Health Impact Assessment in two Planning Projects in England: Reflections on Normative Effectiveness

doi:10.21203/rs.3.rs-2971057/v1

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Health Impact Assessment in two Planning Projects in England: Reflections on Normative Effectiveness

https://doi.org/10.21203/rs.3.rs-2971057/v1

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published 14 Oct, 2024

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Background

This article reports on research commissioned by (what was at the time) Public Health England (PHE) on the normative effectiveness of Health Impact Assessment (HIA) applied in two planning situations; (a) a new town at Cranbrook, Devon (HIA prepared in 2007), and (b) the regeneration of the Marsh farm area in Luton (HIA prepared in 2009). The aim was to examine the contribution of HIA to actions that are intended to lead to good or improved health and wellbeing.

Methods

Normative HIA effectiveness criteria were used to guide the analysis. The two included HIA cases were previously identified as good practice examples with regards to procedure and report quality. Semi-structured interviews with public health, planning and other actors originally involved in the HIAs were conducted in 2021. This was followed up by web-searches for evidence on actual developments in 2023.

Results

Interviews indicated that normative effectiveness was initially high, but that the longer term effects of the financial crash of 2008, reduced this. Delays in initially anticipated timelines and HIA actors moving elsewhere meant that HIAs were not followed-up and connections between developments and the HIAs were no longer made. However, key HIA suggestions were eventually implemented, albeit with delay. There is evidence for improved IMD (index of multiple deprivation) rankings in the Marsh farm case.

Conclusion

A mismatch is observed with regards to HIA exercises appearing to be largely ‘forgotten’ after over a decade of their publication, but recommendations still being implemented, possibly as a result of ‘institutional memory’. Making monitoring and follow-up of HIA binding rather than advisory would allow for direct linkages to be made.

Health Impact Assessment

Normative Effectiveness

Evaluation

Outcomes

Spatial Planning

● HIA can be strengthened by making it compulsory to follow up recommendations.

● Consideration of HIA monitoring plans should be enforced and go beyond planning consent and onsite works.

● Whilst connections between HIA and development were lost, key recommendations were eventually implemented, even if the HIAs themselves were largely forgotten, hinting at institutional memory surviving over time.

● A wider evidence base should be created on substantive and normative effectiveness of HIA.

The use of Health Impact Assessment (HIA) in spatial planning in England has increased substantially over the past years and at least around 100 HIAs are now conducted annually in this context [1]. Also, approximately 30% of local authorities mandate supplementary planning documents or local plan guidance to include HIA in certain projects [2]. This paper reports on research commissioned by what was Public Health England (PHE) in 2021 (replaced in 2022 by the UK Health Security Agency and the Office for Health Improvement and Disparities) on how HIA recommendations were translating into practice.

The ability of HIA to improve health and wellbeing is usually referred to as normative effectiveness [3][4]. It is not straightforward to establish the extent to which HIA has been normatively effective due to the complexity of causal pathways that are closely associated with long time spans between planning and implementation of projects [5]. A precondition for being able to investigate normative effectiveness is that HIA has been successful in impacting a project plan substantively.

Based on previous research for PHE, which graded English spatial plan HIAs for procedural and report quality [1], a database of HIA case studies was created. From this, a long list of seven good practice HIA cases was considered for further research into normative effectiveness, taking into account substantive impact. Two case studies were selected for in-depth analysis and evaluation, based on long enough timescales between the publication of HIA and the possibility to observe outcomes. This was based on the implementation status of projects and also on the availability of original actors for interview. The two cases include:

Cranbrook New Town Development HIA Main and Technical Report, East Devon (2007) [6][7]] (132 pages; three months preparation time).

Marsh Farm Regeneration Programme HIA, Final Report, Luton (2009) [8] (262 pages, nine months preparation time).

