Independent report

Infected Blood Compensation Authority Independent Review

Published 30 October 2025

Background

1. This Infected Blood Compensation Authority (IBCA) independent review was commissioned by the Cabinet Office (CO) and was conducted by Sir Tyrone Urch and Hazel Hobbs as core Review Team (RT) members and supported by government digital/data experts. 

2. The stated purpose of the review was: “to support successful delivery by assessing IBCA’s delivery of the Scheme, identifying potential areas for process improvement, and providing independent confirmation that IBCA is progressing delivery as quickly as possible to meet recently agreed commitments”. 

3. The RT’s terms of reference are at Annex A; they include the widely-welcomed ministerial imperative to “agree a package of measures to increase the risk appetite of both organisations [i.e. IBCA and CO] to accelerate the delivery of the Scheme”.  

4. The review was conducted over a period of circa 12 weeks from 25 July - 20 October 2025. This report summarises the main recommendations and key findings, but does not attempt to provide a detailed analysis of the solutions required, as this is for the CO Senior Responsible Owner (SRO), IBCA Chair and Chief Executive Officer (CEO) to determine.

5. The RT started by reading the powerful testimonies of victims, the findings of the public Inquiry led by Sir Brian Langstaff, and the circa 60 documents provided by the CO. The RT members then met a wide variety of teams and conducted circa 70 private interviews with a wide range of internal and external stakeholders. Finally, the RT observed the current service in action in the headquarters site in Newcastle. All contributors to this review were candid, constructive and very generous with their time and ideas.

6. All 24 recommendations in this report are extracted directly from interviews, independent research, site visits and reading; some conclusions overlap and could fit into multiple thematic areas. Where appropriate “direct but unattributable quotes” are annotated thus. Any errors are the responsibility of the RT. 

The story so far

7. Everyone involved with the IBCA journey is to be congratulated on their efforts which have been exceptional in the face of moral obligations, policy complexity and scheme scale. The substantial early progress is particularly noteworthy given the profoundly important and challenging operational task IBCA has been given, whilst building an organisation from a standing start since May 2024. There has been a particularly impressive collaborative work ethic between the CO and IBCA within the bounds of operational independence.

8. There are a number of extant IBCA strengths that are worthy of early note here so that they can continue to be protected and built upon. These include, but are not limited to, a strong emphasis on the user-centric journey, a rigorous functioning test-and-learn methodology, and a culture anchored around a dedicated sense of purpose. It is clear that the user experience is at the heart of everything that IBCA is doing in a trauma-informed environment. This sense of purpose is an exceptionally strong rallying anchor, but it will be challenging to continue with such momentum in the future when the organisation is scaling up so fast.

9. The RT has noted just how difficult it has been to develop an IBCA minimum viable service, whilst also building a whole new organisation from scratch, to meet the imperative for an independent organisation. Such impressive early progress could not have been made, however, without drawing on considerable cross-government experience and personnel. The RT sees merit in having a much clearer playbook for future schemes, and also more standing functions identified to form a core centre of expertise; noting that the latter is being researched separately by the National Audit Office (NAO) and Parliamentary committees.

10. As at 23 October 2025, IBCA has asked 3614 registered, living, infected people to start their claims, of which 3371 have started the claim process, 2476 have received their offer, and a total of 2033 have been paid compensation totalling circa £1.36 billion. As an early milestone, this is very creditable progress when compared with initial estimates which had indicated the first claims would be paid in autumn 2025. The latest figures can be found on the IBCA website.^{[footnote 1]} For infected and affected victims of this scandal there is immense concern about the speed of payments, particularly given that some are ill, elderly or dying after waiting so many decades, compounded by the lack of clarity at present on future timescales. Nonetheless, it is important to note that IBCA has exceeded expectations for the first cohort. Moreover, the RT observed that they have established an operational service and a rapidly growing organisation with a compassionate ethos which puts “the needs of the community at its heart from the top to the bottom”. This was widely regarded by interviewees with a breadth of wider experience as exceptional, particularly as value for money, proprietary and regularity have still been key considerations throughout.

11. The recruitment of a highly capable and trusted CEO, an independent Chair and a Senior Leadership Team (SLT) has been a critical factor in success so far. The holding of significant financial and reputational risk by the Minister for the Cabinet Office (MCO) and Permanent Secretary has also been vital and has allowed IBCA leaders to operate knowing that the sponsors are committed to this.

12. The RT also notes the immense amount of high quality work across all CO functions to support the early set up of IBCA corporate services, driven by a dedicated and passionate programme team. The transition from an organisation that relied on the CO to coordinate provision from across human resources (HR), finance, information technology (IT), estates services etc, appears on track to fulfil its responsibilities as an independent employer. There are, however, some gaps and risks associated with the transition which need addressing.

13. The RT concludes that there are no substantial requirements unaccounted for in the delivery plan for the current cohort of registered/living/infected victims which is being delivered as quickly as reasonably practicable ahead of 31 December 2025. However, the current methodology “cannot be scaled-up” for future cohorts of victims (e.g. non-registered infected, estates, affected people) without substantial intervention across multiple lines of operation to address the dynamic prioritisation and parallel processing required across different groups.

14. The first cohort has generated a huge amount of learning and creative problem-solving but this has, inevitably, been at the expense of available “intellectual bandwidth” for strategic planning to prepare for the cohorts to come. In operational and risk terms, the future cohorts are significantly more complex, particularly for the various affected people where eligibility criteria are much broader than for legacy support schemes. Evidence requirements will be more difficult to determine in some cases and the personal data security and fraud risks amplified. IBCA is only in the foothills of the work required to scope, build, test and iterate elements of the service that have not been required or mobilised to date (e.g. appeals, dealing with estates and contested beneficiary claims, supplementary exceptional award pathways).

15. The task ahead has also become more challenging because of the requirement, recommended by the Inquiry in July, to open up all cohorts simultaneously to initial applications in parallel with a different priority order. This has necessitated a huge amount of re-planning on the digital and service build which is consequently adding time and may therefore be counter to current community perceptions.

