4.2 Medical and social needs models

This learning object examines the important differences between models of need for health care which are based primarily on medical and social considerations and considers some of the practical difficulties associated with their implementation in the spatial planning of health care services.

‘A particular purpose of healthcare needs assessment is the spatial allocation of resources. Geographical equity of regions, districts, and even localities (such as housing estates) can be addressed by global and surrogate measures of health, particularly deprivation indices and standardised mortality ratios’

(Stevens and Gillam, 1998: 1448)

 

The assessment of need for health care can be undertaken from many different perspectives. In general terms, a distinction can be drawn between medical and social needs models. Medical models of need tend to be highly specific and based on measurable clinical factors or health outcomes. Needs measurement may also have important qualitative aspects, taking into account patients’ perception of their needs. Determining patients’ own perceptions of need is generally reliant on self-reported health questionnaires or patient satisfaction surveys. Within a medical framework, need can often be assessed only at the individual level by direct measurement and despite its apparent objectivity such assessment is generally constrained by the prevailing medical and social context, including the skill of the physician and the availability of appropriate diagnostic tests. While at a specific time and place a patient with an agreed set of symptoms may be accepted as needing a particular treatment, this may vary significantly over time and space. Apparently more robust measures of need based on health outcomes may be hampered by some of the same considerations, as observed levels of a medical condition will in part be due to the prevailing medical practice and in part due to patients’ judgements about when to seek help. Thus the rates of (for example) asthma in a population will in part be due to the actual (unmeasured) prevalence of a medical condition, in part due to the current diagnostic criteria (which will be influenced both by medical knowledge and the financial organization of the health care system) and in part due to the many circumstances which will contribute to patients’ decisions to consult their physician about their asthma-like symptoms. Once this complex construction of an asthma rate is understood, the difficulties in using it to determine the level and location of appropriate health care services becomes all the more apparent: the presence of a service which actively diagnoses and treats the condition may in fact lead to an apparent increase in its prevalence. Stevens and Gillam (1998) introduce the difficulty of how to balance medical needs of differing severity and how to take into account patients’ ability to benefit from care if it were provided. They note that ‘measured needs only take on meaning in relation to existing services’.

Needs measures employed by health care planners are more likely to be based on generalised models of need, taking into account basic demographic and social characteristics. Such models are not based on attempts to precisely understand and predict the prevalence of specific medical conditions in the general population, but rather based on general relationships between age, sex, ethnicity, social status and health which permit broad measures of need to be constructed. The health needs of these groups may be calibrated, for example, by reference to usage of existing services, clinical studies or patient surveys. These sources can usually only be obtained for a small sample of a population and they are thus related to more general demographic and social characteristics, which are obtainable for the entire population using censuses and other whole-population datasets. Such measures are readily adapted to guide the provision of services for particular population sub-groups such as children or the elderly or those with particular health-related behaviour such as smokers or employees in specific industries and occupations. Increasingly, health profiles from individuals taking part in detailed studies may be related to geodemographic types which are identifiable in the entire population as a guide to assessing the levels of need which should be expected in different areas.

Although there are few unambiguous links between the provision of health care services and actual health, there is a strong expectation that improving health care services will indeed improve general levels of population health, which means that relative under-provision of a service for a population group may itself come to be considered as an aspect of need. Asadi-Lari et al. (2003) seek to disentangle this complexity by arguing for definitions of need that reflect clinical reality, focusing on the gaps between services offered and patients’ real health needs which can point to areas for improvement in service quality.
 

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