Normative HIA effectiveness is expressed through criteria that were determined based on a literature review, using the database Scopus® for peer-reviewed articles. The search terms "Health Impact Assessment" AND effective* were used to the title, abstract and keywords, limited to the field of social sciences and English language journal articles between 2005 and 2020. This returned 74 articles. Abstracts were reviewed for relevance, resulting in 30 articles. The following criteria were established for evaluation of normative effectiveness of the case studies (mainly based on [9][10] [11][12][13][14]):

HIA recommendations have been implemented
HIA has contributed to reducing deprivation
HIA has contributed to improving health and well-being
HIA has contributed to enhanced transparency and scrutiny in project implementation

In order to be able to associate observed outcomes with the HIAs, elements of ‘substantive’ effectiveness were considered, including:

HIA has informed the development making process
HIA has led to changes in the project plan
HIA has led to the inclusion of specific measures (mitigation or otherwise)

In both cases, these substantive effectiveness elements were met. This is further explained below. Original HIA project staff from the two cases (7 in total) were interviewed over conference videoing in 2021 (due to Covid19 rules, no physical meetings were possible). Questions based on the effectiveness criteria above were used to guide interviews. Subsequently, in 2023 further evidence was sought through web-based searches on actual developments in the Cranbrook and Marsh Farm areas.

Cranbrook was an outline planning application and Masterplan for a new settlement of 2,900 (with potentially up to 8000) homes and a population of up to 20,000, rail and road infrastructure access, social facilities and open spaces in East Devon. The HIA was released in 2007. Construction subsequently started and the first residents moved into their homes in 2012. Development is progressing in several phases up to 2031.

Marsh Farm was an outline planning application for the regeneration of the central area of Marsh Farm Estate (population about 10,000) in Luton. After securing funding from the New Deal for Communities (2001–2010) programme [8, p16], the HIA was commissioned. It was produced prior to planning consent in 2009. By 2021 on-site works of the final construction phase were completed and the community started resettling back into new developments.

Both HIAs were prospective and comprehensive in scale. They were standalone and applied next to environmental impact assessments (EIAs). They were not used to develop options, but rather to assess options that had already been designed (which is typical for current HIA practice; see [15]). The private sector company ‘Housing Developers’ led the Cranbrook new settlement. Marsh Farm was a publicly funded development. External consultants conducted and produced both HIAs.

Cranbrook New Town Development (Phase 1, 2007)

‘Private Developers’, the East Devon New Community Partners, submitted a planning proposal which was assessed by East Devon District Council (EDDC) with an HIA to support the development of a 'new vibrant, dynamic and socially cohesive community' [6, p. 3].

Regional, countywide, and local planning policy for HIA was in place that supported Devon County Council (DCC) in the decision to commission an HIA. This emphasised a need to create a ‘community’ rather than just a ‘physical settlement’ [6, p. 4]. A public health registrar was on the HIA Team, which worked under governance of a Steering Group, composed of planners and public health practitioners. The HIA:

Assessed how the design of services, transport and connectivity, economy, housing and the built environment, and governance could support social cohesion.
Took an early decision to scope out aspects covered in the Environmental Impact Assessment (EIA) for the development.
Developed 'Health Codes' to ‘hard-wire’ health into the strategic principles of the development; these included developer mitigation payments, design requirements, management arrangements to maximise benefits, and monitoring and review, through a series of indicators and metrics of each phase of development [6, p. 12].

A challenge for HIA public participation was how to profile for a new (i.e. not yet existing) community. This was approached by doing face-to-face and telephone interviews as well as online surveys with stakeholders, including those from neighbouring villages.

HIA recommendations included monitoring on health and deprivation over time, the appointment of a community outreach worker, the construction of a community centre and that a new school would allow the community to access its facilities. Furthermore, it asked for the widening of childcare options, and with the reconstruction of the town hall, for the establishment of a Town Council. Finally, it suggested ways to establish shared history and identity for the town through arts projects.

