The Health and Community Care Act 1990 was based on two separate White Papers. Caring for people (Department of Health (DH) 1989a) acknowledged the importance of providing support for people experiencing a range of needs that were regarded as ‘social’ rather than medical. This included people with long-term mental health needs and intellectual and physical disabilities in which (it was argued) help might be needed by family and friends, or be provided from local authority sources if informal support was not sufficient. Needs arising in old age, as part of a normal life course, were included, but support required by mothers and families with young children were not. Whilst the legislation stipulated that individuals had a right to receive care where an assessment showed that ‘social needs’ existed, the local authority could make a charge for the services they provided. This was distinct from Working for patients (DH 1989b), which concerned the provision of health services that were free at the point of delivery.

This legislation first introduced the notion of an ‘internal market’ into the NHS, stressing that services should be planned strategically within one organisation, then purchased from a different provider service to meet needs in the area. Medical Directors of Public Health led this activity. Whilst this planning requirement legitimised public health activities within the NHS, it tended to reinforce the earlier focus on illness and service provision, instead of wider factors that contribute to health, such as environment or lifestyle. Health and social care services were enjoined to collaborate to provide a seamless service, but distinguishing between ‘health needs’ and ‘social needs’ became a source of much confusion for care providers and service users alike (Bergen et al 1996).

Joint working

Collaborative working was stressed even more firmly within the Health Act 1999, which set out specific ‘partnership arrangements’ designed to overcome this confusion and improve flexibility between the NHS and local authorities in England. Although individuals could still be charged for services provided for ‘social care’, Section 31 of the Act allowed funding derived from different sectors (e.g. NHS and local authority) to be pooled to set up services in which more than one agency has an interest. This facility foreshadowed organisational arrangements such as Children’s Trusts, established under the Children Act 2004, which involved health, social and educational services, as well as the voluntary sector. Importantly, the Health Act 1999 required health authorities to set out a strategy to both improve the health of the people for whom they are responsible, and provide health care to such people. These policies stressed multi-agency working to address the wider determinants of health, although there was a paradoxical lack of emphasis on these wider elements within the NHS Plan (Secretary of State for Health 2000), perhaps reflecting its long association with illness and medical care, rather than public health and health promotion.

By this time, two things were happening. First, the impact of devolution was being felt, resulting in some quite marked differences in health policy between the four parts of the UK. Chapter 4, for example, explains the Community Health Partnerships (CHP) that are required in Scotland. Second, the government recognised the existence of wide and increasing health inequalities, and was developing policies to address them (DH 2003).

Need for what?

Given this background, it is clear that the notion of ‘health need’ is highly politi-cal, complex, value-laden and far from problem-free. However, there has been a burgeoning interest in the use of the term, and in different approaches to assessing needs. Needs assessment processes are considered an essential precursor to the planning of services, on both an individual and population-wide level. It is clear that needs must be assessed with the question in mind always, of ‘need for what?’ In clinical terms, this usually means making an assessment prior to prescribing a treatment; a population-wide assessment may lead to the ‘prescription’ of public health strategy, including the provision of general health services as well as prevention.

The definition of health needs in respect of health improvement is more complex than its clinical counterpart, as it concerns whole populations and determin-ants of health. The Beveridge ideal of being ‘capable of profiting by it’ might not apply to single person or individual, or the advantage may be so long term that it is hard to discern specific changes. The mechanisms used for both assessing needs, and evaluating services, in such circumstances, have to take a population-wide approach.

Need and needs assessment

Nature of need

Whether at a clinical or population-wide level, it is clear that the nature of ‘need’ is highly contested, and there is general agreement that need is a ‘deceptively tricky concept’ (Asadi-Lari & Gray 2005, p. 295). It is problematic as an operating concept (Sheppard & Woodcock 1999) and value laden, in that someone has to decide whether or not a need exists, which is an evaluative judgement (Endacott 1997). In a study carried out in the mid 1990s, the question of what the term meant to them was put to a series of focus groups of, first, service users, then professionals (district nurses and health visitors), then managers and those who commissioned and organised both NHS and local authority social services, then finally practice teachers and lecturers (Cowley et al 1996). They all had different views, and many found it very hard to think about what ‘need’ might mean, unless it was attached to something else, like ‘health need’, or ‘needs assessment’, or ‘clinical need’. Most of the service users were somewhat unhappy with the term, as it had connotations of ‘being needy’, which they felt was stigmatising.

