Influencing the Decision Making Process Through HIA - HDA England - 2003

8/14/2019 Influencing the Decision Making Process Through HIA - HDA England - 2003

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Introduction

Influencing decisionsHealth impact assessment aims to influencedecisions, and the people who take them, toimprove health. Some people argue that thelimits of HIA extend only as far as issuingimpartial recommendations. But most

practitioners feel that the fundamental goal ofHIA goes beyond just providing information the aim of HIA is to achieve changes in policiesand proposals so that they support betterhealth and reduce health inequalities. Therecommendations of an HIA can includesuggestions for enhancing positive aspects ofproposals, as well as recommendations tomitigate any potentially negative aspects. ManyHIAs therefore overtly aim to influence thedecision-making process.

The point with which most people are

concerned is the opportunity to influence theoutcomes of a consultation process or a keydecision-taking committee meeting. But if HIAsare viewed in context, the scope for influencing

appears much more extensive. Influentialoutputs from HIAs include not just the finalrecommendations, but potentially a host oflessons and action points that could influencefuture decisions and activity within partner

organisations involved in the HIA.

This bulletin uses practitioners experience toshow why influencing is best seen as acontinuing process within HIA, rather than anactivity confined to one point in time.Influencing activity built into all appropriatestages of an HIA can help deliver much betterresults, helping to ensure recommendations areaccepted, and that decisions once made areimplemented.

Health impact assessment is a political process

insofar as it requires engagement with politicaldecision-making structures. But HIA should alsobe a transparent and objective process, guidedby evidence from a range of sources, which

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Influencing the decision-making processthrough health impact assessment

This bulletin provides information for practitionersinvolved in planning, leading or contributing tohealth impact assessments (HIAs). It is one of aseries of HIA Learning from Practice bulletins. Thefull series covers:

Evaluating health impact assessment Addressing inequalities through health impact

assessment Influencing the decision-making process

through health impact assessment Deciding when health impact assessment isneeded (screening for HIA).

The information in this bulletin is based on thereal-world, practical experience of HIApractitioners, leading academics, policy makersand commissioners involved in a variety of HIAsacross the country. Much of it was shared at aLearning from Practice workshop organised bythe Health Development Agency (HDA) inDecember 2002. Further information about theLearning from Practice workshop and copies ofthe other summary bulletins in this series can be

found at www.hiagateway.org.uk


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Influencing decisions (continued)

confers independence and credibility on therecommendations produced. This bulletinexplores some of the difficulties involved instriking this balance, and offers practicalsuggestions based on past HIAs.

Much of the activity described in this bulletin iscommon to many areas of public healthpractice. But in the context of HIA, it can be

useful to give more thought than usual toinfluencing decisions. Health impact assessmentis not yet part of the core activity of most of theorganisations involved, and does not havestatutory force. So those involved in HIA need

to pay closer attention to the way they goabout influencing the views of decision makers.

Learning from practice examples

Working with partners to make Westminster a healthier city: HIA through best value review

Westminster City Council applied HIA in aninnovative way, using it as the basis for a BestValue Review (BVR). The BVR addressed twoquestions:

How do the policies of council departmentsimprove health and reduce inequalities inhealth for Westminster residents?

Are the new Joint Health Partnershipstructures and planning processes fit forpurpose?

Nine areas of council policy were chosen forconsideration, including topics such as fuelpoverty and safer routes to school.Departmental management teams used ascreening tool, based on the London HealthCommissions documentation, to decide whatpolicies should be selected. The BVR lead metwith all departmental management teams toexplain what was involved. The policies chosenspanned all main council service areas. Rapidappraisal workshops were held for each topic.

A steering group was set up involving assistantdirectors from all departments, plus theprimary care group public health consultant,the Kings Fund and Croydon Council (HealthBeacon) as external bodies to provide adviceand guidance. A review team of peopleidentified by each of the nine service areasoversaw the HIA workshops, reports andrecommendations.

