The Norfolk Needs Assessment Tool Box

Version 2

April 2002

Produced under the auspices of the Norfolk Public Health Nurses Forum

Comments and requests for further copies (electronic or paper format):

Dr Peter Brambleby
Director of Public Health
Norwich Primary Care Trust
St Andrew’s House
Thorpe St Andrew
Norwich NR7 0HT

Tel: 01603 307206

Fax: 01603 307104
e-mail: peter.brambleby@norfolk.nhs.uk

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 The Norfolk Needs Assessment Tool Box
Version 2

Contents

Read items marked * for rapid scan of main messages

1. Introduction

1.1 About this Tool Box 3

1.2 About the Norfolk Nurses Public Health Forum 3
1.3 What is “Needs Assessment”? Definitions 5*
1.4 Lessons from elephants 6
1.5 When is needs assessment used? 7

2. Practical techniques

2.1 What techniques are available to assess needs? 9

2.2 How to do a population needs assessment 11*
(“What are the needs of our population?”)
2.3 How to address a problem-solving needs assessment 12*
(“Do we need this?”)
2.4 How to prioritise a list of needs 14
(Economic considerations)

3. Epidemiological considerations

3.1 Denominators 15
3.2 Rates 16
3.3 Standardisation 17

4. The difference between “need”, “demand” and “supply” 19*

(Needs assessment as part of demand management)

5. References and further reading 23

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1. Introduction.
1.1 About this Tool Box
This tool box has been produced in response to requests for help from a
variety of sources from within the NHS and outside.

Some people want to do their own needs assessments but don’t know where
to start. Others have been asked to give a perspective on some-one else’s
assessment but don’t know what it’s all about.

Please use it as a resource. It can be read from start to finish to give a

comprehensive overview, or just dipped into for its ideas, definitions and
theoretical frameworks.

It began its development under the auspices of the Norfolk Public Health
Nurses Forum, and had a predominantly “health needs” focus, but has since
been discussed with Social Services and various other statutory and voluntary
organisations and is intended to be a resource for any caring agency. The
approach and techniques should apply in most situations where the needs of
groups of people are being reviewed.

Perhaps the most important concept is that of “needs addressment” – a new

term invented by the Norfolk Public Health Nurses Forum. The process of
assessing needs should never be divorced from addressing them, either with
new resources or redeploying existing resources

1.2 About the Norfolk Nurses Public Health Forum

Following an inaugural meeting on 25 June 1999 it was agreed that a forum

would be set up – one that would continue to meet on a regular basis. It is
convened by the Director of Nursing and Quality at Norwich Primary Care
Trust but covers the whole of Norfolk. Its remit is to:

ƒ Help implement the national agenda for developing the public health role
of nurses
ƒ Raise the confidence and competence of nurse members on boards of
Primary Care Trusts
ƒ Provide a focus for sharing experience, learning and peer support.
ƒ Provide a link with the Public Health specialists.

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Nurses Forum’s initial views on the advantages of needs assessment:-

ƒ bring together people who don’t often work together

ƒ more co-operation
ƒ better team work
ƒ shared information and understanding
ƒ provide a forum for the public and professionals to get together
ƒ break down professional barriers
ƒ allow bottom-up priorities to emerge
ƒ break down paternalistic and professional dominance so that issues of
local public relevance can surface
ƒ a first step in community development
ƒ a useful management tool for review of services, fairer distribution and
better use of resources
ƒ identify and plug gaps
ƒ encourage the broadest view of health and well-being (not just a bio-
medical “disease” model)
ƒ introduce the rigour of evidence-based planning to service development
ƒ improve services on the ground
ƒ improve the quality of data collection as data are seen to be used to
greater effect
ƒ allow people to see the needs in their patch in a wider, comparative
context

Nurses Forum’s initial views on how to go about needs assessment:-

ƒ it is necessary to formulate clear questions before embarking

ƒ time of participants is a scarce resource that should not be wasted
ƒ project management discipline is required to prevent drift
ƒ academic rigour should apply: assessments need to stand up to scrutiny,
especially where changes are brought about
ƒ contributors might find participation intimidating, so openness and
tolerance of inexperience should also apply
ƒ needs assessments should be seen to make a difference
ƒ information gleaned and gaps identified should be recorded and shared so
that learning takes place
ƒ specialist public health may be needed, for example with comparative
data, but grass-roots input is almost always needed.
ƒ there are immediate and continuing training needs in this field (one reason
for producing this tool kit!)

