Health in Regional Public Policy:

Using assessment techniques to improve

the impact of policy on health

School for Health

Contents

Foreword………………………………………………………………………….. 2
Aim ………………………………………………………………………………… 3
Objectives………………………………………………………………………… 3
Introduction……………………………………………………………………….. 3
Regional application of impact assessments…………………………………. 4
What tools to use and how to use them successfully………………………… 4
When to implement an assessment……………………………………………. 5
Advantages and challenges of impact assessment techniques…………….. 6
Conclusion………………………………………………………………………… 9
References………………………………………………………………………… 10
Appendices- Impact assessment methods
1- Health impact assessment…………………………………………… 14
2- Risk assessment………………………………………………………. 16
3- Economic impact assessment……………………………………….. 17
4- Environmental impact assessment………………………………….. 18
5- Social impact assessment……………………………………………. 20
6- Sustainability impact assessment………………………………….... 22
7- Integrated impact assessment……………………………………….. 23

Acknowledgements

Written by:
Jean Brown, independent public health management consultant and part-time
PhD student at the University of Durham JBconsultancy@aol.com; Elizabeth
Shassere and Soumen Sengupta, Health Development Agency, North East
Regional Office, University Science Park, John Snow House, Stockton Rd,
Durham DH1 3YG

Project funded by the Health Development Agency (North East Regional Office)
and developed in partnership with School of Health, University of Durham

Special thanks to:

David Chappel (NEPHO), Lucy Hamer (HDA), Elaine Rodger (RANE), Lorraine
Taylor (HDA), and Derek Ward (GONE) for their comments and guidance to
inform this work.
All of those colleagues within the North East Region and nationally who provided
feedback and input to the completion of this report.

Electronic copies of this report can be accessed at www.hiagateway.org.uk

From 1 April 2005, the National Institute for Clinical Excellence will take on the
functions of the Health Development Agency (HDA). The new organisation will
be the National Institute for Health and Clinical Excellence (to be known as
NICE). It will be the independent organisation responsible for providing national
guidance on the promotion of good health and the prevention and treatment of ill
health. For more information please see the NICE website at www.nice.org.uk

 Health Development Agency - March 2005

1
Foreword

The health and well-being that communities experience are primarily

determined by a range of economic, environmental and social factors. While
health care services do have an important contribution to make, securing
long-term health improvement demands active engagement from other
agencies and sectors.

The White Paper Choosing Health has stated that health is to be incorporated
as an explicit element of the regulatory impact assessment that is undertaken
of all national public policies. This resource seeks to build on this welcome
development, and outlines the potential contribution that impact assessment
can make to improving regional public policy. It briefly describes a number of
impact assessment methods, and addresses some of the challenges these
approaches might present in practice.

It is intended as an introduction to impact assessment for those involved in

policy development and decision-making in the statutory and non-statutory
sectors, particularly those whose primary roles or organisations are not
health-related. Furthermore, while it has been prepared with specific regard to
regional policy development it is not targeted at a solely regional audience - it
should be of assistance to those working to effect more local change too.

Fundamentally, the use of impact assessment methods should facilitate

evidence-based decision-making at policy level, and ultimately support the
implementation of more evidence-based action in practice. However, they are
only part of the health improvement process, and in themselves do not
guarantee real change. In order to be of substantive value, they need to be
backed up by a genuine commitment and willingness to accept their findings
and, critically, change policy accordingly.

We hope that you will find this document useful as you work to develop
policies that make a positive contribution to the health and well-being of all our
communities.

Soumen Sengupta David J. Hunter

Regional Associate Director (North Professor of Health Policy and
East), Health Development Agency Management, School for Health,
University of Durham

2
Aim

To relate policy assessment techniques to the development of regional public

policies to increase the positive effects and minimise the negative impact of
these policies on health.

