Are the new health authorities coming through this week likely to be better and beefier - or just bigger and harder to manage? Ann McGauran reports

As the April shower of mergers falls across trusts and primary care groups, changes being made at health authority level may not be as conspicuous.

But the four HA mergers taking place next month are not without their own significance.

The rush towards primary care trust status means the four HA mergers look set to lead the way as HAs are forced to re-evaluate their roles. They are giving up much of their commissioning role in favour of a strategic focus - across greater geographical areas.

But critics question whether the new HAs coming through this week are likely to be better and beefier - or just bigger and harder to manage.

Responsibility for commissioning services is transferring to PCTs at a rate of knots and the NHS plan outlines a strengthened performance-management role for at least some HAs.

NHS Confederation policy director Nigel Edwards admits to thinking there is 'some cause for concern that we are creating organisations that are rather too large'.

But the imperative, in his view, is to 'clearly define' what HAs are going to be doing, leaving the issue of how big they are going to be as the 'second question'.

Once You have redefined them, it is important they are properly staffed for the job, he adds.

The most radical changes appear to be happening in London. From 1 April, Bexley and Greenwich HA in south-east London combines with Bromley HA.

Michael Kerin, chief executive of the new organisation, says that now there are PCTs in each of the three boroughs, it is right that there should be one new authority. 'This will reduce costs and help us to take on our new role. '

But chief officer of Greenwich community health council Celia Davies says her organisation 'did not agree with the proposal to merge and I am not aware of any enthusiastic endorsements from other bodies'.

The new HA would mean the 'very deprived' area of Greenwich would be merged with Bromley, which is 'among the least deprived' in London.

The result will be to 'disguise the areas of particular need in our borough', she warns.

Given that she expects work to start quite soon on setting up a single HA for the whole of southeast London, she feels it would have made more sense to have hung on and delivered the changes in one swoop. Next month's arrangement will mean 'long-term uncertainty'.

North of the Thames, Christine Outram, chief executive designate of the recently merged Barnet, Enfield and Haringey HA, says many HA functions are devolving to PCTs, 'leaving health authorities free to focus on their strategic leadership and performancemanagement roles'.

It will be working with three PCTs, coterminous with their local authorities for the boroughs of Barnet, Enfield and Haringey, together with a single-focus mental health trust - Barnet, Enfield and Haringey Mental Health trust.

The result, she says, is that the HA 'is uniquely placed to have an overview of the whole health and social care system'. She believes its role is central to ensuring local achievement of the NHS plan, involving 'rapid yet sustainable change'.

But Elizabeth Manero, chair of London Health Link - an umbrella group of London CHCs - says that whatever the strategic advantages of the merger in the medium to long term, 'the disruption it has caused in the short term is worrying'.

Isle of Wight HA - the smallest in the country, covering a population of just 125,000 - is to merge with Portsmouth and South East Hampshire HA from April.

Nick Yeo, assistant director of performance management for South East region, says a PCG on the island is now becoming a trust so there was 'serious potential difficulty of overlap' with the HA.

He outlines three key reasons for the merger: 'A reduction in board costs, greater ability for a larger authority to undertake its strategic and performance-management role, and avoiding significant overlap between having a primary care trust and a health authority covering the island on a one-toone relationship. '

Paul Barber, chief officer of Isle of Wight CHC, says the island's HA felt it could no longer oppose the merger and 'attention was focused on trying to get the best arrangements for the Isle of Wight and trying to protect our funding'.

He points out that the island has the 'second lowest household income in the country' and is pleased to report that the island's budget 'will be protected for at least three years from April'.

So what does the future hold for HAs? Under the new system of traffic lights, green light HAs will be 'licensed' to take over delegated regional office performancemanagement functions.

And over time, the NHS plan says this would 'allow the progressive devolution of performance management and strategic development from the Department of Health and a streamlining of the intermediate tier'.