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1.3 Definitions

“Need” can be said to exist when people could

benefit from some sort of intervention – that their lives
would be measurably improved if this gap was filled.

The only distinction between a “health need”, “health care

need”, “social need”, “educational need” and so on, is the
way in which the question is phrased and the means by
which it is remedied. These needs frequently overlap and
it is usually unhelpful to be too restrictive at the outset of
an assessment. Narrower focus can be introduced later
once the parameters are clearer.

“Needs assessment” is the process of

identifying both the nature and scale of needs as
defined above. Its purpose is to tease out gaps and
priorities. Sometimes this is in absolute terms, as in:
“How many people need this?” or “Do we need this?”.
Sometimes it is in relative terms, as in: “What are our
community’s needs relative to the rest of Norfolk?”, or
“Which three needs should we address first?”.

The themes of measurability and ability to benefit are

central to the process.

Needs assessment deals with populations, and aims to:-

ƒ be objective, systematic and valid
ƒ involve the population served
ƒ include a range of “key informants”, particularly those
with special interest and expertise in the subject
ƒ use a number of agencies and methods of collection
ƒ come up with recommendations for change

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1.4 Lessons from elephants

(Skip this section if you do not find allegories helpful!)

Rather like an elephant, a ‘need’ is easier to describe than define, but

everyone knows one when they meet one. Or do they?

There is a story from the Far East of three blind men in the forest who
encounter an elephant. The first has put his arms round a leg and calls out
“Careful – I’ve just walked into a tree!” The second has hold of the tail and
says to his friends “Yes, and someone’s left a rope hanging down!”. But the
third feels the trunk and shouts out “No! It’s a snake! Run for it!”. The point of
this story is that “need” is a multi-faceted thing, and is viewed differently by
different people at different times. In general it is better to explore it in several
ways in order to build up a more complete picture than to rely on a single
technique or just one perspective.

In another story, a sculptor, famous for his detailed carvings of elephants, was
asked how he went about it. “Easy”, he said, “I just take a block of stone and
chip off anything that doesn’t look like an elephant!”. But that’s the skill. In
the case of needs assessment, it’s the ability to approach a wealth of data and
see the “elephant” hidden within the stone.

Question: How do you eat an elephant?

Answer: A bite at a time!
Moral: Complex tasks like needs assessments have to be broken down
into bite-sized chunks.
Corollary: Complex electronic databases have to be broken down into
byte-size chunks!

Do not be over-elaborate. If it looks like an elephant, walks like an elephant

and sounds like an elephant it probably is an elephant. Do not fall into the
“paralysis by analysis” trap and do not let a “needs assessment” become a
stalling exercise or a substitute for action.

Don’t let your needs assessment exercise become like an elephant with
constipation – ie, three months of intense straining, followed by a loud report,
after which the whole lot is dropped!

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1.5 When is Needs Assessment useful?

1.5.1 Taking the initiative, scanning the whole population, setting the agenda:
as in these questions:

ƒ “ What are the top five health care needs of our practice population, or
of our Primary Care Trust?”
ƒ “What factors do our population believe affect their health or well-being
adversely?”
ƒ “What are the major inequalities in health or well-being across our
county?”
ƒ “What are the top three social care priorities for our senior citizens?”
ƒ “What are the health and educational needs of children in care?”
ƒ “Given our current budget for coronary heart disease, could we deploy
it to better effect?”.

This is horizon-scanning stuff. The initiative is taken by the needs assessors

and the answers will set in train new lines of work. It helps to set the agenda
and sort out priorities from a very long list when one is are starting from
scratch and doesn’t know where to begin. It tends to be deliberately wide in
its scope, and usually looks for relative importance amongst a range of
possible needs.

1.5.2 Responding to a specific proposal or demand:

as in the questions:

ƒ “Do we need to use this new drug in our hospital?”

ƒ “Do we need another health visitor in our practice, or social worker on
our discharge ward?”
ƒ “Do we need to introduce a screening programme for a specific
disease?”
ƒ “Should we suspend a particular service because it is no longer
needed?”

It is often forced upon planners in response to a direct request for a new

service or some external pressure. It is very focused in its remit and tends to
look at a single drug, surgical technique, screening programme, service,
specialist input, disease or client group.

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1.5.3 Needs “Addressment”.

This is a new term, coined by the Nurses Forum. Just as in clinical practice
one tries never to request a test on a patient unless the result will affect the
clinical management, so in needs assessment one would not embark on a
project unless there is some prior commitment to act on the findings.