Objectives

To develop greater understanding of the different kinds of impact assessment

and the value of conducting impact assessment in developing regional public
policy

To highlight the advantages and challenges of impact assessment techniques

To assist partners and key stakeholders in choosing an appropriate impact

assessment technique

Introduction

Though the public health white paper Choosing Health: making healthy
choices easier is an NHS document, much what it proposes are high level
cross-cutting efforts that must transcend sector boundaries1. The growing
awareness of the wider determinants of public health has led to an increase in
requirements to assess the risks posed to health by policies and decisions
made in traditionally non-health arenas. Increasingly, governments and
national bodies are calling for such assessments to be carried out in relation
to policies developed in departments responsible, for example, for economic
or fiscal policy, education, housing and transport.

Assessing policies for their impact or possible effects on health and its
underlying determinants is essential to improving health and reducing health
inequalities. Assessments aim to generate a set of evidence based
recommendations that inform the decision making process associated with
the policy or proposal. These recommendations can highlight the practical
ways to enhance the positive aspects of the policy and minimise the negative
impacts on health and inequalities2.

Whilst an impact assessment might not always be appropriate, there are

occasions when such an approach can be very helpful in policy development.
This report relates impact assessment with the development of regional
public policy, describes the techniques and clarifies their appropriate
use, and addresses their advantages and challenges. The types of
assessment covered are:
1) risk assessment;
2) economic assessments;
3) environmental assessments,
4) health impact assessment;
5) social impact assessment;
6) sustainability impact assessment and
7) integrated impact assessment.

3
Regional application of impact assessments

In the UK, at a regional level, policy or strategy development is rather different

from that at national or more local level. Until relatively recently, a policy will
often have been constructed at a national (government) level and the regional
role might be to adapt and implement at regional level. Under these
circumstances, a region might need to develop its own sub-policies. However,
with the NHS Plan3 in 2000 and the move of directors of public health into the
nine regional government offices in 2002, regions were enabled to approach
health as well as its wider determinants as discussed earlier1. Analysis of
policy from a health viewpoint is also, therefore, very much a regional
responsibility. Thinking of this in more positive terms, it is now becoming
easier for regional agencies to take actions that will benefit the specific
health needs of their populations. Whether as intermediaries between
central and local services or as policy-makers in their own right, regional
organizations increasingly need to assess implications and impacts of
policies. They have an important part to play in the delivery of health
improvement.

A number of policy vehicles can be identified as critical high level policies

crucial to the health portfolio:

• Developing a framework of regional indicators as an overarching

integrated reference for all agencies (Sustainable Development
Framework)
• The Regional Economic Strategy and investment for health
• The Regional Spatial Strategy
• The Regional Sustainability Strategy
• The Regional European Action Plan
• The Framework for Education and Skills Action

As Derek Wanless points out in his 2002 report Securing our future health:
taking a long-term view, good health is good economics4. Other important
policy areas include transport, housing, crime reduction, energy, sports,
image, waste, biodiversity, culture and rural action.

This shows the great scope for regional policy-makers to influence the health
of their region. There are, inevitably, practical issues around capability and
capacity of the regional organizations. The agendas for these organizations
(primarily Government Offices, Regional Assemblies and Regional
Development Agencies) are large and resources (mainly in terms of time and
of suitable personnel) are limited and stretched. This report contains
examples of methods that might prove useful in such assessments at a
regional level.

What tools to use and how to use them successfully

It has already been mentioned that there is no single tool that would be
appropriate to all situations. With that in mind, it might be appropriate for a

4
selection of tools to be kept readily available, with initial screening carried out
to identify the most appropriate, including different levels of assessment, in a
similar way to that suggested by Parry and Stevens and discussed in Health
Impact Assessment5. The criticisms voiced of single assessment and the
awareness that many different assessments are going to have be carried out
(with substantial overlaps between them) suggest that some form of
integrated assessment is probably going to become more practical and better
received than a straightforward health impact assessment. The North West’s
integrated appraisal toolkit mentioned in Appendix 7, Integrated Impact
Assessment, allows for flexibility and adaptation to local needs. There might
also be useful suggestions when the ODPM’s sustainability consultation
finishes.