16. The IBCA leadership team and Board will need space over the next few months to hold-fast to proven test-and-learn principles, by trialling and iterating the end-to-end service for all claim journeys on each new cohort, before scaling more rapidly. Planning and testing will ultimately enable faster overall delivery, by avoiding costly missteps and errors. Navigating the sequencing and rollout decisions ahead, however, presents reputational risk. Ministerial backing, and very clear and effective communication with the community and other key Parliamentary and wider stakeholders will be required, who may otherwise assume that progress will continue to accelerate at a similar rate as today.

17. There is now a window of opportunity over the next circa six months to tackle several significant areas that appear problematic and challenging going forward. If these areas are not addressed, they could derail continuing efforts to speed up the time it will take until the last eligible claim is paid. These include, but are not limited to:

a. Creating the organisational bandwidth to deliver more stability and designing new processes and operational policy.

b. Co-opting more cross-departmental support especially within the National Health Service (NHS) and equivalents in the Devolved Administrations (DAs).

c. Transitioning to an iterative digital system for processing and managing claims.

d. Developing a compelling and clear narrative.

e. Contracting for legal and financial support, and other key personnel demands.

18. The RT offers recommendations based on six major challenges going forward; there are also a number of other subsequent recommendations based on the specific questions posed in the terms of reference.

19. Learning from the 2024 NAO report on Government Compensation Schemes (Government compensation schemes), the RT observed that trust is hard to gain against a backdrop of terrible injustice, and very easy to lose. IBCA, as an independent body, has started to show they can deliver compensation with compassion for victims and their families. IBCA will inevitably build more experience and learning (e.g. for public timescales) from registration and by designing and testing processes for all the different case types.

Principal conclusions - the big six

20. Policy stability. Whilst it is appreciated that the CO and wider government does not control all the levers, there is a sense of frustration and a view that delivery confidence would improve if “IBCA can now get on with their mission without further major policy shifts and distractions”.  Equally the headline message for senior IBCA leadership is to “hold the current course and stop changing priorities”. More detail on the policy response is at Question 7.

Recommendation 1: Pursue a master principle of ‘policy stability’ to support the overall objective of expediting payments as fast as possible.

21. Cross-government support. This has been absolutely critical to date and the RT noted several excellent examples of early support from His Majesty’s Revenue and Customs (HMRC), Department for Work and Pensions (DWP) and Ministry of Justice (MOJ). Greater cross-government support is absolutely required right now from the NHS and, to a lesser degree, other organisations if the rate of evidence gathering is not to act as a “fundamental progress handbrake” when multiple cohort complexities are being dealt with next year. Other departments and organisations could also provide further support (e.g. DWP - for debt management and potentially the loan of staff experienced in developing operational policy, guidance and issue resolution; National Economic Crime Centre (NECC) - a senior level introduction here would be helpful).

a. Priority 1 - NHS. The RT was made aware of particular pinch-points that have arisen for claims awaiting resolution, but that these are currently grouped in a few specific centres of expertise. If agreement could be reached so that the NHS prioritised the provision of medical evidence for victims, this would immediately cut a backlog of extant claims, including some in the ‘end of life’ priority category. Looking ahead, this becomes more of a concern, due to resourcing limitations, case complexity, and the need for additional expert clinical input. This, and associated escalation protocols in the Department of Health and Social Care (DHSC) and the Devolved Administrations (DAs) must be resolved before multiple cohort cases arrive next year. The loan of clinical and/or clerical support to the NHS to find data evidence could prove hugely beneficial, as it was during the Covid pandemic. What additional specific support do the DHSC, NHS and DAs require to provide more timely support?

b. Priority 2 - Ministry of Defence (MoD). An emerging group of victims are military veterans who received infected blood in British Military Hospitals whilst serving in Germany and elsewhere. Noting that these hospitals no longer exist, MoD support is needed to confirm evidence of the medical treatment received.

Recommendation 2: Seek specific NHS and MoD cross-government support to resolve issues with respect to gathering claim evidence.

22. A plan for the future. There is a step change in process complexity and volume coming next year but there has been little IBCA bandwidth available to engage with this up until now; a commonplace comment was “we don’t understand the plan to get there”. A re-focus on effective and integrated planning needs to become IBCA’s priority following their successful operational delivery mission in 2025. The multi-dimensional concurrent nature of what is coming (e.g. complicated eligibility policy, multiple cohorts, a step change in the range of external dependencies, requirement to actively search out evidence, dealing with disputes, new regulations, revisiting existing paid claims, messaging) needs to be addressed as a matter of urgency.

Recommendation 3: Design an integrated plan to prioritise all elements of the service required for each cohort to create the conditions for operational delivery success in 2026.

23. Digital and data delivery. Delivery to date has been based on a largely manual operation with tactical IT tooling, whilst work was progressed to design a bespoke claims system to meet the needs of IBCA users. Whilst this was acceptable for the initial cohort with a pre-existing evidence history and past interim payments, it is not considered scalable by anyone the RT interviewed for all of the future cohorts, where significant policy unknowns, evidence gaps and fraud threats will emerge. Development of a more secure and efficient digital and data platform has been the “biggest brake” to date on delivery scaling. The RT found that the volume of policy and other changes have been “running ahead of the ability of technical build to keep up”, with a period of constantly changing priorities. The RT also heard a lack of clarity across different teams in IBCA on what functionality is being developed and how it will be integrated into a user journey that will retain many human elements, rather than a “faceless” digital claim. Nonetheless substantive progress has been made and there are green shoots of more stable planning. What the IBCA team is asking for most here is stability and certainty in their direction. Four key headlines with a subjective delivery assessment are below:

a. Overall delivery strategy (GREEN/AMBER). The RT believes that the scaled agile test-and-learn approach is the appropriate methodology and this mindset must be sustained across all elements of the service. Starting small and then learning from test cases is essential for each new type of user journey, and the many various circumstances and needs of infected and affected people. Other complex services with early policy gaps like Universal Credit have demonstrated this approach works; see (Universal Credit Programme - Final Lessons Learned) (PDF, 754KB). The RT also assesses that the strategy for which elements of the service are being built in-house, largely by contracted suppliers, bought off the shelf or re-used (e.g. One Login for identity verification) is sound. Opportunities to deploy Artificial Intelligence (AI) to aid efficiency and data analytics are rightly being considered with due care as part of the design and build process, noting extant data quality limitations in historical evidence and ethical considerations. There is a user-centred approach to design, consistent with Government Digital Service (GDS) standards with alternative channels for those who need non-digital options. However, the RT believes that there are key decisions to take around how to develop the service post-registration (i.e. to what extent is it possible to triage and pursue well-evidenced or simpler cases?). This would help to scale volume within each priority group, but may need wider consultation.

