Care Act must be scrapped, as must the government that implemented it, and I’m happy for that to happen through people realising that they ought to be scared of the people who claim to represent therm, but who only care for big business and rich individuals.