Developing a framework for managing the night-time economy in Wales: a Health Impact Assessment approach

Abstract

The night-time economy can have major impacts on the health and well-being of individuals. A framework for managing a safe and prosperous night-time economy aids the coordinated approach to develop sustainable, healthy and safe night-time economies. This case study outlines the approach of a prospective Health Impact Assessment (HIA) to re-develop an existing reactive framework for managing the night-time economy in Wales. Inclusion of a range of stakeholders in the process enabled the reformulation of realistic proactive objectives which account for both health and well-being. This article highlights the benefits of HIA and can be used to inform future policy developments.

Keywords:

• Health Impact Assessment
• night-time economy
• alcohol
• drugs
• safety
• prevention

Introduction

The night-time economy

The night-time economy concerns the economic activity between the hours of 6 pm–6am, and spans multiple sectors including transport, criminal justice, the service sector (for example, restaurants and bars and health (Roberts 2006; Talbot 2006; Rowe and Bavinton 2011). Over the past decade, there has been a dramatic growth of night-time economies, representing a valuable asset to local and national economies (Roberts 2006) through job creation, revenue and providing opportunities for people to socialise (Roberts and Gornostaeva 2007). However, the growth of night-time economies has also resulted in increasing levels of anti-social behaviour, unintentional injury, Emergency Department admissions, criminal activity and substance misuse which can disproportionately affect vulnerable groups (Bellis and Hughes 2011; Moore et al. 2013; Home Office 2015; Quigg et al. 2015a; Quigg et al. 2016). There are also reports of a higher prevalence of serious violence with injury occurring in the evening, with 52% of violent incidents taken place between 6 and 10 pm and 83% between 10 pm and 12 am within the UK (Office for National Statistics 2015). The health of individuals is influenced by a number of factors outside of the health care domain and there is limited evidence on how the night-time economy affects the general health and well-being of individuals, for example the impacts of regeneration and planning.

In addition, changes to alcohol licensing legislation in the United Kingdom (UK) leading to an increase in the availability of alcohol, and increasing levels of alcohol consumption linked to violence, have resulted in substance misuse becoming a key concern for those managing the night-time economy (Roberts 2006; Newton and Hirschfield 2009; Liang and Chikritzhs 2011). Increasing levels of alcohol consumption prior to entering the night-time economy, known as preloading, has contributed to higher levels of intoxication and an increased risk of harm within the night-time economy (Quigg et al. 2015b; Hughes et al. 2008). A lack of transport options within the night-time economy and excess substance misuse is also a contributor to road traffic collisions, as a result of both drinking or drug driving and intoxicated pedestrians (Miller et al. 2012).

This presents fresh challenges to the effective management of the night-time economy to initiate new ways of thinking to help maintain healthy and safe environments. Traditionally, night-time economies have been managed using reactive approaches, responding to issues and situations as they occur. The evidence illustrated above shows how a new preventative and proactive approach is required to manage night-time economies to prevent potentially harmful situations from occurring in the first instance and to maximise any beneficial aspects. The effective management and delivery of a safe night-time economy has potential economic and health benefits to local communities and many interventions have been implemented to minimise the harms to individuals, particularly from alcohol misuse and drug misuse (Drummond et al. 2005; Anderson et al. 2007; Hughes et al. 2008; Edwards 2010; Bellis and Hughes 2011; Graham et al. 2013; Institute of Alcohol Studies 2013). However, concerns still remain around the impact on vulnerable individuals and the need for a preventative public health approach to night life which takes into account the needs of all individuals (Bellis and Hughes 2011).

The development of a framework for managing the night-time economy

A framework for managing a safe and prosperous night-time economy ensures a coordinated, strategic approach across key stakeholders (including local authorities, local health boards, specific night-time economy teams, police, licensing departments and industry) to develop sustainable, healthy and safe night-time economies.