b. Current delivery confidence (AMBER). IBCA has recently released the first iteration of a registration service for everyone who intends to submit a claim; see Register. This is a welcome shift in approach to get an indication of the size of the challenge but brings real handling risks in terms of managing expectations. The development of key elements of the new case management system and a high strength identity verification system have, however, taken longer to build than originally envisaged, with the main releases of the new system expected to move through testing between October and December. The GDS is providing critical friend advice, and the service will be subject to the necessary assessment process for public Beta. Feedback to the RT suggests “it will not be feasible to introduce multiple new journeys at the same time as moving onto a new claims platform”. The contextual risk is in finding a sensible delivery path through phasing-in elements of the system across different cohorts. This needs careful management and could benefit from some additional red-team scrutiny. The RT heard that IBCA was already working on mitigations to meet current commitments.

c. Effective mitigations on fraud, error and data security (AMBER). All contributors to this review understand this is an immense challenge. The RT was reassured, however, by the capability being established in IBCA, particularly with regards to fraud and error, including working in partnership with centres of expertise across government, such as the National Crime Agency (NCA). The RT emphasises that this will require very close management and governance oversight, to support decision-making. Further work is required - which is being led by IBCA’s Chief Information Security Officer - to agree “minimum controls required” to scale delivery according to the risk profile of different cohorts. This will be important as the complexity of claims increases in future phases. In particular, the use of third-party agents in claims will be essential. But this also increases vulnerability to abuse, including potential coercion or scamming of people getting compensation, noting many victims have an active social media presence as a result of the long campaign for justice.

d. Resourcing with the right capability and capacity (RED). Recruitment of digital, data and technology skills for key in-house roles has been a struggle, consistent with experience across government, and made harder by the more competitive salaries in HMRC and DWP in the same Newcastle location. Several rounds of failed recruitment have absorbed too much senior time. At the same time, the interim leadership have had to apply for their own roles; this has been a distraction. This highlights the need for urgent management attention. The opening of a Glasgow office is also significant and has the potential to increase opportunities to recruit expert digital and data personnel. There is also more to do to take full advantage of the ministerial decision earlier this year to enable IBCA to procure its own digital and data services and to disaggregate elements which can be progressed faster by new suppliers with access to a wider talent pool. However, the RT is very clear that the priority now is to ensure continuity and resilience in the core supplier delivery and advisory teams. The RT also makes recommendations later in Questions 4 and 6 respectively regarding reinforcing IBCA Board capacity and also on pay flexibility.

Recommendation 4: Provide immediate support and backing to define a viable testing and scaling pathway which incorporates the phased implementation of a more secure digital platform and contingency measures to avoid any loss of delivery momentum.

24. Compelling clear narrative. There is much to be gained from developing a more proactive internal and external narrative that is fully open and transparent; summarised as a requirement for “more engagement and less comms”. A braver externally-facing engagement approach is required if the current community goodwill amongst cohort one is not to be lost. It is, however, acknowledged that there is an accentuated risk of working more in the open, particularly when baseline research from early 2025 shows “a third trust us, a third don’t, a third don’t know”. Investment in intensive outreach and engagement with support groups and societies, who play a vital role in supporting victims and helping to identify and resolve issues, should continue and will be pivotal to deliver further momentum.

Recommendation 5: Develop a compelling narrative that provides clarity and confidence for all stakeholders and reinforce it at every opportunity.

25. Resourcing. There are a large number of specialist personnel that must / should / could be recruited to support the way IBCA needs to evolve going forward. These requirements are covered in detail at Question 6 later, but additional legal and independent finance support is an immediate priority and essential to community confidence and the efficient processing of claims. One of the key lessons from other compensation schemes the RT spoke to was the vital importance of efficient and constructive channels of communication with longstanding legal representatives, whilst managing any adverse behaviours and the commercial incentive structures robustly.

Recommendation 6: Contract now for the legal and financial support required to cope with the incoming parallel multi-cohort demand, with appropriate commercial levers and review points.

Question 1 - Assess IBCA’s current delivery of the Scheme

26. The RT considers that IBCA is on track to deliver its 2025 milestones. These include being operationally established as an independent employer, all registered living infected victims to receive an offer, develop the service for other groups, with first payments before end 2025. The following qualitative RT analysis of current delivery progress is bench-marked against IBCA’s own, CO-agreed, strategic objectives (SO) for the period ending December 2025, but note that the RT concluded it was not helpful to apply a specific Red-Amber-Green rating here.

a. SO1: Everyone who is entitled to compensation is able to claim and gets paid as quickly as possible. Despite ongoing challenges, the RT has a high degree of confidence that IBCA’s 2025 deliverables will be met. It is noted, however, that there will only be a small number of claims relating to ‘payments to the affected’ and ‘all other cohorts open for applications’ paid this year as the first test-and-learn processes settle down for new customer journeys. This is in line with commitments and plans, but there are numerous issues to be resolved going forward into 2026/7.

b. SO2: Protecting the claimant and the taxpayer from fraud & error. This is a complicated area of assessment. The current evidence threshold for approvals for infected, registered cases rests upon pre-existing legacy claim information and a manual identity verification check. Even though IBCA is operating within the Board risk tolerance for the first registered infected cohort, some data gaps and errors have arisen. In brief, the challenge of defining evidence thresholds to a standard ‘on the balance of probability’ and the fraud, error and personal data threats are manifestly greater going forwards.

