Assessment in primary care: practical issues and possible approaches

This article is a practical guide to help primary care groups (as set out in the NHS white papers¹,²) and also individual practice teams assess the health needs of their respective populations before providing or commissioning services to meet these needs. Historically, much service provision has been service led rather than needs led, provided as before and at the convenience of providers rather than patients. The needs of patients are now accepted as being central to the NHS. An explicit framework is needed to help assess needs more systematically, to demystify the process, and to help prioritise and action changes.³ This paper outlines an approach that is feasible for individual practices, groups of practices, and populations of around 100 000 people (typically the size of the new primary care groups described in the white paper).

Summary points

• A practical strategy for assessing local health needs is required

• This approach uses practice held data, routinely available local statistics, a patient/public consultation exercise, and (possibly) a postal survey to gain various perspectives on need

• Unless specific, useful summary data are obtained, details will obscure the larger picture

• Stages in this strategy are to collate the information, assess priorities, and plan and evaluate changes

• Time and resources must be available at practice and locality level, but many important health needs cannot be met by health services alone

Do we get involved with wider health needs or just health service needs?

Health professionals understandably tend to think of health needs in terms of services they can provide. Patients may have different ideas about what affects their health. This might include getting a job, having a roof over their head, or having a bus route which makes getting to see the doctor easy. A group of practices may decide that they do not have the time and resources to consider these types of needs, and they may feel even less confident about being able to do anything about such needs. But if primary care has the aim of improving the health status of individuals as well as providing health services, such factors must at least be identified for action by someone else. Lalonde, when minister of health in Canada, emphasised the importance of lifestyles and the environment on health as well as the influences of human biology and health- care provision.⁴ Thus this paper embraces needs for health—needs for services and more general needs.

Levels, approaches, and methods

The process of health needs assessment can be carried out at different levels, from international down to individual patient. Different approaches can be used at each level (from global to specific diseases).

Levels

Needs assessment can be carried out at various levels:

• International—By the World Health Organisation, for example

• National—The advantage of tackling some national priorities locally (such as mental health) is that it may be easier for health authorities or boards to fund identified gaps in services. But remember that the most common complaints presented by patients—stress, arthritis, and dyspepsia—have never been identified as national priorities⁵

• Regional—the need for a liver transplantation service could be assessed at this level

• Health authority or board level—The needs for neonatal care, obstetric care, or dietetics may be assessed at this level

• Locality—The creation of primary care groups will lead to increasing importance for needs assessment to be undertaken at this level. Generally, larger populations will produce more robust results than single practices. There is also no need for every practice to carry out similar studies when it is unlikely that there will be different needs between practices. Issues suitable for tackling at this level might include unwanted pregnancy, dental caries, inequalities in service provision of community nursing

• Practice specific—It is worth thinking about a single piece of needs assessment work where a practice is relatively large and is situated in an area of particular need. Issues such as mental health and drug addiction may be particularly relevant

• Small neighbourhood—Some practices have a group of patients who live in a well defined disadvantaged area. Such an area can usefully be targeted

• Individual—used daily in consultations by general practitioners and nurses.

Approaches

When using a global approach, get an initial overview of the health and social needs of the population group, then identify which of a variety of interventions might best improve the health and wellbeing of patients. Issues relating to the wider determinants of health can be taken to the relevant agencies for action (in London and in Edinburgh, bus routes have been changed and play areas developed).

A focused approach can centre on:

• A specialty (mental health, for example)

• A disease (epilepsy, Alzheimer’s disease, cerebral palsy, or diabetes⁶)

• A client group (elderly people, single mothers, the unemployed, farmers)

• Groups waiting for interventions (people awaiting an operation or physiotherapy)

• Vulnerable groups of patients (ethnic minorities, etc)

• Patients who are socially deprived, to address issues of inequity.

Methods of assessing needs

Different information sources and methods of investigating give complementary insights into health needs generally.⁵ Practitioners should concentrate on gathering the information that will give them the most useful insights, rather than on collecting all sorts of information that might turn out to be useful. A locally appropriate mix of methods can use data from various sources: information held by the practice, computer records, and “soft” information from all members of primary healthcare teams. These sorts of data are good for assessing ongoing physical problems.