Within this paper, we describe an innovative case study of the re-development of an existing framework for managing the night-time economy using the approach of Health Impact Assessment (HIA) methodology. HIA is a methodology endorsed by the World Health Organisation (World Health Organisation 2013), to ensure due consideration of the impact on health, well-being and health inequalities in the development of a national policy. To our knowledge, this approach has not been applied elsewhere for a framework of this nature, and here were present a case study outlining the learning.

Methods

Definition of HIA

Public policies aim to benefit the whole population, but can result in unintended negative effects on health and well-being, which could potentially lead to unintended health inequalities within specific localities. Internationally, there is growing support for the inclusion of HIA in the development of all public policies and programmes (Chadderton et al. 2012; World Health Organisation 2016). The European Centre for Health Policy (1999) Gothenburg Consensus defines HIA as: ‘A combination of procedures, methods and tools by which a policy programme or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population’ (World Health Organisation 1999). HIA is a systematic, yet flexible and scalable tool that allows health and wider well-being to be considered in all policy arenas and has the power to influence the decision-making process, by promoting cross-sector collaboration and community participation, addressing the wider determinants of health, tackling inequities and empowering health (World Health Organisation Europe 2002; Ashton 2007; World Health Organisation 2016). HIAs are often directly responsible for changing and influencing public policy and can have an immediate impact on decisions and on the stakeholders involved in the process, resulting in improved understanding of the determinants of health and positive working relationships (Haigh et al. 2013).

HIA is also evidence based. This evidence includes quantitative, statistical data and qualitative knowledge. As practiced in Wales, and following the Welsh HIA Guidance (Chadderton et al. 2012), HIA is grounded in a mixed methodological approach and embraces organisational, community and lay knowledge. Wales emphasises the inclusion of all stakeholders including local community citizens as part of the process. Including this type of qualitative evidence is important to assess individual concerns, anxiety and fears for example, and the data can be quantified for use in decision-making and/or mitigation. It can give a more holistic, contextual view of national and local impacts. Collaboratively involving people and organisations who are able to contribute different kinds of relevant knowledge and insight, a HIA uses the information gathered through the process to build in measures to maximise opportunities for health and well-being and to minimise any unintended consequences.

HIA process

Focussed on the traditional approach to policing the night-time economy and managing it from a reactive perspective, the original framework for managing the night-time economy in Wales was developed in 2008. To address significant changes in legislation, incorporate new evidence and examples of best practice since the initial implementation and the desire to take a more defined public health approach to managing the night-time economy, the need to revise and update the framework was established. A case study was undertaken in Wales using a prospective HIA approach to provide maximum opportunity to influence the structure of the Framework for Managing the Night-Time Economy in Wales. The HIA process is outlined clearly within Figure 1 and illustrates how the HIA process undertaken included a range of standardised approaches led by a steering group.

Figure 1. HIA process flow diagram.

A short evidence review of frameworks for managing the night-time economy, the impacts of these and example of best practice was conducted. This built on the existing evidence and information which had been gathered as part of compiling the draft framework. The stakeholder workshops followed a systematic process as advocated within the 2012 Welsh HIA guidance and were structured through the use of specific HIA tools; the vulnerable and disadvantaged groups check list and the health and well-being determinants checklist (Chadderton et al. 2012). The vulnerable and disadvantaged groups checklist was used as a guide to prompt discussion amongst stakeholders regarding the potential impact of the framework on specific groups, for example age-related groups, income-related groups, groups who suffer discrimination such as black and minority ethnic groups. The health and well-being determinants checklist was again used as a guide to enable discussion in relation to the potential impact of the framework on the following: lifestyles, social and community influences on health, living/environmental conditions affecting health, economic conditions affecting health, access and quality of services and macro-economic, environmental and sustainability factors.