c. SO3: This is done as seamlessly as possible using information already provided and navigating individuals through the process. Case manager selection, training and support is first class and this is allowing current victim payments to be made in a timely and relatively fuss-free way. External user and support group feedback confirmed that allocating a claims manager for every person going through their compensation journey is a real strength. The RT observed appropriate steps are being taken to support individuals with the emotional impact, and also to build-in second line case checks; this will need to be sustained.

d. SO4: People applying for compensation feel supported throughout the process. The RT reviewed comment logs from people who have experienced the IBCA service and spoke to some representative groups and user consultants about the user experience of the service to date. For example, one person wrote: “thank you for what you have done; I’m in pain every day and your work gives me hope”. Nevertheless, there is more to do to develop quantitative measures for tracking the user experience, both for those who only need to use the service once, and for others who for example may have a later supplementary claim, or appeal, or who take compensation in part as an ongoing regular payment (i.e. an adjusted route) and will remain IBCA customers. It was not in the terms of reference for this review to include a fuller survey of users at this early stage of delivery.

e. SO5: IBCA staff feel enabled to provide a professional and caring service. The RT was deeply impressed by the evident commitment of the many leaders, independent Board members and staff at IBCA who are all driven by a powerful sense of purpose and a genuine feeling of delegated enablement. It was not possible in the time available to be definitive about direct staff engagement with victims, but the sense talking to charities and support groups was that this was overwhelmingly positive.

f. SO6: IBCA will work with partners and other organisations to consider the holistic needs of the community. Initial stakeholder engagement and communications activity in this area has been intensive but there is work to do to develop this objective further, particularly to address community anxiety with regards uncertainty of timing, digital process requirements, and what evidence will be required. The support groups have a critical role to play here and should be consulted widely.

g. SO7: IBCA colleagues consider it to be a great place to work. There is a palpable sense of esprit de corps in Newcastle; the challenge will be to maintain this going forward when both scale and complexity increase rapidly. The RT also notes that during the course of this review, plans to open a second main operational site in Glasgow moved rapidly forward which was viewed as a positive for recruitment and capacity. As the concept of being an independent employer settles down, it will be important to ensure that a “fortress mentality” does not take hold. IBCA will need to maintain a focus on sustaining and maturing a strong culture of service working across multiple sites, at the same time as having to manage a planned accommodation move into a split site solution in Newcastle in the year ahead. Nevertheless, the RT consider that the current leadership team, supplemented by new hires in key roles including HR and estates, are well-placed to navigate and deliver this.

h. SO8: The Infected Blood community trusts IBCA to deliver compensation competently and fairly. Other than the observation at SO4 above and bi-annual IBCA surveys of the community and the wider public, the RT has been unable to corroborate this. If this objective applies to the entire community, the RT suspect this is the weakest area of assessment. It is going to be increasingly important for IBCA to position itself to be able to articulate a clear plan, narrative and deliverable milestones for the future, whilst having flexibility to respond to learning that will only become evident as it begins work on all the different types of eligible claims.

Question 2 - Confirm that IBCA is progressing delivery as quickly as possible

27. For the period up to and including December 2025, the answer is certainly yes, although the rapid momentum experienced to date cannot be sustained into the early part of next year, and will likely actually slow down as new digital processes are juxtaposed with dealing with more complex parallel cohorts. This will require cohort manager capacity to be deployed flexibly.

Question 3 - Outline potential areas for process improvement

28. Programme methodology. Although there are good reasons why IBCA is not subject to oversight by the National Infrastructure and Service Transformation Authority (NISTA), the RT has concerns that only the original set up of the organisation is being managed with sound project delivery principles in mind, such as an effective Programme Management Office (PMO). The RT believes that there are, however, benefits in instigating a more programmatic methodology going forward and this is reflected across the RT recommendations (e.g. published vision statement, sponsor oversight, programme board, benefits realisation, dependency management, key performance indicators etc) noting the multiple cohorts over the coming years and especially with the loss of CO PMO functions. The RT heard that there is “too much in people’s heads and our future strategy needs to be written down”.

Recommendation 7: Determine which Association for Project Management (APM) project delivery principles would enhance productivity.

Recommendation 8: Decide whether, on balance, a meaningful set of CO-sponsored performance measures would be helpful in maintaining robust supervision and support.

29. Lessons identified. The RT cannot confirm if all the internal and external (e.g. Infected Blood Inquiry, Horizon, Windrush, Grenfell) lessons have been identified, captured, deposited and learned. The RT received feedback for example that “more could be done to illustrate what has been learned and incorporated into the scaling of payments to registered infected”. There are routine engagement opportunities with claim stakeholders, MPs and Parliamentary groups and these must continue to grow. The RT commends the importance of finding some independent capacity to capture the learnings and lessons from IBCA across delivery phases, including the outgoing CO programme team, before that insight is lost or fades from memory.

Recommendation 9: Ensure all the on-going internal lessons, and those identified from other government compensation schemes, have been captured by a responsible owner in a live, widely-available database that is updated and used regularly.

Question 4 - Assess IBCA’s internal/external assurance processes (with a focus on independent scrutiny, risk assessment, and monitoring)

Governance and independent scrutiny

30. The clarity of purpose, dedication and supportive culture across a high calibre IBCA Board is a key foundation stone for effective scrutiny today. The Chair was noted by many contributors to have deep expertise and is a champion for IBCA’s independence and the need to do things differently. The RT also observed an effective and challenging Audit and Risk Assurance Committee (ARAC). It is not surprising, however, that with a delivery-first priority these demands have “run ahead of the governance”. IBCA now has a “massive amount of digestion to do to mature governance”. Recruitment of two key advisory sub-panels of the Board to cover clinical expertise and community representatives still needs to be expedited.

