Does the NHS plan deliver on Tony Blair's grand vision for transforming the delivery of public health, or is it just a list of things to do? Lyn Whitfield looks at what it has to offer

Five months and what seems like a lifetime ago, prime minister Tony Blair set five challenges for the NHS at the start of the process leading to the NHS plan.

The fifth dealt with prevention: 'to balance spending on tackling the causes of ill-health with treating illness, to develop a more systematic approach to treating people at risk from chronic disease and persuade more people to play their part in achieving better health by adopting a more healthy lifestyle'.

The result is chapter 13 of the plan: 'Improving health and reducing inequality'.

Sadly, some of the more colourful ideas 'leaked' from the prevention and inequalities modernisation action team have been left out.

There are no calls for people to turn their balconies into miniature vegetable plots and no plans for a programme of health walks - possibly because the idea was pilloried by newspaper diarists.

What remains falls under three headings - specific plans to tackle specific issues, such as smoking, a pledge to develop national targets for inequalities and then use them to redistribute NHS funding, and a sketch of a shakeup for the public health function.

It is debatable whether this really delivers Mr Blair's grand vision, although John Nicholson, chief executive of the UK Public Health Association, is not alone in feeling that public health has 'done well' to get a chapter at all.

'The biggest difficulty throughout the plan is that it is more a list of things to do than it is a plan, ' he says.

'In order to improve the health of all the population there would have to be some structural changes involving other departments as well as the Department of Health. The nettle has not been grasped. But I don't want to be too negative, there is a lot to build on.'

The most detailed proposals cover children, smoking and diet. The plan promises a big expansion in the Sure Start programme, extending its reach to 'a third of children under four years living in poverty'.

It promises a 'comprehensive' NHS smoking cessation service by next year, with the National Institute for Clinical Excellence giving GPs evidence about what works and the committee on safety of medicines considering whether nicotine replacement therapy (NRT) should go on general sale.

It also promises free fruit for schoolchildren (see box right), a 'five a day' programme to increase fruit and vegetable consumption, and local action on obesity and physical inactivity, with advice from the Health Development Agency.

Clive Bates, director of Action on Smoking and Health, can hardly restrain his enthusiasm.

'We have been pushing to get NRT on the NHS for years and now we have it, 'he says.'There is also a strong signal from [health secretary] Alan Milburn that he expects the NHS to take this very seriously.'

Mr Bates is confident the subtext to the plan is that NRT will be taken off the 'blacklist', allowing GPs - and possibly nurses, under patient group directions - to prescribe it for the first time.

All he wants now is a more explicit link between tobacco tax revenues and health promotion, which he argues would go a long way towards helping the government meet its new inequalities targets.

Free fruit also gets an almost universal thumbs up. 'Absolutely, ' says Kate Law, head of clinical programmes at the Cancer Research Campaign. 'The nearest kids in the lowest socio-economic groups get to eating five portions of fruit and veg is Christmas Day, when the satsumas come out. Since childhood sets the pattern for life, this is incredibly important.'

But the plan ducks tackling adult behaviour - 'persuading people to play their part in achieving better health by adopting a more healthy lifestyle'. This is hardly surprising. As Mr Bates says: 'If you ask people whether prevention is better than cure, they will say yes. But tell people who are not yet sick that prevention means changing their behaviour and it smacks of nannyism.'

But Dr Nick Finer, consultant physician at Luton and Dunstable Hospital and past chair of the UK Association for the Study of Obesity, thinks an opportunity has been missed.

'It is reassuring that nutrition features in a national plan for healthcare, but it is a shame that action to tackle obesity and physical activity seems downplayed to local action, ' he says.

'There is a continuing failure to get to grips with a problem that is getting bigger year by year.'

Dr Jacky Chambers, director of public health for Birmingham health authority and a member of the scientific advisory group for the 1998 Acheson inquiry into inequalities in health, welcomes the commitment to develop national health inequalities targets.

She argues this shows the government has confidence that its wider strategies - such as the New Deal - will have an impact.

But Mr Nicholson is disappointed that the government failed to heed more of the Acheson recommendations, including its call for all policies likely to impact on health to be evaluated for their effect on inequality.

The plan also promises that a new health poverty index will be drawn up by 2002 and then used to revise the weighted capitation formula that distributes NHS resources to different parts of the country. Strikingly, it promises that primary care will be brought into the system and the new formula used to target resources on poor areas with few GPs.

Hilary Daniels, chair of the Chartered Institute of Public Finance and Accountancy's health group, says this builds into health improvement programme targets and the targets set in last year's public health white paper.

But she warns that any weighted capitation formula will be 'imperfect' and a reasonable rate of change programme needs to be agreed if areas judged to be 'above target' are not to lose out.

