Health

Impact
Assessment:

a guide for local authorities

CoSLA logo
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Health Impact Assessment: a guide for local authorities

Introduction and background

Scottish councils play a key role in promoting health. They are responsible for a wide range of
services which impact directly on public health and well-being – from social care, housing,
education and community safety to environmental health, transport, and leisure and recreation, to
mention but a few areas.

The development of Council-led Community Planning recognises the leadership role of local
authorities in promoting the wellbeing of their population, including their health. The Scottish
NHS Plan, Our National Health, recognised the role of local authorities as public health
organisations and announced that Local Health Plans will contribute to Community Plans.

How should councils demonstrate this commitment to being public health organisations and
promoting the health of their population? A vital first step is to understand the impact of their
policies and activities on people’s health.

What is health impact assessment?

Health impact assessment (HIA) is a way to find and improve the health consequences of any
defined policy or activity. It usually assesses a policy or activity that does not have health
improvement as a primary objective. Any action will, we hope, reach its intended objectives, but
may have other consequences that are unintended and unanticipated. These unintended effects
may be good or bad for people’s health. For example, a new central retail development may bring
employment but cause small local shops to close and reduce access for people without their own
transport.

HIA aims to find all these effects on health in order to enhance the benefits for health and
minimise any risks to health. It includes explicit consideration of the differential impacts on
different groups in the population. HIA is usually forward looking (prospective), done at a time
when it is possible to change the proposal if necessary.

This paper will only deal with prospective HIA and will use ‘proposal’ to include a proposed
policy, programme or project.

Why should you bother with HIA?

Explicitly considering possible health consequences of their decisions demonstrates commitment

to the role of councils as public health organisations.

Fundamentally, it should lead to better policy making. It demands that planners think broadly
about the possible wider effects of their plans. It allows greater transparency of decision making
as the potential impacts are made explicit. HIA is not only about mitigating risks, it should also
enhance the positive effects of a wide range of policies.

Most HIAs need input from people with different perspectives and from different organisations.
Working together in this way brings added benefits in promoting partnership working.

But beware! Conflict may still arise, for example where one group of people stand to gain but
another group stand to lose. HIA does not remove the need for difficult decisions, but it makes
the health consequences more explicit.
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Stages of a health impact assessment

These are the stages involved in doing a health impact assessment:

• Screening The first stage is to select proposals that should be subjected to HIA.

• Getting the HIA HIA needs input from a team of people to provide different perspectives and
team together areas of expertise.
• Scoping This means setting the boundaries of the HIA: the geographical scope, the
population groups whose health is considered, and the timescale over which to
predict impacts.

• Identifying impacts This means identifying possible health consequences of the proposal.

• Assessing impacts This means assessing the identified impacts, in order to inform recommendations
to improve the health consequences.

• Making The HIA should include recommendations to adjust the proposal to maximise
recommendations positive and minimise negative health impacts.

• Monitoring impacts Once the proposal is implemented, the health impacts that arise in practice
should be monitored.

In practice, you often have to return to an earlier stage when there is more information. For
example, once you have identified the impacts you may decide that they will affect a larger
population than you first thought, so you will have to re-define the population scope of the HIA.

How to do it

Screening

In order to decide whether or not to do a HIA, we need a quick review of the possible health impacts,
and also to consider the size and importance of the proposal and availability of resources to do the
assessment. A good way is to use a checklist that covers these questions, like that below. The
questions in the checklist should help you think about how the proposal may affect health but do not
give defined thresholds for when HIA is necessary. It is usually a matter of judgement where the
resources available to do HIA should be spent. However, local partners may agree some definite
criteria, for example always to do HIA where there are possible adverse impacts affecting a
vulnerable population.

Screening can be done:

1) By an external, independent person who is not involved in designing a policy proposal. For
example, in the Netherlands, staff of the Netherlands School of Public Health screen all
government policies to find those that have significant implications for health.

2) By those involved in designing a proposal, as part of the planning process. For example, UK
government policy makers use a series of impact assessment checklists when formulating
government policy. These help them identify impacts on many issues including health,
gender, environment and human rights1.

1) see: http://www.cabinet-office.gov.uk/regulation/1999/checklist/intro.htm
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Questions to use in screening

• Does the proposal impact on one or more determinants of health?

