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clinmed/2000020001v1 (April 7, 2000)
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Health Needs Assessment In Primary Care Groups A study to ascertain where we are, the issues and the barriers Dr Peter Green firstname.lastname@example.org Abstract Objective PCGs have a duty to commission healthcare according to need. HNAs are therefore essential in determining those need. This study sought to determine where PCGs were in their undertaking of HNA, the issues and the barriers. With a view to identifying and easing the barriers. Design Questionnaires, based on a questionnaire previously used by Jordan et al 1996  , were sent to
Health Needs Assessment In Primary Care Groups
A study to ascertain where we are, the issues and the barriers
Dr Peter Green email@example.com
PCGs have a duty to commission healthcare according to need. HNAs are therefore essential in determining those need. This study sought to determine where PCGs were in their undertaking of HNA, the issues and the barriers. With a view to identifying and easing the barriers.
Questionnaires, based on a questionnaire previously used by Jordan et al 1996  , were sent toone in four PCGs in England (117) and all the PCGs in the area previously studied by Jordan et al (16) at a time when PCGs had been in existence 6 months.
Main Outcome Measures
Outcomes were comparative between the area of Jordanís previous study and this study and between PCGs of differing characteristics.
All PCGs believed HNA to be an important activity, almost half (48%) had already carried out HNA, and of those 59% reported tangible changes. Almost three-quarters (71%) had plans to carry out HNA and over four-fifths (83%) had plans to consult local people. Areas of assessment were determined at local level (85%).
Four-fifths (79%) reported that they would need support to carry out local HNA, and rated help with surveying patients as the most important need.
There has been a significant change in the importance attached to HNA since the time of Jordanís study. The effectiveness of HNA activity to produce change remains at about two-thirds, and the amount of support requested remains at about 80%, although the nature of that support has changed.
HNA is an important activity for PCGs but support is required, and the nature of that support is likely to change. HNA produces tangible change in about two thirds of cases, this figure remains constant from previous studies. Perhaps more HNA should be encouraged rather than better HNA.
What This Paper Adds
With the setting up of PCGs, and their responsibility to commission, or advise on commissioning, according to need, HNA should become a core component of primary care activity. Previously primary care may have been more reactive than proactive to needs.
In 1996 Jordan et al assessed attitudes to, practice of and support needed for performing HNA, in primary care. This paper essentially repeats the study within PCGs and assesses changes that have occurred between the studies and discusses the implications for HNA in PCGs.
When PCGs came into existence on April 1st 1999 their functions  were to
These functions shift the primary care emphasis from responding to the needs of those patients that attend, and within particular groups organising screening, vaccination or disease management programmes, to assessing the needs of the community. It has been recognised for many years that what we see is the tip of the iceberg of need . Whether PCGs have the skills or inclination to perform this task is the subject of this study.
At the time of this study PCGs had been in existence for about 6 months, and because this is essentially a point in time study it is important to disseminate these findings back to PCGs and other stakeholders as quickly as possible. The development of Netprints greatly facilitates this, and I believe will encourage the publication of more time-sensitive studies.
Participants and Methods
Jordan et al, in their study of HNA in primary care had developed a questionnaire, which was adapted (with permission) for use with PCGs. The questionnaire was sent to all the PCGs in the area of Jordanís study (16) and a quarter of the PCGs in the rest of England (117), selecting every fourth PCG from a list of PCGs ordered by region, health authority and then alphabetically. There was a concern that Jordanís study itself may have affected the perception of primary care to HNA within that area, and if so it would be inappropriate to extrapolate from the results from that study to this study. Jordanís area was therefore studied separately in order to assess any differences with the results from the rest of England.
Comparisons were made between the area of Jordanís study and the rest of England now, between PCGs of different size, level, previous involvement in commissioning groups and between the results of this study and of Jordanís earlier work, using Chi squared to assess differences.
Response Rate and Epidemiological Characteristics
Three-quarters (99 of 132) of PCGs responded, 73% of the PCGs in the area of Jordanís previous study responded, and there were no statistical differences between their answers and those of PCGs in the rest of England. So for the purposes of describing the results all answers are included together.
Of those responding 21% had previously been involved in commissioning pilots, and 90% were at level 2. Nationally about 70% of PCGs are at level 2, so level 1 PCGs are underrepresented in this study, but analysis showed no significant difference between the results from level 1 and level 2 PCGs.
All respondents reported that it was important to assess the health needs of their population, 88% very important. Almost half (48%) had carried out a local HNA and of those 59% reported that it had led to tangible changes in clinical or management practice, 18% reported no change and 23% were not sure, some commenting that it was too soon to tell.
Over seventy percent (71%) of respondents had current plans to carry out HNA and 83% future plans to consult local people about health needs and how they should be met.
The topics selected for HNA broadly fell into four descriptive categories defined according to age, disease, behaviour or service. The most frequent answers were disease defined with heart disease being the most frequent, followed by mental health, elderly care
issues, teenage health (including sexual health) issues and diabetes. These priorities were mainly identified as PCG concerns 85%.
