John S. F. Wright

Community participation in health impact assessments: intuitively appealing but practically difficult.

Health impact assessment (HIA)attemptsan extremely difficult task. It tries notonly to project the impacts of policies,programmes and developments on publichealth but to influence the politicaldecision-making process on the basis ofits findings. Given its high ambitions,it is not surprising that governments haveencountered difficulties in institutionaliz-ing HIA within the process of makingpolicy. Anticipating health impacts andinfluencing decision-making are difficultenough in their own right, withoutcombining the two in one process. Theambitions of HIA and the time andresource restrictions inherent in the policyprocess dynamic thus place seriousdemands on one another, and the politicaland institutional barriers confrontingHIA may necessitate sober compromiseswithinitsgeneralprocessandmethodology.One key methodological issue thatmay challenge the relationship betweenHIA and policy is the involvement of thecommunity in the HIA process. TheGothenburg consensus paper makes clearthe need for participation to underpinthe assessment process in order to main-tainvaluesofdemocracy,transparencyandequity (1). Indeed, community participa-tion is a central ideal found in almostall the contemporary major national andinternational declarations on health, butlittleempiricalworkhasexploredtheutilityof participation in attaining HIA’s objec-tives. For example, does broad-basedcommunity participation result in a moreaccurate prediction of impacts, improveddecision-making, increased transparency,local accountability, and increased com-munity empowerment and ownershipof policy?Whilst little work has been under-taken in the context of HIA, there is asubstantialbodyofliteraturethatdescribesthe impact of participation in other areasof health policy formulation and imple-mentation(2–4).Communityinvolvementmay have a positive impact on the successof project development and implementa-tion. Participation may also directly affectindividuals by changing attitudes andactions towards the causes of ill-health,promoting a sense of responsibility andincreasing personal confidence and self-esteem.Involvement inthepolicyprocessmay decrease alienation among sociallyexcluded groups and reorient powerrelationships with the ‘‘professional’’decision-makers.But other researchers have reportedconsiderable difficulties in conductingcommunity participation exercises (5–7).Participation is time-consuming andcommunities often questioned the valueof investing time and effort in a project.Local people are often too busy goingabout their daily business to becomeinvolvedinparticipatoryactivities,andthelegitimacy of those who chose to partici-pate with regard to representing the viewsof the wider community is unclear.Communities are not some homogenousbody — they are often fraught withdivisions, tensions and conflicts, andcertainvulnerablegroupsmaybeunwillingor even unable to participate.What can we learn for HIA fromthe participatory experiences of otherprevious policy programmes? Participa-tion is intuitively appealing but it is clearthat participatory approaches do notalways run smoothly. Working with com-munities is far from easy and participatorypartnerships take time to build if theyaretobetrulyparticipatory.Andhereinliesthe problem: HIA usually has to be donereasonably quickly, so as to operatewithinthepolicy-makingtimescale.Togetcommunity participation quickly necessi-tates the use of existing structures andpeople; it means compromising the extentof consultation with hard-to-reachgroups; and it means that assessmentsalmost certainly have to be predomi-nately ‘‘top-down’’ professionally-ledexercises. This type of HIA runs the riskof legitimizing a decision in which asubstantial proportion of the communityhave not been involved despite theassessment being conducted under thebanner of ‘‘participation’’.Sohowcanwecombineparticipationand HIA? Colleagues are developingtechniquesforrapidparticipatoryappraisaland these may go some way towardsovercoming some of the problemsdiscussed (8). But perhaps a more radicalsolution would be to suggest that in thecontext of HIA, limiting involvement toasmallgroupofexpertsmightbethemostappropriate and efficient means to gen-erate sufficient information to influencethe policy-making process (9). Supportfor such an approach comes not froma rejection of the validity of communityinvolvement but because if HIA is to getbeyond the field of purely academicinterest and gain credibility with policy-makers, it must fit policy-makers’ require-ments. And if it is to do this, communityparticipation may be difficult, if notimpossible, to achieve, given the time andresource constraints of the policy-makingdynamic. HIA should explicitly acknowl-edgethetensionbetweenthetimerequiredto deliver on the policy agenda and thetime required to build true participatorypartnerships with communities.Whilst ideal, participation may simplynot be possible for the majority ofHIAs. Those working on HIA should notapologize for this: if an assessment hasnot got the time or resources to bringabout meaningful community participa-tion, is it wise to attempt it at all?