When the first residents moved into the area during 2012, a community outreach worker was employed, and a new Town Council was established, with its first elections held in 2015. In 2019, the District Council submitted a new HIA [16] for Cranbrook's Local Plan extending Phase 1, including decisions on the community centre and other social amenities originally assessed in the 2007 HIA [6][7].

Marsh Farm Regeneration Programme

This scheme includes the redevelopment of a 1960s council owned housing estate, three miles from Luton town centre with 4,000 dwellings and a population of about 10,000. The design of the original estate had contributed to anti-social behaviour, rising incidences of crime, and increased tension between police and young people. This led to local riots in 1995 and a legacy of poor community / institutional relations. The regeneration programme, led by the Marsh Farm Community Development Trust (MFCDT) aimed at providing refurbished or new housing, a new supermarket, a pub, gardens and other community facilities with improved pedestrian and vehicular access.

Luton Council had experiences with HIAs from previous planning projects but had no HIA planning policy. The public health practitioner had supportive managers who was said to have understood the benefits of health and wellbeing for regeneration projects. The longer-term goal was for the Council to increase its capacity for HIA, and that Marsh Farm would offer a flagship HIA case.

MFCDT assisted the HIA team in facilitating equalities-themed workshops with residents from the estate, focusing on children and young people, older people and those with disabilities, ethnic minorities, unemployed people, and tenants of the shopping arcade. They paid participants for their time with shopping vouchers. They adopted this consultation method to bridge the legacy of broken trust between the community and the local authority.

The HIA assigned management for delivery of recommendations to specific lead agencies. HIA recommendations were taken forward, including the introduction of a new housing policy, detailed designs of new open and green spaces, operational management plans of key services during construction, relocation strategies, and ongoing maintenance plans. By 2023, all of these had been delivered, albeit with some delay from the original plans.

Cranbrook and Marsh Farm HIAs were opportunistic in the sense that they were prepared after important decisions had been made prior to assessment, However, they were still given space to develop recommendations (as introduced above). Both were exemplary in terms of how they were run procedurally [1]. Subsequently, we discuss normative effectiveness of the HIAs in the light of the results from interviews conducted in 2021 and web-based searches for evidence in 2023. The numerous quotes are all from the interviewees who included:

(1) Marsh Farm (Luton)

1 HIA consultant

2 Council Public Health Representative

(2) Cranbrook (Devon) interviewees

3; 4: Devon Council Planning Representatives

5: National Health Service (NHS) Public Health Practitioner

6: East Devon Council Planning Representative

7: HIA Consultant

HIAs assessed a range of social determinants of health, with employment, in particular of local people taking centre stage. The Marsh Farm HIA focused on normative impacts of health inequalities, and "members of the Community were engaged with thinking about health and about indicators of health, and how that might translate to the community. They talked about things that were troubling them. We also had workshops… the community were very much engaged in it". On the value of participatory approaches, "I noticed fairly early on… there's a disconnect from where the Council were, and where the community was in Marsh Farm. We hoped the HIA would bring some of these organisations together and would create a kind of common way forward".

The Cranbrook HIA found space to consider community cohesion through the provision of social infrastructure. Without an existing settlement, this was a challenge, and "there wasn't engagement with the developer, we never spoke to the designers… I think that if I was to do this again there would be more opportunities for public engagement".

Perceptions of the HIAs being able to inform and change decisions showed mixed results. In Marsh Farm "I don't think it's made a huge difference, but it has built in health and wellbeing, so it's an intrinsic part… HIA is good at influencing and shifting mindsets". On the decision of having a housing led focus, one interviewee remarked that at least initially "they'd forgotten all about it [the HIA]. There were some horror stories in the press about these developments, about how they were not working well.” This was due though at least in parts to a delay of the development of social infrastructure (which was eventually implemented with some delay, though).

With regards to housing and health, "they [initially] applied a 40% affordable housing target, which meant you had a terrible situation where everyone on the housing lists from both, East Devon and a fair proportion from Exeter were housed in Cranbrook. Without the community infrastructure that you needed to support people… It felt very counter-intuitive trying to make the case for less affordable housing and more community infrastructure".

