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DISCUSSION PAPER ON HOW HEALTH IMPACT ASSESSMENT CAN CONTRIBUTE TO THE SCRUTINY FUNCTION June 2001 The Southwark Health Alliance (SHA) is supporting the development of Health Impact Assessments (HIA) in Southwark. In relation to the development of health and social care scrutiny in Southwark, the SHA believes HIA can contribute. It supports the concept that HIA may provide one of the more "grounded" approaches to selecting / assessing the suitability of topics for scrutiny. It also believes HIA may be used as part of the scrutiny process itself to assess health impacts of specific proposals. This paper sets out some initial thoughts about how HIA can contribute to the scrutiny function, in particular the health and social care scrutiny committee/panel. As a “working draft”, the views described here are open for comment and discussion. After consultation and further consideration, it is recommended that a more substantial proposal be submitted to the Scrutiny of Administration Committee. 1. BACKGROUND Legislative framework 1.1 As part of the United Kingdom Government's plan to modernise Britain, it released the White Paper 'Modern Local Government - In Touch with the People' (July 1998). The aim of the paper was for the Government, in close co-operation and coordination with local authorities, to find new ways of working to demonstrate efficiency, transparency and accountability. In April 1999, a draft bill on political modernisation 'Local leadership, local choice' was followed by the introduction of legislation, the Local Government Act 2000 (the Act). The Act gave local authorities the power to: • • • 1.3 promote the economic, social and environmental well being of their area; develop Community Strategies; and establish a new ethical framework for local government.

1.2

The Government's agenda for change was taken forward by the local authorities. Debate and experimentation of new proposals for political management within local authorities followed. Scrutiny function

1.4

One of the key areas of change is to separate the executive and scrutiny functions of councillors. The checks and balances needed to ensure efficient, transparent and accountable decision making require local authorities to establish a clear distinction between the decision making roles of the executive and the scrutiny function. Section 21 of the Act requires all local authorities to make provision for the appointment of scrutiny committees as part of their new political management arrangements. In establishing new political management arrangements, local authorities have had to consider a number of issues including: • • • best value; the relationship between scrutiny and performance monitoring; and the implications for scrutiny of the proposals continued in the Health and Social Care Bill.

1.5

1.6

Appendix A describes the structure and process of a scrutiny committee.

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Health scrutiny 1.7 The Health and Social Care Act give Local authorities the powers to scrutinise local health bodies and health issues. This includes the National Health Services (NHS) locally. Some issues for local authorities to consider to ensure they are effective in carrying out this role include: • • • 1.8 A good knowledge of health issues; A consistent approach to the scrutiny of health bodies; and A partnership approach to the scrutiny of health issues.

The SHA believes that for health scrutiny to be effective, these issues must be considered. It supports a process where scrutiny is at a strategic level and not a forum to examine individual cases. Further, scrutiny must be properly supported in terms of financial, expertise and administrative and ensuring training need of Panel members are met. Scrutiny should be conducted in a “whole systems” manner taking into account all the factors which impact on health such as education, housing, crime and so forth. Appendix B sets out the SHA’s views and consideration about health and social care scrutiny. Health Impact Assessment

1.9

The SHA supports the development of HIA in Southwark. It believes HIA can contribute to the scrutiny process. What is HIA?

