This edited book is the outcome of a symposium at the Royal Society of Medicine in December 1998. It aims to 'decant the theories and practical experiences involved in developing, implementing and monitoring health improvement programmes'. The symposium was supported by Merton, Sutton and Wandsworth health authority. The book covers the implications of HImPs for general practice, clinical behaviour, quality and standards, performance, technology, substance misuse, ethnic-minority health, children, older people, and mental health. Most are to varying degrees insightful, if rather short.
So what does the book tell us about HImPs? The first paragraph makes a good start. It notes: 'Air pollution, low income, unemployment and poor housing. . . are at least as important as individual lifestyle factors. 'The focus of this book, however, is not the social, economic or environmental determinants of health, but mostly the role of the NHS.
In the wider view, HImPs might well augur the final move from the competitive era of NHS management and dominance of the 'medical model' to the sunny uplands of partnership and participation, and a more holistic view of health. But hold on a minute. I suspect for most of the contributors the fundamental developmental criterion for HImPs is defined by the ability of managers to deliver, or as one put it, 'the ability to quantify and measure the process and its outcome'.
Even if HImPs are primarily concerned with redirecting NHS services towards a stronger model of population health and sharpening the quality of delivery, HImPs will still have a valuable role to play. If the agenda for the NHS can be understood, it is not made clear why local authorities would want to follow an NHS-defined health improvement agenda.
Stevens and Bickler, in their chapter, point to the dangers of 'partnership fatigue'and emphasise the need to develop a knowledge base that can encompass different traditions of evidence collection. Leon Polnay points out in his thoughtful chapter on child health that collaboration involving multiple agencies can easily founder due to lack of leadership, arguments over cost, and a lack of policy continuity.
If this book pays insufficient attention to matters beyond the NHS it may be because so few of the writers come from outside it. If HImPs are going to energise all the different stakeholders, more attention must be given to their point of view and to their different perceptions of health. This point also applies to public participation.
Several contributors stress its importance and introduce the term 'citizens'. But the NHS is unused to seeing the local population as citizens and the number of people in any HA area who have even heard of a HImP is probably less than the local NHS workforce. If HImPs are to capture the public imagination they must operate with a radically different language.
While some contributors move beyond the confines of the NHS, the bigger picture or how it is joined to a discussion on the determinants of health does not get the emphasis it deserves.
Geof Rayner Chair UK Public Health Association.