WORKING DRAFT

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 co-
ordination with local authorities, to find new ways of working to demonstrate
efficiency, transparency and accountability.
1.2 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:
• promote the economic, social and environmental well being of their area;
• develop Community Strategies; and
• establish a new ethical framework for local government.
1.3 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.
1.5 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.
1.6 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:
• 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.
1.8 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)
1.11 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)
1.12 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.
1.13 HIA is based on a number of principles:

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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. PROPOSAL FOR USING HIA IN THE SCRUTINY PROCESS

2.1 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

Local need
Criteria for appraisal
(The criteria is not ranked in priority LBS population as Vulnerable/ deprived
order) a whole 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.
2.6 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.

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Table 2 Examples a high, moderate and low health impact on policies

Impact Policy
Low • 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.
Medium • 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.
High • 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.
2.8 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.
2.9 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).
2.10 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.

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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: 0207 716 7018

Email: 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.
The main functions of scrutiny will be:
• 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 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 Scrutiny Local Executive Scrutiny Full

decides to decides that community puts forward reviews Council
monitor an aspect of raises a Council best refers
policy policy or issue which performance value work matter to
proposals policy needs a /policy issue programme scrutiny
from performance policy and/or
executive should be response implementat-
reviewed ion of best
value
recommend-
ations

Annual Programme of Scrutiny

HIA as part of the scrutiny

process
SCRUTINY
*Screening tool
HIA PROCESS
**Rapid appraisal

Issue report with

recommendations to
the executive

Executive responds with

action plan on
recommendations

EITHER OR

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

*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)
4. 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.

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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
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.
3
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

Categories of Examples of specific influences (health determinants)
influences on health
Biological factors Age, sex, genetic factors
Personal / family Family structure and functioning, primary / secondary / adult education,
circumstances and occupation, unemployment, income, risk-taking behaviour, diet, smoking,
lifestyles alcohol, substance misuse, exercise, recreation, means of transport
(cycle / car ownership)
Social environment Culture, peer pressures, discrimination, social support (neighbourliness,
social networks /isolation), community / cultural / spiritual participation)
Physical environment 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
Public services 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
Public policy Economic / social / environmental / health trends, local and national
priorities, policies, programmes, projects
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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• Nature and size of potential impacts

• Measurability of potential impact – qualitative, estimable or calculable
• Certainty (risk) of potential impact – definite, probable or speculative

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 / Project Predicated health impacts (nature, and Risk of impact - is it
specific Development / where possible, size of impact, and definite (D),
influences on operation how measurable this impact is – ie, it is probable (P) or
health activity qualitative (Q), estimable (E) or speculative (S)?
calculable (C) )
Positive Impacts Negative Impacts

*delete as appropriate

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 14