Published: 11/08/2005, Volume II5, No. 5967 Page 3

The quest for the perfect structure for the health service has occupied some of the finest minds in the NHS and Whitehall since...well...about 1948.

As primary care trusts focus their minds on coterminosity with local authority boundaries and the impact this will have on PCT numbers, some pioneers in health improvement are wondering if they have found their own structural solution. They are calling it a 'public health trust' (news analysis, pages 12-13).

Its proponents liken the hypothetical structure to a children's trust, involving a broad group of stakeholders from local government, the police and primary care.

Such a trust could also impact on planning, the environment and transport, they say.

What makes the proposal interesting is the role it might play in an increasingly hard-nosed climate, where choice and contestability are set to rule.

Detail on how the trusts might work is scant. West Yorkshire strategic health authority chief executive Mike Farrar says the jury is still out on whether such bodies would take a purchasing or provider role. Certainly, public health trusts with a commissioning remit, able to pick and choose from public and private sector providers working in specific services - such as sexual health, and smoking cessation - could be a powerful force for change. The truly radical public health trust might also exploit access to pooled budgets and wage war on obesity by 'commissioning' cycle paths or public swimming pools.

But there is more than one route to joint working. As our cover feature shows, 21 pilot sites in England have established local area agreements in an attempt to get NHS, local government and other partners to commit to meet shared targets and provide the necessary funding (pages 2224). In an era where the dangers of reconfiguration fatigue looms large, these kind of arrangements may be a better bet than yet another new type of organisation.

Public health trusts are an interesting idea, but they should only proceed if they can achieve their goals more quickly and more effectively than other forms of joint-working which are already beginning to deliver.