Health needs assessmentk4ds.psu.ac.th/shf/hna/files/HNA_BMJ.pdf · assessing the supply of new...

Health needs assessmentDevelopment and importance of health needs assessmentJohn Wright, Rhys Williams, John R Wilkinson

Most doctors are used to assessing the health needs oftheir individual patients. Through professional trainingand clinical experience we have developed a systematicapproach to this assessment and we use it before westart a treatment that we believe to be effective. Such asystematic approach has often been missing when itcomes to assessing the health needs of a local or prac-tice population.

The health needs of individual patients comingthrough the consulting room door may not reflect thewider health needs of the community. If people have ahealth problem that they believe cannot be helped bythe health service, then they will not attend. For example,many people with angina or multiple sclerosis are notknown to either their local general practitioner or to ahospital specialist.1 2 Other groups of patients who mayneed health care but do not demand it include homelesspeople and people with chronic mental illness.

Distinguishing between individual needs and thewider needs of the community is important in theplanning and provision of local health services. If theseneeds are ignored then there is a danger of a top-downapproach to providing health services, which relies tooheavily on what a few people perceive to be the needsof the population rather than what they actually are.

What is health needs assessment?Health needs assessment is a new phrase to describethe development and refinement of well establishedapproaches to understanding the needs of a localpopulation. In the 19th century the first medical offic-ers for health were responsible for assessing the needsof their local populations. More recently, in the 1970sthe Resource Allocation Working Party assessedrelative health needs on the basis of standardisedmortality ratios and socioeconomic deprivation in dif-ferent populations, and it used this formula to recom-mend fairer redistribution of health service resources.3

The 1992 Health of the Nation initiative was a govern-ment attempt to assess national health needs anddetermine priorities for improving health.4 Health

needs assessment has come to mean an objective andvalid method of tailoring health services—an evidencebased approach to commissioning and planninghealth services.

Although health needs assessments have tradi-tionally been undertaken by public health profession-als looking at their local population, these local healthneeds should be paramount to all health professionals.Hospitals and primary care teams should both aim todevelop services to match the needs of their localpopulations. Combining population needs assessmentwith personal knowledge of patients’ needs may helpto meet this goal.5

Why has needs assessment becomeimportant?The costs of health care are rising. Over the past 30years expenditure on health care has risen much fasterthan the cost increases reported in other sectors of theeconomy, and health care is now one of the largest sec-tors in most developed countries.6 Medical advancesand demographic changes will continue the upwardpressure on costs.7

At the same time the resources available for healthcare are limited. Many people have inequitable accessto adequate health care, and many governments areunable to provide such care universally. In additionthere is a large variation in availability and use ofhealth care by geographical area and point ofprovision.8 Availability tends to be inversely related tothe need of the population served.9JA

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Summary points

Health needs assessment is the systematicapproach to ensuring that the health service usesits resources to improve the health of thepopulation in the most efficient way

It involves epidemiological, qualitative, andcomparative methods to describe health problemsof a population; identify inequalities in health andaccess to services; and determine priorities for themost effective use of resources

Health needs are those that can benefit fromhealth care or from wider social andenvironmental changes

Successful health needs assessments require apractical understanding of what is involved, thetime and resources necessary to undertakeassessments, and sufficient integration of theresults into planning and commissioning of localservices

Education and debate

This is the firstin a series ofsix articlesdescribingapproaches toand topics forhealth needsassessment,and how theresults can beused effectively

Bradford HospitalsNHS Trust,Bradford RoyalInfirmary, BradfordBD9 6RJJohn Wright,consultant inepidemiology andpublic health medicine

Nuffield Institute forHealth, LeedsLS2 9PLRhys Williams,professor ofepidemiology andpublic health

North YorkshireHealth Authority,York YO1 1PEJohn R Wilkinson,deputy director ofpublic health

Correspondence to:Dr [email protected]

Series editor:John Wright

BMJ 1998;316:1310–3

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Another force for change is consumerism. Theexpectations of members of the public have led togreater concerns about the quality of the services theyreceive—from access and equity to appropriatenessand effectiveness.

These factors have triggered reforms of healthservices in both developed and developing countries.In Britain these reforms resulted in the separation ofthe responsibility for financing health care from itsprovision and in the establishment of a purchasing rolefor health authorities and general practitioners. Healthauthorities had greater opportunities to try to tailorlocal services to their own populations, and the 1990National Health Service Act required health authori-ties to assess health needs of their populations and touse these assessments to set priorities to improve thehealth of their local population.10 11 This has been rein-forced by more recent work on inequalities in health,suggesting that health authorities should undertake“equity audits” to determine if healthcare resources arebeing used in accordance with need.12

At a primary care level, through fundholding, local-ity commissioning, and total purchasing projects,general practitioners have become more central to stra-tegic planning and development of health services. Withthis increased commissioning power has come theincreased expectation from patients and politicians thatdecision making would reflect local and national priori-ties, promoting effective and equitable care on the basisof need.13 The Labour government has committed itselfto ensuring access to treatment according to “need andneed alone,” and the key functions of primary caregroups will be to plan, commission, and monitor localhealth services to meet identified local needs.14 15

NeedsDoctors, sociologists, philosophers, and economists allhave different views of what needs are.16–20 Inrecognition of the scarcity of resources available tomeet these needs, health needs are often differentiatedas needs, demands, and supply (fig 1).

Need in health care is commonly defined as thecapacity to benefit. If health needs are to be identifiedthen an effective intervention should be available tomeet these needs and improve health. There will be nobenefit from an intervention that is not effective or ifthere are no resources available.

Demand is what patients ask for; it is the needs thatmost doctors encounter. General practitioners have akey role as gatekeepers in controlling this demand, andwaiting lists become a surrogate marker and aninfluence on this demand. Demand from patients for aservice can depend on the characteristics of the patientor on the media’s interest in the service. Demand canalso be induced by supply: geographical variation inhospital admission rates is explained more by the sup-ply of hospital beds than by indicators of mortality21 22;referral rates of general practitioners owe more to thecharacteristics of individual doctors than to the healthof their populations.23

Supply is the health care provided. This will dependon the interests of health professionals, the priorities ofpoliticians, and the amount of money available.National health technology assessment programmeshave developed in recognition of the importance of

assessing the supply of new services and treatmentsbefore their widespread introduction.

Need, demand, and supply overlap, and thisrelation is important to consider when assessing healthneeds (fig 2).20

Health needsThe World Health Organisation’s definition of health isoften used: “Health is a state of complete physical, psy-chological, and social wellbeing and not simply theabsence of disease or infirmity.” A more romantic defi-nition would be Freud’s: “Health is the ability to workand to love.”

Healthcare needs are those that can benefit fromhealth care (health education, disease prevention, diag-nosis, treatment, rehabilitation, terminal care). Mostdoctors will consider needs in terms of healthcareservices that they can supply. Patients, however, mayhave a different view of what would make themhealthier—for example, a job, a bus route to the hospi-tal or health centre, or decent housing.

Health needs incorporate the wider social and envi-ronmental determinants of health, such as deprivation,housing, diet, education, employment. This wider defi-nition allows us to look beyond the confines of themedical model based on health services, to the widerinfluences on health (box). Health needs of apopulation will be constantly changing, and many willnot be amenable to medical intervention.

Health needs assessmentAssessment of health needs is not simply a process oflistening to patients or relying on personal experience.It is a systematic method of identifying unmet healthand healthcare needs of a population and makingchanges to meet these unmet needs. It involves an epi-demiological and qualitative approach to determiningpriorities which incorporates clinical and cost effective-ness and patients’ perspectives. This approach mustbalance clinical, ethical, and economic considerationsof need—that is, what should be done, what can bedone, and what can be afforded.25

Wants(felt needs)

Demands(expressed needs)

Needs(normative needs)

Met Unmet

Supply

Fig 1 Differentaspects of needs

Influences on health

• Environment: housing, education, socioeconomicstatus, pollution• Behaviour: diet, smoking, exercise• Genes: inherited health potential• Health care: including primary, secondary, andtertiary prevention

Need

Supply Demand

1

1

Health promotion, somescreening

2

Treatment of child abusers

Examples:

3 Termination of pregnancy,waiting lists

4 Antibiotics for viral upperrespiratory tract infections

2 3

4

Fig 2 Relation between need, supply, and demand—central areashows ideal relation. Modified from Stevens and Raferty.24


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Health needs assessment should not just be amethod of measuring ill health, as this assumes thatsomething can be done to tackle it. Incorporating theconcept of a capacity to benefit introduces theimportance of effectiveness of health interventions andattempts to make explicit what benefits are being pur-sued. Economists argue that the capacity to benefit isalways going to be greater than available resources andthat health needs assessment should also incorporatequestions of priority setting,26 suggesting that manyneeds assessments are simply distractions from the dif-ficult decisions of rationing.27

For individual practices and health professionals,health needs assessment provides the opportunity for:x Describing the patterns of disease in the local popu-lation and the differences from district, regional, ornational disease patterns;x Learning more about the needs and priorities oftheir patients and the local population;x Highlighting the areas of unmet need andproviding a clear set of objectives to work towards tomeet these needs;x Deciding rationally how to use resources to improvetheir local population’s health in the most effective andefficient way;x Influencing policy, interagency collaboration, orresearch and development priorities.

Importantly, health needs assessment also providesa method of monitoring and promoting equity in theprovision and use of health services and addressinginequalities in health.28 29

The importance of assessing health needs ratherthan reacting to health demands is widely recognised,and there are many examples of needs assessment inprimary and secondary care.21 30 31

There is no easy, quick-fix recipe for health needsassessment. Different topics will require differentapproaches. These may involve a combination of quali-tative and quantitative research methods to collectoriginal information, or adapting and transferringwhat is already known or available.

The stimulus for these assessments is often the per-sonal interest of an individual or the availability of newfunding for the development of health services.However, assessments should also be prompted by theimportance of the health problem (in terms offrequency, impact, or cost), the occurrence of criticalincidents (the death of a patient turned away becausethe intensive care unit is full), evidence of effectivenessof an intervention, or publication of new research find-ings about the burden of a disease.

Why do projects fail?Some needs assessments have been more successfulthan others. Projects may fail for several reasons.31–33

Firstly, what is involved in assessing health needsand how it should be undertaken may not beunderstood. Educational strategies can improve theunderstanding and necessary skills of health profes-sionals, and local public health teams can provide valu-able support and guidance. Common sense can be amore important asset than detailed methodologicalunderstanding.34 Starting with a simple and welldefined health topic can provide experience andencourage success.

Secondly, projects may fail because of a lack oftime, resources, or commitment. The time andresources required can be small when shared amongprofessionals in a team, and such sharing has thepotential to be team building. Involving otherorganisations such as social services, local authorities,or voluntary groups can provide similar advantagesand encourage multiagency working. Integration ofneeds assessment into audit and education can alsoprovide better use of scarce time. Such investment oftime and effort is likely to become increasinglynecessary in order to justify extra resources.

A third reason is the failure to integrate the resultswith planning and purchasing intentions to ensurechange. The planning cycle should begin with theassessment of need.28 Objectives must be clearlydefined (box) and relevant stakeholders oragencies—be they primary care teams, hospital staff,health authorities, the voluntary sector, the media,regional executives, government, or patients—must beinvolved appropriately (fig 3). Although such an assess-ment may produce a multitude of needs, criteria can beused to prioritise these needs—for example, theimportance of a problem in terms of frequency orseverity, the evidence of effectiveness of interventions,or the feasibility for change. Needs assessments that donot include sufficient attention to implementation willbecome little more than academic or public relationsexercises.This series will describe the different approaches toassessing health needs, how to identify topics for health

Questions to ask when assessing health needs

• What is the problem?• What is the size and nature of the problem?• What are the current services?• What do patients want?• What are the most appropriate and effective (clinicaland cost) solutions?• What are the resource implications?• What are the outcomes to evaluate change and thecriteria to audit success?

Hospital staff

Regionalexecutives

Healthauthorities

Primary careteams

PressGovernment

PatientsVoluntarysector

HealthneedsHealthneeds

Fig 3 Contributors to needs assessment

HEALTH

NEEDS

ASSESSMENT

DISEASE

DEMANDS

RESPONSE

Not just

Not just

Not just


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needs assessments, which practical approaches can betaken, and how the results can be used effectively toimprove the health of local populations. It will giveexamples of needs assessment from primary care butwill also cover the specific problems of needsassessment for hard to reach groups. Many of the tech-niques of community appraisals used in needsassessment originate from experience in developingcountries, and some of the lessons from thisexperience will be described.

We are grateful to John Bibby and Dee Kyle for their valuablecontributions and to Margaret Haigh for secretarial support.

Funding: None.Conflict of interest: None.

1 Smith R. Rationing: the search for sunlight. BMJ 1991;303:1561-2.2 Ford HL, Gerry E, Airey CM, Johnson MH, Williams DRR. The

prevalence of multiple sclerosis in the Leeds District. J Neurol NeurosurgPsychiatry 1998 (in press).

3 Department of Health and Social Security. Sharing resources for health inEngland: report of the Resource Allocation Working Party. London: HMSO,1976.

4 Department of Health. The Health of the Nation: a strategy for health inEngland. London: HMSO, 1992. (Cm 1986.)

5 Shanks J, Kheraj S, Fish S. Better ways of assessing health needs inprimary care. BMJ 1995;310:480-1.

6 Organisation for Economic Cooperation and Development. Health caresystems in transition: the search for efficiency. Paris: OECD, 1990. (Socialpolicy studies No 7.)

7 Harrison A, Dixon J, New B, Judge K. Funding the NHS. Can the NHScope in future. BMJ 1997;314:139-42.

8 Anderson TV, Mooney G. The challenge of medical practice variations. Lon-don: McMillan, 1990.

9 Tudor Hart J. The inverse care law. Lancet 1971;i:405-12.10 Department of Health. Working for patients. London: HMSO, 1989. (Cm

555.)11 National Health Service Management Executive. Assessing health care

needs. Leeds: NHSME, 1991. (DHA project discussion paper.)12 Variations Subgroup of the Chief Medical Officer’s Health of the Nation

Working Group. Variations in health. What can the Department of Health andthe NHS do? London: Department of Health, 1995.

13 National Health Service Executive. An accountability framework for GPfundholding: towards a primary care led NHS. Leeds: NHSE, 1994.(EL(94)54.)

14 Secretary of State for Scotland. Designed to care. Edinburgh: Departmentof Home and Health, Scottish Office, 1997.

15 NHS Executive. The new NHS. London: Stationery Office, 1997.(Cm 3807.)

16 Culyer A J. Need and the National Health Service. London: Martin Robert-son, 1976.

17 Bradshaw J. A taxonomy of social need. In: McLachlan G, ed. Problems andprogress in medical care. 7th series. London: Oxford University Press, 1972.

18 Frankel S. Health needs, health-care requirements and the myth ofinfinite demand. Lancet 1991;337:1588-9.

19 Williams. Priorities not needs. In: Corden A, Robertson G, Tolley K, eds.Meeting needs. Aldershot: Avebury Gower, 1992.

20 Stevens A, Gabbay J. Needs assessment needs assessment. Health Trends1991;23:20-3.

21 Feldstein MS. Effects of differences in hospital bed scarcity on type of use.BMJ 1964;ii:562-5.

22 Kirkup B, Forster D. How will health needs be measured in districts?Implications of variations in hospital use. J Public Health Med 1990;12:45-50.