The decision-making structure for the HIAsrecommendations was clearly identified:

The Chief Officers Board agreed the scopeof the BVR and use of HIA for all service

areas in the council and gave high-levelcommitment to HIA Departmental management teams decided

what recommendations from the

workshops would be taken forward as partof the business planning cycle of work forthe council and agreed ownership of theCross-Council Action Plan

When blockages were identified (such as adepartment not coming up with a policy toreview) this was referred to the steeringgroup for action

The Cabinet Member for Social Servicessigned off the Cross-Council Action Planafter it had been agreed by thedepartmental management teams and

Chief Officers Board.

The experience provided the following lessons:

What worked well using the BVRframework provided status and credibilitythroughout the council; having ChiefOfficers support was essential; having theinterface between specialists and the publichelped in making changes to council policy

What was difficult some departments hadgreat difficulty seeing what benefit it wouldbe: they thought of HIA as consultation,and some areas had already consulted fullyon their policies; not all made theconnection that HIA could inform otherwork.

As a result of the BVR, the council has linkedHIA into council policy making, including theperformance plan, best value and partnershipwork. It is also developing links betweenenvironmental assessment and HIA for lettingcontracts, and carrying out assessments fornew projects, programmes and policies.

With thanks to Colleen Williams, Policy

Manager (Health), Westminster City Council


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HIA on economic development and regeneration policy in the East End of Sheffield

The East End Quality of Life Initiative (EEQOL)was established in 1999 to tackle healthinequalities by increasing communityinvolvement in strategic developmentdecisions for the East End of Sheffield.

EEQOL conducted a comprehensive,participatory and prospective HIA of theRotherhamSheffield M1 Corridor PlanningStudy. The study was designed to informinvestment in one of three strategic economiczones within South Yorkshires Objective Oneregeneration programme.

The team was interested to see whether HIAcould be a tool to support a more integrated,participatory, and therefore more sustainableapproach to development strategy, and gavecareful consideration to how it could influence

the decision-making process.

A number of decision-making fora wereidentified as relevant to the HIA, including:

Local community forum meetings East End Standing Conferences (community

business agencies) East End Strategy Group (City Council;

Community Forum, Health; Business Forum,working towards sustainable developmentof the East End of Sheffield)

The local strategic partnership.

The main focus was on influencing theintegrated development plan for the strategic

economic zone. With this in mind, HIArecommendations were widely disseminated toinform debate and discussion on investmentplans for the area. Those that had the mostimpact were:

HIA recommendations submitted toconsultants developing the integrateddevelopment plan for the strategiceconomic zone

Submissions to various drafts of theintegrated development plan

Contributions to integrated business plansrequired by developers

The team is currently working on detailedcommunity engagement at an importantdevelopment site.

An evaluation of the process concluded that

the HIA had helped articulate not only localcommunity concerns, but also potentialsolutions, and that understanding anddialogue between the key stakeholders hadincreased as a result. It encouraged a widerdebate on the dilemma, by no means uniqueto Sheffields East End, of how to integrate thetwin goals of inclusion and prosperity. The HIAhas informed subsequent work onmainstreaming sustainable development withthe local strategic partnership, and at theregional level, a sustainability appraisalincorporating health impacts.

With thanks to Neil Parry, Project Worker,Sheffield East End Quality of Life Initiative

Why will decision makers welcome HIA?

Health impact assessments are likely to be moreinfluential if they directly address issues ofconcern to decision makers. However,establishing whether HIAs have been influential isalways difficult. It can be difficult to establish acause-and-effect relationship between HIArecommendations and subsequent decisionsbecause, in reality, decision makers are subject toa much fuller range of influences. The followingissues have been identified by HIA practitioners ashaving helped to generate support and interest inHIA among decision makers.

Better services

HIA can be a useful driver for service excellence.Participatory HIAs provide information based onstakeholder knowledge which can reveal gaps in

provision. By focusing not just on the likely impactof the proposals or policies in theory, but on theissues likely to affect their implementation inpractice, participants involved in HIA can generate

suggestions for ways in which systems andorganisations could work better together tosupport health. This information, and the linksforged by participation in the HIA process, can bea useful basis for further work to achieveimprovements in services and partnershipworking. A growing number of organisationsnow see HIA as a strength when shaping bids forfunding, or applying for awards and excellenceratings.