Increased scrutiny of the monitoring stages of HIA can bridge a frequently existing evidence gap in providing HIA case studies illustrating health outcomes [5, 17, 18]. For Marsh Farm,

"the 25-year monitoring plan didn't happen, I left and there was no one to follow through". For Cranbrook: "I look at these health codes [proposed in the HIA] and wonder if they had any life beyond the HIA? That would be some interesting learning, if they didn't then why not?".

In both cases, there were individuals underlining how the HIAs positively influenced receptive institutional leaders. For Cranbrook, "the HIA was important, fitting into a larger vision of what this development should be". For Marsh Farm, "The public health realm in the local authority was increasing, and the authority understood poverty".

The 2008 global financial crash had an impact on HIA effectiveness in that "there was a rupture between all the work that had been done. The HIA lost a lot of momentum " (for Marsh Farm)" and "it made a difference to the power of the developers and what the Council wanted to be done and how much they felt they could… seek to impose health and wellbeing considerations on a market driven solution, as none of the land was publicly owned" (for Cranbrook).

Both cases had enthusiastic champions and leadership for the HIAs and developments. "Marsh Farm HIA had to be the flagship HIA, in which all the other HIAs base themselves". The Marsh Farm team involved local community stakeholders, but also built networks within the commissioning organisations. "It's very rare that you find planners who really can understand and visualise the impact that the plan can have on health and wellbeing, particularly the wider determinants. That's the bit we [public health] bring to it.".

Champions operated within arenas that had experiences with HIA, with individuals that understood HIA well. Luton also had a local HIA policy. Planning and public health actors had different roles, but could decide equally on funding, scope, and methods. The focus on the social determinants of health offered a bridge between planning and public health. In this context, it is important that both cases were of high procedural effectiveness [19, 20].

Cranbrook HIA recommended the priority scheduling of community infrastructure, which was accepted in the development plan. As mentioned above, a community outreach worker was employed in 2012, and a new Town Council was established. Also, the construction of a school (Cranbrook education campus) had been completed in 2015 (https://www.cranbrookeducationcampus.org.uk/). The school has allowed for community access, as had been recommended in the HIA. At the time of the interviews in 2021, it was not clear though when exactly community and childcare centre would eventually be delivered. However, this changed in August 2022, when work on Cranbrook Town Centre (including community and childcare centres) started (with delay). Importantly the 40% affordable housing target, which had raised concerns, was not kept. Instead, for the first stage of development, a 30% target was used. Subsequent stages then only applied a 15% target [21]. With regards to HIA recommendations on supporting the arts and cultural activities, it is observed that a ‘Cranbrook Festival’ initiative was started in 2012, with the aim of bringing ‘together the people of Cranbrook town, Devon, by staging one or more annual arts and community festival events during the year’ (https://cranbrookfestival.com/about-us/). Also, a Cranbrook Cultural Masterplan was prepared in 2015 (https://www.ginkgoprojects.co.uk/cranbrook).

On the Marsh Farm Estate, refurbished and new housing, a new supermarket, gardens and other community facilities with improved pedestrian and vehicular access were delivered. With regards to evidence on how health determinants have developed over time, indices of multiple deprivation (IMD) ranks are considered for the relevant seven lower layer super output (statistical) areas (LSOA), consisting of the following seven domains of deprivation (weighting in brackets; following [22]):

• Income (22.5%)

• Employment (22.5%)

• Health Deprivation and Disability (13.5%)

• Education, Skills Training (13.5%)

• Crime (9.3%)

• Barriers to Housing and Services (9.3%)

• Living Environment (9.3%)

Neighbourhood level data taken at the time of construction and on completion illustrate that domain rankings had improved between 2015 and 2019, with notable variations, including the impact on living environment during construction works (Fig. 1).

