The Deceptive Sideshow of the NHS Risk Register

February 24, 2012

Further to my Politics Home article this week:

I spoke in the debate exposing the flaws in Andy Burnham’s argument on the risk register.


Chris Skidmore (Kingswood) (Con): It is a pleasure to follow two of my fellow Health Committee members. The Chairman of the Committee wrote to the Secretary of State on 16 November 2011 to ask for the Government’s reasons for not publishing the risk register. In response, the Secretary of State wrote:

“It is important to understand that the risk register sets out all of the potential risks identified by the Department of Health for the entire range of areas for which it is responsible. These include financial risks, policy risks and sensitive contractual risks. It is a means by which the Department focuses on risks and acts to mitigate them. If the Department were to release risk registers in the future, there is a genuine possibility that the most significant risks will no longer be recorded, and no solution or mitigating action will therefore be identified. Any action that could deter staff from articulating and addressing business risk to their senior management and ministers carries with it the potential for highly damaging consequences.”

That is remarkably similarly to an answer given in Hansard on 23 March 2007 by the right hon. Member for Leigh (Andy Burnham) in response to a parliamentary question tabled by my hon. Friend the Member for South Holland and The Deepings (Mr Hayes). The right hon. Gentleman stated that the Department’s risk register dealt with

“emerging risks to the Department’s programme and the national health service, and what can be done to control and mitigate these risks. It also informs discussions between the Department and top management in the NHS about addressing key issues in policy, resourcing and service management. Putting the risk register in the public domain would be likely to reduce the detail and utility of its contents. This would inhibit the free and frank exchange of views about significant risks and their management, and inhibit the provision of advice to Ministers. We therefore cannot agree to place a copy of the current version of the register in the Library.”—[Official Report, 23 March 2007; Vol. 458, c. 1191W.]

We had a similar example on 31 July 2008, when the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson) responded to a freedom of information request by stating:

“Putting the risk register in the public domain would be likely to reduce the detail and utility of its contents. This would inhibit the free and frank exchange of views about significant risks and their management, and inhibit the provision of advice to Ministers.”

The Department of Health also refused a freedom of information request for copies of any presentations given by the director of public health concerned with the risk of not delivering on targets to reduce health inequalities, so it is not only risk registers that the Department has previously refused to reveal.

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Members have talked today about the risk register in apocalyptic terms, as though it were a document that should remain within the confines of MI5 or MI6. The Health Minister, Earl Howe, has revealed details of the broad issues that are covered by this risk register. I should like to read them out, so as to set the debate properly in context. They include:

“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”.—[Official Report, House of Lords, 28 November 2011; Vol. 733, c. 16.]

John Healey: The hon. Gentleman is right to draw the House’s attention to that fact, but does he accept that that is information that has not been published elsewhere and that the Secretary of State’s argument that the impact assessments that have been published are sufficient therefore simply will not wash?

Chris Skidmore: It is interesting that the right hon. Gentleman raises that point, because Earl Howe was mentioning the transition risk register, which is continually updated. That is an important point, because the appeal to the Information Commissioner to release the risk register was made on 29 November 2010, in the autumn when the register was live. The Information Commissioner made his ruling based on the fact that there was an issue of public interest at the time of the request. If the risk register is released today, it will be the risk register from autumn 2010 rather than that from February 2012. That is the moment when the wheels come off the bandwagon. The Opposition are asking the Information Commissioner to release the risk register from autumn 2010, not the risk register from February 2012. The risk register that would be released is that from the time of the White Paper, before the changes were made and before the listening exercise. It is complete nonsense. If the document was released, it would be out of date, inaccurate and would scaremonger among the population.

John Healey: So the hon. Gentleman agrees with Lord Henley, the Minister in the House of Lords, who told that House in January that if the Government lose the appeal next month they will publish not only the risk register from November 2010 but the updated risk registers, too?

Chris Skidmore: The Government do not have to publish the updated registers on the basis of the Information Commissioner’s verdict, which was on the autumn 2010 register. That is the Information Commissioner’s advice 

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that is referred to in the motion. The Opposition are asking for an out-of-date document—we might as well give up and go home.

Rosie Cooper (West Lancashire) (Lab): Is the hon. Gentleman aware of the comments made by David Nicholson, the chief executive of the NHS Commissioning Board, who said:

“I’ll not sit here and tell you that the risks have not gone up. They have”?

Chris Skidmore: I am, as I have the parliamentary Labour party brief—I can see that that is on the back of it.

Mr Robert Buckland (South Swindon) (Con): My hon. Friend’s point about the Information Commissioner’s decision is vital, because the public interest test is the test applied at the time of the request. That makes the decision interesting but, frankly, historical rather than relevant to the issues raised by Members today.

