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Assessing health needs: a

public health perspective

Peter Whincup,
St George’s, University of London
Learning objectives
• Be able to outline the public health approach to
to health needs assessment, including the
components of an epidemiological needs
assessment

• Describe the concepts of need, demand and


supply as applied to healthcare

• Describe the concept of rationing in healthcare


including the difference between implicit and
explicit rationing mechanisms
Total Hip replacement-
the context
• Total Hip Replacements (THR) undertaken
for two main reasons:-

– fracture of neck of femur, emergency -


20% of all cases

– osteoarthritis of hip joint, elective -


80% of all cases (Nargis Aktar waiting
for THR)
Nargis Akhtar – waiting for a total
hip replacement….

• Whether and when he gets a THR will be


influenced by….

– The quantity and type of services provided by


society

– Alignment of service provision to needs of


individual patients

– Decisions by clinicians about his individual


health needs
Need, demand and supply in a
health context

• Need – is a condition susceptible to


benefit from treatment

• Demand – is treatment for which people


are prepared to pay for in a market

• Supply – treatment which is actually


provided

These do not always match in practice….


Expressed
Unmet need
need

N D
Unmet
Demand
Met
need S

Services
Unused meeting
Services demand
Defining needs for health –
a hierarchy
• “Basic needs for health (survival)”
– Food, water, shelter

• “Health needs” Whole community


– Needs for the prevention of disease (e.g. immunization)
– Needs for the protection of health (e.g. healthy diet)

• “Health care needs” Patients & carers


– Treatment if effective
– Care if not treatable
Health need vs health
care need

• In practice, generally assumed that


modern societies attend to `basic needs’
and `health needs’ as a matter of course….
(is this a reasonable assumption?)
• Most of interest in health needs has been
in health care needs (i.e. specific needs
which can be responded to by health care,
rather than more generic health needs)
Defining `need’ in the
health care setting

Bradshaw’s taxonomy of need

Felt need Patient defined


Expressed need Patient defined
Normative need Defined by experts
Comparative need Need compared
between populations
Bradshaw’s taxonomy of
health (care) needs

– Felt need

`I’ve got a bad pain in my hip, which I


would like to go away.…’

The need expressed by the individual

-does not take professional views into account

-may be culturally determined/influenced


Bradshaw’s taxonomy of
health (care) needs
-Expressed need

– `I’ve got a bad pain in my hip… doctor, can


you do something about it..? ’

A felt need which has been expressed, by making


a demand upon the health service

-again does not take professional views into


account
-excludes need where individual is unable to ask
-may be met or remain unmet
-culturally determined/influenced
Bradshaw’s taxonomy of
health (care) needs
– Normative need
A need endorsed by professional(s) –
should be related to an evidence base

`I saw your patient today in my


clinic…She has severe osteoarthritis of
the hip and would benefit from a total
hip replacement….’

-may involve assessment of severity


-cultural influences
-serving gatekeeper function
Bradshaw’s taxonomy of
health (care) needs
– Comparative need

Need defined at the level of the population in


comparison with another similar population

e.g. Population A has total hip replacement


rate of 10/1000/year. In Population B, rate is
6/1000/year - therefore Population B has an
unmet need of 4/1000/year…..

(Is this a reasonable assumption?....(later)


Bradshaw’s taxonomy of
health (care) needs
– Comparative need (2)

This type of need is based on concepts of


fairness/equity

Comparative need may (or may not) link to


felt need and expressed need in the
individual
Health needs assessment in the
National Health Service
Is really about health care needs….
with a strong focus on evidence….

Need for health care = the ability of the


population to benefit from health care
Stevens et al 2004

“One of the challenges of needs assessment and


purchasing services is to improve the link between
clinical practice as it affects individuals and health gain
at the population level”

`Evidence based medicine’ approach


Health needs assessment in
the National Health Service
Need for health care = ability of the
population to benefit from health care
Stevens et al 2004

Challenges
-difficult to measure benefit for chronic illness
-`needs’ may change dramatically with new
technological advances
-often difficult to define exactly who will
benefit from an intervention, and who will not
Definition Of
Health Needs Assessment
• Health needs assessment (HNA) is

`a systematic method for reviewing the health issues


facing a population, leading to agreed priorities and
resource allocation (for effective health care and
prevention) that will improve health and reduce
inequalities….’