1.10

HIA is a tool designed to bring public health issues into the foreground of policy and decision making, in short to make public policy healthy. HIA was defined by Alex Scott-Samuel as ‘the estimation of the effects of a specified action on the health of a defined population’ and can be used to ‘inform decision making in relation to a particular policy, program or project.’ (Alex Scott-Samuel 1998) It is generally accepted that a range of factors determine, and impact on, the health of a population. Such factors, or as they are often referred to as the determinants of health, include biological, social and economic, environment, lifestyle and access to services. There are strong links between human health, the environment, the community and the economic needs of the population. HIA tries to take into account the opinions and expectations of those that may be affected by proposals and combines this information with the analysis of the potential health impacts along with the risk assessment. This information is then evaluated and used to inform decision makers. (Jenner 1996) HIA has been widely supported by various bodies. It is recognised by Article 152 of the Amsterdam Treaty which calls for the European Union to examine the possible impact of major policies on health. The UK Government in the White Paper ‘Saving Lives: Our Healthier Nation’ has made a strong commitment to the principle of prospective HIA so that the consequences for health can be considered when policies are developed and implemented. The Acheson report on inequalities in health has endorsed its use in a recommendation. Recent guidance, from the NHS Executive in London, stated that HIAs should be performed on proposals that affect or influence health. Subjecting proposals to such assessments is also a key feature of the Greater London Assembly (GLA’s) London Health Commission. HIA has also been included in the National Service Framework (NSF) Targets and Milestones for Coronary Heart Disease. HIA is based on a number of principles:

1.11

1.12

1.13

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• • • • •

an explicit focus on equity and social justice; a multidisciplinary, participatory approach; the use of qualitative as well as quantitative evidence; explicit values; and an openness to public scrutiny.

HIA Procedures 1.14 The NHS Executive London have produced a ‘Short Guide to Health Impact Assessment – Informing Healthy Decisions. In the short guide they set out the five basic steps involved in carrying out HIA, as follows:A. Screening: The main function of screening is to act as a selection process during which proposals are quickly assessed for their potential to affect the health of the relevant population. Thus, screening acts as a filter to ensure that only those proposals which require assessment are subject to the entire process of HIA. In this way, resources can be targeted at proposals that may have important implications for the public health. To support the process of screening, a screening tool, which provides a systematic framework for the assessment of proposals, is required. B. Scoping or setting the Terms of Reference: This involves setting the boundaries for the appraisal of health impacts; agreeing the way in which the appraisal will be managed; allocating responsibility for decision making; and agreeing how to monitor and evaluate the HIA process and outcomes for health. C. Appraisal of impacts and effects on health: This is the ‘engine’ of health impact assessment, moving the whole process along towards practical outcomes. Key activities during this step are: analysing the proposal; profiling the affected population; identifying and characterising the potential health impacts; reporting on the impacts; and making recommendations for the management of those impacts. There are broadly three types of appraisal within HIA: rapid; intermediate and comprehensive. Many organisations use rapid appraisal as an entry point to HIA. D. Decision making: The decision makers for any proposal may or may not regard health as a central issue. For example, they may prioritise economic benefits over health. And the decision makers may or may not be part of the steering group for the HIA – it all depends on who agreed to take part during the scoping step of the HIA process. But, whether or not it has the power to make direct decisions on the proposal being considered, the steering group will be in a position to make recommendations to the decision-makers on the potential changes that can be made to a proposal to minimise its harmful impacts and maximise the health gain. E. Monitoring and evaluation: To complete the HIA process, monitoring and evaluation provide valuable insight into the ways in which it is possible to: • • • improve the process of HIA modify future proposals so as to achieve health gain assess the accuracy of predictions made during appraisal.

HIA benefits

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1.15

Some key benefits of using HIA as an appraisal tool include : • Community participation (for example, the scrutiny committee’s recommendations can be based on the participation of a wide range of stakeholders to provide a fully considered view on issues affecting the health of the local community). Informed decision making. Aims to reduce inequalities. Ensure policies do not actively damage health. Add value (Considering the situation where the policies are provided on a basis of value for money, health gain represents added value from the resources invested. For example, with a social renewal or regeneration programme health gain is increasingly viewed as an important outcome rather than as a by-product of the programme). Responsive government (Central and local governments have made a commitment to assess major new Government policies for their impact on health).