Step 1 gathered professional and stakeholder knowledge and qualitative evidence about the potential impacts of the existing framework and to identify potential benefits and harms in the context of health and well-being. Participants assessed the framework based on their understanding of the national policy context, their local circumstances and their practical experiences from both rural and urban night-time economies. The online public consultation included 31 responses from organisations and individual members of the public including Local Health Boards, the Police and the third sector. The stakeholder workshop was attended by 20 stakeholders including representatives from Planning and Licensing departments, Local Health Boards, public health, members of the third sector and emergency services. Notes from the workshop were recorded by hand, verified by the workshop participants, then collated alongside comments from the public consultation and analysed thematically by two researchers. The evidence review consisted of screening and reviewing existing publically available strategies and examples of best practice in the night-time economy within the United Kingdom. The results and the evidence review were used to produce a revised set of aims and objectives on which to base the re-drafted framework (Figure 1 Step 2).

In Step 3, additional stakeholder workshops were completed to assess the revised aims and objectives and their potential impact on health, well-being and inequalities and to identify case studies of best practice for inclusion in the framework. Two workshops were held in urban and rural Wales and attended by 36 individuals across public organisations such as Local Health Boards, public health, criminal justice, Trading Standards and business agencies. As with the previous workshop, all notes from the workshops were recorded by hand and thematically analysed which were incorporated into the final Framework and informed the development of key objectives and outcomes (Figure 1 Step 4). This was achieved by the HIA assessors collating all information and evidence gathered from each individual step of the process to formulate recommendations. A final HIA report was produced which documented the full HIA process and the data and evidence gathered (Wales Health Impact Assessment Support Unit 2016a).

Results

Results from the HIA process were supportive of the need for a framework for managing the night-time economy. However, stakeholders concluded that the existing Framework required a more defined focus on prevention, early intervention and collaboration. In particular, specific examples of best practice and evidence would enhance the delivery and implementation of a framework at the local level. Thus, all elements of the HIA process enabled the development of three key proactive objectives and outcomes to underpin the framework which reach outside traditional approaches to managing the night-time economy (Table 1). These, alongside key outcomes and identified examples of best practice, were presented in the framework to be used by key stakeholders to inform local strategies for developing sustainable, healthy, and safe night-time economies.

Table 1. Key objectives and outcomes of the framework.

Objectives	Outcomes
Objective 1: To support the development of a systematic approach to increase understanding of the night-time economy based on intelligence and accurate information	(a) Sharing of information, intelligence and resources amongst partnership agencies at the local, regional and international level which helps promote preventive action
	(b) Development of a programme of coordinated actions or projects to address identified problems using profiles of local area needs
	(c) Recognition of a shared responsibility for the effective engagement and coordination of relevant agencies, stakeholders and local communities
	(d) Effective and sustainable monitoring and evaluation of existing and new interventions to monitor progress and impact within the night-time economy
Objective 2: To promote sustainable environments and support prevention strategies to create healthy, safe and diverse night-time economies in Wales	(a) Development and maintenance of diverse, safe and accessible environments in the night-time economy which support the needs of all night-time economy patrons, including vulnerable groups
	(b) Effective provision of tailored facilities and infrastructure for all users of the night-time economy, including an effective and safe transport system
	(c) Promotion of key preventative messages to encourage a culture shift which minimises the risk of harm from substance misuse and violence in the night-time economy
	(d) Working with industry to encourage use of evidence-based regulatory frameworks to improve safety
Objective 3: To support effective multi-agency management of the night-time economy and enforcement at the local level	(a) Sustainable provision of flexible and targeted emergency services in the night-time economy
	(b) Efficient planning and use of licensing and legislative powers through joint-working and collaboration to ensure safety in the night-time economy
	(c) Proactive enforcement of existing and new legislation incorporating a public health approach to policing
	(d) Constructive and positive engagement between all key stakeholders, including public sector, industry and voluntary sector

The HIA process also identified the need for the framework to be available in an innovative, transparent and accessible format which led to the development of an info graph, stressing the importance of individual aspects with a focus on prevention and public health (Figure 2).

Figure 2. Journey through a healthy, diverse and safe night-time economy in Wales – see attached pdf (the print version can be done in black and white to avoid additional costs).

A final publication of the Framework for Managing the Night-time Economy in Wales is publically available on the Welsh Government’s website (Welsh Government 2016).