23 Wilkin D. Patterns of referral: explaining variation. In: Roland M, CoulterA, eds. Hospital referrals. Oxford: Oxford University Press, 1992.

24 Stevens A, Raferty J, eds. Health care needs assessment—the epidemiologicallybased needs assessment reviews. Oxford: Radcliffe Medical Press, 1994.

25 Black D. A doctor looks at health economics. Office of Health Economics annuallecture. London: OHE, 1994.

26 Donaldson C, Mooney G. Needs assessment, priority setting, andcontracts for health care: an economic view. BMJ 1991;303:1529-30.

27 Mooney G. Key issues in health economics. Hemel Hempstead: HarvesterWheatsheaf, 1994.

28 Womersley J, McCauley D. Tailoring health services to the needs of indi-vidual communities. J Publ Health Med 1987;41:190-5.

29 Majeed FA, Chaturvedi N, Reading R, Ben-Shlomo Y. Monitoring andpromoting equity in primary and secondary care. BMJ 1994;308:1426-9.

30 Gillam SJ, Murray SA. Needs assessment in general practice. London: RoyalCollege of General Practitioners, 1996. (Occasional paper 73.)

31 Jordan J, Wright J, Wilkinson J, Williams DRR. Health needs assessment inprimary care: a study of the understanding and experience in three districts.Leeds: Nuffield Institute for Health, 1996.

32 London Health Economics Consortium. Local health and the vocal commu-nity, a review of developing practice in community based health needs assessment.London: London Primary Health Care Forum, 1996.

33 Jordan J, Wright J. Making sense of health needs assessment. Br J GenPract 1997;48:695-6.

34 Gillam S. Assessing the health care needs of populations—the generalpractitioner’s contribution [editorial]. Br J Gen Pract 1992;42:404-5.

Coping with lossThe dying adultColin Murray Parkes

This paper focuses on two common problems thatarise when people come close to death, fear and grief.Fear is the psychological reaction to danger; grief thereaction to the numerous losses that are likely to occurin the course of an illness that is approaching a fataloutcome. Both can be expected to arise in patients,their families, and—though we are reluctant to admitit—in their doctors and other carers. Both fear andgrief need to be taken into account if we are to mitigatethe psychological pains of dying.

FearThough it may seem obvious that people who aredying are likely to be afraid, we should not assume thatwe know what they fear. The box shows the fears, inapproximate order of frequency, expressed to me bypatients in a hospice. It is clear that fears of death itselfcome quite far down on the list. Difficult to quantify butof particular importance is reflected fear, the fear thatpeople see in the eyes of those around them or hear inthe questions that are not asked.1 Many problems in

communication arise out of fear, and we may need totake time to create trust and a safe place in whichpeople can begin to talk about the things that makethem feel unsafe.

These articleshave been adaptedfrom Health NeedsAssessment inPractice, edited byJohn Wright,which will bepublished in July

Summary points

We should never assume that we know whatpeople with terminal illness fear

Most patients will benefit if we can help them tofeel secure enough to share their fears

Fear can aggravate pain, and pain fear

Patients with life threatening illnesses experiencea series of losses as the illness progresses

Grief is natural and needs to be acknowledgedand expressed


This is theseventh in aseries of 10articles dealingwith thedifferent typesof loss thatdoctors willmeet in theirpractice

St Christopher’sHospice, Sydenham,London SE26 6DZColin MurrayParkes,consultant psychiatrist

[email protected]

Series editors: ColinMurray Parkes andAndrew Markus

BMJ 1998;316:1313–5

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Health needs assessmentEpidemiological issues in health needs assessmentRhys Williams, John Wright

The first article in this series explained the importanceof health needs assessment in the context of planningand delivering health care to populations.1 Itmentioned the “epidemiological approach” to healthneeds assessment—the traditional public healthapproach of describing need in relation to specifichealth problems using estimates of the incidence,prevalence, and other surrogates of health impactderived from studies carried out locally or elsewhere.This approach has been be extended to the considera-tion, alongside these measures, of the ways in whichexisting services are delivered and the effectiveness andcost effectiveness of interventions intended to meet theneeds thus described (fig 1).2 This is a logical extensionas there is little point in estimating the burden of illhealth (except for determining priorities for futureresearch) if nothing can be done to reduce it.

Epidemiology has been defined as “the study of thedistribution and determinants of health-related statesor events in specific populations and the application ofthis study to control of health problems.”3 It tends, forthe most part, to use the “medical model” of healthneed, viewing need in terms of the occurrence of spe-cific diseases and health related states rather than clientgroups. Descriptive epidemiology (as opposed toanalytical epidemiology—the investigation of thedeterminants of health related states or events)describes the occurrence of disease in terms of person,place, and time:

x Person—who the affected people are (in terms oftheir age, sex, occupation, socioeconomic group, etc);x Place—where they are when they get diseases and inwhat way prevalence and incidence vary geographi-cally (locally, regionally, nationally, or internationally);x Time—when people get diseases, whether this variesby, for example, season; and how disease occurrence ischanging over time.

Case definitionThe usual starting point for any epidemiologicallybased needs assessment is the question, what is a case?

Epidemiologists place great importance on casedefinition; yet, for a thorough health needs assessment,simple case definitions usually need to be expanded toinclude valid measures of severity.

Patients who are cases may possess relatively clearcharacteristics which separate them from those whoare not cases. Examples are patients with the floridsymptoms or signs of hypertension, asthma, ordiabetes. However, in most conditions, including thesethree, individuals are encountered who are close to theborderline between normality and abnormality (fig 2).For these, internationally agreed criteria are requiredand are available.4–6

Such criteria may seem arbitrary but are, or at leastshould be, based on the probability of the future occur-rence of specified outcomes known to be associatedwith the relevant condition. They may be based onphysical signs or symptoms, or on physiological or bio-chemical characteristics which need to be measured byappropriate and standardised tests—for example, validand repeatable questionnaires or physiological or bio-chemical tests. The criteria may change from time totime as further knowledge accrues but should not varyfrom place to place if estimates of incidence and preva-lence are to be at all generalisable.JA

NESMITH

Summary points

Epidemiological methods can be used to describehealth needs in terms of the distribution ofspecific diseases

Although incidence and prevalence do notnecessarily equate with need, they are bothimportant in describing the population burden ofdisease

Specific epidemiological studies can be expensiveand time consuming. Existing information fromprevious studies can be used to inform localneeds if criteria for generalisability are met

Routine sources of health information can sufferfrom inaccuracy and inappropriateness, but theycan provide valuable descriptions of health andhealthcare use in a defined population

Incidence and prevalence Effectiveness and costeffectiveness

Existing services

Fig 1 Components of health needs assessment. Modified fromStevens and Raftery2


This is thesecond in aseries of sixarticlesdescribingapproaches toand topics forhealth needsassessment,and how theresults can beused effectively

Nuffield Institute forHealth, LeedsLS2 9PLRhys Williams,professor ofepidemiology andpublic health

Bradford HospitalsNHS Trust,Bradford RoyalInfirmary, BradfordBD9 6RJJohn Wright,consultant inepidemiology andpublic health medicine

Correspondence to:Professor [email protected]


BMJ 1998;316:1379–82

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Incidence and prevalenceIncidence and prevalence are measures fundamentalto the science of epidemiology. Both of these requirethe estimation of the numerator—the number of newcases observed (in the case of incidence) or the numberof cases present in a population (in the case ofprevalence)—and the estimation of the denominator(the number of people in the population at risk). Inci-dence is a rate (it has a time dimension) and prevalenceis a proportion that is measured at a point in time butdoes not have a time dimension.

Neither prevalence nor incidence necessarilyequates with need, but knowledge of incidence andprevalence is usually an essential starting point for theassessment of need. Prevalence increases if incidence(or the rate of relapse) increases. It also increases if themortality (or remission) decreases. The relationbetween these variables is best summarised as the“prevalence pool” concept (fig 3). Only a part of thisprevalence pool may be visible at any one time if anyproportion of the existing cases of a disease remainsunrecognised. Unrecognised cases may be those at anearly stage of development or may be the least severe.

In health needs assessment it may be important toestimate both incidence and prevalence. Incidence isparticularly important for diseases or conditions thatare of short duration (such as many communicablediseases) or for those for which a substantial amount ofthe healthcare input occurs shortly after diagnosis(myocardial infarction, for example). Prevalence is par-ticularly important when the duration of disease islong—for example, asthma, diabetes, or multiplesclerosis. Several types of incidence and prevalencemay be used in needs assessment:

x Stratum specific estimates: for example, agespecific—for those in a given age group;

x Crude estimates: crudely calculated by summing thenumerators over all strata (for example, all ages) anddividing by the denominator of the total population;x Standardised estimates: taking into account that thepopulations being compared may differ in terms of ageor another important attribute.

Standardised estimates may be derived by thedirect or indirect method. In the direct method, thestratum specific estimates are taken from thepopulation being standardised (this might be a town orlocality) and applied to the stratum specific populationfigures of the standard population (that of the country,for example). The incidence or prevalence that wouldpertain in that population if those of the town or local-ity were applied to it can thus be calculated. In the indi-rect method, the process is reversed. The directmethod is more usual and, in most cases, preferable.Using the indirect method is justified when the dataitems required for the direct method are not availableand when small numbers in the stratum specificestimates in the population being standardised makethem statistically unstable. The standardised mortalityratio is a ratio derived from the technique of indirectstandardisation.

GeneralisabilityThe NHS Management Executive set up the districthealth authority project in 1990 to support healthauthorities in their responsibility for assessing needs.This led to a series of reviews of healthcare needsassessment.2 The aim of these reviews was to give prac-tical guidance to purchasers on moving from a serviceled healthcare system to a needs led healthcare system.They provided an “off the shelf” guide to populationneeds for important health topics such as asthma andstroke.

Such general information, however, is oftendisregarded on the grounds that “it’s not like that here.”Standard epidemiological tools and guidance areextremely important. However, existing techniques areoften crude, particularly when measuring morbidity. Inthe absence of dedicated research, evidence of morbid-ity is often derived from mortality data, and whenresearch is available, extrapolation to different popula-tions can disguise underlying variations.7 Clearly,populations will differ in age, sex, socioeconomic andethnic mix, and other attributes, or there may be otherlegitimate reasons for thinking that work carried outelsewhere is not applicable (use of an incorrect casedefinition, for example). Issues of generalisability canusually be divided into four broad areas:

x Case definitions—are they acceptable?x The time since the study was carried out—is theinformation still timely?x Is the study sound in other respects—methods ofascertainment (numerators) and demographic infor-mation (denominators)?x Have the data been presented (or are they available)for the relevant strata of known confounders? (Theterm “confounders” is used here to encompassattributes which influence incidence or prevalencesuch as age, sex, and socioeconomic or ethnic group.)

% o

f pop

ulat

ion

80 100 120 140 160 180

Systolic blood pressure

NormalModerateandseverehypertension

Borderline Mild

Fig 2 Classification of hypertension by systolic blood pressureshows the continuum from normal to abnormal

Incidence orrelapse

Prevalence

Mortality orremission

Fig 3 Prevalence pool


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Diabetes is an example of a condition for whichknowledge of incidence and prevalence in relation toconfounders is essential if any valid estimate of need isto be made. In general practices that are known to haveidentified their diabetic patients comprehensively, theprevalence of diabetes shows a close and totallyexpected relation with the proportion of the practicelist aged 65 years and over.8 Thus, practices that areunsure of the completeness of their diabetes registercan get some indication of how close they are to com-plete ascertainment by comparing their observedprevalence with that expected on the basis of this rela-tion with age. However, this holds only if the practicepopulation has a similar composition, in terms of eth-nic origin, to the practices on which the initial observa-tions have been made. Since it is known that theprevalence of diabetes varies between ethnic groupsand, equally important, that the relation betweenprevalence and age is different in different ethnicgroups, the ethnic composition of the practice needs tobe taken into account.

Although no convincing relation has been foundbetween prevalence of diabetes and socioeconomicgroup, relations have been found between outcomes ofdiabetes and socioeconomic status: worse outcomes inthe more disadvantaged groups are worse. For this rea-son, any estimate of need (“the ability to benefit fromcare”2) for diabetes services must take socioeconomicstatus into account.

If the four aspects described above are satisfiedthen there is no reason why information from otherlocalities cannot be applied to the local situation. To doso, with all reasonable care, can save precious resourceswhich might otherwise be squandered in carrying out

yet another health needs assessment on a given healthproblem merely because of a misplaced enthusiasm forlocally derived data.

Small populations“Locality based health needs assessment”—needsassessment dealing with populations smaller thandistrict health authorities or their equivalents—has theadvantage of allowing knowledge of the local scene tobe used in planning local services. The use of localdata, to the exclusion of data available from elsewhere,needs to be carefully considered. Apart from the costimplications of repeating locally what may have beendone perfectly well elsewhere and can be extrapolated,statistical considerations need to be taken into accountwhen assessing the frequency of relatively rare events.Even diseases that are common enough to be regardedas major public health problems (for example,carcinoma of the cervix) occur relatively infrequentlyin small populations.

Three important issues need to be taken intoaccount when deciding the minimum size of the popu-lation on which a needs assessment should be based:the frequency of occurrence (incidence, prevalence, orboth); the impact of the condition on those who haveit; and the cost implications of treatment.

For a rare condition with a high impact on patientsand carers and with high treatment costs (childhoodleukaemia, for example) a relatively large populationneeds to be studied for needs assessment to be worthwhile. The extent of need for common, low impact, lowcost conditions can be assessed on smaller populations.For a single practice it would be unwise to assess needfor conditions with a prevalence of less than 1%. Sowhereas a needs assessment for childhood leukaemiawould be of limited value for a population of underone million, a needs assessment for mild depressioncould be based on the population served by a fourdoctor practice.

The NHS, in common with many other organisa-tions, devotes more care and resources to collectingdata than it does to using the data it collects. Routinereports of information are not as comprehensive inBritain as in some countries (such as Scandinaviancountries) but they do exist, and it is surprising howinfrequently they are used or even known about (box).

Undertaking an epidemiological survey

Routine sources can provide only limited descriptionsof disease; for more details, special surveys may berequired. There are two main types of descriptivesurvey: prevalence (cross sectional) surveys andlongitudinal surveys. These principles apply to allsurveys, whether they are to describe disease or toprovide patients’ perspectives.

• Surveys cost time and money. It is important toensure that the information wanted is not availablefrom routine sources• There should be a clear aim for the survey. Whatdisease, or risk factor, is being measured? What is thecase definition? What is the population of interest?• Good planning is needed. Staff and resources will beneeded to carry out the survey and produce a report• Sample size for the survey must be calculated. This isusually a balance between the need for precision(more precise estimates of incidence and prevalencerequire larger samples) and the resources and timeavailable• Recruitment of the sample must be considered. Asampling frame must be chosen and from this thesample selected randomly, systematically, orpurposefully• The survey instrument (a symptom questionnaire,quality of life measure, physiological measurement, orlaboratory test) should be valid, reliable, andrepeatable• Steps should be taken to ensure a high responserate. Questionnaires should be piloted

A

B

Incr

easi

ng ra

rity

Increasing impactIncreasing cost

A (common) - low cost, low impact - can use a small population

B (rare) - high cost, high impact - need a large population

Fig 4 Attributes of a health problem that influence the size of thepopulation for needs assessment



Unfortunately, “Murphy’s law of information” plays apart at this stage: “The information we have is not whatwe want. The information we want is not what we need.The information we need is too expensive to collect.”Despite that pessimistic view, routinely available datacan be used, even if this entails some compromise interms of precision. Used with survey information, rou-

tinely collected data can provide a powerful assessmentof health needs and use of services (box).