• • • •

2. 2.1

PROPOSAL FOR USING HIA IN THE SCRUTINY PROCESS HIA is a tool designed to bring public health issues into the foreground of policy and decision making, in short to make public policy healthy. In the development of health and social care scrutiny, the SHA believes HIA can add value to the process. As a tool, HIA can be adapted for use in the scrutiny process in two ways: • • to prioritise the policies for a health scrutiny committee work program, and to assess the health impact of the policies it will review.

Prioritising policies for a health scrutiny committee work program 2.2 As described in Appendix A, in Southwark the proposal scrutiny structure has a fixed membership standing committees/panels which have cross-cutting terms of reference. The committee/panel will comprise of a number of Councillors and have a politically balanced membership (and co-optees as the case may be). It is expected that the health and social care panel will run some 3 to 4 inquiries each year. SAC will oversee the running of the panels including approving all inquiries. Given the potentially large number of inquiries expected to be carried out each year, SHA believe the Panel will need to clearly identify the policies it will review. For health scrutiny to be effective, the prioritisation of inquiries for the work program needs to be sound. The SHA believes a health scrutiny committee/panel will need to consider: • A process to decide which policy to include in its annual work program. Given the number of health policies that can be reviewed, a scrutiny committee/panel will need a structured work programme. The work programme should list the policies for review in order of priority. However, the work programme must be flexible enough to allow other requests for inquiries to be included, for example, a referral from full council. Good practice in health scrutiny. The SHA has set out some thoughts on health and social care scrutiny for example: scrutiny should be at a strategic level and not a forum to examine individual case, the level of support needed for effective health scrutiny (see appendix B).

2.3

As one of the more “grounded” approaches to selecting / assessing the suitability of topics for scrutiny, the SHA is supportive of the use of HIA. It believes that HIA can

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assist by providing a structured mechanism to assess the health impact of policy proposals and compare them to determine the priority in which they are examined. The proposal HIA screening tool can be used to quickly assess policies. Its outcome will be to show the order in which policies should be examined based on the level of impact it has on the determinants of health in relation to its population experience. Appendix A (flowchart) shows the stage where the proposal screening tool fits in to the scrutiny process. 2.4 The HIA screening tool is able to prioritise the health impacts of a policy by looking at the effect it has on both the general population and the vulnerable populations of Southwark. The purpose is to target those policies that have a high health impact on the general or vulnerable population and ensure they are examined as a priority. As a national priority and local priority, health impacts that affect the wider community or increase inequalities should be given preference in the health work program to be examined by the scrutiny committee. Table 1 sets out an example of how the proposal screening tool would look. Table 1: The proposal screening tool
Effect on population Criteria for appraisal (The criteria is not ranked in priority order) Local need LBS population as a whole Vulnerable/ deprived population (Inequalities) Rating: 1 (low impact) 2 (medium impact) 3 (high impact) Importance to health Amount of health gain Benefit downstream Easy to implement National/local target priorities Value for money Added value Evidence based Total

2.5

The process involves rating what the scrutiny committee/panel perceive to be the health impact of each criteria against the local and vulnerable population. The higher scoring proposals indicate the priority. Table 2 shows some examples of a high, medium and low health impact on policies. Once the scores have been tallied, a scrutiny programme can be compiled. This tool is designed to clearly show the level of importance of each policy in terms of its impact on the local and vulnerable populations which will assist a scrutiny committee to prioritise which policies to examine.

2.6

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Table 2 Examples a high, moderate and low health impact on policies
Impact Low Policy • • • Medium • • High • • • • Expensive services directed at small numbers of patients Services with little or no short term health gain Services with expenditure on health infrastructure rather than patients. Policies/services that may be evidenced based and effective but only impacts on a small proportion of the total population. Note: the proposal screening tool prioritises services that impact on the whole population or a vulnerable group. A clear health gain for the population or vulnerable groups Good evidence base and priority (national or local) A straightforward process of implementation Good value for money/added value.

