Feature

Whose needs are they anyway?

There are multiple benefits to a community-based approach to health needs assessment, argue Georgina Webster and Jan Smithies

An article by Nigel Edwards about community-based needs assessments, assessments that involve the participation of local communities, appeared in the Health Service Journal in September last year.¹ The article, based on research undertaken by the London Health Economics Consortium (LHEC), was critical of such approaches, citing problems with conceptual underpinning, lack of objectives, problems with methods, and the validity of priority setting which results. The author also asserted that community-based health needs assessments have had ‘no significant impact’ on purchasing. He went on to suggest that epidemiological research and specific service reviews are more effective methods and that community-based assessments merely legitimate purchasing decisions taken elsewhere.

Our experience contradicts that research, and challenges some of the assumptions of the LHEC work. We believe that community-based needs assessments are useful. In particular we argue that participatory health needs assessments:

• provide a participatory model for obtaining useful and relevant qualitative and quantitative information, as well as increased involvement of agencies, communities and individuals in health;
• lead to specific changes in purchasing decisions;
• lead to changes within the priorities and practices of other organisations whose actions impinge on people’s health;
• enable the continued expression of the views of local people, especially those whose voices have not been heard;
• provide a vehicle for facilitating organisational development within health authorities and other organisations, to bring about the cultural changes necessary for improved action on health;
• lead to improvements in the health and well-being of the people involved and inform and broaden the commissioning agenda.

We have worked with different HAs and boards on at least 15 separate community-based health needs assessments. All of these have prioritised gathering ‘qualitative’ information. They have sometimes been complemented by quantitative information, although this is difficult where agencies do not use coterminous geographic boundaries for information collection. The results have not only included vital indicators of what needs to be purchased by the HA; but have also indicated why people believe certain factors influence their health and what action needs to be taken to address those factors in a way that has real (and measurable) effect.

There is an impressive list of purchasing decisions which have been heavily influenced by community-based needs assessments. For instance:

• research in Sheffield on the needs of children living in temporary accommodation led to contracting for a specific health visitor post to work with homeless families;
• participatory needs assessment in Kirkby led directly to a locality resource centre being developed by the health authority, the ‘Kirkby Health Suite’; the introduction of local physiotherapy sessions; and local outpatient clinics;
• a participatory survey on a small housing estate in the Western Isles of Scotland revealed a need for work on women’s health issues which has since been resourced; the health board was unaware of the high local priority given to these issues prior to the survey, which was within too small an area for conventional epidemiological research.

Participatory needs assessments, which start with people’s own definitions of health and well-being, usually highlight changes necessary in the policies and practices of other organisations and groups, as well as those of HAs. The fact that community-based assessments highlight a ‘common list of health concerns… which usually includes issues only indirectly related to health services’, as Edwards states in his article, is not a problem.

Instead it focuses attention on the role of the HA as health commissioner in taking, influencing or enabling action on these issues. And it is interesting when different communities do not come up with the same list, or they prioritise that list differently, and provide specific detail as to why they consider these factors important.

Examples of health-enhancing decisions taken by agencies as results of participatory needs assessments include:

• submission of a bid to the Single Regeneration Budget by the Richmond Partnership in North Yorkshire, an alliance of local agencies aimed at improving the economic prospects, training and health of the local community, which includes commitment of resources by those bodies in addition to their SRB bid. One of the components is a leisure centre which will aim to improve the local population’s health.
• endorsing the building of a low-cost supermarket; traffic calming work by the local authority; education of parents and children in accident prevention — all took place in a deprived part of Oldham as a result of a participative survey.

In many areas community-based needs assessments represent the first serious and ongoing attempts of HAs, boards and trusts to seek out the views of their local populations systematically. This has had both immediate effects and has sometimes led to the creation of longer-term mechanisms of involvement, so that a partnership can be built up between communities, health services and other relevant agencies.

At the same time, such assessments often take place in communities which are deprived or under represented, and become part of a strategy to reduce inequalities in health. For example:

• Salford and Trafford HA has trained a number of representatives of minority ethnic groups in their area to carry out needs assessments and join a forum for community views;
• West Pennine HA appointed a ‘local voices’ co-ordinator to enable the continuous input of local views into purchasing decisions;
• the Western Isles health board is seeking to help to resource a Community Health Forum on its most southerly island, Barra, as a way of ensuring a continuing Barra community voice into its decisions.

The Local Voices document published by the Department of Health in 1992 states that: ‘To give people an effective voice in the shaping of health services locally will call for a radically different approach from that employed in the past. In particular, there needs to be a move away from one-off consultation towards ongoing involvement of local people in purchasing activities’.² This implies the need for organisational development within health organisations in order to bring about this new approach.

Since 1992 many HAs have begun to make such changes.³ Participatory needs assessments have played a part in this because they usually highlight issues which can only be tackled by health purchasers who take this challenge seriously. That is because they also throw up issues about process: the wayservices are provided as well as what they provide; the ways professionals from different agencies relate to each other as well as with local people; the need for agencies from different sectors to co-ordinate their activities more; and so on.

In our research we spend time working with HAs on the implications of a participatory approach to needs assessment; on new structures and mechanisms which may need to be set up so that needs assessments can directly link into decision-making forums; on changes to the internal culture and so on.

Community-based surveys will throw up complex issues at organisational and inter-agency level, because they are based on the ways that local people see health and well-being, rather than on a medical model of health. It is a mistake to blame the participatory methodology for raising these issues. It would be more effective to enable HAs to tackle these organisational and inter-agency issues so that the necessary action to improve health can be taken.

In other words, the answer is not to ‘drop’ community-based needs assessments because their findings and their implications do not fit into existing organisational and service patterns. The answer surely is to address the organisational issues. This has been done in some cases as part of participatory needs assessments. For example:

• workshops for board members on the implications of this approach;
• capacity building for professional staff in using a participatory approach;
• joint workshops between HAs and local community representatives on establishing ongoing mechanisms of involvement;
• internal organisational reviews of decision-making systems and structures in relation to health needs assessment.

It has been stressed time and time again that the primary role of HAs, and indeed the rationale for the purchaser/provider split, is to improve people’s health. Part of this role includes purchasing healthcare services, but wider roles such as health promotion, building ‘healthy alliances’ with other organisations and encouraging steps to prevent disease, accidents and ill health are perhaps even more important in terms of improving health rather than just managing illness. The Health of the Nation and its sister documents in Scotland and Northern Ireland are an important backdrop to community-based health needs assessment, as is Health For All, and other health-enhancing policy initiatives such as Agenda 21, which is concerned with environmental, health, social and economic issues.

Similarly, the increasing research on redressing inequalities in health stresses the importance of community involvement. Within this broad context, the role of community-based needs assessments needs to be highlighted more, rather than less, as Edwards proposes. At the same time, such assessments need to be taken seriously. Their achievements can then be given the recognition they deserve.