Service needs of individuals and populations

Mike Slade

Michele Tansella

Graham Thornicroft

Introduction

The importance of needs assessment has been one of the most consistent themes to emerge from the evolution of community mental health services. However, the concept of ‘need’ is used in different, and sometimes contradictory, ways. The aim of this chapter is to

define needs assessment
consider different approaches to assessing needs, both at the individual and at the population levels
discuss how needs assessments can be applied in real-world settings in planning and delivering clinical care.

Defining needs

At its simplest, a need involves a lack of something. But of what? In operational terms the concept of need is usually applied to a difficulty (in this case in relation to a person with mental illness) for which a possibly effective intervention exists. By implication an experienced difficulty for which there is no known effective intervention is therefore not defined as a need.⁽¹⁾ The clearest categorization of such needs was identified by Brewin, who grouped definitions of need within mental health care into three categories: lack of health, lack of access to services or institutions, and lack of action by mental health workers.⁽²⁾ Approaches to need within each of these three categories will be reviewed.

(a) Needs for improved health

The psychologist Maslow established probably the best-known hierarchy of need, when he formulated a theory of human motivation.⁽³⁾ In his model, fundamental physiological needs (such as the need for food) underpin the higher needs of safety, love, self-esteem, and self-actualization. He proposed that people are motivated by the requirement to meet these needs, and that higher level needs could only be met once the lower and more fundamental needs were met. The clinical relevance of this theory is that it implies a hierarchy of clinical priorities—interventions to meet basic physiological need (e.g. to ensure adequate food supply) should take priority over interventions to foster, for example, self-esteem.

In practice health-related needs are often considered in a widely defined way. In England, for example, the requirement to base the provision of services on level of need was first made explicit in the National Health Service and Community Care Act,⁽⁴⁾ which defined need as the requirements of individuals to enable them to achieve, maintain, or restore an acceptable level of social independence or quality of life. This requirement was retained when national standards for mental health services were set.⁽⁵⁾ This involves needs-led care planning—basing care for an individual patient on an assessment of their health and social needs. The needs-led approach offers many benefits:

1 The overall level of need gives guidance about which part of the mental health system should treat the patient, for example that people with less disabling mental disorders should be seen in primary care settings.⁽⁶⁾

2 Needs assessment can improve the comprehensiveness of case formulations and care plans by incorporating a broad range of health determinants, such as poor housing or lack of social support.

3 Explicit identification of need can support clinician–patient discussions about care priorities, which is associated with improved treatment satisfaction⁽⁷^, ⁸⁾ and compliance.⁽⁹^, ¹⁰⁾

4 Identification of needs helps to identify the contribution of services outside the psychiatric sector.

5 Needs-led care can facilitate more individualized treatment planning than diagnosis-driven approaches, by more closely matching the help offered to patient’s needs and by explicitly identifying problems which require the involvement of both health and other agencies.

Needs-led care planning focussing on health can be differentiated from the assessment of care needs. Assessing care needs involves identifying whether the patient will benefit from a predefined menu of interventions, and by definition will not identify all unmet needs for individual patients. Assessment of need at the patient level should therefore be a separate process from decisions about what care or treatment to provide. There are, however, other reasons to assess needs for services, which we now review.

(b) Needs for services

The second category of need is a requirement for a particular type of service. At the population level, it is possible to use epidemiological methods to develop prevalence for different disorders, which can be translated into estimates of the need for services. A recent epidemiological survey in the United States, for example, found very considerable unmet need of the population level nationwide.⁽¹¹⁾ This study identified that between 1990–92 and 2001–03 the overall annual period prevalence of mental illnesses remained constant at between 29.4 and 30.5 per cent. Among these cases, however, there was an increase in the proportion who received any treatment at all, rising from 20.3 to 32.9 per cent between the two time periods. The inverse is however very revealing, namely that the most recent data show that 67 per cent of people with mental disorders in the United States receive no treatment. The situation is worse in other countries. A recent comparative international study of depression found that 0 per cent of patients in St Petersburg received evidence-based treatment in primary care, and only 3 per cent were referred on to specialist mental health care.⁽¹²⁾ The inability of patients to afford out-of-pocket costs was the primary barrier to care for 75 per cent of the depressed Russian patients studied.

