The lessons of earlier area-based approaches to health and social welfare should be heeded if health action zones are to avoid past pitfalls, says Joan Higgins

The proposal to establish health action zones, education action zones and employment action zones is part of a long tradition of area-based social programmes in Britain. Although the government has placed them within the context of current economic regeneration projects, the area-based approach goes back much further.

The 1964-70 Labour government, for example, strongly favoured positive discrimination in favour of poor areas and a number of initiatives emerged. The urban programme in 1968 was designed partly in response to Enoch Powell's 'rivers of blood' speech, to address problems of racial inequality and poverty in the inner cities. In the same year, five educational priority areas were identified as 'demonstration projects', with the aim of tackling the educational needs of children in deprived areas. In 1969 the Home Office launched 12 community development projects in 'selected areas of high social need', describing them as 'a modest attempt at action research'. These programmes were informed by the belief that targeted investment in areas of high deprivation would have a beneficial 'ripple effect' for local people well beyond the original investment. A few years later there was the comprehensive community programme, the so-called 'joint approach to social policy' and the inner area studies.

The language, expectations and ambitions of HAZs echo, very strongly, the approach to social engineering reflected in these programmes of the 1960s, and there are many lessons to be learned from that experience.

First, the aims of these earlier programmes were so broad that there were many (often conflicting) perceptions of what was intended. While local agencies benefited from this vagueness at first, their imaginative attempts to develop local solutions later fell foul of civil servants at the centre who had begun to shift their expectations. HAZs face the same danger.

The lack of a government blueprint may be positively stimulating to local initiative and 'dynamism' but, as the zones are held to account against tough targets, tensions are likely to emerge. It is essential that developing policies, practices and priority setting becomes a mutual process between the zones and the Department of Health. Performance management criteria should also be debated fully so that the zones are tested against realistic targets linked to local needs. The relevant Executive letter's reference to 'agreed milestones' does suggest there will be this sort of dialogue before criteria are imposed.

Second, the EL's emphasis on 'partnership' needs more thought. There appear to be six kinds of partnership, between different public agencies; the statutory sector and the voluntary sector; the public and private sectors; the HAZ teams and local people; different HAZs; and HAZs and central government. The different groups within and outside the zones are almost certain to have different aspirations and ambitions for HAZs. While 'partnership' and 'collaboration' seem in principle to be desirable goals, we know that in practice they are rarely realised. Mere exhortations to 'add value through creating synergy between the work of different agencies' will not be enough.

One of the most obvious lessons from the 1960s is that cultural, departmental and organisational differences are not easily overcome. Writing about the urban poverty programmes of the day, Nicholas Deakin commented: 'Nobody has believed sufficiently strongly in the importance of the objective.' Co-ordination and collaboration, he argued, were often 'an administrative opiate' and principles which were 'honoured in the abstract but not seriously attempted in practice, except in a purely ritual sense. Documents emerging from joint exercises are said, with a wink and a nudge, to be 'co-ordinated with a staple'.

1Nothing has fundamentally changed since the 1960s in the relationships between these different interest groups. It is relatively easy to mount a collaborative bid, over a short period of time, to become a 'trailblazer' in the new NHS. Sustaining that level of enthusiasm and commitment over five to seven years is altogether different. Successful HAZs will accept this real issue and address it directly. Inter-agency tensions will not go away just because there is money to oil the wheels.

There are basic differences in style, accountability and approach which are built in to agencies' structures and need resolving. The really powerful zones will create new models of joint working, a genuine 'third way' towards a value-driven and inclusive culture not based on traditional power structures.

A third danger is that HAZs become so absorbed with process and structure they lose sight of their main aims. In the early days there are certain to be local power struggles to achieve dominance over steering groups and local management boards. Since there are no prescribed models of governance and accountability there will be painful battles to achieve leadership. There will be disagreements about 'representativeness' and control. The programmes of the 1960s demonstrated that these disputes could last for years and were a real distraction. There may be a case for central direction, to ensure the debates about management and leadership do not obscure the main aims.