(will focus especially on unmet needs)

(National Institute of Clinical Excellence, NICE, 2009)


Elements Of A
Health Needs Assessment

Will generally include three elements:-

• Epidemiological needs assessment

• Comparative approach

• Corporate approach
Epidemiological Health
Needs Assessment
– Which interventions helpful?
(clinical trials, other studies, Cochrane database)

– In exactly which patient groups are the


interventions helpful? (age group, gender, other
characteristics)

– How large is the population which will benefit from


the effective interventions available?
(routine data, published data or special surveys)
Which interventions helpful?
Assessing quality of available
evidence

I At least one proper RCT


II-1Non-randomised controlled trials
II-2Well-designed cohort or C-C studies
II-3Multiple time-series or dramatic
“natural experiments”
III Opinions of respected authorities
IV Inadequate or conflicting evidence
Analysis of effectiveness
A High probability of strong benefit
B High probability of moderate benefit
(or mod probability of high benefit)
C Mod or high probability of small benefit
D Mod or high probability of no benefit or
adverse effect
I Insufficient evidence to reach a decision
about benefit/harm

US Preventive Services Task Force definitions


How does this work for
total hip replacement?
• Procedure developed in 1960s
• Good evidence of benefit both in
emergency and elective settings
• Data based on observational studies;
no clinical trial evidence
• Both effective & cost-effective
• Other conditions often ‘measured’
against it- cost per Quality Adjusted
Life Year of approximately £1000
Effectiveness of THR?

Elective THR
• Reduced pain, immobility, disability
• Greatly increased independence
• At age 60 years, THR gives ~ 7
additional high quality life years
• At age 80 years, THR gives ~2
additional high quality life years
• Highly effective and cost effective
especially at younger ages
Effectiveness of THR

Elective THR (continued) adverse effects

-short term risk of venous thromboembolism


and mortality

-longer term mortality not increased

-about 1% per annum risk of joint failure


or loosening
Effectiveness of THR
• In ‘emergency’ setting after hip fracture-

– after THR survival rate ~80%, among


survivors, 25% require long term care- major
problems with activities of daily living

– prognosis if not treated with THR


(alternative = longer term bed rest, traction)
is considerably worse (high morbidity and
mortality rates)
Factors influencing THR effectiveness

• Training and experience of surgeon


(high = good)

• Throughput of THR at operating centre


(high = good)

• The joint prosthesis used (Charnley, Stanmore,


Exeter, Howse good)

• Patient factors – do not influence effectiveness,


as long as fit enough to have procedure done
(e.g. BMI)
Challenges in assessment of THR
effectiveness

• Challenge of novel prostheses, often more


expensive – are they actually better (as good as)
existing options?

• Hybrid and cementless hydroxyapatite coated


models – look hopeful

• RCTs may have particular place in evaluating the


novel prostheses – but need long follow-up, need
to continue for several years before clear
answers emerge
THR is effective - how many are needed?
• THR used to restore function & relieve
symptoms of hip disease- mostly
osteoarthritis (OA)

• How many people have OA hip which will


benefit?

• Not easy to define, use combination of:-


– hip pain
– loss of mobility
– X-ray changes
How many THRs are needed (cont)?

….measuring OA hip requiring THR is


not easy….

– No gold standard method

– Symptoms variably reported, assumed


linked to OA….

– Radiological survey findings….not closely


linked to symptoms and symptom
progression
How many THRs are needed?
• Best estimates…
– Symptoms
Daily Hip Pain in 11% of Men, 17% of Women over 35 y
– Severe symptoms
Severe Hip Pain in 1.5% of M and W over 35 yrs
– Incidence of new severe symptoms
2.2 per 1000 per year in M and W over 35 yrs

– Radiological changes
In 5% of over 55 yr-olds
In a population of 100,000
•55,000 people over 35 years
•~8000 with Chronic Hip Pain (HP)
•~825 with Severe HP
•~122 New Severe HP/Year
Combine data on treatment effectiveness and size of
problem
• Number of existing cases of end-stage arthritis (Unmet Need)
• Number of new cases per year (New Need)

Prevalent Unmet Need may need additional surgery before a


steady state to meet New Need

Map Current Provision (including private) to establish what is


already being provided and how much new provision needed

Estimate usually a mixture of science and art!


Current surgical Options for Increasing
capacity Capacity

•Surgeons •More Staff/Resources


•Beds •Improved Efficiency
•Operating Theatres •Cases/List
•Assessment Facilities •New Ways of Working
•Physiotherapy •Early Discharge
•GP Assessment
•Private Providers
Other Elements Of A
Health Needs Assessment
• (Epidemiological health needs assessment)

• Comparative needs assessment approach


– compares service use with those in other,
comparable areas of the country (or other
countries)
– is such comparison fair and valid?

