The controversy over the Government’s proposals for NHS reform refuses to die down. I have long argued that the issues underpinning the debate are ideological and no amount of amendment to the Health and Social Care Bill will be sufficient to appease those who are philosophically opposed to large elements of the Bill. Put simply, if you fundamentally don’t believe in competition in healthcare, then nothing less than abandoning competition in the NHS will be sufficient. Simply tweaking Monitor’s responsibilities will hardly be enough.
Seeking to quell opposition to reform is therefore not a realistic objective. The political imperative must then be to limit the opportunities for opponents to attack your policy is the only sensible way forward. In this sense, introducing one of the lengthiest and most complex pieces of legislation ever (and into a hung parliament at that) may not have been the most sensible move. But that is now ancient history. However, there are other areas where the Government could make life easier for itself.
The non-release of the Department of Health’s risk registers has become a lightning rod within the debate on NHS reform, with opponents arguing that the Government is refusing to release it because it contains devastating information about what will happen to the NHS post-Bill. I believe the truth to be more mundane, but it is a classic example of how good governance and good politics can come into conflict.
Let’s start with the governance. Risk registers are – by definition – meant to explore every possible issue that could go wrong and therefore never make happy reading. I dare say the Department of Health risk registers do examine what could potentially go wrong as a result of reform, but they will also assess other threats, such as those posed by terrorism and outbreaks of infectious disease. There are clearly good reasons why these should not be exposed to public scrutiny. And there is also the issue of cross-government precedents: if the Department of Health publishes its risk register, then why not the Treasury, which could cause serious havoc on the financial markets? This explains why previous administrations also refused to publish such documents.
Therefore from a governance perspective the Government’s stance is entirely understandable. Yet the politics make less sense. There is something discordant about an administration that has made much of its commitment to the cleansing power of transparency refusing to release the document. It gives fuel to the conspiracy theorists’ fire (and they have plenty already).
Opponents of the Bill are quite capable of using their imagination when it comes to potential risks of reform. From widespread hospital failures, to ‘top ups,’ professional conflicts of interest or the end of a comprehensive health service which is free at the point of need, they have already imagined – and spoken at length about – the worst. I very much doubt that the risk register contains anything on NHS reform that could shock. It is probably far more mundane than most people imagine, and more measured than some of the more outlandish claims made about the reforms.
So I understand why governance may demand non-disclosure, but I also believe that the politics of reform require transparency. Is it possible to reconcile these apparently conflicting imperatives? Here’s my suggestion: the Secretary of State should offer to brief the Shadow Secretary of State and the Chair of the Health Select Committee on Privy Council terms. That way they can examine the contents of the risk register without compromising the operational security of the NHS. This approach is not new. Indeed it was used successfully both before and during the pandemic flu outbreak, including when Andy Burnham was Secretary of State. Alternatively the registers could be released alongside an explanation of the steps that have been taken to mitigate the risks.
The bad politics of the situation have not gone unnoticed by the Department of Health, but this is a situation in which the whole government machine has an interest. Rightly or wrongly, the release of risk registers is seen as having the potential to undermine swathes of policymaking across government. Perhaps there should be a risk register on the risk registers? The use of Privy Council terms could be one way of addressing this. However, good cross-Whitehall governance appears to have clashed with good politics. The result is another running sore in the debate on NHS reform.