Needs assessment can be time-consuming and expensive, and it raises

expectations. It involves the scientific disciplines of

- epidemiology (to identify the nature and scale of the problems) and
- economic appraisal (to identify cost and savings, benefits and
disbenefits of doing different things and doing things differently).

There must be some clear end in mind, and action must follow, otherwise the
needs assessment will be futile and the engagement of others will be harder
to secure next time around.

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2. Practical techniques
2.1 What techniques are available to assess needs?
Broadly, there are three techniques:
1. Analysis of routinely held data
2. Acquisition of information from local informed sources
3. Surveys of those who live in the area or use the services

2.1.1 Routinely available data at national or local level, such as:

ƒ census-based population statistics (numbers of people, age profiles,

housing tenure, car ownership, self-reported limiting illness, etc),
ƒ births and deaths statistics,
ƒ data on current resource allocation – money, staff and facilities – and
future expectations
ƒ data held by local authorities, benefits agencies, police
ƒ hospital utilisation data held by health authorities
ƒ data held by general practices, now rapidly getting easier to access, such
as disease registers, community contacts, prescribing.

These have the advantage of being fairly readily available and “pre-digested”
(e.g. rates and comparative information calculated as in the national public
health common data set, Health Authority annual report of the Director of
Public Health, reports from Housing, Voluntary Agencies, Education, Police
and Social Services, and PCG profiles). They allow comparisons between the
locality of interest and similar localities elsewhere.

This aspect of a needs assessment is often best handled by data analysts

who have access to large databases and experience in dealing with
spreadsheets.

Remember: routinely available comparative data are almost always

useful, but very seldom sufficient on their own to complete a needs
assessment. There is no substitute for up to date information, drawn
directly from the people affected, couched in their own terms (see
below).

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2.1.2 “Rapid participatory appraisal”
(“focus groups”, “key informants” or “health forums”).

One of the fastest and most useful techniques is “participatory appraisal”.

Here, a group of local informants such as health workers, social workers,
patient support groups, teachers, police, clergy, women’s groups, community
health councils, elected members of local government and so on can get
together and give rapid opinions of what the needs and gaps are. Health
forums that exist in most Primary Care Trust areas are a good example. Most
primary care groups have experience in drawing on their input. Focus groups,
perhaps convened on an ad hoc basis for a single issue, are a similar
concept.

2.1.3 Surveys of the population

The third approach is to conduct a survey – by post, telephone or interview -

and simply ask a random sample of the population what their views are. This
can be done in a structured, semi-structured, or totally open format. It can
contain open questions about what they feel the health needs are, or direct
them to specific areas that the assessor wants to explore. Surveys are also a
way of getting reaction to a health needs assessment that has already been
conducted, to validate its findings and see if the respondents can spot gaps.

In choosing a sample of the population for a survey, care must be taken that
they are a representative cross-section so as not to introduce bias. It helps if
the sample is truly random, and it also useful to know the characteristics of
any non-responders just in case the views of an important sub-group have
been omitted.

A number of statutory and voluntary caring agencies conduct periodic surveys

or “market research”. It makes sense to pool effort, pool resources and pool
results. Local strategic partnerships are one such forum, led by local
authorities, and as they get off the ground they should be used to full
advantage.

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2.2 How to do a population needs assessment
(“What are the needs of…?”
1 Formulate a clear question, or questions, that your needs assessment
will address. Rather than just asking open questions about what might
be done in an imaginary ideal world, it is often better to phrase a
question along these lines: “Given our present level of resources (money,
people, facilities, partners), and what we can reasonably expect in the
next few years, are there better ways of aligning them with what our
population needs?”
2 Check the question, or questions, with the people who commissioned
the assessment and who will act on the findings
3 If it’s a big project, convene a project group; agree the tasks, timetable
and administrative support.
4 Check to see if anyone has done something similar, from which you
could learn, either locally or from a literature review
5 Discuss the project with the Public Health Department at the Health
Authority – they will be able to help you design your needs assessment
and may be able to provide the comparative data from routine sources
that are part of the assessment or put you in touch with others who can.
6 Identify routine data sources that might help (taking advice from Public
Health Department, University, information department of local trust,
local authority, police, etc). This might shed light on the questions being
addressed and provide comparative information about other localities to
put the findings into context.
7 Think of informed local sources for “participatory appraisal”, either
something like a health forum that already exists, or a new focus group
convened specifically to address the question.
8 Think of a representative sample of the local population who could be
approached for a population survey.
9 Consider testing your methodology with a pilot, especially if you are
treading new ground.
10 Go for it! Local flavour and local participation are the greatest strengths!
11 Validate your assessment and draft recommendations by feeding back
to the people who contributed and the people who are affected by
change.
12 Agree the priorities and gaps you have identified, at Board level in the
participating organisations, and start addressing them!
13 Register your project with the HImP partnership so that others can tap
into your experience. This is also an important record to ensure
standards, openness and corporate governance.
14 Conduct a “de-brief” or “washing-up” session with your group to see if,
with hindsight, it could be handled even better in future.
15 Depending on the importance and generalisability of your assessment,
consider publishing your findings in a peer-reviewed journal.

