1. HELED Health Need assessment 17.9.2007 Grete Botten

2. Signature (unit, name, etc.) The goal of the course Exploring the demographical and epidemiological changes of health problems and diseases (medical needs) Epidemiological changes will be related to the political, social and economic situation for various population groups (gender and age, socio-economy, ethnicity, etc) and in different countries and priority questions Demographical and epidemiological data will be used to assess future need for health care in different settings

3. Signature (unit, name, etc.) Learning objectives Be familiar with demographic terms, trends and projections Be able to find and use vital statistics in planning health services Know basic epidemiological concepts and be able to use them in order to perform need assessment Be able to identify epidemiological changes globally and to present evidence as to why this changes have happened Be able to interpret trends and use techniques to make projections to estimate need for future health care services See the relationship between the concepts need, demand and supply Relate need to priority and effectiveness Use need assessment as basis for resource allocation

4. Signature (unit, name, etc.) A systematic method of identifying unmet health and healthcare needs of a population, and making changes to meet those unmet needs The objective is to Specify services that will improve the health of the population What is Health Needs Assessment (HNA)?

5. Signature (unit, name, etc.) Central concepts related to health need assessment Needs Demand Supply Efficiency Priority

6. Signature (unit, name, etc.) Health Needs Assessment Used for service planning, monitoring/ evaluation, responding to changing needs Internal market/commissioning (like England) Three approaches to HNA have been suggested: -Epidemiological (focus in this course) -Corporate -Comparative

7. Signature (unit, name, etc.) The idea of need assessment Health services may be based on two opposite ideologies –Based on planning within a public ownership –Based on market and competition Within a planned service without market mechanism, facilities and capacity should meet the need of the population –Need assessment relevant for planning the services (within budget) –Need assessment relevant for the purchaser in in a provider/purchaser split model Within a competitive market services will develop in response to the demand –Need assessment relevant for the owners, as they need to know the market situation

8. Signature (unit, name, etc.) What is included in Health Needs Assessment? Defining “disease” and services Know the prevalence of diseases Know the number that should be served Know the medical guidelines for examination and treatment- “state of the art” Know the services available and their cost

9. Signature (unit, name, etc.) How should need be defined? Medical definition –Linked to diagnosis –Linked to guidelines for examination and treatment/care –Often expressed as the optimal, no resource limitations Lay people/patient defined –Linked to suffering –Linked to human/patient’s right Management defined –Linked to resources and “the contract” Politically defined –Linked to patients’ rights –Linked to resources –Linked to priority

10. Signature (unit, name, etc.) Person with a health problem Seeks health care Get an examination of a GP – and treatment and follow up Is referred to specialist health care/hospital Get further examinations and treatment Is followed up by various professionals/GP NEED?NEED? The entire population

11. Signature (unit, name, etc.) ”Need” for health care A medical concept refecting Need is supposed to be linked to ”objective” prevalence of disease/illness and the existing “state of the art” examinations, for treatment and care Need is related to measures for a population that reduces their risk for becoming ill Need is thereby defined according to criteria given by health professional But Need links to the process of being diagnosed/not diagnosed, based on symptoms, complains and questions about being sick Need is closely inked to possibilities and expectations and links to medical and lay people’s culture and beliefs Need has a political dimension and is linked to priority Within public health the political dimension is most evident Saying that Need is not (only) objective and globally equal for the equal diseases/patients or populations

12. Signature (unit, name, etc.) Relation between medical and lay peoples need conncept Lay people perspective Political perspectine Sick/needNot sick Medical perspective Disease/needAgree about need Who define need No diseaseWho define need Agree about no need

13. Signature (unit, name, etc.)

14. Unmet needs essential to identify Identifying unmet need requires a public health focus which includes those not getting/seeking services Need large surveys to identify those not identified through the health services The relationship between –needs (unidentified, unmet, and met) –services (appropriate and inappropriate)

15. Signature (unit, name, etc.) Factors that will influence need for health care in a population Demographic changes New technology (both increase and reduce demand) Prevention like vaccination, less smoking (public health measures)…. Identification of risk factors and possibility for reduction (need assessment in itself) New knowledge and changing attitudes

16. Signature (unit, name, etc.) Demand for health care An economic concepts, reflecting The percieved need for services –Population –Patients –Health personell (throug their referrals …) The willingness (ability) to pay for the services –Services are unlikely to be paid directly –Asymmetric information…. What influences demand?

