20 March 2012

As the health reform bill faces its final hurdle, the debate now focuses on the (non) disclosure of the risk register. We may or may not get to see the risk register on the NHS reforms. It may not be worth the wait.

Most civil service risk registers are barely worth the name. When I was at Defra our risk registers made no mention of dangerous climate change, or new evidence suggesting all our environmental policies were unaffordable, or large scale flooding, or the animal health equivalent of the five plagues. Instead the usual risk register focused on minor internal inconveniences – with the classic mitigation of bringing in a consultant or a temp to cover a short term staffing problem. Since a good risk register had to have mitigations we only ever selected risks we had the power to mitigate.

To be any use, a risk register needs to think the unthinkable. It needs to make sure that the department is ready to act if there is a breakdown of care in London or Newcastle; if GPs prove incapable of managing budgets or game the system to line their pockets. If it doesn’t have these sorts of risks in it, they are more, not less, likely to happen as no one will have put any effort into thinking about how to counter them.

One reason many policies fail is that those taking them forward suffer from “optimism bias” – an assumption that things will work. So the Dome would be alright on the night; all those deadbeat dads would just write their cheques to the Child Support Agency without a quibble and people would happily pay the poll tax – and in a recent high profile case, the Care Quality Commission would be able to take care of both registering care providers and maintain quality inspections with far fewer staff.

Optimism biases are dangerous territory for policy makers. The Treasury Green Book requires economists doing appraisals to adjust for optimism in their assessments of costs and benefits (experience of budget overruns on government projects suggests they may not adjust enough).

But the impact can be more severe: the overconfidence induced by optimism bias can lead directly to policy failure. One way of mitigating optimism bias, recommended by psychologist Gary Klein is what is called the “premortem”. That challenges people to think forward a year and assume the outcome of the scheme as implemented was a disaster – and then write a brief history of that disaster. The potential benefits are spelt out by Nobel Laureate Daniel Kahneman in his book “Thinking Fast and Slow”: “it overcomes the groupthink that affects many teams once a decision appears to be have been made and it unleashes the imagination of knowledgeable individuals in a much-needed direction. .. The main virtue of the premortem is that it legitimises doubts. It encourages even supporters of the decision to search for possible threats they had not considered earlier...It does not provide complete protection against nasty surprises but it goes some way to reducing the damage of plans that are subject to biases…”

The government of Singapore was thinking of experimenting with “reverse post-mortems”. We don’t have them. The nearest we come are the risk registers which provide space to think about what might go wrong – and how to deal with the consequences. The health bill is a very major undertaking. So if the health reforms risk register does not curdle the blood, we should be very afraid.