We are grateful to John Bibby for his advice and comments andto Margaret Haigh and Pam Lilley for their secretarial support.


1 Wright J, Williams DRR, Wilkinson J. The development and importanceof health needs assessment. BMJ 1998;316:1310-3.

2 Stevens A, Raftery J. Introduction. In: Health care needs assessment. Vol 1.Oxford: Radcliffe Medical Press, 1994:1-30.

3 Last JM. A dictionary of epidemiology. 3rd ed. Oxford: Oxford UniversityPress, 1995:55.

4 Subcommittee of WHO/ISH Mild Hypertension Liaison Committee.Summary of 1993 World Health Organisation-International Society ofHypertension guidelines for the management of mild hypertension. BMJ1993;307:1541-6.

5 National Asthma Education Program. Guidelines for the diagnosis andmanagement of asthma. Rockville, MD: US Department of Health andHuman Services, 1991.

6 World Health Organisation Study Group. Diabetes mellitus. WHO TechRep Ser 1985;727.

7 Doyal L. Needs, rights and equity: moral quality in healthcare rationing.Qual Health Care 1995;4:273-83.

8 Williams R. Diabetes. In: Stevens A, Raftery J, eds. Health care needs assess-ment. Vol 1. Oxford: Radcliffe Medical Press, 1994:31-49.

9 Payne N, Saul C. Variations in use of cardiology services in a healthauthority: comparison of coronary artery revascularisation rates withprevalence of angina and coronary mortality. BMJ 1997;314:257-61.

InnovationsAn unusual use of a stethoscope

The patient awaiting operation was 94, well oriented, and fit for hisage. At his preoperative anaesthetic assessment the only significantfinding was deafness and I had to shout at the top of my voice forany communication, so it took a long time to explain matters tohim. It suddenly struck me. “Why not try using a stethoscope in hisears?” I did and to my surprise I had only to whisper. It amused thewhole ward, but it was a solution to my problem. I used this trick towake him up from the anaesthetic and also asked the recoverynurses to try the same method. It was strange to see a patient in therecovery room with a stethoscope round his neck.

Others might find this unusual use of a stethoscope helpful.

Bela Vadodaria, specialist registrar in anaesthetics, High Wycombe

We welcome articles up to 600 words on topics such asA memorable patient, A paper that changed my practice, My mostunfortunate mistake, or any other piece conveying instruction,pathos, or humour. If possible the article should be supplied on adisk. Permission is needed from the patient or a relative if anidentifiable patient is referred to. We also welcome contributionsfor “Endpieces,” consisting of quotations of up to 80 words (butmost are considerably shorter) from any source, ancient ormodern, which have appealed to the reader.

National sources of health information in theUnited Kingdom

Population:• Census data can be used to describe populations ata district or electoral ward level by age, sex, ethnicgroup, or socioeconomic status• Census information on variables such asunemployment and overcrowding can be used toproduce indices of deprivation for electoral wards(Jarman index, Townsend score)

Mortality:• National registration of deaths and causes of deathprovide comprehensive (though not always accurate)information on mortality• Perinatal and infant mortality “rates” (they are notrates but proportions) are used for comparisons of thequality of health care• Standardised mortality rates are used to comparelocal information on total mortality or mortality fromspecific causes

Morbidity:• National and local registers provide data of variableaccuracy. Registers exist for cancers (type of cancer,treatment, and survival); drug addiction; congenitalabnormalities; specific diseases (such as diabetes andstroke)• Communicable disease notification provides asource of information for local surveillance• The Royal College of General Practitioners collectsmorbidity data from sample practices around Britain• Prescribing data can be a valuable surrogate markerof morbidity• Insurance companies can be an important source ofhealth information in countries with systems basedlargely on insurance

Health care:• Hospital activity data can provide information onhospital admissions, diagnoses, length of stay,operations performed, and patients’ characteristics• Clinical indicators such as the health serviceindicators, can provide information on thecomparative performance of hospitals and healthauthorities

Example of an epidemiological health needsassessment9

Objective: To assess whether the use of health servicesby people with coronary heart disease reflected need.

Setting: Health authority with a population of 530 000.

Methods: The prevalence of angina was determined bya validated postal questionnaire. Routine health datawere collected on standardised mortality ratios;admission rates for coronary heart disease; andoperation rates for angiography, angioplasty, andcoronary heart disease. Census data were used tocalculate Townsend scores to describe deprivation forelectoral wards. Prevalence of angina and use ofservices were then compared with deprivation scoresfor each ward.

Results: Angina and mortality from heart disease wasmore common in wards with high deprivation scores.Treatment by revascularisation procedures was morecommon in more affluent wards.

Conclusion: The use of revascularisation services wasnot commensurate with need. Steps should be taken toensure that health care is targeted at those who mostneed it.

These articleshave been adaptedfrom Health NeedsAssessment inPractice, edited byJohn Wright,which will bepublished in July.



Health needs assessmentNeeds assessment: from theory to practiceAndrew Stevens, Stephen Gillam

The purpose of needs assessment in health care is togather the information required to bring about changebeneficial to the health of the population. It isgenerally, but not universally, accepted that this takesplace within the context of finite resources.1 “Healthgain” can therefore be achieved by reallocatingresources as a result of identifying four factors:

x Non-recipients of beneficial healthcare interven-tions (that is, unmet need);x Recipients of ineffective health care (and releasingthe resources for unmet need);x Recipients of inefficient health care (and releasingresources for unmet need); andx Recipients of inappropriate health care (for whomthe outcomes could be improved).

The subjects of healthcare needs assessment arethe populations and patients who are recipients orpotential beneficiaries of health care. Populations, ofcourse, include individual patients. The assessment ofindividuals’ needs may form part of the assessment ofa population’s needs, but it may be costly and it risksignoring individuals with needs who do not presentthemselves for health care. Table 1 shows thecircumstances favouring individual needs assessmentfor planning purposes.

The priority attached to different needs, whether ofpopulations or of individuals, raises philosophicalproblems. For example, should the principal criterionbe the benefit that could potentially be obtained foreach individual, or the severity of their presenting con-dition?2 In other words, should greater priority (agreater assessed need) be attributed to the need forsurgery of a patient with early stage colorectal canceror to the need for hospice care of a terminally ill lungcancer patient? In practice the former, the approachthat favours the greater benefit, takes precedence informal needs assessment, but not exclusively. In eithercase, cost enters the equation. Some marginal benefitscannot be afforded in a publicly funded system becauseof the other treatments and benefits that need to besacrificed to fund them.

New practitioners of needs assessment are emerg-ing. The New NHS white paper requires primary caregroups to contribute to health authorities’ healthimprovement programmes, “helping to ensure thatthey reflect the perspectives of the local communityand the experiences of local patients.”3 More generalpractitioners will therefore face the dilemmas thatneeds assessment is intended to tackle.

From theory to practiceDifferent frameworks for healthcare needs assessmenthave reflected different purposes as well as differenttimes and contexts.4 The life cycle model, for example,is a framework which encourages needs assessors tothink comprehensively about different populationgroups of different ages.5 It is an attractive modelbecause of its simplicity, but it does not distinguishneed and demand or emphasise the pivotal theme of“capacity to benefit.”

A particular purpose of healthcare needs assess-ment is the spatial allocation of resources. Geographi-cal equity of regions, districts, and even localities (suchas housing estates) can be addressed by global and sur-rogate measures of health, particularly deprivationindices and standardised mortality ratios.6 Measuringrelative deprivation is a step forward from approachesthat do not distinguish need from supply and demand,but relative deprivation cannot be used to specify pre-cise needs for service planning: measuring deprivationindicates whether Burnley is less well resourced thanBelgravia but does not help in deciding the number ofcoronary care beds needed in either.

The definition of “need as the capacity to benefit”represents a further advance because it can be directedat specific services.7–9 It has generated new practicalapproaches in an area of sometimes paralysing contro-versy. Four points apply to needs assessmentundertaken both at the level of health authority andgeneral practice:

x The population’s ability to benefit from health careequals the aggregate of individuals’ ability to benefit.For most health problems (but see table 1) this can bededuced more readily from epidemiological data thanfrom clinical records.x The ability to benefit does not mean that every out-come will be favourable, but rather that need impliespotential benefit, which on average is effective.

Table 1 Factors determining basis for assessing healthcareneeds

Individual basis Population basis

Case load Light Heavy

Cost per patient High Low

Hidden patients Few Many

Variability in case mix High Low

Summary points

Healthcare need is the capacity to benefit fromhealth care

The assessment of population benefit includes ameasure of epidemiology (how many) and of costeffectiveness (how good)

Other sources, especially comparisons andcorporate knowledge, can contribute usefully

An optimal approach requires good informationgathering, clinical involvement, and a closerelation to the planning process


This is the thirdin a series ofsix articlesdescribingapproaches toand topics forhealth needsassessment,and how theresults can beused effectively

Department ofPublic Health andEpidemiology,University ofBirmingham,BirminghamB15 2TTAndrew Stevens,professor of publichealth

King’s Fund,London W1M 0ANStephen Gillam,director, primary careprogramme

Correspondence to:Professor Stevens


BMJ 1998;316:1448–52


x The benefit is not just a change in clinical status butcan include reassurance, supportive care, and the reliefof carers. The list of beneficiaries of care can extendbeyond the patient to families and carers.x Health care includes not just treatment but also pre-vention, diagnosis, continuing care, rehabilitation, andpalliative care.8

Such benefits are ideally assessed by an approachthat combines epidemiological factors and costeffectiveness, supplemented by “corporate” and “com-parative” methods.8 9 All of these methods include theenumeration of current services. But other contempo-rary approaches to service related assessment of needsshould be noted: not just population healthcare needsassessment but also social services assessments,individual healthcare needs assessment, participatoryand Oregon-style planning, population and clientgroup surveys, expert specialty recommendations, andclinical effectiveness research.10

The usefulness of these approaches can be assessedwith the following criteria:

x Is the needs assessment about populations orindividuals?x Is there a clear context of allocating scarce resources(are the needs assessed in the context of priority settingamong competing needs)?x Is the needs assessment exploratory or definitive (isthe object to clarify what should be done or just tohighlight problems that are accompanied by noobvious intervention)?x Is the determination of the most important needsbased on expert knowledge or participatory methods?

Table 2 shows how other approaches compare withpopulation healthcare needs assessment on the basisof the capacity to benefit. In population healthcareneeds assessment the concern is with the health ofpopulations with a common condition orpresentation—for example, all patients with diabetes(known or not known) on a practice’s list. It recognisesthat resources are finite and avoids focusing onadvocacy for individual groups without consideringcompeting priorities. It is definitive rather thanexploratory in that client groups are consideredtogether with actual interventions (this is not a featureof, say, some lifestyle or disability surveys), and theneeds are determined by expert appraisal of theevidence rather than principally through publicparticipation. However, any approach that contributesinformation on numbers in a particular group(incidence and prevalence), the effectiveness and costeffectiveness of interventions, and the distribution of

current services and their costs will be useful inpractice.

Defining baseline servicesMeasured needs only take on meaning in relation tothe existing services. Needs assessment is aboutchange, and it is essential to know what to change fromas well as what to change to. Several steps are involved.Firstly, the service under consideration has to be disag-gregated into meaningful units. For example, mentalhealth can be split up into adult, elderly, child, forensic,substance abuse, etc. Adult mental health could then befurther subdivided as services for long stay, short stay,day care, community treatment, and so forth. Each ofthese encompasses a variety of different interventions.There follows a decision on what to measure.Structural factors such as bed capacity, staffing levels,and costs provide a powerful starting point.Measurement of process (for example, throughput)and outcomes (for example, death rate) will have littlemeaning unless case mix and severity are well defined.A plausible mental health baseline service specificationfocusing on structure and cost is set out in table 3. Theemphasis is on obtaining the information needed tosummarise existing levels of service as succinctly aspossible.11

Corporate approachesThe “corporate approach” involves the systematiccollection of the knowledge and views of informants

JANESMITH

Table 2 Different approaches to healthcare needs assessment10

Criterion Basis Is resource scarcity clear? Definitive or exploratory Expert or participatory

Population healthcare needs Population Yes Definitive Expert

Individual healthcare needs Individual Sometimes Definitive Expert

Social services assessments Individual Sometimes Both Both

Participatory planning Population Sometimes Definitive Participatory

Oregon-style planning Population Yes Definitive Both

Population surveys Population No Exploratory Expert

Client group surveys Population No Exploratory Both

Specialty recommendations Population No Definitive Expert

Effectiveness reviews Population Yes Definitive Expert



on healthcare services and needs. Valuable infor-mation is often available from health authority staff,provider clinicians, and general practitioners, as well asfrom users. The box lists possible informants. Althoughsuch an approach blurs the distinction between needand demand and between science and vested interest,the intimate, detailed knowledge of interested partiesamassed over years might otherwise be overlooked.Furthermore, the corporate approach is essential ifpolicies are to be sensitive to local circumstances. Elic-iting local views is not the same as being bound bythem. This approach allows sensitivity to local circum-stances, particularly those consequent on historicalprovision. The unmet needs of discharged seriouslymentally ill people from closed long stay hospitals orthe absence of primary care for homeless groups maybe uncovered only by speaking to people. Where costeffectiveness considerations are otherwise equal, localconcerns may justifiably attach priorities to particularservices. Furthermore, local experience and involve-ment will make any needs assessment easier to defend.

Comparative approachesThe “comparative approach” to needs assessment con-trasts the services received by the population in onearea with those received in other areas. If nothing elseis known about the optimum service to be provided,there is at least reason for investigation if the level ofservice differs markedly from that provided elsewhere.Comparisons have proved to be powerful tools forinvestigating health services.12 13 For example, the needto raise renal dialysis and transplantation levels from20 per million in the 1960s to 80 per million was indi-cated by comparison with European countries andsubsequently confirmed epidemiologically.14 New per-formance indicator packages are being piloted in bothprimary and secondary care.15 Although they requiresensitive interpretation, comparative process andoutcome indicators may help identify deficiencies inprovision of services.

Epidemiological and cost effectiveness approachesThe essence of needs assessment is an understandingof what is effective and for whom. Critical steps consistof:

x A clear statement of the population group whoseneeds are to be assessed (normally a group with a par-ticular disease). In the case of a needs assessment fordiabetic services, this might include people who havenot yet been diagnosed; in the case of substance misuseit would include past, present, and potential misusers;x Identifying subcategories of this population (per-haps “health benefit groups”) with particular serviceneeds. People with insulin dependent diabetes wouldbe distinguished from those with non-insulin depend-ent diabetes; current, dependent substance misuserswould be distinguished from intoxicated misusers,those with comorbidities, those in recovery (at risk ofrelapse), and those at risk of becoming new users;x Setting out the prevalence and incidence of the sub-categories: how many of each are there?x Setting out the current services available (thebaseline)—all services whether in primary care,secondary care, or elsewhere;x Identifying the effectiveness and cost effectiveness ofinterventions and the associated services—the essenceof evidence based health care; andx Setting out a model of care that apportions relativepriorities.9 10

As a general rule, establishing the effectiveness ofan intervention must be the most important step.There is little point in counting potential beneficiariesfor an intervention which is of no benefit. Mostchallenging of all is the task of apportioning relativepriority to different services and recipients. Cost effec-tiveness must be taken into consideration. The use ofunitary cost-utility measures can be helpful if these areavailable, and decision matrices render decisionmaking more explicit. However, flexibility aroundpatients’ particular circumstances is often required.