Objective 1: to support the development of a systematic approach to increase understanding of the night-time economy based on intelligence and accurate information

Through the HIA process, stakeholders highlighted the importance of effective collaboration, data sharing and the potential to foster and mobilise co-production actions to manage the night-time economy. Multi-agency collation, assessment and exchange of data from both the private and public sectors are crucial to effective management of the night-time economy (The Police Foundation 2009) and this emerged as a theme through the stakeholder consultation. Stakeholders agreed the long-term shared goal of improving the night-time economy for future generations should include an increased understanding of local environments to enable effective future regeneration of cities and towns. Taking a wider viewpoint than just health and criminal justice data, results indicated the importance of the contribution of all to a complete a full picture of activity in the night-time economy.

In addition, the HIA process outlined the importance of raising the awareness of the varying impacts and differing needs of the night-time economy can have on different town centres and geographical contexts across Wales. It was highlighted that the management of the night-time economy needs to be adaptable to take these into account and was emphasised that any resources, evidence and examples of good practice included in the framework should represent these diverse environments.

Participants of the HIA noted that both planning policy and planning development management play a positive role in the development of a thriving night-time economy. Whilst Town Centre regeneration schemes are positive in themselves with the creation of new housing options in town and city centres, key stakeholders cited unintended consequences of this as tensions between businesses and residents develop as the night-time economy is improved and expanded. It was noted there could be a potential increase in noise and environmental impacts such as litter and anti-social behaviour (if not managed correctly).

Objective 2: to promote sustainable environments and support prevention strategies to create healthy, safe and diverse night-time economies in Wales

The HIA process stressed the potential impact the night-time economy can have on vulnerable groups and individuals within society and the significant need to address this. Vulnerable groups highlighted through the process included younger and older age groups, women, the homeless, residents within city and town centres, and also individuals who may not traditionally be considered as vulnerable outside of the night-time economy, but become vulnerable when entering the environment. In addition, mental ill health and well-being emerged as a theme of vulnerability. It was highlighted that the night-time economy can exacerbate existing conditions within individuals, but may also lead to the emergence of undiagnosed conditions as a result of substance misuse. For example, students with mental health issues in university towns and cities were identified as a key vulnerable group within the night-time economy, which may not manifest until linked with alcohol (Tamburrini et al. 2011). Furthermore through engagement with a wide range of stakeholders bringing a public health lens to the discussion, results from the HIA process enabled the recognition of how it is not only patrons of the night-time economy who may be potential victims of harm. Workers within the night-time economy, such as bar workers, transport staffs, door staff and restaurant staff are also potentially subject to abuse and this was required to be covered within the Framework. The importance of collaboration between stakeholders was emphasised as an effective method for protecting vulnerable groups. For example, students provide vital business opportunities for businesses to hold student nights and promotional events. Stakeholders such as police and universities should work with industry partners to effectively control and manage this aspect of the economy to ensure consideration is given to the health and well-being of this group.

Results indicated that by creating safer and more protective environments there is huge opportunity to reduce harm and the risk of harm in the night-time economy. Stakeholders noted that strong and vibrant night-time economy need to cater for all groups in society, including families and non-drinking cultures. Stakeholders from all workshops agreed this could be achieved through the promotion of diversification and there is a need to learn from other successful experiences of achieving this. Key examples highlighted were the potential of moving away from vertical drinking establishments and alcohol-free pubs. A shift of focus moving away from licensed premises to other entertainment options such as cinemas and cafes was discussed which could result in wider community benefits and positive impacts on health and well-being, for example rural pubs diversifying into community hubs. This also links to the re-branding of the night-time economy and how it is integral that efforts are made to publicise the differing facilities and opportunities that the night-time economy can provide.

However, participants of the workshops did note that there could be a few unintended negative consequences of diversifying the night-time economy which would need to be protected against. A more vibrant and diverse night-time economy could have the potential of being perceived safe or safer and therefore the increased numbers of patrons could lead to a potential risk of increased injuries or unplanned sexual behaviour. In addition, it was noted that drinking establishments are an integral part of a thriving night-time economy and this should be taken in consideration when developing the new framework for managing the night-time economy.

