Background: The Salford Health Investment for Tomorrow and the Local Improvement Finance Trust proposals for the comprehensive redevelopment of Salford Royal Hospital and the provision of four integrated primary health and social centres in the City of Salford are a response to the challenge of the NHS Plan to modernise delivery and service provision. The scale of the proposed developments will have a major effect on the quality of life in Salford. This health impact assessment was undertaken to determine how these proposals could be amended to ensure that the impacts are optimised so that potential benefits to Salford’s communities are realised to maximise their health and wellbeing.
Method: This involved a comprehensive prospective health impact assessment and a series of interviews with key stakeholders, community organisations, and local people to identify and prioritise potential positive and negative impacts of the proposals.
Results and conclusions: The assessment pointed to a wide range of positive and negative impacts that provided the basis of a set of recommendations, which were linked directly to the themes of the Salford Community Plan. These related to setting employment, education, and training opportunities to maximise health and wellbeing and improve quality of life for all communities in Salford within the framework of the plan. In presenting the findings of the health impact assessment and discussing the recommendations, the paper presents a unique approach in health impact assessment reporting by offering perspectives from the assessor and the project’s steering group.
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- HIA, health impact assessment
- SHIFT, Salford Health Investment for Tomorrow
- LIFT, Local Improvement Finance Trust
- PCT, primary care trust
Health impact assessment (HIA) is a technique that allows “whole systems” thinking to be incorporated into the health planning process. The need for HIA of policies, plans, and projects was acknowledged in the white paper, Saving Lives: Our Healthier Nation.1 This enables decision makers to consider the consequences for health when they develop plans and before they implement them. Health impact refers to a change in the health status of a population within defined geographical and temporal boundaries. This paper reports the approach and results of the assessment of the joint Salford Health Investment for Tomorrow (SHIFT) and Local Improvement Finance Trust (LIFT) project.2 The proposals involved the redevelopment and changes in methods of service delivery at Salford Royal Hospitals Trust (SRHT) under SHIFT and the provision of four health and social care centres under LIFT.
The NHS Plan refers to the potential for the NHS to contribute to sustainable regeneration of community areas through its influence over training and employment opportunities, building uses, local supplier linkages, and in-commuting.3 This potential is supported by the expectation that primary care trusts (PCTs) will engage in local strategic partnerships to fulfil their responsibilities to improve the health of the population and reduce health inequalities. An HIA offers the opportunity to highlight the way in which decision makers can change projects to make positive contributions to communities and improve their health status, while still achieving the initial goal of service modernisation. This was the context for the commissioning of the HIA of the joint SHIFT and LIFT project in Salford, Greater Manchester. The combined projects sought to attract private sector investment to facilitate the expansion of secondary healthcare service through the provision of additional beds, out-placing some secondary care services to the community, and building four integrated PCT health and social care centres across Salford. An HIA steering group is of central importance to its commissioning, scoping and in drawing up implementation and monitoring strategies with the developer. Three steering group members represented public and community health in Salford and local people and were instrumental in commissioning the HIA. In preparing this paper, the assessor requested their independent views on the HIA, including its outcomes and potentials.
THE HIA COMMISSIONING PROCESS
The HIA was commissioned after the lobbying for an assessment by the Salford Community Health Council (CHC), the director of public health in Salford, and a number of concerned locals. Following the procedural and methodological approach suggested by the Liverpool Public Health Observatory, a steering group was formed to recruit an HIA assessor to advise the process accordingly.4 The remit of the HIA assessor was to identify, evaluate, and prioritise the project’s impacts, to determine how it could contribute to health and wellbeing, personal development, and reduction of health inequalities in Salford. The prospective nature of the HIA offered the opportunity to influence the project’s proposals at the planning stages and enabled the “whole systems” approach to be applied in the health planning process within Salford.