Although integrated assessment is still in the early stages, advantage can be

taken now in an ad hoc manner of any types of assessment that are known to
be taking place. For example, joint working arrangements for an
environmental impact assessment that is under way for a particular policy
would allow some form of health sector input, be it health services, public
health, or input from the wider health community. This could even be fairly
informal. This would help to reinforce the value and workability of a proper
holistic assessment approach.

When to implement an assessment

Impact assessments can be prospective, concurrent or retrospective. The

choice between these will depend on circumstances, such as the timing of the
decision to carry out a study in relation to the start of an intervention or
implementation of a policy. Other factors influencing the choice will be cost,
availability of appropriate people to do the assessment, and the existence or
non-existence of related evidence bases.
• Prospective assessments might be viewed as ideal, in that they could
identify possible harm to health before the policy or practice is
implemented and the damage is done. However, inevitably there will be an
element of guesswork involved in the estimations of the extent of such
harm. Scott-Samuel states that “ideally assessment should take place
early enough in the development of a policy or project to permit
constructive modifications to be carried out before its implementation but
late enough for a clear idea to have been formed as to the nature and
content of the proposal”6.
• Concurrent assessments are conducted during implementation of the
policy or intervention. A concurrent assessment allows the modification as
negative health impacts are realised, and monitoring of predictions of
potential health impacts.
• Retrospective assessments have value in providing much-needed
evidence for subsequent prospective assessments7. There could be
occasions when a retrospective assessment is the only option, for
example if an unplanned event (such as a major foot and mouth outbreak,
a nuclear disaster or a terrorist gas attack in an underground railway
system) has occurred. Retrospective analysis of such events can lead to
suggestions in changes in policy.

5
Whilst there appears little dissent from the idea that a policy’s effects on
health and its determinants should be taken into account, it should not be
automatically assumed that a formal analytical impact assessment (such as
those described in this report) is the best way forward. There will be
occasions when such an approach is inappropriate, perhaps because of
serious resource difficulties or because unfortunate timing will not allow such
an assessment to have any influence.

However, should it be decided that a formal, analytical assessment is

appropriate, then users of the techniques might wish to consider which type of
assessment is more suitable, looking at its advantages and possible pitfalls.

Advantages and challenges of impact assessment techniques

In this section, common advantages to public health are discussed, and

potential problems and ways to address them are paired in Table 1.

Advantages to public health common to several techniques

All of the techniques, by definition, have the potential in some way to identify
parts of a policy that are likely to affect health, its determinants or inequalities.
Having identified these, a receptive policy-making structure will allow the
policy to be adapted so that they have, at least, very little negative impact
and, at most, a very positive impact on the lives and health of the population.

One very important advantage of many of the techniques is that they lead to a
raised awareness of the effects of “non-health” policies on health and of the
scale and scope of the wider determinants of health. This awareness-raising
can occur both within the NHS and in other stakeholder organizations, as well
as in the general public. It should therefore increase the likelihood that health
becomes a regular, embedded element of policy-makers’ thinking.

Assessments (and, particularly, the evidence collection which is an integral

part of them) potentially increase the bank of evidence available for
subsequent studies. Ensuring that this evidence base is useful and used
requires good dissemination of results, so that every new study can rely on it
rather than having to start again, spending time and money replicating the
work. It is not only the evidence underlying the assessments that is of value
but also any evidence accumulating about the successful impact of the
assessment itself. Particularly with Health Impact Assessment and Integrated
Impact Assessment, “the primary output is a set of evidence-based
recommendations geared to informing the decision-making process
associated with the proposal”2.

Because the techniques are analytical, they tend to be relatively

straightforward to use. Simple, step-by-step processes can be developed.
This adds to the ease of carrying out any policy assessment, possibly allowing
a wider range of people to be involved than more complex processes.

6
Some of the techniques have the potential to identify better resource
allocation, possibly freeing up money or other resources for more beneficial
use.

