1. How health impact assessment can support ‘world class commissioning’ Andy Pratt Health impact specialist practitioner, Public Health Development Unit Plymouth PCT Andrew.pratt@plymouth.nhs.uk

2. Learning outcomes Participants will be able to describe the stages taken in HIA Participants will be able to apply HIA approaches to service commissioning and delivery

3. Today: Introducing Health Impact Assessment Health determinants &‘pathways’ The Government HIA ‘toolkit’ HIA and stroke services in Plymouth Testing HIA‘toolkit’

4. ‘World-class commissioning’..To ensure services effectively meet needs People will live longer healthier lives Health inequalities reduced 11 competencies, including: Work with community partners Manage knowledge & assess needs

5. Welcome to the world of health assessment! Health needs assessment (HNA) Health impact assessment (HIA) Integrated impact assessment (IIA) Health equity audit (HEA) Equality Impact Assessment (EqIA) See p 11 Clarifying Approaches to HIA

6. Health needs assessment Reviews health needs of a population What are the needs? What services are available? What could be provided? Community engagement Prioritisation

7. Health equity audit How fairly are resources provided in relation to need? Identify inequity or gaps in provision Prioritise intervention/changes Review

8. Health impact assessment …a combination of procedures, methods & tools …that systematically judges the potential, & sometimes unintended, effects of a policy, programme or project … on both the health of a population, & the distribution of those effects within the population …HIA identifies appropriate actions to manage those effects International Association for Impact Assessment 2006 NB – it’s not “human health risk assessment”

9. Policy context - HIA Central govt IA must accompany legislation – includes health & well-being (Acheson) Inequalities in Health (98) Our Healthier Nation (DoH 99) Article 152, EU Amsterdam Treaty (99) DoH & NRU (etc) guidance 2002 Securing Health… (Wanless, Treasury, 04) Choosing Health (DoH 04) Guidance for Joint Strategic Needs Assessment

11. Health inequalities ‘you could live for 10 more years in Glenholt’ (the richest part of town) Early years support Better social housing, less fuel poverty Education & skills in disadvantaged areas Improved income DoH (Programme for Action) 2003

12. Stages of (H)IA Screening (relevance to health) Scoping (identify key issues*) Assessment (identify potential effects*) Reporting/feedback (present results) Monitoring/Management (ongoing action) (* Particular opportunities for wider involvement)

13. Screening: which is most suitable? New clinical procedures for NHS dentists Changes to local acute cancer services A power-generating waste treatment facility New hotel/disco in residential area New vending machines in Hospital New inner-city bypass road Policies of the new Plymouth social landlord

14. Some screening criteria… Effect on equalities Population size Existing evidence base Opportunities to influence decision-making Commonly NOT health sector proposals

15. Scoping Aims, terms of reference, ‘management’ Decision-making context Boundaries (time, place etc) Resources Methods?

16. Assessment (I) Gather evidence: who will be affected? Analyse proposals Profile the population & groups within Literature/evidence review Policy context Participative stakeholders

17. The evidence base: Accessing services Access to green space Air quality Community severance (congestion) Economic activity Noise Physical activity Road traffic accidents Sustainable development

18. The health profile Relative deprivation Poorer health Data for families with young children (also as a proxy) Changing area: housing improvements, health improvements, diversity

19. Assessment (II): consultation Who are the key stakeholders? How to consult? The adopted approach Limitations

20. Assessment (III) What is the impact ? Pos or Neg? The cause? Who is affect -ed? Is it definite,pro bable or speculat -ive?

21. Health determinant and/or pathway Negative impacts? Positive impacts? Proposed additional mitigation and/or enhancement of the health impacts Access to community services (including leisure, local shops etc)… …can be positive for health There will be some inevitable disruption for the local community and broader populations at different points during construction Will improve access to the Embankment Road area New and improved bus services across the East End and through the city The potential to improve pedestrian/ cycle access to the centre (1)to undertake a ‘mobility assessment’ of the area for people with reduced mobility (2) To give the highest possible priority to improving pedestrian surface level crossings, especially at Cattedown Roundabout and Heles Terrace

22. So HIA can… Balance a diversity of data, qualitative & quantitative Pragmatic.. Not primary research Rigorous, systematic Evidence based… & requires professional judgment Distributive impacts Prospective Aid for policy-makers Not just desk-top.. value lay judgments.. prioritise community input Non health sector

23. HIA values Equity Sustainable development Democracy Ethical use of evidence Promotion of health & equality

24. How can transport issues affect health? Access to services Access to green space Accidents & injuries Air quality Community severance/cohesion Economic impacts (Mental health impacts eg congestion/freedom) Noise Physical activity Sustainable development/climate change

26. The Government HIA ‘toolkit’ 1. Affect the wider health determinants? 2. Significant impact on lifestyle-related variables? 3. Significant demand on health & social services? 4. Will ‘sub-groups’ be disproportionately affected? 5. Will effects cause changes in service use, quality of life, mortality? 6. Will there be public concern about potential health impacts?

