news focus: The evolving strategic health authorities are tasked with making a crucial contribution to the NHS agenda.But could they turn out to be an intermediary stage in the reorganisation process, asks Alison Moore

Published: 16/05/2002, Volume II2, No. 5805 Page 11 12

Ask the man in the street what a strategic health authority is and what it does and you are likely to get a fairly blank stare: ask many people working in the NHS and you might get a similar response.

SHAs may be the building blocks of the future NHS but they are pretty low profile at the moment.Many have still to fill key roles and even to find suitable offices: even tracking them down is difficult.

But in theory they are going to performance-manage the hospital and primary care trusts in their patch, work closely with the four new directorates of health and social care (DHSC) and liaise with the Department of Health centrally.

They are going to keep their fingers out of much of the day-to-day business of the NHS - but will be co-ordinating and taking a long-term approach.

Above all, they are meant to be different to the health authorities and regions which went before - working developmentally with the trusts, rather than telling them what to do, and liaising with a wide range of partners, both within the local health economy and local authorities.

That is the theory, anyway. The reality, of course, is a bit more messy.

At the moment, SHAs are a hybrid - both taking on their new roles and still, formally at least, having some of the responsibilities of the old HAs until legislation to hand them over to PCTs is in place. However, as PCTs become more competent, an increasing number of responsibilities are passing to them.

SHAs are struggling with many practical issues, such as not having staff in post and dealing with the upheaval of replacing several organisations - some cover the areas of six former HAs.

These issues have perhaps been particularly pressing for chief executives who have come from outside the local health economy.

'You are not going to come in after a few weeks like a knight on a white horse, ' says Alan Burns, Trent SHA chief executive, who was new to his patch when he arrived.

In Shropshire and Staffordshire, chief executive Dr Bernard Crump was new to management in the area - and seven out of 10 PCTs in his patch were created on 1 April.

He admits that this made the strategic and financial frameworks round very difficult - although he was able to draw on the experience of other staff members who had worked in the area and knew the local health economy.

In contrast, Ian Carruthers - the former head of Dorset HA, and now in post as chief executive of Dorset and Somerset SHA - seems quite at ease and even describes it as 'business as usual'.

Some SHAs have inherited large numbers of staff from predecessors - and this may determine how they carry out their role.

Those who have senior staff from former regions, for example, may find they see their jobs in a different way from those who have come from HAs.

One or two chief executives do admit this could be a problem - although Mark Outhwaite, in Avon, Gloucestershire and Wiltshire, says working in the midst of so much uncertainty and change does offer the opportunity to change behaviour.

But if SHAs change their behaviour, will the other NHS bodies they work with respond in kind?

There is qualified praise for the actions of the DoH centrally.

'I genuinely think there is a real effort from the DoH to work as a collaborative team with SHAs, ' says South Yorkshire SHA chief executive Mike Farrar.

'It is still early days, but we are trying to get the relationship right.'While the DoH bods can be excused for looking favourably on the former head of primary care at the DoH, other chief executives echo his views.

Dr Crump praises the monthly meetings of SHA chief executives and key DoH officials - which health secretary Alan Milburn usually manages to attend.

'Certainly I would feel very confident in picking up the phone and speaking to any member of the management board, ' he says.

'There is ample evidence that [NHS chief executive] Nigel Crisp and his team are listening and adjusting as we go along, ' says Mr Burns. 'There is still quite a lot of confusion about the role of the directorates of health and social care and the role of the SHA, and that will take another month or so to sort out.'

But Mr Burns points out that SHAs are still getting documents from the centre telling them they will be taking the lead on policy initiatives which would be more appropriately done by other organisations.

One reason for pushing more out to PCTs and trusts is simply limited capacity at the SHA: his SHA will have around 60 staff while the local health economy has 55,000, he points out. 'The system still expects SHAs to do things which are no longer reasonable, ' he says.

Dr Crump says in the transitional phase how exactly the work previously done by regional offices will be allocated is still to be resolved.

He has weekly meetings with other chief executives in the area to stop 'things dropping through the cracks during the transition'.

Although there has been extensive guidance on who does what post-regional office, some issues still have not been addressed - and have to be worked through when they come up. What role should SHAs and DHSCs play when local trusts want to merge, for example, he says.

Mr Outhwaite describes the relationships with DHSCs as 'evolutionary'.

'When rapid pressures come up we all get round a table and talk about who should do what. It is about saying we have to get something on the table in two to three days - so who's best placed to do it?' he adds.

Even Mr Carruthers, one of the most upbeat chief executives, admits there is sometimes a little confusion. 'I've not really noticed a big difference in the DoH but neither has it been in any way impeding, ' he says.

Appropriate splitting of roles and responsibilities is being addressed through the SHAs' franchise plans, which aim to bring in a longer-term perspective to planning.

In Greater Manchester, a number of priorities have been highlighted, such as developing intermediate care and improving information systems and tackling waiting for emergency care. Chief executive Neil Goodwin says they are longer-term issues which will change the way the system does things.

In Dorset and Somerset, service-level agreements and accountability agreements have been reached between the SHA and local trusts.

But perhaps the biggest challenges lie ahead: turning SHAs into fundamentally different organisations from their predecessors. Alan Burns describes it as 'learning to fly at 19,000 feet when no one has ever done it before'.

But he acknowledges that there is a risk SHAs will get bogged down.

'There is a real danger we will get pulled back down to 12,000 feet.'

South West Peninsula chief executive Thelma Holland says it is not what they do, but how they do it which is the fundamental shift for SHAs: a point echoed by many others.

'One of the worst-case scenarios for me is if we are seen to operate like an old-style HA, ' says Mr Goodwin. 'I see it as a positive advantage that our£4m management costs are capped. We have to focus very closely on what we do and how we do things to add value. It will stop us dabbling and interfering as the old-style HAs did.'

He warns that SHAs may only have a year to show the local health community they are worthwhile, or risk being seen as 'the intermediate tier by another name'.

'I think longer-term if SHAs do not prove that they add value and are capable of translating the NHS plan into local meaning, it would be reasonable for the government of the day to say it is not working, let's have another look at it and make some changes.

'But I do think that in terms of national structure for the NHS we have got it about right. The real trick is making it work.'