Managing the taskSeveral challenges are commonly encountered inunderstanding needs assessment. Firstly, the mosaic ofinformation required for needs assessment reflects itskey components: the services already in existence, theprevalence and incidence of client groups (sub-categorised appropriately), and the effectiveness ofinterventions. The evidence based medicine movementhas meant that information on effectiveness can moreeasily be obtained,16 17 but this is not true forinformation on epidemiology or services provided.Good quality local data on the structure and utilisationof health services can be surprisingly difficult to obtain.The absence of common disease definitions, commonclassification systems, and compatible software—andthe partial recording of activity—limits the value ofmany databases.18

The triangulation of information sources istherefore critical. Useful information can be eitherlocal or national, either numerical or textual, andcollected either routinely or ad hoc. The figure sets out

Table 3 Example of table of baseline services11

Resource name Resource function Capacity Unit cost Notes on quality and performance

Acute ward A Acute assessment Beds £1000/bed Nurse morale problems

Community team B Community support for mild orstable conditions

Places £1000/place Poor coordination with general practice

Long stay facility C Long stay and dementia Beds £1000/bed Being run down

Corporate informants

• General practitioners• Hospital doctors• Nurses and professions allied to medicine• Public health doctors• Commissioning managers• Trust managers• Voluntary organisations• Community health councils• General public• Patients (service users)



key items for the needs assessors.19 The task is greatlyaided by skilled librarians with access to a basic rangeof texts and databases. National sources of epidemio-logical and effectiveness data offer assessors of health-care needs a firm starting point for their work.

A second challenge is the involvement of healthprofessionals in healthcare needs assessment. Thetraditionally individualistic approach of doctors in par-ticular may be difficult to reconcile with the utilitarianapproach of planners with a population focus. Thisfocus implies a fundamental reappraisal of the doctor’srole and the balance of power within the doctor-patient relationship.20 It is also important not to neglectthe contribution of other health professionals. Forexample, in primary care much information iscollected by community nursing staff, and healthvisitors’ skills in particular are easily overlooked.21 Evenwhere doctors and nurses have a population focus,needs assessment has opportunity costs; not everyonecan devote time to it. At the very least, targetefficiency—directing services to the people who willpotentially benefit the most—requires doctors’ involve-ment.

Thirdly, needs assessment is futile if it does notresult in improved services to patients. A key tosuccessful needs assessment is the proper understand-ing of how it is related to the rest of the planning proc-ess. Too much needs assessment is divorced frommanagers’ deadlines and priorities. If the informationand recommendations produced are not timely, theywill not be useful. The results of needs assessmenttherefore need to be encapsulated in strategies or busi-ness plans. These need clear definitions of objectives:describing what needs to be done, by whom, and bywhen.22 The key to effecting change is an understand-ing of the opportunities that may facilitate and theobstacles that may obstruct what is being attempted—knowing which “levers” to use. An understanding ofthe sources of finance, their planning cycles, and thecriteria used to fund new initiatives is essential. Healthauthorities and health boards clearly indicate thetiming of development bids and the structure of appli-cations they wish to be submitted.

A fourth challenge is to ensure that needsassessment is not just effective but efficient and costeffective. Little is known of the cost effectiveness ofneeds assessment, but at least one survey found that itled to service change at little cost.23 Evaluation ofdifferent purchasing models should help clarify thepopulation sizes for which needs assessment for differ-ent services is most efficiently undertaken.24

ConclusionIn practice, although needs assessment represents anamalgam of epidemiology, economics, and values, ithas to be turned into a practical tool. But making needsassessment practical can have two unfortunate effects.Firstly, it is unhelpful to see the outcome of needsassessment as a document—the culmination of a seriesof easily defined, finite steps. Rather, needs assessmentis an iterative, sometimes messy, process that may serveseveral different political purposes. The most impor-tant of these is to develop a consensus amongplanners, managers, and clinicians regarding prioritiesfor service development. Secondly, needs assessment is

too easily seen as some arcane preserve of publichealth specialists. The technical skills required can beexaggerated.25 Basic numeracy and common sense arethe most important prerequisites.

The current approaches to needs assessment maybe limited by time and context. Much needs assessmentactivity was stimulated by the advent of an internalmarket and by doubts about the cost effectiveness andappropriateness of care. Health authorities andgeneral practitioners in their role as purchasers requiredetailed service specification for the first time.However, with increasing evidence of the equivocalefficacy of many healthcare interventions, delayeduptake of effective health care,26 unexplained geo-graphical variations, and rising costs, the concern withcapacity to benefit within finite resources is unlikely towane. The rhetoric may change, but the demand forincreasingly sophisticated approaches to needs assess-ment will intensify.


1 Dixon, J, Harrison A, New B. Is the NHS underfunded? BMJ1997;314:58-61.

2 Culyer A. Need: the idea won’t do—but we still need it. Soc Sci Med1955;40:727-30.

3 Department of Health. The new NHS, modern, dependable. London: HMSO,1997.

4 Stevens A, Gabbay J. Needs assessment, needs assessment. Health Trends1991;23:20-3.

5 Pickin C. Assessment of health need using the life cycle framework. Manchester:Northwestern Regional Health Authority, 1991.

6 Department of Health and Social Security. Sharing resources for health inEngland. Report of the Resource Allocation Working Party. London: DHSS,1976.

7 Culyer A. Need and the National Health Service. London: Martin Robertson,1976.

8 National Health Service Management Executive. Assessing health careneeds. London: Department of Health, 1991.

9 Stevens A, Raftery J. Introduction. In: Health care needs assessment, the epide-miologically based needs assessment reviews. Vol 1. Oxford: Radcliffe MedicalPress, 1994:11-30.

10 Stevens A, Raftery J. Introduction. Alternative approaches to health careneeds assessment. In: Health care needs assessment. Second series. Oxford:Radcliffe Medical Press, 1997:xxxii-xliv.

11 Stevens A, Raftery J. The purchasers’ information requirements onmental health needs and contracting for mental health services. In:Thornicroft, Brewin C, Wing J, eds. Measuring mental health needs.London:Gaskell, 1992:42-61.

12 Saunders D, Coulter A, McPherson K. Varieties in hospital admission rates: areview of the literature. London: King’s Fund, 1989.

Routine

Practice age-sexregistersHospital episodestatisticsCensus small areastatistics

Morbidity statistics in general practice Public healthcommon data setPerformanceindicators

Epidemiologicalstudy data

Health of the NationdocumentConfidential inquiriesNeeds assessmentseries9 10

Evidence series andcompendiums17Governmentcirculars

Localsurveys

Local reportsand audits

Public healthreportsServicespecifications

Ad hoc

RoutineAd hoc

Local

National

Text

ual

Num

eric

al

Text

ual

Num

eric

al

Examples of sources of information



13 Wennberg JE, Mulley AG, Hanley D, Timothy R, Fowler F, Roos N, et al.An assessment of prostatectomy for benign urinary tract obstruction.Geographic variations and the evaluation of medical care outcomes.JAMA 1988;259:3027-30.

14 Beech R, Gulliford M, Mays N, Melia J, Roderick P. Renal disease. In:Stevens A, Raftery J, eds. Health care needs assessment, the epidemiologicallybased needs assessment reviews. Vol 1. Oxford: Radcliffe Medical Press,1994:58-110.

15 NHS Executive. Consulting the NHS on a set of provisional clinical indicators.Leeds: NHSE, 1997. (EL(97)49.)

16 Haynes B, Sackett D, Muir Gray J, Cook D, Guyatt C. Transferringevidence from research into practice. 2. Getting the evidence straight.Evidence-Based Medicine 1997;2:4-6.

17 Booth A. Scharr guide to evidence based practice. Sheffield: University ofSheffield, School of Health and Related Research, 1997. (Occasionalpaper No 97/2.)

18 Pringle M, Hobbs R. Large computer databases in general practice. BMJ1991;302: 742-3.

19 NHS Management Executive. Purchasing intelligence. London: Depart-ment of Health, 1991.

20 Gillam S, Murray A. Needs assessment in general practice. London: RoyalCollege of General Practitioners, 1996. (Occasional paper No 73.)

21 Royal College of Nursing. The GP practice population profiles. A frameworkfor every member of the primary health care team. London: RCN, 1993.

22 Spiegal N, Murphy E, Kinmonth A L, Ross F, Bain J, Coates R. Managingchange in general practice: a step by step guide. BMJ 1992;304:231-4.

23 Fulop N, Henscher M. A survey of needs assessment activity in London healthauthorities. London: King’s Fund, 1997.

24 Mays N, Goodwin, Bevan G, Wike S on behalf of TP-net. Total purchasing:a profile of national pilot projects. London: King’s Fund, 1997.

25 Gillam S J. Assessing populations’ health needs: the general practitioners’contribution. Br J Gen Pract 1992;42:404.

26 Antman E, Lau J, Kupelnick B, Mosteller F and Chalmers T. A compari-son of results of meta-analyses of randomised control trials andrecommendations of experts. JAMA 1992;268:240-8.

Coping with lossLoss in late lifeBrice Pitt

Old age can be seen as a succession of losses, gradualor sudden.1 Stopping work means a loss of the workingrole, of the companionship of fellow workers, and ofa full, structured day; it means a reduction in income—and, for those who live with someone, less time apart.Some people feel much diminished by retirement,hardly know what to do with themselves, and suffer aloss of status. Most developed societies do little toenhance the image of the “senior citizen,” who isliable to be patronised, marginalised, or simply ignoredand is seen as a problem for an overburdened welfarestate.

There is a view, though, that successful ageingmeans compensating for some losses by making thebest of change. So, the strains of having to commute,living for the job, and struggling to keep up are alsolost; some pensions are at least adequate; there areconcessions that make life a little cheaper for theover 60s. Having more time to oneself, for hobbiesand interests, and to spend with partner are oftenregarded as benefits. Though it is usually a suddenevent, retirement is (unless there is unheraldedredundancy) expected and there is time to preparefor it.

Many types of lossSensory loss afflicts most people as they age.Presbyopia is readily remedied by glasses, presbyacusisless readily (or perhaps less acceptably) by hearing aids.These are very gradual processes, usually acceptedwithout distress, though blindness or severe deafness isa different matter. Some memory loss may be normalwith ageing; speed seems to be affected more thansecondary memory, and verbal IQ is very wellpreserved.2 “Benign” memory impairment3 presentsno serious problems, apart from the fear of dementia—which is, unfortunately, realised in a fifth of peopleover 80.4

It is not often acknowledged, except as a rueful andribald joke, that loss of sexual enjoyment is commonand distressing, and not an inevitable part of ageing.5

Hormone replacement therapy and prostaglandinsmay do much to restore sexual function andenjoyment, but some older people are too shy to seekhelp, fearing that they should be “past it” and may beregarded as ridiculous or as “a dirty old man” (orwoman).

The risk of serious health problems—stroke,myocardial infarction, heart failure, falls and fractures,arthritis, obstructive airways disease, cancer—increaseswith ageing,6 though many old people are spared seri-ous infirmity until a short final illness. Those who areless fortunate suffer loss of comfort, mobility, and lifeexpectancy. There is a risk of being widowed, especiallyfor women, which represents a major loss after 40 yearsor more of being together.

Secondary to health problems (which make it diffi-cult to get out and about), to reduced means (for trans-port and entertainment), and to the dying off of friendsand family is isolation, which may be accompanied byloneliness. In Britain, about half of people 80 and overlive alone,7 and the extended family is stretched very


Summary points

In old age comes a succession of losses: dementiaoccurs in 20% of those over 80; loss of sexualenjoyment is common but not inevitable; half ofoctogenarians live alone

Depression in elderly people is oftenunrecognised; it is often caused by loss and, inturn, causes further losses

Preparation for retirement, health checks for theelderly, continued access to education, and the useof “at risk” registers can mitigate some of theproblems of old age

The rationing and limitation of social support forthe elderly is not justified


This is the ninthin a series of10 articlesdealing with thedifferent typesof loss thatdoctors willmeet in theirpractice

Department ofPsychologicalMedicine, ImperialCollege School ofMedicine,HammersmithHospital, LondonW2 0HABrice Pitt,emeritus professor ofpsychiatry of old age

Series editors: ColinMurray Parkes andAndrew Markus

BMJ 1998;316:1452–4


families to express grief, why should we deny ourselvesthat privilege? It would seem that, like soldiers andmembers of the emergency services, we are trained toremain calm in the face of danger. This leads us to theassumption that, even when the emergency is over, wehave no need to get upset. Yet, as Bennet’s paper in thisseries showed, such stoicism is bought at a cost anddoctors who find ways to meet their own needs foremotional expression and support are likely becomebetter doctors and to find greater satisfaction in theirwork.10

Chronic griefSome people become stuck in states of chronic grief thatcannot easily be put aside; this may result from high lev-els of anxiety about the world that now exists. Grief isboth an expression of distress and a cry for help.

A woman who has had a bad experience ofpregnancy may experience high levels of anxiety and apropensity to depression which may spoil her nextpregnancy. Similarly people who have recovered frommental illness may dread its return. If they experiencea loss that triggers natural feelings of grief they mayconvince themselves that they are “breaking down,”and this may indeed increase the risk that they will.

Those who overreact to loss will benefit fromopportunities to re-examine their negative assump-tions about themselves and their world, to review and

replan their lives in ways that value and build on the past,and to venture forth into a world that seems more dan-gerous than it really is. Nothing succeeds like success,and quite small beginnings can lead to a restoration ofconfidence that eventually allows great progress to beachieved. There is much to be said for John Bowlby’sclaim that the most important thing that we have to offerfrightened or grieving people is a “secure base,” arelationship of respect—with a person who has the time,knowledge, and willingness to remain involved—that willlast them through the bad times.11

Funding: No additional funding.Conflict of interest: None.

1 Doka K, ed. Disenfranchised grief. Lexington, MA: Lexington Books, 1989.2 Hollins S, Esterhuizen A. Bereavement and grief in adults with learning

disabilities. Br J Psychiatry 1997;170:497-501.3 Bryan E, Higgins R. Infertility: new choices, new dilemmas. Harmondsworth:

Penguin, 1995.4 Rosenblatt PC, Walsh RP, Jackson DA. Grief and mourning in cross-cultural

perspective, Washington, DC: HRAF Press, 1976.5 Parkes CM, Weiss RS. Recovery from Bereavement. New York: Basic Books,

1983.6 Jacobs S. Pathologic grief: maladaptation to loss. Washington, DC: American

Psychiatric Press, 1993.7 Schut HAW, Stroebe M, van den Bout J, de Keijser J. Intervention for the

bereaved: gender differences in the efficacy of two counselling programs.Br J Clin Psychol 1997;36:63-72.