Addressing institutional and community concerns

As well as providing fresh insights into howsuccessfully existing services are being provided,or how well proposals are likely to operate inpractice, HIA can also provide a vehicle foraddressing broader community or organisational

concerns. By adopting participatory methods, andby considering the interplay between thedeterminants of health, HIA can help build abetter understanding of community concerns.


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Challenges in influencing the decision-making process through HIA

As experience of conducting HIAs grows,practitioners are developing a more sophisticated

understanding of the factors that HIAs affect, andhow far HIAs can exert a beneficial influence.Some of the challenges commonly encounteredare listed below.

Resolving conflict

Health impact assessments can uncover areas oftension not previously resolved, makinginfluencing the decision-making process a difficulttask. Those involved need to work towardspresenting a single set of clear recommendations,based on the best available evidence, and

informed by stakeholders knowledge andexperience. But what happens when stakeholdersperceptions differ? Or when stakeholders views,such as a specific concern held by a localresidents group, are not borne out by theevidence? It can be a demanding job to reconcilethese different viewpoints, build commonunderstanding, manage expectations, and presentdecision makers with enough information toconsider the options before them. This processmay present a steep learning curve forprofessionals and experts unused to engagingdirectly with lay opinion. Yet decision makers will

want to know the range of views that exist, andhow these have been obtained and explored. Afull report that openly acknowledges areas ofdisagreement or uncertainty will be of more usethan an oversimplified version of the debate todecision makers who are used to applying political

judgement.

Being accountable

The process for commissioning the HIA can beimportant. The client for the HIA and the endaudience for the recommendations may not

always be the same. It is increasingly common forprospective developers to commission HIAs to

support planning applications for large-scaledevelopments. Some practitioners have reported

concerns about vested interests in such situations.The HIA process should always be conductedaccording to agreed good practice, andrecommendations should be made openly andimpartially, with adequate explanation of howthey were reached.

There should be no inherent difference betweenHIAs commissioned by the private or the publicsector. The key distinction is most likely to be inthe directness of the relationship between thoseconducting the HIA, and those who need to takedecisions based on it. An HIA undertaken by

consultants on behalf of a private-sector housingdeveloper, who then presents it to a planningauthority, displays a less direct influencingrelationship than an HIA undertaken by a publichealth team reporting to a local strategicpartnership panel or primary care trustmembership. Practitioners need to adapt theirtechniques accordingly.It is occasionally suggested that HIA may be opento legal challenge, although this has not yetoccurred in practice. Provided those involved areopen about the process they have gone through,this need not be a concern. Practitioners should be

transparent about the basis for theirrecommendations, including describing the typesof evidence used, showing how it was the bestavailable within the scope of the exercise, but alsoacknowledging any limitations.

These concerns and challenges are common tomany HIA practitioners but there are manyexamples of HIAs that have addressed andovercome these issues to deliver effectiverecommendations that have changed policies andpractice. Suggestions for addressing the challengesoutlined above can be found in the following

section.

Health impact assessment can provide anopportunity for these concerns to be addressedthrough dialogue with the professionalsresponsible, improving the chances of commonground being reached. It can therefore be avaluable tool for addressing contentious issuesand proposals, although the complexities of doing

so should not be underestimated.

Transparency and accountability

HIA should be a transparent and open process,and as such has much to offer organisations that

wish to demonstrate that they have considered allaspects of their proposed actions. Health impactassessment can contribute to better decisionmaking by providing information andrecommendations based on the best availableevidence from a range of sources. Many decisionmakers are interested in the potential for HIA to

contribute to scrutiny of proposals and servicedelivery, and in some cases this has provided themomentum for conducting an HIA beforeproposals are considered by a scrutiny committee.


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Promising practice guidance

Getting it right from the start

Your approach to influencing should beconsidered at every stage of the HIA process, tomake the most of opportunities for building

relationships and passing on information.

Know what you want to achieve

Be clear about what you want to influence.The outcomes of a key decision-takingmeeting may be just one of a number ofgoals. Other outcomes might include betterpartnership working, or specific service andsystems improvements.

