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Health Impact Assessments and Equity – Do they help?

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:

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.

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?

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