Published: 20/06/2002, Volume II2, No.5810 Page 22

While the NHS continues to struggle with the pace of organisational change, its main partner - local government - is also braced for a new throw of the structural dice following the publication of the white paper on regional government.

The paper identifies four levels of government in England - central, regional, local and frontline - and talks of the need 'to ensure that functions are carried out at the appropriate level'. It is not always evident where parts of the NHS fit into this dictum.

The current position is a hotchpotch, with regional development agencies, regional chambers, government offices for the regions and a number of other quangos interacting in a confused and disjointed manner.

The government now proposes to allow the creation of elected regional assemblies with some funding and a limited tax-raising role where there is proven demand for them through a referendum. Among the main aims are decentralisation of power from central government, giving regions freedom and flexibility, making government in the regions more accountable, and ensuring better co-ordinated government at regional level. It is a proposal which has potential significance for the NHS.

One of the corollaries of introducing a regional tier is that a third tier of local government - either at county or district level - is seen as one tier too many. Thus in any region where the government decides that a referendum on an elected assembly should be held, there will first be a review of local government structures which will deliver proposals for a wholly unitary local government structure for the region.Voters in the referendum will be aware of the implications for local government when choosing whether to have an elected regional assembly, and will be effectively taking part in two linked referendums.

In the short term this is already resulting in the sort of local blood letting that characterised the last local government review, as counties and districts vie for supremacy. In the medium term it will probably result in the loss of established NHS partners, the departure of key members of networks and a further round of partnership musical chairs. And in the longer term it will result in a patchwork quilt of arrangements, with unitary local government in those parts of the country with elected assemblies and twotier arrangements in the rest. By the same token, some parts of the country will have an elected assembly and others will not.

A more direct issue for the NHS is the extent to which any new regional assemblies will have a 'health' role. Such bodies will be under a duty to ensure that separate regional strategies are consistent with one another and will be encouraged to produce an 'overarching' strategy setting out their vision for the region.Much of this will have a strong healthrelated dimension.

As part of this duty, an assembly will appoint the regional director ofpublic health as its health adviser in order to strengthen the public health function in the region, a post based in one of the four new directorates of health and social care rather than in the assembly itself.

The vast majority of assemblies' functions will be devolved from central government bodies, yet one of the questions not posed in the white paper is whether some current NHS functions could be located at this level.

Given the unclear relationship between the new strategic health authorities and the four directorates, some devolution of their tasks to an elected assembly is worth exploring.

The white paper seeks to encourage support for regional assemblies by stating that England now includes virtually the only regions within the EU which do not have the choice of some form of democratic regional governance, and it is noted that in such states, regional tiers have played an increasingly important role.

In the paper, the regional arrangements in 11 other countries are described, and what emerges is that in most of them - Austria, Belgium, Canada, Finland, Italy, the Netherlands, Poland and Spain - health is within the responsibility of the regional tier.This is surely the point about having a vibrant regional focus - if there are not real powers over the issues which matter in people's lives, it will be difficult to attract high-calibre members and engage voters.

Bob Hudson is a principal research fellow at Leeds University's Nuffield Institute for Health.