An additional benefit common to approaches which have more than one focus
is the increased potential for joint working, with its ensuing cost-saving,
avoidance of replication and sharing of ideas and responsibilities.

Potential problems and ways to address them

Table 1
Problems common to many Addressing the problems
approaches
• Shortage of resources A culture of public health awareness is
o Finance already being fostered in most public
o Time organizations. Continued efforts to
o Expertise/people with promote this, combined with good
the right knowledge dissemination of evidence of any
and skills successes in influencing policy, should
help people to recognize the value of
policy assessment.
Additionally, sharing of information and
underlying evidence can help to ensure
that resources are not wasted on
duplication.
Also, the balance of level of rigour with
resources can be facilitated by prioritizing
tiers of evidence available to the process.
Though the assessment might be costly,
the expense may identify potential
problems and lead to a saving in costs
attributable to poor health or underutilised
services.
• Organizational and Relationships between the regional
stakeholder issues organizations are key, as well as the ability
o Leadership and to build relationships with other
ownership stakeholders across the region, including
o Getting public voluntary sector, the public and local
participation commerce and industry. The joint working
agenda has increased considerably over
the past few years and the environment is
becoming more conducive to it. Sometimes
it is more appropriate for one organization
to lead an assessment but this should not
be seen as detracting from the
contributions of others. Good joint working
practices should also reduce duplication of
work and helping better use of scarce
resources (also see above).

An appropriate dissemination of results

7
 and, particularly, of any successful
implementations of findings could help to
overcome this problem showing that the
exercise has had a very practical, useful
outcome.

Good communication and transparency

(further discussed later) might help to
increase the knowledge and acceptance of
the techniques and therefore the
willingness of the public to become
involved.
• The impact of the impact It is to be hoped that, as the techniques
assessment become more widely accepted, appraisals
o Is it going to influence of their impact/influence become a routine
the policy? part of them and that dissemination of the
results also takes place to show how
successful (or otherwise) impact
assessments can be. (It might be that the
Public Health Observatories have a big
part to play here.)
• Evidence and data: Good dissemination of evidence helps to
transparency and credibility build confidence and credibility, as does a
o Availability of good “warts and all” approach, allowing criticism
evidence, particularly and discussion of assumptions and
robust data possible bias.
o Acceptability of
approach
• Selection criteria, timing and Plans need to be in place for an initial
weighting of findings screening of policies to determine
o Identifying policies for suitability or necessity for analytical
assessment assessment and the extent and timing of
o Assessing at the any such assessment
appropriate stages of
policy development Whilst accommodating all concerns equally
o Avoiding bias seems unlikely, transparency should help
to allay such criticism.
A tick-box exercise? Increasingly, the need for health
consideration is on the agenda of most
public organizations. Continuing to foster
this culture might help to ensure that
professionals do not regard an assessment
as any form of tick-box exercise.
Dissemination of evidence, of results and,
in particular, of evidence of influence of the
assessments will also be vital to show the
value of the work.

8
Conclusion

Whatever the approach taken, it is important that a robust evidence base is

maintained, developed, and used. For example, a good selection of evidence
is accumulating on all the websites that specialise in health impact
assessment. Assuring that this is readily accessible to potential users would
be a valuable step, helping to reduce the time taken and the amount of
repetition that happens when trying to collect evidence. Similarly, the
continued sharing of experience at a regional level could allow regional
decision-makers to see other ways of approaching problems and to learn the
types of approach that are less or more successful than others.

It is important to keep in mind that while impact assessment techniques can

produce effective recommendations to maximise health benefit and minimise
health risk, just conducting an assessment is not adequate. There must be
cooperation and buy in from all parties with control over policy development in
order to make changes that will make a difference.

