Process, Practice and Progress: A Case Study of the Health Impact Assessment (HIA) of Brexit in Wales
2. Materials and Methods
2.1. Screening and Scoping
2.5. Monitoring and Evaluation including Review and Reflection
3.1. Findings of the HIA
3.2. Reporting, Review and Reflection (Including Monitoring and Evaluation)
Challenges/Limitations of the Work
Conflicts of Interest
|Priority Determinants of Health||Potential Impact on Health||Potential Impact of Brexit||Comments/Rationale|
|Health and Social Care|
|Medicines and medical devices—regulation and licensing||Yes||Negative||Medicines and Healthcare Regulatory Agency (MHRA) currently works with the European Medicines Agency (which is moving to Amsterdam)—post-Brexit position still unclear.|
|Medical and professional qualifications||Yes||Negative||United Kingdom Government (UKG) proposing to continue with existing arrangements but subject to agreement by European Union (EU).|
|Staffing and recruitment||Yes||Negative||British Medical Association (BMA) survey has shown that 45% of EU doctors considering leaving UK. Royal College of Nursing (RCN) and others have expressed concern about recruitment of nurses.|
|Research and development||Yes||Negative||UKG plans to discuss temporary mobility of scientists and researchers subject to agreement by EU. Access to EU networks may be reduced.|
|Working hours and conditions||Yes||Negative||UKG assurances on long-term continuation of existing workers’ rights under EU law questioned by RCN and others.|
|Reciprocal healthcare||Yes||Negative||UKG proposals for continuation of reciprocal healthcare for United Kingdom pensioners, the European Health Insurance Card (EHIC) scheme and cooperation on planned medical treatment subject to agreement by EU. Position on other types of reciprocal healthcare unclear.|
|Fitness to practise||Yes||Negative||UKG position on continuation of participation in EU Internal Market Information (IMI) alert system that records cases of professionals unfit to practise unclear.|
|Health protection and security||Yes||Negative||UKG proposals for ongoing work with key EU agencies on health security to enable information sharing and access to key datasets subject to agreement with EU.|
|Rare diseases||Yes||Negative||As above.|
|Patient care and services||Yes||Negative||Subject to staffing and recruitment and other issues.|
|Pandemics and infectious diseases||Yes||Negative||See Health protection and security.|
|Clinical trials||Yes||Negative||UKG proposals for continued participation in EU wide clinical trials subject to agreement with EU.|
|Life sciences||Yes||Negative||UKG proposals for continuation of existing or similar arrangements subject to agreement with EU.|
|Medical students||Yes||Negative and Positive||Potential vacancies created by fall in EU students may lead to increased opportunities for UK students.|
|Health promotion||Yes||Negative||UKG position unclear but Welsh National Health Service (NHS) Confederation calling for highest possible level of coordination on health promotion.|
|Behaviours affecting health|
|Food and diet||Yes||Negative||UKG proposing common framework with EU but subject to agreement with EU. Implications of Trade Agreements, i.e., regulations and labelling.|
|Alcohol, cigarettes, nonprescribed drugs||Yes||Negative||Continuation of EU cross-border approach to antismoking measures through the Tobacco Products Directive (TPD) unclear. Implications of Trade Agreements, i.e., regulations and labelling.|
|Mental well-being including:sense of control, resilience and participation||Yes||Negative and Positive||Likely to dependent on population profile and attitudes/belief.Indirect impact of potential economic downturns post exit.|
|Social and community influences|
|Family organisations and roles||Yes||Negative and Positive||Likely to depend on population profile and attitudes/belief. Impact of changes to immigration rules—impact on non-UK EU nationals who live and work in Wales.|
|Citizen power and influence/social isolation/community networks/racism/hate crime||Yes||Negative and Positive||Likely to depend on population profile and attitudes/belief.|
|Living and Environmental factors|
|Built environment||Yes||Negative||A significant portion (>90%) of environmental legislation currently derives from EU law, giving rise to uncertainty in the short term.|
|Housing||Yes||Negative and Positive||Stock may increase if EU and other non-UK nationals leave but house prices may fall subject to market conditions.|