Objective 3: to support effective multi-agency management of the night-time economy and enforcement at the local level

The need for effective enforcement was an existing key element of the previous framework for managing the night economy. However, results of the HIA emphasised the important need to move away from reactive enforcement towards a more upstream approach to incorporate a proactive focus on prevention, intervention and a public health approach to policing. Stakeholders highlighted the prime opportunity for stakeholders to work collectively to combine public health messages and initiative within their enforcement work to reduce harm. Key examples provided included the use of Street Pastors, training of door staff and the monitoring of potential flashpoints in the night-time economy. The need was highlighted for education and quality training for personnel involved in the night-time economy so that early intervention becomes a key focus and best practice to ensure safe environments. In addition, stakeholders also linked the need for education to those who use the night-time economy.

Discussion

Health in All Policies (HiAP) is an approach which takes into account the implications of all policies on health and health systems, in order to improve population health and health equity (World Health Organisation 2013). Supported by the WHO, HIA methodology follows a transparent, flexible and structured approach which is transferable and applicable to all policy arenas and can be used as a decision supporting tool in the development of policy and initiatives across a range of sectors (Edwards 2010). This case study provides the learning from applying HIA methodology to inform the re-drafting of a framework for managing the night-time economy in Wales. The night-time economy is a complex policy area, involving a range of sectors which required a move away from traditional reactive approaches to management (Rowe and Bavinton 2011). HIAs have emerged as key tools to ensure health and well-being are considered in all policies, and was integral to transforming the focus of the existing NTE framework in this case study. To our knowledge, this method has not previously been undertaken anywhere nationally or internationally on the development of a framework within this policy area. HIA has also been credited as contributing to the consistency of decision-making and policy development (European Observatory on Health Systems and Policies 2007) and this proved evident in this case study. The impact of the HIA on this framework illustrates comparative outcomes to results documented on other policies internationally (Haigh et al. 2013). For example, contributing to the development of objectives and outcomes which incorporate health and well-being and promote effective partnership working across sectors.

The added value of the use of a HIA was reflected in this case study enabling the contribution of a range of viewpoints from key stakeholders, and provided the opportunity to analyse the potential impacts of the framework through proactive and preventive lens. The open and participatory nature of bringing a range of stakeholders together to hold structured discussions contributed greatly to the change in focus from the existing framework. A strong consensus between stakeholders to move away from the traditional reactive approach to managing the night-time economy, to a more proactive and preventive approach was evidenced through the HIA process.

Results of the HIA process outlined the reformulation of the key objectives of the framework to focus on a more proactive approach to prevention, early intervention and collaboration, enabling considerations of the impact of the framework to be given to all groups in society. The rationale for the previous framework focussed on legislative needs and costs to the economy, and the objectives lacked a proactive focus on health and well-being. For example, the previous framework focussed on making effective use of available enforcement powers to tackle crime and disorder reactively and improving uptake of licensing schemes, whereas the re-formulated framework objectives focus on proactive policing and increasing understanding and responsibility by all key stakeholders to improve the health and well-being of those individuals within the night-time economy and safeguard them. Understanding the night-time economy emerged as a major key theme with stakeholders stressing the need to work collaboratively to share knowledge and intelligence regarding night-time economies to allow efficient management of individual localities. Prevention was also highlighted as a key theme through the HIA process, with diversity of the night-time economy and accessibility being stressed as crucial methods to efficient and effective management. The health and well-being of vulnerable groups such as students and women were reported as groups within society which need to be considered when action is being undertaken in the management of the night-time economy. Finally, the key theme of a public health approach to policing through enforcement emerged and allowed targeted approaches to tackling this to be discussed amongst relevant stakeholders. The HIA process undertaken on the re-development of the framework for managing the NTE led to a more comprehensive and flexible framework being developed, which takes into account the health and well-being of individuals, without drifting away from existing policy focuses in Wales.