9
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government have been good for your health?” British Medical Journal;
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2. Quigley, R, Cavanagh, S, Harrison, D, Taylor, L (2003) Clarifying health
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reform. London: Stationery Office, 2002.
4. Wanless, D, (2003) Securing Good Health for the Whole Population
Department of Health, London. www.doh.gov.uk
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6. Scott-Samuel, A. (1998). "Health impact assessment--theory into practice."
J Epidemiol Community Health 52(11): 704-5
7. WHO Regional Office for Europe Health impact assessment.
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1, jan 2004
8. Department of Health (2004). Choosing health: making healthy choices
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Spatial Strategy, North East Public Health Observatory.
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process through health impact assessment. Learning from practice
bulletin. London, Health Development Agency.
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epidemiologic risk assessment." Epidemiology 10(5): 585-93
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the 21st century: new perspectives on policy, participation and practice. J.
Orme, J. Powell, P. Taylor, T. Harrison and M. Grey. Maidenhead, Open
University Press.
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other forms of impact assessment." J Public Health Med 25(2): 107-12
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in support of the European regional strategy for health for all, World Health
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DTLR.http://www.planning.odpm.gov.uk/eia/guideline/index.htm,
18. Kunzli, N. (2002). "The public health relevance of air pollution abatement."
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20. de Hollander, A. E. M., J. M. Melse, et al. (1999). "An aggregate public
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health impact assessment help?" J Law Med Ethics 30(4): 734-8
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11
APPENDICES

Impact assessment methods

12
Appendix 1
Health impact assessment

HIA is an approach that can help identify and consider the health and
inequalities impacts of a proposal on a given population. The usual starting
point for an HIA is a policy, programme, strategy plan, project or other
development that has not yet been implemented. Its primary output is a set of
evidence-based recommendations geared to informing the decision-making
process associated with the proposal2. Application of health impact
assessment to a policy or strategy will necessarily focus on the wider
determinants of health.

The public health white paper Choosing Health: Making Healthy Choices
Easier8 emphasises that regional Department of Health representatives will
lead on ensuring that regional partners take into account the health impact of
their policies, such as housing, transport, planning, employment and
education.

The process

Health Impact Assessment includes:

1. The screening process, exploring which policies or programmes could
have an impact on health and what kind of impact.
2. A scoping process is carried out if further information is needed to
determine what further work should be carried out, by whom and how
3. The appraisal process, identifying and considering the evidence of health
impact
4. Formulating and prioritizing recommendations
5. Further engagement with decision-makers
6. Ongoing monitoring and evaluation2

Using Health Impact Assessment

At a regional level in England, a rapid health impact assessment was carried

out in the Government Offices North East (GONE) region on the Regional
Planning Guidance RPG1. Guidance was also provided on the sorts of
impacts to consider under each heading. At the time of writing (November
2004), the North East Assembly is developing a Regional Spatial Strategy
(RSS) to replace current Regional Planning Guidance in 2006. A screening
Health Impact Assessment was carried out on the pre-consultation draft for
this RSS9 assessing nine of its 54 policies. The assessment considered
health impact, inequality impact, and effect on health services and allowed for
comments as well as scores.

Unique characteristics of HIA

• Public or community understanding of health and determinants can be

enhanced by the participatory nature of health impact assessments.10

13
• No one blueprint could suffice for all occasions. The purpose and the
approach differ according to who is carrying them out and the resources
available also vary.
• Health impact assessment can mean different things to different
professional groups. There is a lack of clarity and of shared understanding
of exactly what HIA is comprised.
• Much of the data that could help health impact analysis is not readily
available but remains in the grey literature5, difficult to access and easily
overlooked.
• Lack of attention to inequalities and too much focus strictly on economics
can minimise the potential benefits to the community.
• Communication of results of assessments to both policy-makers and the
community can be challenging, both do the logistics of the exercise and in
translating the results into accessible language for a variety of
professionals and lay people.

Recent years have seen tremendous growth in both the theory and the
application of health impact assessment. Major national and international
centres have developed, providing a wealth of information. The London
region has also used the technique in efforts to engage the public in policy
making, with assessments carried out on several strategies, including
transport. Many of the centres listed On the Health Impact Assessment
gateway website (http://www.hiagateway.org.uk) contain up-to-date examples
of guidelines and variations on the HIA process.