31. The Board is still operating in an interim capacity, and the CEO role was out for permanent recruitment at the time of this review; permanent executive HR/finance directors are due to join shortly. The Board currently has some gaps as a result of recent non-executive departures, most notably in digital and data expertise and the Chair of the Remuneration Committee (RemCo); this is unfortunate at this critical time. Other Board skill sets which the RT heard needed reinforcement for the next phase of delivery include experience in scaling operational delivery from start-up to stable, customer-centric outcomes. More intensive use could be made of the non-executive skills and experience outside of Board meetings.

32. Given the volume of work required, it should be open to the Chair to widen the Board membership and/or to recruit in additional specialists to support the ARAC if required. Consideration could also be given to bringing in interim advice/mentoring for the Chair or Board members to provide effective challenge and support for digital ways of working, and the key decisions on service rollout ahead.

33. As transparent decision-making is of particular importance to the community and will be more contested going forwards (e.g. as some ineligible claims will start to be received) it is vital that IBCA has clarity on how decisions are made and by whom. It is recognised that this includes defining more clearly the respective responsibilities of the Chair, Board, CEO and leadership delegations, as well as between IBCA and CO. This would also enable the draft governance framework to be finalised and published. The governance team is currently underpowered, and is part of ongoing recruitment.

34. The RT would reinforce the importance of healthy challenge, which is hard to choreograph when teams must also be empowered to make decisions fast. The RT found a culture that was open to challenge, but with more scope for bringing the outside view in. User consultants have brought real insight. The SLT has benefited from a prior peer review, but lacks regular, external input or red-team capacity, which is best practice for complex programme delivery. Leaders carry an immense responsibility in an unusually emotional context, and will need ready access to external mentoring.

Recommendation 10: Accelerate the resourcing required for a governance reset, including Board capacity and an experienced company secretary.

Recommendation 11: Establish capacity for more robust red team challenge, critical friend support, and SLT mentoring.

Risk assessment

35. At the time of the review, the IBCA Board was in the process of formalising its risk appetite statement. Whilst Board papers and meetings have focused closely on the top risks and issues, there is at this stage an immature top-down and very limited bottom-up process for strategic risk management. There are risk logs and separate reporting via the sponsorship team into CO, but it would be beneficial to focus energy on maturing a live strategic risk report. This will help to target IBCA Board time on the strategic risks, mitigations and decision points and ensure a no-surprises culture for ministers/CO.

36. From interviews, the key strategic risks are assessed to be:

a. Delivery speed and reputational risks. This is linked to community confidence and owned jointly by IBCA and CO, and on which this review focuses. The RT found broad agreement that “about the right level of risk” is being taken to expedite delivery. The CO Accounting Officer has written to set this out transparently to relevant Parliamentary committees^{[footnote 2]} and to note how this will be kept under review; this is to be commended.

b. Fraud, error and data protection risk. Public Sector Fraud Authority (PSFA) observations noted from the experiences of other similar schemes, suggest that a significant proportion of future claims could be fraudulent; it notes that there are circa 80 existing risks that IBCA is currently monitoring. This will need to be a core focus for oversight and monitoring going forward.

c. Financial/fiscal risk. This is owned primarily by HM Treasury but also CO with regards running costs, driven primarily by the lack of robust data on infected and affected people eligible for compensation; initial estimates ranged from 25,000 to 115,000 people. Funding for all eligible compensation claims is absolutely guaranteed by HM Treasury, but the actual volume of claims and pace of delivery across years is significant for the fiscal forecasts. The NAO has qualified the first set of IBCA accounts for 2024/5 on the basis of inadequate information on the future caseload; see (Annual report and accounts 2024 to 2025)(PDF, 5.6MB). It is expected that the new registration process will generate the first meaningful data to begin to narrow this range of uncertainty.

37. Specifically on the fiscal risk, the RT heard that there is not yet a plan to address the NAO’s findings, and to mature the modelling capability and quality assurance to the standards expected of “business critical models” see details at The Aqua Book: guidance on producing quality analysis for government (PDF, 1,045KB) and Quality assurance of models: a guide for audit committees (PDF< 537KB). This work has been handed over from CO as part of the transition, but additional support may be required, for example drawing on the wider analyst community or the Government Actuary’s Department. This capability is essential for IBCA business planning, and for HM Treasury.

Recommendation 12: Develop a live strategic risk register to focus energy on the medium and longer term strategic decisions.

Recommendation 13: Decide how to mature the business critical forecast model and quality assure key assumptions.

External assurance

38. Whilst there is a standard Government Internal Audit Agency (GIAA) first year plan, this did not appear to the RT to be fully fit for purpose, given an immature organisation operating at out of normal tempo/risk and the scale of public expenditure. Without a robust, targeted and timely assurance plan, there is a risk of uncoordinated reviews, which can be a drain on leadership bandwidth and therefore negatively impact on delivery.

39. The ARAC should be empowered to commission a fresh mapping exercise of proportionate and integrated assurance activity, bringing in external second and third line assurance providers as required. This will need to address the needs of all government stakeholders and encompass previously agreed external reviews led by CO, specifically on the arrangements set out by the Permanent Secretary to Select Committees and the wider review of the operation of the compensation scheme required under the primary legislation.

40. The reconstituted Cabinet Office Audit and Risk Committee should receive regular reporting and access to the IBCA ARAC Chair, given IBCA represents the “biggest financial risk” to CO budget planning. A recommended approach here is for the senior CO Chief Financial Officer to be invited to attend the IBCA ARAC.

Recommendation 14: Develop a more coordinated and robust assurance plan against the principal risks.

Recommendation 15: Retain continuity of CO Chief Financial Officer insight and oversight via attendance at the IBCA Audit and Risk Assurance Committee.

Scrutiny of performance

41. There is a strong appetite in IBCA for rounded and robust Board scorecard reporting, which should also form the ‘single version of the data’ for reporting to the CO sponsor team. For example this would likely include forecasting and variance, speed, cases outstanding, accuracy, user experience, complaints and appeals, staff well-being, caseworker productivity etc. This will need to guard against inappropriate target setting for different types of case complexity, but internal KPIs are usually helpful for continuous improvement and driving productivity.