Assessing the impact of health of the policies 2.7 To improve the health of the population, health needs to be considered in the decision making of policies that will effect peoples health, eg. transport policies, housing strategies, regeneration developments. In regard to health and social care scrutiny, the SHA believe, among other things, that scrutiny should be conducted in a “whole systems” manner taking into account all the factors which impact on health such as education, housing, crime and so forth. It supports the use of HIA as part of the scrutiny process itself to assess health impacts of specific policies. HIA offers those working in and out of the health service a way to assess the health impacts of their decisions. A scrutiny committee will review a policy, for example, in terms of best value, accountability and transparency in decision making. For those policies included in the annual programme of scrutiny, a health impact rapid appraisal could be carried out to assess the health impact of the policy under review. It can be submitted to the scrutiny committee as part of the evidence. Appendix A shows where HIA can contribute to the scrutiny process. One of the scrutiny roles is to provide advice to the Executive on major issues before a final decision is made. Ideally HIA should be carried out prospectively. That way it can identify and reduce potential negative health effects as well as enhance positive ones. It is important to note that HIA is not about vetoing proposals on health grounds. Its value as a decision making tool lies in identifying options for achieving shared objectives that aim to do so in a way that maximises health gain and minimises harm. The ‘Merseyside Guidelines for HIA’ set out an example of an HIA methodology (Appendix C). Subjecting policies to HIA as part of a scrutiny process is being carried out elsewhere. The GLA with its powers of scrutiny over the Mayor’s Strategies has started a programme of rapid HIAs of each of the eight strategies. To date they have completed work on informing transport HIA; a rapid HIA of the draft economic development strategy; Biodiversity and Air Quality Strategies.

2.8

2.9

2.10

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Feedback This paper has been released to stimulate thought and discussion about how HIA can contribute to the scrutiny function. Please forward your thoughts on this topic to the address below. Issues raised within this paper do not restrict the scope of submissions. Comments may be made on any matter considered relevant.

Helen Atkinson Health Specialist - Health Impact Assessment Lambeth, Southwark and Lewisham Health Authority 1 Lower Marsh London SE1 7NT

Phone: 0207 716 7000 Ext.: 7516 Fax: Email: 0207 716 7018 helen.atkinson@shaw.lslha.sthames.nhs.uk

Further reading


• •

A Short Guide to Health Impact Assessment, Informing Healthy Decisions. NHS Executive London, 2000 Department of Environment Transport Regions (DETR), New Council Constitutions: Guidance Pack Volume 1 - Local Leadership, Local Choice. DETR New Council Constitutions and the Health and Social Care Act 2001
Dr. Malcolm Perkin, ‘Rapid HIA of the LSL Health Investment Program’ (2001)


• • •

National Service Framework for Coronary Heart Disease. DOH 2001 New Local Government Network, Starting to Modernise - developing your council's scrutiny role, a practical guide. Scott-Samuel, Birley, Ardern, "The Merseyside Guidelines for HIA", Merseyside HIA Steering Group, Liverpool Public Health Observatory, Department of Public Health, University of Liverpool, 1998 Secretary of Health for Health. Our Healthier Nation: a contract for health. Cm 3584. The Stationary Office, London 1998 Sir Donald Acheson. Independent Inquiry into Inequalities in Health Report. The Stationary Office, London 1998 Southwark Council Scrutiny of Administration Committee, “Review of Scrutiny”, 29 January 2000 Southwark Council Scrutiny of Administration Committee, “Structure of Scrutiny”, 1 May 2001. http://www.london.gov.uk/mayor/strategies/index.htm www.londonshealth.gov.uk http://www.liv.ac.uk/~mhb/publicat/merseygui/index.html