|Noise/air quality/waste/community safety||Yes||Negative and Positive||A significant portion of environmental legislation currently derives from EU law, giving rise to uncertainty in the short term, although the majority of environmental legislation is devolved.|
|Workplace and working conditions||Yes||Negative||The majority of health and safety legislation derives from EU law, giving rise to uncertainty.|
|Economic inactivity/income/employment||Yes||Uncertain||Dependent on market conditions/future trade agreements.|
|Skills||Yes||Negative and Positive||Expected short-term shortages may lead to increased opportunities for UK nationals to gain skills in longer term.|
|EU Funding||Yes||Negative||UKG has guaranteed funding for EU projects agreed before Brexit, but it is likely the majority of EU funding will disappear.|
|Access and quality of services|
|Careers advice||Yes||Unclear||Will likely depend on economic conditions.|
|Other caring services||Yes||Negative and Positive||Short-term shortages may mean increased opportunities for employment for UK nationals in the longer term.|
|Shops and commercial services||Yes||Negative and Positive||Potential price rises and reduction in choice may led to closures, but opportunities may arise to create new businesses.|
|Public amenities/services||Yes||Negative||Will likely depend on economic conditions.|
|Education and training||Yes||Negative and Positive||Reduction in EU students may lead to increased opportunities for UK students.|
|Information Technology||Yes||Negative||UK proposals on a data protection agreement subject to agreement by the EU.|
|Macro-economic, sustainability and governmental factors|
|Gross Domestic Product||Yes||Uncertain||May increase or decrease, depending on market conditions.|
|Government policies||Yes||Negative and Positive||Following transition from EU to UK law, policy impacts may be mixed.|
|Economic Development||Yes||Uncertain||May increase or decrease, depending on market conditions.|
- Commission on the Social Determinants of Health. Closing the Gap in a Generation. Available online: https://www.who.int/social_determinants/thecommission/en/#:~:text=The%20Commission%20aimed%20to%20draw,among%20the%20most%20vulnerable%20people (accessed on 13 August 2020).
- Dahlgren, G.; Whitehead, M. Policies and Strategies to Promote Social Equity in Health. Background Document to WHO—Strategy Paper for Europe. Available online: https://ideas.repec.org/p/hhs/ifswps/2007_014.html (accessed on 13 August 2020).
- Frieden, T.R. A framework for public health action: The health impact pyramid. Am. J. Public Health 2010, 100, 590–595. [Google Scholar] [CrossRef] [PubMed]
- Islam, M.M. Social Determinants of Health and Related Inequalities: Confusion and Implications. Front. Public Health 2019, 7, 11. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Marmot, M. Fair Society, Healthy Lives. Available online: https://www.local.gov.uk/marmot-review-report-fair-society-healthy-lives#:~:text=The%20Marmot%20Review%20into%20health,can%20lead%20to%20health%20inequalities (accessed on 13 August 2020).
- Dean, H.D.; Williams, K.M.; Fenton, K.A. From theory to action: Applying social determinants of health to public health practice. Public Health Rep. 2013, 128, 1–4. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Kokkinen, L.; Shankardass, K.; O’Campo, P.; Muntaner, C. Taking health into account in all policies raising and keeping health equity high on the political agenda. J. Epidemiol. Community Health 2017, 71, 745–746. [Google Scholar] [CrossRef] [PubMed]
- World Health Organization. Health in All Policies: Helsinki Statement. Framework for Country Action. Available online: https://www.who.int/publications/i/item/health-in-all-policies-helsinki-statement (accessed on 4 September 2020).
- Collins, J.; Koplan, J.P. Health impact assessment: A step toward Health in All Policies. JAMA 2009, 302, 315–317. [Google Scholar] [CrossRef] [PubMed]
- Kemm, J.; den Broeder, L.M.W.; Fehr, R. How Can HIA Support Health in All Policies: Draft Policy brief Circulated at 11th International HIA Conference in Granada. European Observatory on Health Systems and Policies. Available online: http://public-health.medunigraz.at/archiv/artikel/Artikel%202011/2011_How%20can%20HIA%20support%20HiaP%20-%20Consultation%20Draft.pdf (accessed on 4 September 2020).
