1. Assessing need, equity and impact

2. Learning Objectives 1.To consider concepts of need 2.To consider dimensions of equity 3.To understand what is meant by: Health needs assessment Health equity audit Health impact assessment 4.To be aware of other forms of impact assessment

3. What is need?

4. Maslow’s hierarchy of needs Esteem needs achievement, status, responsibility, reputation Self-actualization personal growth and fulfilment © Alan Chapman 2001-7 Belongingness and Love needs family, affection, relationships, work group, etc. Safety needs protection, security, order, law, limits, stability, etc. Biological and Physiological needs basic life needs - air, food, drink, shelter, warmth, sex, sleep, etc.

5. Bradshaw’s taxonomy of need normative need Based on professional judgement – e.g. need for treatment felt need Individuals’ perceptions of variations from normal health expressed need Vocalisation of need / how people use services comparative need Based on professional judgements as to the relative needs of different groups

6. Need for healthcare The population's ability to benefit from health care Need for health care vs need for health Interaction between need, supply and demand

7. health needs assessment

8. Why conduct health needs assessment? NHS Planning Guidance 2005-2008 PCTs and their partners will need to consider the particular needs of their population, taking into account different needs and priorities within each community. World Class Commissioning (2008) By identifying current needs and anticipating future trends, PCTs will be able to ensure that current and future commissioned services address and respond to the needs of the whole population, especially those whose needs are greatest. PCTs should.... undertake robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements

9. Core standard C23 1. The PCT assesses the health needs of its local population, including analysis of its demography, health status, health and social care use and patient and public views. 2. The PCT’s commissioning decisions and local target setting are informed by its assessment of health needs.... 3. The PCT commissions or provides targeted programmes and services.... based on the needs of its local population. Why conduct health needs assessment?

10. http://www.nice.org.uk/niceMedia/documents/clarifying_approaches.pdf

11. HNA involves… The assessment of the size of the problem –how many people need the service/intervention The assessment of the effectiveness and cost- effectiveness of services –do they confer any benefit, and if so at what cost The assessment of baseline services –knowing what already exists, and how to free up resources

12. Health needs assessment: definitions A systematic review of the health issues facing a population leading to agreed priorities and resource allocation that will improve health and reduce inequalities. Health Needs Assessment: A Practical Guide (NICE 2005) The epidemiological approach to needs assessment Prevalence and incidence Services available and their costs Effectiveness and cost-effectiveness of services Quantified models of care and recommendations Outcome measures, audit methods and targets Information and research requirements http://hcna.radcliffe-oxford.com/ 1994 & 1997 The systematic method of identifying unmet health and healthcare needs of a population and making changes to meet those unmet needs. Wright J, Williams R & Wilkinson J. BMJ 1998; 316: 1310-3.

13. BMJ 1998;316:1310-1313 Development and importance of health needs assessment John Wright, Rhys Williams, John R Wilkinson HNA terminology

14. Health needs assessment may focus on… …a disease …a service …a community or social experience

15. Cycle of health needs assessment 1 What population? 3 Prioritisation 4 Action planning for change 5 Review 2 Identifying problems and challenges... and who to involve? population profiling perceptions of needs which issue(s) to tackle? what are effective and acceptable interventions? IMPLEMENTING ACTION measuring impact learning

16. Case study: people at risk of self harm and suicide Bexley To examine the scope for preventing suicide and self harm in Bexley Group involved Directors of A&E, voluntary agencies and coroner, representatives of the Mental Health Trust Reviewed mortality data and case notes Found high suicide rates in young deprived males Plan to target at risk people in A&E Action plan formulated but only partially implemented Main message: HNA may not be effective if local decision makers not involved

17. health equity audit

18. What is equity? Health inequality –Differences in health experience between population groups differing in terms of e.g. geography, age, sex, ethnicity, socio-economic status Health equity –“Fair” distribution of health/health care resources or opportunities according to population need –Allocating relatively more resources where there is relatively more need –Equal quality of care for all If all PCTs in England have a Coronary Artery Bypass Graft rate of 750 operations per 1,000,000 pop this is equality but is probably not equitable - some PCTs will have a higher level of need.