HEALTH STATUS AND DETERMINANTS OF HEALTH
HIA assessors base their approach on a model that has psychological, social, economic, cultural, and biological factors as its premise in terms of the determinants of health.4–6 This arises from a definition of health that rests upon notions of health and wellbeing. Health status thus relates to economic and social conditions across community groups in an area.7,8 These studies suggest that specific influences within the categories of such non-medical health determinants; for example, biological factors, family circumstances and lifestyle behaviours, social and cultural environments, physical environments, public services and policies can significantly affect the wellbeing of people within a local community as they influence people’s health status.9–11 This means that HIA studies should include assessments of those factors that are known health status determinants. Thus, the sustainable future of a community requires improvements in and maintenance of its health status along with future economic opportunities.
PROFILE OF THE CITY OF SALFORD
The City of Salford lies central to the Greater Manchester conurbation and has a population of 230 500.12 Salford is the fourth most deprived local authority area in north west England and the 28th nationally. In the period between 1965 and 1991 the city lost 49 000 jobs, 32% of its employment base.13 Some service sector expansion occurred during the 1990s but this did not compensate for the decline in the city’s traditional economic base. Many wards of Salford are among the worst affected by deprivation and ill health in the country and reflected the relatively low health status within the city. The continued relatively high unemployment of the 1990s across Salford has compounded the social malaise. Risk taking behaviour, such as crime, violence, vandalism, and substance use, affects personal and family circumstances and lifestyle and social environment, two important categories of influences on health.4 Crime is comparatively high in Salford and with unemployment is a significant influence on health status in the city.
OUTLINE OF THE PROJECT’S PROPOSALS
The joint SHIFT and LIFT project put the NHS Plan into practice in transforming local health and social care infrastructure in Salford. The project entails a redesign of services to improve patients’ experience, to deliver more accessible, effective, and responsive care and to provide responsive and personalised 24 hour integrated health and social care across the city. The proposals entail two distinct aspects. First is a physical aspect, which relates to the redevelopment of the SRHT, which employs around 3500 people, provides local, regional, and national services and is a major teaching facility, and the provision of four PCT health and social care centres at locations in Salford. The second aspect is a decentralised service model. This relates to the proposed shift in some healthcare elements from the central SRHT site to the PCT health and social care centres within the city’s communities. Both aspects have radical implications for the potential sustainable futures of Salford’s communities. The project’s proposals follows the “whole systems” approach, which implies that it will take account of the full range of agencies involved and the factors that influence health and wellbeing in Salford.
Policy implications involve the willingness of the Partnership Board in Salford and health authorities across the UK to develop a health agenda that is based around healthy living and wellbeing. The Partnership Board must:
Promote the shift in thinking and provide the impetus to change by using the project’s economic and social regeneration potentials to attain this objective.
Appreciate and understand the potentials of the project and its role in developing and maintaining the sustainable future of Salford. In so doing, it must use the phases of the project to implement and promote economic prosperity and encourage social and community inclusion within the city.
Develop the policy of working with the Salford Partnership, local forums, and enterprise units to realise the positive impacts revealed by the assessment and reduce the negative impacts.
Recognise and promote the need of Salford’s communities for wider multi-purpose facilities and use of local healthcare centres. For example, the health and social centres should provide onsite facilities for voluntary services, health promotion activities, leisure, sport and play, community cafes, and green garden areas around them.
Take up the opportunity to make significant contributions to promoting creativity and learning by developing programmes that link with local schools and colleges. This will be of benefit to Salford’s children and young people as it will enhance their self belief and esteem as they become aware of career potentials with the project in its developmental stage and operational years.
The HIA was carried out over a period of four months in which the views of local people and key informants were gathered, evaluated, and prioritised. The scope of the HIA, in terms of the geographical boundaries, time covered by the assessment, and the sources of secondary data by which to determine the health status of the local population, was agreed upon with the HIA steering group. The geographical boundaries were confined to the City of Salford as this was the principal area in which the major impacts would be felt. The assessment covered the period from site clearance up to completion and over the first 10 years of operations. A prospective HIA day was held at the University of Salford, which was attended by 50 delegates, including carers, health managers, and community leaders. Delegates self selected into impact assessment groups under each of six themes of the City of Salford’s community plan (fig 1).