8 Kumar R, Robson KM. A prospective study of emotional disorders inchildbearing women. Br J Psychiatry 1984;144:35.

9 Brockington I. Puerperal mental illness. Practical Reviews in Psychiatry1986;8:3-9, 9:1-8.

10 Bennet G. The doctor’s losses. BMJ 1998;316:1238-40.11 Bowlby J. A secure base: clinical applications of attachment theory London:

Routledge, 1988.

Health needs assessmentAssessment in primary care: practical issues and possibleapproachesJohn R Wilkinson, Scott A Murray

This article is a practical guide to help primary caregroups (as set out in the NHS white papers1 2) and alsoindividual practice teams assess the health needs of theirrespective populations before providing or commission-ing services to meet these needs. Historically, much serv-ice provision has been service led rather than needs led,provided as before and at the convenience of providersrather than patients. The needs of patients are nowaccepted as being central to the NHS. An explicit frame-work is needed to help assess needs more systematically,to demystify the process, and to help prioritise andaction changes.3 This paper outlines an approach that isfeasible for individual practices, groups of practices, andpopulations of around 100 000 people (typically the sizeof the new primary care groups described in the whitepaper).

Do we get involved with wider healthneeds or just health service needs?Health professionals understandably tend to think ofhealth needs in terms of services they can provide.Patients may have different ideas about what affects

The articles in thisseries are adaptedfrom Coping withLoss, edited byColin MurrayParkes andAndrew Markus,which will bepublished in July.

Summary points

A practical strategy for assessing local healthneeds is required

This approach uses practice held data, routinelyavailable local statistics, a patient/publicconsultation exercise, and (possibly) a postalsurvey to gain various perspectives on need

Unless specific, useful summary data are obtained,details will obscure the larger picture

Stages in this strategy are to collate theinformation, assess priorities, and plan andevaluate changes

Time and resources must be available atpractice and locality level, but many importanthealth needs cannot be met by health servicesalone


This is thefourth in aseries of sixarticlesdescribingapproaches toand topics forhealth needsassessment,and how theresults can beused effectively

North YorkshireHealth Authority,York YO3 4XFJohn R Wilkinson,deputy director ofpublic health

continued over

BMJ 1998;316:1524–8


their health. This might include getting a job, having aroof over their head, or having a bus route whichmakes getting to see the doctor easy. A group of prac-tices may decide that they do not have the time andresources to consider these types of needs, and theymay feel even less confident about being able to doanything about such needs. But if primary care has theaim of improving the health status of individuals aswell as providing health services, such factors must atleast be identified for action by someone else. Lalonde,when minister of health in Canada, emphasised theimportance of lifestyles and the environment on healthas well as the influences of human biology and health-care provision.4 Thus this paper embraces needs forhealth—needs for services and more general needs.

Levels, approaches, and methodsThe process of health needs assessment can be carriedout at different levels, from international down to indi-vidual patient. Different approaches can be used ateach level (from global to specific diseases).

LevelsNeeds assessment can be carried out at various levels:x International—By the World Health Organisation,for examplex National—The advantage of tackling some nationalpriorities locally (such as mental health) is that it maybe easier for health authorities or boards to fund iden-tified gaps in services. But remember that the mostcommon complaints presented by patients—stress,arthritis, and dyspepsia—have never been identified asnational priorities5

x Regional—the need for a liver transplantation servicecould be assessed at this levelx Health authority or board level—The needs for neona-tal care, obstetric care, or dietetics may be assessed atthis levelx Locality—The creation of primary care groups willlead to increasing importance for needs assessment tobe undertaken at this level. Generally, larger popula-tions will produce more robust results than singlepractices. There is also no need for every practice tocarry out similar studies when it is unlikely that therewill be different needs between practices. Issuessuitable for tackling at this level might includeunwanted pregnancy, dental caries, inequalities inservice provision of community nursingx Practice specific—It is worth thinking about a singlepiece of needs assessment work where a practice isrelatively large and is situated in an area of particularneed. Issues such as mental health and drug addictionmay be particularly relevantx Small neighbourhood—Some practices have a groupof patients who live in a well defined disadvantagedarea. Such an area can usefully be targetedx Individual—used daily in consultations by generalpractitioners and nurses.

ApproachesWhen using a global approach, get an initial overviewof the health and social needs of the population group,then identify which of a variety of interventions mightbest improve the health and wellbeing of patients.Issues relating to the wider determinants of health can

be taken to the relevant agencies for action (in Londonand in Edinburgh, bus routes have been changed andplay areas developed).

A focused approach can centre on:x A specialty (mental health, for example)x A disease (epilepsy, Alzheimer’s disease, cerebralpalsy, or diabetes6)x A client group (elderly people, single mothers, theunemployed, farmers)x Groups waiting for interventions (people awaitingan operation or physiotherapy)x Vulnerable groups of patients (ethnic minorities, etc)x Patients who are socially deprived, to address issuesof inequity.

Methods of assessing needsDifferent information sources and methods ofinvestigating give complementary insights into healthneeds generally.5 Practitioners should concentrate ongathering the information that will give them the mostuseful insights, rather than on collecting all sorts ofinformation that might turn out to be useful. A locallyappropriate mix of methods can use data from varioussources: information held by the practice, computerrecords, and “soft” information from all members ofprimary healthcare teams. These sorts of data are goodfor assessing ongoing physical problems.

Local statistics are routinely available from healthauthorities or health boards, hospitals, and the census.Public consultation exercises, which can utilise focusgroups, rapid appraisal, or other methods of interact-ing with local people, are good for uncoveringproblems relating to drug abuse, HIV, and social issues.

A postal survey may be worth considering toprovide data about acute illness in the community andsuggestions for changes to services. A covering letterby the patient’s general practitioner may improve thereturn rate.

Detailed guidance on practical aspects is now avail-able, including a workbook and a “really roughguide.”7–11

Department ofGeneral Practice,University ofEdinburgh,EdinburghEH8 9DX

Scott A Murray,senior lecturer



JANESMITH



Involving othersMost approaches can be undertaken by an individualor a group. Although group work is more difficult toorganise, there are major benefits. Group memberswho work in the community, such as health visitors anddistrict nurses, have valuable knowledge of local needsand will feel an ownership of the results if they havebeen involved. Practice staff involved may require addi-tional resources or locum cover. Public health and pri-mary care can contribute complementary skills andinsights at every level.

Any practice or group of practices needs to decidehow the public will be involved at an early stage. Meth-ods for involving the public have been described byMays et al.12

Consultants working in hospital or communitytrusts usually have a clear picture of the needs for theirparticular service. This can be a rich source of help,advice, and information. Combining specialist exper-tise and the experience of generalists can producevaluable information. Other service providers shouldalso be considered, such as hospices and otheragencies both in the statutory and voluntary sector.

Depending on funding, some aspects of needsassessment may be carried out by an external agency ifthe relevant skills or time is not available (for example,to carry out focus groups or a postal survey).

Defining the problem or area to beassessedMost practices and even locality groups will have littletime to devote to needs assessment, and therefore it isimportant to target any effort in the most productiveway. A first needs assessment project needs to deliverrapid success to stimulate those involved to progressfurther. In a few practices—perhaps in an area of innercity deprivation—the issues that need to be tackled willbe very obvious, but for most practices the prioritieswill vary depending on the demographic profile, com-mon illnesses, and social needs of the practice popula-tion. Consider the frequency, impact, and costs ofdifferent diseases. Priorities might be defined with thefollowing questions:x Is there a realistic chance of achieving change?x Is the cost of undertaking the work proportional tothe likely benefits?x What are the priorities being suggested by otheragencies—the health authority or health board, socialservices?x Does the practice or primary care group wish tolook at issues that are not directly under their controlsuch as housing and transport?

Five stage approachStage 1: Collect routine practice informationRoutine data from general practices can highlight needsthat are dealt with in primary care. The box lists data thatgive an overall practice perspective on needs: ask yourpractice manager to collect as much as is reasonablyavailable. Some computer software (such as GPASS inScotland) can generate a practice profile automatically.This is especially useful for comparing practice data withother practices, or for collating data for groups of prac-tices. Several networks exist in different parts of thecountry to optimise the use of such data.13

Stage 2: Collect hospital, community trust, andcensus dataStandard “routine” hospital utilisation data does notroutinely get fed back to practices. Thus the knowledgeand understanding that most general practitionershave of the hospital services that their group ofpatients receive is limited. Although routinely collectedclinical data may contain inaccuracies,14 the quality ofsome databases has substantially improved.15 With thehelp of local public health departments, detailedhospital utilisation can now be compared betweenpractices and localities. Such data must be interpretedcarefully, as demand and supply often have more influ-ence on hospital usage than does need. Use of hospitalservices may not be a proxy for morbidity in the com-munity.16 The box on the next page lists the variableswhich general practitioners working in Edinburgh’ssouth east locality found most informative forunderstanding the current usage of hospital services byindividual practices.

Health authorities and boards also have a range ofcensus information, available at small area level. This

Core practice data• Age-sex profile in 5 year bands for male and female patients• Prescribing details:

Repeat prescribing rates from practice computerCollated prescribing figures (PACT or Scottish Prescribing Analysis)

• Prevalence of some specific chronic disease (for example, ischaemic heartdisease, chronic obstructive airways disease, asthma, epilepsy, psychosis,thyroid disease, hypertension, diabetes)• Data from practice’s payment details:

Percentage of patients attracting deprivation paymentsFamily planning uptakeTemporary residentsObstetric care and other item of service payments

• Health promotion and disease prevention data:Smoking, alcohol consumption, substance misuse, body mass indexImmunisation coverage (2 and 5 year olds)Cervical cytology coverage

• Contacts with general practitioners:Surgery consultation rate per 1000 registered patients per yearHouse call rate per 1000Out of hours visits per 1000

• Knowledge (mostly implicit) of local health needs:Health visitor: practice profile, breast feeding rates, use of other agenciesDistrict nurse: workload details, observations in patients’ homesPractice nurse: workload details (for example, influenza coverage rate)Receptionists: patients’ perceptions, availability of appointments

• Deaths—causes, place of death, preventable factors• Turnover of patients• Other sources—suggestions box, patient participation group• Notes search may yield:

Incidence of acute illnesses and symptoms presentingTelephone ownership (percentage)Unemployment rate, domestic problems documented

If reliable data (on use of investigations, referrals, etc) are available fromother sources, use these data rather than duplicate work in the practice forthe following:• Use of investigations (per 1000 patients per year, individually formicrobiology, haematology, biochemistry, radiology, electrocardiography• Referrals to physiotherapy, chiropody, occupational therapy (per 1000patients per year)



information is extremely useful to highlight socialinequities at small area level such as in an underprivi-leged housing estate. Jarman and Townsend scoresmay be available, but at practice or locality level the sixcensus categories listed in the box may be sufficient togive a view of social need. Unless you request very spe-cific, interesting summary data from the health author-ity or board you will be swamped with too much detail,which will obscure the larger picture and be toolengthy for general practitioners to absorb.

At practice level such data can be presented at apractice planning meeting and inform the practice’sannual business plan. In southeast Edinburgh locality,the above data were fed back at a meeting to which onegeneral practitioner from each practice was invited. Pro-tected time—and hence a good attendance—was gainedmaking a fee from the general practice fundholdingmanagement allowance available to all attendees. Afterthe abolition of fundholding, similar exercises should bepossible, using the management allowances associatedwith the new primary care groups. This data highlightedconsiderable variations in the use of inpatient services,outpatient services, and community services such asnursing and chiropody, with the two most commonreasons for admission (termination of pregnancy anddental caries) both preventable. The general practition-ers, after presentation of the data and discussion, leftwritten comments about what they found most interest-ing about their practice, suggestions to improve orextend the data, and how the data could be used by indi-vidual practices and the locality. Subsequent meetingsare planned to gain other perspectives of need in thelocality from other data sources.

Stage 3: Gaining public involvementHealth professionals define “needs” in terms ofservices that they can provide, whereas patients mayhave a different perception of what would make themhealthier: a job, a bus route to the hospital, or someadvice on benefits, for example.Thus interaction and in-put from patients and the public is vital to gain an “hon-est consumer perspective.” It can be obtained through:x Interviews with patientsx Informal discussions with, for example, voluntarygroups, community health councilx Suggestion boxesx Complaints proceduresx Health forumx Focus groups (with elderly or diabetic patients, forexample; see box)x Rapid appraisal (see box, next page).

Stage 4: Undertake (or use an existing) postal surveySurveys to assist local decision making must bemodestly defined and use a mixture of lay and medicalconcepts. Computerised search and mail mergefacilities allow most practices to send questionnaires(with covering letters and reply paid envelopes) to spe-cific patient groups. A well conducted postal survey ofa representative sample can give a reliable estimate ofthe true burden of morbidity in the population, andmay inform contract specification. Assistance will nor-mally be required to select an instrument or to designone, and with sampling and data analysis. Various vali-dated instruments for generic and disease specific sur-veys are available.20 Questions concerning the areas

outlined in the box on the next page may be especiallyrelevant, as such data may not be obtained easily fromother sources.

Hospital, community trust, and census data

Inpatient data• Ten most frequent diagnoses made at hospital inpatient discharge (ratesper 1000 registered patients), tabulated in descending order. (ICD-10 codesto three digits are recommended; transfers are excluded; patients withmultiple discharges from the same hospital, using the same facility and withthe same diagnosis, are counted only once.)• Elective admission (rate per 1000 residents)• Non-elective admission (rate per 1000 residents)• Mean waiting time (days)• Ten most frequent day case diagnoses (per 1000 patients), tabulated indescending order of frequency• Top three day case procedures (per 1000 patients), in descending order offrequency

Outpatient data• Outpatient referral rate per 1000 residents• Referral rates for five most used specialties, tabulated in descendingfrequency• Mean waiting time (days)• Attendances at accident and emergency department (per 1000 patients)

Obstetric data• Births (rate per 1000 registered patients)

Community data• District nursing visits (per 1000 patients per year)• Health visitors, visits, and clinic attendances (per 1000 patients per year)

Investigations• Use of investigations (per 1000 patients per year) for microbiology,haematology, biochemistry, radiology, electrocardiography

Referrals• Physiotherapy (per 1000 patients per year, clinic and domiciliary)• Chiropody (per 1000 patients per year, clinic and domiciliary)• Occupational therapy (per 1000 patients per year)

Census• Percentage of residents with limiting long term illness• Demographic profile, in 5 year bands• Unemployment rates (%) for men and women• Percentage of house owners• Percentage of car owners• Percentage of households with lone parents

Focus groups17

• Facilitated discussion groups that allow the members of the targetpopulation to express ideas spontaneously• Can give useful insights into perceived needs, quality of services, andunderstandings of health issue• Can raise issues that are important to patients• Information gained is not quantifiable• Facilitators need some training• A variety of groups may be necessary to be representative in somesituations

Practical points:• Optimum size is 8-12 participants• Facilitator introduces topics for discussion• Proceedings are recorded using a tape recorder and later transcribed, ornotes are taken, preferably by another facilitator



Stage 5: Collation of the information from thedifferent sources

At practice levelPresent the major findings of each method to a meet-ing attended by as many of the practice team as possi-ble, and discuss what changes should be made to theestablished work patterns and services the practiceoffers. New initiatives identified should be prioritisedand incorporated in the practice’s business plan for thecoming year. Feedback can be given to the local hospi-tals and community trusts if relevant.

