Plans to be set out by health minister John Denham this week for the future of health authorities represent a more fundamental rethink of their role than many would have expected - even if, for the time being at least, widely predicted structural changes leading to a big reduction in numbers still appear some way off (news, pages 2-3).
Leadership for Health makes it clear that HAs will retain substantial power over not just primary care groups but primary care trusts and the whole local health economy. It will, for example, be the role of HAs to 'take tough decisions about what really are the priorities, what the evidence says, what can be afforded and what can be delivered'.
They will have to ensure not just that every PCG has the opportunity to develop into a level-four PCT, but also to see that they have the capacity to do it as well. They will need to performance-manage the whole mix of PCGs and PCTs, stimulate change, develop joint support services with other HAs, rethink public consultation exercises, and solve as well as define problems. And, of course, they will 'need to have the courage of their convictions and be prepared to take decisions'.
No wonder the Department of Health says the new strategic leadership agenda is 'perhaps the most demanding ever'. No organisation can be expected to deliver it without real clout. Nor can any HA be expected to cope effectively and give ministers what they want without real resources. And that is where the problems start.
It is all very well to talk about streamlined administrative functions, HAs sharing functions between themselves, realising economies of scale, cutting down paperwork and so on. But having lost so many experienced staff and so muchof their management budget to PCGs, HAs will be hard-pressed to take on a radically new role - particularly if there is to be no central initiative to free up cash by consolidating and merging HAs, and on this point Leadership for Health is reassuringly emphatic. So will there or won't there be more money - and if so, where will it come from?
In the long term it would be a surprise if HA mergers were not back on the agenda. Mr Denham himself makes clear that the document is 'written for the very specific needs of summer 1999'. And when that happens, some people may begin to wonder precisely what regional offices are for. There are interesting times ahead.