14
Appendix 2
Risk assessment

Risk assessment has been used historically for longer than any of the other
techniques in this report. It is a method for “systematically identifying and
assessing factors that influence the probability and consequences of a
negative event occurring”11.

The process

Risk assessment for environmental or occupational exposures classically

involves four phases:
1. hazard identification (the detection of the potential for agents to cause
adverse health effects in exposed populations);
2. exposure assessment (the quantification of exposures and the estimation
of the characteristics and sizes of the exposed populations);
3. dose-response assessment (understanding the distribution of risk in the
populations);
4. risk characterization (the evaluation of the impact of a change in exposure
levels on public health effects).12,13

Using Risk Impact Assessment

This technique is mostly used in exposures to potentially toxic substances.

However, as it is a rigorous approach, other types of assessments incorporate
many of the techniques. It can also in itself provide an evidence base for
environmental and health assessments.

Unique characteristics of RIA

• It can be difficult to balance scientific evidence with social concern.

15
Appendix 3
Economic impact assessment

Economic impact assessment considers the effects of a policy or project on

the economy or on particular aspects of it. It systematically assesses the
relative values of different courses of action. It has relevance to health in at
least two ways:
1) Health status is known to be influenced by economic circumstances, so
that if an economic impact assessment leads to an improvement in
economic situation, this could be expected to have a knock-on effect on
health.
2) With regard to specific health policy, if economic evaluations lead to a
saving in cost in a particular area of health spending, this could free up
funding for further investment in other areas of health care expenditure.

An economic evaluation will basically look at costs (including resources,

generally expressed in monetary terms) and outcomes. Where the outcome
(the change in the burden of disease that results from the intervention) is
measured in health indicators, this is referred to as a cost-effectiveness
analysis – an example of health indicators would be the number of deaths or
cases. Where the outcome is measured in units that reflect not just health
indicators but also less quantifiable factors such as quality of life, this is
referred to as a cost-utility analysis. In cost-benefit analysis, all outcomes
are measured in monetary units.

The process

A framework for economic evaluation of public health interventions comprises

four stages:
1. Pre-implementation- defining interventions and identifying key components
2. Piloting- greater definition of the problem and identifying comparison
group, costs and outcome measures
3. Main evaluation - measure costs and outcomes of interventions
4. Long-term implementation.14

Using Economic Impact Assessment

Economic evaluations could certainly be used in the development of any

policy aimed at addressing a particular major disease or the burden of that
disease or, indeed, a risk factor for a disease (such as smoking). Derek
Wanless, in his 2003 report Securing Good Health for the Whole Population,
describes trends in smoking cessation and presents evidence to question the
way data is looked at to inform resource allocation and measurement of
impact.4 He emphasizes that the correct indicators must be chosen to ensure
an accurate economic impact assessment.

Unique characteristics of EIA

Because it aims to be rational and structured, there is scope for ignoring
certain ethical issues at the expense of purely financial returns or gains in
efficiency.

16
Appendix 4
Environmental impact assessment

What is it?

An environmental impact assessment “determine[s] potential environmental,

social and health effects of a proposed development in a form that permits a
logical and rational decision to be made”.15

The term “environmental health assessment” is frequently used to denote an

environmental impact assessment that has a specific human health
component. Joint health and environment assessments are further discussed
under Integrated Impact Assessment later in this document.

The process

As well as being part of the World Health Organisation’s Targets for Health for
All by the Year 200016, environmental impact assessment is now an integral
part of EC directives (Directive (85/337/EEC as amended by 97/11/EC) and a
statutory planning requirement in the UK. Department of Transport, Local
Government, and the Regions (DTLR) guidelines specify the circumstances
under which environmental impact assessment must take place and indicate
the types of questions that must be posed and answered.

