The use and impact of rapid health technology assessments

OBJECTIVES: To consider the impact of rapid health technology assessments undertaken as part of a program in a provincial healthcare system in response to urgent requests for advice. METHODS: Review of the development and preparation of 20 rapid assessment reports, communication with decision makers within the healthcare system, and appraisal of data subsequent to preparation of the reports. RESULTS: Fourteen of the assessments were judged to have had an influence on policy and other decisions, as judged by responses from those who had requested advice. Another four were considered to have provided guidance, while having less immediate influence on decisions, and two others had no apparent impact. Quality of the assessments was considered acceptable, on the basis of literature that subsequently became available and from comments received. CONCLUSIONS: These brief reports are considered to be a useful component of a health technology assessment program. However, they should be regarded as provisional appraisals and followed up with more detailed evaluation where possible.     

A prospective health impact assessment of the Merseyside Integrated Transport Strategy (MerITS)

BACKGROUND: Prospective health impact assessment is a new approach to predicting potential health impacts of policies, programmes or projects. It has been widely recognized that public policies have important impacts on health. In 1997, the Liverpool Public Health Observatory was commissioned to carry out a health impact assessment of the Merseyside Integrated Transport Strategy (MerITS). A secondary aim was to pilot a method for health impact assessment at the strategic level. METHODS: The methods used drew on previous health impact assessments of projects, on strategic environmental assessment, and on policy research. They included policy analysis, semi-structured interviews with key informants and literature searches. RESULTS: Four priority impact areas of MerITS were identified: establishing road hierarchies, economic viability, air quality, and public transport. Potential health impacts in each of these areas were estimated, and recommendations were made to minimize the effects of negative impacts and to enhance positive ones. CONCLUSION: This health impact assessment prospectively identified the key health impacts of a strategy on a defined population and made recommendations to maximize potential positive and minimize potential negative health impacts. The methods employed are generally applicable to prospective health impact assessments of public policies and strategies.     

Supporting health impact assessment in practice

Health impact assessment (HIA) is a process that aims to predict potential positive and negative effects of project, programme or policy proposals on health and health inequalities. It is recommended by national government and internationally. Supporting health impact assessment is one of the roles of English Public Health Observatories. The few centres in England with accredited health impact training centres have inadequate resources to meet demand. Currently, the London Health Observatory is providing the bulk of the training nationally. Some Public Health Observatories are currently investigating the preferences for support of those commissioning or conducting health impact assessment within their regions. The availability of published guidance on how to conduct health impact assessments has increased substantially over the past few years. The Department of Health has funded a research project led by the London Health Observatory to develop advice for reviewing evidence for use in health impact assessment. Completed health impact assessments can be useful resources. Evaluation of the process and impact of health impact assessment is important in order to demonstrate its usefulness and to learn lessons for the future. The focus for Public Health Observatories is to train and support others to conduct health impact assessment according to good practice, rather than undertaking health impact assessments themselves. The aim is to create sufficient skilled capacity around the country to undertake health impact assessments. The London Health Observatory plans to share its support models and to roll out a train the trainer programme nationally to enable effective local delivery of their national health impact assessment programme.     

Mini-symposium — Public Health Observatories: Supporting health impact assessment in practice

Health impact assessment (HIA) is a process that aims to predict potential positive and negative effects of project, programme or policy proposals on health and health inequalities. It is recommended by national government and internationally. Supporting health impact assessment is one of the roles of English Public Health Observatories. The few centres in England with accredited health impact training centres have inadequate resources to meet demand. Currently, the London Health Observatory is providing the bulk of the training nationally. Some Public Health Observatories are currently investigating the preferences for support of those commissioning or conducting health impact assessment within their regions. The availability of published guidance on how to conduct health impact assessments has increased substantially over the past few years. The Department of Health has funded a research project led by the London Health Observatory to develop advice for reviewing evidence for use in health impact assessment. Completed health impact assessments can be useful resources. Evaluation of the process and impact of health impact assessment is important in order to demonstrate its usefulness and to learn lessons for the future. The focus for Public Health Observatories is to train and support others to conduct health impact assessment according to good practice, rather than undertaking health impact assessments themselves. The aim is to create sufficient skilled capacity around the country to undertake health impact assessments. The London Health Observatory plans to share its support models and to roll out a train the trainer programme nationally to enable effective local delivery of their national health impact assessment programme.     

