Health needs assessment is not required for priority setting

Editor—The series of articles on health needs assessment provided insights into how the approach could be used to describe health problems in populations and to identify inequalities in health and access to services.^1–3 The authors of the articles failed to recognise, however, that prioritising healthcare services on the basis of need can lead to inefficient use of resources.

Allocating finite healthcare resources according to the total amount of ill health in the population—whether this is measured by lives lost, morbidity, or any other agreed measure of need—overlooks the potential for patients to benefit from healthcare interventions and ignores the costs of those interventions. How, for example, would an epidemiologically driven approach prioritise healthcare services if conditions with great need (however defined) were not amenable to treatment and conditions with less need were amenable to an array of low cost, effective treatments? Needs assessment cannot form the basis of an efficient strategy for planning and purchasing health services.

The economic approach offers a more satisfactory framework for prioritising healthcare services. It estimates the incremental costs and benefits of altering the existing balance of expenditure between healthcare programmes, independent of any changes in the overall health budget.⁴ It does have limitations, not least the paucity of adequate data on the costs and benefits of healthcare interventions with which to make strategic decisions and disagreements about the merits of alternative measures of health benefit (for example, the quality adjusted life year and the healthy year equivalent). These limitations, however, should not distract from the appeal of an approach that aims to maximise health gains within available resources.

The proponents of needs assessment might argue that an understanding of the distribution of severity of health problems within the population is required, even where maximising quality adjusted life years or healthy year equivalents is the agreed objective. With this understanding the incremental cost per unit of health gain can be estimated at each level of unmet need. Even this view, however, cannot be accepted uncritically. For most services, unmet need is so great that gain in quality adjusted life years or healthy year equivalents can be assumed to remain constant over the range of any marginal increase in the provision of services. Moreover, the economic approach takes existing expenditure patterns as the starting point and uses evidence from formal and informal sources to examine the effects of small changes to those patterns.⁴