- Human Impact Partners. Health in All Policies: An Upstream Approach to Advance Health and Equity. Available online: https://www.mpha.net/Resources/Documents/HiAP/hiap_overview%20_HIP.pdf (accessed on 16 June 2020).
- Birley, M. Health Impact Assessment: Principles and Practice; Earthscan: Oxon, UK, 2011. [Google Scholar]
- World Health Organization. Constitution of the World Health Organization 1948. Available online: https://www.afro.who.int/publications/constitution-world-health-organization (accessed on 16 June 2020).
- National Research Council (US) Committee on Health Impact Assessment. Improving Health in the United States: The Role of Health Impact Assessment; National Academies Press (US): Washington, DC, USA, 2011. [Google Scholar]
- Parry, J.; Stevens, A. Prospective health impact assessment: Pitfalls, problems, and possible ways forward. BMJ 2001, 323, 1177–1182. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Elliott, E.; Francis, S. Making effective links to decision-making: Key challenges for health impact assessment. Environ. Impact Assess. Rev. 2005, 25, 747–757. [Google Scholar] [CrossRef]
- UK Government. European Union (Withdrawal). 2018. Available online: http://www.legislation.gov.uk/ukpga/2018/16/contents/enacted (accessed on 16 June 2020).
- Wincott, D.; Peterson, J.; Convery, A. Introduction: Studying Brexit’s causes and consequences. Br. J. Politics Int. Relat. 2017, 19, 429–433. [Google Scholar] [CrossRef]
- Harris-Roxas, A.B.; Harris, P.J. Learning by doing: The value of case studies of health impact assessment. N. S. W. Public Health Bull. 2007, 18, 161–163. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Welsh Government. Well-being of Future Generations (Wales). 2015. Available online: http://www.legislation.gov.uk/anaw/2015/2/contents/enacted (accessed on 16 June 2020).
- Wales Health Impact Assessment Unit. Health Impact Assessment. A Practical Guide. 2012. Available online: https://whiasu.publichealthnetwork.cymru/files/1415/0710/5107/HIA_Tool_Kit_V2_WEB.pdf (accessed on 16 June 2020).
- HM Government. Implications for Business and Trade of a No-Deal Exit on 29 March 2019. Available online: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/781768/Implications_for_Business_and_Trade_of_a_No_Deal_Exit_on_29_March_2019.pdf (accessed on 16 June 2020).
- Confederation of British Industry. Modelling the Future: Estimating the Impact of Brexit. Available online: https://www.cbi.org.uk/media/2169/2019-03-modelling-the-future-estimating-the-impact-of-brexit.pdf (accessed on 16 June 2020).
- Parker, G.; Hughe, L. Economic Cost of Brexit Laid Bare in OBR Forecasts. Official Budget Watchdog Model for 5.2% Loss of Potential GDP over 15 Years. Available online: https://www.ft.com/content/72938c66-638f-11ea-a6cd-df28cc3c6a68 (accessed on 16 June 2020).
- Stats Wales. Welsh Health Survey. Available online: https://statswales.gov.wales/Catalogue/Health-and-Social-Care/Welsh-Health-Survey (accessed on 16 June 2020).
- Stats Wales. Welsh Index of Multiple Deprivation. Available online: https://statswales.gov.wales/Catalogue/Community-Safety-and-Social-Inclusion/Welsh-Index-of-Multiple-Deprivation (accessed on 16 June 2020).
- Green, L.; Gray, B.J.; Edmonds, N.; Parry-Williams, L. Development of a quality assurance review framework for health impact assessments. Impact Assess. Proj. Apprais. 2019, 37, 107–113. [Google Scholar] [CrossRef][Green Version]
- Davies, A.R.; Grey, C.N.B.; Homolova, L.; Fisher, J.; Burchett, N.; Kousoulis, A. An Action Framework to Support the Mental Health and Well-Being of Farmers at Times of Uncertainty. Available online: http://howis.wales.nhs.uk/sitesplus/documents/888/Brexit%20young%20people%20report_English_final_Feb%202020.pdf (accessed on 16 June 2020).