At locality level (primary care group)As the stages of the needs assessment may take severalmonths, present the major findings of each method asthey become available. Protected time is vital for prac-tice representatives to study the information together;starting to get a feel for the needs of the locality as thecomplementary data builds up. A specific meeting,possibly facilitated by the local public health depart-ment, will be important to prioritise the suggestionsraised by the various sorts of data. Techniques for pri-oritising needs include the nominal group technique,and use of a ranking matrix can give useful structure tosuch meetings. With the nominal group technique,needs or interventions are listed, discussed, thenranked by each participant until an agreed level ofconsensus is reached. This encourages debate, andquick decisions can be made. To use a ranking matrix,criteria for priority interventions are defined, such as

potential to improve health, capacity to implement,and equity implications. Participants score each poten-tial intervention for each criterion, and the scores aretotalled.20

Health needs assessment is a cyclical process.Needs change over time; evaluating how well needshave been met will bring you back to assessing theneeds that have not been met by your action.

How realistic is assessment of healthneeds in primary care?Lack of planning time and the pressure to respond tothe immediate needs of patients has to date preventedneeds assessment in primary care. The fundholdinginitiative, emphasising efficient purchasing of services,has not championed needs assessment and has largelyignored aspects of health needs not related to thehealth service. The advent of locality commissioningand the creation of primary care groups will now allowsome general practitioners protected time for needsassessment. This strategic work is realistic and possibleand has the potential to make primary care moreeffective at improving health by targeting availableresources. But resources, training, and liaison withpublic health physicians will be necessary for this towork.


1 Secretary of State for Health. The new NHS. London: Stationery Office,1997. (Cm 3807.)

2 Secretary of State for Scotland. Designed to care: renewing the NHS in Scot-land. Edinburgh: Stationery Office, 1997.

3 Shanks J, Kheraj S, Fish S. Better ways of assessing health needs inprimary care. BMJ 1995;308:480-1.

4 Lalonde J. A new perspective on the health of Canadians. A working document.Ottawa: Information Canada, 1974.

5 Murray SA, Graham LJC. Practice based needs assessment: use of fourmethods in a small neighbourhood. BMJ 1995;310:1443-8.

6 Williams R. Diabetes mellitus. In: Stevens A, Raferty J, eds. Health careneeds assessment. Oxford: Radcliffe Medical Press, 1994:31-57.

7 Harris A. Needs to know:a guide to needs assessment for primary care. London:Churchill Livingstone, 1997.

8 Gillam S, Murray SA. Needs assessment in general practice. London:Royal College of General Practitioners, 1996. (Occasional paper 73.)

9 Hooper J, Longworth P. Health needs assessment in primary care. A workbookfor primary health care teams. Wakefield: Calderdale and Kirklees HealthAuthority, 1997.

10 Scottish Needs Assessment Programme. A rough guide to needs assessmentin primary care. Glasgow: Scottish Needs Assessment Programme, 1997.

11 Acton C, Newbronner E. Health needs assessment. Step by step. York: Univer-sity of York, York Economics Consortium, 1998.

12 Mays N, Pope C. Observational methods in healthcare settings. BMJ1995;311:182-4.

13 Smith N, Wilson A, Weekes T. Use of Read codes in the development of astandard database. BMJ 1995;311:313-5.

14 Hobbs FDR, Parle JV, Kenkre JE. Accuracy of routinely collected clinicaldata on acute medical admissions to one hospital. Br J Gen Pract1997;47:439-40.

15 Harley K, Jones C. Quality of Scottish morbidity record (SMR) data.Health Bull 1996;54:410-7.

16 Payne J N, Coy J, Patterson S, Milner PC. Is use of hospital services a proxyfor morbidity? A small area comparison of the prevalence of arthritis,depression, dyspepsia, obesity, and respiratory disease with inpatientadmission rates for these disorders in England. J Epidemiol CommunityHealth 1994;48:74-8.

17 Kitzinger J. Introducing focus groups. BMJ 1995;311:299-302.18 Murray SA, Tapson J, Turnbull L, McCallum J, Little A. Listening to local

voices: adapting rapid appraisal to assess health and social needs in gen-eral practice. BMJ 1994;308:698-700.

19 Annett H, Rifkin SB. Guidelines for rapid participatory appraisal to assesscommunity health needs: a focus for health improvements for low-income urbanand rural areas. Geneva: World Health Organisation, 1995.

20 Wilkin D, Hallam L, Dogget M. Measures of need and outcomes in primaryhealth care. Oxford: Oxford Medical, 1992.

Rapid appraisal

A team, ideally with a mixture of professional insights, gathers data aboutboth needs and resources in the area under study from:• Interviews with key informants (individuals with knowledge of thecommunity) and patients• Available documents about the neighbourhood or community• Observations made inside homes and in the neighbourhood

Practical points:• Use the framework of an information pyramid18 19 to guide collection andanalysis• Collate the needs, priorities, and solutions perecived in the communityfor each box of the information pyramid• Consider facilitating change in primary care services, commissioning ofsecondary care, and local advocacy to improve wider determinants of health

Areas for questionnaire surveys• Acute illnesses and experience of common symptoms• Use of health services over the past 6 or 12 months• Patients’ satisfaction• Perceived need for current and potential services• Specific concerns and worries that may affect health• Specific questions for people with specific long term health problems orcarers• Chronic illness (may not be necessary if data obtained already):

Any long term illnessSeveral marker conditions (for example, hypertension, back pain)

• Consider a general health status instrument (SF-36, SF-12)• Consider a disease specific instrument

(Consider checking a sample of medical records from non-respondents.)




Health needs assessmentWhose priorities? Listening to users and the publicJoanne Jordan, Therese Dowswell, Stephen Harrison, Richard J Lilford, Maggie Mort

External inputs to health needs assessment and the pri-oritisation of health services may be seen as one meansof addressing the “democratic deficit” in the NHS. Suchexternal inputs can be discussed on three levels. The firstconcerns the formal governance arrangements of theservice and encompasses questions about electinghealth authority members and transferring the NHSpurchasing function to local government authorities1 2; itis not discussed further here. The second level of inputmay be characterised by arrangements for consultationwith the general public, whether or not they happen tobe current patients or users. The third level concerns theconsultation of current users about needs and priorities.The importance of these two levels was recentlyrecognised in a new white paper.3

Consultation of the publicThe nature and extent of public involvement indetermining health needs has increased, but the qualityof consultation remains questionable.4 5 Some healthauthorities have established ongoing consultationprocedures, including citizens’ juries, large scale postalpanels, and smaller face to face panels, but most consul-tation has consisted of one-off surveys of the public orconsultation with local user groups. Most authoritieshave no provisions for ongoing means of consultation.4

These approaches may be classified according totwo simple dimensions.4 One dimension relates towhether respondents to the consultation exercise wereprovided with any information, and the second relatesto whether respondents were able to engage in any dis-cussion or deliberation in arriving at their views. Thesedimensions define the matrix shown in the box.

Citizens’ juries and similar panels of members of thepublic place respondents in the situation where they are

informed about the issues and choices at stake and mustdeliberate with others to arrive at a recommendation.6 7

Such mechanisms attempt to collect the views of thepublic not necessarily as they are, but as they might be ifinformation and the opportunity for discussion areavailable. Diametrically opposed is an approach thatseeks to consult the public as it is, usually on the basis ofstatistically representative sampling. Such opinionsurveys collect data from a generally uninformed publicand do not encourage deliberation. The other two cellsin the matrix are hybrids: focus groups encouragediscussion of uninformed opinion, and in a few casesattempts have been made to provide a written briefing tosurvey respondents.

Either construction of the public—as uninformedand undeliberating, or as informed and deliberating—isopen to objection, and of course any such objection canbe used by NHS “insiders” as a pretext for ignoring oroverriding the outcomes of consultation.The organisersof consultation exercises can help to produce theoutcomes that they prefer by their choice of questions,though this can be avoided through involving the publicin the formulation of the inquiry.

Some studies have found that participants on juriesand panels have been satisfied with their experience andthink that ordinary people can participate effectively insuch exercises.8 Other research has found that respond-ents to opinion surveys are reluctant to accept a publicrole in determining priorities for health care.9 This sug-gests that mechanisms with informed and deliberatedcomponents may enhance participation when the aim isto produce substantive recommendations.JA

NESMITH

Summary points

Although health authorities have increased localconsultation, its quality remains dubious, withgreatest emphasis on one-off consultation exercises

Information gained through public consultationmay either be marginalised or incorporatedaccording to professional priorities

It is important to acknowledge limitations toprofessional knowledge as well as to respond toinequalities in health; through citizens’ juries, userconsultation panels, focus groups, questionnairesurveys, and opinion surveys, local knowledge canbe used to effect such a response

There is scope for greater local involvement indecision making

Changes to the organisation and funding ofprimary care are vital if effective involvement is tobe sustained


This is the fifthin a series ofsix articlesdescribingapproaches toand topics forhealth needsassessment,and how theresults can beused effectively

Centre for Researchin Primary Care,Research School ofMedicine,University of Leeds,Leeds LS2 9LNJoanne Jordan,senior research fellow

Department ofPsychology,University of LeedsTherese Dowswell,senior research fellow

Nuffield Institute forHealth, Universityof LeedsStephen Harrison,reader in health policyand politics

continued over

BMJ 1998;316:1668–70


Responding to user groupsWhen health authorities have opted to involve existinguser groups, it is because they have been influenced bylegislative change and occasionally by strong personalcommitment to user led services and have accepted thegroups as legitimate stakeholders in healthcaredecision making.10 Often, a strong feature of this recog-nition is officials’ need for better information aboutexisting services and about needs and priorities identi-fied by the groups. When it is recognised thatmanagers and professionals do not necessarily knowbest, user groups are seen as excellent conduits ofinformation.

Even so, officials can be quick to qualify andcircumscribe the influence of user groups, typicallythrough questioning their “representativeness.” Thisambivalence is part of a more encompassing approachin which officials are able to undermine the legitimacyof groups, should the perceived need arise,1 while atthe same time using the user groups’ views in their ownnegotiations with other officials.11

Local consultation in primary careAttention has been most keenly focused on the needand opportunity for local consultation within healthauthorities,12 so it is no surprise that most initiativeshave occurred at this level. Relatively little attention hasbeen paid to local consultation specifically in primarycare.13 The increasing role of primary care in purchas-ing, and most likely in future locality basedcommissioning of health services, makes it necessary todetermine and respond to specifically local needs.12 14

These developments set up the appropriateness oflocal health needs assessment as a basis of purchasingand commissioning, but they do not in themselvesrequire local participation in such assessment. Many ofthe ways of assessing the health needs of a local popu-lation do not entail going anywhere near thepopulation itself.15 The remainder of this section there-fore discusses why primary care practitioners shouldinvolve the local community in decision making abouthealthcare provisioning, and importantly, considersthe obstacles to such participation.

Two related issues bring into question the assump-tion that general practitioners are in a position to act asproxies for patients’ health needs16: firstly, the evidenceon differing perceptions of doctors and patients,17 18

and secondly, the disparity between demand andneeds.19 20 Taken together, these highlight the danger ofbasing knowledge about the distribution of health(need) in a community solely on experience of generalpractice. Many health professionals, including generalpractitioners, see the proactive seeking out of need assecondary to a primary care responsibility forindividual demand, and they see knowledge held bypeople living locally as “inferior” to that generated byclinical observation and diagnosis.21 22 Most illnesses,though, do not lead to a medical consultation,23 soprofessional knowledge cannot be assumed to reflectthe experience of individual patients, and presentationat surgery may best be understood as one expressionof demand. One way of filling gaps in understanding isto consult the local community.

Providing for equityThe issue of equity in health (provision) also makes itincumbent to move beyond a model of primary carethat is based on professional response to demand—to amodel that recognises the importance of respondingto need that is otherwise unidentified. There is increas-ing evidence that the distribution and degree ofinequality in economic welfare has a direct impact onhealth.24 Local participation in healthcare decisionmaking can run the danger of increasing this inequal-ity by allowing the members of the public who are mostable to register their demands or needs to do so atthe expense of the less articulate25; nevertheless, ifparticipation is handled appropriately, previously mar-ginalised groups can be provided with a voice and canbe involved in decision making.26

Methods of public consultation• Citizens’ juries—Participants are selected asrepresentatives of public or local opinion. Juries sit fora specified length of time, during which they arepresented with information to help in decisionmaking. Typically, experts give evidence and jurorshave an opportunity to ask questions or debaterelevant issues6

• User consultation panels—Consist of local peopleselected as representative of the locality or population.Typically, members are rotated to ensure that a broadrange of views is heard. Topics for consideration aredecided in advance and members are presented withrelevant information to encourage informeddiscussion. Meetings are often facilitated by amoderator7

• Focus groups—Typically, semistructured discussiongroups of 6-8 participants led by a moderator, withfocus on specific topics. Debate and discussion areencouraged

• Questionnaire surveys—Can be postal or distributed(in the surgery, for example). This structured orsystematic means of data collection allowsinformation to be collected from a large sample ofrespondents and the relation between variables to beexamined. Most appropriate when the issues relevantto the topic being investigated are already known insome detail

• Opinion surveys of standing panels—Standing panelsare large, sociologically representative samples(typically 1000 or more) of a the population in ahealth authority; they are surveyed at intervals onmatters of concern to the authority. There is usually areplacement policy aimed at ensuring that individualsdo not serve on the panel indefinitely

Citizens' juries

User consultation panels

Informed Uninformed

Deliberated

Undeliberated

Focus groups

Questionnaire surveys withwritten information

Opinion surveys of standingpanels / one-off questionnaires

Approaches to public consultation on health care priorities


University ofBirmingham,BirminghamRichard J Lilford,professor of healthservices research

Department ofManagementStudies, LancasterUniversity,Lancaster LA1 4YTMaggie Mort,senior research fellow

Correspondence to:Dr Jordan



Current potential for consultation inprimary careWhat scope exists for local consultation under currenthealthcare policy and organisation? As alreadymentioned, problems arise from the fact that not onlyis primary health care essentially demand driven butthis demand is arbitrarily divided into practice specificpopulations which often do not correspond tonaturally occurring geographical localities and popula-tions.13 Professional and official thinking thereforeneeds to acknowledge in both the organisation andfunding of primary care the appropriateness ofresponding to the needs of the local (as distinct fromthe practice) population.27

The poor understanding and limited uptake oflocal consultation within primary care21 28 arises partlyfrom the absence of relevant training—which makes aninherently challenging activity even more difficult.Working with groups representing different commu-nity interests demands considerable skills and flexibil-ity, and health professionals are currently poorlyprepared for this.26 Local people may not be used tohaving their opinions invited, let alone being asked totake a more active role.29 One-off consultationinitiatives are thus likely to have limited benefit, andthey may work against longer term effectiveness, whichdepends on proper structures and mechanisms forsustained, meaningful communication and action.