• Corporate needs assessment approach


– consults to assess local public priorities
& determine expert opinion
Age-Standardised Primary THR Rate per 100,000, London, 2011-12
Sutton
Kingston
Bexley
Greenwich
Havering
Richmond
Bromley
Hillingdon
Merton
Barking
Lambeth
Southwark
Lewisham
Islington
Waltham Forest
Croydon
Enfield
Wandsworth
Hammersmith &F
Harrow
Redbridge
Haringey
Hounslow
Barnet
Hackney
Tower Hamlets
Ealing
Newham
Camden
Westminster
Kensington
Brent

0 20 40 60 80 100 120 140


Comparative need
Rates of THR per 100,000 population per year

USA white 76
USA black 35
Finland 58
Denmark 82
Sweden 115
Norway 115
UK 80 (guideline is 105)

• Does this mean there is unmet need in the UK,


when compared with e.g. Norway?
Merx et al Ann Rheum Dis 2003
Assumptions in assessment
of comparative need
-those receiving THR in different locations
have the same degree of need, including in
locations where rates are high

-lower levels of provision therefore imply


corresponding unmet need for increased
services

HOWEVER, there are many reasons why THR


provision could vary between locations….
Differences in THR rates between locations
could result from:-

• Differences in data quality in different settings –


their reliability and completeness may differ

• Differences in disease prevalence (potentially


reflecting differences in population age and sex
structure) – OA hip a disease of older population

• Differences in case ascertainment, diagnosis and


criteria for operation in different settings

• Differences in resource availability (staff, beds,


theatres)

• Differences in health care priorities between locations


(high/low rates of other conditions)
Implications
• Basing provision of care (e.g. THR) on
studying variations in procedure rates
between different populations is tricky!

• Need to explore variations in great detail


(considering all the factors on previous
slide) to be sure they reflect differences in
the provision of treatment, rather than
other factors
Other Elements Of A
Health Needs Assessment
• (Epidemiological health needs assessment)

• Comparative needs assessment approach


– compares service use with those in other,
comparable areas of the country (or other
countries)
– is such comparison valid?

• Corporate needs assessment approach


– consults to assess local public priorities
& determine expert opinion
Structured collection of the knowledge and views of
Stakeholder on policies, services and need
• Professionals, Patients, Public all involved

Responsive to Local Concerns

May not be “Evidence Based”

Subject to Political process – loud voices predominate, not


the quiet or the voiceless, not necessarily balanced views
Perfect Overlap

Need = Demand = Supply


Expressed
Unmet need
need

N D
Unmet
Demand
Met
need S

Services
Unused meeting
Services demand
 Increasing needs and demands
◦ ageing population
◦ medical progress
◦ new technologies
◦ rising expectations (see next)

 Needs and (especially) demands affected by


culture, social & educational factors, media,
patient interest groups

 Needs also influenced by current professional


concerns and awareness (research agenda)
 Limitations on supply-
◦ Restraints on public expenditure on health
care (political/economic influences)

 Supply also influenced by:


◦ historical patterns
◦ local enthusiasms & inertia (inverse
care law)
◦ public pressures
 Planned spending for the Department of
Health (DoH) in England is approximately
£124.7 billion in 2017/18.

 Though DoH funding continues to grow,


the rate of growth has slowed considerably
compared to historical trends. The DoH
budget will grow by 1.2% per annum in real
terms between 2009/10 and 2020/21.
 This is far below the long-term average
increases in health spending of ~4% a year
(above inflation) since the NHS was
established. (Kings Fund)
Silent Suffering, Disability and Death

Waiting Lists

Emergency Presentation

Pressure on Other Services

Low Patient Satisfaction

Professional Dilemmas

Political Pressure
Shortage of resources leading to people being denied or having
delayed access to a beneficial service due to resource restraints

• Rationing can be Implicit or Explicit


• Rationing can be Rational or Irrational

Decisions taken in a resource-limited context lead to


“Opportunity Costs”

• One Person Denied Treatment while Another Receives It

Ethical Issue for all Health Services Staff


Implicit rationing - the traditional
NHS Approach
• Professional Decision Making
• Delay Assessment and Specialist Referral (using severity/other)
• Use of Waiting Lists as a rationing mechanism
• Restricted Capacity

Explicit-More Recent, involving NICE


and Local NHS agencies
• Do Not Provide Service or Technology at All
• Introduce criteria based on disease severity/needs
• Introduce other access criteria (Smoking/Obesity)
Rational rationing

• Rationing to preserve use treatments of high effectiveness and cost


effectiveness, and remove ineffective treatments
• Provide for all patients who will benefit
• Apply criteria consistently

Irrational rationing

• Rationing on criteria other than effectiveness and cost effectiveness


• Rationing on patient characteristics unrelated to effectiveness (e.g. BMI for
hip replacement)
• Locally defined criteria, particularly conflicting with evidence (e.g. IVF
withdrawal in specific CCGs)
Oxford Hip score is ≤26 on the 0 to 48 system – this
means either/or:- (0 = very bad hip problems)

Severe joint pain AND minor to severe functional


limitation despite extended nonsurgical treatments
AND radiographic evidence of joint damage

Mild to moderate joint pain AND severe functional


limitation, AND radiographic evidence of joint damage
Pain is constant and interferes with most
activities of daily living.