It is a procedure that must be followed for certain types of development before

they are granted development consent17. The procedure requires the
developer to:
1. Compile an Environmental Statement (ES) describing the likely significant
effects of the development on the environment and proposed mitigation
measures.
2. Circulate the ES to statutory consultation bodies and make it available to
the public for comment.
3. The competent authority (e.g., local planning authority), must take account
of the ES and its contents, together with any comments before it may grant
consent.

Using Environmental Impact Assessment

Specific aspects of public health concern have been addressed in some

environmental assessments. For example, air pollution attributable cases
(mortality, chronic bronchitis incidence, hospital admissions, acute bronchitis
among children, restricted activity days, asthma attacks) were studied using
results of a tri-national (Austria, France and Switzerland) impact assessment
study18.

Unique characteristics to EIA

• Action taken following identification of issues around toxins, pollutants,

noise and other factors through environmental impact assessment can
have a very direct effect on human health.

17
• Can evaluate risks to the environment of individual hazards, rather than
considering cumulative impacts of several substances19,20.
• Environmental health problems are complex and require interdisciplinary
working. On its own, an environmental impact assessment does not focus
on human health. Therefore, it does not meet the needs of a health
assessment. Impacts on human health must be specifically incorporated.
• The timing of environmental assessments can reduce their impact. When
the assessment is of a project rather than a policy, it is often at too late a
stage to influence the broader policy itself21.

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Appendix 5
Social impact assessment

Developed in the USA to fulfil requirements under the National Environmental

Policy Act (NEPA) for assessment of impacts on the human environment,
social impact assessment looks at many of the determinants of health. Within
the UK, it is sometimes used where particular proposals do not need an
environmental impact assessment15. Connected with social impact
assessment are various other assessments, such as human rights impact
assessment22,23 and equity assessment.

The process

The Interorganisational Committee on Guidelines and Principles for Social

Impact Assessment provide the following process outline for SIA:
1. Public involvement - Develop an effective public involvement plan
2. Identification of alternatives - Describe the proposed action or policy
change and reasonable alternatives.
3. Baseline conditions - Describe the relevant human environment/area of
influence and baseline conditions.
4. Scoping - Identify the full range of probable social impacts that will be
addressed based on discussion or interviews with numbers of all
potentially affected.
5. Projection of estimated effects - Investigate the probable impacts.
6. Predicting responses to impacts
7. Indirect and cumulative impacts - Estimate subsequent impacts and
cumulative impacts.
8. Changes in alternatives - Recommend new or changed alternatives and
estimate or project their consequences.
9. Mitigation - Develop a mitigation plan.
10. Monitoring – Develop a monitoring program.24

Using Social Impact Assessment

Rural-proofing, connected with social exclusion, is an aspect of social impact

assessment that has had a lot of coverage in recent years. Even as early as
1981, attempts were being made to consider effects of changes in policy or
services on rural communities. In the UK, the rural white paper addressed the
issues of rural communities and stated the government would establish a
rural-proofing mechanism to ensure that all major policies were assessed for
their rural impact25. The Local Government Association produced a paper to
help local authorities to deal with the problems of social exclusion in rural
communities26 and the Countryside Agency produced a checklist
(http://www.countryside.gov.uk/Images/CA%2035_tcm2-12127.pdf) for policy-
makers, advising what steps to take and including a set of questions to be
posed of any policy27.

Other examples include the use of quality of life measures to assess the
impact of changes in rehabilitation services on disabled people28 and a study
of perceptions of mental health patients, providers and families following a

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policy of moving from hospital-based towards community-based mental health
services29.

Unique characteristics of SIA

• Social Impact Assessment can indicate measures of social exclusion and

rural social exclusion, which are on the public health agenda for reducing
health inequalities. Assessment addressing those problems will therefore
be of great relevance to public health.

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Appendix 6
Sustainability impact assessment

Strongly linked to environmental impact assessment, techniques for

assessing effects on sustainability have been used or suggested for use at
international, national and UK regional levels. Sustainability encompasses
economic, environmental and social dimensions30.