27. Stroke = a medical emergency A brain injury caused by sudden interruption of the blood flow 3 rd most common cause of death Most common cause of severe disability (250,000 people in UK) Face Arm Speech Test

28. Mini-stroke & silent stroke Mini-stroke (TIA attack) Similar but temporary symptoms (a few hours) 5 x more likely to suffer a full stroke ‘Silent stroke’…up to 4% 0.24% of population stroke incidence p.a

29. Causes & risk factors Can happen to anyone with no obvious cause Age: more common for over 55s Sex: under the age of 75, men are more vulnerable Family history of stroke can increase risk Asian/African & African-Caribbean people in the UK can be at greater risk High blood pressure (hypertension) Heart disease Diabetes

30. Causes and risk factors Diet (fatty food, salt) Obesity Alcohol bingeing Smoking Inactivity

31. Please note: Mental/emotional state is relevant (depression, stress, divorce/bereavement can increase risk) Risk increases with deprivation (up to double the risk)… …which appears to be demonstrated by relatively high incidence in city centre, Honicknowle, St Budeaux

32. Stroke health effects Most symptoms can improve as brain recovers Can affect bodily & cognitive functions Weakness, balance, paralysis Swallowing (50% of victims) Fatigue Speech & language Mood swings (very common) Mental processes Effects on relationships; isolation; financial issues

33. Effects… Only 10% return to pre-stroke health 13% NHS & 25% nursing home beds (6 months after) 53% totally dependent on others 32% with clinical depression (= 500 in P) Care requirements can diminish with recovery …but the cohort needing care grows each year

34. In Plymouth… 10,000 in Plymouth could have suffered a silent stroke 645 strokes/year (538 as 1 st stroke) Between 1344-1882 people who have survived stroke (about 6 people per 1000) Relatively high local levels of hypertension, heart disease, deprivation, smoking, inactivity

35. Commissioning stroke services in Plymouth ‘Poor’ past performance Differences between service providers Aiming to fulfil National Strategy Economic impacts Clinical Service Line, dedicated leadership, clinical posts Reducing hospital stays Greater investment in family & carer support

36. When someone suffers a stroke attack: Rapid access to TIA clinic (new) (or) admitted direct to specialist hospital Acute Stroke Unit asap (new) 24 hour access to clot busting drugs (new) 10 day average hospital stay (improved) Medically “stabilised” Medication prescribed Brain scan (improved)

37. National hospital “indicators”/model…. Screening for swallowing (?) Rapid access to physio (?) Mood assessed (?) Patient weighed (?) Occupational therapy (?) Rehabilitation goals agreed (?)

38. After hospital discharge for TIA/stroke: Some referred to Rehab Stroke Unit (Mount Gould, Mon- Friday) Others referred home or to Care Home etc All discharged patients will be assessed by a specialist nurse home visit (extra investment) for 6 months only (NHS led ). Ongoing home support from Community Services (City Council led) >4 “carer visits” per day Supposed to have 4 x GP appointments in the first year (TIA patients contacted by phone)

39. After hospital Information supplied to patients/carers The planned “Directory” of useful services not yet available Carers support group Carers Emergency Response Service (new) Equalities issues?

40. Applying HIA to commmissioning stroke services Describe the key features of the service(s) & plans Is it useful to apply the HIA ‘questions’? Apply the HIA matrix tool

41. HIA & commissioning What are the key commissioning issues? What are the health impacts? Whose health? Mitigation and/or enhancement of impacts

42. HIA approaches… “ Increasing access to psychological services” “best commissioning value” “Vascular checks for 40-45 year olds” Targeted health promotion/stroke prevention for TIA patients? “Post-hospital GP support” Engage with housing providers/planners Is there a local stroke network & city Coordinator?

43. The importance of prevention & recovery I suggest that health promotion activities can reduce risk - & with targeted support services significantly help recovery Value of support & advice for caregivers NICE guidance due 2012 Existing research dominated by pharmaceutical & clinical interests rather than prevention & rehab

44. Some other thoughts The need to bridge the NHS and ‘Social Services’ gap ‘Particular lack of support with communications, emotion, coping with change’ (NHS Clinical Lead) In the absence of a robust complete pathway, the centre of gravity shifts to rehabilitation as an adjunct of acute care e.g. preventing blocked beds, rather than its true purpose, to rebuild life (Stroke Association 2009)

45. Your final thoughts? Top tips for stroke? Top tips for general commissioning? Is HIA-“thinking” useful? Is this kind of toolkit useful?