Pain at rest or interferes with sleep.

Pain not controlled, even by narcotic


analgesics.
 Numbers waiting have increased

 Trauma & Orthopaedics elective waiting list–

 2008 376,000 people


 2017 506,000

 Probably ~33% of these awaiting elective THR

 Median waiting time for THR remains high


~ 250 days
Does rationing contradict the
NHS’s founding principles?
• Comprehensiveness
• Equal access
• Free at point of need
• Universality

• Rationing:-
– conflicts with conventional medical ethics
• Doctor patient relationship – doing best for
that individual patient
– is unpopular with the public
Professional guidance on
rationing
• Doctors have a responsibility to treat their
individual patients to the best of their ability and
a duty to society to make the most equitable use
of resources overall. The fact that not all available
medicines are affordable should be openly
discussed within the context of the doctor-
patient relationship. (Royal College of Physicians,
2000).
• ….rationing decisions are complex, often requiring
the sacrifice of one strongly held value in order to
uphold another. (BMA, 2001)
Increasing • More Resources for Services (Money/Staff)
• Other Approaches to Care

Supply • Redirect Underused Services

Managing • Patient Advice and Education


• Waiting Lists
need

Redefine • Adjustment of Disease and Severity Criteria

Need
to redefine levels of need requiring treatment
Rational allocation of
limited resources
Need to consider for all important conditions:-
• Size of the ‘problem’ (burden of disease)
• Responsiveness to treatment; ‘size’ of benefit
(health gain)
• Accessibility, equity in treatment
• Reflect wishes of public/professionals
• Reductions in health inequalities
• Not doing harm
• Agreement with national priorities
Decisions in health care supply
• 1.How much national resource (taxation)

• 2. How much for health compared to other


sectors (e.g. defence)

• 3. How distribute health budget


– geographically?
– between broad sectors and client groups
– among specific forms of treatment
– to ensure access to treatment among patients

• 4.How much to spend on individual patients?


Conflicts between different
elements of health care
• Between services e.g. for elderly, mental
health, paediatrics

• Between primary, secondary, tertiary care

• Between curative, caring, prevention

• Between health professionals

• Between emergency and elective treatment


Issues for the future
• Responding to population ageing and technological
improvements - increases in needs, and demands!

• Government initiatives- treatment centres & integrated


care pathways (?greater efficiency)

• Expansion of orthopaedics (~1300 new consultants


appointed in last few years)

• More private procedures (in NHS and outside)

• Use of waiting lists to limit demand a consistent feature of


provision/policy

• International element - Search for treatment (and health


professionals) abroad
Professor Archie Cochrane
`Effectiveness and Efficiency’
• `All effective treatment should be free’
Professor Archie Cochrane
`Effectiveness and Efficiency’
• `All effective treatment should be free’

• Can we manage this?

• Only if curtail treatments which are harmful,


ineffective or of limited effectiveness and cost-
effectiveness)

• Role of the National Institute for Clinical Excellence


(NICE) which examines effectiveness and cost
effectiveness of treatments and makes
recommendations about their use in the NHS
Use of ineffective treatments….

....primary care prescribers reportedly waste £400m (4%


of primary care prescribing expenditure) per year on a
range of products that are considered to be of low value…

(Drugs and Therapeutics Bulletin 2017).


Patient care is determined by societal decisions on
allocation of resources as well as individual clinical
decisions and competence

Need is a complex concept with many elements


(Bradshaw)

Health Needs Assessment is a tool for improving the fit


between service provision and need

Epidemiological, Comparative, and Corporate


Approaches are possible and all may be needed
An Imbalance between Need, Demand and Supply can
lead to Unmet Need

Where resources are insufficient, rationing becomes


inevitable

Rationing may be implicit or explicit

Waiting lists have been the conventional NHS


approach to Rationing
Further reading
A Stevens et al. Health Care Needs Assessment (first
series, second edition, vol 1. Introduction and Chap 8)
Library WA525 STE

Faulkner A et al. Effectiveness of hip prostheses in primary


total hip replacement: a critical review of evidence and an
economic model. Health Technology Assessment 1998; 2: 1-
133.

Cochrane A. Effectiveness and efficiency. BMJ


publications (WA525 COC)

National Institute for Clinical Excellence (www.nice.org.uk)