What people desire or request from a healthcare system may not be what they actually require. Although there is a need for treatments to be developed for incurable diseases, in the absence of a cure it cannot be argued that there is a current need for a particular treatment to be provided. This is captured in the definition of need for healthcare used by Stevens et al who define needs assessment as ‘the population’s ability to benefit from healthcare’ (Stevens et al 2004).

The fact that healthcare resources, whether hospital beds, appointments, healthcare professionals’ time or money, are finite means that it is possible for capacity to be inadequate to meet the need in the population. In addition, there is scope for demand to outstrip the capacity of the system. Healthcare needs assessment is a key element in ensuring that there is sufficient and appropriate capacity to address need. However, once needs are defined, demand management measures will also be needed to ensure capacity is used appropriately.

Need that is being addressed by services is met need. Need that is not being addressed by services is unmet need. Similarly demand associated with need is appropriate demand whereas demand that is not associated with need is inappropriate. Managing inappropriate demand will help to protect resources that are required for others with real needs. However, converting unmet need into met need requires further action. Many people in need are not aware that they are in need, and often many of their carers, paid and unpaid, are not either. Describing the full extent of need and potential responses to it is an early step to converting unmet need into met need.

Further definitions of need which are widely used were proposed by Bradshaw. He suggested four different types of need: normative need, expressed need, comparative need and felt need (Bradshaw 1972). In Bradshaw’s view, normative need is what expert opinion based on research defines as need. This roughly equates to a professional expert opinion on the ability to benefit from healthcare.

Comparative need is an extrapolation of the principle of distributive justice: those in equal need get equal response, those with greater need get greater response. Comparative need seeks validity not from expert opinion based on research but from extrapolation from one community to determine the services required in another area with a similar population. This assumes that the service provision in the first area is appropriate. Comparative needs assessment is sometimes undertaken by professionals, and also by communities or individuals, who compare the service they receive with that of another community or individual. Examples of this include people comparing differences in treatment for cancer across geographical areas.

Expressed need is estimated by observation of the community’s use of services. The interplay of capacity and demand can confuse this. There may be no evidence of demand for a treatment which is not provided, for example. Again therefore this assumes a comprehensive range of appropriate services in the first place. Naidoo and Wills (2000) indicate that expressed needs are those that are articulated by service users and public health workers may empower people to turn felt needs into expressed needs in an effort to promote action to enhance health.

Felt need refers to what communities and individuals may feel they need in order to improve their health. Sometimes this is articulated; however, at other times felt needs may remain suppressed. Views from those in the community may be solicited in a comprehensive formal manner such as from a survey, or may be offered spontaneously. Felt needs may be constrained by beliefs, or by a lack of knowledge, assertiveness or confidence. For example, communities may think that an increase in hospital beds offers a solution to addressing a health need better than community-based services or preventive public health activity. People are more likely to express strong feelings about services they believe they will use in future. Public health workers may work with communities using community development approaches to try to identify felt needs.

While great weight will inevitably be given to normative needs, these other dimensions of equity and of service users’ experiences are important aspects of need and service responses. Communities are more likely to accept findings of needs assessment which capture these wider dimensions of need as part of a holistic picture of community problems and appropriate responses.

A definition can describe the nature or purpose of something. Those grappling with the concept of needs assessment for the first time require an understanding of both the reasons why needs assessments are undertaken and what is done during a needs assessment. Given the definition of need used by Stevens et al (2004) it would seem reasonable to suggest that they might define needs assessment as ‘asssessment of the population’s ability to benefit from healthcare’. Two definitions of needs assessment are shown in Table 6.1.

For educational purposes, Montana North Central Education Service Region describes needs assessment as ‘a systematic exploration of the current situation of how things are and the way they should be’ (Montana North Central Education Service Region 2006). Within this definition is the concept of a systematic exploration which implies a holistic and thorough analysis within defined limits. It also explores a potential direction for change.

Hooper (1999) described needs assessment as the process of measuring the extent and nature of the needs of a particular target population so that services can respond to them. The definition of needs assessment which follows draws on both of these. Needs assessment is a systematic exploration of the extent and nature of the needs of a particular target population which seeks to effect change in services to maximize benefit from healthcare. Needs assessment involves collection of information on the needs of a defined population or group who could benefit in some way. The process should identify current resources available to meet those needs and determine what gaps in care provision or in services exist.

In the UK the National Health Service (NHS) was founded on the principle of care being made available to all, free at point of delivery, on the basis of need. The approaches to assessing and responding to need have evolved over time and are worthy of consideration. There are differences across the countries of the UK which reflect the different legal system in Scotland, and a process of devolution which effectively commenced in the late 1970s, taking 20 years to be achieved. The content of this chapter is focused mainly on the approaches used in England and Wales, summarized in Table 6.2.

Needs assessment is a process intended to bring reason to decisions about which elements of care are and are not provided. If resources were unlimited then all needs and desires could be addressed and no decisions would be required. Thus needs assessment is used in many publicly funded healthcare systems to balance benefits against costs. High-cost and low-benefit elements of care are unlikely to be funded.

