Feature

Those magical mystery zones

Health Action Zones are being hyped as a key element of the government’s plan to remove competition and promote collaboration in the NHS. But what are they? David Glasman reports

Health service managers, social services directors, doctors, community group leaders and local business people who decide to bid for their area to become a Health Action Zone (HAZ) will be taking on a huge responsibility. They will be responsible for deciding the future direction of health – in its broadest sense – under New Labour.

That appears to be the task in Prime Minister Tony Blair’s eyes. Speaking at this year’s Labour Party conference he described the job of the proposed HAZs: ‘Their remit: to experiment with new ideas in the way healthcare is delivered, so patients get a better deal. The NHS was a beacon to the world in 1948. I want it to be so again.’

There were no other ‘ideas’, just a promise of more money for hospital building, a determination to end ‘the two-tier NHS’ and a call for barriers between hospitals, social services and GPs to be broken down.

Shortly afterwards the Department of Health provided examples of what patients might find in a HAZ. These included:

• a network of one-stop primary care centres including pharmacy, optician, dental and drug-counselling services as well as the GP;
• one-stop clinics to investigate problems and make appointments for follow-up treatment;
• healthy living centres working with schools to improve pupils’ diet and fitness;
• joint management of budgets by health authorities and social services to provide better co-ordinated services for elderly people;
• alternatives to the internal market.

HAZs, then, appear to be magic zones which could pilot major changes in primary, secondary and tertiary care, in health promotion and education, in new relationships between health and local government and places where players test out alternatives to the internal market in healthcare.

In other words, HAZs will not champion a single cause – a primary care-led NHS, locality commissioning, the public health agenda or moving continuing care from health to local government. Instead, they are places, in Tony Blair’s words, ‘to experiment’.

To understand why HAZs are to take this form it is necessary to look at the current healthcare context.

The major impetus for setting up these experiments is the desire to scrap the internal market, which the Tory government made the showcase of its health policy. Labour’s problem has been in thinking of alternatives. HAZs are therefore a key element of the NHS White Paper.

In fact, Labour appears committed to maintaining the purchaser/provider split and so its attack on the internal market is centred on eliminating the administrative costs of invoicing and contracting and on replacing the market ethos of competition with collaboration. When Frank Dobson announced his intention to create Health Action Zones he said: ‘We have got to get every part of the NHS working together. We simply can’t afford some of the wasteful crack-pot competition that the internal market provoked at the outset.’

Other political imperatives also appear to have come into play, in particular the imperative to keep the lid on public spending. The Department of Health is promising mainly managerial, not financial, support for the new HAZs, although preferential access to public sector capital and Lottery funding has been promised. Significantly, Labour is also suggesting HAZs will get extra support for private sector finance initiative projects and the opportunity to access private sector and EU funds. Additionally, the government hopes HAZs will produce savings. The Health Service Journal (26 June 1997) revealed that a discussion group of senior health service managers had estimated that through service rationalisation and reduction of bureaucracy each zone could generate between £5m and £30m in revenue savings, potentially realising up to £1.2bn nationally.

Peter Davies, HSJ editor, said the idea for HAZs originated with a group of senior health service chief executives who met ‘around election time’. ‘They were aware there was a policy vacuum and they set out to make the most of it by trying to influence things instead of having them foisted on them from above,’ he said.

The managers, mindful of Labour’s spending plans and its opposition to competition, couched the proposal in terms of realising savings and collaborative working, he added. Frank Dobson, a minister in search of a policy, was receptive.

Others feel that people working in health and social care were chafing at the bit and that Labour, in fact, has just caught the mood.

Jo Lenaghan, health researcher at the Institute of Public Policy Research, said: ‘People tried the internal market and found it didn’t work and have been gravitating towards more collaborative working.’

Certainly the Tory government itself in its later years established projects to see how collaborative working could be improved. Pat Gordon is director of the London and Northern Health Partnerships project, an undertaking to examine radical ways of solving apparently intransigent problems of improving healthcare in cities. Collaboration, listening to users and working across agency boundaries were found to be the key.