The advent of primary care groups and trusts also complicates the picture. HAs could have some primary care groups/primary care trusts above target, and some below - a situation that will need 'careful management' on tight budgets.

Meanwhile, the plan recognises that 'the NHS cannot tackle health inequalities alone' and sets out a number of 'new partnerships' to tackle inequality.

The NHS will be required to plan 'a full part' in the government's strategy for neighbourhood renewal. By 2002, there will be 'single, integrated public health groups across NHS regional offices and government offices of the regions'.

But the future of health action zones looks less bright than ever. The plan says the NHS will build 'local strategic partnerships' in the medium term, into which they can be incorporated.

Only 'effective'HAZs will be allowed to continue in the short term.

Louise Sarch of the National Heart Forum says the plan puts too much emphasis on the NHS leading work that it is not equipped to lead, and which should be led by the DoH.

She adds: 'Loads of different initiatives come out of Saving Lives and yet we are seeing very little action. Has dropping bits about public health and prevention into the NHS plan superseded last year's white paper?

'And if not, how are they supposed to fit together? We welcome the free fruit and the 'five a day programme', but we want to know how it will be implemented.'

Award with bite

Gateshead Health trust has developed a 'healthy teeth award' for local nurseries. To qualify, they have to sign a charter saying children will not be given fizzy drinks or sweets at breaks. Special events are also celebrated without sweets.

Zoe King, senior oral health co-ordinator at the trust, says it approached 10 nursery schools and seven were 'very positive and enthusiastic', with parents reporting they found it hard to turn down demands for sweets as treats and rewards.

'Staff felt that by setting a good example they could influence children into eating more healthily at home, ' she says.

However, three nurseries were less enthusiastic. 'Staff felt that as nurseries were situated in areas of deprivation, children rarely got sweets and taking them away at nursery would mean they got even less, 'Ms King says.

'Some also felt that children would not eat fruit and vegetables after being given sweet biscuits and cakes for so long. Other staff felt they had enough responsibilities without taking part in the pilot.'

Ms King says nurseries started with apples, bananas and oranges but children soon 'got bored' and asked for sweets and biscuits again.

'To overcome this, parents who wanted to send in a treat to celebrate a child's birthday were asked to send in more exotic fruit, such as a kiwi or star fruit instead of cake.'

The trust feels the pilot has been successful and will be expanded, but the scheme has implications for the government's plan.

'Issues include the real possibility that children will become easily bored and more exotic fruit may need to be offered to keep their interest, ' says Ms King, who argues that the 'lack of treats' issue in deprived areas also needs to be considered.

Feeling fruity US politicians have long tried to be as wholesome as motherhood and apple pie.Now the UK government has gone one better. Hold the pie - full of tooth-destroying sugar and artery-clogging fat - and just hand out the apples.

The pledge to set up a 'national school fruit scheme' was one of the attention-grabbing ideas of the national plan. Every nursery and primary school child is to get a free piece of fruit every school day - although, unfortunately, nobody yet seems to know how this will be achieved.

This is one reason for piloting the project: probably in 20 Sure Start areas, probably starting between now and November. Another reason is that everybody can see a few pitfalls in what is still generally agreed to be an incredibly good idea.

John Ransford, head of social affairs for the Local Government Association, says: 'Not only will this ensure they do get some fruit, it sends out a really important signal. It gives people something to talk about. 'Or as a Department of Health press officer says: 'Most children, even in the middle classes, only get two to five portions of fruit and veg a day. Most get less than that. Eating more fruit helps with heart disease and some sorts of cancer, two of the government's target areas.'

But a slightly wary DoH press officer says Friends of the Earth has already demanded a guarantee that the fruit will be pesticide free, while the Ministry of Agriculture, Fisheries and Food is so pleased the DoH is making it clear that 'this is a public health initiative, not something to help ailing farmers'.

Meanwhile, Beverley Baker, vice-chair of the Local Authority Caterers Association, says she thinks free fruit is a wonderful idea, but LACsA is desperately trying to find out 'who orders it, who distributes it, who cleans it, and who tidies up afterwards'.

Teachers seem willing to embrace the concept, as long as they don't have to do any of the above.The National Association of Head Teachers says it welcomes the scheme 'as long as it is voluntary, non-bureaucratic and supported by parents'.

Jean Whitfield, a former headteacher in Swindon, who introduced a ban on sweets at play-times, says that allowing children to bring fruit instead was welcomed by parents.

'Children like to eat and if fruit is all that is available, they will eat it, even if they only take two bites and put the rest in the bin or play football with it, ' she says.

Meanwhile, the DoH press office can't wait for the pilots. 'I'm looking forward to stories about children being battered by NHS fruit, ' says one press officer.