Local statistics are routinely available from health authorities or health boards, hospitals, and the census. Public consultation exercises, which can utilise focus groups, rapid appraisal, or other methods of interacting with local people, are good for uncovering problems relating to drug abuse, HIV, and social issues.

A postal survey may be worth considering to provide data about acute illness in the community and suggestions for changes to services. A covering letter by the patient’s general practitioner may improve the return rate.

Detailed guidance on practical aspects is now available, including a workbook and a “really rough guide.”^7–11

Involving others

Most approaches can be undertaken by an individual or a group. Although group work is more difficult to organise, there are major benefits. Group members who work in the community, such as health visitors and district nurses, have valuable knowledge of local needs and will feel an ownership of the results if they have been involved. Practice staff involved may require additional resources or locum cover. Public health and primary care can contribute complementary skills and insights at every level.

Any practice or group of practices needs to decide how the public will be involved at an early stage. Methods for involving the public have been described by Mays et al.¹²

Consultants working in hospital or community trusts usually have a clear picture of the needs for their particular service. This can be a rich source of help, advice, and information. Combining specialist expertise and the experience of generalists can produce valuable information. Other service providers should also be considered, such as hospices and other agencies both in the statutory and voluntary sector.

Depending on funding, some aspects of needs assessment may be carried out by an external agency if the relevant skills or time is not available (for example, to carry out focus groups or a postal survey).

Defining the problem or area to be assessed

Most practices and even locality groups will have little time to devote to needs assessment, and therefore it is important to target any effort in the most productive way. A first needs assessment project needs to deliver rapid success to stimulate those involved to progress further. In a few practices—perhaps in an area of inner city deprivation—the issues that need to be tackled will be very obvious, but for most practices the priorities will vary depending on the demographic profile, common illnesses, and social needs of the practice population. Consider the frequency, impact, and costs of different diseases. Priorities might be defined with the following questions:

• Is there a realistic chance of achieving change?

• Is the cost of undertaking the work proportional to the likely benefits?

• What are the priorities being suggested by other agencies—the health authority or health board, social services?

• Does the practice or primary care group wish to look at issues that are not directly under their control such as housing and transport?

  Core practice data

  • Age-sex profile in 5 year bands for male and female patients
  • Prescribing details:

    Repeat prescribing rates from practice computer

    Collated prescribing figures (PACT or Scottish Prescribing Analysis)

  • Prevalence of some specific chronic disease (for example, ischaemic heart disease, chronic obstructive airways disease, asthma, epilepsy, psychosis, thyroid disease, hypertension, diabetes)
  • Data from practice’s payment details:

    Percentage of patients attracting deprivation payments

    Family planning uptake

    Temporary residents

    Obstetric care and other item of service payments

  • Health promotion and disease prevention data:

    Smoking, alcohol consumption, substance misuse, body mass index

    Immunisation coverage (2 and 5 year olds)

    Cervical cytology coverage

  • Contacts with general practitioners:

    Surgery consultation rate per 1000 registered patients per year

    House call rate per 1000

    Out of hours visits per 1000

  • Knowledge (mostly implicit) of local health needs:

    Health visitor: practice profile, breast feeding rates, use of other agencies

    District nurse: workload details, observations in patients’ homes

    Practice nurse: workload details (for example, influenza coverage rate)

    Receptionists: patients’ perceptions, availability of appointments

  • Deaths—causes, place of death, preventable factors
  • Turnover of patients
  • Other sources—suggestions box, patient participation group
  • Notes search may yield:

    Incidence of acute illnesses and symptoms presenting

    Telephone ownership (percentage)

    Unemployment rate, domestic problems documented

  If reliable data (on use of investigations, referrals, etc) are available from other sources, use these data rather than duplicate work in the practice for the following:

  • Use of investigations (per 1000 patients per year, individually for microbiology, haematology, biochemistry, radiology, electrocardiography
  • Referrals to physiotherapy, chiropody, occupational therapy (per 1000 patients per year)

Five stage approach

Stage 1: Collect routine practice information

Routine data from general practices can highlight needs that are dealt with in primary care. The box lists data that give an overall practice perspective on needs: ask your practice manager to collect as much as is reasonably available. Some computer software (such as GPASS in Scotland) can generate a practice profile automatically. This is especially useful for comparing practice data with other practices, or for collating data for groups of practices. Several networks exist in different parts of the country to optimise the use of such data.¹³

Hospital, community trust, and census data

Inpatient data

• Ten most frequent diagnoses made at hospital inpatient discharge (rates per 1000 registered patients), tabulated in descending order. (ICD-10 codes to three digits are recommended; transfers are excluded; patients with multiple discharges from the same hospital, using the same facility and with the same diagnosis, are counted only once.)

