Health inequalities have been discussed with vigour by politicians over the past couple of years, although they are not new. The earliest links between poverty and health go back to 1837 and the first superintendent of statistics, William Farr. Edwin Chadwick also made the connection and it was key to much of his public health work. The conviction that all should have equal access to health care was, of course, a founding principle behind the NHS.

Despite 30 years of the welfare state, evidence during the 1970s that Britain lagged behind in health improvements led to the setting up of a working party under Sir Douglas Black. The Black Report was very influential on an international basis, although largely ignored in Britain during the 1980s. More recently, work done by various bodies through the Health of the Nation initiative has led to a growing body of evidence about inequalities.

Sir Donald Acheson's independent inquiry into inequalities in health, published at the end of 1998, examined trends in the socioeconomic determinants of health. These were seen as layers of influence. Some, like gender, sex and age are fixed, but others, such as personal behaviour and environment, are at least capable of modification.

Acheson sees that wider influences on a person's ability to maintain health extend to mutual support within a community as well as economic and cultural conditions in society as a whole. Policies have different effects on different groups in society. This scrutiny of policy for its impact on health inequalities has been extended to:

• poverty, income and tax benefits
• education
• employment
• housing and environment
• mobility, transport and pollution
• nutrition.

Health Improvement Programmes
Health Improvement Programmes [HImPs] form a cornerstone to the present Government's policy on health and are the main means of prioritising and measuring effectiveness in strategies to improve health. The main provisions are laid out in the recently issued white paper Saving Lives - Our Healthier Nation. The two key aims are:

• to improve the health of the population as a whole by increasing the length of peoples lives and the number of years people spend free from illness
• to improve the health of the worst off in society and to narrow the health gap.

Ill health is not distributed evenly across the country. In nearly every instance the highest incidence of illness is experienced by the worst off.

Arguments about responsibility for health have often gone from one extreme to another. Blame is attached to individuals at one end of the scale, with nanny state social engineering at the other. Saving Lives - Our Healthier Nation proposes a shared responsibility between local and national government, the NHS, communities, families, and individuals.

Examples of where this has already happened include the 1997 appointment of the first Minister for Public Health and a cabinet committee that works across 12 government departments. Local authorities and health authorities are now bound by statute to work together. The public health function of health authorities is being enhanced in the current round of reorganisation in the NHS.

HImPs are to be developed at a local level and have to contain measurable targets. Four areas have been selected that are significant causes of premature death and poor health. There are marked inequalities in those that suffer from them. By picking only four areas initially, the Government has allowed for other targets of special local significance to be included eg oral health, teenage pregnancy, diabetes.

The four national targets are:

• heart disease and stroke - a reduction in the death rate of one third in under-65s by 2010
• accidents - a reduction in the accident rate by one fifth by 2010 [this is calculated from figures for accidents requiring treatment from a hospital or GP]
• cancer deaths - a reduction in the death rate of under-65s by one fifth by 2010
• mental health - reduce the death rate from suicide and undetermined causes by one sixth by 2010.

The white paper looks at the way in which risks about health are communicated. Getting people to take notice of the right information in the right way will be key to the success or otherwise of the HImPs. Multi-agency working will be an essential ingredient in this contract for health. A wide variety of organisations need to be involved from both the public and the private sector and at all levels. There must be close involvement at both, in policy making and at the operational "coalface".

Primary Care Groups
The principle of Primary Care Groups (PCGs) was introduced in the white paper The new NHS, Modern and Dependable, in 1998. The PCGs are run by a board consisting of four to seven elected general practitioners, one or two elected nurses, one social services nominee, one lay member, one health authority non-executive and one PCG chief executive. On 1 April 1999 they were given a duty to provide and commission health care for roughly 100,000 people in each locality. The PCGs are accountable to the health authority and will agree targets for improving health, health services and value for money.

PCGs have three main functions:

• to develop primary and community health services
• the commissioning of secondary care services
• to improve the health of their community.

This key role in promoting and improving the health care of their local population will involve close working with other organisations, including local authorities if this aim is to be achieved. The health of a community depends upon a wide variety of factors including many, eg housing, employment, pollution etc, that are outside the control of the board of the PCG. This new approach offers primary care the opportunity to further integrate health promotion and health care at the individual and population level.

Local Agenda 21
The original Agenda 21 document consists of 40 chapters, chapter 6 of which focuses on health issues, although there are health issues in many of the others, eg those on poverty, fresh water, sewage and pollution. In Nottingham, there has been a multi-sectoral group set up to specifically address these issues, consisting of representatives from local authorities, the health authority, primary care groups, the voluntary sector and other health care providers. The group administers a small budget to fund innovative local projects and has organised a number of cross-sectoral seminars on key issues where action plans have been developed. These plans have been incorporated into mainstream health strategy documents so as to ensure environmental issues are addressed as part of the wider determination to improve health.