− Personal/family lifestyles and characteristics
− Socio-economic environment
− Physical environment
− Access to and quality of health and other services

• Will any of the results of the proposal be irreversible?

• What population subgroups will be affected by the proposal?
• Who might be DISADVANTAGED by the proposal?
• What is the geographical and population scale of the proposal?
• Is there conflict or disagreement about the proposal? If so, would a HIA help to resolve it?
• Are there time, money and expertise to do a HIA?
• Is it possible to change the proposal if necessary?

Source: adapted from Scottish Needs Assessment Programme Health Impact Assessment: piloting the process (2000)
and Netherlands School Of Public Health Checklist for Health Impact Screening (1998).

Getting the HIA team together

When a decision has been taken to do an HIA, someone needs to do the work! Doing a HIA
usually involves several different areas of knowledge and expertise:
− Knowledge of the topic being considered (transport, housing, industry etc)
− Knowledge of health and its determinants
− Knowledge of local communities

Usually a team of people is needed, to contribute all these areas of expertise. The team often
reports to a steering group that has the authority and responsibility to set the terms of reference
for the assessment and agree the final recommendations.

Scoping

The boundaries of a HIA are usually set simply by agreement between the stakeholders involved.
Remember to consider different population groups that may bear different impacts, and the
possibility of impacts on neighbouring populations or long term impacts.

Identifying impacts

We usually do HIA of proposals that do not have promoting health as a primary aim. It means
assessing health consequences that are unintended, so we need a systematic way to identify the
possible health impacts.

Brainstorming, interviews with key informants and published literature can help to identify impacts.
A checklist or matrix can be used as an aide memoire to make sure you consider different areas of
impact and different population groups. The impacts often arise in an indirect way so the most
important thing at this stage is just to think broadly!

Remember to consider different population groups who may be affected in different ways and
therefore bear different impacts. It is very important to find a way of involving affected communities
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at this stage, as they will often have a different view on how a proposal will affect their health. It can
also be empowering for communities to participate in the HIA process.

Checklist of potential health impacts/health determinants

Personal/family lifestyles Social environment Physical environment Access to and quality of

and characteristics
• diet
• exercise/physical activity
• substance use
• education & learning
• skills, eg coping skills
• social status
• employment, or having
other recognised roles
• social/family support
• cultural and spiritual
participation
• stress
• income, & relative
income
• equity: will it alter
relative positions of
people/attitudes to
vulnerable people
• living conditions services
• working conditions • social services
• pollution • housing
• climate • leisure
• accidental injuries • transport
• public safety • education
• transmission of • health services
infectious disease

Source: WHO European Centre for Health Policy, Screening, A preliminary draft. (1999)

Assessing impacts

Further assessment should aim to inform recommendations to improve the health consequences of
a proposal. Sometimes simply identifying the impacts is enough. Sometimes more information is
needed, for example to help weigh up benefits and harms or suggest ways to mitigate adverse
impacts.

You should make sure the information you get from the assessment is what you need to decide what
changes, if any, should be made to the proposal. This means deciding which impacts seem critical.
The further information about these impacts required could include:

• quantifying the number of people who will be affected by each impact

• exploring the pathways by which impacts occur
• finding out what value people place on each impact
• formally prioritising the impacts, against each other or against other factors

The methods and evidence used will depend on exactly what information you need to inform
decision making, the kind of impacts identified, and the scope of the proposal. It is often helpful to
involve someone with expertise in public health or health promotion, but HIA does not require new
methods or new skills. It often involves critically appraising and using evidence in published
literature, and applying it to a local situation. Again it is important to involve affected communities,
especially when trying to value or prioritise impacts.

Making recommendations

HIA is not done solely as an academic exercise, its purpose is to make recommendations to
maximise health benefits from a proposal and also to minimise harm. The stakeholders involved in
the HIA usually agree the appropriate recommendations as part of the work. Often the suggested
adjustments to the proposal will be relatively minor changes. Sometimes, recommendations may
impinge on other sectoral areas, for example recommendations from a HIA of a transport policy may
be directed to land use policies.
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Monitoring impacts

The recommendations of most HIAs include a recommendation for future monitoring of the
health impacts that result from the proposal. This means that action can be taken to address any
impacts that were not foreseen, and it also builds the evidence base for future HIAs.

