Real results may be some time coming for Plymouth health action zone, despite copious sub-committees. Laura Donnelly continues our occasional series

Picture the scene: a top movie mogul offers Arnold Schwarzenegger the lead in a Hollywood action romp. Arnie's eyes light up at the thought of guns, girls and events happening at breakneck speed.

Then his agent reads the small print: when the director says 'action' that is not exactly what he has in mind.

Rather, he wants a 'developmental' long-term approach - a collaborative 'whole systems' journey to produce a film seven years down the line.

Luckily for film buffs, Hollywood and the NHS run differently. Take Plymouth health action zone - one of 11 'trailblazing' HAZs set up last year by health secretary Frank Dobson to 'tackle all the bureaucratic impediments which get in the way'.

Time for 'action', then?

First Plymouth HAZ set up a steering group which heads 12 programme boards. Membership of all 12 boards has yet to be finalised but averages at around 12-14 members, rising to 36 in one case. Of course, there are subgroups of the boards to examine some of the 48 projects outlined. And the odd working party.

HAZ team leader Debra Lapthorne insists that the labyrinthine structure is the best way to attack the 'massive workload' via delegation. 'It is a question of sharing. If you had a traditional way of working it would be immensely time-consuming, ' she says.

The largest programme boards reflect a need to 'be inclusive' on issues such as substance abuse and mental health, to ensure priorities reflect the city's health needs.

Ms Lapthorne admits that delegation has yet to leave her team with time on its hands. 'But when we get the programme boards set up right it should mean we won't be working 60-hour weeks in seven years' time.'

The central team is certainly capable of working at speed. At its regular meetings, it whips through an impromptu agenda and is quick to identify the best person for the many jobs in hand.

But in the short term the agenda remains largely concerned with strategy and structure.

Much of the HAZ's plans concern the structural change behind 'seamless' services, the development of monitoring mechanisms and 'wholesystems' approaches to bring all stakeholders into decision making. This will include a health and lifestyle survey and an 'Edinburgh Festival' type event to persuade 'hard-to-reach groups' to contribute towards setting health priorities for future years.

Key to all this is a city health action plan merging the HAZ with Plymouth's contribution to South and West Devon health authority's health improvement programme. It will work with the city's education and employment zones, single regeneration budget and local Agenda 21.

And Plymouth city council has recently altered its structure, with new, larger departments likely to dovetail more closely with some of the HAZ's broader aims.

Meanwhile, there has been little action to implement measures to improve health now.

Rob Nelder, a South and West Devon HA public health specialist seconded to the team, says: 'There has been frustration from people not understanding that the first year of the HAZ was a developmental one. Some people expected radical change straight away.'

So if expectations are being dashed, did Mr Dobson's 'trailblazing' fanfare raise them too high?

GP Dr Colin Bannon is chair of Plymouth primary care group - the largest in the country, covering the whole city - and a member of the HAZ steering group, which oversees the programme boards' work. He says the structural and developmental work has been 'appropriate' so far and 'the time for action is now'.

Ms Lapthorne focuses on two HAZ projects as evidence of first steps to practical change.

A young people's drug service has been given£300,000 by the Department of Health and the Home Office to employ youth workers and link up with local voluntary and leisure agencies.

A mental health employment service will build on work already carried out by Routeways - a local service offering jobseekers advice and support - and offer specialist help to get people with mental health problems back to work.

But with almost six years to run, it is hard to predict the likely impact of the HAZ on some of Plymouth's most intractable problems. Pregnancy rates among 16 to 19-year-olds are five times higher in affluent parts of the city than in poorer areas, and antidepressant prescribing is twice as high as in the rest of South and West Devon.

Action, anyone?

Made to measure: 'increases' and 'improvements' Plymouth HAZ's implementation plan contains few measurable targets beyond two specific goals on dental health: to halve the prevalence of dental caries in five-year-olds by 2005 and to halve next year's figures for 14-year-olds by 2014.

Instead it calls for unspecified 'increases' and 'improvements' in a wide range of good health measures and 'reductions' in things like drugs and crime that get in the way.

Councillor Mike Sheaff (pictured), steering group co-chair, city council health and social services committee chair and a co-opted primary care groups member, defends the use of open-ended targets.

'There is an urgency about addressing the issues and the tight timescales, ' he says. 'We are working to reflect that.

'There is a danger that can create a narrow and fragmented focus that goes against the spirit of what was intended.'

Mr Sheaff adds: 'We need to keep the scope open to engage with people and make sure we get the priorities right.'