There is already considerable scope for communitybased health needs assessment within primary care.Members of the wider primary healthcare team arealready in touch with local networks, including resident’sassociations, mother and toddler groups, schools, andother voluntary organisations.30 Community nurses havebeen producing community profiles, which could beused to develop stronger links with the community.13

The spread of appropriate knowledge and skills and thepractical need to divide any workload makes it vital toinvolve the whole primary care team, and such involve-ment is in line with the underlying general ethos of fullparticipation in healthcare decision making.31

Reconciling conflicting needsOne overriding issue remains. Comprehensive healthneeds assessment is likely to produce different, poten-tially conflicting needs.15 32 How are these different pri-orities, views, and opinions to be weighed against oneanother in order to avoid a position of stalemate and toeffect positive change? Available suggestions maydiffer, but academic contributors and decision makersalike are acutely aware of resource limitations and theirimplications for meeting the full range of need identi-fied through any health needs assessment process.32 33

There are no easy answers, but with regard to localinvolvement at least it is clear that people must beinvolved in identifying need and also in prioritisingand responding to these needs.26

There is no doubt that the concept and practice oflocal participation in health needs assessment is particu-larly challenging. Although there are no models for howto go about it and there are a number of potential obsta-cles, there is already considerable potential for existingarrangements to be extended to incorporate localparticipation. While it has been argued24 that the recent

policy obsession with needs assessment has beenprompted by a desire to reduce public expenditure, thisshould not detract from the possibility of using needsassessment, particularly that with community involve-ment, as a means of not only promoting good health butreducing inequalities in its distribution.

1 Harrison S. The rationing debate: central government should have agreater role in rationing decisions: the case against. BMJ 1997;314:970-3.

2 Hunter DJ, Harrison S. Democracy, accountability and consumerism. In:Iliffe S, Munro J, eds. Healthy choices: future options for the NHS. London:Lawrence and Wishart, 1997:120-54.

3 Secretary of State for Health. The new NHS: modern, dependable. London:Stationery Office, 1997. (Cm 3807.)

4 Mort M, Harrison S, Dowswell T. Public health panels in the UK:influence at the margins? In: Khan UA, ed. Innovations in participation.London: Taylor and Francis (in press).

5 Pickard S, Williams G, Flynn R. Local voices in an internal market: thecase of community health services. Social Policy and Administration1995;29:135-49.

6 Lenaghan J, New B, Mitchell E. Setting priorities: is there a role forcitizens’ juries? BMJ 1996;312:1591-3.

7 Bowie C, Richardson A, Sykes W. Consulting the public about healthcarepriorities. BMJ 1995;311:1155-8.

8 Dowswell T, Harrison S, Lilford R J, McHarg K. Health authorities usepanels to gather public opinion. BMJ 1995;311:1168-9.

9 Heginbotham C. Rationing. BMJ 1992;304:1168-9.10 Barnes M, Harrison S, Mort M, Shardlow P, Wistow G. Users, officials and

citizens in health and social care. Local Government Policymaking1996;22:9-17.

11 Mort M, Harrison S, Wistow G. The user card: picking through theorganisational undergrowth in health and social care. ContemporaryPolitics 1996;2:1133-40.

12 NHS Management Executive. Local voices, the views of local people inpurchasing for health. London: Department of Health, 1992.

13 Peckham S. Local voices and primary health care. Critical Public Health1992;5(2):36-40.

14 NHS Executive. Developing NHS purchasing and GP fundholding. London:Department of Health, 1994. (EL(94)79.)

15 Gillam SJ, Murray SA. Needs assessment in general practice. London: RoyalCollege of General Practitioners, 1996. (Occasional paper 73.)

16 Department of Health, Welsh Office. General practice in the National HealthService: a new contract. London: HMSO, 1989.

17 Heritage Z. Community participation in primary care. London: RoyalCollege of General Practitioners, 1994. (Occasional paper 64.)

18 Barnes M, Wistow G. Understanding user involvement. In: Barnes M,Wistow G, eds. Researching user involvement. Leeds: Nuffield Institute forHealth Services Studies, 1992:1-15.

19 Bradshaw JR. A taxonomy of social need. In: Mclachlan G, ed. Problemsand progress in medical care. Oxford: Nuffield Provincial Hospital Trust,1972.

20 Stevens A, Gabbay J. Needs assessment, needs assessment . . . . HealthTrends 1991;23(1):20-1.

21 Jordan J, Wright J, Wilkinson J, Williams R. Health needs assessment inprimary care: a study of understanding and experience in three districts. Leeds:Nuffield Institute for Health, 1995.

22 Bowling A, Jacobsen B, Southgate L. Health services priorities.Exploration in consultation of the public and health professionals onpriority setting in an inner London health district. Soc Sci Med1993;37:851-7.

23 Last JM. The iceberg: completing the clinical picture in general practice.Lancet 1963;ii:28-31.

24 Bradshaw J. The conceptualisation and measurement of need. In: PopayJ, Williams G, eds. Researching the people’s health. London: Routledge,1994:45-57.

25 Percy-Smith J, Sanderson I. Understanding local needs. London: Institutefor Public Policy Research, 1992.

26 Dockery G. Rhetoric or reality? Participatory research in the NationalHealth Service. Participatory research in health. London: Zed Books,1996:164-76.

27 Ruta DA, Duffy MC, Farquhaeson A, Young AM, Gilmour FB, McElduffSP. Determining the priorities for change in primary care: the value ofpractice-based needs assessment. Br J Gen Pract 1997;47:353-7.

28 Pritchard P. Community involvement in a changing world. In: Heritage Z,ed. Community participation in primary care. London: Royal College ofGeneral Practitioners, 1994:26-8.

29 Dowswell T, Drinkwater C, Morley V. Developing an inner city healthresource centre. In: Heritage Z, ed. Community participation in primary care.London: Royal College of General Practitioners, 1994:8-10.

30 Findlay G, Palmer J. Reorientating health promotion in primary care toparticipative approaches. In: Heritage Z, ed. Community participation inprimary care. London: Royal College of General Practitioners,1994:29-32.

31 Brown I. The organisation of participation in general practice. In: Herit-age Z, ed. Community participation in primary care. London: Royal Collegeof General Practitioners, 1994:1-4.

32 Robinson J, Elkan R. Health needs assessment: theory and practice. London:Churchill Linvingstone, 1996.

33 London Health Economics Consortium, SDC Consulting. Local healthand the vocal community, a review of developing practice in community basedhealth needs assessment. London: London Primary Health Care Forum,1996.




giving provided by community pharmacies operatingin different localities.24 The needs of black and otherethnic minority groups will also need to be taken intoconsideration in the development of telephone advicelines such as “NHS Direct.”25

ConclusionManaging demand better at the interface between thepublic and the NHS will require three things:• Integrated information about self care closelyintegrated with health care;• Graduated access• Shared control—a willingness from both professionalsand patients to share control, risk, responsibility,information, and decision making.The last point requires a recognition of the responsibili-ties that people already have for their own health careand of the unequal resources that people have availableto be able to respond to and manage illness.

With special thanks to Philip Hadridge.

1 Stacey M. ‘Who are the health workers ? Patients and other unpaid work-ers in health care’. Economic and Industrial Democracy 1984;5:157-84.

2 Dean K. Social support and health: pathways of influence. Health Promo-tion 1986;2:133-50.

3 Fleming GV, Giachello AL, Andersen RM, Andrade P. Self-care:substitute, supplement or stimulus for formal medical care services ? MedCare 1984;22:950-66.

4 Eyles J, Donovan J. The social effects of health policy: experiences of health andhealth care in contemporary Britain. Aldershot: Avebury, 1990.

5 Dean K. Lay care in illness. Soc Sci Med 1986;22:275-84.6 Alonzo A. An illness behaviour paradigm: a conceptual exploration of a

situational-adaptation perspective Soc Sci Med 1984;19:499-510.7 Blaxter M, Patterson E. Mothers and daughters. London: Heinemann, 1982.8 Eliott-Binns C. An analysis of lay medicine: fifteen years later. J Roy Coll

Gen Pract 1986;33:256-8.

9 Jesson J, Jepson M, Pocock R, Sadler S, Dunbar P. Ethnic minority consum-ers of community pharmaceutical services. Birmingham: Aston UniversityPharmacy Practice Group and Social and Consumer Research Unit,1994: 66-7.

10 Blenkinsopp A, Bradley C. Patients, society and the increase in self-medication. BMJ 1996;312:629-31.

11 Gurwitz JH, McLaughlin T, Fish S. The effect of an Rx to OTC switch onmedication prescribing patterns and utilization of physician services. Thecase of vaginal antifungal products. Health Serv Res 1995;30:672-85.

12 Pearson M, Dawson C, Moore H, Spence S. Health on borrowed time?Prioritising and meeting needs in low income households.Health Soc CareCommunity 1993;1:11-68.

13 Hassell K, Noyce P, Rogers A, Harris J, Wilkinson J. A pathway to the GP:the pharmaceutical ‘consultation’ as a first port of call in primary healthcare. Family Practice 1997:14:498-502.

14 Hopton J, Dlugolecka M. Need and demand for primary care: acomparative survey approach. BMJ 1995;310:1369-73.

15 Shipman C, Longhurst S, Hollenbach F, Dale J. Using out of hours serv-ices: general practice or A & E ? Fam Pract 1997;14:503-9.

16 Anctil B, Winters M. Linking customer judgements with processmeasures to improve access to ambulatory care. Joint Commission Journalon Quality Improvement 1996;2:345-57.

17 Rogers A, Hassell K, Nicolaas G. Demanding patients? Analysing primarycare use: Buckingham: Open University Press (in press).

18 Little P, Williamson G, Warner G, Could C, Gantlet M, Kinmonth AL.Open randomised trial of prescribing strategies in managing sore throat.BMJ 1997;314:722-7.

19 Frewer LJ, Shepherd R. Attributing information to different sources:effects on the perceived qualities of information, on the perceivedrelevance of information and on attitude information. Public Understand-ing of Science 1994;2:112-21.

20 Coulter A. Partnerships with patients: the pros and cons of shared clini-cal decision-making. J Health Serv Res Policy1991;2:112-21.

21 Macfarlane JT, Holmes WF, Macfarlane RM. Reducing reconsultations foracute lower respiratory tract illness with an information leaflet: arandomised controlled study of patients in primary care. Br J Gen Pract1997;47:719-22.

22 Laine C, Davidoff F. Patient-centred medicine: a professional evolution.JAMA 1996;275:152-6.

23 Secretary of State for Health. The new NHS. London: Stationery Office,1998.

24 Rogers A, Hassells K, Noyce P, Harris J. Advice giving in communitypharmacy: variations between pharmacies in different locations. Healthand Place (in press).

25 Free C, McKee M. Meeting the needs of black and minority ethnicgroups. BMJ 1998;316:380.

Health needs assessmentAssessing health needs in developing countriesJohn Wright, John Walley

In most developing countries, the evolution of healthservices has been dominated by Western models ofhealth care. These have rarely taken into account howlocal people explain illness, seek advice, or usetraditional healing methods. The emphasis has beenon hospitals and curative care rather than on trying toaddress local health needs equitably and effectively.Since the Alma Ata declaration on primary healthcare, more attention has been given to increasing cov-erage of basic services and preventing commondiseases. However, the bias in resource allocationtowards secondary care and urban areas remains.

Health needs are changing and new challengesfrom chronic diseases and HIV infection must befaced. Better coverage of preventive and essentialhealthcare services has led to greater emphasis onimproving the quality of health care and ensuring thatthe most efficient use is made of scarce resources. Forexample, infant mortality has fallen dramatically in thepast two decades through interventions such as oralrehydration for diarrhoea and immunisation pro-grammes. With fewer children dying there has been

Summary points

Timely and accurate information is essential ifhealth services in developing countries are tomeet the needs of their populations

Routine health information can provide anepidemiologically based assessment of ill healthand identify what health services are needed

Community appraisals can provide valuableinsight into patients’ needs as well as empoweringcommunities

Emergency health needs are similar whatever thedisaster. Community involvement, goodsurveillance, and foresight are important

The global burden of disease can be representedby disability adjusted life years; these can help toidentify international health needs


This is the lastin a series ofsix articlesdescribingapproaches toand topics forhealth needsassessment,and how theresults can beused effectively

continued over

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greater emphasis on the need to tackle the causes ofinfant and child morbidity. Families can be smaller, andthis has highlighted the need improve the availabilityof family planning.

If health services are to respond to the changinghealth needs of their local populations, then plannersand managers need useful and timely informationabout the health status of these populations. Some ofthis information can come from routine data sourcesor may be collected from large, one-off populationstudies. Some information can be obtained from com-munity surveys.

Routine informationInformation about diseases or use of health servicescan help to build up a picture of the health needs of alocal population.1 Such epidemiological informationcan come from national, regional, or local sources.x National census data can provide information onthe age and sex distribution of a population. Thisinformation can be used to calculate crude birth ratesand fertility ratesx Death certification and registers can provideinformation on the cause and place of death. Infantmortality rates can be calculated from the number ofliveborn infants who die in the first 12 months of lifex Hospital inpatient records can be used to obtainnumbers of admissions, cause of admission, and lengthof stay, and outpatient consultations can be used fornumbers of patients and diagnoses (figure)x Disease notification systems can provide infor-mation on important infectious diseasesx Maternity unit statistics can describe births rates,maternal ages and parity, numbers of low birthweight( < 2500 g) babies, and maternal mortalityx Pharmacy information provides information on theuse of essential and non-essential drugs

x Laboratories can provide information on theappropriate use of tests and numbers of positive tests(for example, sputum samples for pulmonary tubercu-losis, malaria blood slides)x Workplaces can provide data on absences due tosickness, occupational injuries, and regular employ-ment health checks.

This information provides a snapshot of apopulation’s health—but without comparative infor-mation this will be of limited use in planning healthservices. Comparison can be with other populations(national or regional) or with the same populationover time.

The disadvantage of routine information is that it isoften inaccurate, incomplete, and out of date. Forexample, outpatient records may give only the maincomplaint of patients attending and may notdistinguish new patients’ visits from repeat visits. Noti-fiable diseases may be missed, and when they arepicked up they are often not reported. It is also difficultto make generalisations about a local population fromroutine data. For example, people who attend a hospi-tal are more likely to reflect a more affluent and urbanpopulation. One-off studies can provide more detailed,relevant, and accurate information on a specific topic(box) but are time consuming and costly.

Community appraisalsCommunity appraisals describe approaches to needsassessments that emphasise involvement of localpeople. A confusing number of terms describe similarmethods: rapid evaluation methods, rapid appraisalmethods, rapid community surveys, rapid ruralappraisal, relaxed rural appraisal, participatory ruralappraisal.3–7 The development of rapid appraisal

Malaria

Obstetricconditions

Injuries

Skin or skeletalconditions

Lower respiratorydisorders

Intestinal infectiousconditions

Pulmonarytuberculosis

Abortion

Ill definedconditions

Female genitaldisorders

0 2 4 6 8

1990-51989-94

10 12

Percentage of admissions

Top 10 causes of admission over five years, all hospitals, MashonalandCentral Province, Zimbabwe. Figures exclude normal deliveries, whichcomprise 27% of admissions in 1995 and 25% in 1994

Combining different methods of needsassessment2

Bacterial and tuberculous meningitis is an importantcause of morbidity and mortality in developingcountries despite the availability of effective treatment.