Almost four-fifths of PCGs (79%) reported that they would need support to undertake local HNA, with help in surveying PCG populations as the most common need. (Figure1)
Forty six percent of PCGs had already consulted local people about health needs and how they should be met, and a variety of means and methods had been used. Including public meetings, multi-agency conferences, focus groups, local forums or workshops through to patient questionnaires and often more than one approach was being used. Some of these approaches tapped into existing local stakeholders via organisations or groups of individuals, or by setting up new groups or structures.
Within the other comments received as part of the questionnaire, was a range of enthusiasm for local HNA from those who believed the needs to be known and delivery the problem, or questioned the expense or value of the process of HNA, to those who felt it to be very important or even obligatory if inequalities are to be addressed. Others commentated on the knowledge and practical difficulties involved, the need for support, and the difficulties of limited resources, raising expectation without the resources to meet the needs.
Comparison with Jordanís earlier study
The importance of HNA and the number who had carried out a local HNA has significantly increased (88% cf 46% p<0.001 and 49% cf 26% p< 0.001 respectively) (Figure2). The response rate to the questionnaire (75% cf 44% p<0.001) also showed significant change. Lesser but still positive change was shown in the number who had consulted local people.
The effectiveness of HNA activity to produce tangible change remains about the same (57% cf 64%) as does the percentage requesting support ( 79% cf 76%), although there was a change in the prioritisation of the topics selected. Jordanís study ranked guidance on topics highest this study ranked it lowest, but otherwise the order remained the same.
Comparison between groups that had and had not been part of commissioning pilots.
There was no statistical difference between the two groups. Those that had been involved in commissioning pilots felt HNA to be slightly less important, only 80% rating it as very important cf 90%, but of the activity carried out 71% reported tangible change cf 54%.
Comparisons between PCGs of different size and level
There were no significant differences noted within this study between these groups. However level 2 PCGs were almost twice as likely to have carried out a local HNA ( 61% cf 37%), to have consulted local people (44% cf 20%) and also had more future plans to consult local people (93% cf 76%) and were less likely to require support (78% cf 90%).
Of the four national Health Improvement priorities, in both this study and Jordanís earlier work, mental health and cardiovascular disease scored highly whereas accidents and cancer got relatively low ratings. This probably reflects the perception that primary care has little ability to influence these areas. The Kingís Fund report  ĎLocal Inequalities Targetsí in discussing the Ďminimal impact on GPísí of the Health Of The Nation strategy attributed this to the priorities being beyond the control of or irrelevant to the size of the populations primary care was dealing with, the same appears true here.
Support is still needed but the nature of that support has changed, and it would appear that there is a consistent and logical hearty of process within the ranking (Figure 1). The recognition of a hierachy is important as it implies that both the support needed will alter with time and that it is predictable. Gillam  commented Ďto be practically useful HNA needs to match the developmental stage of the PHCT itselfí the support must also match the developmental stage.
Hanlon  felt that Ďneeds assessment will have little involvement from primary care until there are changes in the attitudes and skills of the majority of GPísí. It would appear from this study that there has been a change of attitude and also to some extent skills. Changes in attitude are probably now more important than changes in skills, as from a PCG perspective the skills can be brought in. Jordan concluded her study by saying that Ďany attempts to promote needs assessment in primary care which focus either primarily or exclusively on the provision of Ďeducationí are unduly simplisticí feeling that Ďmore fundamental questions about the perceived relevance and opportunities for assessing health needs should be consideredí. This study firmly establishes the value of the concept of assessing health needs within PCGs and also goes someway to establishing the relevance of and opportunities for HNA by PCGs.
This study demonstrates that HNA is considered an important activity for PCGs and that the importance of local NHA in Primary Care has risen over the last 3 years. This is demonstrated by an increase in activity; in carrying out local HNA, in consulting the public and in plans to do so.
The effectiveness of these activities in producing tangible change remains at about two-thirds. It may be more prudent to encourage more activity than to try to ensure that all activity leads to change.
The level of support needed is high, (80%) and unchanged, although the nature of the support has changed. Having taken the view that healthcare needs should underpin the health service being provided, then it would be remiss of the government not to respond to PCGs need for support in this area.
This study was carried out as part of a dissertation project for a
MSc in Paraclinical Sciences,
Kent Institute of Medicine & Health Sciences,
University of Kent.
There was no external funding.
Figure 1. Support Required By PCGs To Undertake HNA.
Comparison Between This And Jordan et alís Study.
Do you believe that it is important to assess the health needs of your PCG population?
There is a significant shift (p<0.001) from Jordan et alís study to this study in the reported importance given to HNA.
Figure 2. The Reported Importance Of HNA.
Comparison between this study and that of Jordan et al.
PCGs were asked what support they would require in order to undertake local HNA? The highest three priorities were selected and ranked in order of importance from 1 to 3, where 1 = most important and 3 = least important. The results were then scored 3 points foe most important, 2 for next most important and 1 for least important.. Because the sample sizes were different between this study and Jordan et alís the results were then converted into percentages, the highest score in each study being 100%.
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