November 2003
A Holistic approach to housing

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EHJ November 2003, pages 340-343

Carrying out a health impact assessment can greatly assist a local authority assess the wider health effects of its housing strategy. Viv Mason explains

Promoting health is the aim of all chartered environmental health practitioners so why does it not feature more highly in our list of priorities for developing and assessing new policy and strategy? All too often, policy is dictated by the amount of financial resources that are available, short-term priorities to satisfy the "now" rather than looking at long-term effects on health and sustainability.

A local authority's housing strategy will include a number of discrete strategies designed to tackle specific issues such as private sector regeneration, empty homes, houses in multiple occupation, single person accommodation and homelessness. The basis of all of these will be to promote the wellbeing of communities, improve health and reduce social exclusion.

The Regulatory Reform (Housing Assistance) (England and Wales) Order 2002, repealed the existing legislation regarding the provision of renovation grant assistance to owners and occupiers of privately owned housing, other than to provide disabled facilities. Local authorities can now provide assistance for the purposes of improving living accommodation when they have developed and published a new policy. The policy is required to support a locally determined strategy and has to be evidence based. This represents a welcome change in government policy by giving control back to local councils to provide assistance where they see a need. That need must largely depend on improving health and it would seem sensible to assess the health impact of such a policy.

Renewal areas are an important tool in regenerating areas of depressed housing and again the Government has recognised that local decisions based on community aspirations will produce better long-term results. The relaxation of declaration criteria as a result of the RRO, housing guidance circular 6/02 and the National Assembly for Wales circular 20/02 give local authorities added impetus to consider an area-based approach. Renewal areas are not just about housing and need to take into account crime, health, infrastructure and community opportunities to allow comprehensive revitalisation of an area.

WHAT IS A HEALTH IMPACT ASSESSMENT?

According to the World Health Organisation's European Centre for Health Policy, a health impact assessment (HIA) is "a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population and the distribution of those effects within the population". It originates from environmental impact assessments.

A HIA can be carried out in a number of different formats depending on the type of strategy or project being assessed, its importance and the financial resources available. A rapid HIA is carried out by an exchange of views of representatives with some knowledge and/or expertise of the issues. Background statistical information is used to ensure that all participants understand the project or policy's base. The policy or project is briefly presented at the time. Assisted by a facilitator, participants "free think" the ideas around the health determinants.

An intermediate HIA is a more in-depth consideration of the health effects and is carried out by an individual or team with the benefit of more evidence. A comprehensive HIA is virtually the same except that it is more detailed and entails a longer time scale, and is most suitable for complex and detailed policies and projects.

 

A HIA can be undertaken before a policy/project is introduced to estimate the likely health effects or retrospectively to look at the consequences. A concurrent HIA can also be instigated in an intermediate or comprehensive style. The World Health Organisation defines health as "a state of complete physical, mental and social wellbeing". The health determinants are key areas that have an effect on an individual's health, and include socio-economic and environmental conditions as depicted in the diagram (above).

The role of a HIA was specifically highlighted in the cross-government public health strategy Saving lives: our healthier nation and strongly endorsed by the Cabinet Office within the framework new deals for communities, Bringing Britain together: a national strategy for neighbourhood renewal.

THE BENEFITS OF USING HIAs

Using a HIA ensures that improving health is at the heart of any policy and not merely an "add on". At the "Healthy housing: promoting good health" conference held in Warwick in March this year, which was supported by WHO, the CIEH and the Royal Society for the Promotion of Health, a number of presentations highlighted the need to fully consider the impact on health before introducing a plan. In his paper, "The big picture", Peter Molyneux from the Housing and Health Network stated that: "Too often health is a late arriver at the regeneration table and so health projects end up being chimney-stacked on to existing programmes and do not cut across every theme". In his second presentation, "Residents know best", he discussed the assumption that professionals can have that new developments improve housing and therefore improve health. However, we are all familiar with recent developments where noise and condensation become inherent problems or the new children's playground is situated in an inaccessible position.

Edwin Chadwick recognised the impact of poor housing on health in 1842. More recently, the Acheson report, Inequalities in health, specifically highlighted the importance of assessing the effects of policy on health inequalities. Multiple housing deprivation appears to pose a health risk that is of the same magnitude as smoking and, on average, greater than that posed by excessive alcohol consumption. Poor quality housing is often situated in impoverished surroundings or in "unhealthy" neighbourhoods. Poor accommodation and a poor general environment each contribute to the other's negative impact on health. In the same way the socio-economic and environmental aspects of health should not be overlooked.

At the local level, a HIA has a potential contribution to make to many areas of activity and, in particular, can provide a valuable tool to support the work of local strategic partnerships. To support and improve evidence-based decision-making, and contribute to improvements and a reduction in health inequalities, a HIA can be used as a tool to demonstrate:

  • commitment to the wellbeing of communities;
  • commitment to social inclusion strategies;
  • best value;
  • compliance with comprehensive performance assessment;
  • human rights;
  • public involvement and consultation with decision making;
  • multi disciplinary and partnership working;
  • neighbourhood renewal requirements;
  • health improvement plans; and
  • regeneration initiatives.