Health needs assessment and needs-led health service change: a survey of projects involving public health doctors

OBJECTIVES: To describe the criteria that define an effective health needs assessment and to explore which factors are important for the delivery of effective health needs assessment in the English National Health Service (NHS). METHODS: A postal questionnaire to all public health doctors in an English health region to describe health needs assessment activity, including initiating factors, methods and outcomes. This was followed by semi-structured interviews with public health professionals and others involved in 10 purposively selected needs assessments. RESULTS: A response rate of 62% identified a total of 102 health needs assessments undertaken between 1993 and 1998. A number of themes emerged as being important in the impact of health needs assessments on policy and planning. These included careful design, methodological rigour, decisive leadership, good communication, involvement and ownership of the work from relevant stakeholders, support from senior decision-makers, appreciation of the political dynamics and engagement with local priorities, availability of resources and, finally, an element of chance. These themes can be categorised broadly into contextual factors and quality or robustness of the work. Our findings suggest that, although methodological and analytical quality are necessary characteristics of effective health needs assessment, they are not sufficient without a favourable political environment. CONCLUSION: There appear to be conditions under which needs assessment is more likely to be effective in terms of its influence on policy and planning. However, it is clear that needs assessment does not occupy a central position in health service decision-making, remaining vulnerable to a range of factors over which those responsible for its conduct have little or no control.     

Lessons from San Francisco: health impact assessments have advanced political conditions for improving population health

Health impact assessment is a structured decision support tool used to systematically characterize the anticipated health effects, both adverse and beneficial, of societal decisions. In San Francisco, the use of health impact assessments has not only produced evidence to inform health policy decision making but has also contributed to the political conditions needed to achieve optimal population health. Health impact assessments have helped increase public awareness of the determinants of health, routine monitoring of these determinants, cooperation among institutions, health-protective laws and regulations, and organizational networks for health advocacy and accountability. Drawing on more than a decade of local experience, we identify the direct and indirect effects of the assessments on the politics of governance as well as on health. We demonstrate that health impact assessment is both an analytic tool and a process that helps build the social institutions that can improve health.     

Health impact assessment and the consideration of health inequalities

Equity and the consideration of the differential impacts of public policy within populations are core values of health impact assessment. A recent paper setting out the results of the government's consultation exercise on tackling health inequalities argues for health impact assessment to be used as a mechanism to bring about reductions in health inequalities. However, we would contend that most, if not all, published health impact assessments have not considered the effects of public policies on health inequalities in a robust or reliable manner. In this paper we set out and explore some of the issues that require consideration if health impact assessment is fulfil the government's expectations.     

Transport policy and health inequalities: a health impact assessment of Edinburgh's transport policy

Health impact assessment (HIA) can be used to examine the relationships between inequalities and health. This HIA of Edinburgh's transport policy demonstrates how HIA can examine how different transport policies can affect different population groupings to varying degrees. In this case, Edinburgh's economy is based on tourism, financial services and Government bodies. These need a good transport infrastructure, which maintains a vibrant city centre. A transport policy that promotes walking, cycling and public transport supports this and is also good for health. The HIA suggested that greater spend on public transport and supporting sustainable modes of transport was beneficial to health, and offered scope to reduce inequalities. This message was understood by the City Council and influenced the development of the city's transport and land-use strategies. The paper discusses how HIA can influence public policy.     

Health impact assessment in relation to other forms of impact assessment

Health impact assessment (HIA) has many advocates for its use to identify and optimize the health effects of non-healthcare interventions. It is an assessment of the health effects, positive and negative, of a project, programme, or policy. Expertise developed in the United Kingdom from a realization that health impacts are often overlooked during the planning stages of development projects but prior planning can avoid detrimental effects. Considering health impacts is now recommended in all continents; the focus has moved from less to more developed countries and upstream from projects to policies. Health impact assessment shares certain concepts and methods with risk assessment, environmental impact assessment, strategic environmental assessment, social impact assessment, and economic assessments. This paper describes the development of health impact assessment and its relation to these other forms of impact assessment.     

Health impact assessment: one way to introduce health in all policies. SESPAS Report 2010

Health impact assessment is a predictive tool to support decisions in policy-making. Current experience shows that health impact assessment could play an important role in the development of the Health in All Policies strategy. This strategy has been extensively used in other European countries and in a wide range of policy and administrative sectors. Health impact assessment is hardly ever mandatory and is frequently carried out separately from other impact assessments. The use of this process in Spain is relatively new, limited and fundamentally based on local level experiences and the screening of regional interventions. The current normative and organizational reform of public health in Spain provides an excellent opportunity to promote the development of health impact assessment. Some of the barriers to the development of this process are related to the biomedical model of health prevailing among health professionals, politicians, and the general population, political disaffection, lack of assessment culture, underdevelopment of community participation processes, and insufficient intersectoral work. Health impact assessment provides an opportunity to move toward improving the population's health and reducing inequalities in health. Consequently, political commitment, as well as investment in education and research, is needed to introduce and develop health impact assessment in all administrative settings and policy sectors.     