A detailed analysis across the focus group responses revealed many contradictions within the concept, and a conclusion was reached that need is a dual concept, in that it has some very contrasting meanings (Cowley et al 1995). It is possible to describe needs quite objectively, at least in part. Needs are recordable, and can be measured, observed and made explicit, to some degree. It is possible, for example, to assess someone’s blood pressure, or their mobility, or whether they have postnatal depression, using a carefully developed and validated instrument. Such assessment tools give a good degree of what researchers call ‘inter-rater reliability’, which basically means that if two or more people take the measurement, they will reach the same conclusion. But needs are also very variable and personal, in that the same issue, for example, a child or young person’s behaviour, or limited mobility in an older person, may result in different views of whether it is a problem or not. In this respect, needs are very subjective and changeable according to context. This is the polar opposite of inter-rater reliability, where completely different conclusions are reached about what, on the surface, may appear to be the same thing.

Some needs are very obvious, particularly those associated with clear phys-ical diagnoses, perhaps with an obvious wound or a rash, or in a desperately run-down area that clearly displays its deprivation through graffiti, neglected or derelict buildings, and lack of facilities. Other needs – physical as well as social, emotional and mental health needs – are more hidden. Where genteel poverty and pride go hand in hand, where emotional distress is seen as a source of shame, or where the mental trauma is severe, clients may hide their needs from an assessor, or not reveal things that are worrying them simply because they cannot formulate the words. Indeed, people may experience a level of anxiety or difficulty without fully realising what lies beneath their worries. They may be quite genuine in stating that their childhood was happy, for example, because the ‘family secrets’ of sexual or emotional abuse that lay behind a façade are too deeply hidden for them to recognise themselves. Does that mean they are not needs? Or not needs until they are revealed, or only if experienced as problems? These were the kinds of very complex question asked in the study referred to above, about what constituted a ‘need’ (Cowley et al 1995, 1996).

Needs assessments

A whole taxonomy of needs assessment was developed after carrying out a series of observations in practice and interviews to develop the ideas voiced in the focus groups described above (Bergen et al 1996, Cowley et al 2000a, 2000b). Needs assessments can be considered under three main headings, each with different, interlinked elements. These are:

1. Ideals

In policy – Discipline specific – Ascribed worth.

2. Timing

Client issues – Service issues – Practice issues.

3. Types

Purpose – Formality, specificity – Complexity.

Ideals

Formal policies and laws set out whose assessment counts in particular situations, and the rights and responsibilities that flow from the assessment. These constitute a specific set of values and ideals, agreed in the particular society that approves them and made real as they are enacted. The difference between health and social need, for example, is clear only in the duties placed upon different public services to meet identified needs. Expectations of the rights, responsibilities and choices available to service users are set out in policy, as well as the duties of service providers.

Despite the policy commitment, and frequent use of the terms ‘need’ and ‘needs assessment’, they tend to be used very differently by different disciplines, including economists, epidemiologists, policy makers and professionals (Billings & Cowley 1995, Lightfoot 1995, Robinson & Elkan 1996). Apart from differences when considering needs at an individual or service level, each profession has a distinct underlying philosophy, which influences their understanding of the term ‘need’. For doctors, reaching a diagnosis is a central part of their professional work, which affects both their communication style (ten Have 1991) and their interest in disease-specific needs assessments (Asadi-Lari & Gray 2005). Nurses, too, tend to concentrate on deficits and difficulties, with Endacott (1997) also emphasising the importance of prioritising and the ability to meet needs. The social work literature highlights deficits, although Shephard and Woodcock (1999) argue that a more differentiated concept is needed for their work with children and families. Since health visitors focus on health promotion and positive health (Prime Research and Development 2001), to concentrate on deficits or problems would negate their main purpose (Cowley & Frost 2006). Community development workers, too, avoid focusing on deficits, preferring instead to highlight the capacity, strengths and resources found in the local population (see Chapter 5). The different uses of the term ‘need’ can create difficulties, for example, when a problem focus is used to determine needs assessment schedules for use by health visitors resulting in a medicalised approach to the work (Cowley et al 2004).

