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An HA in an apparently affluent area is showing how co-operation is the key to a successful health improvement programme. Pat Healy reports

The leafy outer London health authority of Kingston and Richmond seems unlikely as a place where a health improvement programme focusing - as the government requires - on inequalities and social exclusion can flourish.

Home, for part of the year at any rate, to celebrities such as Mick Jagger and Jimmy Tarbuck, even its annual public health report admits the area is affluent, with a healthier population than average and lower death rates from the most common diseases.

The point is driven home by the fact that the HA population has a high rate of breast cancer, a disease more commonly experienced by the better off.

Yet the area can lay claim to some of the more imaginative uses of local authority services by the NHS, extending beyond

simply collaborating with social services.

And the HA is co-operating in a bid by one of the two local councils to become the first area to ditch a separate community care plan in order to combine it with its next HImP.

Public health director Dr Carole Martin says: 'We have worked with local authorities in the past, but there was much less involvement of the top echelons. It has brought on everybody from the very top.'

For example, the chief executives of the HA and of Kingston and Richmond councils meet about every six weeks to discuss implementation of The New NHS white paper, including the HImP.

To back that up, a health co-ordinator has been appointed by Kingston council, and Richmond is expected to follow suit.

Dr Martin's deputy, Houda Al Sharifi, has just spent a year seconded to Kingston council to ensure that every local authority department has a health agenda. She is about to do the same task at Richmond.

On the ground, Kingston's trading standards officers have been drawn into the aim of reducing overall health inequalities. If they seize illegal tapes, they are no longer destroyed but converted into talking books for the blind.

The trading standards staff also work closely with public health on anti- smoking campaigns, cracking down on shops selling cigarettes to under- age children.

And the partners involved in working on the HImP include primary care groups, trusts, community health councils, and voluntary and private sector bodies, including a training and enterprise council and the water company.

This is happening partly because of what Dr Martin calls the 'coherence' of the government's strategy to encourage partnerships and partly because of two key events.

Dr Martin focused on inequalities in her 1998 report, to address the basic themes of HImPs. From that emerged the fact that in the midst of the affluence, there are pockets of poverty with people isolated from mainstream life and with limited access to health

services.

The report clearly identifies Norbiton in Kingston as the most deprived electoral ward in the HA district (see box). Its residents can expect to live seven years less than people in the rest of the district. They have one of the highest rates of deaths from respiratory disease, and twice the average proportion of lone-parent families.

The second catalyst was the appointment of Norbiton councillor Julie Reay as chair of the HA. She brought with her a history of working in local government partnerships.

She was delighted at Dr Martin's report because it produced the hard evidence to argue on the need for health action plans. Ms Reay describes Norbiton as being in a bit of a time warp, although she insists that most local people are just ordinary folk who have never had any breaks.

But the isolation and lack of community networks mean that if a GP offers an appointment some days ahead, it will not be kept because 'next Thursday is somewhere in the future to them'. Most do not use health services until they are seriously ill.

And it doesn't help that they live 'cheek by jowl with extreme affluence' next to the Coombe ward, which is home to television and music industry stars.

Ms Reay says she experienced a different kind of culture shock when she went to the HA and discovered how little went on in the way of public consultation.

One of her first acts as HA chair was to introduce a public question time at board meetings. Some board members were 'very nervous' about this, which she attributes to the different cultures of health and local authorities.

'Councillors have to go out and meet people because they have to be re- elected,' she points out. 'Because HA board members are appointed, they don't need to do the same and the HA has been seen as a bit of an ivory tower.'

Dr Martin admits that a health authority consultation usually concerns not the actual decision to close a hospital, but how it is to be done.

And she accepts that local government is much better at handling public involvement.

This is an important skill when the HImP makes public participation a key area for urgent action. She says: 'For health improvement actions to be effective, they have to be owned by the public.'

So far, there have been two public seminars on the HImP, at which a common theme has been concern with the impact on air pollution of transport and environment policies.

But while people think there are too many cars on the road, few are willing to give up their own.

Which means that the partners working on the HImP need to be wary of populism, says Ms Reay. Health service managers and professionals can be 'way ahead' of the public, particularly in assessing long-term needs.

Winning public acceptance is an uphill climb. Dr Martin says people are 'cynical because they have heard it all before. They think consultations are meaningless because they have been consulted on a very narrow base before.'

This is another reason for Dr Martin's determination that Kingston and Richmond should be given the freedom to develop its HImP in a way that is relevant to local people and is not overly prescribed by guidance.

At one of the public seminars the phrase was coined: 'Keep it focused. Keep it local.'