It should not be assumed that additional ear-marked funding will be enough to iron out local difficulties. Debates about the use of joint funds can become a battleground and can stall desired change rather than promote it. Extra funds for HAZs will be welcome pump-priming money. They are unlikely to be enough to eradicate long-standing structural problems of poverty and ill health, so early discussion must focus on how they can make a sustainable and lasting impact.

The fourth issue is that HAZs will echo the 1960s tensions between government's desires to control and centralise and to devolve. HAZs will evolve most imaginatively and appropriately if they are allowed to grow their own solutions around local problems and issues. But it is a high-risk strategy for a government committed to equality and a comprehensive approach to allow such diversity and experimentation. As we have seen with most recent innovations in health policy, the first wave of trailblazers have considerable freedom to innovate, but the controls on subsequent cohorts grow increasingly tight and prescriptive. As the laggards follow the innovators the whole process becomes routine and standard. If the strong emphasis on local solutions in the EL is to be sustained, ministers and civil servants may have to become more 'hands off' than is comfortable.

The final point is about the role of research. Although the programmes of the 1960s were 'action research projects' or 'demonstration projects', the relationships between research and intervention were problematic.

Evaluation was, essentially, an afterthought and not planned from the beginning. There were enormous tensions between the 'action teams', who felt they were being constantly monitored by people who had no responsibility for making complex activities work, and 'research teams', who were frustrated at the lack of tangible measures of success or outputs. These tensions may well be replicated in the HAZs unless steps are taken to resolve them. Adding a research phase after the zones are up and running is asking for trouble and will not capitalise on the potential learning emerging from the early stages of implementation.

It would also make sense to begin the second round of bidding for HAZs after the initial evaluation of the first zones is underway. But political priorities are unlikely to allow for a planned and evidence-based roll-out. If this does prove to be a constraint, it simply underlines the need for researchers to hit the ground running with the HAZ teams on day one.

It will be a real challenge for HAZs to keep the focus on health gain rather than on health service reorganisation. The EL seems ambivalent here. It is rumoured that the zones were originally to be called 'health service action zones' and it is a welcome shift to see the explicit commitment to a person-centred, holistic approach. But while recognising that 'organisational change inevitably diverts energy from the real objectives of improving health', the EL also talks about locating zones in areas where 'the reshaping of services is a significant issue' and in which the modernisation of services will be a high priority. Although some of the areas of greatest deprivation, especially the inner cities, are making good progress on the reconfiguration agenda there is still a great deal to be done to rationalise acute services and improve primary care. HAZs will need to work hard to maintain a sharp and focused commitment to health gain, while other day-today service pressures continue.

Evaluations of the social programmes of the 1960s revealed two particular criticisms: first, that an area-based rather than a people-based approach to tackling deprivation only addressed the needs of a small minority, and second, that 'demonstration projects' created a flurry of activity, at low cost, but had little lasting impact. Cynics concluded that they were essentially a way of avoiding a more fundamental attack on the roots of inequality. There is evidence in the EL that the government has recognised these issues. HAZs are to have a 'national impact'. Their achievements will 'become mainstreamed' and new ways of working will 'become the norm across the country'.

The HAZs that started work on 1 April have an enormous opportunity to make their mark. There is a lot of local enthusiasm about breaking moulds and a real commitment to collaborative working. If the zones can quickly absorb the lessons from the 1960s they can move ahead to an agenda which is genuinely radical and innovative.

Key Points

The government's health action zones are part of a long tradition of area-based social programmes in Britain.

Most have had only marginal success.

The HAZ programme will rely on partnerships between organisations which are difficult to achieve.

The success of HAZs will partly depend on local autonomy which could prove politically risky for a government committed to equality.

REFERENCE

1 Higgins J, Deakin N et al . Government and Urban Poverty: inside the policymaking process . Oxford: Blackwell, 1983.

Joan Higgins is professor of health policy, health services management unit, Manchester University.