Health authorities can have a key strategic role in the new NHS - but only if they earn it. Lyn Whitfield reports

Health authority managers have an agenda 'to die for' in the current NHS reforms. Yet up and down the country people are describing them as 'yesterday's men'.

So are they going to be the 'strategic leaders' of the new NHS, or relics of the 'male and macho' days of the internal market?

The question was posed by Geoff Meads, professor of health services development at London's City University, at a conference on the changing roles of HAs.

'Wherever I go, I am struck by the contrast between what the government says about HAs and the reality,' he said.

'I am also struck by the contrast between what the headline chapter in the white paper says about HAs and the rest of the text, which makes them sound much less strong.

'Personally, I am sure HAs will be absolutely fundamental to the successful development of primary care. But HAs are going to lose some of their functions, and it will be important for them to be developed in other ways.'

Ken Jarrold, chief executive of County Durham HA and former NHS human resources director, said HAs would have a key role if they earned it.

'You will not get a leadership role because the secretary of state says you have one,' he said. 'In fact, that might not help you at all. You have to go and win one.'

Mr Jarrold told the conference he felt 'very comfortable' with the white and green papers but was worried 'the whole political process is getting hold of the reforms' and 'we are going too fast'.

He backed concerns about the practicalities of setting up primary care groups, voiced by the Healthcare Financial Manage-ment Association after a survey carried out with HSJ last month, and also called for the NHS to be 'really, properly funded'.

'All this government has done is to put funding for the NHS back on an even keel,' he pointed out. 'For all Tony Blair has said, he is only spending what Churchill or Eden spent.'

Turning back to HAs, Mr Jarrold 'welcomed' PCGs as 'a political solution to fundholding' that maintained the involvement of GPs in commissioning.

But he saw the move away from practice-based commissioning as a disadvantage and asked where the incentives were in the new system for GPs to control their budgets 'if some crap practice down the road does nothing'. He also saw tensions between HAs and PCGs as 'inevitable' and urged managers to be 'honest' with the new groups about the constraints they faced.

'They are not going to be given pounds 50,000 to do what they want with,' he said. 'They are going to be working within a national system.

'For example, I have my own views on the waiting list initiative, but it is a national priority and we must meet it. We must be honest and tell PCGs they must work within a hierarchy of demands.'

Mr Jarrold also said HAs would have to reassess their relationships with trusts, respecting their 'devolved management'.

And he argued they would have to 'rebuild' relationships with local authorities that had lost their hospitals, ambulance services and influence in successive waves of NHS reforms.

In his concluding talk, Professor Meads argued 'strong' HAs were needed to 'champion' the 'profound systemic change' represented by the latest reforms.

'The change will be easier in Wales, because everybody kept hoping old Labour would come back in, and in Scotland, because it never really engaged with the Tory agenda,' he said.

'England is lumbered with having moved from a practice model to a managed model for commissioning (fundholding), but the practice is still sovereign.

'It is going to be difficult to untangle that and move towards a model with a population focus.'

Professor Meads also argued that 'sophisticated ideas about primary care commissioning' had 'outstripped' what was being done on the ground.

HAs, he said, would be needed to help primary care professionals make the transition from being 'primary medical providers' to 'primary healthcare providers'.

'We need to look after HAs. They are the guardians of the healthcare process,' Professor Meads concluded.