On Friday and Saturday nights, Birmingham sees a vast influx of young people into the thriving clubs and pubs of the redeveloped city centre.

These young people were responsible for a sizeable chunk of the 9,344 'accident' admissions to Birmingham hospitals last year.

The green paper definition of an accident is an event which requires a visit to a GP or hospital. It is not a definition which finds universal favour (see box).

But if such events are to be cut by one fifth, as Our Healthier Nation proposes, there will need to be a degree of social engineering - or more people will have to tend their own wounds.

'We have a vast amount of work on Friday and Saturday nights as a result of fights involving beer glasses,' says Andrew Hobart, specialist accident and emergency registrar at Birmingham City Hospital.

'The other problem is that, after 10 o'clock at night, more than 75 per cent of the injured have had a significant amount of alcohol. That's not just fights or road accidents, and it's not just adults. It's very young children in some cases.

'As an inner-city A&E, we get a lot of stabbings, shootings and injuries related to crime - especially drug dealing. When one person gets upset with another drug dealer it's usually settled by violence.'

Birmingham's health action zone bid hopes to reduce childhood accidents, the city's second biggest cause of hospital admissions and readmissions.

The City Hospital has a system of follow-up for children under six who present at A&E. The health visitor makes a visit to the child's home and offers advice on what would stop a repeat incident.

But for the green paper targets to produce tangible results 12 years hence, clinicians and managers agree that making people rely less on the NHS will require coercion as part of the government's side of the 'contract for health'.

Semira Manaseki, senior registrar in public health at Birmingham health authority, says co-operation across all agencies is vital if there is to be a cut in accident rates.

'We feel the green paper is a good development of The Health of the Nation. It is not too prescriptive and allows us to do our own things. We are working with other agencies on prevention,' she says.

'But unless the white paper comes up with some prescriptive element, it presupposes goodwill on both sides. The trouble is that local authorities are busy with their own work.

'Almost every department of a local authority has an impact on health. There is no way we can deliver without getting all of them together on this.'

Dr Manaseki says the HA has worked with the city council on practical measures - expanding traffic calming, for example. And extending the city metro system to Wolverhampton will go some way to cutting car use.

The fact that the two authorities are coterminous is a help in getting a focus on accident prevention in schools and at work, she says.

Commissioning GPs in Primary Care Act pilots are hoping to cut accidents among elderly people. In Small Heath and Selly Oak, GPs and health visitors are targeting accidents in the home.

Patients can be referred to a specialist nurse based at Selly Oak Hospital, who carries out a home visit to see what could be done to cut the risk.

Using Department of Health winter pressures money, a nurse response team, which can be called out by a GP or by A&E staff, has been set up to target those who could stay at home with a little extra care and support.

Dr Manaseki hopes the service could become permanent. 'We have a big inner-city deprived population with lots of people who are more prone to injury or accident but could be looked after at home.'

She says simple things such as chiropody can help. 'Healthy feet prevent falls. Keeping people fitter and healthier reduces their risk of accidents. Diet is also important. It is vital for primary care staff to recognise risk.'

The Birmingham-based Royal Society for the Prevention of Accidents is enthusiastic about the proposals. 'We welcome the green paper because it builds on what was said in The Health of the Nation.'

RoSPA wants a 'home safety act' to complement road safety legislation. And it says many car accidents are simply logged as that when in fact they are work related.

'We would want to see some legislation for companies and staff to take responsibility when jobs involve driving.'

But a trawl of other agencies in Birmingham to find out what approach they are taking to the green paper produces a less optimistic picture.

At West Midlands Constabulary, a spokesman admits to not having heard of the green paper, its contract for health or multi-agency approaches to cutting accidents.

'Why are you contacting us?' Because the police are one of the agencies that might have a role in accident reduction. 'Er, no. Sorry, I can't help you.'

But police inspector Andy Crowson, who works in the city centre, thinks the HAZ bid and the sentiments of the green paper are useful. He agrees a unified approach is vital.

'Better public transport, traffic calming and pedestrianisation can only cut accident rates,' he says. 'A lot of pubs and clubs employ excellent bouncers, which can cut down on the problems.'

Despite the commendable talk of partnership at Birmingham city council, calls to social services and to the department dealing with health education and accident prevention demonstrate the extent of the problem.

'You are best to talk to the health authority,' says a spokesman.

In the third of a four-part series on the public health green paper, Mark Gould reports on accidents