42. Again, the capacity required in IBCA to progress this vital work has been very limited and may risk stalling as the CO programme team steps away. The RT notes that plans are still in early recruitment to grow a business services team. Some of the usual mechanisms for holding an independent body to account in government are also not yet in place (e.g. defined senior responsible owner (SRO) accountabilities, annual approval of the IBCA business plan and letter from the sponsoring Minister to the Chair).

Recommendation 16: Develop a balanced scorecard of key performance measures for transparent reporting to the IBCA Board and CO Sponsor.

Question 5 - Identify any improvements to CO-delivered support

Memorandum of understanding

43. As noted earlier, the CO programme, policy, legal and wider corporate services teams have all given dedicated support to set up IBCA. It is heartening to note that the RT can report few significant concerns in relation to the specific arrangements now in place for IT, commercial, HR, shared services and finance transition. The RT also heard that relationships at senior levels are largely constructive, with goodwill and flexibility very apparent. As in other areas, this is the foundation for past and future progress. A pragmatic decision has been taken to extend HR and recruitment support beyond the agreed transition point, given the volume of ongoing recruitment and time taken to appoint the HR Director.

44. The RT endorses the approach being taken by the CO Chief Operating Officer (COO) to bring together the services being provided by CO post 1 October 2025 into a single memorandum of understanding. Governance, chaired by the COO, is also in place for co-ordination and escalations. Focusing on improvement, there are two main areas the RT have identified to facilitate IBCA independence and speed of delivery, namely delegation and sponsorship.

Cabinet Office delegation and controls

45. Whilst there are excellent senior relationships and strong backing from the CO Permanent Secretary and MCO for appropriate risk-taking to accelerate delivery, The RT heard that the “CO machinery has not yet aligned with the intent”. There is also more work required to build really strong joint partnering relationships and culture.

46. Steps have been taken in respect of the ministerial plan for acceleration to create bespoke delegations, notably with regards allowing IBCA to diversify the provision of contracted digital and related services beyond CO framework providers. Nonetheless, and despite no lack of will on the part of the CO, the RT considers that process decision-making could be more risk-based and agile.

47. The RT repeatedly heard and saw examples of where speed of delivery is “bumping up against the standard controls and is a brake on pace”. Examples of this included decision-making on the office space in Glasgow although this is now progressing well, incremental extensions of digital development contracts with suppliers at the “last minute”, and other low cost approvals (e.g. consultancy spend) which all still require ministerial approval.

48. The RT notes that the CO could be more strategic regarding which controls really matter, and so design more agile governance; this should be easier now with an experienced commercial lead now established in IBCA to get a grip on the pipeline. Consideration should be given to releasing lower threshold and individual cost controls within the overall authority delegated to the IBCA CEO for expenditure up to £15 million, holding the IBCA Chair and CEO to account via the business planning and sponsorship arrangements. This should also free up more bandwidth to plan ahead and coordinate advice with CO for those significant choices which do require a ministerial policy decision and to address blockers and barriers to delivery.

Recommendation 17: Introduce a bolder and more agile approach to CO decision-making approvals and release the burden of lower threshold cost controls.

Cabinet Office sponsorship

49. Throughout the review, the RT heard feedback that CO was not by culture or experience an operational department and lacked some of the skill set required to be the “enabler and assurer of last resort”. Whilst passionate individuals have gone the extra mile, the sponsor function has been built out of an extremely busy policy team. The lead sponsor is described as “a potential game-changer role” to ease the transition from an experienced CO programme team, and to drive exceptional partnership working between IBCA and government. The RT understands this has to be balanced against the difficult backdrop of CO restructuring and downsizing.

50. From the RT perspective, there is also a lack of alignment on what independence means across CO, IBCA Board, and potentially also with what matters most to the community. From the RT’s limited window via this review, the RT assumption is that it matters hugely that IBCA is led by an independent-minded Board and leadership team, with full operational autonomy to decide each individual case in line with legal provisions and the flexibility to organise its operating model within an agreed budget. Independence does not, however, in the RT’s view preclude continued use of back office services and government / external sources of expertise; and the RT would encourage this as it will support safer and faster delivery. Ministers of course retain overall accountability for the policy and for delivery progress, whilst the CO Accounting Officer retains the usual responsibilities to Parliament for the systems of control concerning public expenditure as set out in the Framework Document (PDF, 363KB)].

Recommendation 18: Review the required skill set for an empowered and experienced sponsor in this specific operating environment.

Recommendation 19: Continue to reach-back into CO and wider government back office services and centres of expertise where this does not impact on operational or decision making independence.

Question 6 - Assess IBCA’s current and future resource requirements

51. To date there has been a huge amount of senior bandwidth expended on recruitment and dynamic organisational design, reflecting the need for urgency, and a best-guess estimate on the volume of staff required. Whilst this has been pragmatic for initial start-up, the lack of any accurate demand forecasting is problematic and is addressed elsewhere in this report.

52. Despite the huge uplift in numbers to date (i.e. circa 30 to 385 in less than a year), the quality and sustained ability to recruit to this standard of operational staff is not causing any concerns. The RT heard this success reflects the fact that people want to come and work on the mission, allied with a flexible reward and recognition package, albeit still subject to public sector recruitment practices and pay approvals through HM Treasury business cases. Some of the supporting functions for operational delivery are still growing and need more capacity, including but not limited to quality assurance, safeguarding and psychological support, though the RT heard in good confidence that these key elements are in progress. 

53. The RT also heard that expertise is being contracted in to conduct an operating model review which is timely, as this will need to address feedback such as more customer-first contact handling support may be required to protect the ability of claims managers to work on evidence gathering and decision making.

54. The task of juggling parallel lines of recruitment also becomes more challenging going forwards, as managing a rapid scale-up but then declining organisation moves into sharper focus. Key decisions will be required, for example, on the scale of continuing permanent recruitment versus other resourcing options. Building on what has been done already, the incoming HR Director will need to expedite strategic workforce planning.

