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Health and Quality of Life Outcomes BioMed Central Commentary...

Health and Quality of Life Outcomes BioMed Central Commentary Open Access Need for redefining needs Mohsen Asadi-Lari1, Chris Packham2 and David Gray*1 Address: 1Division of Cardiovascular Medicine, University Hospital, Nottingham, UK, NG7 2UH and 2Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK Email: Mohsen Asadi-Lari - [email protected]; Chris Packham - [email protected]; David Gray* - [email protected] * Corresponding author Published: 21 August 2003 Received: 03 June 2003 Accepted: 21 August 2003 Health and Quality of Life Outcomes 2003, 1:34 This article is available from: http://www.hqlo.com/content/1/1/34 © 2003 Asadi-Lari et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL. Abstract Defining needs is difficult due to the inherent complexity of the concept of 'need', so it is not surprising that numerous definitions have been proposed. 'Health' consists of a wide range of characteristics so 'health needs' ought to include personal and social care, health care, accommodation, finance, education, employment and leisure, transport and access. Target-driven standards in areas of health care with a high political profile appear to be replacing the concept of universal provision and clinical need; this major change in clinical care warrants a re- evaluation of health care outcomes. Identifying who might benefit from this new approach to health care is equally important if scarce resources are to be fully and appropriately utilised. If the goal of care is 'optimal health', the key marker of success ought to be to ascertain individual patients' health care needs (HCN) and tailor services accordingly. Wide variation in the description of 'needs' directly affects policies and services intended to meet a population's health care needs. Consequently, the definition of 'needs' has important implications for healthcare provision- the more constrained the definition, the less healthcare will be made available and vice versa. This paper describes some common definitions of needs and discusses their respective benefits and disadvantages in terms of health care provision and their potential impact on health policy. Introduction Defining 'need' In health care, need has a variety of meanings which may A wide variety of definitions of 'need' has been developed. change over time so it is not surprising that different Although each was intended to improve service delivery to groups of health professionals refer to 'needs assessment' the population, ambiguity increased to such an extent that in very different ways. Stevens et al considered that "it may be an illusion to suppose that there might ever be interest in a needs-driven health system passed through a consensus about the meaning of needs". It is impor- several stages. A sociological approach in the 1960s was tant to recognise the different perspectives illuminating followed by 'rational planning' and resource allocation the relationship between the concepts of need, and health- based on deprivation and epidemiology (RAWP ) in care needs. Davis proposed a relatively simple definition of the 1970s; in the 1990s, National Health Service reform need as 'a subjective feeling state that initiates the process introduced need-target resource allocation and by the year of choosing among medical resources'. 2000 the focus was on 'collaborative action" where the need for health care was to be collectively identified by interested 'stakeholders'. Page 1 of 5 (page number not for citation purposes) Health and Quality of Life Outcomes 2003, 1 http://www.hqlo.com/content/1/1/34 Societal view from health care provision' [14,15]; in other words, 'need' In a sociological environment, Bradshaw defined need as: exists only if there is a 'capacity to benefit' from a particu- normative (distinguished by professionals, such as vacci- lar healthcare service.[10,16] Need may be assumed to nation), felt (wants, wishes and desires), expressed (vocal- exist, therefore, when there is an effective treatment ised needs or how people use services) and comparative or 'health gain'. Ability to benefit from health care can needs, which indicates that needs arising in one location be influenced by several factors including epidemiological may be similar for people with similar socio-demographic aspects such as incidence and prevalence of disease and characteristics living in another location. the effectiveness of interventions. Applying this defini- tion, the outcomes of health interventions assume greater Bradshaw's typology of need creates a definition which is importance. more practical for health service research workers, although it does not include the concept of cost contain- First of all, Culyer proposes that 'capacity to benefit' ment. He recently argued that his taxonomy of need was (as an outcome measure) differs from needs (as a resource constrained because of inherent problems with the con- input), so these two concepts are measurable in different cept of need. ways which do not necessarily match. Physical, physiolog- ical, and social benefits may be identified in individuals as Philosophical points well as groups or communities. In addition, the benefits Some experts describe needs as 'instrumental' or funda- of health care can be determined as improvement in clin- mental to the achievement of a desirable goal while ical status, reassurance, supportive care, and relief of car- others highlight a non-instrumental (or absolute) sense of ers rather than a narrow medical definition in which needs[9,10]. Baldwin proposed a rather theoretical merely objective, measurable clinical improvements are definition