The Making of a Community Health Impact Assessment (and Toolkit)
There is no defined HIA template, only guidance; the London NHS HUDU template greatly differs from the Public Health Wales HIA on the health impacts of climate change . This means that it is malleable as opposed to other technical guidance - perhaps an ironic benefit of there being no definition of health in the context of urban planning (via the National Planning Policy Framework).
Getting Started
We wanted to let our imaginations and lived experiences determine what would make a successful HIA. We then would use what we have created and hold it up against what is produced to see any alignments or discrepancies.
To guide our collaboration we reviewed a number of articles and studies on co-design, such as this piece and this, as well as looking at service design models - given the output of this work questioned how a system operates with the various stakeholders.
The project was made possible by a small grant from the Community Knowledge Fund to run a pilot project with capacity for a stage 2 funding opportunity to grow the work. Therefore we designed a programme of work that was relevant to the resources (time/money) we had available. Below is the programme.
The Vale of Scheduling and Creating Boundaries
The project leads from CL & CASH agreed on a schedule of work and presented it to wider members of our respective organisations in an evening virtual call. We then agreed on a calendar of activities that were inclusive of people’s needs and boundaries.
We also agreed that there would be some shared responsibilities in the group but they would match each other's respective capabilities as to not overburden people - this was after all something being done in evenings and spare time . It must be noted that everyone received remuneration for their time equivalent to that of a professional.
we are all experts of our lived experiences, people shouldn’t need acronyms at the end names to be paid for their expertise
Within the programme schedule we designed a number of exercises that would guide our thinking in what would make a successful HIA.
Over the course of 4 months we met through fortnightly virtual calls in the evenings. For the most part we met as a group but there were daytime sessions for certain members to research specific issues that didn’t merit inclusion of all people’s time.
Starting the Work
Our approach to ensuring this was justice and lived-experience led was to centre conversations by looking at the problem holistically. We did this by starting the first session on sharing all the blockers the members of CASH had experienced in advocating for their health, including engaging with health systems and all related departments.
We felt that this would shed light on how the HIA could work in a multi-stakeholder and cross departmental framing rather than just looking at improving the margins of the current status quo within planning policy.
The following is an outline of the work sessions that followed, in order:
Reviewing what an HIA is via the current literature, guidance documents, and language to see how it works and reflects recent experiences.
Reviewing the number of HIAs performed for planning applications to the local planning authority, and regrouping for sharing findings.
Coworking to discuss what the HIA process and system misses about health in community oriented life.
Developing a series of principles to guide how our HIA would be developed and performed
Developing a theory of change model for how our HIA would work to have success.
Lastly explored whether the HIA should interlink to other planning conditions such as obligations from S106 Agreements and Community Infrastructure Levy however we opted to not go further with this work as it would open up additional bureaucratic and political layers that would likely impair the success of community-led action.
Through all sessions we allowed for questions to be answered in an open manner. For example, when asking what “good” looked like there was no parameter on whether this was explicitly about the process or outcome. This ensured that a full range of ideas were brought forward and discussed.
Results
For this section we’re going cover what we discovered and learnt through the research phase.
The members of CASH experienced various levels of gaslighting, being told that it was “only them” experiencing these issues, “no-one” else is complaining, and “it’s more likely a result of other factors in their lives”. Their requests for help and claims of injustice were brushed away as authorities could not point to other data sources, such as GPs, to verify that this was a public health issue. However, using a very metric of GP visits be local residents complaining directly of air pollution related problems is problematic, Southall is a predominantly working class area with many parents working shift-work meaning accessing GPs can be difficult; childcare can be complex if taking a child out of school for a GP appointment; there are internalised stigmas in taking children out of school or taking sick days from work in order to keep up appearances in a racially prejudiced society. This institutionally led to an erasure of their lived experiences and a prejudicing of their lifestyles.
