METHOD

Through the regional health staff seconded into the GLA (HSB), JM and LS received an early confidential draft of the strategy for comments on health impacts. We were able to be very positive about the initial proposals, which focused on encouraging a modal shift from private car to public transport use. We recommended an increase in emphasis on active transport (walking and cycling), particularly for targets for the first five years of the strategy both because of the beneficial health and environmental effects and because it is much cheaper and easier than the major structural rail proposals.

The regional health staff organised a participatory rapid appraisal HIA of the GLA draft of the strategy to fit in with the political processes. The assembly draft was the first time the document was in the public domain and was available for participatory HIA. The very limited time between publication of the assembly draft and the public consultation draft (box 1) allowed only a month to:

• organise the workshop (box 2), including inviting stakeholders and speakers and distributing the summary of a rapid review of evidence on transport and health commissioned by the RDPH, London²²; the congestion charging review (appendix A)²¹; and a booklet on HIA for transport²³ to those attending;

  Box 2 Stakeholders invited to the participatory workshop

  • London Health Commission Members

  • Members of the Environment Committee of the Greater London Assembly

  • Academics specialising in HIA or transport and health

  • Public health practitioners

  • Staff from the Greater London Authority, local authorities, and health authorities

  • Police

  • Others representing groups such as the elderly population, women, the disabled, public transport users and providers, private car users, cyclists, and pedestrians.

• hold the participatory workshop;

• report the outcome to the London Health Commission and the Greater London Assembly’s Environment Committee; and

• give the resulting recommendations to the transport planners for use in the re-drafting process.

Details of the method used in the participatory workshop are described elsewhere.²⁴

LS performed a changes audit that was reported to the London Health Commission, comparing the assembly draft (box 1 (1)) with the public consultation draft (box 1 (2)) to assess the impact on policy of the HIA process. The public consultation draft went out to statutory and public consultation, then the final strategy (box 1 (3)) was published.²⁵ A further audit of changes compared the public consultation draft with the final strategy.

RESULTS

Key themes that emerged from the HIA were:

• Increased promotion of modes of transport other than the car (public transport, walking, and cycling) and reducing reliance on private cars

• Linking transport, economic and spatial development to encourage the development of economically and socially sustainable communities

• Linking proposals for the greatest benefits to health, for example, linking proposals for congestion charging with vehicles’ emissions and with proposals for low emission zones

• Encouraging and improving safety for vulnerable modes of transport (cycling and walking) through road space reallocation and segregation

• Involvement of boroughs in the development and implementation of plans to improve transport

• Development of baseline statistics and targets for transport improvement and health gain.

In a report presented to the London Health Commission meeting in January 2002,²⁶ a number of changes were noted in the draft strategy that met the recommendations of the HIA. Many recommendations had been incorporated and there was greater emphasis on the areas that could improve health (table 1). Significant changes included:

• promoting sustainable travel plans for workplaces and schools;

• giving priority to infrastructure and services that benefit London’s deprived communities;

• increased promotion of walking and cycling; and

• a commitment to track the health impacts of the final strategy and its implementation.

Much of the document concentrated on improvements in the public transport system to encourage modal shift for travel, including improved access to public transport for all, especially previously disadvantaged groups. Most recommendations from the HIA were incorporated into the final strategy.

Much of the thrust of the strategy was about making London a more accessible city, enhancing its economic development and leading to the development of more jobs. The transport strategy should help to address social exclusion by taking account of the needs of all Londoners to access jobs, facilities, and services. A number of policies ensured that the needs of deprived communities and those with specific travel needs are taken into account, as well as highlighting the effects of the employment and training policies of transport companies themselves. For example, the final version of the strategy emphasised the need to integrate transport investment with economic development, developing business regions and regeneration areas, with better links to regeneration areas planned and improved transport links for the development of East London. The affordability of public transport was addressed and the need for transport to assist in addressing social inclusion and equality of opportunity. The specific travel needs considered included the needs of those with disabilities, the elderly population, as well as the needs of those whose preference is to walk or cycle.

Road space reallocation was not mentioned in the early drafts but was a recommendation of the HIA. The final strategy recommended use of street space reallocation to assist road safety initiatives; support bus, pedestrian, and cyclist initiatives; and ensure that congestion charging does not lead to diverted traffic using unsuitable streets.

Some particularly important areas for local transport, recommended by the HIA and included in the final draft, were low speed limit zones, the development of safer routes to school, and home zones. The HIA also raised door to door and community transport, included in a separate chapter of the final strategy.

The strategy committed Transport for London to “review, develop and implement overall Transport Strategy performance indicators”, with some collection of new data proposed, especially consumer opinion. The HIA recommended a subset of health related indicators, including indicators relating to access and regeneration. An important addition to the strategy was a set of targets for road traffic accident reduction (table 2). The GLA proposed quality of life and environmental indicators, within the GLA’s principal purposes of economic and social development, wealth creation and environmental improvement.

DISCUSSION

Stakeholder involvement

The HIA involved a wide group of stakeholders, representing professional transport groups, statutory agencies, private sector, and voluntary organisations with a remit for vulnerable groups. The only professional transport groups not represented were taxi drivers and freight operators. As the time frame was short and mechanisms for public participation were not fully set up, it was not possible to invite individual Londoners to participate, only those representing organisations. However, the London Health Commission members themselves come from a wide range of organisations and reflect the sex and ethnic make up of the London population; and the draft strategy went out for consultation to the general public as well as to statutory consultees, with widespread advertising of this.

Attributing causality

The changes from the Assembly draft to the public consultation draft were definitely attributable to the HIA. Changes between the public consultation draft and the final strategy might have been attributable to other consultation responses, or such responses may have added weight to recommendations from the HIA. (There was very little time between reporting our recommendations and publication of the public consultation draft, so changes attributable to the HIA did not necessarily appear in the public consultation draft (H Abraham, personal communication)). Transport planners at Transport for London and the GLA told us that most of the changes noted in the final strategy as concordant with the HIA recommendations were attributable to the HIA process (H Abraham, personal communication). The mayor himself attributed to the recommendations of the HIA the emphasis in the final Transport Strategy on increasing walking and cycling, reducing reliance on private cars, and reducing the need to travel.²⁷

Reasons for success

We engaged with the policy makers and they participated in the HIA workshop. We had to overcome initial unease but knew enough about the subject to be confident of showing overall health gain. We could praise much of the strategy and we made constructive suggestions to further enhance health gain and mitigate problems. This helped create a positive reaction towards our recommendations among the policy makers.

Monitoring and evaluation

This paper is an impact evaluation²⁸ of the HIA; the process evaluation of the London rapid appraisal HIAs will be reported elsewhere (Bowen C, et al, manuscript in preparation). The next step is an outcome evaluation, monitoring the effects of the proposals once implemented. The GLA is monitoring its own performance through the indicators it has developed and consulted on. The London Health Commission has proposed indicators: some are specifically health related, while most relate to the wider determinants of health. Transport for London is monitoring the effects of congestion charging. It is important that external evaluation also occurs and that health impacts are included.

Although transport affects health in several ways, the worlds of transport planning and of health promotion seldom overlap. The use of health impact assessment in London was successful in influencing the transport strategy, resulting in changes to increase health benefits, including reducing inequalities. HIA also increased policy makers’ understanding of the relevance of determinants of health.