In the second of an occasional series on the progress of Plymouth's health action zone, Laura Donnelly finds that the pressure to deliver means targets are not always as radical as they might be

First-wave health action zones have to deliver results - and fast - because of the 'strong political imperatives' from central government, admits Neil Boot, development manager of Plymouth HAZ.

'We are pragmatic and realistic about this. Any new initiative has to demonstrate momentum early on - hence the need for a number of early gains.'

He sees a tension between this and the brief for HAZs to work with partners to deliver radical long-term improvement in the health of the city.

'In a sense it is a recipe, if not for disaster, then certainly for problems.'

He goes on: 'Encouraging people to think in an innovative way and doing it in partnership means we have to take things quite cautiously - or we run the risk of not keeping people on board. One of the challenges is to take developments forward in an effective way without controlling and stifling innovation. It is about a balance.'

But steering group joint chair Judy Leverton insists the balance must tip towards something radical. Ms Leverton, who chairs South and West Devon health authority, says: 'That is supposed to be one of the joys of HAZs - piloting new ideas. The wider statutory agencies will remain in place to make sure the shop is kept open.'

Other key players insist communication, partnership and consultation will not be sacrificed to meet the political will for swift change. So far, they have tackled the issue with a heavy dose of lateral thinking.

Early targets flagged up in Plymouth HAZ's implementation plan include improved consultation, partnership working and community involvement.

Some of the more tangible targets, such as providing support to elderly people in their own homes, build on current practice.

Steering group joint chair Mike Sheaff - also chair of Plymouth city council's social services committee - admits the early gains may not be what they seem. 'In a sense this scheme is a continuation of what has already been going on since last year's winter pressures. Plymouth HAZ has put a focus on it - and the money that comes with it is an extra lubricant.'

Team leader Debra Lapthorne insists the HAZ has not gone so far as others elsewhere - which she accuses of 'rebadging' existing schemes to create easy-to-meet early targets.

Last month, having accepted Plymouth HAZ's implementation plan, the government allocated it£3.3m for the next three years.

The steering group met last week to choose a future operational structure, dividing its 12 programmes into two groups. Issues programmes - which cover researching and evaluating the population's health - are grouped together, while a separate team, coordinated by a joint commissioning board, covers six health service areas.

Next the HAZ has to select each team's membership. It has set up a sub-group of six who will meet next week to 'identify' a chair and programme lead for each group.

Each chair will also become, if they are not already, a member of the steering group, in order to 'create clear linkage' between the groupings, explains Ms Leverton.

After that it is up to them.

Individual groups will choose their own membership. For some this will be a formal group - others might choose to convene 'stakeholder conferences' to discuss issues with a wider public.

Lines of accountability have 'yet to be defined in detail', says Mr Boot, who admits 'things are moving so fast' that he has yet to be given a job description.

Steering group members are still discussing how best to make their group's accountability explicit - while leaving its structure and membership open to review.

Ms Lapthorne told the meeting: 'It is important that we don't get stuck in a rigid way of doing things and create a bureaucracy that we are stuck with.'

The steering group is currently responsible for the activity and performance management of Plymouth HAZ. Financial accountability remains with the health authority.

Health secretary Frank Dobson has committed the government to 'tackling all the bureaucratic impediments which get in the way' of improving local health.

Last month HAZ leaders met health minister John Denham to learn details of funding allocations and future legislative freedoms to encourage the development of primary care premises in deprived areas.

HA chief executive Peter Colcough told fellow Plymouth HAZ steering group members that the Department of Health wanted to hear what other obstacles were impeding the process of HAZs.

Plymouth HAZ's implementation plan spells out the need for freedoms to integrate commissioning, lead commissioning and pool budgets.

Charles Howeson, deputy vice-chair of Plymouth Chamber of Commerce, told fellow steering group members 'joined-up thinking' could not get rid of bureaucracy without 'joined up budgets'.

And Mr Sheaff sees the different timescales of agencies, local government and health as an obstacle to collaboration. Plymouth HAZ aims to produce a city health action plan with arrangements for 'unified leadership towards jointly agreed targets' by December 1999.

But Mr Sheaff points to more than 30 existing statutory plans in health and local government as proof of the size of the challenge.

He also highlights the fact that Plymouth HAZ has produced its implementation plan at the same time as the HA developed a health improvement programme. The two worked separately, he says.

'At a local level it was difficult to have collaboration because everyone was having to get the tasks completed for the first time very quickly. I hope that in future it will be easier.'

Plymouth: what next?

February Bids due in for the government's Sure Start funding (for Plymouth's parenting programme).

March Community consultation on healthy living centres.

Apr i l Action plan on oral health and audit of appropriateness of acute admissions of elderly people.

May Multidisciplinary group on behavioural disorder in children and young people.

June 'Process map' of community involvement for city health action plan developed.

Funding and strategy for young people's substance misuse initiative finalised. Action plan for community and voluntary sector involvement produced. Social services audit of residential care placements for elderly people. Review of evidence on effective interventions in parenting.

September Pilot study on evaluating health baselines. Work programme agreed between primary care groups, Plymouth HAZ and community pharmacists to develop pharmacists' role.

December City health action plan produced. Implementation plan for one-stop shop agreed.