But Pat Gordon argues that the Labour government, in establishing HAZs, is crucially acknowledging that past attempts at collaboration have not worked and that health and social care workers have its backing for looking to collaboration not competition as the future.

She said: ‘This is a wonderful signal from the government that they want people to do things differently. Many professionals have wanted to do things differently but have been worn out by the internal market.’

Professionals tended to see inter-agency working as peripheral to their daily job, she added. The government’s creation of HAZs ‘make the importance of cross-boundary working central rather than peripheral’, she said.

But she warned that cross-boundary working was not easy and the government needed to recognise that it took time to develop, professionals needed to gain confidence in doing it and that service users needed to have a strong voice so that new services were truly local.

The creation of HAZs also chimes in with the rebirth of the public health agenda. Donald Reid, chief executive of the Association of Public Health, said there needed to be much more detail about HAZs’ role and function but they had a great potential in public health with greater effort being put into establishing links between things such as housing and health, and education and housing policies being judged in terms of improvements in health.

An NHS Executive document issued with a draft invitation for HAZ bidders says HAZs will enjoy freedoms from red tape which include allowing bidders to propose their own approach to measuring efficiency and performance. This appears to imply a shift away from traditional performance indicators such as waiting lists.

Manchester is one city which is expected to have a bid on Frank Dobson’s table by the deadline of 23 January 1998. If a HAZ is established in the city it will be the latest in a line of initiatives in health, and beyond, which stress inter-agency working – showing that HAZs have precursors.

Existing initiatives which involve Manchester City Council in joint working include the Single Regeneration Budget, the Healthy Cities initiative and City Pride. In addition, a GP locality commissioning scheme is being prepared in the Wythenshaw district. Yet the council and Manchester health authority have only £2m for jointly financed schemes.

James Murphy, Manchester’s social services director, said HAZs would be important in threading these initiatives together and carrying inter-agency working forward.

For example, they might provide the council with a freedom, not currently enjoyed by local authorities, to purchase community health services which, he argued, would help towards seamless community health services on the boundary between health and social care.

The HAZ could also be a vehicle for wedding targets in improving the health of Manchester’s population with the economic regeneration of the city, which has seen investment flow into its boundaries with the help of the Single Regeneration Budget.

James Murphy added: ‘If HAZs are an exercise in co-ordinating service delivery better that in itself will be beneficial. But they could help us start to tackle the real causes of ill health which we need to address as we go into the next century.’

His opposite number in the health authority, Neil Goodwin, was more cautious but said HAZs could integrate health issues into the urban regeneration schemes and build on the city’s existing strengths in joint working. But he warned that HAZs would not be universal panaceas: ‘There is of lot of joint working in Manchester and a HAZ would be the icing on the cake, not the cake itself.’

Denise Platt, head of social services at the Local Government Association, believes HAZs herald an important breakthrough in approaches to health, exemplified in the criteria for successful bidders. Health agencies which wish to set up a HAZ have to include working with a range of council departments, not just social services. It marks a crucial acknowledgement that better health includes housing, planning, leisure.

‘This is about a much more holistic approach to health which is much wider than health and social care,’ she said.

Health, which had been a crucial absentee from schemes for urban regeneration, would now be a partner in initiatives nurtured by the Single Regeneration Budget.

Professionals involved in mental health also see great potential for HAZs, so much so that it is understood that government ministers have considered the possibility of setting up discrete mental health action zones.

‘If HAZs mean integrated working between the NHS, social services, housing and employment they could almost have been made for mental health,’ said Dr Matt Muijen, director of the Sainsbury Centre for Mental Health.

But many issues need to be addressed if HAZs are to fulfil their enormous potential – how to avoid becoming unaccountable new bureaucracies, how to marry the different cultures of health, local government and the voluntary sector, and how to ensure that best practice spreads widely.

As HSJ editor Peter Davies said: ‘This is devolution on a massive scale and completely uncharted waters.’

But the potential for change is there and Frank Dobson looks set to ensure HAZs do make a difference. In the language of trusts and GP fundholding, but in a radically different spirit, he announced that HAZs which started next April would be the first wave, with others to follow.