• Elective admission (rate per 1000 residents)

• Non-elective admission (rate per 1000 residents)

• Mean waiting time (days)

• Ten most frequent day case diagnoses (per 1000 patients), tabulated in descending order of frequency

• Top three day case procedures (per 1000 patients), in descending order of frequency

Outpatient data

• Outpatient referral rate per 1000 residents

• Referral rates for five most used specialties, tabulated in descending frequency

• Mean waiting time (days)

• Attendances at accident and emergency department (per 1000 patients)

Obstetric data

• Births (rate per 1000 registered patients)

Community data

• District nursing visits (per 1000 patients per year)

• Health visitors, visits, and clinic attendances (per 1000 patients per year)

Investigations

• Use of investigations (per 1000 patients per year) for microbiology, haematology, biochemistry, radiology, electrocardiography

Referrals

• Physiotherapy (per 1000 patients per year, clinic and domiciliary)

• Chiropody (per 1000 patients per year, clinic and domiciliary)

• Occupational therapy (per 1000 patients per year)

Census

• Percentage of residents with limiting long term illness

• Demographic profile, in 5 year bands

• Unemployment rates (%) for men and women

• Percentage of house owners

• Percentage of car owners

• Percentage of households with lone parents

Stage 2: Collect hospital, community trust, and census data

Standard “routine” hospital utilisation data does not routinely get fed back to practices. Thus the knowledge and understanding that most general practitioners have of the hospital services that their group of patients receive is limited. Although routinely collected clinical data may contain inaccuracies,¹⁴ the quality of some databases has substantially improved.¹⁵ With the help of local public health departments, detailed hospital utilisation can now be compared between practices and localities. Such data must be interpreted carefully, as demand and supply often have more influence on hospital usage than does need. Use of hospital services may not be a proxy for morbidity in the community.¹⁶ The box on the next page lists the variables which general practitioners working in Edinburgh’s south east locality found most informative for understanding the current usage of hospital services by individual practices.

Health authorities and boards also have a range of census information, available at small area level. This information is extremely useful to highlight social inequities at small area level such as in an underprivileged housing estate. Jarman and Townsend scores may be available, but at practice or locality level the six census categories listed in the box may be sufficient to give a view of social need. Unless you request very specific, interesting summary data from the health authority or board you will be swamped with too much detail, which will obscure the larger picture and be too lengthy for general practitioners to absorb.

Focus groups¹⁷

• Facilitated discussion groups that allow the members of the target population to express ideas spontaneously

• Can give useful insights into perceived needs, quality of services, and understandings of health issue

• Can raise issues that are important to patients

• Information gained is not quantifiable

• Facilitators need some training

• A variety of groups may be necessary to be representative in some situations

Practical points:

• Optimum size is 8-12 participants

• Facilitator introduces topics for discussion

• Proceedings are recorded using a tape recorder and later transcribed, or notes are taken, preferably by another facilitator

At practice level such data can be presented at a practice planning meeting and inform the practice’s annual business plan. In southeast Edinburgh locality, the above data were fed back at a meeting to which one general practitioner from each practice was invited. Protected time—and hence a good attendance—was gained making a fee from the general practice fundholding management allowance available to all attendees. After the abolition of fundholding, similar exercises should be possible, using the management allowances associated with the new primary care groups. This data highlighted considerable variations in the use of inpatient services, outpatient services, and community services such as nursing and chiropody, with the two most common reasons for admission (termination of pregnancy and dental caries) both preventable. The general practitioners, after presentation of the data and discussion, left written comments about what they found most interesting about their practice, suggestions to improve or extend the data, and how the data could be used by individual practices and the locality. Subsequent meetings are planned to gain other perspectives of need in the locality from other data sources.