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2.3 How to address a problem-solving needs assessment
(“Do we need a ….”)
(Note: this section was drafted from a health care perspective, but is probably
applicable in other types of need, such as social care and education.)

Most of this resource pack deals with pro-active population-based needs

assessments, but situations can arise – often prompted by a local provider of
services – when the question is: “Do we need a new member of staff, … or
building, … or major piece of equipment, … or screening programme, … or
expensive new medicine…and so on?” In the case of new medicines there is
an established policy for handling these at primary care level, in secondary
care trusts (Drugs and Therapeutics Committees) and whole-county level
(Therapeutic Advisory Committee), but for others the decision-making process
and checklist for scrutiny are less well established at present.

The following list (all beginning with “E” for convenience) may be helpful.

Epidemiology What is the nature and scale of the problem in our area, for
which this innovation offers a solution?
Can we estimate the prevalence (existing cases) and
incidence (new cases)? Note: with a new service there may
be a temporary prevalence “pool” to mop up, followed by a
different steady state when new cases balance those being
cured or dying.
What are the likely demographic trends over time?

Effectiveness What is the quality of the evidence of effectiveness?

Has there been a head-to-head comparison with current
practice, rather than just placebo, and what is current
practice in our patch?
Can the research evidence be extrapolated to our area?
How many people will benefit? (“numbers needed to treat”)
What are the likely benefits, eg longer life, improved quality of
life, better experience of care, or improved efficiency?
What are the adverse effects of the intervention, and how
many people will be expected to have them? (“numbers
needed to harm”.)

Economics What are the added costs of the new intervention in our area,
if any, over what we do at present?
Are there savings - do they release money, staff, facilities?
Where and when do costs and savings fall?
Do we judge that the overall added benefit is in proportion to
the overall added cost?
How do the benefits of using resources in this way compare
with other ways of using the same amount of resource?
Is there some other, perhaps unrelated, area of activity in
which we should now disengage?

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Expectations What, if anything, do we know about what local patients and
professionals want? Note: if there is little outside pressure,
especially from the public, there is less chance of the issue
getting priority. This is not a defence of “prioritising by
decibels” but a reminder that commissioners need to show
that they are responsive to local needs and wishes.

Equity How well does this proposal fit with the current Health
Improvement Programme or Service and Financial
Framework, and do they need to be re-negotiated?
Are we satisfied that we are maintaining a fair distribution of
resources between care groups and providers?
Will the new initiative increase or reduce inequalities?

Education How will we raise awareness of the changes?

Is staff training required in any of the collaborating
organisations?
Who will compile the guidelines for staff, patients and carers?
Is this such a significant change that a major publicity
campaign or public consultation is called for?

Execution How do we make it all happen?

Are shared care protocols needed?
What does the patient pathway look like now, and can we
enshrine that in a new long-term service agreement?

Evaluation How will we know if it is all working according to plan?

What programmes of clinical audit, contract monitoring and
reporting do we need to establish?

Adapted and expanded from:

Best L, Stevens A, Colin-Jones D: Rapid and responsive health technology assessment: the
development and evaluation process in the South and West region of England. J Clin. Effect., Vol 2, No
2, 1997, 51-6

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2.4 How to prioritise a list of needs
This is the domain of Economics – the discipline that deals with scarcity and
choice. In some specific clinical areas, such as cancer or stroke, there are
validated “instruments” (sets of questions) for assessing the outcomes of
treatment, but comparing between different types of need is always difficult.
There has been expansion in the department of health economics at UEA -
(try Ric Fordham at UEA – 01603 593543). Meanwhile, even though we often
fall back on qualitative judgements, we should still be systematic and open
about the reasons for our decisions.

