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Health needs and all that
Public Health (1992), 106, 89-90
© The Society of Public Health, 1992
Editorial
Health Needs and All That
The extensive NHS documentation which accompanies the move to the internal market environment includes, as one would expect, advice on how districts are to function. An element of this has been the emphasis on needs-based planning and needs-based purchasing strategies. This feature of the White Paper scene has generally been welcomed by Public Health workers whatever their basic discipline. A 'rational' methodology for constructing a programme of health development is a fundamental and essential component of the 'Public Health process'. It is not, however, as simple as that. The concepts of rational planning for health have been current for more than a decade. In practice, to devise and effect a strategy for health based on these principles has not been quite so easy to carry out as its proponents would have us believe. It is difficult to define the problems in effecting an exercise of this sort but some idea of why they exist can be appreciated by examining the course of events which usually accompanies the process of defining and agreeing a set of goals for a health district. The task can appear to be endless and, when agreement is reached, the end result is often disappointing. At this point the prospect of turning these goals into a set of quantified objectives seems daunting and a side issue compared with the problems of coping with the basics of the contracting process. A further difficulty which arises in the context of the Health Service changes is the problem, 'What do we mean by the term needs?' This is really a basic issue which comes up in any structured approach to defining the Public Health process. At a personal level a need can be quite idiosyncratic and one cannot produce a population need on the basis of aggregating a lot of individual needs. In any case an individual with ischaemic heart disease doesn't see his needs as a national campaign of prevention. Nor, come to that, does a young man see his need as a new unit for cardiac surgery. In terms of need, these two interventions can be mutually exclusive in any system of prioritisation. A r e c o m m e n d e d approach to assessing needs, and a perfectly logical and rational one, is to look at what services are provided and compare utilisation with other districts. Adjustments can then be made by consulting service providers and service users and bringing provision up to some consensus norm. T h e r e is nothing intrinsically wrong with using this procedure for a situation where there are manifestly gross shortfalls in service provision. The difficulty comes when there are competing claims for improvements in what are, basically, adequate or nearly adequate services. In short, where there must be some sort of prioritisation, the concept of a 'need' is a very poor one as it can be, and often is, generated by vested interest. This is dressed up in exhortations to seek the views of the public and to take particular note of the priorities perceived by family doctors. 'Quite right' you will say and it is clear, and has been so for some time, that health districts should consult widely on the content of health development programmes. However, this
90
Editorial
should not obscure the fact that a 'need' may not, in itself, justify a decision to proceed with an intervention. A 'need' may be the expression of a 'problem' in the health of that community. If the problem is sufficiently extensive or severe it will dictate its own importance which is accessible to objective methods of assessment and prioritisation. As a concept it is easier to conceive in public health terms. A clinician responds to a patient's needs, a public health practitioner to the health-related problems of a community. If a community can be said to have a 'need', it is for a coherent prioritised programme of health development. It is interesting to note that the main thrust of Health o f the Nation s is, in general, a problem-based approach to determining a programme of interventions for health. It does, however, talk about health authorities meeting the needs of their populations, not seeking solutions to the health problems of their populations. Did the writers of Health o f the Nation see these as two different processes leading to, perhaps, different responses? Is all the above a question of semantics, just playing with words? I think not. The Government's obsession with waiting times for hospital elective admissions is perhaps an example of a priority determined by a needs-based assessment. Action on waiting lists runs the risk of diverting resources from problems which are more important. Any such programme should be based firmly on a n u m b e r of considerations. The first is undoubtedly, 'What are the health problems we want to solve?' This question should be answered in some way even if it is merely a matter of making an implicit understanding more visible. References 1. The Health of the Nation: A Consultative Document for Health in England (1991). London: HMSO (Cmnd 1523).
© The Society of Public Health, 1992
Editorial
Health Needs and All That
The extensive NHS documentation which accompanies the move to the internal market environment includes, as one would expect, advice on how districts are to function. An element of this has been the emphasis on needs-based planning and needs-based purchasing strategies. This feature of the White Paper scene has generally been welcomed by Public Health workers whatever their basic discipline. A 'rational' methodology for constructing a programme of health development is a fundamental and essential component of the 'Public Health process'. It is not, however, as simple as that. The concepts of rational planning for health have been current for more than a decade. In practice, to devise and effect a strategy for health based on these principles has not been quite so easy to carry out as its proponents would have us believe. It is difficult to define the problems in effecting an exercise of this sort but some idea of why they exist can be appreciated by examining the course of events which usually accompanies the process of defining and agreeing a set of goals for a health district. The task can appear to be endless and, when agreement is reached, the end result is often disappointing. At this point the prospect of turning these goals into a set of quantified objectives seems daunting and a side issue compared with the problems of coping with the basics of the contracting process. A further difficulty which arises in the context of the Health Service changes is the problem, 'What do we mean by the term needs?' This is really a basic issue which comes up in any structured approach to defining the Public Health process. At a personal level a need can be quite idiosyncratic and one cannot produce a population need on the basis of aggregating a lot of individual needs. In any case an individual with ischaemic heart disease doesn't see his needs as a national campaign of prevention. Nor, come to that, does a young man see his need as a new unit for cardiac surgery. In terms of need, these two interventions can be mutually exclusive in any system of prioritisation. A r e c o m m e n d e d approach to assessing needs, and a perfectly logical and rational one, is to look at what services are provided and compare utilisation with other districts. Adjustments can then be made by consulting service providers and service users and bringing provision up to some consensus norm. T h e r e is nothing intrinsically wrong with using this procedure for a situation where there are manifestly gross shortfalls in service provision. The difficulty comes when there are competing claims for improvements in what are, basically, adequate or nearly adequate services. In short, where there must be some sort of prioritisation, the concept of a 'need' is a very poor one as it can be, and often is, generated by vested interest. This is dressed up in exhortations to seek the views of the public and to take particular note of the priorities perceived by family doctors. 'Quite right' you will say and it is clear, and has been so for some time, that health districts should consult widely on the content of health development programmes. However, this
90
Editorial
should not obscure the fact that a 'need' may not, in itself, justify a decision to proceed with an intervention. A 'need' may be the expression of a 'problem' in the health of that community. If the problem is sufficiently extensive or severe it will dictate its own importance which is accessible to objective methods of assessment and prioritisation. As a concept it is easier to conceive in public health terms. A clinician responds to a patient's needs, a public health practitioner to the health-related problems of a community. If a community can be said to have a 'need', it is for a coherent prioritised programme of health development. It is interesting to note that the main thrust of Health o f the Nation s is, in general, a problem-based approach to determining a programme of interventions for health. It does, however, talk about health authorities meeting the needs of their populations, not seeking solutions to the health problems of their populations. Did the writers of Health o f the Nation see these as two different processes leading to, perhaps, different responses? Is all the above a question of semantics, just playing with words? I think not. The Government's obsession with waiting times for hospital elective admissions is perhaps an example of a priority determined by a needs-based assessment. Action on waiting lists runs the risk of diverting resources from problems which are more important. Any such programme should be based firmly on a n u m b e r of considerations. The first is undoubtedly, 'What are the health problems we want to solve?' This question should be answered in some way even if it is merely a matter of making an implicit understanding more visible. References 1. The Health of the Nation: A Consultative Document for Health in England (1991). London: HMSO (Cmnd 1523).