Stage 3: Gaining public involvement

Health professionals define “needs” in terms of services that they can provide, whereas patients may have a different perception of what would make them healthier: a job, a bus route to the hospital, or some advice on benefits, for example. Thus interaction and input from patients and the public is vital to gain an “honest consumer perspective.” It can be obtained through:

• Interviews with patients

• Informal discussions with, for example, voluntary groups, community health council

• Suggestion boxes

• Complaints procedures

• Health forum

• Focus groups (with elderly or diabetic patients, for example; see box)

• Rapid appraisal (see box, next page).

Stage 4: Undertake (or use an existing) postal survey

Surveys to assist local decision making must be modestly defined and use a mixture of lay and medical concepts. Computerised search and mail merge facilities allow most practices to send questionnaires (with covering letters and reply paid envelopes) to specific patient groups. A well conducted postal survey of a representative sample can give a reliable estimate of the true burden of morbidity in the population, and may inform contract specification. Assistance will normally be required to select an instrument or to design one, and with sampling and data analysis. Various validated instruments for generic and disease specific surveys are available.²⁰ Questions concerning the areas outlined in the box on the next page may be especially relevant, as such data may not be obtained easily from other sources.

Rapid appraisal

A team, ideally with a mixture of professional insights, gathers data about both needs and resources in the area under study from:

• Interviews with key informants (individuals with knowledge of the community) and patients

• Available documents about the neighbourhood or community

• Observations made inside homes and in the neighbourhood

Practical points:

• Use the framework of an information pyramid¹⁸,¹⁹ to guide collection and analysis

• Collate the needs, priorities, and solutions perecived in the community for each box of the information pyramid

• Consider facilitating change in primary care services, commissioning of secondary care, and local advocacy to improve wider determinants of health

Areas for questionnaire surveys

• Acute illnesses and experience of common symptoms

• Use of health services over the past 6 or 12 months

• Patients’ satisfaction

• Perceived need for current and potential services

• Specific concerns and worries that may affect health

• Specific questions for people with specific long term health problems or carers

• Chronic illness (may not be necessary if data obtained already):

  Any long term illness

  Several marker conditions (for example, hypertension, back pain)

• Consider a general health status instrument (SF-36, SF-12)

• Consider a disease specific instrument

(Consider checking a sample of medical records from non-respondents.)

Stage 5: Collation of the information from the different sources

At practice level

Present the major findings of each method to a meeting attended by as many of the practice team as possible, and discuss what changes should be made to the established work patterns and services the practice offers. New initiatives identified should be prioritised and incorporated in the practice’s business plan for the coming year. Feedback can be given to the local hospitals and community trusts if relevant.

At locality level (primary care group)

As the stages of the needs assessment may take several months, present the major findings of each method as they become available. Protected time is vital for practice representatives to study the information together; starting to get a feel for the needs of the locality as the complementary data builds up. A specific meeting, possibly facilitated by the local public health department, will be important to prioritise the suggestions raised by the various sorts of data. Techniques for prioritising needs include the nominal group technique, and use of a ranking matrix can give useful structure to such meetings. With the nominal group technique, needs or interventions are listed, discussed, then ranked by each participant until an agreed level of consensus is reached. This encourages debate, and quick decisions can be made. To use a ranking matrix, criteria for priority interventions are defined, such as potential to improve health, capacity to implement, and equity implications. Participants score each potential intervention for each criterion, and the scores are totalled.²⁰

Health needs assessment is a cyclical process. Needs change over time; evaluating how well needs have been met will bring you back to assessing the needs that have not been met by your action.

How realistic is assessment of health needs in primary care?

Lack of planning time and the pressure to respond to the immediate needs of patients has to date prevented needs assessment in primary care. The fundholding initiative, emphasising efficient purchasing of services, has not championed needs assessment and has largely ignored aspects of health needs not related to the health service. The advent of locality commissioning and the creation of primary care groups will now allow some general practitioners protected time for needs assessment. This strategic work is realistic and possible and has the potential to make primary care more effective at improving health by targeting available resources. But resources, training, and liaison with public health physicians will be necessary for this to work.