Health Needs Assessment
What is health needs assessment?
Health needs assessment is a systematic public health process for identifying the unmet health and health care needs of a population, making changes to meet those unmet needs and creating health gain(1).
Need is a complex concept, and several aspects have been described (fig 1).
Figure 1: aspects of need
*= opportunity for disinvestment with no health loss
**= opportunity for health gain.
Public health sees need as the ‘ability to benefit’. This means effective interventions must exist to meet need. Health need can exist without being expressed as demand. Demand tends to focus on treatment services, while preventive services, although undoubtedly needed, are less likely to be demanded. Health needs include wider social needs such as housing, education and employment. These should be considered in the health needs assessment process.
What is health needs assessment used for?
Health needs assessment is a tool for change. The aim is to maximise the health gain from available resources by identifying appropriate services and priorities for commissioning. Section 24 of the National Health Service Reform and Health Care Professions Act 2002 placed a duty on each Local Health Board (LHB) and Local Authority (LA) in Wales to implement a health and well-being strategy for their area.
Each strategy was informed by a comprehensive health, social care and well-being needs assessment carried out by the LHB and LA in partnership with other statutory and non-statutory stakeholders (2).
Health gain is maximised by the provision of effective services to meet currently unmet need. In addition, resources may be released by the disinvestment from ineffective services or those identified as responding to demand, rather than need (fig 1).
Health needs assessments should;
· inform and lead to effective, sustainable actions targeted at those with most to gain,
· engage the services most likely to make these changes happen via the commissioning process
· encourage equity in the provision and use of health services.
In addition, the needs assessment process facilitates engagement with populations, allowing them to contribute to service planning and resource allocation, and provides opportunities for cross-sectoral partnership working(3).
How is health needs assessment carried out?
Many approaches to carrying out Health Needs Assessment have been described (3-6). All aim to maximise population health benefit and effective resource use. Most involve assessing population health needs in epidemiological, corporate and comparative terms (table 1). In all the methodologies, the steps are presented as a sequence, but in practice needs assessment is an iterative process.
The population for a health needs assessment could be people sharing:
· Geographic locations, eg living in deprived housing estates;
· Settings, eg prisons;
· Social experiences, eg asylum seekers, gypsies; or
· Particular medical conditions, eg low back pain
Often the population shares several factors, eg children and young people suffering from cancer living in England and Wales.
Table 1: elements of health needs assessment
Epidemiological / Description of the problem:
incidence and prevalence;
availability, effectiveness and cost-effectiveness of interventions/services,
possible models of care,
outcome measures.
Corporate / Assessment of stakeholder views, including professional and patient groups.
Comparative / Contrasts the services provided in one region with those available elsewhere.
Challenges in health needs assessment.
Senior commitment to the process and to making the necessary changes is essential. Team impetus and commitment may be difficult to sustain over time. Working across professional and organisational boundaries requires effort. Access to valid, robust data may be difficult, particularly where the population is small. There are few primary studies of health need. Primary studies measure the true population incidence/prevalence and severity of a particular condition, and for each severity category determine whether there is an effective intervention. Primary studies are expensive to conduct. Most needs assessments use proxies for need. Access to the population itself may need careful negotiation. Finally, it is essential that the findings of the needs assessment are translated into effective, sustainable action and that the resulting changes are evaluated.
The choice of population is crucial. For example, specialised services commissioned by Health Commission Wales affect small numbers of people in each LHB area. Needs assessment at this level would be neither statistically robust nor efficient. For this reason, needs assessment for these services is more appropriately conducted at an All-Wales level, rather than by aggregating locally conducted assessments. Health, social care and well-being needs assessments are inappropriate to inform specialised services commissioning, as they were conducted for a different purpose and the specific condition of concern may not even have been recognised.
How can health needs assessments contribute to sustainable services?
Sustainable services are appropriate, affordable, acceptable to the population and to policy makers, and thus continue to achieve their intended outcomes in the long term.
The selection of appropriate issues is important. Ideally, the issues chosen should have a high impact on the population in terms of severity or numbers of people affected and have the potential to be successfully changed. Issues may also arise as a result of community or political pressure, or because of difficulties within an existing service.