Health impact assessment, human rights and global public policy: a critical appraisal

Public policy decisions in both the social and economic spheres have enormous impact on global public health. As a result of this, and of the skewed global distribution of power and resources, health impact assessment (HIA) potentially has a key role to play in foreign policy-making and global public policy-making. Governments, multilateral bodies and transnational corporations need to be held to account for the health impacts of their policies and practices. One route towards achieving this objective involves the inclusion of human rights assessments within HIA. International commitments to human rights instruments and standards can be used as a global auditing tool. Methodological issues may limit the effectiveness of HIA in promoting health equity. These issues include the use of procedures that favour those holding power in the policy process or the use of procedures that fail to apply values of equity and participation. The identification and production of evidence that includes the interests of less powerful groups is a priority for HIA and would be furthered if a human rights-based method of HIA were developed. Because HIA considers all types of policies and examines all potential determinants of health, it can play a part when foreign policy is developed and global decisions are made to treat people as rights holders. Since the human right to health is shaped by the determinants of health, developing links between the right to health assessment (that is, an assessment of the impact of policies on the right to health) and HIA--as recently proposed by the United Nations Special Rapporteur on the right to health--could strengthen the development of foreign policy and global decisions. Such links should be pursued and applied to the development of foreign policy and to the operation of multilateral bodies.     

Public health impact of large airports

Large airports with the related infrastructure, businesses and industrial activities affect the health of the population living, travelling and working in the surroundings of or at the airport. The employment and contributions to economy from the airport and related operations are expected to have a beneficial effect, which, however, is difficult to quantify. More pertinent data are available on the, largely negative, health effects of environmental factors, such as air and soil pollution, noise, accident risk, and landscape changes. Information on the concurrent and cumulative impact of these factors is lacking, but is of primary relevance for public health policy. A committee of the Health Council of The Netherlands recently reviewed the data on the health impact of large airports. It was concluded that, generally, integrated health assessments are not available. Such assessments, as part of sustainable mobility policy, should accompany the further development of the global aviation system.     

Comparative assessment of transport risks--how it can contribute to health impact assessment of transport policies

Health impact assessment (HIA) and comparative risk assessment (CRA) are important tools with which governments and communities can compare and integrate different sources of information about various health impacts into a single framework for policy-makers and planners. Both tools have strengths that may be combined usefully when conducting comprehensive assessments of decisions that affect complex health issues, such as the health risks and impacts of transport policy and planning activities. As yet, however, HIA and CRA have not been applied widely to the area of transport. We draw on the limited experience of the application of these tools in the context of road transport to explore how comparative assessment of transport risks can contribute to HIA of transport policies.     

Health and environmental impact assessment in Canada

Potential health effects of proposed development activities are an important component of environmental impact assessment (EIA). I report results of a survey to determine the nature and extent of health impact assessments in EIA in Canada. Most proponents conduct health impact assessments when there is an identified health concern. However, few Canadian jurisdictions require health impact assessments in their EIA legislation. The extent to which health is considered depends on several factors and concerns can be addressed at several different stages of the EIA process. Health impact assessments have dealt with a wide range of concerns, although the specific health issues addressed depend on the nature of the project. Several procedures and methods have been used by proponents and government reviewers. Often health impact assessments are qualitative or rely on relevant standards or guidelines. Occasionally, quantitative risk assessments are conducted. Survey respondents identified several problems which hinder health impact assessments including a shortage of suitably trained and experienced health professionals, inadequate communications between government agencies and insufficient or conflicting scientific data to allow accurate prediction of any health effects.     

Health, environmental assessments and population health: tools for a complex process

Place is more than physical and natural environment. The role of biophysical environment has still to be articulated in population health discourse and its relations with human health are fraught with scientific uncertainty and dissension. An environmental impact assessment (EA) evaluates the environmental effects of a proposal--a rational and technical process. Sometimes health assessments are included, usually by quantitative risk assessments which are subject to the limits of scientific knowledge and bedevilled by data limitations. The goal must be to add health to the process, yet the relevant features to include are complex. Impacts are non-specific and they interact and have spatial and temporal characteristics. To integrate environment into population health, there is a need for a physical environment-health database and inter-sectorial policy and action. There is also a need for different types of indicators to measure process, impact and effectiveness, and for new tools (stories, photography) to account for context and values.     

Lessons from the eight countries

While the eight countries presented in this issue differ considerably from each other, they have important similarities. All have faced the problem of increasing health care expenditures, and all are coming to recognize problems with health care technology such as inappropriate use and poor quality of care. Health reforms appear to be accelerating in the countries examined. In addition, all countries now have stated policy goals of assessing the benefits of health care technologies and most have established formal programs for health care technology assessment. Technology assessments impact varies, but it is becoming an important factor in technology acquisition. These trends point to a future for technology assessment and perhaps to better management of health care technology. International cooperation is important if this goal is to be realized.     