Key informant interviews were conducted with community representatives, professionals, and health agencies across Salford. During the process of carrying out the interviews, some interviewees suggested further informants who could make contributions. Using this snowballing technique, further experts and informants were consulted, which culminated in 25 interviews. Five meetings were held with local groups in communities across Salford. These included discussions with a young mums and toddlers group, a local credit union group, an elderly people’s healthy hips and heart group, and two local residents’ action groups. Thus qualitative information was collected that related to the views, perceptions, and opinions expressed by experts, key informants, and community group members. Quantitative data on health, demography, economic, unemployment, and social conditions by which to determine the health status of the city were collected from published secondary sources.
HIA findings and ASSESSORS and steering group perspectives
Discussions with the key informants suggested that there would undoubtedly be positive health benefits from the redevelopment and the provision of the new PCT health and social centres, especially those that will be located in the peripheral areas of Salford. These experts considered that positive benefits would flow directly from the planned “whole systems” model of care, the new and improved facilities and the advanced information technology in administrative applications. Positive health outcomes will also flow from the improved access to secondary care, from the reduced waiting times because of the planned numbers of new beds, and from the improvements in clinical and community services both at SRHT and in the new health and social centres. They considered that the new PCT centres will also alleviate distance related illness, reportedly incurred by elderly patients and their families who make long journeys to the central hospital site. Interviews with the community groups identified the need for the project to support their health by helping to develop social and community facilities at the main SRHT site and at the new health and social centres. Many called for SHIFT and LIFT to promote social inclusion and encourage local empowerment. In contrast, the emphasis from health agencies involved in the project was predominantly the modernisation of treatment and delivery services.
The comprehensive assessments in which delegates were arranged under each of the separate themes of the Salford community plan produced 94 separate tables of impacts.2 Table 1 to table 6 provide the prioritised set of impacts for each of the main categories of health determinants of biological factors, personal/family circumstances and lifestyle, social environment, physical environment, public services, and public policies. As the set of tables show, the impacts were considered by each of the groups that were set up under the respective themes of the Salford Plan. The tables of impacts suggest that, separate from the direct and immediate clinical health benefits that will come from the new hospital with its modern equipment and facilities, positive health impacts will arise if the project realises its potential as a major job creator at all occupational levels in Salford. The assessment found that negative outcomes are likely to arise unless the project regeneration potentials are used efficiently and accordingly directed to prevent their occurrences or the circumstance by which they arise.
This HIA reinforces the assessor’s views that it was important to engage and listen to local communities in any attempt to identify and evaluate the nature of concerns and impacts on their lives. The study provides confirmation that community perspectives on healthcare and regeneration potentials can be very different from those of professionals. The HIA found that Salford’s high unemployment, relatively high crime levels, low incomes, poor attainment and achievement levels, and poor occupational progression created a feeling of low esteem and dependency in many of its communities. Yet the locals, independently and in their community groups, were aware of their situations and of the nature of the regenerational inputs from the project, and the local authority, that would help to improve their situations. The resultant view is that the locals should be trusted and the “bottoms up” approach encouraged in HIA assessment.
Throughout the course of the assessment, local people have raised issues that sprang from different perspectives and understanding of the role of the PCT health and social centres in the communities. Although the assessor’s remit was to carry out the HIA in relation to development effects of the SRHT site and the PCT centres together, it became clear during the assessments that there was a need for a separate and thorough appraisal of the primary care centres. That was, with regard to their location, the potential health impacts of each on the communities in particular areas of Salford, the nature of the intended services, their role as centres of social and community activities, and their potential for providing local employment.
Steering group perspectives
Steering group member 1—director of public health of Salford
It was reasoned and accepted that a HIA exercise would highlight the potential to link the SHIFT project to the regeneration of Salford. As the assessment progressed, it became apparent that the study was carrying out part of the consultative process by introducing the SHIFT project to communities in Salford who were unaware of such a major proposal to redesign health and social care in Salford. The HIA therefore introduced a level of community involvement in SHIFT that had previously been missing.