Over time the members of CASH experienced what can be described as being “cancelled” - they were excluded from a variety of public engagement activities despite them being an active organisation concerned with health and placemaking matters. According to the Oxford Dictionary, being cancelled is ‘ a systemic approach to removing someones agency to express their views that challenge an orthodoxy’. This can be seen in their exclusion from public engagement events due to their challenging of the local authority and developer’s agenda. Therefore, community consultation continues to be seen as a one-directional process parading as equity.
When given a platform to discuss and present their informed criticism of the real estate housing development it felt that this was just deference politics at play, that they were being placated through a thin veil of ‘democracy’ through participation when in reality the concerns they were raising could not be actively acted upon by the authorities who would need to act on their behalf, meaning little was done from the feedback.
Academic institutions offered support but the length of work, perceived extractive nature of research, and lack of control over research methods presented another frustrating avenue in aiming to demonstrate their injustices through “legitimate” evidence. Grassroots organisations around the world are forever told to present legitimate evidence and hard data beyond their own views. This is knowledge supremacy and a suppression tactic. Knowledge supremacy is a knowledge pool that self-identifies as supreme to systematically dictate the knowledges that are valuable, trusted, and acknowledged, resulting in hegemonic policies that affect our health.. Legitimate evidence often means something that is produced by “professional” researchers or academics. Therefore, the only accepted avenues to demonstrating ones cause for concern are met with impractical realities resulting in grassroots groups and citizens impotent in fighting their case on equal, or even equitable, terms.
Poor governance was rife, there was a perception that local government figures, such as councillors, were easily manipulated through investments in initiatives they were keen on and increases in their own levels of power, such as being invited to sit on new committees and representative boards in the borough. A major frustration was the lack of public oversight in how this unfolded over time and that this was a perceived infiltration of local systems by foreign actors with vested interests.
Early planning documentation demonstrates a distinct awareness of the problems related to contaminated land and the need for high levels of due diligence and compliance in remediation techniques if works were to take place - contrary to personal stories on the quality control of soil hospitals where tarpaulins would be seen flailing in the air at times.
Language in current literature is opaque and to be justice-led need stronger definitions - e.g. social determinants of health only looks at downstream outcomes rather than upstream causes and actions. The NPPF offers no definition of health in context to the built environment other than some macro objectives of safety, natural environments, food options, etc., however this ignores the biological relationship to the built environment as well as how cultural differences influence matters. This means that “health” is open to interpretation by local planning policy officers resulting in unintended consequences of exclusionary practices or at worse discriminatory practices due to a person’s personal views on what makes a person healthy.
In the cold light of day there appears to be low-to-no accountability on what is produced via an HIA. Without different indicators, metrics, and outcomes measurements the results of an HIA are not ‘material considerations’ and therefore have no legislative or policy powers to ensure accountability.
There is an apparent lack of connection of HIA to other authority departmental policy initiatives. It was hard to identify how a HIA through the planning system related to initiatives from other departments such as social care. CASH felt that given the power that local health boards, like Primary Care Trusts and Integrated Care Boads, have they should be a stakeholder in the process - whether that be developing HIAs, being connected to the activity, reviewing applications alongside stakeholders, or being connected to and holding to account the outcomes.
Accessing information about HIAs at the local planning authority levels was very difficult. Local planning authority websites do not allow for the easy identification of this information. This demonstrates a lack of democratic transparency.
Conclusion
Having reviewed documentation there is an overwhelming feeling that assessments such as the HUDU template are self-serving and designed to support policy rather than people. In the document September 2023 Rapid Health Impact Assessment for The Green Quarter by planning consultancy Lichfields a project that has repeatedly caused harm to local community members has scored overwhelmingly positive. Make of that what you will.
We however see this as a form of corruption; a system designed to advantage one party through “organised” means. Rather than a scoring system it was beleved that any indicator and metric should be looked at independently and used as a discussion point within planning with relevant stakeholders (namely, local residents) for a solution co-design process - and not a box-ticking one that currently exists.
Learnings and Insights from the Work