• • • •

• • •

Report authors: Rachelle Stacey, Helen Atkinson

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APPENDIX A -

THE SCRUTINY FUNCTION

Scrutiny committee structure
A scrutiny committee is a body of Councillors (and co-operatives as the case may be) selected by the Council to undertake particular tasks. Primarily, a scrutiny committee’s function is to develop and 1 review Council policy (as proposed by the Executive , which covers all major strategies and council services). The purpose of a scrutiny committee is to provide greater accountability by making the policy functions of the local authority more open and accountable. It: • • • • Provides a forum for investigation into matters of public importance. Gives Councillors the opportunity to enhance their knowledge of such issues. Enables the Council to ensure that the right decisions are being made at the right time and for the right reasons. Enhances the democratic process by taking the Council to the community and giving them a role in its operations. Monitoring service delivery; Scrutinising policy outcomes; Scrutinising and reviewing policies and practices; Considering the outcome of best value reviews; Holding executive councillors and chief officers to account; Submitting reports to policy and resources committee through the executive board in waiting, to the scrutiny management committee (for information) and to council if necessary.

The main functions of scrutiny will be: • • • • • •

The flowchart on page 9 shows how the scrutiny function would progress.

Scrutiny in Southwark
The London Borough of Southwark (the Council) commenced a review of its scrutiny arrangements in December 2000. On 23 June, the Council agreed a proposal for political management arrangements that included one overview and scrutiny committee and six scrutiny sub-committees, five of which will be themed. The themes for the sub-committees will be: Stable and inclusive communities; A safe place to live and work; A thriving and sustainable economy; Better education for all; Quality environment; and A healthy and caring borough (Figure 1 below). It meets the key requirements for an effective, accountable and transparent scrutiny function with a fixed membership standing committees/panels which have cross-cutting terms of reference that reflect the key priorities set out in the Community Strategy. Figure 1: Themed Committee/Panel Approach to Scrutiny
Overview and Scrutiny Committ ee

S table and Inclus ive Comm unities Better Educ ation for All

A Safe Plac e to Live and Work, A Thr iv ing and Sus tainable economy A Quality Envir onment

A Healthy and Caring borough

Sub-com mittee without a portfolio

Flowchart: The scrutiny process
1

Executive: Elected mayor, another member of the executive, the executive collectively, or a committee of the executive as the case may be.

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Scrutiny decides to monitor policy proposals from executive

Scrutiny decides that an aspect of policy or policy performance should be reviewed

Local community raises issue which needs a policy response

Executive puts forward a performance /policy issue

Scrutiny reviews Council best value work programme and/or implementation of best value recommendations

Full Council refers matter to scrutiny

Annual Programme of Scrutiny HIA as part of the scrutiny process HIA *Screening tool **Rapid appraisal SCRUTINY PROCESS

Issue report with recommendations to the executive

Executive responds with action plan on recommendations

EITHER

OR Scrutiny dislikes some of the action plan and difference goes to Council

Scrutiny accepts action plan

*See Section 2, Paragraph 2.2 – 2.6 for information about how the screening tool works. **See Section 2, Paragraph 2.7-2.10 for information about how the rapid HIA works. Executive: Elected mayor, another member of the executive, the executive collectively, or a committee of the executive as the case may be

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APPENDIX B SHA VIEWS AND CONSIDERATIONS ABOUT HEALTH AND SOCIAL CARE SCRUTINY Health and Social Care Scrutiny – Some issues and considerations from the SHA
This paper sets out some initial thoughts from the Southwark Health Alliance on developing health and social care scrutiny. The SHA is an established partnership of local community, voluntary and statutory agencies working together to improve the health of Southwark’s population. The views set out here are initial views of members of the alliance and will require wider consultation and further consideration of their implications. 1.

Composition – That consideration be given to:
• • • Election of non Councillor members to the Panel such as representative of the community and voluntary sector including users and carers. Granting non Councillor members voting rights. An umbrella organisation such as Southwark Community Care Forum or SAVO to organise the election of non Councillors to Panel.

2.