55. On the corporate services side, recruitment has been slower, and in some areas as noted earlier, subject to repeated failed recruitment campaigns. Key gaps have included finance (now coming on stream) and digital, data and technology. Many areas have plans to recruit in line with the expected growth in demand (e.g. in the legal team) and numerous required capabilities are covered-off elsewhere in this report. The planned opening later this year of a Glasgow site presents new opportunities, including for access to digital and data or other more scarce skill sets. 

56. There are, however, some key areas that the RT consider are not moving quickly enough to prepare for the incoming bow wave of activity. These include (although there may be others):

a. An empowered deputy CEO to relieve the considerable burden on the incumbent CEO and integrate key delivery elements (e.g. external engagement, digital and data, operational planning, communications and messaging).

b. Operational policy personnel to develop the detailed guidance, training and case learning required for future parallel cohorts, perhaps looking to organisations with experience for secondees or surge support (e.g. DWP).

c. Digital, data and technology specialists where more bespoke digital pay scales and location flexibility will be required.

d. Sufficient strategic planning and project delivery capability (i.e. a resourced PMO) particularly as the CO programme team is stepping away.

e. Additional case managers and operational staff will inevitably be required for high-volume periods but designing in some future flexibility will be key.

57. Although morale is generally strong, the RT heard that some senior and long-standing members of the team are very tired. An IBCA Board focus on well-being, culture and succession planning will remain absolutely critical for staff working in a trauma-informed context, particularly as they start working with more bereaved people and estates. Linked to this, is the key question of how the staff and their achievements are recognised and advocated for in a way that is appropriate given the external environment.

Recommendation 20: Decide which of the resource requirements above must, should or could be actioned with more speed and flexibility on the reward offer to create the conditions for success next year.

Recommendation 21: Empower the incoming HR Director to provide bespoke people reward and recognition strategies, drawing on best practice outside government.

Recommendation 22: Implement comprehensive personnel resilience measures to support a high quality workforce that is going to become increasingly tired.

Question 7 - Offer any reflections/recommendations from wider IB Inquiry findings

Impact of the July 2025 Inquiry Report

58. As noted earlier, a key request to the RT and the Minister from all contributors to this review was the need for policy stability as quickly as possible, recognising the fact that new significant proposals have been accepted from the July Inquiry Additional Report.

59. The IBCA scheme is tariff based, rather than individual settlements negotiated by legal teams (e.g. Horizon) or a broad Secretary of State discretionary power (e.g. Windrush). The RT heard that this puts a premium on getting the policy rules and operational policy as tightly and comprehensively defined as possible to meet Parliament’s intent, as IBCA has absolutely no discretion to pay compensation outside of the legislative provisions. The NAO report referenced earlier drew out a pertinent lesson from other schemes that “small policy changes can lead to big and often unintended delivery impacts”.

60. The changes announced by the Minister following the July Inquiry Report will expand eligibility and increase some tariffs for compensation. The RT noted this is being put into effect by a third set of more straightforward amending regulations imminently, and further regulations will be laid before Parliament in 2026 after consultation. The RT were told that when aggregated up, the new policy regulations could require up to 70% of core compensation claims already paid by IBCA to be revisited, and double-handling of many cases determined from now until those final regulations are in place. This is a further pressure in the IBCA sequencing and prioritisation decisions and confirms that one of the most important levers to de-risk delivery is to reach policy stability as soon as possible.

61. A related plea to the RT was to test whether the timetable for laying the fourth set of regulations, which must be informed by consultation and engagement with the community and representative groups, could go any faster. The RT is satisfied that given the way the legislation is set up under the Victims and Prisoners Act 2024 which requires affirmative legislation and Parliamentary debate for any changes, no further shortcuts would be feasible; indeed the RT agree this would be risky. The RT heard that achieving the fastest path to lay those final regulations in 2026 may require ministerial advocacy to the Parliamentary authorities, to expedite each of the required stages.

62. The RT considers that there is scope for more systematic and ongoing two-way communication between CO policy, legal and IBCA as the consultation proceeds and to ensure ongoing policy advice to the Minister reflects all the delivery trade-offs. The RT was reassured to hear that plans are in place for CO legal and policy teams to retain additional resourcing for the weight of case-work queries that will subsequently need to be worked through for future cohorts during 2026/7.

63. Given the variety of lived experience of victims and their families, and the learning that comes from operational delivery, it is inevitable that some further adjustments within a settled framework will be required. As an example, the original regulations specify that an application should be on a form, which is not aligned with how the digital service is being developed and some unusual scenarios have already been identified for which the regulations are being corrected.

Recommendation 23: Review systems and ways of working for continuous feedback loops between CO and IBCA operational, policy and legal teams for the next phase of delivery.

Infected Blood Support Schemes Transition

64. The RT also looked at the implication of the change proposed by IBCA and accepted in July 2025 by the MCO, to defer the transfer of ongoing regular payments from the predecessor schemes known as the Infected Blood Support Schemes (IBSS) across the four nations by one year to early 2027. IBCA has been consistent and clear in its advice on the operational difficulties of setting a specific date in legislation.

65. All those involved with existing IBSS services expressed a strong appetite for much more dialogue and engagement at operational level to make “more explicit common cause”. To date, the review found that stakeholders had felt “blindsided” by changing decisions. The RT heard there are gaps and a lack of joined up formal governance between regular CO policy level discussions with DHSC/DAs and separate operational working group arrangements with IBCA and the respective delivery bodies.

66. Just under half of the infected people who have completed their claim to date and accepted an offer of compensation from IBCA have chosen to retain a support payment. People will rely on this source of regular income and have a baseline expectation already on their legacy service, so smooth transition and communication will be vital. The RT heard that key decisions are needed early in the next six months including whether any IBSS staff transfer over to work for IBCA and to scope and build new elements of the digital and live service. IBSS staff have built up an immensely useful knowledge base, including by developing processes for making interim payments to victims and their families/estates as directed by the Inquiry, and most importantly hold relationships with individuals.