The Process
The Office of the Deputy Prime Minister in England has recently published a
consultation paper on sustainability appraisal of regional spatial strategies and
local development frameworks. It suggests the following eight stages for use
of sustainability assessment with Regional Spatial Strategies:
Stage 1: Draw up a project plan in consultation with the Government Office (GO).
Stage 2: Develop strategic options in co-operation with GO and other stakeholders,
Stage 3: Submission of the draft revision to the Secretary of State with SA Report;
Stage 4: Examination-in-Public;
Stage 5: Publication of the Panel Report;
Stage 6: Publication and consultation on proposed
Stage 7: Issue of revised RSS; and
Stage 8: Implementation, monitoring and review.31
http://www.odpm.gov.uk/stellent/groups/odpm_planning/documents/page/odp
m_plan_030923.pdf

Using Sustainability Impact assessment

In the UK, under the Planning and Compulsory Purchase Act, 2004,
Sustainability Impact Assessment is mandatory for Regional Spatial
Strategies, Development Plan documents and Supplementary Planning
documents.

Unique characteristics of SIA

• As the emphasis on the societal element is stronger than in most other

assessments, there are definite advantages to public health in that even
more of the underlying determinants of health are considered.

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Appendix 7
Integrated impact assessment

Integrated impact assessment has been defined as “a diverse collection of

methods and practice for which the common goal is to integrate
environmental, economic, social and other forms of impact assessment32. In
many ways, this is similar to sustainability impact assessment.

There have been many instances where two or three types of impact
assessment have been linked and essentially carried out together. Often this
has been in response to concerns that a particular aspect has not been
covered in one type of assessment. In particular, in recent years many
attempts have been made to combine health and environmental impact
assessments.

The process

Key elements of an integrated environmental health impact assessment

model include:
1. Project analysis
2. Analysis of status quo (including regional analysis, population analysis,
and background situation)
3. Prediction of impact (including prognosis of future pollution and prognosis
of health impact)
4. Assessment of impact
5. Recommendations
6. Communication of results
7. Evaluation of the overall procedure33

Using Integrated Impact Assessment

In the UK, the Office of the Deputy Prime Minister has published the 3 Rs
guidance (regeneration, renewal and regional development), which aims to
“set out the broad framework within which the assessment of spatially
targeted interventions should take place”31. The techniques are intended also
to be used on occasions when the prime focus of a policy is not one of the
three Rs.

In the North East region of England by the Government Offices, a rapid

integrated impact assessment was carried out in March 2003 on the regional
housing strategy, as part of a set of pilots under the Department of
Transport’s Integrated Policy Appraisal initiative. This made use of Better
Policy Making’s Integrated Policy Appraisal screening checklist and summary
appraisal tables.

The North West region has developed an integrated impact assessment

tool34, available on the Health Impact Assessment gateway website
(http://www.hiagateway.org.uk).

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Unique characteristics of IIA

• Integrated impact assessment has a significant capacity to consolidate –

rather than duplicate – other assessment frameworks35.
• There could be extra difficulties in prioritising and weighting different
outcomes when more than one type of assessment is being used. To
produce assessments with conclusions or recommendations,
multidisciplinary teams need to find ways of agreeing priorities and
effectively rank outcomes against one another.
• There are difficulties over finding appropriate methods for integrated
assessments and also for incorporating the stakeholder consultation
element30. As a result of their findings from several case studies, Bond et
al presented a set of recommendations, including: clarity from the outset of
the roles of the different disciplines; planning of stakeholder consultation;
development of effective communication of results; and assessment at the
beginning of the skills needed for the assessment, so that deficiencies
could be addressed.
• In the same way that there are no standard blueprints for health or
environmental impact assessments, each occasion for use of integrated
impact assessment will have its own characteristics. This does mean that
there is scope for subjectivity and political influence although ideally good
consultation processes will help to avoid these.

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