Health Impact Assessment--and beyond.

National and international pressure is growing for public policies and programmes to be prospectively evaluated to determine what their impacts will be on public health. This is evident from statements from bodies including the WHO, 1 the European Union, 2 and the British Medical Association 3 and may be seen as a natural development of evidence-based principles that are currently being applied in other health and non health-related fields. But where can policymakers find evidence of health impacts, and how can it be integrated with other influences on decision making? One proposed solution, which is attracting increasing interest, is Health Impact Assessment (HIA). 4 However, we suggest that the current formulations of HIA, which combine both health assessment and option-appraisal, may have diYculty fulfilling both roles. To understand why this might be true, it is worth considering the history and typical methods of HIA. HIA is the oVspring of Environmental Impact Assessment and has inherited its major features. It usually begins with a screening process to exclude interventions with no significant health eVects. Where health impacts might occur, the process of scoping identifies the kinds of information that need to be gathered. This allows terms of reference to be agreed, and forms the basis for assembling and appraising information on health impacts. Emphasis is given to non-quantitative information, of which community consultation is a prominent component. The resulting information about potential health impacts is then presented to decision makers to help them decide how best to mitigate harm and augment benefit to health. A range of approaches to make HIAs of policies, programmes and projects has been developed in the UK, 12 13 among others, and in the UK HIA has been promoted as a tool for reducing health inequalities. One of the strengths of HIA is that it gathers a comprehensive collection of factors that influence health, based on a socioenvironmental model of health. 14 Importance is placed on stakeholders' views and feelings as much as quantitative health outcomes. By engaging organisations and individuals in a debate about health impacts, HIA can function successfully as an agent of health promotion and health education. However, two problems can arise from community consultation. The first is that by opening up the field of influences on health, a variety of health concerns may be identified that the policy or project has no ability to resolve. This may be worse than ineVective and …