Principles – initial thoughts include:
• • • • • Scrutiny should be conducted in the spirit of inquiry (rather than adversarial / nit picking). Scrutiny should be conducted in a “whole systems” manner taking into account all factors impact on health such as education, housing, crime etc. That scrutiny should cover both health and social care area and joint areas of work and not just restricted to major health service reconfigurations. Scrutiny should be at a strategic level. Operational issues should only be considered as part of drilling down after having had a strategic over view. Scrutiny is not the right forum / process to examine individual cases (in drafting the ToR, Standing Orders and criteria for selecting scrutiny subjects there needs to be clear reference / pathways / process for referring to existing mechanisms for complaints, inquiry into individual cases, critical incident inquiry, etc). Scrutiny needs to be properly supported – not just in terms of administrative support but to have access to on-going local expertise (although experts will be invited on specific topics). For scrutiny to work effectively, it will need to have on going support providing: • • Access to quality health and related data (and understanding of health information issues); and Expert knowledge on evidence based interventions / on what works.

3.

Training needs – for scrutiny to be effective, Panel members may benefit from “introductory” programmes / on going training / seminars. These need to be varied in delivery formats / topics. Their development should be based on experience (eg from Healthier Lewisham which has run several seminars on health issues for Councillors) Also to consider:
• • • Relationship to Best Value. Health scrutiny will be very much a “Partnership affair” and lessons need to be learnt from experience eon how best to engage Councillors and non-executives. The SHA is supporting the development of HIAs in Southwark. HIA may provide one of the more ”grounded” approaches to selecting / assessing the suitability of topics for scrutiny. HIA may also be used as part of the scrutiny process itself to assess health impacts of specific proposals.

4.

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APPENDIX C -

Merseyside Guidelines for HIA "Methods for undertaking HIA"

The Merseyside Guidelines for health impact assessment was published by Merseyside Health Impact Assessment Steering Group who represent four Merseyside health authorities (Liverpool, St Helens and Knowsley, Sefton and Wirral) and other agencies involved in the HIA programme commissioned 2 by the health authorities from Liverpool Public Health Observatory in 1997. The guidelines were written for those who wish to commission or to carry out a HIA and are of particular use to those 3 whose work influences (or is influenced by) public policy.

Methods for undertaking HIA involve:
A. Policy Analysis HIAs of policies will require initial policy analysis to determine key aspects which the HIA will need to address; this may build on or use material already available from earlier policy development work. Key aspects may include content and dimensions of the policy; the socio-political and policy context in which it will be implemented; policy objectives, priorities, and intended outputs; and tradeoffs and critical social-cultural impacts which may determine the effectiveness with which it is implemented. B. Profiling of affected areas / communities A profile of the areas and communities likely to be affected by the project should be compiled using available socio-demographic and health data and information from key informants. The profile should include an assessment of the nature and characteristics of groups whose health could be enhanced or placed at risk by the project’s effects. Vulnerable and disadvantage groups require special consideration. It will often be possible to use specially collected survey or other information in the profile in addition to routine data. Depending on the nature of the project being assessed, affected communities may be defined by geography, age, sex, income, or other social, economic or environmental characteristics; they may also be communities of interest, eg arts or sport enthusiasts, vegetarians, or cyclists. C. Stakeholders and key informants The process of HIA requires broad participation if a comprehensive picture of potential health impacts is to be established. The co-operation and expertise of a wide range of stakeholders (people who are involved in the project or will be directly affected by it) and key informants (people whose roles result in them having knowledge or information of relevance to the project and its outcomes) will be needed. Public participation throughout the HIA is essential, both to ensure that local concerns are addressed and for ethical reasons of social justice. While the exact identity of stakeholders and key informants is clearly project-specific, they are likely to include: • • • • • • Representative(s) of affected communities Proponents of the project Experts whose knowledge is relevant to the project ( or particular aspects of it ) and who may or may not be from the locality concerned Relevant health (or related) professionals, eg general practitioners, health visitors, social or community workers Relevant voluntary organisations Key decision makers

2 3

Scott-Samuel, Birley, Ardern, "The Merseyside Guidelines for HIA", Merseyside HIA Steering Group, Liverpool Public Health Observatory, Department of Public Health, University of Liverpool, 1998. Further information about the Merseyside HIA Steering Group can be found on the group’s web site: http://www.liv.ac.uk/~mhb/publicat/merseygui/index.html

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D.

