The NHS reform transition risk register

There is a memorable scene in ‘Doctor in the House’ in which the surgeon, Mr Lancelott-Spratt tells a patient who is wondering what’s wrong with him, “Don’t worry my good man, you won’t understand our medical talk” 

It’s rather like the government’s attitude to the risk register …

Dear Mr Donovan,

Thank you for your correspondence of 21 and 22 November about the Information Commissioner’s recent judgment that the Department should publish its transition risk register.  I have been asked to reply.

The Department’s view is that the ruling of the Information Commissioner carries with it very significant implications, not only for the Department of Health, but also for other departments across Government.

The Department has been open about the outcomes that our modernisation proposals will deliver throughout the reform process, for example through the Impact Assessments that were originally published alongside the Health and Social Care Bill in January.  The Impact Assessments have been updated during the Bill’s passage through Parliament, most recently in September, and are available on the Department of Health’s website at by typing the reference number ‘16620’ into the search bar.

You may be aware that risk registers are a basic tool for the management of policy implementation.  They are working documents that inform advice relating to the entire range of areas for which Government departments are responsible, including financial risks, policy risks and sensitive commercial and contractual risks.  To enable robust risk management, the Department believes that officials must be free to record all potential risks and their mitigating actions together with an estimation of their likelihood and impact, fully, frankly and with absolute candour, in confidence that this information will not be disclosed.  The Department believes that the way in which these risks are expressed in worst-case terms would present a misleading picture and be open to misinterpretation if placed in the public domain.

The Department therefore considers that making this information publicly available at the time the requests were made would have compromised both the register’s quality and value as a basis for advice to ministers and decision making.  The Information Commissioner’s decision has caused concern in other Government departments in terms of the effects of publication on risk management in general, and the construction of risk registers in particular.

In light of this, the Department of Health has decided to appeal against the Information Commissioner’s decision in both cases.  Earl Howe made a statement to the House of Lords on 28 November that outlined the Department’s position and set out the reasons for our decision.  Earl Howe also went as far as he could in offering up the categories of risk contained in the transition risk register.  These 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 manage planning so that changes happen in a co-ordinated way 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 the transition;
– how best to ensure financial control during the 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 how to maximise the capability of the future NHS Commissioning Board;
– how stakeholders should be engaged in developing and implementing the reforms; and
– how to properly resource the teams responsible for implementing the changes.

It is expected that the Appeals Tribunal will consider this case in the new year.  The Bill is currently before the House of Lords to continue its Parliamentary scrutiny.

More information on the Bill can be found on the Department’s website at

I hope this reply is helpful.
Yours sincerely,

Paul Larkin
Customer Service Centre
Department of Health


23.02.2012 NHS Risk regiseter and FOI   “…the Information Tribunal will be focussing on that public interest issue around Section 35: Is the public interest best served in maintaining the convention of confidentiality around advice to ministers, or is it, in this case best served by going against this convention given the scale of the reforms, that the register should be released?”

15.12.2011 See this FOI request from Lord Owen about a major study on competition commissioned by Labour in 2006, on NHS Vault

Update 06.02.2012

Andrew Lansley covers up NHS report because it warns costs will ‘surge’ as a result of his bill.  Éoin Clarke blog

8 responses to “The NHS reform transition risk register

  1. I was the NHS user who received this reply. It beggars belief. I can assure Mr Lansley and poor Mr Larkin that I am not easily alarmed and would be happy to read the document and make up my own mind. Meanwhile I shall be forced to continue to assume that they have something to hide – like facts which don’t support the attacks on our National Health Service.

    • Thanks for letting me post this Kevin. I was trying to find the Lancelott Spratt clip where he tells the patient, “What is wrong with you, my dear man, has a long Latin name and you wouldn’t understand it even if I told you”

  2. I think it repulsive that the DoH assumes we, ‘the public’ i.e. the owners of the NHS, are insufficiently educated or bright enough to understand the contents of the risk register. The only assumption that I can make (if they can make an assumption well so can I!) is that the DoH do indeed have something to hide in the risk register. This is a similar situation to a recent FoI request for evidence of guidelines used by CQC inspectors at the ‘Registered Manager interview’; it appears that there aren’t any! How odd!

  3. In this context a letter I received from Health Minister Simon Burns, dated 28 november (relating to his comments about 38 Degrees in the Houae of Commons) is interesting:

    Dear Mr Voute,
    Thank you for your recent letter and I can certainly assure you that I do not think that you are a zombie.
    My cricism is not with the signatories of electronic template letters but the tactics employed by 38 Degrees itself. I obviously entirely agree with people expressing their views and concerns to their MP.
    However, what I challenge is the way that 38 Degrees have selectively used information about our plans to modernise the NHS which has misled some people ingto believing things that are not true. People deserve better. They should be presented with all the facts, so that they can make an informed decision and engage in meaningful debate. I feel, having read the email campaign of a few months ago about the NHS, this was not the case.
    Yours sincerely, Simon Burns.