Epidemiological assessment—A national study wasundertaken in Swaziland to describe the epidemiology,clinical features, and outcomes in each case ofmeningitis admitted to hospital. The overall casefatality was found to be 42% in all ages and 63% inadults. Significant association with a period of droughtwas found, and the increasing contribution of HIVinfection was highlighted. The results also identifiedthe age distribution and aetiology of meningitis in thecountry and allowed an assessment of the potentialimpact of immunisation programmes.

Community appraisal—Semistructured interviewswere carried out on a random sample of mothersattending a health centre. These were used as the basisof a focus group discussion with a purportedlyselected group of health workers. The need foreducation about the awareness of symptoms and theimportance of prompt referral and treatment wasidentified.

Action—To reduce the high mortality frommeningitis by reducing delays in treatment, acoordinated education campaign for the public andhealth workers, using posters and outreach teachingsessions, was undertaken.


Nuffield Institute forHealth, Universityof Leeds, LeedsLS2 9PLJohn Wright,consultant inepidemiology andpublic health medicineJohn Walley,senior lecturer ininternational publichealth



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methods during the 1980s came in recognition of thetime consuming and rigid nature of traditionalepidemiological and questionnaire surveys.Experience with these appraisal methods showed thatwhen they were done well they provided valuable, reli-able, and timely information on health status,knowledge, attitudes, and behaviours. More recently,emphasis has been placed on encouraging people toparticipate in their own appraisal (for example, partici-patory rural appraisal).3–5 Many of the principlesbehind these techniques stem from the formative workof Paulo Freire in enabling oppressed people tounderstand and address their own educational needs.8

In community appraisals the assessors support andfacilitate community understanding and action ratherthan just record information (see box above forexample of one programme). Local communities canbe empowered by the opportunity to participate inhealth planning, and health workers have theopportunity to appreciate the perceived strengths andweaknesses of services.

The information collected in community apprais-als is used to develop acceptable and sustainableprogrammes in partnership with the community.These may be programmes of health care, nutrition, orfamily planning that improve services for the commu-nity. The same methods can be used to monitor andevaluate the developments.

Whatever method is used for appraisals, theemphasis is on qualitative techniques of interviewingand listening to people.9 Methods of communityappraisal include the following:x Summarising existing information from routinesources or previous surveys (for example, causes ofmorbidity and mortality)x Exit interviews after a clinic visit to obtain thepatient’s perspective on the quality of care and under-standing of the health messages received (for example,checking that the mothers of children with diarrhoeaunderstand how to make up oral rehydration solution)x Interviews with health workers (for example, to assesspeople’s perception of local needs, interviews can bestructured with a standard list of questions, or semistruc-tured, with just a list of topics that need to be covered)x Ranking of priorities or preferences (for example,asking local people to produce a “league table” ofneeds)x Case note review and audit (for example, examiningthe recording of tasks and health education given topatients)

x Household survey to assess family health needs (forexample, seasonal variation in food intake and accessi-bility to clean water)x Focus group discussion to obtain the opinions of aspecific population group (for example, a facilitatorguides the group of purposefully selected informantsthrough a framework of questions that aim to stimulatediscussion and communication of opinions; anassistant takes notes of the discussion for later analysis)x Direct observation of chosen indicators or behav-iours (for example, the performance of health workersin communication or clinical skills).

The assessors need to have good listening skills, arecognition that communities know their own needs,and common sense in analysing the results. Sometraining is necessary to provide the assessors with theskills needed to undertake appraisal techniques andgenerate good quality, reliable findings. They mustbeware of generating false hopes in the community forwhat can be achieved.

The choice of subjects for questionnaires orinterviews will determine whether the results can begeneralised. This sampling can be done randomly, sys-

Community appraisal: an example

Factors affecting participation in nutrition, health, and development incommercial farms in Zimbabwe9

The workers and their families on commercial farms are one of the mostdisadvantaged groups in Zimbabwe. A farm health programme has beenoperating for 15 years in Mashonaland Central Province, including childhealth and preschool and nutrition activities. As malnutrition in childrenunder 5 remains more common on the communal farms than elsewhere, abetter understanding of the factors influencing nutrition, health, anddevelopment is needed.

Eight farms, ranging from well developed to underdeveloped, wereselected. Permission of each commercial farmer was requested by telephoneand followed up by an explanatory letter delivered by hand. On each farmthe commercial farmer or representative was interviewed.

Participants for group discussions were recruited randomly amongworkers with preschool children, aiming for 6-8 female workers, 6-8permanent male workers, and 6-8 seasonal workers. Anyone who seemed tohold some kind of authority was tactfully removed from the groupdiscussion by asking them to assist in drawing the social map, which wasdrawn on the ground and then copied.

The research investigated:• Knowledge, attitudes, and practices relating to health• Felt needs, priority problems, opportunities, and solutions• Factors affecting communication• Factors affecting participation in health activities• Factors likely to assist or hinder an intervention programme.

ResultsChildren’s nutrition was not viewed as a priority problem by farm workersor farm owners. Farm workers gave poor working conditions, workinghours, low salaries, and lack of family food as priorities; health care forchildren came much lower on the priority rankings.

The workers are a fragmented community with no sense of belonging toa group. There is tension between permanent workers, who have betterconditions, and seasonal workers.

An unhealthy child is described as dirty, sick, thin, eats cold food and hasa pot belly, and is miserable. Contributory factors include parental fighting,inadequate food, sickness, and lack of child care at home or at preschool.

Issues likely to influence negatively participation included zvondo—jealousyand mistrust among women: for example, not organising a cooking roster forthe preschool, as they don’t want the woman whose turn it is to cook tobenefit from the food. Another example is poor response by the commercialfarmer to efforts to improve workers’ health—once the toilet pits were dug, thefarmer failed to provide cement and a builder to finish the job.

Steps in community appraisal• Define aims of appraisal• Identify community for assessment• Identify study team and train in qualitativetechniques• Examine available information• Define key questions and issues• Pilot questions in interviews or questionnaires• Identify key informants• Choose and use appropriate methods• Analyse information after each interview• Write report and develop action plan



tematically (every fifth house in a village, say), or bypurposefully selecting key informants (people withexpert knowledge: patients, mothers, sex workers,chiefs, elders, church leaders, shopkeepers, healthworkers, government officials). Care should be takenwhen selecting key informants that they reflect therange of different interest groups.

Ideally a combination of methods should be usedwhen assessing health needs—for example, analysis ofroutine health data plus a questionnaire or focusgroup. This allows cross checking and validation ofresults, and it increases their relevance or generalisabil-ity to the study population. Routine population datacan be superficial and inaccurate; however, they doallow a quantitative comparison with other populationdata. A small number of interviews may not provideopinions representative of the whole community butcan show people’s true priorities.

Language and literacy barriers may arise indiscussion of complex health issues. Techniques toovercome these barriers in non-literate populationsinclude community mapping, seasonal calendars,Venn (chappati) diagrams, and dramatisation tech-

niques.4 5 These visually based methods provideopportunities for local people to explore and analysetheir needs in their own terms and enhance theirinvolvement in the assessment.11

Emergency needs assessmentQuick decisions and actions are imperative in theaftermath of a disaster. The immediate, life supportingneeds after any major disaster are similar whether thecause is of gradual onset, such as drought, famine, orwar, or sudden onset, such as floods or earthquakes.These include clean and adequate water andsanitation; adequate food rations; shelter—includingclothing and blankets; and essential medical care.12

Information must be obtained not only fromgovernment or other agencies (including, increasingly,the international media) but from the affected commu-nity. This community will have the capacity to helpitself, and any disaster response should build on this.

Involving the community is essential in assessingthe effects of the disaster and targeting vulnerablegroups (young children, elderly people, pregnantwomen). It is also vital to avoid cultural problems.Some problems (such as sending pork products toIslamic countries) can be avoided with intelligence.Others require more insight: a famine relief pro-gramme ran into problems because the affected popu-lation, which was used to a staple of white maize, hadstrong traditional beliefs that the yellow maize beingdistributed was inedible and poisonous.13

In addition to considering immediate needs, it isimportant to plan for the future. A community depend-ent entirely on donor food supplies will be vulnerablewhen these are withdrawn, especially if normal foodproduction is still disrupted. Good surveillance systemsto monitor health and malnutrition are also vital. Forexample, anthropometric surveys of children in refugeecamps or outreach clinics, measuring weight for heightor upper arm circumference, can provide valuable nutri-tional assessments.12 Monitoring of infectious diseasessuch as measles can prompt timely immunisations.

Global needsNational and international health needs are also impor-tant in planning health services. Most assessments of therelative importance of different diseases are based onhow many deaths they cause. This convention hascertain merits: death is an unambiguous event, and thestatistical systems of many countries routinely producethe data required. There are, however, many diseases orconditions that are not fatal but that are responsible forgreat loss of healthy life: examples are chronicdepression and paralysis caused by polio. Theseconditions are common, can last a long time, and oftenlead to considerable demands on health systems.

Global needs are represented by the global burdenof disease. This burden of disease includes bothmorbidity and mortality. Morbidity can be assessedaccording to the amount of disability—for example,from blindness—and mortality can be expressed interms of life years lost. The needs can then beexpressed through a combined measure of such as thedisability adjusted life year (DALY).14

People oriented planning

The United Nations High Commission for Refugeeshas developed a simple needs assessment tool calledpeople oriented planning to help guide decisionsabout refugee needs:• Which foods should be supplied, and to whom?• How should they be distributed?• Who should live where?• What are the critical medical needs?• What are the cultural patterns of health care?• How are target groups best reached?

This is approached through an analysis of the refugeepopulation profile, activities, and use of resources.Specific questions about the refugees help to clarifywhat activities people did (farming, teaching, social,political, house building) before their displacement,who did what and when.

JANESMITH


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The proportion of disability and loss of life variesfrom disease to disease so there will be more disabilitydue to leprosy but more years of life lost from tubercu-losis. Overall the global burden of disease, when calcu-lated as disability adjusted life years, is made up ofabout two thirds from years of life lost (mortality) andone third from disability (morbidity).

Disability adjusted life years can be used to rank dis-eases in order of magnitude of burden of disease indeveloping countries. The existing rankings can be com-pared with a prediction of the future.15 The table showsthe scale of the demographic and epidemiological tran-sition anticipated by 2020, with depression and trafficaccidents predicted to be the biggest burdens of disease.

Disability adjusted life years should be interpretedwith caution because of the assumptions that aremade.16 For example, the combination of discountingand age weighting means that an infant’s death equateswith the death of a young adult. Disability adjusted lifeyears are based on incomplete, internationallyavailable data that may contain inaccuracies, and theyare calculated on the basis of specific diseases ordisease groups. Many diseases have multiple outcomes,and interventions may reduce the burden for morethan one disease. For example, treatment of diabeteswill reduce the risk of stroke, coronary heart disease,and renal failure.

To date, disability adjusted life years have beencalculated globally and by WHO region. Attempts arebeing made to estimate the national disease burden, asin Ghana, but limitations in data make this a difficulttask.

Despite these limitations, disability adjusted lifeyears are the only data available that combine morbid-ity and mortality into a simple indicator of burden ofdisease. This can be used to identify current and futureinternational health needs and to plan essentialnational health services.17

Acting on the assessmentThe hardest part of any needs assessment is translatingthe results into policies and practices that will providebeneficial change. The involvement of health workers intechniques such as rapid or rural appraisal will encour-age changes at an individual level. Local workshops canprovide an opportunity to review the lessons learnt withother health workers. If this change is going to besustainable and adaptable then the appraisal should be acontinuous process with ongoing feedback. Implemen-tation of strategic changes can be facilitated if the policymakers themselves are active in the process.

We are grateful to Anthony Zwi for comments and advice, to DrAad van Geldermalsen for the figure, and to Margaret Haigh forsecretarial support.


1 Vaughan JP, Morrow RH. Manual of epidemiology for district health manage-ment. Geneva: World Health Organisation, 1989.

2 Ford H, Wright J. The impact of bacterial meningitis in Swaziland: an 18month prospective study. J Epidemiol Community Health 1994;48:276-80.

3 Cornwall A, Jewkes R. What is participatory research? Soc Sci Med1995;41:1667-76.

4 Chambers R. Rural appraisal: rapid, relaxed and participatory. Brighton:Institute of Development Studies, 1992. (Discussion paper 311.)

5 Chambers R. Participatory rural appraisal (PRA): analysis of experience.World Development 1994;22:1253-68.

6 Rahman MA, Fals-Borda O. A self-review of PAR. In: Action and knowledge:breaking the monopoly with participatory action research. London: Intermedi-ate Technology Publications, 1991.

7 Reynolds J. Primary health care management advancement programme: assess-ing community health needs and coverage. Geneva: Aga Khan Foundation,1993.

8 Freire P. Pegagogy of the oppressed. New York: Seabury Press, 1968.9 Adams L, Goche T, Marime W, Mungate B, Shamuyarira L. Report of

participatory rural appraisal. Bindura: Mashonaland Central Province,1996.

10 World Health Organisation. Rapid evaluation method guidelines formaternal and child health, family planning and other health services.Geneva: World Health Organisation, 1993.

11 De Koning K, Martin M. Participatory research in health: issues andexperiences. Johannesburg: Zed Books, 1996.

12 Seaman J, ed. Disasters. Tropical Doctor 1991;21(suppl 1):38-42.13 Wright J, Ford H. Another African disaster. BMJ 1992;305:1479-80.14 World Bank. World development report 1993: investing in health. New York:

Oxford University Press, 1993.15 Murray C. Investing in health research and development. Geneva: World

Health Organisation, 1996.16 Barker C, Green A. Opening the debate on DALYs. Health Policy and

Planning 1996;11:179-83.17 Bobadilla J-L, Cowley P, Musgrove P, Saxenian H . Design, content and

financing of an essential national package of health services. Bull WorldHealth Organ 1994;72:653-6.

Projected burden of ill health in the developing world*

Rank in2020 Cause of death Rank in 1990

1 Depression 4

2 Road traffic accidents 11

3 Ischaemic heart disease 8

4 Chronic obstructive pulmonary disease 12

5 Cerebrovascular disease 10

6 Tuberculosis 5

7 Lower respiratory infections 1

8 War 16

9 Diarrhoeal diseases 2

10 HIV/AIDS —

*In 1990 measles and malaria were ranked sixth and seventh; “conditionsarising during the perinatal period” were ranked third.

Medical information needs

As in developed countries, evidence of effectiveness isan essential component of needs assessment. Attemptsare currently being made to improve access toresearch information and effectiveness informationusing the internet, including:• UK Cochrane Centre (http://www.cochrane.co.uk)• South African Cochrane Centre (http://www.mrc.ac.za/mrcnews/march96/cochrane.htm)• International Network for the Availability ofScientific Publications (http://oneworld.org/inasp/network.html)• Global Health Network (http://www.pitt.edu/HOME/GHNet/GHNet.html)


EpiInfo

EpiInfo is a software package developed by theCentres for Disease Control and Prevention in theUnited States. It allows easy questionnaire design(EPED), data processing, and analysis. The analysismodule provides a user friendly statistical package. It isconsidered public domain and may be freely copied.Its simplicity and free availability make it ideal forresearchers in developing countries. (Contact: Divisionof Surveillance and Epidemiologic Studies,Epidemiology Program Office, Centers for DiseaseControl and Prevention, Atlanta, Georgia 30333,USA.)



Health needs assessmentk4ds.psu.ac.th/shf/hna/files/HNA_BMJ.pdf · assessing the supply of new...

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