Development of health improvement programmes could be hampered by pressure on health authority management costs, a study by Birmingham University's health services management centre has warned.

The study of seven HImPs found HAs had tried to involve a wide range of stakeholders.

But the 'embryonic' state of primary care groups - and 'the tight timetable imposed on the development of HImPs' - limited the 'depth' of their involvement.

The report says 'behaviour is already changing to meet the deficiencies identified during the first HImP development process'.

But it argues 'the pace of change within the NHS family, and particularly the wide variation in preparedness and enthusiasm among PCGs' will force HAs to 'run multiple approaches' for their 'mixed-ability classes'.

'Such multi-tasking is going to become more difficult as HAs find their resources and workforce squeezed by pressure on management costs, and this must raise issues of HA capacity to deal with the new agenda.'

The authors argue that 'aggregation' of HAs may take place to 'provide economies of scale', or boundaries between HAs and local authorities may blur 'to allow more efficient use of scarce resources.'

Jonathan Shapiro, co-author of the unpublished report due to be discussed at a conference today, said there was widespread support for HImPs in principle 'and because of that they were willing to be very forgiving of problems in the first year'.

In most areas, the 'stewardship' of the HImP process was provided by the public health director.

The report says this made sense because they had a 'holistic view of health'.

But it identifies a potential tension between public health directors and other HA directors.

'For the former, the HImP offered a way into health improvement, while for the latter, external pressures such as waiting lists, financial balance and activity levels sometimes took priority,' it says.

The report argues that as HImPs 'become more central to the management agenda', control will move to other directors.

It says this could show 'departments of public health are not seen as part of central management arrangements', and suggests their role needs to be reviewed.

The review says there are also 'palpable tensions' between local needs identified in the HImP process and 'nationally imposed imperatives'.

Dr Shapiro said tackling heart disease was an example.

'Heart disease is a national priority. Heart disease is a key issue in the HImPs.

'But one of the areas we looked at had the second lowest incidence of heart disease in the country,' he said.

The report argues that HAs will need to create clear frameworks for the implementation and performance management of HImPs, and involve stakeholders in them.

It also argues that creating 'space' for local and national priorities will be 'a key test' of HImPs and the balance 'will need to extend to funding'.

'In the longer term, the concept of HImPs must be underpinned by some signs of genuine health improvement, or the whole development will have been nothing more than an exercise in futility,' it concludes.