67. To date there has been a small ‘discovery’ exercise, identifying issues such as differing payment schedules but little obvious progress. The window to get detailed plans coordinated, agreed and tested will quickly pass without an uplift of capability. In the RT’s view, this will require a focussed senior governance sprint with supporting dedicated project delivery capacity to run a joint workstream between IBCA, CO, DHSC and the DAs’ schemes; and user input will be crucial.

Recommendation 24: Establish a joint IBCA/CO/DHSC workstream for IBSS transfer to include a dedicated project manager, senior cross-nation governance, regular ministerial focus and user input.

Acknowledgements

68.The RT would like to thank everyone who has given their time and candid views freely, and often on more than one occasion, to support this review. The RT remains in awe at the passion and dedication of all those it met in public service, and would like to pay tribute to all the victims, families and support groups who have worked tirelessly to understand and begin to address the lessons from this terrible scandal.

Annex A: Terms of reference

Background

A1. The Government is committed to paying compensation to the victims of the infected blood scandal quickly and effectively. IBCA are the arms-length-body which was established to deliver the Infected Blood Compensation Scheme (the Scheme) in order to meet this commitment.

A2. The Cabinet Office (CO) and IBCA have recently discussed and agreed a package of measures to increase the risk appetite of both organisations to accelerate the delivery of the Scheme. This included delaying the transfer of Infected Blood Support Scheme (IBSS) payments to IBCA for a calendar year (until January 2027) to enable IBCA to focus on meeting new commitments of:

a. All registered living infected to be paid or receive an offer by the end of 2025;

b. Payments are started to unregistered living infected as soon as possible;

c. Payments to the affected start by the end of 2025; and

d. All other cohorts open for applications by the end of 2025.

A3. The Minister for Cabinet Office (MCO) has requested that a review into IBCA’s services and delivery of the Scheme takes place as a condition of agreeing to the IBSS transfer delay. MCO has also expressed the need for external assurance that IBCA is delivering to the best of its ability to expedite payments and deliver the Scheme as swiftly as possible.

A4. Further to this, as a condition of gaining HM Treasury’s agreement on the package of measures increasing IBCA and CO’s risk appetite, HMT asked that IBCA work with CO and the National Infrastructure and Service Transformation Authority (NISTA) to assess IBCA’s assurance processes, which will be included in this review.

Purpose

A5. The purpose of the review is to support successful delivery by assessing IBCA’s delivery of the Scheme, identifying potential areas for process improvement, and providing independent confirmation that IBCA is progressing delivery as quickly as possible to meet recently agreed commitments (as outlined at paragraph 2).

Scope

A6. The review will provide an assessment of IBCA’s delivery of the Scheme and outline potential process improvements in order to further accelerate payments to victims of the infected blood scandal.

A7. The review will also assess IBCA’s assurance processes, with a focus on independent scrutiny, risk assessment and monitoring, in order to cover the condition from HM Treasury.

A8. The review should also look at the services the Cabinet Office provides to IBCA (in absence of IBCA’s own resources to provide these) including HR, commercial procurement and finance, and outline any improvements for how these are delivered.

A9. The review should take into account the current and future resource IBCA has / will have in terms of its capability for delivery. It should be conducted in a manner that minimises the burden on IBCA’s current capacity and does not disrupt the progress they are already making towards delivering the Scheme.

A10. The Infected Blood Inquiry published a further report on the adequacy and timeliness of the delivery of compensation on 9 July 2025. The review should consider any reflections or recommendations from the Inquiry and ensure they are accounted for and reflected in its outcome and following advice to MCO.

A11. The IBCA Framework Document1 sets out the relationship between the Cabinet Office and IBCA and is agreed by HMT. The outcome/s of this review should remain cognisant and not jeopardise the agreement or expectations set out in the Framework Document, including but not limited to the commitment that payments to the affected begin in 2025 and on the expected spend profile: whereby ‘the bulk of payments to the infected are completed no later than 2027, and the bulk of payments to the affected are completed no later than 2029.’

A12. The Infected Blood Compensation Scheme Regulations 2025 (85) require the Minister for the Cabinet Office, or Secretary of State, to undertake a review of the administration of the IBCS by IBCA between 1st April 2026 and 31 March 2027. For avoidance of doubt, the administrative review is out of scope of this review of IBCA’s services and delivery of the Scheme.

Deliverables

A13. The Cabinet Office will develop a Terms of Reference (this document) and programme of work for the review. These will set clear timings and scope for the review, to gain a shared understanding of the work undertaken and requirements.

A14. The objective of this review will be to produce a single report that provides an assessment of IBCA’s delivery of the Scheme, outlining either the potential process improvements for IBCA to take forward or confirmation that IBCA is delivering compensation as quickly as possible.

Responsibilities

A15. The review will be led by an independent reviewer and supported by NISTA to provide the Minister for the Cabinet Office, Principal Accounting Officer and the IBCA Accounting Officer / Chief Executive with assurance of IBCA’s delivery approach.

A16. Final acceptance of the report will be for the Permanent Secretary and the Minister for the Cabinet Office. The report will be shared with IBCA’s Accounting Officer / Chief Executive and IBCA’s Board prior to publication.

Timings

A17. The review should be completed in a short time frame to enable IBCA to maximise the use of any identified process improvements and to prevent the review from negatively impacting their ability to meet commitments (outlined at paragraph 2) for delivering the Scheme.

A18. The terms of reference (this document) and Programme of Work to be agreed by the start of August 2025, by the CO and the lead reviewer.

A19. The review should start in August 2025 and it is anticipated to last 20-25 days.

A20. The draft internal government report is due early October, to be published at a point thereafter in late October when the Minister for Cabinet Office decides.

1. Compensation progress update: 23 October 2025 - IBCA.ORG.UK ↩

2. CO Accounting Officer letter (PDF, 235KB) ↩