17. Signature (unit, name, etc.) Supply of health care An economic concepts, reflecting What services are offered (in the market) The price of those services –Often unknown both for ”buyer and seller”, at least in a public system What will influence supply

18. Signature (unit, name, etc.) Need, demand and supply - summary Need (medical) relates to the prevalence of a disease – what people might benefit from and the number of people with a need Demand relates to what is actually asked for in a market – expressed need Any difference between them is unmet need Supply relates to which services are offered in the marked Met need is the services the population actually gets However Need at the political/policy level relates to priority and efficiency

19. Signature (unit, name, etc.) NEED DEMAND SUPPLY More details in Stevens

20. Signature (unit, name, etc.) In a ”perfect situation” need, demand and supply would be equal Need may exceed demand Demand may exceed need (as it is medically defined and prioritized) Supply may be less than demand (and need) resulting in regulation/rationing – and queuing May supply be higher than demand?? Unstable situation

21. Signature (unit, name, etc.) Different scales/levels of HNA National level Regional level/County level Municipality level Community GP/clinical level

22. Signature (unit, name, etc.) National level Relevant for –National strategies to improve the services for eg Specific/defined patient group Build new facilities –Public health activities eg Legislation Vaccination program (influenza) –Reduce inequity eg Assess the unmet need in various groups (based on diagnosis or social criteria) –Monitoring the situation / evaluation –Allocate resources according to needs On national level important question: –Do all geographical areas get equal amount of resources, related to their population (need)? –Do all population/patient groups get equal access to the health services as response to their need

23. Signature (unit, name, etc.) Regional/county level Need assessment relevant when –services are delivered at the regional level (provider) –public health programs aim at reaching a regional population The same questions as at national level

24. Signature (unit, name, etc.) Local municipality/community level In a provider/purchaser split model (know what to buy) Planning necessary services for the local population/various patient groups Hire health personnel to cover the need of the population, eg. in a patient list system, for nursing homes etc For offering local private services

25. Signature (unit, name, etc.) Focus i HNA Individual need or populations’ need? –Focus is populations’ need (as a sum of the individual needs) –Public health has per see a population approach Specific diagnosis or relevant services? –Focus is on need for services more that diagnosis –Different medical diagnoses may need the same services The past, present or future? –Focus is on the future (developing services for the number of people in the future) –Implement public health measures that reduces health problems in the future

26. Signature (unit, name, etc.) Health Needs Assessment Used for service planning, monitoring/ evaluation, responding to changing needs Internal market/commissioning Three approaches to HNA have been suggested: -Epidemiological -Corporate -Comparative

27. Signature (unit, name, etc.) Epidemiological approach Statement of the problem Subcategories (i.e. type 1, type 2 and gestational diabetes; severity categories for dementia) 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

28. Signature (unit, name, etc.) Components in an epidemiological approach to HNA Defining the problem and objectives Define the population Prevalence and incidence of the actual health problem (in relation to treatment possibilities, not etiology) Number intended to be covered/treated Models and guidelines for treatment Available services, their cost and their cost- effectiveness Recommendation Model for future evaluation Research requirement

29. Signature (unit, name, etc.) Corporate Approach Based on the demands, wishes and perspectives of interested parties - professional, political and public views Blurs difference between need and demand, and between science and vested interest Encouraged by the 1989 reforms with its ‘local voices’ and current emphasis on partnership and collaboration [and public involvement] Essential if policies are to be sensitive to local circumstances

30. Signature (unit, name, etc.) Comparative approach Contrasts the services received in one area with those elsewhere Should take into account local population characteristics (demography, mortality, morbidity)

31. Signature (unit, name, etc.) Methodological aspects Approaches to Health Need Assessment –Population perspective –Use indicators that may express need (suurogates may be valuable) – Types and sources of data (vital statistics, demography mm) Analysing and interpreting the data Conclusions

32. Signature (unit, name, etc.) Incidence/prevalence of disease Number of people Existing services Effectiveness/ Cost/effectiveness The future services

33. Signature (unit, name, etc.) Need Time 2005 Illustration how need may be developing in a population 2015 The supply

34. Signature (unit, name, etc.) Table 3 in Stevens - etc. The concepts Efficacy/effectiveness Size of effect (scaled) Quality of evidence about effectiveness –Several RCTs –One RCT –Clinical intervention trial (non RCT) –Uncontrolled experiments –Opinion based on experience –Non evidence

35. Signature (unit, name, etc.) Methodological problems related to Inadequate date on incidence/prevalence Inadequate date on effectiveness and cost/effectiveness Lack of agreement on threshold for intervention Heterogeneous patient group Treatment complex and often several possibilities

36. Signature (unit, name, etc.) Role of need assessment i NHS Health care needs of a defined population Appraisel of service options for meeting the needs Specification of pattern of service provision Choosing providers Contracts Health services is bought on behalf of a population Populations ability to benefit from health care must be included A balance between enough information and not too many details

37. Signature (unit, name, etc.) Summary Need will be defined and discussed in a medical context, both within care and public health Demograpfy must to be taken into consideration, a population approach In four cases you will apply such need data and relate them to reality in different settings Use of need indicator as basis for resource allocation will be discussed in a last lecture