19. 1.“HEA is a process for identifying how fairly services or other resources are distributed in relation to the health needs of different groups and areas, and the priority action to provide services relative to need. 2.The overall aim is not to distribute resources equally but, rather, relative to health need. 3.The purpose is for health and other services to help narrow health inequalities by taking positive decisions on investment, service planning, commissioning and delivery that narrow inequalities.” Defining HEA

20. Why conduct health equity audit? NHS Planning Guidance 2005-2008 PCTs and their partner organisations should demonstrate that they have taken account of different needs and inequalities within the local population, in respect of area, socio-economic group, ethnicity, gender, disability, age, faith, and sexual orientation, on the basis of a systematic programme of health equity audit and equality impact assessment. This should address issues of race equality. All PCTs should work in partnership with LAs, using health equity audit, to demonstrate that effective interventions are provided for all groups in the population, targeting those with highest needs. Healthcare Commission core standard C23 The PCT’s commissioning decisions and local target setting are informed by its assessment of health needs, the Director of Public Health’s Annual Public Health Report, and information from equity audits...

21. Health Equity Audit compares the provision of a service with a measure of the need for it Service Measure of Need x y

22. Equity : high need is matched by high service provision - the desirable situation Service x y Measure of Need

23. Inequity : those with most need get the lowest level of service - the undesirable “inverse care law” Service x y Measure of Need

24. Cycle of health equity audit 1 Agree priorities and partners 3 Identify local action to tackle inequalities 4 Agree local targets with partners 5 Secure changes in investment and service delivery 6 Review progress and impacts against targets 2 Equity profile

25. Case study: the “Fresh Start” Smoking cessation service in Derbyshire 1.how fair is the service in relation to the needs of different groups within the population? 2.fairness of what? –?provision –?access –?uptake –?outcome 3.what measure of need? 4.which dimensions of equity –gender, age, ethnicity, social class, area of residence etc

26. Smoking cessation: selecting a measure of need Possible measures –number of smokers –number of smokers wanting to quit –number/rate of smoking-related deaths –socio-economic deprivation –?other Selection criteria –how well does it reflect need and the purpose of the service? –can we look at different dimensions of equity? –do we have robust, timely local data? –would synthetic estimates do?

27. Smoking cessation: constructing use:need ratios number of service users/estimated number of smokers.... in each of several cuts of the population differing by age gender electoral ward ethnic group

28. Erewash locality : Use: Need Ratios by Age (Men) Age group Male Est.Smoking Prevalence % Estimated No.No. Fresh StartUse/Need Adults 16+SmokersUsersRatio 16 - 24536436%1931201.04% 25 - 34745038%2831702.47% 35 - 44855034%29071143.92% 45 - 54725230%21761175.38% 55 - 64660024%15841157.26% 65 - 74438418%789749.38% 75+304710%305123.94% Erewash locality : Use: Need Ratios by Age (Women) Age group Female Est.Smoking Prevalence % Estimated No.No. Fresh StartUse/Need Adults 16+SmokersUsersRatio 16 - 24525736%1893824.33% 25 - 34789635%27641535.54% 35 - 44863430%25901485.71% 45 - 54722228%20221376.77% 55 - 64640323%14731459.85% 65 - 74486418%876637.20% 75+531710%532173.20%

29. Erewash locality: Use: Need Ratios by Ward Ward NamePopulationEstimated SmokingEstimatedNo. Fresh StartUse/Need Prevalence %No. SmokersUsersRatio Little Eaton and Breadsall295415.7464163.45% Sandiacre North349325.7898323.56% Ockbrook And Borrowash588817.81048373.53% Old Park321835.71147464.01% Draycott316521.5680294.26% Ilkeston Central355035.41257635.01% Sandiacre South353217.3612325.23% Sawley536825.21353765.62% Nottingham Road503028.01407815.75% Derby Road East377729.81124726.41% Long Eaton Central482525.01204776.39% Kirk Hallam505729.01468986.68% West Hallam and Dale Abbey412114.2587416.99% Cotmanhay349435.41236887.12% Stanley172820.0346277.80% Breaston371314.9554488.67% Ilkeston North309536.111171069.49% Little Hallam330917.65848113.88%

30. Smoking cessation: problems in investigating equity of uptake between ethnic groups 1. generating appropriate smoking prevalence estimates –differences in ethnicity classification system between Health Survey for England and smoking cessation service 2. patchy collection of ethnicity data 3. small numbers in most ethnic groups

31. Working with service managers & commissioners Local service managers and commissioners did take notice Accepted the identified broad inequities Sophistication and high degree of accuracy unnecessary “Real” local data on need unnecessary - synthetic estimates were an acceptable alternative Did service provision change?