Participation in health impact assessment: objectives, methods and core values

Health impact assessment (HIA) is a multidisciplinary aid to decision-making that assesses the impact of policy on public health and on health inequalities. Its purpose is to assist decision-makers to maximize health gains and to reduce inequalities. The 1999 Gothenburg Consensus Paper (GCP) provides researchers with a rationale for establishing community participation as a core value of HIA. According to the GCP, participation in HIA empowers people within the decision-making process and redresses the democratic deficit between government and society. Participation in HIA generates a sense that health and decision-making is community-owned, and the personal experiences of citizens become integral to the formulation of policy. However, the participatory and empowering dimensions of HIA may prove difficult to operationalize. In this review of the participation strategies adopted in key applications of HIA in the United Kingdom, we found that HIAs aim of influencing decision-making creates tension between its participatory and knowledge-gathering dimensions. Accordingly, researchers have decreased the participatory dimension of HIA by reducing the importance attached to the communitys experience of empowerment, ownership and democracy, while enlarging its knowledge-gathering dimension by giving pre-eminence to expert and research-generated evidence. Recent applications of HIA offer a serviceable rationale for participation as a means of information gathering and it is no longer tenable to uphold HIA as a means of empowering communities and advancing the aims of participatory democracy.

Institutionalizing policy-level health impact assessment in Europe: is coupling health impact assessment with strategic environmental assessment the next step forward?

European Union (EU) Member States are interested in using health impact assessment (HIA) as a means of safeguarding their obligations to protect human health under the 1997 Treaty of Amsterdam. However, several have encountered difficulties institutionalizing HIA with the policy-making process. As a consequence, the World Health Organization (WHO) Regional Office for Europe has suggested coupling HIA with strategic environmental assessment (SEA). Traditionally, the incorporation of HIA into other forms of impact assessment has been resisted, for fear of losing its focus on health issues to environmental concerns, and compromising its social model of health with the introduction of biophysical indicators. But can these fears be substantiated? In this paper, we investigate the grounds for such concerns by reviewing the relevant policy documents and departmental guidelines of four non-European countries that have considered the use of integrated assessment. We found that the case for associating HIA with SEA in Europe is strong, and offers potential solutions to problems of screening, theoretical framework, causal pathways and ready entry to the policy process. Coupling HIA with SEA may thus be the next step forward in a longer journey towards institutionalizing HIA as an independent policy-linked device.

Investigating the governance of autonomous public hospitals in England: multi-site case study of NHS foundation trusts

Objective To investigate the external and internal governance of NHS foundation trusts (FTs), which have increased autonomy, and local members and governors unlike other NHS trusts. Methods In depth, three-year case studies of four FTs; and analysis of national quantitative data on all FT hospitals and NHS Trust hospitals to give national context. Data included 111 interviews with managers, clinicians, governors and members, and local purchasers; observation of meetings; and analysis of FTs documents. Results The four case study FTs were similar to other FTs. They had used their increased autonomy to develop more business-like practices. The FT regulator, Monitor, intervened only when there were reported problems in FT performance. National targets applying to the NHS also had a large effect on FT behaviour. FTs saw themselves as part of the local health economy and tried to maintain good relationships with local organisations. Relationships between governors and the FTs executives were still developing, and not all governors felt able to hold their FT to account. The skills and experience of staff members and governors were under-used in the new governance structures. Conclusions It is easier to increase autonomy for public hospitals than to increase local accountability. Hospital managers are likely to be interested in making decisions with less central government control, whilst mechanisms for local accountability are notoriously difficult to design and operate. Further consideration of internal governance of FTs is needed. In a deteriorating financial climate, FTs should be better placed to make savings, due to their more business-like practices.

Reconsidering Regulation and Governance Theory: A Learning Approach

Theories and frameworks for regulation of particular industries or types of behavior have grown in richness in recent years. This article identifies three perspectives within contemporary regulatory theory: “normative,”“descriptive,” and “poststructuralist” perspectives. We ask whether contemporary models of regulatory governance arrangements adequately capture and explain the characteristics and operation of existing regulatory spaces. We outline three key models linked to these perspectives (responsive regulation, smart regulation, and nodal governance) and discuss their relevance with specific reference to one complex case study, the gambling industry in a federal polity, Australia, where the regulatory arrangements are quite diverse. We argue that regulatory theory needs to remain flexible if it is to inform an understanding of concrete regulatory challenges, thereby assisting analysts and practitioners to assess current and potential approaches for improved regulatory governance arrangements. Accordingly, we build a case for considering a learning perspective on regulation and governance theory linked to pragmatism.