Health Action Zones
The Government identified funding to support the development of Health Action Zones (HAZ) in June 1997. There are now 26 HAZs across England, each with the overall aim of improving the health of the most deprived areas by a programme of accelerated action. The way this is to be undertaken is by means of three objectives:

• to identify and address the health needs of local people
• to increase the effectiveness, efficiency and responsiveness of services, and
• to develop partnerships for improving health and health services, bringing together different agencies.

They are seven-year programmes of action, the first year of which is about developing mechanisms to ensure that there is involvement from the grass roots as well as strategic commitment. There are opportunities within the HAZ process for sharing resources for health to allocate some to local authority initiatives that would improve the population's health for example. There are key opportunities within this process for local authorities to both engage in a more meaningful dialogue with other organisations and to gain funding for innovative ideas to improve the health of the local population.

Healthy Living Centres
The common purpose of Healthy Living Centres is to promote health; helping people of all ages to maximise their health and wellbeing. Their focus will be on health as a positive attribute that helps people to get the most out of life, embracing both physical and mental wellbeing. The main features of them are:

• they are complementary to Our Healthier Nation and the achievement of local health targets
• they focus on health in its broadest sense
• they will be targeted at areas containing the most deprived sectors of the population
• users and local communities must be involved in their planning from the start
• no standard blueprint exists and the initiative will encourage innovative proposals
• they are an opportunity to foster creative partnerships across the voluntary, public and private sectors
• projects will be expected to find a proportion of their funding from partnership sources and have a forward strategy for sustainability.

The New Opportunities Fund Lottery money has allocated £300m for Healthy Living Centres, but bids for funds have to demonstrate both joint funding and sustainability. As this is a relatively new area of work with no blueprint for ideas there are tremendous opportunities for partnership working.

Health Impact Assessment
This is a development of what many already know as Environmental Impact Assessments. It is a process that examines the potential health effects that may arise from new planning proposals or new strategies and policies. The British Medical Association has produced a book on Health Impact Assessment (HIA) and there are also guidelines published by the Liverpool Observatory. From these, a number of health authorities have drawn up proforma to facilitate HIA in practice. What is now needed is for the proforma to be piloted and for health authorities and local authorities to agree what and which plans and proposals HIA could be used for.

As well as the areas already described, there is a vast range of new initiatives and programmes that involve, or should involve, partnership working, including Single Regeneration Budget, New Deal, Sure Start, local transport plans etc. In Lincolnshire, the county council, district councils, health authority, community health council and the local bus company have formed a rural transport partnership which has successfully bid for funds from the Countryside Agency. Local transport projects, such as brokerage schemes, will be run by the partnership over the next three years.

All of these initiatives have an effect on health by impacting on the wider determinants of health, although many organisations do not readily see the links between what they are doing and improving the health of the population. There are clear opportunities at this stage to get the wider determinants of health on the agendas of these key initiatives, but it is important to act quickly as the chances will not be there indefinitely.
There is a need for local authorities in general, and in particular environmental health, to understand that the key functions they administer have a wide impact on the health of the population. In fact it could say that they have more of an effect than the traditional health care services. A lot of the statutory functions ie food safety, housing, economic regeneration have a preventative role in sustaining and promoting health of communities.

There is also a need to promote mutual understanding as an important early objective in particular:
a) Promoting an understanding among those working in public health of the pressures, priorities and working practises of local government, and
b) Promoting an appreciation among those in local government of the value of the specialist skills of public health specialists.

Potentially, one of the most positive things that could be done to improve partnership working between health and local government, is the attachment of EHOs and other local government professionals to health authority public health departments, and vice versa. EHOs, and other local government professionals, can offer a great deal to health authorities, for example:

• An in depth knowledge of the working arrangements of local government, used to facilitate the development of partnerships between health authority and local authorities.
• A link between organisations and an ability to advise colleagues on the roles of various pieces of the organisations, and who to contact to establish meaningful links on particular issues.
• The removal of some of the perceived barriers, from both sides of the partnership, enabling, eventually, a seamless interchange of views and ideas. They can show that both organisations are on the "same side" and wish to achieve the same aims ie the improvement of the health and wellbeing of their population.
• Expert comment on consultation documents etc that positively assists and integrates the work of the health authority with the work of local authorities.

The whole of the "new agenda" is based on partnership working. These partnerships include all sectors of the National Health Service, local authorities, the further and higher education sector, the voluntary sector, community organisations and the business sector. What is vital is that environmental health embraces this new and innovative way of working and brings its professionalism, pragmatism and expertise to the table before the rest of the players carry on without them.

Ann Goodwin is a public health professional at Nottingham Health Authority, Sarah Webb is principal EHO at Lincolnshire Health Authority

References
Department of Health. "Saving Lives - Our Healthier Nation" White Paper 1999
Department of Health. The New NHS: White Paper 1997
Department of Health. Independent Inquiry into Inequalities in Health Report: 1998
BMA. Health and Environmental Impact Assessment. Published by Earthscan 1998 ISBN: 1 85383 541 2
The Merseyside Guidelines for Health Impact Assessment 1998 Alex Scott-Samuel, Martin Birley, and Kate Arden