The consideration of appropriate models of care, encompassing appropriate delivery methods along the whole patient pathway, is key to developing sustainable services. Services commissioned on the basis of a robust needs assessment are likely to be sustainable as sustainability is a key consideration throughout the process. Evaluation of such services and of the needs assessment process itself allows lessons to be learnt which can contribute to sustainability and to the success of future needs assessments.
Role of National Public Health Service
Although health needs assessment is a public health process, it is the responsibility of the commissioning bodies to ensure its use. The process may be undertaken by a variety of organisations.
The role of the NPHS, as the specialist public health resource in Wales, is to:
· Advise on epidemiology
· Assist with design of corporate and comparative elements (See Table 1).
The NPHS is able to undertake or lead specific needs assessments in their entirety; a programme of work is agreed with all stakeholders.
NEXT STEPS
A programme of needs assessment will be an integral part of the NPHS work programme. The specific content of this programme and its priorities should be agreed with stakeholders.
CONCLUSION
Appropriately conducted needs assessment is an important tool in ensuring the provision of sustainable services.
INFORMATION SOURCES
1. Wright, J. Assessing health needs. In: Oxford Handbook of Public Health Practice, Oxford, 2001 Ed. Pencheon D.
2. http://www.wales.gov.uk/subihealth/content/keypubs/pdf/policy-guide-e.pdf accessed 1.9.05
3. NICE. Health needs assessment: a practical guide. Accessed at: http://www.publichealth.nice.org.uk/page.aspx?o=513203 26.8.05
4. Scottish Needs Assessment Programme. needs assessment in primary care: a rough guide. Accessed at http://www.phis.org.uk/PDF.pl?file=publications/roughguide.PDF 8.12.04
5. Stevens A, Raftery J. Health Care Needs Assessment: the epidemiologically based needs assessment reviews. Vol 1 Radcliffe Medical Press, Oxford 1997
6. Hooper J, Longworth P. Health Needs Assessment Workbook. 2002 Health Development Agency London
Appendix: Examples of health needs assessments carried out by NPHS
Geographic population: Primary care in an isolated housing estate
Step 1: getting startedWhat population and why? / The population of a deprived housing estate in Torfaen. Local GPs intended to withdraw from the health centre on the estate, reducing access.
Aims / · assess the population need for primary health care
· identify ways of meeting that need.
Objectives / · describe the population and its main health needs
· consult the local community and stakeholders regarding determinants of health and priorities
· identify suitable models of care and levels of service
· consult the local community regarding models of care
· develop a business case for the establishment of the preferred service model
· identify evaluation criteria for the service adopted.
Who was in the project team? / A specialist registrar in public health, Two community development officers (LHB and voluntary sector), an LHB planning officer, a health visitor and a midwife.
Which stakeholders were involved? / Torfaen County Borough Council, Torfaen Voluntary Alliance, local schools, health visitors, district nurses and midwives, primary care teams, councillors, Action Team for Jobs, Surestart,
Drug and alcohol team, community pharmacist, Church of England vicar, local residents
Step 2: Identifying health priorities
What data were available on the health of the population? / ONS: demography, mortality, morbidity, households with dependant children, socio-economic status, transport, housing
Torfaen Health & Environment Survey: household income, problems with housing, satisfaction with environment, lifestyle, morbidity,
PEDW: hospital admissions,
Torfaen LHB: GP registrations,
WAG: primary care staffing
How was information gathered about the population’s and service providers’ perception of needs? / Semi-structured interviews with stakeholders and primary care teams.
Public meeting.
Any barriers encountered? / Very little data available about primary care use by the population.
How were these overcome? / The LHB paid practices to extract data on the relevant postcodes. The quality and usefulness of this data was poor.
What were the key issues for the population? / Access to services.
Poverty
Anti-social behaviour
Lack of available mental health services.
What priorities were chosen? / Provision of accessible services within the estate.
Step 3: assessing a priority for action
What interventions were considered most effective and acceptable? / Provision of open-access Nurse Practitioner service, available to all residents, and including mental health input.
