Getting things right for our communities is more important than ever. With significant structural change on the horizon and resources already stretched, confident commissioning decisions can be harder to come by. Fundamentally, however, delivering services that meet the needs of our population is an enduring ‘north star’ that the NHS can rely on during tumultuous times.
Health needs assessments (HNAs) are typically used by public health services to determine which prevention approaches are the best fit for the local community, but their potential value extends beyond this. There is both an art and a science to developing high quality HNAs that inform effective commissioning decisions by bringing together policy, evidence and data with the views of the local community, advocacy groups and healthcare staff. HNAs can help NHS organisations reduce inequalities and focus attention on the areas that deliver most value for their own patients.
As we wait for the detail of the 10-Year Health Plan, we do know that this will be structured around the government’s three priority shifts in care delivery, including moving care from hospitals to communities and shifting focus from treating illness to improving prevention. These shifts need to be underpinned by a clear understanding of the wider determinants of health. But while ICBs have tended to look to quantitative population health data to inform commissioning, local authority public health teams rely on a rolling programme of HNAs that assess information from a range of sources to support decision making.
Developing a holistic view
When it comes to prevention, we have to understand enough about enabling access and reducing potential barriers to develop services people can and will realistically engage with. HNAs ideally consider many different types of information synthesized to provide a holistic view of current services and needs of the population including:
- Local and national policy and guidance
- Latest evidence about what works
- Data about the local population, service usage and key performance indicators
- Documents such as service specifications, minutes from relevant groups and annual reports
- Views of the service gathered from residents, service users, frontline healthcare professionals, provider leads, advocacy groups and commissioners, covering areas such as barriers and enablers and who can or can’t access the service.
Data about services can only tell us so much, mostly about the service itself, not about the people who need it. It is crucial that views from people who need to use the service are prioritised to identify challenges such as lack of public transport at appropriate times or locations, appointments not being available outside typical work hours, or lack of accessible information about the service. It’s also important to know any psychological barriers to accessing services such as perceptions of treatment, fear of health outcomes and previous negative experiences. Other good sources of information are from frontline health professionals who often advocate for the people they treat as they witness many of the issues people experience.
Tailoring services to individual needs
Making services available to individuals is not necessarily the same thing as meeting their needs. For example, local authorities are required to offer smoking cessation services and there are established national programmes which support this. However, a deeper dive into population needs in Oxfordshire showed smoking levels overall are low but high among those with mental ill health and people who misuse drugs and alcohol. Generic smoking services are often principally focused on signposting and may include telephone-based support, often from out of area contact centres. For those with mental health needs, a more intensive, tailored service with face-to-face support in the community is needed. By understanding the current need and the current service offer, the gap is in the process of being addressed with a new service specification enabling the council to make best use of resources.
With support from national funding, secondary care services in Oxfordshire have placed smoking cessation teams in acute, mental health and maternity settings, to reach patients at a time when they are prevented from smoking on hospital premises. The collaboration between community services commissioned by the council and secondary care services commissioned by the NHS aims to seamlessly extend smoking cessation support across the health economy.
Secondary prevention
This personalised approach to understanding health needs can be used within different specialties and linked community services to enhance secondary prevention strategies. This might be to reduce the risk of readmission or further adverse events. For example, there is evidence that follow-up support in the form of a coaching programme for those with cardiovascular disease – which helps people to address lifestyle risk factors, medication adherence and optimise medication regimes – reduces the likelihood of future cardiovascular events. In other cases, prevention support made available prior to treatment can help at risk patients by preparing them better for treatment and reducing the likelihood of complications.
There is scope to apply this more broadly to maximise impact with limited resources. For example, conducting a needs assessment for each of the six main groups of long term conditions that account for 60% of mortality and morbidity in England could support hospital trusts to plan coordinated interventions in partnership with other healthcare providers to improve patient health and reduce readmission.
Flexible response
If we are to truly focus on meeting health needs and reducing inequalities, we need flexibility to respond appropriately to patients according to their circumstances and offer support which is truly helpful for individuals. We are starting to see some local authorities adopt a Human Learning Systems (HLS) approach to service delivery which empowers staff to provide bespoke solutions for individuals, especially those with complex needs. For example, as part of its alcohol and substance misuse prevention strategy, Thurrock Council is developing locality network hubs, bringing together staff from the drugs and alcohol service with mental health, primary care, social care and third sector organisations to co-design single integrated solutions with residents. Trust is needed to enable a move away from prescribed service specifications towards solutions which staff and individuals collaboratively determine. These solutions might differ from ‘textbook’ support based on evidence for whole populations but are actually effective in reducing mental and physical health risks in the long term in individuals.
HNAs are not a panacea and there are still limitations in the extent to which interventions can be tailored to individuals, with funding sources sometimes limiting the ability to work cohesively across different settings within the health economy. An understandable focus on outcomes can also make it more difficult to prioritise interventions which will only bear fruit long term, particularly when resource pressures are so high. But the value of developing a deeper understanding of the health needs of our population and the inequalities that can result from barriers to service uptake cannot be understated. When every penny counts, we need the right information to make the best decisions for our communities.
Solutions for Public Health is a specialist NHS public health consultancy working as part of NHS Arden & GEM CSU
