Endeth the time, cometh the risk register

"A risk register is not a forecast or a prediction. It's where civil servants contemplate the most extreme consequences of any major government project. They think the unthinkable to ensure that the unthinkable never happens"
- Simon Burns, 22 February 2012

"We do not comment on leaks. We have always been open about risk..."
- Department of Health, 27 March 2012

Yesterday, the Health and Social Care Bill transitional risk register was leaked to both Dr Phil Hammond and Roy Lilley. Or at least a version of it was. The excel document is dated October 2010, with a version number of 1.1, an "as at" date of 28 September, and a headline of "draft for discussion".

First and foremost, I have read through the risk register and to my utmost surprise, I haven't gone blind and my brain hasn't turned to mush and leaked out of my ears. Who would have thought it? Viewing risk registers isn't so risky after all.

Secondly, I sincerely doubt that the fact the risk register has been leaked is going to change the way all risk registers are used forever more.

Now, on to the actual content.

45 risks are listed (numbered 1-46, but there is no number 8... too risky to even document?!?), with associated descriptions, actions and owners. Each risk is also given a priority (imminent or longer term), likelihood (from 1 = rare to 5 = almost certain), impact (from 1= very low to 5 = very high), and overall rating (its likelihood score multiplied by its impact score).

This is absolutely standard, text book, risk register stuff. Nothing scary, nothing extreme, nothing outlandish, and nothing unthinkable. Just an attempt to methodically detail, categorise and prioritise the relevant risks.

Leaving aside the fact that the colour coding of the overall risk ratings seems to have gone a bit awry, 7 of the 45 risks have a red overall risk rating (designated by a likelihood of 4/5 and an impact of 4/5) with a priority of imminent. Snippets from these risks are below:

"risk that Bill proceeds on basis of incomplete/flawed design"


"As the Bill proceeds through Parliamentary stages, amendments are made which have unforeseen consequences for the system, with possible impact on costs or performance of the system"


"Bill proceeds, without assurance that the whole system is affordable... system could be more costly if GP consortia make use of private sector"


"Aspects of implementation begin before adequate planning has been done"


"As transition progresses, management lose focus on BAU performance"


"Financial control is lost"


"Planning, preparation and governance is hindered and... policy design is limited leading to mistakes in design and legislative drafting"

A further 7 risk risks are red rated with a priority of longer term. Snippets from these risks are below:

"more failures, including financial, eg GP consortia go bust or have to cut services"


"lack of clarity during the transition in terms of acountability... leads to delays and increased costs and poor BAU performance"


"NHS commissioning board is not sufficiently developed to assess capability of consortia. GP leaders are not sufficiently developed to run Consortia"


"Staff morale"


"Public reputation"

Interestingly, 6 of the 45 risks have not been scored or rated. And one of these has not been marked as being covered by, or overlapping with, other risks. Snippets from that risk are below:

"Inability to reduce running costs because of consortia numbers"


"Loss of clinical time by GPs due to consortia management responsibilities"


"Failure to manage referral demand"

Now, reading through the above, do they sound like the unthinkable, the bizarre, the outlandish, the extreme? And how many of them do you think are no longer risks? And how many of them do you think have now actually become issues, rather than risks?

And although I agree that a risk register is not strictly an actual forecast, when you look at the highest risks (defined as high partly because they are likely) in this particular risk register, you are left thinking that it is pretty close to the mark and a pretty accurate prediction.

There's already some talk that the risk register has been deliberately leaked at this point, as it is too late to influence the passage of the Health and Social Care Bill, and it is a good distraction from 'Cam Dine With Me'. Whether deliberate or otherwise, having reviewed the risk register, I think it blows apart any and all arguments put forward for its suppression. It would have provided an excellent basis upon which to have an informed, intelligent debate about the proposed Health and Social Care Bill.

Just a shame that our elected and unelected representatives did not agree... or maybe they just didn't care?

Chris