ASSESSING THE PARTICIPATORY POTENTIAL OF BRITAIN'S NEW DEAL FOR COMMUNITIES:

Community participation is a key characteristic of the British Labour Governments New Deal for Communities (NDC). However, the National Evaluation reports serious difficulties involving local communities in the programme. This article assesses the NDCs potential as a site for bottom-up community participation by reviewing government policy guidance, programme notes and strategy documents. We identify themes and mechanisms within the programme that facilitate and limit participation. It is argued that if NDC is a community-led programme, it is community-led in the sense that government decides how the community will be involved, why they will be involved, what they will do and how they will do it.

Regulatory space and the contextual mediation of common functional pressures: Analyzing the factors that led to the German Efficiency Frontier approach

There are no automatic links between the functional advantages and pressures associated with delegation to independent agencies for Health Technology Assessment (HTA) and their emergence in national regulatory spaces. We argue that the rise of these organizations is mediated by contextual factors, which must be explained. Accordingly, we analyze the German regulatory space for health policy decision-making, identifying contextual factors relevant to the adoption of the Efficiency Frontier approach. Based on qualitative interviews with key stakeholders, we argue that the development of the Efficiency Frontier can be associated with cultural reluctance to frame healthcare prioritization decisions around cost based valuations of human health and related doubts about the validity of metrics for human health gain. Based on this finding, we conclude that the delegation of authority to independent HTA agencies follows a broadly evolutionary pattern, in which contextual factors allow for significant variation in institutional and methodological responses to the functional pressures and advantages leading to their establishment.

Regulatory Capitalism and the UK Labour Government's Reregulation of Commissioning in the English National Health Service

Today, policy analysts and regulatory governance scholars are sceptical about the capacity of the regulatory state hypothesis to describe change at the institutional level. For many, the hypothesis is a convenient oversimplification that fails to account for the hybridity of institutional arrangements within individual policy sectors and also for the divergence of reform trajectories across different national and sector-based policy contexts. This article assesses the influence of the key themes of the regulatory state on the UK Labour governments reregulation of National Health Service (NHS) commissioning organizations. Following the critics, it argues that these themes are only partially evident in the programme. While the government has codified previously informal relationships with policies like Patient Choice and has also subjected commissioning organizations to metaregulatory techniques, its reforms have neither displaced public ownership and the direct supply of commissioning services with markets and new mechanisms for rule making and standard setting, nor have the reforms divided labour within the state by creating an independent agency to regulate NHS commissioning organizations via technocratic means. Under the reforms, NHS commissioning continues to take place within a structure of bureaucratic relationships. However, the article suggests that the hybridity of regulatory techniques at work within the UK Labour governments reregulation of NHS commissioning lends weight to the claim that the current era is one of regulatory capitalism. It concludes with a discussion of the consequences of this finding for the public policy and regulatory governance literatures.

European Non-Communicable Respiratory Disease Research, 2002-13: Bibliometric Study of Outputs and Funding

This study was conducted in order to map European research in chronic respiratory diseases (CRDs). It was intended to assist the European Commission and other research funders to identify gaps and overlaps in their portfolios, and to suggest ways in which they could improve the effectiveness of their support and increase the impact of the research on patient care and on the reduction of the incidence of the CRDs. Articles and reviews were identified in the Web of Science on research in six non-communicable respiratory diseases that were published in 2002–13 from 31 European countries. They represented only 0.8% of biomedical research output but these diseases accounted for 4.7% of the European disease burden, as measured by Disability-Adjusted Life Years (DALYs), so the sub-field is seriously under-researched. Europe is prominent in the sub-field and published 56% of the world total, with the UK the most productive and publishing more than France and Italy, the next two countries, combined. Asthma and Chronic Obstructive Pulmonary Disease (COPD) were the diseases with the most publications and the highest citation rates. They also received the most funding, with around two acknowledgments per paper (in 2009–13), whereas cystic fibrosis and emphysema averaged only one. Just over 37% of papers had no specific funding and depended on institutional support from universities and hospitals.

A regulatory governance perspective on health technology assessment (HTA) in France: the contextual mediation of common functional pressures.

The new regulatory governance perspective has introduced several insights to the study of health technology assessment (HTA): it has broadened the scope for the analysis of HTA; it has provided a more sophisticated account of national diversity and the potential for cross-border policy learning; and, it has dissolved the distinction between HTA assessment and appraisal processes. In this paper, we undertake a qualitative study of the French process for HTA with a view to introducing a fourth insight: that the emergence and continuing function of national agencies for HTA follows a broadly evolutionary pattern in which contextual factors play an important mediating role. We demonstrate that the French process for HTA is characterised by distinctive institutions, processes and evidential requirements. Consistent with the mediating role of this divergent policy context, we argue that even initiatives for the harmonisation of national approaches to HTA are likely to meet with divergent national policy responses.