Identification of potential positive and negative health impacts

Clearly the range of potential health impacts identified in HIA is dependent on the definition of health which is employed. We use a socio-environmental model of health derived from the work of Lalonde (1974) and Labonte (1993). This model is similar to that currently being applied by the UK Government and other bodies such as the World Health Organisation. The elements of this model can be used to generate detailed lists of health determinants which have been demonstrated to influence health status (table 3)

Table 3

Key areas influencing health
Examples of specific influences (health determinants) Age, sex, genetic factors Family structure and functioning, primary / secondary / adult education, occupation, unemployment, income, risk-taking behaviour, diet, smoking, alcohol, substance misuse, exercise, recreation, means of transport (cycle / car ownership) Culture, peer pressures, discrimination, social support (neighbourliness, social networks /isolation), community / cultural / spiritual participation) Air, water, housing conditions, working conditions, noise, smell, view, public safety, civic design, shops, (location / range / quality), communications (road / rail), land use, waste disposal, energy, local environmental features Access to (location / disabled access / costs) and quality of primary / community / secondary health care, child care, social services, housing / leisure / employment / social security services; public transport, policing, other health-relevant public services, non-statutory agencies and services Economic / social / environmental / health trends, local and national priorities, policies, programmes, projects

Categories of influences on health Biological factors Personal / family circumstances and lifestyles Social environment Physical environment

Public services

Public policy

The collection of data on potential health impacts involves qualitative research with the stakeholders and key informants identified above. The nature and number of subjects involved will obviously depend on the nature and scope of the project under study, as well as on sampling considerations and practical constraints. The range of potential methods includes semi-structured interviews, focus groups, Delphi exercises and with and without-project scenarios. The first step involves providing informants with a summary of the proposed project which is sufficiently detailed to elicit an adequate response. Timeliness is crucial; assessment should ideally take place early enough in the development process to permit constructive modifications to be carried out prior to implementation, but late enough for a clear idea to have been formed – and documented – as to the nature and content of the project. While in some contexts open-ended questions will be sufficient to facilitate the identification of potential health impacts, on others it may help to ask closed questions using the categories and determinants listed in Table 3. Issues which have been highlighted in initial interviews can also be explored in greater depth in focus groups or brainstorming sessions. Interviews are more appropriate where sensitive or confidential issues are involved. Data are recorded on the form shown at Table 4 (identification of potential health impacts) which is designed to separately record the following information • • • • Potential health impacts during project development and operation phases Positive and negative health impacts (for example – a potential negative impact – increased levels of asthma) Health categories and determinants resulting in the impacts identified (eg physical environmental and air pollution) Project activities altering determinants (eg increased traffic flow)

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Table 4

Identification of potential health impacts

Phase 1: development / Phase 2: operation* In the first column of the table, list the categories (eg physical environment) and health determinants (eg noise) which may be affected by the project’s development / operation. In the second column, list all the activities likely to case these effects during the project’s development / operation. In the third and fourth columns, identify all predicated health impacts during project development / operation, separating positive from negative health impacts, and assessing their measurability (see below). In the final column, estimate the degree of certainty (risk) of the impact. Categories / specific influences on health Project Development / operation activity Predicated health impacts (nature, and where possible, size of impact, and how measurable this impact is – ie, it is qualitative (Q), estimable (E) or calculable (C) ) Positive Impacts
*delete as appropriate

Risk of impact - is it definite (D), probable (P) or speculative (S)?