Monitoring should be meaningful. This means defining the population(s) to monitor and deciding
in advance the questions to answer, for example: Has the defined population benefited as
predicted from this proposal? Has the defined population suffered more adverse impacts than
expected and deemed acceptable?

A planning framework for HIA

HIA as part of Environmental Impact Assessment

Many proposals are already subjected to Environmental Impact Assessment (EIA). The proponent
pays for an EIA, which is done by consultants. In these cases, it makes sense to integrate health
impacts into the EIA rather than duplicate the assessments. But we also need to build in health
impacts that are not environmental impacts. When setting terms of reference for these
assessments, it is important to be sure that:
− all health impacts are included, not only those that result from physical hazards
− there are opportunities for affected communities to participate early in the assessment
− it considers health benefits to be maximised, as well as risks to be minimised.

Many proposals cause important health impacts but little environmental impact and do not require
an environmental impact assessment. So if we want to assess and enhance the health effects of all
relevant proposals, we cannot rely on including health in EIA.

HIA as an integral part of planning

A powerful way for HIA to be done is for it to be integrated into the planning process. Those
planning a proposal understand the background situation, including the potential for change. If
they are involved in the HIA, they will have some ownership of the results. It will also raise
awareness of the wider impacts of their policies and activities.

There is also a need for HIA to be seen to be independent and unbiased. This conflicts with the
need to draw on local knowledge of the proposal when doing the assessment. This means that
there should be a mechanism for other interested parties to raise concerns about proposals that
should be subjected to HIA, and to ensure that other views are sought during an assessment. The
HIA should inform an accountable decision making process.

Community planning and other partnerships offer a way for HIA to be done in a way that
involves those planning a proposal and also other stakeholders, including health professionals and
community views.

Screening: The first challenge is for a partnership to identify proposals that should have a formal
HIA. Planners developing proposals in each organisation could be asked to use a screening
checklist to identify proposals with significant health implications. Alternatively, health
professionals on the partnership could be asked to consider new developments using a similar
checklist. Sometimes, there may be pressure from other sources, for example communities may
raise concerns about proposals they think will affect their health. The partnership will need a way
to identify and address these concerns and where relevant proceed to HIA.
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Doing the HIA: When screening identifies a proposal that should have a HIA, the work needed to
do the HIA would then be agreed and resourced jointly. The HIA group would include those
planning the proposal, public health or health promotion specialist(s), and community
representation. This group could report to the appropriate group in the community planning
structure. This would allow the recommendations of to feed more directly into decision making
processes. Responsibility for implementation of the recommendations could also be agreed
between the partners.

Resource implications

There is a spectrum of HIA activity, so it is not possible to give a cost that applies to every HIA.
At its simplest, it just means having an increased awareness of possible health impacts when
planning, often using a checklist of potential impacts. This can lead to a request for further advice
or input from health professionals or other interested parties on the likely impacts. A fuller
assessment might involve commissioning further work from an external body, or could be done
as a partnership activity as suggested above.

What next?

We want to hear your views.

This guidance has introduced HIA and outlined how to do it. CoSLA and the Public Health
Institute for Scotland (PHIS) are interested in supporting further development of HIA and
exploring the practicalities of making it part of every day decision making. What further
information and support do you need?

PHIS will be setting up a network of people from a range of sectors and disciplines to develop
and support health impact assessment in Scotland. We want to hear views on who should be
involved in the network and what its priorities should be. If you are interested in being a part of
this network, please contact Margaret Douglas at the address below.

Key contacts

HIA network lead The HIA network will develop and support Dr Margaret Douglas
HIA in Scotland Consultant in Public Health Medicine
Lothian Health
It will include a wide network of interested 148 Pleasance
people and smaller groups taking forward Edinburgh EH8 9RS
specific pieces of work.
Margaret.Douglas@lhb.scot.nhs.uk
PHIS PHIS is working Jackie Willis
Programmes to increase understanding of Public Health Institute of Scotland
Manager the causes of health and ill health, help to Clifton House
formulate public health policy, and increase Clifton Place
the effectiveness of public health actions Glasgow G3 7LS

jackie.willis@phis.csa.scot.nhs.uk
CoSLA Morag Hamil
public health team CoSLA