Setting clear aims and objectives for the HIAwill help you to define who your

stakeholders are, and to identify themethods needed to involve and influencethem. Some key individuals may not beinvolved in HIA events or workshops, andyou will need to consider other ways ofengaging with them.

Identify the partners that can help youachieve your objectives, including those whoalready have good communications andrelationships with decision makers. Aim toinvolve them positively from the start, inworking groups or by providing briefings.

Understand how decisions will be made

Make sure you know how the decisions youhope to influence will be reached, when,and by whom. Develop key contacts whounderstand the organisational structures andprocesses that you will need to know about.

Establish whether there are formalproceedings to work through, such ascommittee meetings or examinations inpublic. Find out how information should bepresented to such meetings, including the

length and format of any written material. Consider presenting to the decision makers

the best available qualitative and quantitativeinformation (given your resources).

Be clear about the timescale against whichdecisions will be made, and ensure yourinformation is ready to be circulated inadvance. Be prepared to be flexible in yourmethods to allow you to deliver on time.

Make your contacts and begin networkingearly in the process. This will allow maximumtime for influencing.

Look for opportunities to turn recommendationsinto action

Identify a health champion in each partnerorganisation. Ensure they have as much

support as possible, so that they can overseethe adoption by their own organisation ofkey HIA lessons and action points.

Try to make HIA recommendations relevantto existing mainstream work priorities,linking them to ongoing projects orprogrammes where possible. Identify thelevers through which recommendationscould be delivered, including specificperformance indicators. Proposals for futuremonitoring could be linked to New Deal forCommunities targets, for example. It can

also be helpful to look for opportunities toembed targets based on recommendations inthe work plans of health partnerships orlocal strategic partnerships.

Communicating your messages

Try to use the insights into organisationalconcerns and priorities that you have gainedto give shape and direction to yourrecommendations, highlighting not just howhealth could be improved, but how thiscould address other goals as well.

Try to establish and involve inter-sectoralnetworks, so that relationships can createshared values and agendas.

Tailor the presentation of information. Seniordecision makers are unlikely to read aweighty report, so provide single-pagesummaries of key messages.

Think about circulating an early draft of yourrecommendations to partners for commentand advice. Some areas have found thatopen drafting, where successive drafts areshared, can help improve the quality of

recommendations, ultimately increasing thechances of their adoption.

Consider using alternative means ofcommunicating with opinion formers andstakeholders, such as producing bulletins andnewsletters reporting on emerging messagesfrom the HIA, or working through the localmedia.

Avoid jargon in written and verbalcommunication assume an intelligent, butnon-expert, audience.


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Further information

The HIA Gateway website

www.hiagateway.org.uk provides access toHIA-related resources, networks and

information to assist those participating in theHIA process. The site is designed for bothbeginners and seasoned HIA practitioners. Bothcase studies used in this bulletin are available asfull reports on the website, under theResources section (Completed HIAs).

The website also features an additional casestudy (Health Impact Assessment Report on

proposal to substitute chopped tyres for someof the coal fuel in cement kiln), which discusses

decision making in section 27 of the report.

To add to the website information about yourHIA, toolkit or resource, or your contact details,go to the Contact us section and follow thesimple instructions.

AcknowledgementsWe wish to thank all the workshop participants,in particular the case study presenters, and thepeer reviewers, for their valuable contributionsto this bulletin.

Health Development Agency 2003

F u r t

h e r c o p i e s o f

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P O B o x

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Y o r k s h

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Contact:website: www.hda.nhs.uk

email: [email protected]

ISBN: 1-84279-216-4

Learning from Practice workshops

The HDA held a series of Learning from Practiceworkshops during 2002/03. Attended by expertpractitioners and academics, theseworkshops demonstrated the value of sharing

real-life experience of a number of aspects ofHIA. A report of the workshops can be found atwww.hiagateway.org.uk ('Resources', 'Othermaterials').

Authors:Taylor, L., Gowman, N., Quigley, R.

Influencing the Decision Making Process Through HIA - HDA England - 2003

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