What changes were required? / Employment of Nurse Practitioner (by LHB) and mental health nurse (via SLA with Gwent Trust)
How were resource needs met? / Met by LHB out of existing funding.
Step 4: action planning
Summary of the action planning process / The LHB and CHC jointly produced a long-list of options, which was circulated for comments. A shortlist of options was taken to public consultation.
The LHB board approved the establishment of the Nurse Practitioner service, and the subsequent business plan.
Step 5: Moving on/review
What did the project achieve? / Access to primary care services ensured. The needs assessment process and outcome gained the support of an initially suspicious community.
How did it contribute to reducing inequalities? / Provided easy access to primary care for a deprived community, over and above that provided by their GPs.
What needs to happen next? / Evaluation of the Nurse Practitioner service
What main message from this HNA will you take forward to the next? / The process of HNA is beneficial as long as it leads to change. The population was sceptical that the needs assessment was anything other than a PR tool. If no change had resulted, this impression would have been confirmed and the population would have been disinclined to participate in any future work.
Specific health experience population: Adults with CNS tumours
What population and why? / Adults with brain and other CNS tumours (malignant or benign) in England and Wales. The population matched the scope of NICE service guidance
Aims / Improve service provision and outcomes for the population.
Objectives / · Describe the epidemiology and service provision for the population
· Guidance Development Group (GDG) to develop recommendations for the ‘improving outcomes for people with brain and other central nervous system tumours’ NICE guidance
Who was in the project team? / A specialist registrar in Public Health, Local Public Health Director.
Clinicians from the GDG and the Director of the National Cancer Services development team acted as a steering group.
Which stakeholders were involved? / NICE GDG, patient/ carer groups, 27 neurosurgical and 52 radiotherapy units in England and Wales.
Step 2: Identifying health priorities
What data were available on the health of the population? / · Cancer registrations Wales and England
· ONS mortality statistics Wales and England
· ONS population estimates Wales and England
· Government actuarial department population projections
· PEDW and HES hospital statistics
· National waiting times (England only)
How was information gathered about the population’s and service providers’ perception of needs? / Survey of radiotherapy and neurosurgical units in England and Wales.
Any barriers encountered? / Major deficiencies in the data, especially survival data.
Difficulties in agreeing a classification for the assessment.
Getting good response rates from the questionnaires was difficult.
Steering group members were from all over Britain including Scotland.
How were these overcome? / Classification: the ultimate classification was determined as much by the data available as by what was considered useful
Questionnaires: The Society of British Neurosurgeons was key in obtaining a 100% response rate to the questionnaire from neurosurgical units.. .
Steering group meetings were held by teleconference.
What were the key issues for the population? / These rare tumours will become more common as the population ages.
Hospital activity is increasing in younger patients
Wide variation between units in development of multidisciplinary working.
What priorities were chosen? / Improved data collection, multidisciplinary working and co-ordination of care
Step 3: assessing a priority for action
What interventions were considered most effective and acceptable? / The guidance document to which the needs assessment contributed is currently in draft following public consultation.
What changes were required? / None as yet
Step 4: action planning
Summary of the action planning process / See above
Step 5: Moving on/review
What did the project achieve? / First national needs assessment for these patients in England and Wales.
Integration of multiple data sources in a relatively short period of time.
Good questionnaire response used not only to influence recommendations, but also as a basis for assessment of economic impact.
How did it contribute to reducing inequalities? / The needs assessment uncovered wide disparity in services available between units. National guidelines will reduce these variations.
What was learned from the project’s successes and challenges? / The time taken to do the work was under-estimated, in particular time spent chasing questionnaire returns
Epidemiological data could have been used more fully.
The questionnaire was developed without input from radiologists, which meant some of the questions on diagnostic imaging could have been improved on.
What needs to happen next? / Publication and monitoring of guidance and standards.
What main message from this HNA will you take forward to the next? / Allow sufficient time
Work with the data currently available, and take steps to ensure future data collected is more useful.
Healthy Heart Project arising out of HSCWB Needs Assessment