Practical advancement of multipollutant scientific and risk assessment approaches for ambient air pollution

Objectives: The U.S. Environmental Protection Agency is working toward gaining a better understanding of the human health impacts of exposure to complex air pollutant mixtures and the key features that drive the toxicity of these mixtures, which can then be used for future scientific and risk assessments.Data sources: A public workshop was held in Chapel Hill, North Carolina, 22-24 February 2011, to discuss scientific issues and data gaps related to adopting multipollutant science and risk assessment approaches, with a particular focus on the criteria air pollutants. Expert panelists in the fields of epidemiology, toxicology, and atmospheric and exposure sciences led open discussions to encourage workshop participants to think broadly about available and emerging scientific evidence related to multipollutant approaches to evaluating the health effects of air pollution.Synthesis: Although there is clearly a need for novel research and analytical approaches to better characterize the health effects of multipollutant exposures, much progress can be made by using existing scientific information and statistical methods to evaluate the effects of single pollutants in a multipollutant context. This work will have a direct impact on the development of a multipollutant science assessment and a conceptual framework for conducting multipollutant risk assessments.Conclusions: Transitioning to a multipollutant paradigm can be aided through the adoption of a framework for multipollutant science and risk assessment that encompasses well-studied and ubiquitous air pollutants. Successfully advancing methods for conducting these assessments will require collaborative and parallel efforts between the scientific and environmental regulatory and policy communities.     

'It's a small world': mental health policy under welfare capitalism since 1945

Much sociological theorising about community care in mental health universalises from Anglo-American contexts. So do assessments of policy shifts towards deinstitutionalisation, whose tendency towards negativity largely reflects the downsized mental health care systems that have emerged in welfare regimes, strongly influenced by neoliberal political ideology. Drawing on the framework of Esping-Anderson (1990), the article seeks to theorise from a wider range of welfare regimes, including Sweden and Italy, where political influences on policy provide more support for a degree of optimism. It also seeks to demonstrate in outline the advantages of analysing global influences on mental health policy under welfare capitalism, as key factors shaping policy throughout the whole post-1945 period.     

Recommendations in health technology assessments worldwide

OBJECTIVES: The objective of this study is to analyze statistically the possible determinants and implications of including or not including recommendations in health technology assessments (HTAs). METHODS: A sample of 433 HTAs published by eleven leading institutions or agencies in nine countries was reviewed and analyzed statistically by multiple logistic regression. RESULTS: The extent of policy and research recommendations in HTAs varies greatly from country to country. The content and scope of HTAs have some impact on recommendations. Extensive assessment of economic and organizational aspects increases the likelihood of including policy recommendations. Extensive assessment of technological and patient aspects increases the likelihood of including research recommendations, whereas extensive focus on economic aspects is negatively related to research recommendations. The most striking result is that the use of external partners for assessment increases the likelihood of including research recommendations in HTAs but not policy recommendations. CONCLUSIONS: HTA commissioners, agencies, institutions, and funding authorities need to be aware of the consequences of the choices they make in advance of assessing health technologies. Outsourcing HTA to external partners suggests a greater likelihood of being told that "more research is needed." The scope and content of HTAs has an impact on the type of recommendations, and country-specific preferences are strong predictors of recommendations in HTAs.     

Evidence-based screening in the United Kingdom

OBJECTIVE: To review the assessment of screening in the United Kingdom, focusing on three methods: mammography for breast cancer, screening for prostate cancer, and routine use of ultrasound in pregnancy. METHOD: To review policy documents and published papers dealing with prevention and screening in the United Kingdom. RESULTS: Indicate that the United Kingdom has an active policy concerning the assessment of screening methods. Generally speaking, this assessment policy is part of the national program for health technology assessment (HTA). The government has given HTA an important place within health care in the United Kingdom, and prevention and screening is no exception to this general rule. The assessment of screening is now implemented through the National Screening Committee, established in 1997. The three issues reviewed in this paper have all been assessed within the context of the Department of Health. In the case of mammography, the assessment was done more than 10 years ago and was followed by a rational implementation of a national screening program for breast cancer. In the case of prostate cancer screening, two systematic reviews have concluded that screening should not be carried out. In general, this recommendation has been accepted in the United Kingdom. Use of ultrasound in pregnancy has been assessed by the National Screening Committee. This complex technology is difficult to assess, and the screening procedure is deeply embedded in clinical practice in the United Kingdom, so assessment has not had much impact on the frequency of screening. CONCLUSION: HTA and the assessment of screening are well established in the United Kingdom. Policy is generally based on the assessments done, and practice generally follows the results of assessment. Assessment of screening is expected to become increasingly important in the United Kingdom during the next years.