    This is my, rather obvious reply:

    Dear Mr Burns,
    Thank you for your fast response. I am indeed happy to leave the zombies (whoever they may be) to their own gloomy pursuits and am ready to deal with more substantial issues.
    Without specific examples I cannot say anything about 38 Degrees’
    alleged misuse of selective information. However, I enthusiastically agree with your splendid idea that people should be presented with all the facts so that they can make an informed decision and can engage in meaningful debate. I hope that this will catch on, for it has not happened so far.
    I recall, for example, that when reading the House of Lords’
    Grand Committee scrutiny debate of the Health and Social Care Bill on 25 October I was been unable to find certain government documents and information the Lords referred to:
    1. A letter to the Lords by the Health Secretary, (according to
    press coverage 72 pages long) which was according to Lord Hennessey of Nympsfield sent on 20th October (Hansard 25 October, Column 740).
    This letter must obviously have contained new information
    since it would have been rather pointless for the government to re-iterate
    existing information at such length. As far as I am aware, this letter still has not been published.
    2. Evidence to the House of Commons’ Health Select Committee a week
    earlier, provided by Professor Malcolm Grant, quoted by Lord Harris of Haringey (Hansard 25 October, column 741). In particular, it seems to be unclear whether Lord Harris had to rely on 3rd party quotations of fragments of Professor Grant’s evidence or whether he had the full evidence available to him. The Lords themselves commented that the information was not published and that they had to rely on second-hand selective information.
    Furthermore, on 11 and 24 November the London Evening
    Standard reported that it had won a freedom of information battle forcing the Health Secretary to hand over a secret report on the risks he is taking with the NHS with his reorganisation of the health service. This document apparently lays out the risks to patient safety, finances and the very workings of the NHS as GPs are given power over the £60 billion budget to commission services. The Department of Health has fought for nearly a year to keep the strategic risk register on the NHS reforms concealed but Information Commissioner Christopher Graham has ruled in The Standard’s favour and told Mr Lansley to publish the report, but it has still not been published.
    In all these case both Parliament and the House of Lords, and indeed the general public, have been debating the Health and Social Care Bill reforms without access to this rather vital information and the House of Lords is now continuing to do so. This is a total shambles.
    I do not know, of course, how much other crucial information about the
    implications of the Health and Social Care Bill the government is still
    suppressing. I trust that your new commitment to openness and to presenting the people with all the facts will now lead to full disclosure of all documentation.
    It would obviously be sensible if all parliamentary activity in respect
    of the bill were suspended until full disclosure has been achieved so that MPs and Lords (as well as 38 Degrees and the general public) are, as you put it, presented with all the facts so that they can make an informed decision and engage in meaningful debate.
    Yours sincerely, Tom Voûte

    I have heard nothing more about Health minister Burns’ notion that people should be presented with all the facts. Has anyone else?

  4. Lansley and co are tying themselves in ever tighter knots in their bid to hide the corruption and wickedness (I can find no better words) at the heart of their proposals. I recall that Fox and Werritty were at it in health before they switched their allegiances to death (or, as they choose to call it, defence).

  5. 20 December 2011

    Mr Simon Burns MP
    House of Commons
    London SW1

    Dear Mr Burns,

    NHS Transition Risk Register

    Thank you for arranging for the Department of Health to send me its template letter on the subject as a reply to my letter. As it happens, the Department had already sent exactly the same text to Mr Donovan who posted it on 13th December on the blog “”. I enclose a copy and I am responding to you because I do not know whether you are aware of this rather extraordinary statement which the Department’s Customer Service Centre is mailing to members of the public.

    I obviously agree that: “officials” (civil servants, I presume) “must be free to record all potential risks and their mitigating actions together with estimation of their likelihood and impact, fully, frankly and with absolute candour.” That is what we, the tax payers, pay them to do. It is, however, also essential that this impartial expert advice is in the public domain so that ministers and legislators are accountable for what they do with the expert advice they are given. That is a matter of basic democracy.

    Reading the nine bullet points of topics as summarised by Earl Howe in the House of Lords, it seems quite obvious that all of the subject matter covered should be in the public domain and the inevitable conclusion must be drawn that the only conceivable reason why the Department might want to avoid disclosure of such information is that some of it is politically inconvenient, embarrassing or involves underhand manipulations of the political process, or all three at once.

    Secrecy breeds ignorance, incompetence, mismanagement and worse. To show the real meaning of the relevant paragraph of the Department’s letter more clearly, I will now reproduce it with two small substitutions:

    “To enable robust risk management, the company believes that engineers must be free to record all potential risks with their mitigating actions together with an estimation if their likelihood and impact, fully, frankly and with absolute candour in confidence that this information will not be disclosed. The company believes that the way these risks are expressed in worst-case terms would present a misleading picture and be open to misinterpretation if placed in the public domain.”

    Would it be wise to rely on a railway signalling system, to travel in an aeroplane or to live near a nuclear power station which has been designed and built on the basis of such non-disclosure of risks assessments?

    There is yet another aspect to this statement. Why is it assumed that only a few ministers and senior departmental officials are capable of reading the risk assessments without misinterpreting them? Would you not agree that the policy of not disclosing the risk assessments for such a reason expresses a high degree of patronising contempt for the general public (not to speak of the thousands of experts who work for the NHS and collectively know a great deal more about the subject than any Department of Health officials, as well as for MPs and the Lords). Frankly, this statement is offensive. It is also inept politics and PR to insult the intelligence of the people you want to persuade of the merits of your policies.

    I am copying this letter to Emma Backhouse of the Customer Service Centre of the Department of Health and to the “abetternhs” and 38 Degrees blogs.

    Yours sincerely,

    Tom Voûte

    • Excellent, Tom. No surprise to find that the response is standard but I’m still reeling at its patronising and insulting approach.

  6. Pingback: NHS Reform Under the X-Ray « constitutionunitdotcom

Leave a Reply to Kathryn Cancel reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s