• Look at the numbers of people who will receive the new service or
treatment
• Estimate the numbers who are likely to benefit (may be all those receiving
the new service, but depends on the evidence about the particular
intervention)
• If it is an intervention with possible adverse effects (eg false positives in a
screening test or dangerous side effects from a new medicine), estimate
the possible scale of harm
• Look at the kinds of effects being generated, for example:
♦ length of life
♦ quality of life
♦ relief of pressure on carers
♦ improved efficiency of service
♦ improved conditions for staff
♦ benefits for other caring agencies (eg invest in health care to reduce
pressure on social care)
• Look at the magnitude of that effect (By how long is life extended? By how
much is quality of life enhanced?)
• Look at the duration of that effect: …a few months? … a few years?
• Look at all the costs (not just cash, but travel time, time off work, etc) and
the savings too. Don’t just focus on the caring agencies, think of the
patients and families too. Ask for the help of a health economist if the
scale of the changes warrant this
• Having looked at all these factors, try to prioritise those which give the
greatest health gain – ie, combination of length and quality of life – and
then look at relative costs and affordability. Do this in a qualitative way,
when quantitative ways are impractical. Try to make it clear what the
reasoning is.
• Remember: data on costs and outcomes can only ever be estimates;
certain vulnerable groups may need a protected (or “weighted”) share of
resources; national priorities and imperatives have to be accommodated; it
is justifiable to adjust the priority list so long as the reasons are clearly
stated and the final decision taken in open forum.

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3. Epidemiological considerations

3.1 Denominators

Remember studying fractions at school? The number on top is the numerator

and the number on the bottom is the denominator.

Now think of needs assessments.

The number of “needy” people identified is the numerator. The population

from which they are drawn is the denominator. Deciding on the relevant
population to act as the denominator can be difficult.

Take a Primary Care Trust (PCT) for example.

Its population could be taken as the people registered with the practices that
make up the PCT, wherever they live, or those who are resident within the
PCT boundary drawn on a map, whether they are registered with practices in
that area or not.

We know about practice populations broken down into age and sex groups, so
we can calculate rates (another term for fractions) for the needs and NHS
activity that goes on in those practices. For example, we could look at
numbers of health visitors attached to each practice per 100 children aged
under 5 years in the practice, or per 100 low birth weight babies born in the
previous year. In this example we are relating provision of a service (health
visiting) to indicators of need (pre-school children and vulnerable new-borns).

But suppose we were looking at house ownership, or unemployment, or social

deprivation (which is based on replies to the ten-yearly national census) in the
PCT area. This information is not routinely available from GP records. In this
situation we might use resident, as opposed to registered, population. Instead
of GP practices being the building blocks which add up to a PCT total, we
could look at electoral wards or post-codes falling within the geographical
boundary of the PCT. The difference between registered and resident
population in PCTs in Norfolk is +6.7% to –1.9%.

The practical relevance of this for needs assessments at the level of primary
care or community services is the selection of a population that suits the data
available and suits the purposes of the study being conducted.

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3.2 Rates

In needs assessments it is usually necessary to know both numbers and

rates. Rates are essential to make comparisons between geographical areas
that have different population sizes, and to look at trends over time if a
population is growing or shrinking.

Three tips about interpreting rates:-

ƒ Always have a look at the size of the population from which the rate was
calculated – if the population is small a large change in rate can arise from
a small change in numbers.
ƒ Services are delivered for numbers of people, not rates! The rate of
pregnancies in village A may be 10/1000 and in city B be only 5/1000, but
if the population of B is 100 times larger, then most births will occur in B
and that may be where to concentrate the services. Similarly, the rate of
Down’s syndrome babies rises with mother’s age, especially over the age
of 40, yet most Down’s babies are born to young mothers because that is
where most births occur.
ƒ Rates can either be “crude” where all events are divided by the total
population, or they can be “specific”, for example age specific, sex specific,
social class specific, ethnicity specific and so on.

Here are some of the more commonly reported rates:-

ƒ Incidence. The rate of new cases arising in a defined population in a
defined period, eg the incidence of meningitis in school aged children in
Norfolk in 1999. It is particularly useful for acute events or illnesses.
ƒ Prevalence. The rate of existing cases in a defined population at a point
in time, eg the prevalence of rheumatoid arthritis in females aged 20-64 in
Norfolk on 1 January 2000. It is particularly useful for chronic diseases.
ƒ General fertility rate. This is a form of birth rate, being the number of
registered live and still births (ie all births) per thousand women aged 15-
44 (ie of child-bearing age), per year.
ƒ “Teenage” conception rate. As used by NHS planners to track trends
and targets: the number of live and still births, plus the number of
registered terminations of pregnancy, per thousand girls aged 13-15 years,
per year. Note that it counts just three of the teenage years and excludes
miscarriages, so the title is not a precise one.
ƒ Perinatal mortality rate. The number of stillbirths and deaths occurring in
the first seven days after birth per thousand live and still births (ie
proportion of all babies born who died just before or soon after birth). It is
a useful indicator of factors affecting the health of pregnant mothers and
their newborn infants.
ƒ Infant mortality rate. The number of deaths in the first year of life per
thousand live births. Note that stillbirths are left out of the numerator and
denominator – this indicator just looks at outcomes for babies born alive.
ƒ Low birth weight rate. This is the number of live babies weighing less
than 2,500g at birth, per thousand live births. It is used increasingly
frequently as an alternative to mortality rates in infancy because it picks up
additional factors and the numbers are much greater.