Chris Skidmore: Absolutely. We are debating whether we should release a register that is no longer relevant and that was written in autumn 2010, at the time of the request on 29 November. The topic is completely irrelevant, as the debate has moved on. We ought to be talking about reform and why we need it. We have wasted six hours of parliamentary time today discussing an out-of-date risk register.

Margot James (Stourbridge) (Con): Does my hon. Friend envisage that some of the amendments and changes to the Bill that the Government have introduced since that time would deliberately have taken account of some of those risks and that the situation would therefore have moved on?

Chris Skidmore: Yes, the situation has moved on. We have had the listening exercise under Steve Field and various Select Committee on Health reports. The name of the commissioning bodies, which were called consortia, has changed. Nurses have been added and we have opened things up so it is not just about GP commissioning.

Yasmin Qureshi (Bolton South East) (Lab): If the register is as irrelevant as the hon. Gentleman says, why not publish it?

Chris Skidmore: The Opposition are asking—[ Interruption. ]The shadow Secretary of State has already said that risk registers should not be published because they are confidential documents that must be used by policy makers. The Opposition are asking for a risk register that is out of date when what we should have been discussing today was reform of the NHS and how we can deal with an ageing population at the same time as dealing with a rise in chronic diseases.

I thought that it was striking that the shadow Secretary of State said at the end of his remarks that he would put the NHS first, without any mention of the patients. That is what these reforms are here for. They are allowing patients to be put in the driving seat and to sit down with their doctor, to understand what treatments they need and to have a choice of treatment through the opening up of providers. We could have had that debate—we could have spent six hours discussing that instead of this irrelevant document that you want to have a look at, which is out of date and from November 

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2010 when it is now February 2012. You are two years out of date, you are out of time and you are out of touch. I urge everyone to vote down the motion, simply because it falls outside the point.

Reform and the NHS

February 15, 2012

Alan Milburn’s strident article on health reform presents the urgent need for further reform of the NHS in years to come. Unlike another former Health Secretary, Andy Burnham, who seems to have sacrificed his credentials for opposition for opposition’s sake, having once embraced the reforms to GP commissioning and private sector involvement that he now dogmatically opposes, Milburn accepts that reform cannot be an issue simply left to party-politics.

The rise in chronic illnesses, such as diabetes, together with a rapidly ageing population which will see the number of over 85-year olds double by 2030, means that the NHS is facing a perfect storm. As a result, reform is not an option, it is a must: without it, we will not be able to achieve better outcomes at lower costs, or in Milburn’s words, ‘the new holy grail in health policy’.

What is striking about Milburn’s article is its commitment to the understanding that reform is not an event, but must be a continual progress driven by a quest for excellence, productivity and efficiency. This includes a need for integrated budgets for health and social care, advocated by the Health Select Committee last week, increasing payment by results for healthcare providers, ensuring the frontline take ownership of their services, and above all more competition: ‘Monopolies in any walk of life, whether private or public, rarely deliver operational efficiency or respond well to customer demand … competition may not be appropriate for every service, but if the NHS is to meet the challenges of the next decade it will need more of it, not less.’ Andy Burnham would do well to reflect on this.

The most radical of Milburn’s proposals is his insistence that we have to make patients ‘active participants’ in their healthcare. Stating that studies in the US and the UK have demonstrated that giving patients themselves direct personal control over their budgets, as the government has begun to do with personal budgets in social care, ensures that levels of satisfaction rise and public spending fall. He concludes that ‘hundreds of thousands of patients, particularly those with a chronic condition, should have their own personal state-funded healthcare budget.’

These are ideas which Milburn is right to look at- as he suggests, the evidence and experiences in the US demonstrate individual health savings accounts are revolutionising healthcare and delivering better care at better costs. For instance in Indiana, the introduction of Personal Wellness and Responsibility Accounts, which provide the first $500 of preventative care and encourages enrolees to take responsibility for their healthcare, have allowed 40,000 previously uninsured Indiana residents to register with the plan- all of whom are on incomes below 200% of the federally-set poverty level. Health outcomes are up, and costs are coming down.

Obviously the US is a very different case, but if we are to ensure that the NHS remains able to deliver the best possible care to its most vulnerable patients with chronic illnesses, we need to ensure that personal responsibility becomes the watchword within the service. As other evidence from the US shows, by focusing on those with chronic conditions, so-called ‘super users’, often with high rates of obesity, diabetes, or alcohol dependency and addiction, estimated to be around 15-20% of the population who cover 80% of all healthcare costs, healthcare dependency can be reduced and huge savings can be made- to be reinvested in a better service .

With an older population that will be more dependent on care than ever before, tackling the issue of personal responsibility, neglected for too long, is today’s challenge to ensure the NHS’s survival for tomorrow.