When the NHS was established in 1948 the provision of hospital care came from the hospitals which chose to join the new NHS. Most of these had previously relied on private care and charitable donations and were located in large urban areas. Attempts to address healthcare need on a more equitable basis commenced in the 1960s with efforts to improve access to hospital care outside large metropolitan areas through the Hospital Plans (Department of Health for Scotland 1962, Ministry of Health 1962). The Hospital Plans recognized the need to improve access outside large metropolitan areas and this was delivered through building district general hospitals typically to serve 125 000 to 250 000 population. In the late 1970s the emphasis moved from building of hospitals to moving of financial resources, although the building of new hospitals continued. In fact the building of the new hospitals had been slower than planned because of underestimates of costs that continued into the 1980s and 1990s. Within England the Resource Allocation Working Party examined NHS spend per head of population and sought over a period of years to allocate funding to regions on the basis of need (Department of Health and Social Security 1976). Within this formula need was assessed on the basis of mortality.

This process was not applied across the UK. However, in 1978 the Barnett Formula was introduced as a short-term measure to create a steady process of change to equalize public spending (including health spending) across the UK (Twigger 1998). The process was designed to produce a slow change. In recent years the higher levels of public spending in Scotland, Northern Ireland and Wales resulting from this formula have been defended on the basis of greater deprivation and need in those countries.

The Resource Allocation method used in England was updated in the period from 1991 to 1995 incorporating a broader weighted capitation formula (NHS Management Board 1988), to recognize need broader than mortality; however, this model was criticized (Judge and Mays 1994, Raftery 1993, Sheldon et al 1993). It was not until 1991 that a more detailed local assessment of need was formally put at the heart of NHS planning and decision-making in England and Wales as a result of the NHS and Community Care Act 1991.

Detailed needs analysis as conducted currently would not have been possible in the early 1960s or in the mid 1970s as techniques were less developed than they are now. However, by the early 1990s a range of indicators to measure disease, health status and social impact had been developed which were not available a quarter of a century earlier. There were also developments in critical appraisal and in accessing the scientific literature that facilitated needs assessment. Table 6.3 summarizes these changes.

The separation of contracting services from provision of care was intended to help contain costs. Partly this was intended to be through the use of market forces to create downward pressure on costs and partly through more critical decision-making about what would and would not need to be provided. The separation of contracting from provision of care was seen as advantageous because in the preceding years many decisions had been made in response to shroud waving and lobbying. The problem with shroud waving and lobbying are that the voices of the most vocal and politically adept are more likely to be heard and hence their demands addressed. This was one of the contributing factors to the ‘inverse care law’. Julian Tudor Hart used this phrase to describe the perverse outcome where more deprived populations in greater need of care generally have poorer access to care and poorer quality services (Hart 1971).

Thus one of the principles upon which needs assessment was established by the 1990s was that the assessment of need should be undertaken by a third party and not by a provider or beneficiary of care (Liss 1990). General medical practitioners had often been described as gatekeepers to hospital care for individual patients and to some degree were a third party although not a completely disinterested one. For decisions on the commissioning of services in the 1990s the third party was typically a public health trained individual, expected to review and appraise a range of information on need and the evidence base for responses to that need and to provide advice based on analysis.

Epidemiological tools to measure health have developed since the 1960s and made it easier to describe need in a range of ways, not just through mortality figures. During the 1990s critical appraisal also evolved. Initially an art practised by a few it became more of a scientific approach practised by many. As computers became commonplace, the indexing of evidence moved from books to electronic databases which could be searched rapidly. Once access to the evidence was easier there was a need to improve skills in appraising the evidence. Evidence-based practice was rolled out from academic centres to the heart of public health working and it has made a contribution to NHS decision-making. It combined a description of need and a critical appraisal of potential responses to that need.

These changes came quickly and needs assessment rapidly moved from being an art to being a science. The pace of change can be seen in the content of public health texts. The second edition of the Oxford Textbook of Public Health was published in 1991 and made no reference to need or needs assessment in its index. The third edition published in 1997 had indexed references and a chapter on measuring health need. During the intervening period, in 1994 Volume 1 of the first edition of Health Care Needs Assessment edited by Stevens and Raftery was published. This comprehensive document described a standard approach to needs assessment for a series of common conditions. It was sponsored by the NHS Management Executive and circulated to health authority public health departments.

The NHS Management Executive sponsored the publication to support the development of the role of the health authorities in line with guidance they had published (National Health Service Management Executive 1989). This guidance highlighted the need to implement the following tasks in order:

The assumption was that a detailed needs assessment was the foundation upon which commissioning of services would be constructed.

In the 1990s public health professionals attached to purchasers of healthcare conducted needs assessments. They produced reports which either influenced the care process or gathered dust on shelves. To those not trained in public health the assessment of need often seemed to be something of a black art practised behind closed doors. Over time, needs assessment was demystified. Critical appraisal allowed more people to understand the strengths and weaknesses of evidence. As the process of needs assessment uses standardized approaches, models or techniques, the process became more transparent.

Now needs assessment is less likely to be conducted by a third party in isolation; it is becoming common for needs assessment to be conducted in partnership, engaging commissioners, providers and users of care. An open process using standardized approaches, quality assured with public health support and with a partnership or community contributing or leading the work, combines objectivity and inclusion, meaning findings are more likely to be implemented by all parties.

Stevens et al (2004) describe three types of needs assessment: comparative, corporate and epidemiological. The former two are less labour intensive. Comparative needs assessment compares services in one area with those elsewhere. This relates closely to the comparative need described by Bradshaw (1972). The underpinning assumptions are that difference justifies investigation and, if the differences are to continue, justification. The comparisons which can be made are limited by the availability of relevant data.

The corporate approach to needs assessment is a process of engagement of relevant stakeholders. Inevitably demand is blended with need and vested interest with science. This approach has the advantage that information from all parties and perspectives is engaged in the process to create a corporate view.