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Health Impact Assessments and Equity – Do they help?

June 19, 2011

I have recently started doing  a piece of work across the EU – a “Joint Action” for Health Action Partnership International which is concerned with strengthening Health Impact Assessments with an Equity Focus. As part of this work I was at a Euregio III symposium last week in Liverpool looking at Health Impact Assessments and their role.

I think that in most countries including the UK there is no duty to conduct an HIA. As far as I understand it in the UK there are two statutory impact assessments. These are an “Impact Assessment” and and “Equality Impact Assessment”. If you go to the DH website you can see examples of both of these. DH defines an Impact Assessment as:

DH Definition – An impact assessment (IA), (which replaced regulatory impact assessments in May 2007) is a short structured template published with regulatory proposals, new legislation and policy implementation. It concisely describes the issue and identifies costs and benefits that are likely to impact the public, private and/or third sector. An IA must accompany any published new legislation (including European legislation). An IA is an important tool to ensure that the principles of good regulation are followed: proportionality, accountability, consistency, transparency, targeting.

I think that a clearer description is the one provided by DWP it helps us understand that an Impact Assessment is not something that is just a technical exercise carried out by some civil servants in Whitehall – it is actually a gateway that enables communication and lobbying by organisations OUTSIDE government.

DWP Definition – Impact assessments (formerly regulatory impact assessments) help to explain the effects of government proposals which impact on the private, public and third sectors. The third sector includes charities and voluntary organisations. Impact assessments are published so that those with an interest understand and can challenge:

  1. why the Government is proposing to take action
  2. how new policies may affect people
  3. the estimated costs and benefits.

Impact assessments also help the Government and policy-makers think through and understand the effects of their proposals.

For more on DWP impact assessments see this link.

It may just be me – but I think that few people outside of government pay much attention to impact assessments – instead focussing on the white papers etc. In fact it is the Impact Assessment that gives us a more tangible grasp of what a particular policy might do. Impact Assessments provide more territory to fight over and offer a framework within which to do it.

A good summary produced by the Cabinet Office is here.

This is not to say that government impact assessments are particularly good. People have said to me that they can just be box ticking exercises.

So lets look at one that impacts on health – but is concerned with the wider determinants of health. The Government changes to Work Capability Assessment – to get more people off Employment Support Allowance (ESA) and back into work. This is titled – “Amendment to Work Capability Assessments – the Employment and Support Allowance (Limited Capability for Work and Limited Capability for Work-Related Activity) (Amendment) Regulations 2011”

I think that the Impact Assessment is here.

When we look at it we see that it is called ‘Impact Assessment’ I think this is the Statutory Impact Assessment – and wrapped up in it is the ‘Statutory Equalities Duty Impact Test” which looks at the impact on Race, Disability, Gender and Sexuality. There are then a host of other impact assessments which I think are mandatory but not statutory. In other words Government recognises that they should be done but is not required to do them by law.

They include economic, environmental, social and sustainability impact assessments. One of the social ones is health – hooray! It all seems pretty sensible stuff too:

  • Will your policy have a significant impact on health – specifically the wider determinants of health?
  • Will there be an impact on lifestyle?
  • Is there likely to be a significant demand on health and social care services?

If your answer is yes to any two of the above – then you need to conduct a full HIA.

When we look at the ESA Impact Assessment we would expect to see consideration of the impact on peoples health and well being – yet apparently there is NO impact to health and well being! This is despite the fact that 38% of people are receiving ESA because of mental health problems, there are a huge inequalities in terms of who relies on ESA, there are real issues of poverty, housing insecurity etc.

While the Equalities Impact box is ticked it seems to me that the assessment focusses almost exclusively on delivery issues associated with assessment – how to ensure that staff who conduct assessments do so in a way that is culturally aware for example – rather than on the impact of the regulatory change itself.

As I understand it the responsibility to produce a Health Impact Assessment rests with DH – there is no evidence that I can find that they have produced one.

So what to conclude?

Some of the frameworks feel quite good but this Impact Assessment seems to have presented little challenge.

  • boxes have been ticked.
  • The Health and Wellbeing agenda has been ignored
  • DH has not championed the health and wellbeing agenda

If I am right about the above then I think that this presents a real challenge to those of us who are charged with making impact assessments work at a national and a local level – and for me highlights the fact that it is possible to have a great looking process on paper – but little impact in reality.

Or have I missed something?

2 Comments leave one →
  1. Dave Buck permalink
    June 23, 2011 16:24

    I agree entirely with what you say here. The structures are in place in central government – hooray – but there are no incentives to use them, or penalties if they’re not. If the Dept of Health is really seriously interested in “improving the health of the poorest fastest” the first thing it would do is get behind HIA in government. One way to do this is to get central government’s own house in order and give the Select Committee on Public Health a remit to both undertake and publically monitor HIAs – so that the quality can be seen by all.

    Of course, there are other challenges to HIA’s, including my own opinion that they need to up their game in terms of quantificatin. We also need to get equity weights or other techniques into cost-effectiveness and cost-benefit analysis of health and healthcare interventions to start to balance the focus on efficiency with how the population values equity or fairness in distributiuon of gains in health, as well as maximising the amount overall. There has been a lot of academic work in this area already, but it needs to be tested in real situations.

  2. Jordan Panayotov permalink
    July 6, 2011 15:32

    RE: Health Impact Assessment and Equity

    HIA has the potential to be very useful for informing decisions for resource allocation, however, it has problems with the methodology, especially with validity of predictions.
    As result many HIAs are HIA by name and not by content. Apart from this, there is a plethora of names for HIA, which creates confusion and diminishes credibility of HIA.

    The Report “EU Joint Action on Health Inequalities” which is available here
    notes that:
    “there was a consensus that HIA should be the only term used with other terms not being appropriate and that a HIA is incomplete if it does not consider equity impacts within its process”

    At last there is consensus about the name! I consider this as an important step to stop the confusion stemming from different names used and to raise the value and credibility of HIA at all levels of decision-making. Another very important point is the acknowledgement that HIAs which do not specifically address health inequalities are incomplete. I think that it will be useful for future HIAs if someone could conduct a systematic review of HIAs completed during last 10 years to find out how many of these are in fact “complete” ones, i.e. specifically addressing health inequalities.

    For more on the subject see “Equity Focussed Health Impact Assessment – A Step Forward or Two Steps Backwards” available here

    RE: Equity – Efficiency debate

    See “Equity – A Premise for Efficiency in Health”
    (with example from real situations) available here

    Other useful presentations:

    “What should we strive for in urban development – increasing Average Health Status or decreasing Health Inequalities: the role of HIA”

    “Health Promotion: Is Sustainable Development Possible Without Health Equity?”

    “HIA: Is Sustainable Wellbeing Possible Without Health Equity?”

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