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3.2 Standardisation

A technique for getting around the problem of making comparisons between

populations that have different structures (typically in relation to age and sex)
is to standardise them so as to compare on a like-for-like basis.

There are two approaches to standardisation: direct and indirect.

Direct standardisation. In this technique a “standard” population is chosen,

such as the UK population or (increasingly frequently) an imaginary
“European Standard Population” (ESP, see below). Direct standardisation
against the ESP is easy if you know the age-specific rates in your own
population broken down in the 5-year age bands used in the ESP. Simply
multiply each age-specific rate by the number of people in the same age band
on the ESP table, and add up the totals to give an ESP-standardised rate.
Obviously, since this was an imaginary population the actual figure is
relatively meaningless, but compared with other ESP-standardised rates it is
instantly meaningful because differences in rates cannot be due to age or sex.
Direct standardisation is most useful when wishing to make direct
comparisons between populations with different age or sex structures.

The European Standard Population (ESP)

The ESP is widely used to compute directly age-standardised rates. The same
population is used for males, females or all persons.

Age Group European Standard Population

0 1,600
1-4 6,400
5-9 7,000
10-14 7,000
15-19 7,000
20-24 7,000
25-29 7,000
30-34 7,000
35-39 7,000
40-44 7,000
45-49 7,000
50-54 7,000
55-59 6,000
60-64 5,000
65-69 4,000
70-74 3,000
75-79 2,000
80-84 1,000
85+ 1,000
Total 100,000
Source: 1991 World Health Annual of Statistics – based on J Waterhouse et al (eds). Cancer Incidence
in Five Continents, Lyon, IARC, 1976 (Vol. 3, p 456)

17
Indirect standardisation. This is useful in making comparisons in rates
between one population (such as Norfolk) and a real “standard” population
(such as the UK). Its most familiar use is in the “standardised mortality ratio”
(SMR), but it applies equally to standardised illness ratios, standardised
hospital admission ratios, or other such events.

To perform an indirect age standardisation you need to know the age-specific

(and sex-specific too if you wish) rates in the standard population. Multiply
these by numbers of people in each of those age bands in your study
population. The total of all of these gives you an “expected” number of events
– ie the number you would expect if standard rates applied in your population.
But you may well have observed a different number in reality. If the
“observed” events are divided by the “expected” events and multiplied by 100,
it gives the standardised ratio. The figure you get is instantly meaningful. If it
is greater than 100 then the events are occurring at a higher rate in your study
population than the standard population, and if less than 100 then at a lower
rate. Differences in age (and sex) structures of the two populations have
been taken out of consideration.

Statistical significance. Some published sources, such as the PCG profiles

produced in 2000 for Norfolk and the national Public Health Common Data
Set, give 95% confidence intervals for SMRs. This gives a range within which
you can be 95% certain that the “true” value lies. It is particularly helpful in
smaller populations where the reliability of the estimate is weaker. A 95%
confidence interval, eg 102-134, gives the lower and higher value of the range
within which the true SMR is likely to lie. In this example even the lowest
estimate is above 100 so the SMR can be said to be statistically significantly
higher than 100. If the 95% confidence interval for an SMR was 87-98 that
would be statistically significantly lower than 100 because even the highest
estimate is below 100. If the 95% confidence interval for an SMR was 85-105
that would not be statistically significant because the figure 100 falls within the
range.

18
4. The difference between “need”, “demand” and
“supply”

Need (the ability to benefit in some measurable way) is not the same as
demand (what patients ask for) and different again from supply (what is on
offer for them). To illustrate the differences the following schematic
presentation relating to secondary care (hospital) services may be helpful.

Have a look at diagram 1 (representing where we are now) and diagram 2

(where we aspire to get to in an ideal system). These are schematic, and not
drawn to scale, but as a general framework they are pretty robust. Diagram 1
appeared in NHS guidance back in 19911.

