Putting a health improvement programme in place demands consultation with a huge range of organisations. Linda Ewles reports on how the second largest HA in the country set about it

Avon health authority, like all others, first heard of the health improvement programme in December 1997, with the publication of The New NHS white paper. The task was daunting: to produce a three-year rolling programme for improving health and services for health and social care.

As the second largest HA in the country this meant working in partnership with four local authorities, 11 trusts, 12 primary care groups, two community health councils, a huge number of other statutory, voluntary and community organisations, service users and, of course, our local population of 1 million.

Building the HImP partnership

We started in April 1998 by holding a consultation event on the green paper, Our Healthier Nation, attended by local authorities, trusts, CHCs, GPs, universities, voluntary and community groups and others. We presented the green paper in the wider context of NHS changes and the HImP. People were asked for their views on local priorities, and made useful comments on the HImP process.

In May and June 1998, we organised four partnership seminars, one in each of the four local authority areas within our HA boundaries, to share information and discuss the new NHS changes.

These raised points which helped us to develop the HImP. Participants stressed the need to keep it simple; to see the HImP as an inclusive process rather than another plan to be implemented; to take account of priorities in the field as well as those from above; to include early achievable objectives and actions at grassroots level; and to ensure a strong sense of ownership by communities and organisations.

They saw reducing the health gap as a priority. They made practical suggestions which we took up, notably to deal with the HA's annual process of commissioning health services for 1999-2000 separately from the emerging HImP process, and to incorporate information on HImP into communication processes.

Key principles which emerged were:

keeping people fully informed about the HImP and how it was being developed;

fostering joint ownership and responsibility;

developing new communication channels where this was helpful, but avoiding creating new bureaucracies.

A clear challenge also emerged: to ensure that the HImP was user-friendly, useful and manageable.

While waiting for the long-delayed national guidance we continued to involve people. We issued a HImP position paper, setting out the purpose and function of the HImP, the national guidance that had been issued, roles and responsibilities of the partners involved, plans for developing the HImP, and underpinning values. More than 100 copies were distributed, and helpful comments were fed back.

We also issued a monthly newsletter with information on the HImP, which continued until March 1999. This had circulation of more than 3,000 copies. We set up four area HImP groups in September 1998, one for each local authority population. Membership included the HA, the relevant local authority, trusts and PCGs, and was co-ordinated by an HA working group.

We sought to weave HImP issues into existing local authority mechanisms. This included putting questions on health in citizens' panel surveys, teasing out the health issues in Local Agenda 21 events, and incorporating existing work on regeneration and healthy living centres into HImP plans.

We offered community groups, service user groups, voluntary organisations and parish councils the opportunity of an informal talk on the new NHS changes, with a chance to ask questions and give us their reactions and ideas. More than 50 groups took up this offer.

We sought to harness user involvement - already a well-established part of service planning and delivery in both local authorities and the NHS - as part of the HImP process.

Producing the first HImP

In the early days, we recognised that decisions would have to be made about the level of detail and the form of presentation. We looked at population levels and groups, issues such as health inequalities, health and disease topics, services and policy areas. But in the end, national guidance largely dictated a framework of national and local priorities.1

In late summer 1998, we drafted an outline of the first HImP, and consulted the four area groups, asking each to identify two local priorities to include alongside the national priorities. When the national guidance was finally published in October, we revised our outline, asked 25 contributors to draft sections, and allocated the task of co-ordination to a senior manager.2 Under intense time pressures, we produced a draft in December 1998 for comments from the HA and partner organisations. We sent a revised version to South West region by its mid-January deadline.3

The HImP ended up long and fairly technical, so we also produced 10-page summaries, in plain English, for each of the four local authority areas.3

Next steps

We are developing some aspects of the HImP further, and are also restructuring the HA to respond to the new agenda of PCGs and HImPs. Directorates previously focused on commissioning and primary care are being replaced with a small team of central staff dedicated to planning and monitoring performance, and four directorates focused on working with the four local authorities and the PCGs in each local authority area.

Our HImP process posed many challenges and has given rewards. But it is still only at an early stage of development.


1 Modernising Health and Social Services: national priorities guidance 1999-00 - 2001-02. HSC(98)159: LAC(98)22.

2 Health Improvement Programmes: planning for better health and better health care. HSC 1998/167: LAC(98)23.

3 www.avonhealth.org