Health impact assessment (HIA) explores the effects of policies, programmes and projects initiated in "non-health" sectors (for example, a regeneration programme, or a new transport system) on public health and health inequalities. HIA can be undertaken at a number of decision-malting levels: for example, an HIA may be undertaken on proposals for a new leisure centre (project level), a regional transport scheme (programme level), national taxation schemes (national policy level) or even international policies such as the Common Agricultural Policy (supra-national policy level). Early studies of HIA focused on its application to projects and developments, but today, there is growing interest in its application to policy (1).
In 1999, a formal expression of the methods and values of HIA was made in the Gothenberg Consensus Paper (GCP). The GCP argued that that HIA must embrace the broader ideals of social policy or be divorced from the "reality" of the environment in which it hopes to find a place, and asserted the right of people to participate in the "formulation, implementation and evaluation of policies ... both directly and through elected political decision makers" (2). According to the GCP, participation in HIA made the policy process more transparent and democratic. It empowered people within the decision-making process and redressed 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.
Early applications of HIA adopted the values set out in GCP and directly involved communities in the identification, assessment, and prioritization of health impacts. However, in the four years since the GCP was drawn up, policy-linked HIA faces serious difficulties. Although advocated at regional, national and supra-national levels, the incorporation of HIA into decision-making has been patchy at best (3 8). Numerous reasons for this "failure" have been suggested--for example, the loss of key supporters of the process, or the existence of other forms of impact assessment (e.g. environmental health assessment, sustainable impact assessment) (9). However, even where the political climate has been broadly supportive, HIA has proved difficult to operationalize--its participatory and empowering dimensions in particular. While participation may encourage open, democratic debate about policy options, the time and resource demands of the political process limit the extent to which the community can be engaged, and for decision-makers, time and resource constraints are among the most frequently mentioned barriers to conducting policy research (10). The requirement to operate within the time frame of policy creates tension between HIA's participatory and knowledge-gathering dimensions. In other words, community participation presents HIA researchers with a conundrum: the adherence to the core values of community participation and empowerment threatens the likelihood of being able to influence policy-making processes.
We have outlined the potential difficulties facing participation in HIA elsewhere (1, 11). In this paper, we review actual experiences with participation in the United Kingdom. In particular, we consider whether HIA should welcome participatory methods of appraisal in the name of empowerment, representation and ownership, or whether participation should be restricted in the name of timely and resource-efficient assessments.
Our examples are drawn from the United Kingdom Health Development Agency web site, a well-known and accessible resource offering an abundance of information on HIA (12). We have selected assessments in which the requirement for public participation might be expected to have been greater than usual. Thus, our examples include assessments undertaken on both policies and projects by key government agencies--the Scottish Executive, the London Health Observatory--in which public participation was actively courted. …