Managers grappling with the guidance that hit their desks last week are finding priorities that vary from the broad brush to very fine detail.
On one level, health and social services must develop joint action plans to address 'areas of particular local health inequality', with targets such as reducing unwanted teenage pregnancies.
But at another level, by 2003 the average five-year-old should 'have only one decayed, missing or filled tooth, and 70 per cent should have no caries experience at all'.
The first joint national priorities guidance for health and social services is nothing if not comprehensive.
Together with guidance on implementing the targets through health improvement programmes it fleshes out a hugely ambitious programme.
The two documents outline priorities for the next three years, but ministers insist this is just the start. They want to tackle the 'root causes of ill health', break down barriers between health and social services and provide a measurable level of high-quality services.
Launching the guidance in the London region last week, health minister Baroness Hayman said: 'It is an enormously ambitious agenda but we have always said it is a 10-year programme of change. We know that not everything can be achieved immediately.'
Baroness Hayman's words may not prove much reassurance to health and social services managers. By mid-January next year health authorities, working with local authorities, trusts, primary care groups, patients and service users and NHS staff, must have drawn up their first HImPs and drafted their service and financial frameworks, 'showing that local plans are in place to meet the targets' set out in the guidance.
HImPs go live in April 1999, at the same time as PCGs. HAs must ensure that each PCG, from next year, has 'a rolling annual programme of action covering its three main functions', from cutting health inequalities to commissioning services and developing primary and community care.
And objectives for each national priority in the guidance are to be achieved by the end of 1999-2000, unless specifically excluded.
Some NHS managers believe the guidance is more threatening than ministers will admit. Barry Page, chief executive of the Queen Elizabeth the Queen Mother Hospital in Margate, Kent, welcomes the overall policy. But he adds: 'There is lots of talk about giving people time to develop this on the ground but at the same time we are being given very short deadlines for implementation.
'There are overt threats that if you don't deliver to the time scales then heads - chief executives' heads - will roll.'
Certainly the targets ministers have set for health and social services, from protecting children in local authority care to reducing deaths from cancer, are no wish-list.
Allocations from the£5bn NHS modernisation fund 'will be specifically linked to robust plans and the achievement of targets', the priorities and planning guidance emphasises.
This is minister-speak for the fact that each HA will have to get its HImP approved by the regional office before obtaining confirmation of the local share of the modernisation budget.
Performance against targets outlined in the guidance will be monitored by the NHS Executive or the Social Services Inspectorate.
These bodies will have the power to investigate failing health or local authorities and 'reward' successful organisations with 'additional nonrecurrent funding'.
Baroness Hayman was challenged about the stringent quality management regime last week.
West Kent HA chief executive Ruth Carnall warned against developing a 'blame culture'.
She said: 'Genuine partnership is very difficult to achieve, it implies willingness to sacrifice power and to trade and that is not easy. We are bound to make mistakes.'
Baroness Hayman replied that the process was bound to include some 'discomforts', although she did recognise people would make mistakes. 'We do want to encourage sharing experiences, unsuccessful as well as successful. But that does not mean there are no boundaries. We cannot exist in a system where there are no bottom lines.'
Strict assessment also risks creating a barrier to joint working unless it is integrated across the players, managers warned.
Mark Outhwaite, chief executive of East Kent HA, said: 'We are trying to implement joined-up action.
Increasingly, what we need is joined up performance management to act as a catalyst for joint working.'
The 'worst-case scenario' would be if, on each priority, health agencies measured progress among themselves and social services did likewise, he said. He called for a ministerial-level 'dedicated team' to lead joint working.
The guidance suggests that ministers are committed to turning joint working into a reality at the level of each authority, at least. Provision should mirror the real-life problems of real people rather than drawing artificial lines in the sand between social and healthcare. HAs may start by consulting their town hall colleagues on the local HImP but eventually legislation will be introduced to create 'a statutory duty of partnership'.
In the immediate future, health and social services will have to work together on the 10 national priorities the document outlines.
Joint working will focus on the three 'shared lead' areas: cutting health inequalities, promoting independence and improving mental health.
Health and local authorities will have to develop programmes to reduce teenage pregnancies and make services accessible to socially excluded, deprived or ethnic minority groups.
Joint working also covers public health targets in the Our Healthier Nation green paper, from reducing the rate of accidents to reducing smoking and drug use. Inter- agency strategies for implementing the forthcoming national service framework for mental health within HImPs are another priority.
The final shared lead, promoting independence, involves both departments reducing unplanned hospital admissions among the over-75 age group, developing preventive services for adults and providing support for carers, such as respite care.
Health organisations w ill drive efforts on cutting waiting lists and times, developing primary care and reducing deaths and numbers of cases of cancer and coronary heart disease.
Social services will lead on children's welfare, inter-agency working with young offenders and children at risk of social exclusion, and using existing regulations to protect children in care or adults in registered homes.
Many managers welcome the overall thrust of the guidance, despite their concerns. But one points out that the modernisation programme could prove even more dangerous to the politicians who dreamed it up.
Peter Coe, chief executive of East London and the City HA, describes the package as 'a very powerful tool' for 'the clarification of despair'.
Children with learning difficulties, for example, would no longer fall into the gap between different services. 'We will demonstrate exclusion as never before.'
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