32. More examples of HEAs 1.Revascularisation for patients with CHD How does uptake compare with need among residents of the most deprived and the least deprived wards in an area? 2.Health visiting and children’s services Is school nurse time allocated in relation to need - how might the latter be measured? 3.Do people from black and minority ethnic communities use primary and secondary care services? 4.Further examples in NICE “Learning from Practice Bulletin” http://www.nice.org.uk/niceMedia/docs/HEA-bulletin-FINAL-NEWISBN-25-02.pdf

33. Measures of need in HEAs What measure(s) of need might be useful in an HEA of.... general practices in a PCT area health visitor services a local flu vaccination programme services provided by a GUM clinic services for people with lung cancer chest pain clinic What measure(s) of need were used in.... any local case study of your own

34. Cycle of health equity audit 1 Agree priorities and partners 3 Identify local action to tackle inequalities 4 Agree local targets with partners 5 Secure changes in investment and service delivery 6 Review progress and impacts against targets 2 Equity profile The cycle isn’t complete until something CHANGES to reduce inequity

35. Step 3: Identify effective local action Understanding why the inequity is occurring? What local interventions might help? –Are there examples of effective action elsewhere? –Prioritise highest impact interventions What is feasible and affordable?

36. Step 4: set targets for action –Prioritise groups with the poorest level of service/greatest levels of unmet need –Identify what should happen to who and by how much –Targets should be clear and signed up to by all Step 5: secure changes in investment and service delivery –Move resources and change service delivery to address inequities –Ensure changes in contracts & commissioning to specify equity of access Step 6: monitor and review –Vital to close the loop –Set up effective monitoring systems and a regular review process –Assess progress - have targets for action been achieved and inequity reduced? –Identify whether and where more remedial action is required... and round the cycle again

37. health impact assessment

38. HIA is… …a combination of procedures, methods & tools …that systematically judges the potential, & sometimes unintended, effects of a policy, programme or project … on both the health of a population, & the distribution of those effects within the population …HIA identifies appropriate actions to manage those effects International Association for Impact Assessment 2006

39. …NOT statutory but widely advocated (Acheson) Inequalities in Health (1998) Our Healthier Nation (DH 1999) Article 152, EU Amsterdam Treaty (1999) DH & NRU guidance (2002) Securing Health (Wanless, Treasury, 2004) Choosing Health (DH 2004) Council for Science and Technology 2006 HIA is…

40. Assessing the impact of a health intervention Prospective=HIA Concurrent=Monitoring Retrospective=Evaluation

41. Applications of HIA new urban housing scheme proposed waste incinerator new casino in Manchester hospital vending machines policy third runway at Heathrow motorway widening leisure centre charging policy home energy efficiency scheme

42. Health Impact Assessment: key steps 1.List all the aspects of the proposal that are likely to have an impact on the health of the population 2.Decide whether the identified impacts are positive (+) or negative (-), i.e. are they likely to make people’s health better or worse? 3.Identify when this impact is likely to occur, i.e. in the short, medium or long term? 4.Decide how certain you are that the impact will occur, i.e. is it definite, probable or speculative? 5.Note likely differential impacts on different groups (e.g. women, children, elderly people, BME communities, etc.) 6.identifying recommendations for maximising the positive and minimising the negative health impacts of the proposal.

43. HIA: Home Energy Efficiency Scheme

45. www.apho.org.uk

46. Welcome to the world of impact assessment! Environmental Impact Assessment Strategic Environmental Assessment Sustainability Appraisals Equality Impact Assessment Integrated Impact assessment Health Impact Assessment Privacy Impact Assessment

47. Learning Objectives 1.To consider concepts of need 2.To consider dimensions of equity 3.To understand what is meant by: Health needs assessment Health equity audit Health impact assessment 4.To be aware of other forms of impact assessment