Negative Impacts

In recording the views of stakeholders and key informants (and – later – in judging these against the available evidence base), it will be necessary to assess the extent to which predicted impacts are modified by factors specific to the project being studied. There may be particular groups affected by the project whose resistance or vulnerability differs from that of the population at large. Environmental conditions (such as wind direction, water courses, or pre-existing local conditions) may influence health impacts prior to the development of certain diseases may mean that some impacts are distant in time from the intervention under study. In addition to these specific constraints, predicted impacts will also need to be assessed against the temporal and spatial boundaries which were defined in the Terms of Reference of the HIA. The quality and quantity of health care and other health-relevant services (eg environmental health, social services) should not be overlooked as factors which may also mediate potential impacts. E. Assessment of health risks Perceptions of risk are, when possible, recorded at the time of identification of potential impacts. In some instances existing evidence (which may require to be researched) will permit precise assessment of risk. In many cases, however, risk assessment will be based on subjective perceptions – especially in the case of informants such as community members. Assuming adequate sampling, such subjective risk data are arguably no less valid or important than are more precise technical data – particularly where sensory perceptions (such as increased noise or smell, or deterioration of outlook) are concerned. Risk perceptions are recorded using simple three point scales of measurability (potential impacts are characterised as qualitative, estimable or calculable) and of certainty of occurrence (definite, probable or speculative). The temptation to quantify such scales should be resisted – such numbers could not be compared with validity and would carry a wholly spurious authority. It should also be pointed out that definite, quantifiable data are in no sense superior to speculative, qualitative data. For instance, a definite increase of, say, 0.5% in levels of the common cold is arguably less important than a speculative risk of a less attractive outlook from the windows of a block of houses. F. Quantification and valuation of health impacts In some cases it will prove possible to assess the size of quantifiable impacts at the time they are identified by informants; in others, this will require to be done separately. Eg through reviews of previously published evidence. The same applies to valuation – through evidence on the resource implications and opportunity costs of potential impacts will often prove hard (or impossible) to come by. However such date can in principle be made comparable using quality-adjusted life years (QALYs) or other such cost-utility measures.

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G.

Ranking and researching the most important impacts

In almost all health impact assessments it will prove impossible to consider all potential impacts in detail; informants should be encouraged to prioritise or rank those they identify. Once all the initial evidence has been collected, a priority-setting exercise should be carried out – the Steering Group may be best placed to undertake this. Because of differential perceptions of risk there will rarely be complete consensus; criteria may need to be agreed so that the views of all informants are adequately reflected. The number of priorities to be pursed will vary with the size of the HIA, the importance of the project and the nature of the impacts identified. Once this has been done, available information and relevant evidence concerning priority impacts (from both published and ‘grey’ literature) will need to be collated. This may result in some re-evaluation of the TOR – for instance, when detailed consideration of the possible scale of an important impact suggests that the agreed geographical boundaries of the HIA need broadening. H. Consideration of alternative options and recommendations for management of priority impacts Although it will occasionally prove possible to define a single clear solution which will provide the optimum health impact of the project being assessed, in the most cases a series of options will require to be defined and presented. Formal option appraisal will in some cases be appropriate; in others a less formal approach based on criteria agreed by the Steering Group will suffice. In either case the ultimate result will be an agreed set of recommendations for modifying the project such that its health impacts are optimised – in the context of the many and complex constraints which invariably constitute the social, material and political environment in which it will be undertaken. Occasionally, the option of not proceeding with the project will need to be addressed. The following characteristics of alternative options or recommendations are likely to require consideration: • • • • • • • • • The stage(s) of project development of operation when the recommendation will be implemented. The precise timing of implementation The health determinants which will be affected by implementation The nature of these effects and the probability that they will occur The agencies that will implement and fund the carrying out of the recommendation The technical adequacy of the recommendation The social equity and acceptability of the recommendation The costs of the recommendation – direct / indirect; capital / revenue/ fixed / variable; financial / economic How the implementation of the recommendation will be monitored

DISCUSSION PAPER ON HOW HIA CAN CONTRIBUTE TO THE SCRUTINY FUNCTION

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