- Green, L.; Edmonds, N.; Morgan, L.; Andrew, R.; Ward, M.; Azam, S.; Bellis, M.A. The Public Health Implications of Brexit in Wales. A Health Impact Assessment Approach. Technical Report Part 1. Available online: https://phw.nhs.wales/services-and-teams/policy-and-international-health-who-collaborating-centre-on-investment-for-health-well-being/publications-and-resources-bucket/implications-of-brexit-technical-report-part-1-english-only/ (accessed on 16 June 2020).
- Quigley, R.; den Broeder, L.; Furu, P.; Bond, A.; Cave, B.; Bos, R. Health Impact Assessment International Best Practice Principles; Special Publication Series, No. 5; International Association for Impact Assessment: Fargo, ND, USA, 2006. [Google Scholar]
- WHIASU. Trade Health and Well-Being Event. Available online: https://whiasu.publichealthnetwork.cymru/en/news/trade-health-and-well-being-event/ (accessed on 16 June 2020).
- Senedd Home. How are the Welsh Government preparing for a “No-Deal Brexit”. Available online: https://seneddhome.com/2019/01/how-are-the-welsh-government-preparing-for-a-no-deal-brexit/ (accessed on 16 June 2020).
- Welsh Government. Public Health (Wales). 2017. Available online: http://www.legislation.gov.uk/anaw/2017/2/contents/enacted (accessed on 16 June 2020).
- Frankish, C.J.; Green, L.W.; Ratner, P.A.; Chomik, T. Health impact assessment as a tool for population health promotion and public policy. WHO Reg. Publ. Eur. Ser. 2001, 92, 405–437. [Google Scholar]
- Haigh, F.; Harris, E.; Harris-Roxas, B.; Baum, F.; Dannenberg, A.L.; Harris, M.F.; Spickett, J. What makes health impact assessments successful? Factors contributing to effectiveness in Australia and New Zealand. BMC Public Health 2015, 15, 1009. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Green, L. Health Impact Assessment (HIA) in Wales: From voluntary to statutory. Eur. J. Public Health 2017, 27, 241. [Google Scholar] [CrossRef]
- Green, L.; Morgan, L.; Azam, S.; Evans, L.; Parry-Williams, L.; Petchey, L.; Bellis, M.A. A Health Impact Assessment of the ‘Staying at Home and Social Distancing Policy’ in Wales in response to the COVID-19 pandemic. Executive Summary. 2020. Available online: https://whiasu.publichealthnetwork.cymru/en/news/health-impact-assessment-staying-home-and-social-distancing-policy-wales-response-covid-19-pandemic-executive-summary/ (accessed on 13 August 2020).
- Petchey, L.; Green, L.; Edmonds, N.; Van Eimeren, M.; Morgan, L.; Azam, S.; Bellis, M.A. The Public Health Implications of Brexit in Wales: A Health Impact Assessment Approach. A Rapid Review and Update. Available online: https://phw.nhs.wales/news/the-health-impacts-of-brexit-risks-of-harmful-impacts-increase-whilst-chances-of-positive-impacts-remain-unchanged/the-public-health-implications-of-brexit-in-wales-a-health-impact-assessment-approach-a-rapid-review-and-update/ (accessed on 16 June 2020).
- Faculty of Public Health UK, Continuing Professional Development. Available online: https://www.fph.org.uk/professional-development/cpd/ (accessed on 13 August 2020).
- Chartered Institute of Environmental Health, UK Continuing Professional Development. Available online: https://www.cieh.org/professional-development/cpd/ (accessed on 12 August 2020).
- Pew Trust. The HIA Process. Available online: https://www.pewtrusts.org/en/research-and-analysis/articles/2014/08/28/the-hia-process (accessed on 16 June 2020).
- Centers for Disease Control and Prevention. Health Impact Assessment. Available online: https://www.cdc.gov/healthyplaces/hia.htm (accessed on 16 June 2020).