The overall rank change worsened during the construction works for all but two of the LSOAs. All but one LSOA had improved in rank from 2010 at the start of the development to 2019 at completion and resettlement of the 2nd construction phase (with the 3rd and final construction phase being underway).

Observing changes in health and wellbeing outcomes as a consequence of spatial planning takes time. Even though it has been over a decade since the assessments were conducted, it is arguably still early to assess normative outcomes. However, over a decade is a considerable part of a personal career, and the aim was to interview original HIA personnel, who are currently working in public health and planning. This was a challenge because e.g. personnel had left, there were no contact details, and there was wariness of being ‘evaluated’. A weakness of IA research is the role of the private sector; where sharing of knowledge is monetarised, findings are business sensitive and expectations in editing approvals need managing [23, 24]. To help counter these limitations, PHE emphasised that the research was not an evaluation but an examination of effectiveness of HIA in spatial planning. Finally, it is not possible to clearly connect observed effects with any particular document, as numerous other planning documents and strategies are usually prepared that go hand in hand with the HIAs.

In this paper normative effectiveness of HIA in English spatial planning was examined on the basis of two case studies that had previously been identified as examples of good practice with regards to how they were conducted procedurally; Cranbrook New Town in Devon and Marsh Farm Estate in Luton. The contexts of the case studies were supportive in terms of individual actors, host communities, institutional operations, approval from leadership, or by policy/funding objectives. Contextual support changed in response to external factors, namely the 2008 financial crash, stalling long-term HIA monitoring. The scale of development means that in parts it is still early to assess normative effectiveness, although neighbourhood indices for regeneration outcomes in Marsh Farm are promising. For the Cranbrook case, whilst HIA recommendations such as the employment of a community outreach worker had been taken up early on, budgetary constraints following the 2008 financial crisis meant that this didn’t initially continue. Evidence from 2023, though, shows that all key HIA recommendations had eventually found their way into practice, albeit with delays (including construction of a community centre and a new school which allowed the community to access its facilities). However, HIA monitoring and evaluation stages were ultimately not effective and monitoring plans had been forgotten. Therefore, whilst HIAs have not been able to contribute to enhanced transparency and scrutiny in project implementation, key recommendations survived, possibly due to institutional memory and also because recommendations reflected what communities wanted.

In this context, impact assessors should review their use of the word 'recommendations', as this has more power when a planner uses the term because of the delegated authority process in the English planning system, compared to health practitioners, where it is defined as advice (to the planner).

A limitation to the research underlying this paper is the long timescales, not only of the development process but also of health and wellbeing outcomes, compared to the career paths of original actors. Currently, HIA has a weak policy status, and efforts are needed to create a stronger enabling context, for example, HIA recommendations should be binding and not advisory.

Ethical Approval and Consent to Participate

The study and interview protocols were approved by Public Health England’s Ethical Committee. Interviewees gave informed consent to be interviewed. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for Publication

Not applicable

Availability of Data and Materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests

There are no competing interests.

Funding

This paper presents results produced in the project ‘Strategic Planning – links between health issues and the development of strategic plans’ for Public Health England - Contract Reference Number 426627157

Authors contributions

Thomas B Fischer wrote the main manuscript text and researched actual developments in the two case study locations. Tara Muthoora conducted the interviews and wrote up associated parts in the paper. Michael Chang provided input to the text and contributed to setting up the research. All authors reviewed the manuscript.

Acknowledgements

The authors are grateful to interviewees for their willingness to share their insights and time.

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No competing interests reported.

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You are reading this latest preprint version

Health Impact Assessment in two Planning Projects in England: Reflections on Normative Effectiveness

Status:

Journal Publication

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Abstract

Figures

Key points

Introduction

Methods

HIA cases under consideration

Cranbrook New Town Development (Phase 1, 2007)

Marsh Farm Regeneration Programme

Findings and Discussion

Limitations

Conclusions

Declarations

Consent for Publication

Availability of Data and Materials

Competing interests

Funding

References

Additional Declarations

Status:

Journal Publication

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