The HIA did not so much introduce new ideas about the wider determinants of population health as highlighted the key factors and brought them to the recognition of the Partnership Board. The full report, with its extensive impact tables, linked the expression of these determinants to specific, current, and major proposals for investment in Salford.2 The HIA was successful in capturing the preference of Salford communities for investments that would affect their general wellbeing rather than solely the provision of better health care. The HIA made more tangible the potential links between the SHIFT project and existing projects to develop the Salford economy through employment and training opportunities. It made a significant step forward by presenting the findings in a format that mirrored the Salford community plan. This placed the SHIFT proposal in the middle of the local strategic planning process. The HIA of the SHIFT project was successful in meeting its aim of recommending changes to the project to maximise the positive health impacts of the developments. However, it remains to be seen whether such recommendations can withstand the highly pressured environment of the modernisation of the NHS.
Steering group member 2—chief officer of Salford Community Health Council
The SHIFT project is the most important NHS development in Salford and as the HIA has shown will be a major factor in the long term development of the city and the quality of life of its citizens. From the start Salford CHC lobbied strongly for an assessment of the scheme’s economic, social, environmental, and health impact on Salford. Given the scale of the proposals, Salford CHC saw their collective potential to have a major effect on quality of life in the city. Salford PCT agreed to ensure that the SHIFT partners implement the recommendations of the HIA and exploit the opportunities to maximise investment opportunities for local firms in Salford when establishing contracts with the preferred private sector partners. The HIA suggested that the SHIFT partners should work with the Salford Partnership to exploit opportunities in education, commerce, and employment and seek to link with social care led initiatives wherever possible.
It was particularly significant that the HIA actively sought the views of a range of local citizens, as well as influential professionals, as this gave the findings and recommendations more reality and force. The HIA made it clear that non-clinical related issues arising or linked to the SHIFT and LIFT projects need to be considered. The study also highlighted the relevance of many non-NHS agencies to health status in the city. The recognition by the NHS agencies in particular of their impact (other than through healthcare delivery) on the quality of life in the city has been significantly heightened. In parallel, it has helped other agencies to recognise the contribution that the NHS might make to their own fields of endeavour.
Steering group member 3—neighbourhood coordinator, Salford City Council
The HIA findings have many implications for the project and for all members of the Salford Partnership. The HIA makes explicit the need for the Trust to reassess its relationship with the wider community and its impacts, both positive and negative, on Salford. In particular, the Trust and other partners should identify employment opportunities created by SHIFT and LIFT and develop training to help local people access those opportunities. This applies to both the project’s construction and operational phases. Local supply chains should be used wherever practicable throughout SHIFT. This objective should perhaps be strongly pursued through the Salford Partnership so that other partners also develop this objective. This suggests that SRHT should be represented on the Salford Partnership. At the time of writing, Salford PCT represents the whole of the local NHS on the Partnership.
The HIA study suggests that the wider NHS needs to radically rethink its role as a partner in increasing the wellbeing of citizens. This includes rethinking the range of uses its buildings can accommodate, for example, youth and community activities. It further suggests that the NHS needs to radically rethink its role as a neighbour, and as part of a community, and how it interfaces physically and socially with locals and environment. As the HIA suggests, the NHS and other partners need to minimise the impact of road traffic upon the city and its communities. It needs to build on the participation and communication initiatives that have been a part of SHIFT.
This research conducted a health impact assessment of the combined SHIFT and LIFT project. The assessment was wide ranging in its considerations by eliciting the views of experts, community groups across the city and by carrying out a comprehensive HIA. The study found that the perception of health across communities of Salford was much wider than that which was based upon medical or clinical perspectives. Salford people reported a view that was based upon the philosophy of healthy living and wellbeing. It is in these respects that the assessor recommended the need for the SHIFT and LIFT Partnership to extend their operational definitions of health, from the traditional clinical service provisions and delivery perceptions, to include considerations for social inclusion and activities by which to improve wellbeing and healthy living for the communities across culture, ethnicity, and gender in Salford. More consultation by the Trusts and SHIFT Partnership and greater community involvement was a recurring theme throughout the assessment process. They should provide support for vulnerable individuals, and support parents and families in the city.
We thank the experts and local people who took part in this research. We also thank the Capital Development Directorate of Salford Royal Hospital NHS Trust for their support and funding of the HIA.
Funding: the Capital Development Directorate of Salford Royal Hospital NHS Trust.
Conflicts of interest: none declared.
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