- Kemm, J. (Ed.) Health Impact Assessment: Past Achievement, Current Understanding and Future Progress; Oxford University Press: Oxford, UK, 2013. [Google Scholar]
- Mindell, J.; Ison, E.; Joffe, M. A glossary for health impact assessment. J. Epidemiol. Community Health 2003, 57, 647–651. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Linzalone, N.; Assennato, G.; Ballarini, A.; Cadum, E.; Cirillo, M.; Cori, L.; De Maio, F.; Musmeci, L.; Natali, M.; Rieti, S.; et al. Health Impact Assessment Practice and Potential for Integration within Environmental Impact and Strategic Environmental Assessments in Italy. Int. J. Environ Res. Public Health 2014, 11, 12683–12699. [Google Scholar] [CrossRef] [PubMed][Green Version]
- WHIASU. Temporary Changes to Women’s and Maternity Services in North Wales. Health Impact Assessment Report. Available online: https://whiasu.publichealthnetwork.cymru/files/6414/9553/7616/Temporary_Changes_to_Womens_and_Maternity_Services_in_North_Wales.pdf (accessed on 16 June 2020).
- WHIASU. Health Impact Assessment of the Holyhead Brand Project, Isle of Anglesey. Available online: https://whiasu.publichealthnetwork.cymru/files/3014/9554/6624/Project_Brand_HIA_Workshop_2012_Final_Report.pdf (accessed on 16 June 2020).
- WHIASU. Bodelwyddan Key Strategic Site Draft Development Brief—Health Impact Assessment (HIA) Report. Available online: https://whiasu.publichealthnetwork.cymru/files/7214/9554/0175/Bodelwyddan_Housing_Devt_Final_Report.pdf (accessed on 16 June 2020).
- Dannenberg, A.L. Effectiveness of Health Impact Assessments: A Synthesis of Data from Five Impact Evaluation Reports. Prev. Chronic Dis. 2016, 13, E84. [Google Scholar] [CrossRef] [PubMed]
- Fahy, N.; Hervey, T.; Greer, S.; Jarman, H.; Stuckler, D.; Galsworthy, M.; McKee, M. How will Brexit affect health and health services in the UK? Evaluating three possible scenarios. Lancet 2017, 390, 2110–2118. [Google Scholar] [CrossRef]
- Allen, J.; Balfour, R.; Bell, R.; Marmot, M. Social determinants of mental health. Int. Rev. Psychiatry 2014, 26, 392–407. [Google Scholar] [CrossRef] [PubMed]
- Institute for Government. Theresa May’s Brexit Deal: Declarations on the Withdrawal Agreement. Available online: https://www.instituteforgovernment.org.uk/explainers/theresa-may-brexit-declarations-withdrawal-agreement (accessed on 16 June 2020).
|• Positive—impacts that improve or maintain health status|
|• Negative—impacts that diminish health status|
|• Confirmed—actual direct evidence in existence|
|• Probable—more likely to happen than not, direct evidence but from limited sources|
|• Possible—may or may not happen|
|• Major—sufficiently great or important to be worthy of attention, noteworthy|
|• Moderate—average in intensity quality or degree|
|• Minimal—of a minimum amount, quantity or degree, negligible|
|• S = Short term—less than 1 year|
|• SM = Short to medium term—1–3 years|
|• ML = Medium to long term—3–5 or 10 years|
|• L = 10+ years|
© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Green, L.; Ashton, K.; Edmonds, N.; Azam, S. Process, Practice and Progress: A Case Study of the Health Impact Assessment (HIA) of Brexit in Wales. Int. J. Environ. Res. Public Health 2020, 17, 6652. https://doi.org/10.3390/ijerph17186652
Green L, Ashton K, Edmonds N, Azam S. Process, Practice and Progress: A Case Study of the Health Impact Assessment (HIA) of Brexit in Wales. International Journal of Environmental Research and Public Health. 2020; 17(18):6652. https://doi.org/10.3390/ijerph17186652Chicago/Turabian Style
Green, Liz, Kathryn Ashton, Nerys Edmonds, and Sumina Azam. 2020. "Process, Practice and Progress: A Case Study of the Health Impact Assessment (HIA) of Brexit in Wales" International Journal of Environmental Research and Public Health 17, no. 18: 6652. https://doi.org/10.3390/ijerph17186652