of need, that is a 'tension need' which implies a recorded. The rational result of this definition is that ben- desire to compensate for some dis-equilibrium such as efit from healthcare may be affected inversely by the sever- thirst due to fluid loss. He also proposed a 'teleological ity of disease. For instance someone who suffers from need' reflecting the gap between actual and desired status, mild symptoms of coronary heart disease may have a such as a desire for coronary bypass surgery to improve greater chance of being offered coronary bypass surgery both quality and longevity of life. This approach to need than an older patient with severe 3-vessel coronary dis- implies 'necessity to be explicit about whether it is effec- ease, whose life expectancy may not be extended greatly tive, how effective it is and for whom'. Baldwin consid- by surgery, on the grounds of having less capacity to benefit. ered teleological need to arise 'when the goal is not realised Moreover, equity in access to healthcare is fundamental to and there is a need of a certain thing when this is necessary for the economists' definition, otherwise it might not be equi- realising the goal' , which seems to be a characteristic table. Also, this definition minimises the influence of lay attributable to any kind of need. While this definition use- people; focuses on "health care" rather than "health" con- fully expounds the concept of need, a significant improve- trary to Bradshaw's model ; and is concentrated on a ment in health services is unlikely without specific efforts causal model. This can be problematic when studying to develop needs-oriented services. human behaviour based on complex interactions between: individual behaviour, social circumstances, cul- Pragmatic view tural beliefs and genetic construction. Furthermore it Green and Kreuter considered need as 'whatever is required often leads to a belief that current services are the basis for for health or comfort' , covering personal, social and healthcare needs assessment. Even the supporters of environmental conditions, including family planning the definition concede this, arguing that measured needs information, smoke-free zones, seat belt rules, and health are only based on existing services. On the other 'hot lines' but appears ineffective in terms of 'life creativ- hand, this terminology is innovation-disoriented, that is it ity' and cost-effectiveness. Doyal and Gough suggested limits population healthcare needs to readily available 'objective needs', asserting that 'health needs' and 'auton- services, ignoring potential needs arising from emerging omy' are not only two universal human needs, but also health technologies. One example is the increased 'need' basic human rights , as some have previously claimed that followed the introduction of automatic implantable. cardioverter defibrillators in late 1990s. Even so, individ- uals who have more 'capacity' to improve their health sta- The Economists' approach tus or prevent deterioration might benefit more from Cost containment is the focus of policy-makers' attention, healthcare provision -for example health professionals therefore combining satisfactory services with cost-effec- have more knowledge about their health/ill-health condi- tiveness could provide a solution to health care rationing tions, therefore may benefit from health services at higher issues. The most widely presented definition of need levels. favoured by economists is 'the ability of people to benefit Page 2 of 5 (page number not for citation purposes) Health and Quality of Life Outcomes 2003, 1 http://www.hqlo.com/content/1/1/34 Literature review reveals that cost effectiveness is already attitude of the population can all influence demand for receiving greater emphasis, although there is no evidence health care, while medical guidelines and effectiveness of that direct questioning of individuals to establish their interventions may affect the provision and availability of health care requirements is being overlooked. health care. Ideally, the provision of health care services should meet most of the populations' needs but the latter A health service approach? may not be constant. Consequently health needs assess- The Medical Research Council considers need to exist ment surveys are necessary both locally and nation-wide when a patient's functioning falls below -or threatens to to establish what services are required to meet these needs. fall below- some minimum specified level and there is a remediable cause. This definition takes into account the Some health economists define demand as a measure for effectiveness of the care process and implies that a need is desire, wherein willingness to pay or spending time reflects met 'when it has attracted some at least partly effective inter- the extent of demand. If health care services become more vention'. In a similar vein, Buchan et al defined health accessible (for economic, physical and cultural reasons), service needs as 'those for whom an intervention produces a the demand for healthcare based on need will increase. In benefit at reasonable risk and acceptable cost'. This defi- the past, demand for health care such as attendance at nition does incorporate effectiveness and cost-effective- clinic has often been used as a proxy for need , but this ness. approach generates various problems. Converting felt need to demand requires numerous factors- individuals' beliefs A more reasonable definition of needs is 'the requirement and the imposed costs (as well as time off work) are of individuals to enable them to achieve, maintain or restore an involved. acceptable level of social independence or quality of life, as defined by particular