Diagram 1
Need, Demand and Supply for secondary health care – the present.

Diagram 2
Need, demand and supply for secondary health care – the objective

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In these diagrams:
ƒ “Need” is the ability to achieve a measurable change in health status as a
result of a secondary health care intervention. Technological advances
push back the boundaries of need – for example, before there were
effective coronary artery re-vascularisation procedures the NHS did not
have to assess the need, but now it does. “Need” can also be defined
arbitrarily for local circumstances – for example most health authorities
have decreed that tattoo removal is not a legitimate NHS need.
ƒ “Demand” is seen here from the hospital perspective, ie what the GP is
referring the patient to hospital for (for those who have been through the
sieve of General Practice) or the patients who self-refer (eg via casualty).
ƒ “Supply” represents what is provided by way of hospital services (ie
capacity).

Note, from diagram 2, that a better overlap between all three is

theoretically possible without new resources.
If we look at each of the numbered areas in diagram 1 in turn we can tease
out the components of the problem and begin to see some solutions. The
ultimate objective of demand management is to get a better overlap between
need and supply.

Zone 1: Supply that is neither demanded nor needed.

This is spare capacity, wastage and inefficiency. Think of drugs thrown away
unused, cottage hospitals only three-quarters full or excessive numbers of
specialist registrars in obstetrics and gynaecology. This Zone has been
squeezed hard over many years, but largely on a Trust by Trust basis. There
may still be scope for a whole-system approach that enables further waste to
be excluded. This frees up resources for covering more of the need. It would
not mean taking resources out of the system but re-deploying them.

Zone 2: Demand that is not a need, and therefore not supplied.

This represents silt in the system that can clog up the machinery. It is, in part,
what NHS Direct was set up to address. Practice charters, patient education,
information and campaigns all have a role in mitigating this problem in primary
care before it translates into an inappropriate demand on secondary care
(think of the milder end of the tonsillectomy demand). At Trust level it can be
difficult to turn away inappropriate demand because patient and GP
expectation are, by that stage, very high. That, together with the fact that
service agreements and targets are skewed towards rewarding intervention
and not refusal, means some patients move on to Zone 3.

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Zone 3: Demand that is met even though it is not strictly needed.
This is a waste of scarce resources. Think of the milder cases of glue ear that
proceed to surgery where “watchful waiting” would be more appropriate.
Tightening up the local criteria for referral and thresholds for intervention, or
rewarding appropriate clinical management rather than activity per se, are
ways to free up resources here. Taking Zones 1 and 3 together gives the total
area of current provision that is not addressing true need. It represents the
principal hunting ground for disinvestment and re-deployment of resources
(such as staff, theatre sessions or finance). It requires considerable effort in
public information and education.

Zone 4: Demand that fulfils criteria of need but is not yet met.
This zone equates with the waiting list for admissions after the patients have
been assessed in the outpatient clinic. There is such intense managerial and
political pressure to address this group that it is easy to concentrate on
nothing else – to lose sight of the bigger picture and miss the whole-system
approach. Note that a hospital’s outpatient waiting list contains a mixture of
Zone 2 and 3 patients – all of whom have expressed a demand but are not
necessarily in need.

Zone 5: Unmet need, not brought to medical attention.

An important but neglected part of demand management is generating new
demand where it ought to be greater. Think of a 54-year-old man, a life-long
smoker with a family history of heart attacks, who has not come forward for
health screening. Now look closely at practices within PCTs that have
unexplained low referral rates. Remember that the objective of demand
management is not to curtail demand per se but to get a better fit between
need and supply. This is where needs assessment links up with demand
management.

Zone 6: Services that are supplied to meet need without prior demand
by the patient.
Do we ever meet needs without them being demanded? An unusual concept
at first glance, but think of cancer screening, childhood immunisation, health
promotion and well-person clinics. This is where the Health Service goes into
proactive mode. It is a major plank in the strategy to get need and supply to
overlap better. Go get them!

Zone 7: Needs that have been demanded and met.

This is the ideal situation. In reality, the scale should show this to be a very
substantial box. We tend to forget just how good a population coverage we
do achieve in the NHS. This is the ideal situation, and the closest
approximation to diagram 2, which is our aspiration.

