opinion: THINK TANK

Public health minister Tessa Jowell had to launch two major initiatives in the same week recently. First, it was teenage pregnancy: a drive to improve sex education and access to contraception. Two days later, it was time to announce the ban on tobacco advertising. All consistent with the government's joined-up public health policy - except for the promotional material. On the second launch, Ms Jowell found herself promoting a T- shirt emblazoned with 'Leave the pack at home!' Ideal for one campaign, the minister quipped, but not for the other.

Joining up policy-making is never easy. Joining up practice will always be harder. The phrase has become so over-worked, I worry that the Conservatives will enter the next election promising to reverse the trend: 'What this country needs is clear demarcation lines! Each department for itself! Separate budgets!'

But for all the frustrations and complications that joining up produces, I cannot imagine anyone wanting to abandon the attempt. Trying and failing - or perhaps half-succeeding - is surely better than not trying at all.

The main vehicle for joining up health policy and practice is, of course, the health improvement programme. Health authorities have a statutory duty of partnership, obliging them to work with other NHS bodies and with local authorities, which in turn have clear powers to develop partnerships with a wide range of other organisations, including NHS bodies, to address the needs of local communities. HImPs are supposed to encourage innovative cross-sectoral working, including pooled budgets and integrated provision. Each HImP is expected to assess local needs, map resources, identify priorities for action and develop strategies for change.

The future success of integration in health could depend quite heavily on how well HImPs work in practice. Will they be a tiresome and vacuous gesture or a meaningful and productive instrument for change? It is too early to tell. But research published next week will shed some light on the problems and possibilities that lie ahead.1

The study focuses on the first round of HImPs in London and on the contributions of HAs, local councils and primary care groups. It explores the different players' perceptions of HImPs, how they have experienced partnership so far, their approaches to priority-setting and HAs, and what they have done to involve the public and render themselves accountable.

The good news is that all the players express enthusiasm about the initiative and are glad of the opportunity to work together. But HAs, which are leading the process, will need to ensure that their partners really do feel they share ownership. Local authorities are already overwhelmed with new obligations to work in different ways and achieve fresh objectives. PCGs are preoccupied with their own genesis and are in no position yet to make a significant contribution.

It is not easy to move resources to reflect the shift in emphasis from healthcare to health improvement. One local authority interviewee asked: will the HImP really influence spending on medical services? That's a vital question, and quite beyond the borough's influence.

Pooling or transferring budgets between health and social services may be on the cards, but it remains almost impossible to find new money for other local authority services which might be deployed for health improvement. For example, two of the boroughs want to make better use of their leisure services to help reduce coronary heart disease, as part of the local HImP, but they cannot get access to health funds to pay for them.

Partly the trouble is a lack of established ways to measure local authorities' contributions to health improvement. Before money earmarked for health can legitimately be redirected, clear evidence is needed that other services, such as gyms and swimming pools, are delivering appropriate results. So although integration is the name of the game, it is unlikely to be achieved, paradoxically, without distinctive indicators to show how the different players are performing.

PCGs in the study see HImPs as an opportunity to improve their service quality. As one interviewee put it, clinical governance and health improvement are the same. Like the boroughs, PCGs feel the need for clear, measurable outputs. But this presents two dangers: HImPs could become too narrowly focused on clinical issues which can be readily understood by doctors; or they could just be a tool for top-down performance management. In any event, it is not going to be easy to persuade GPs to function differently, especially if contributing to a HImP is simply seen as more work.

The fact that doctors dominate most PCG boards makes it harder for other team members, who may be more attuned to the public health agenda, to exert influence. No one has yet worked out how to give local people, especially marginalised groups, an effective voice in developing HImPs. The study points to the problem of user fatigue and suggests that responsibility for public involvement should rest with one partner, probably the local authority. It also suggests that the role of local councillors could be developed, to bring them up to speed on public health issues and make them more effective lay representatives, working closely with PCG boards.

Local partnerships will have to build on the lessons of the first year, and it will be some time before they are working smoothly. Despite genuine enthusiasm for joined-up working, cultural barriers endure. As one PCG member said of the local authority: you think you are using the same language, but you are not. It's like talking to Americans.


1 Arora A, Davis A, Thompson S. Developing Health Improvement Programmes: learning from the first year. King's Fund.

Anna Coote is director of the King's Fund public health programme.