care agency or authority'. Taking Need, demand and supply do overlap in Venn-like fash- this definition into account, health authorities and other ion to some extent, although each has its own distinctive health-related organisations at local, regional, and characteristics. There is no standard model. In the NHS, national level set out to provide appropriate services to service provision or supply has almost always been less meet its population needs, targeting an acceptable level of than demand or need. Individual needs usually exceed social independence and improved quality of life. If their expressed needs or apparent demands, although this assessing needs is being considered to change current hypothesis remains to be fully evaluated. Interven- healthcare services, definitions that focus on 'maxi- tions may become more effective when they are targeted mum health' seem preferable. to fulfil need. Macro or micro level? Geographical variations A distinction needs to be made between individual and Demand for healthcare may also be affected by geograph- population-based health. Several approaches have been ical variation [35,36] and medical charges. Healthcare adopted as a proxy for assessing population's healthcare providers too may constrain patients' ability to benefit needs: mortality rates, [25–28] socio-economic sta- from healthcare; for example, low-referring General Prac- tus, service utilisation, or prevalence rates, titioners may fail to refer patients who need special which are all at macro level. However, needs can be care. Hospital utilisation data cannot be assumed to defined at micro level too, as demonstrated by the doctor- be a valid proxy for need since hospital use is a product of patient relationship, consultation with health profession- many variables including service supply and clinical deci- als, or patients' healthcare needs at a local surgery or sion-making rather than population need. These data health centre. Both macro- and micro-health needs are more likely reflect patients' propensity to consult, the will- important in different settings of health decision mak- ingness of family doctors to refer, access to hospital beds ing. Nevertheless, in routine clinical management, and the availability of alternative facilities provided by the health professionals deal with rather wider aspects of private sector. healthcare needs than 'capacity to benefit', such as social support, informational needs and equipment for daily Do existing definitions satisfy clinically relevant activities. health care needs? Coronary heart disease is increasingly common with Demand and supply in relation to need advancing age and has a significant impact on daily life. It 'Demand' is defined as what people ask for, and the constitutes a large proportion of the clinical workload for media, advances in medical technology and social and UK general and hospital practitioners, but a range of phar- educational background can have a profound influence macological and surgical interventions are available. Our on patients' and society's expectations. Geographic varia- clinical experience led us to suspect that this patient group tion, socio-economic status, knowledge about health and had specific needs that existing definitions failed to cover. Page 3 of 5 (page number not for citation purposes) Health and Quality of Life Outcomes 2003, 1 http://www.hqlo.com/content/1/1/34 We developed a comprehensive, self-administered needs approach to health care and towards a needs driven sys- tool In order to identify cardiac patients' specific health tem. In addition, it is important to ensure that patients care needs through patient interviews, expert opinions express their needs to a suitable agency, which can provide and literature review and administered this to 240 consec- the sort of specialist information required. Providing utive patients admitted to an acute cardiac unit. The meth- patients with a forum in which to express their needs to odology has been described extensively elsewhere access health professionals might be productive. but briefly the needs assessment questionnaire consists of 46 questions in 5-score Likert scale (1 indicates more Politicians keen to propose how they intend to meet the needs versus 5 with no needs) in five domains of 'physical needs of the voting public may find that it is easy to be needs, 'satisfaction', 'informational needs', 'social needs, seduced by definitions of 'need' which lead to a situation and 'concerns', with satisfactory internal consistency where limited resources appear sufficient. While some (Cronbach's alpha ranged between 0.83–0.89). This was genuine needs will be met, others, perhaps of greater value administered with a specific (Seattle Angina Question- if met, will be denied. The comprehensiveness of 'health' naire) and generic instruments (SF-12 and EQ-5D). deserves a definition of health needs which over-rides political considerations, or providers' limitations, and The main needs expressed by our patient group were for embraces current political strategy to conceptualise and information about current and long-term plan of treat- meet health need in the widest sense. If assessing ment, nutrition, any recommended limitation on daily needs is being proposed as a trigger to change current activities, advice on rehabilitation, more support from the healthcare services, definitions that address optimum lev- family doctor and easier access to the clinic and health els of health are preferable and must be clinically appro- services. Precise needs differed to some extent according priate for the population served. to age, educational level and social status. 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