The extent to which an assessment is valued in an organisation varies according to who carries it out (‘ascribed worth’) and how important particular needs seem within an organisation. Where individual nurses and health visitors had assessed needs in their caseloads, for example, Bergen et al (1996) found their profiles tended to be disregarded, because they were not sufficiently senior in the organ-isation for their assessment to count for much. In contrast, local needs assessments made by senior public health doctors usually over-ruled everyone else.

Different perceptions about what constitutes a need vary between organisations, often in line with changing policies. Under the Childcare Act 2006, for example, English local authorities are all required to improve the wellbeing of young children and the reduce inequalities between them. Although the main emphasis is on provision of childcare so parents can work, and information that may be of benefit to them in bringing up their children, the Act also specifies local authorities’ duties in providing ‘early childhood services’. These include social services, health services relating to young children, parents and prospective parents and early years provision. There is an expectation that these services will generally be delivered through integrated Children’s Centres, so it would be helpful to have an agreed understanding about the nature of needs to be met in order to improve children’s wellbeing.

Timing

People need to be ready to talk about things that are bothering them, so timing is important from the client’s perspective. Also, practitioners need the time to carry out assessments sensitively. Cowley and Houston (2003) found that clients were either bemused or offended when rushed practitioners read through a list of questions without listening to responses, because their organisation required the assessment form to be completed by the time an infant reached a certain age.

Services may introduce quality indicators suggesting that certain topics need to be introduced by a particular age; such requirements will influence the timing of when needs assessments are carried out as well. Indeed, time is one element of the model of service quality outlined in Chapter 13. The timing of an assessment is also related to the level of prevention; once a problem has become manifest, it is no use aiming to achieve primary prevention, nor to offer anticipatory advice about a developmental stage once it has passed. A policy focus on early prevention has been increasingly evident since the start of the 21st century.

Types

Some assessments are much more formal than others. Typically, the most formal assessments are those that have financial implications, such as those carried out at a strategic level to inform decisions about which services to fund or prioritise. At the grass-roots level, information may be gathered to feed into those de-cisions, either by collecting one or two particular types of information (perhaps the weight of school-aged children, for example, to feed into a strategy about obesity prevention) or may be collated into a community profile, considered further below.

The informal and non-specific assessments are no less important, and sometimes help to complete a complex picture; a mother struggling to introduce solids to a reluctant baby might make a throwaway remark about power battles in the home around mealtimes when she herself was a child, for example, that will be far more telling than a whole battery of behavioural tests. Also, the purpose of the assessment influences both how, and when, it is carried out.

In practice, assessments rarely fall neatly into a single format, with the different types and timing issues involved being intertwined with policy priorities and specific professional perceptions about what constitutes ‘need’. Overall, needs assessments carried out on a well population, at the level of the community, child, family or individual for purposes of preventive care and health promotion, is less widely documented than approaches used for planning either services or treatment.

Assessing community health needs

The terms ‘local health needs assessment’ and ‘health profile’ tend to be used interchangeably. Billings (2002) distinguishes between them, regarding ‘health needs assessment’ as a broad term concerned with a description of factors that must be addressed in order to improve the health of the population. This defin-ition allows for the delineation of a range of factors that make up the concept of need, whereas the health profile is a method by which needs are assessed (Billings 2002). It has been identified in its widest sense as: ‘the systematic collection of data to identify the health needs of a defined population, and the analysis of that data to assess and prioritise strategies in health promotion’ (Twinn et al 1990, p. 2). Health profiles use mainly quantitative health data, such as statistical information, but qualitative health data, such as individual assessments and client perceptions, can be incorporated to form a more holistic picture (Billings 2002).

Health profiling may be carried out as a search for specific, prioritised needs, which have been identified as important at a national, international or local level. Alternatively, a ‘bottom up’ approach may be used, to allow the local population to discern for themselves what they consider to be their own needs. This is a more common approach in community development and community practice work, as explained in Chapters 6 and 14. Often, the two are used to some extent in combin-ation. Either way, the four questions to be considered before planning to assess needs at the level of grassroots practice are summarised in Box 1.1.