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Summary

This simplistic model has limitations, but reminds us that in needs assessment
we cannot take what we know about either demand or supply as substitutes
for need, tempting though this may be since the data are often readily
available. (How many health authorities or PCTs simply roll over the previous
year’s contracts with local hospitals as a proxy for need?) The model also
directs attention to practical steps to address the mismatches, which is often
the rationale for embarking on needs assessment in the first place. Here are
some of the groups who could get involved and activities that they could
engage in.

Patients and carers.

• Education, information and periodic campaigns to use the service
responsibly, including NHS Direct
• Parenting skills for common minor childhood ailments
• Uptake of preventive and screening opportunities

Primary care staff.

• Involvement in drafting guidelines, referral thresholds and patient
pathways, and writing them into Long Term Service Agreements with their
neighbouring hospitals
• Provide regular feedback on referral rates relative to peers and seek
explanations of major variances (high or low)
• Regular dialogue sessions with secondary care
• Look for major gaps in services and inequalities of access
• Explore enhanced role for pharmacists, nurses and professions allied to
medicine.

Secondary care staff.

• Involvement in guidelines, thresholds and pathways, as for primary care
• Regular feedback and dialogue with referrers
• Active search for re-deployment opportunities based on a robust
understanding of clinical and financial flows within the Trust.
• Scrutinise activity trends monthly and act early on adverse trends.

Reference:
1. NHSME, DoH, 1991. Assessing health needs: a DHA Project Discussion Paper

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5. References and further reading
1 Hooper J and Longworth P. Health Needs Assessment in Primary
Health Care – A workbook for primary health care teams. DoH
Resource Pack, ring-binder format. Sept 1997

Available free on request from: Health Literature Line: 0800 555777

A potentially useful resource for team development, but follows a fairly

rigid sequential set of steps and requires several hours to complete.
Not a book to dip into, but a valuable primer for individuals and teams
with time for training. (See also new version, reference 13 below)

2 Rowley J and Bhuhi J. Participatory Needs Assessment: a

practical approach in partnerships between local residents and
professionals. Public Health Medicine 1999; 1:27-30

London-based. Strong on public participation. Broad brush scanning

type of approach to tease out environmental, social, economic and
political determinants of quality of life.

3 UK Health For All. What is Community Health needs Assessment

– a Protocol? UK HFA Network, 1993

Community-development orientated approach, long-term perspective.

4 Shanks J, Kheraj S, Fish S. Better ways of assessing health

needs in primary care. BMJ 1995; 310: 480-1

Short, punchy leader in the BMJ – recommended.

5 Murray SA, et al. Listening to local voices: adapting rapid

appraisal to assess health and social needs in general practice.
BMJ 1994; 308: 698-700

One of the key references in this field – recommended.

6 Murray SA, Graham LJC. Practice based health needs

assessment: use of four methods in a small neighbourhood. BMJ
1995; 310: 1443-8

Highly recommended. Sets out the methods which are used in this
Norfolk resource pack.

7 Wright J, Williams R, Wilkinson JR. Development and importance

of health needs assessment. Br Med J 1998: 316; 1310-3.

First in a series of 6 weekly articles (two more follow below) in the BMJ
which covered the topic.

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8 Stevens A, Gillam S. Needs assessment: from theory to practice.
Br Med J 1998; 316: 1488-52

9 Wilkinson JR, Murray SA. Assessment in primary care: practical

issues and possible approaches. Br Med J 1998: 316; 1524-8

10 Balding J, Foot G, Regis D. The assessment of health needs at

the community level. Schools Health Education Unit, Exeter 1991.

Sets out the groundbreaking, and still market-leading, needs

assessment service in schools. This unit conducts schools surveys
and has a wealth of comparative data going back for several years.

11 Health Needs Assessment and the cycle of change (chapter) in:

Public Health Practice Resource Pack. DoH 1999, pp 41-44
(Copies available from: Strategic Development, DoH - 01908 844584
or from www.doh.gov.uk/publichealth.htm

An excellent overview of public health practice. Essential reading for

all nurses who practice in the community.

12 Picken C, St Leger S. Assessing Health Needs using the Life

Cycle Framework. OUP. 1993

Used by Sarah Kember and team in the schools needs assessment.

13 Harris A. Needs to know – a guide to needs assessment for

primary care. Churchill Livingstone. 1997

14 Hooper J, Longworth P. Health Needs assessment workbook.

HDA. 2002 Available from: Health Development Agency, PO Box
90, Wetherby, Yorkshire LS23 7EX

15 NHSE. Public Health Resource Pack. Out of print, but available

from www.doh.gov.uk/publichealth.htm

16 Pencheon D et al (eds). Oxford Handbook of Public Health

Practice. OUP. 2001

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