A HIA contributes to ensuring ownership of a policy, cross-departmental working and partnership development by involving the community and professionals. HIAs are being actively used in other policy areas. For instance, the Greater London Authority screens all new policies to see if a HIA is required. Examples of their use at an early stage should reap benefits in the future. In Devon, for instance, a retrospective HIA concerning the foot and mouth outbreak is being undertaken.

Linking a HIA with a sustainability appraisal during the development of community plans should ensure an authority's long-term commitment to the future health and wellbeing of its constituents. Two examples that demonstrate the value of using HIAs are shown below. In both cases, the studies used a similar methodology based on the framework derived from the Merseyside Health Impact Assessment Steering Group's Merseyside guidelines.

 

Case study 1

NEIGHBOURHOOD RENEWAL

A HIA was undertaken as part of the option appraisal during the neighbourhood renewal assessment (NRA) carried out in south Northumberland Park for Haringey LBC. The area involved has a high population of refugees and asylum seekers living in poor quality temporary accommodation. The options developed were required to reflect the council's housing strategy and to fit in with existing SRB strategies.

The options developed as part of the renewal assessment process underwent an appraisal against economic, socio-environmental, original objectives and decision rules. A HIA of the favoured option was undertaken to identify any additional effects on the health of the population and any practical consequences. Undertaking the HIA supported and improved evidence-based decision-making, contributed to improvements in health and led to a reduction in health inequalities.

The method chosen was a rapid HIA, which was used to support the consultation of the community and involve health professionals further. As part of the NRA, evidence taken from the health improvement plan and collected from personnel at Haringey PCT was used to draw up the options. The HIA looked at the practical health impacts of implementing the option.

One of the main objectives was to "stabilise the population". During the HIA this objective was challenged as being undefined and having a possible negative health impact. The origination of this objective was to reduce the transient nature of the population as a whole but the assessment suggested that it could reduce refugees and asylum seekers' self esteem by not being targeted properly. Rather than improving conditions "to keep them in" as a permanent part of the population, it was being targeted towards "keeping them out". The cultural diversity of the area was assessed as having a positive health impact.

Martin Davies, former project managerat Haringey LBC says: "The HIA caused us to review the way we expressed our objectives. It is much better to encourage longer tenancies and deal with transience from a much more positive perspective. The net effect will be a more welcoming and inclusive renewal area programme".

This suggests that carrying out a HIA before formulating the objectives and using the results to inform the objectives may be beneficial in this type of project.

Two additional unexpected results were the importance of education as a prime driver for housing choice within the area and the need to instil confidence within the local population to use any new community facilities provided.


Case study 2

STRENGTHENING ENFORCEMENT STRATEGY IN NORTHWEST LEICESTERSHIRE THROUGH RAPID HEALTH IMPACT ASSESSMENT

Northwest Leicestershire DC commissioned a rapid health impact assessment (HIA) on its draft private sector housing renewal policy. An initial meeting was held to decide the scope of the assessment and the stakeholders to invite. The HIA was used as one of the main methods of consultation. This enabled health professionals and council members as well as representatives of clients and the wider community to be brought together.

"This exercise has allowed members to feel more involved in strategy development through a practical realisation of its aims," says Gareth Crossley, head of environmental protection at northwest Leicestershire DC.

In carrying out the HIA, a wide range of health determinants was discussed against a background of statistical information regarding the tenure and property type. Recommendations at the end of the report assessed the policy as having a positive effect on health, particularly towards the target groups but highlighted some areas for improvement. As a result, the policy was tightened and matters that were not directly related were formulated into future strategy.

One of the unexpected issues raised during the rapid health impact assessment was the exclusion of private tenants from the policy. Recognition of this has allowed the enforcement strategy to be strengthened.

"It was particularly useful to bring interested parties together to access the direct health impact of the new policy, it was particularly welcomed by elected members," says Bruce Birkett, head of private sector housing at northwest Leicestershire DC.

The names of assistance available and language within the draft policy were found in some cases to be different from related policies within the public and health sectors. Altering these so that everyone speaks the same language should increase understanding and communication between professionals.

References

  1. WHO European Centre for Health Policy, Gothenburg Consensus, 1999.
  2. Saving lives: our healthier nation, Department of Health, 1999.
  3. Bringing Britain together: a national strategy for neighbourhood renewal, Cabinet Office, 1998.
  4. The Acheson report, Inequalities in health, Department of Health, 1998.
  5. Scott-Samuel A, Birley M and Arden K. "The Merseyside guidelines for health impact assessment," Liverpool, 1998. The Merseyside Health Impact Assessment Steering Group.
  6. Taylor and Blair-Stevens. Introducing health impact assessment - informing the decision-making process, Health Development Agency, 2002.
  7. Ison, E. Resource for health impact assessment, NHS Executive, 2000.
  8. Housing and health: building for the future. BMA Board of Science and Education, May 2003

Viv Mason is a chartered environmental health practitioner and director of Hollesley health and housing. She works in the field of private sector housing, helping local authorities with housing strategy, area renewal and problematic housing. Viv Mason can be contacted by e-mail at viv@hollesley-health-housing.com