One of the main strengths of the HIA is the systematic approach undertaken to provide a structure for discussion, strengthening partnerships and co-production and increasing understanding across policy areas to maximise positive health outcomes and reduce inequalities (Tamburrini et al. 2011). A large range of stakeholders were involved in the process, from a range of sectors which helped to elicit a range of viewpoints and allowed for the identification of novel aspects and impacts of managing the night-time economy. The HIA process described within this case study was managed and facilitated by experienced professionals from the Wales Health Impact Assessment Support Unit (WHIASU) who are internationally recognised for their contribution to the field of HIA (Wales Health Impact Assessment Support Unit 2016b). All the workshops were evaluated and feedback was obtained from the participants. Positive feedback was received from all participating stakeholders on both their participation experience and the HIA process itself and helped to ensure the framework is relevant to those who will be involved in managing the night-time economy. The added value from this process is that it helped to facilitate links between stakeholders to reach a better consensus and ultimately can lead to the development of a more effective policy (Tamburrini et al. 2011).

By undertaking a proactive and preventative approach, the HIA allowed consideration of potential impacts of the Framework on inequalities and vulnerable groups in society, future generations and the wider determinants of health. These are methods which are transferrable to the development of other key policies and frameworks internationally. This case study of redeveloping a national framework using a HIA contributes to the limited existing evidence base for the management of the night-time economy to incorporate sectors traditionally thought to be outside the remit of such a framework, for example planning and housing (Wales Health Impact Assessment Support Unit 2016a).

However, this case study has a number of important limitations. Here, we solely describe the process and key findings of a case study of a HIA in Wales which will be relevant to Welsh night-time economies and the views of the Welsh stakeholders who contributed. Nevertheless, the methods used within the HIA are transferable to the development of frameworks and policies in other locations and policy arenas. In addition, although the HIA process enabled the development of key objectives and outcomes, there was limited scope to specifically define action to be taken to meet these objectives and outcomes and specifically how they can be achieved. It is envisaged that action taken to meet the objectives will be dependent on several influencing factors, for example location and resources which were out of the scope of this HIA process. The success of the revised framework after the HIA process has not yet been assessed and this paper only outlines the immediate effectiveness of the HIA on the redevelopment of the framework. In addition, there may also have been some stakeholder views that were not able to be incorporated through the HIA process which may have had an impact on final outcomes. For example, as a result of representatives not being able to attend a stakeholder workshop in a particular location. However, these limitations were mitigated where possible and stakeholders were provided with opportunities to comment through different methods.

To add to the value of carrying out a HIA on the development of a framework for the night-time economy, further research is required on how effective the final framework was in informing the practice of stakeholders going forward. Findings from this HIA would to some extent be transferrable to similar economies; however, results would need to be tailored to the individual needs of local communities and this is an aspect which could be evaluated in future work.

Conclusion

This paper outlines the HIA process undertaken on the re-development of a framework for managing the night-time economy in Wales and adds to evidence to the growing international literature of the benefits of HIA to the health and well-being of individuals in an area traditionally viewed to be outside of the remit of the health sector and promotes a ‘HiAP’ approach. The paper outlines the process of a HIA, using transparent methods which could be applicable to similar policy developments across difference sectors. Commonly, management of night-time economies focus on reactive approaches to enforcement in efforts to reduce substance misuse and harm. The HIA process allowed proactive and preventive themes to emerge which were incorporated into the revised objectives and outcomes. By working collaboratively with a range of stakeholders, the re-development of the framework moved the focus of the framework towards proactive and preventative initiatives. For example, through increasing sharing of knowledge between stakeholders, practicing proactive policing techniques and promoting key preventative messages amongst users of the night-time economy. Although this paper does out outline the impact of the re-developed framework on the health and well-being of individuals, this case study can be used to promote the benefits of HIA within different policy sectors to understand the process, the benefits it can elicit and the impact it can have on national policy frameworks.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This study did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.