International comparisons of population-level needs have been conducted in recent years. The ESEMed Study, for example, carried out cross-sectional surveys in Belgium, France, Germany, Italy, the Netherlands, and Spain among 8796 representative members of the general population. Individuals with a 12-month mental disorder that was disabling or that had led to use of services in the previous 12 months were considered in need of care. The study found that about 6 per cent of the sample was defined as being in need of mental health care. Nearly half (48 per cent) of these people reported no formal health care use, so that 3.1 per cent of the adult population had an unmet need for mental health care. In contrast, only 8 per cent of the people with diabetes had reported no use of services for their physical condition.⁽¹³⁾

In health care, the concept of need has been taken to mean the ability to benefit in some way from health care, and thus distinguished from demand (what the person asks for) and supply (services given).⁽¹⁴⁾ For example, the MRC Needs for Care Assessment Schedule is premised on the assumption that need is ‘a normative concept which is to be defined by experts’.⁽¹⁵⁾

Using this approach, an Australian study compared current and optimal treatment for 10 high-burden mental disorders in Australia.⁽¹⁶⁾ This found that current levels of treatment at current coverage avert 13 per cent of the overall burden attributable to these disorders. Providing optimal treatment at current coverage would avert 20 per cent of the burden, and optimal treatment at optimal coverage would avert 28 per cent. The development of a more robust treatment evidence base makes this innovative approach to informing public policy more possible, and the approach can be recommended for evidence-based policy initiatives.

Patient and staff perceptions of need

There has been a long-standing recognition that differences in perceptions of need can exist, in particular between staff and patient. In the 1990s the emphasis was put on acknowledging these differences, but then prioritizing the staff perspective. For example, UK policy stated that all users … should be encouraged to participate to the limit of their capacity. …Where it is impossible to reconcile different perceptions, these differences should be acknowledged and recorded.⁽¹⁷⁾ Several societal and scientific developments challenge this prioritization of staff over patient perspectives.

First, general societal changes towards consumerism and an emphasis on rights have produced more assertive mental health service users. Easier access by patients to internet-based information reduces the knowledge disparity. Reduced societal trust in the authoritative expert has eroded the position power of mental health staff. The emphasis put on choice and empowerment raise patient expectations of being more than passive recipients of care.⁽¹⁸^,¹⁹⁾

Second, the prioritization of staff perspectives has been actively challenged by an increasingly vociferous and organized user movement. This opposition has found its voice in the ‘recovery’ movement, which emphasizes the meaning and values of the patient, and the need for services to foster self-management rather than dependency. There has been widespread international policy support for recovery-focussed services⁽²⁰⁾ although there can be tensions between what professionals construe as their duty of care and being led by the patient perspective on need, which can create ethical dilemmas. Care planning which emphasizes agreement between staff and patients may have additional advantages. A recent study in Verona showed staff–patient agreement on needs was significantly associated with better treatment outcomes both rated by the patient and by staff (psychopathology, social disability, global functioning, subjective quality of life, and satisfaction with care).⁽²¹⁾ Similarly, there is emerging evidence that crisis plans (advanced statements) which are jointly agreed between staff and patient can be cost-effective in reducing compulsory admission to hospital.⁽²²^,²³⁾ Such emerging findings indicate that needs assessment and care planning, which are based on negotiation and jointly agreed analyses of problems and interventions, are likely to become increasingly important in future.

Finally, emerging empirical evidence strongly supports the positioning of the patient perspective at the heart of needs assessment and care planning. Evidence from several studies consistently shows differences between staff and patient perspectives on need,⁽²⁴^,²⁵⁾ so the two perspectives are not interchangeable. Empirical research suggests two reasons for basing care on the patient rather than staff assessment of need. First the patient rating is more stable than the staff rating.⁽²⁶⁾ Second, longitudinal studies indicate a causal relationship between patient-rated (but not staff-rated) unmet need and quality of life.⁽²⁷^,²⁸^,²⁹⁾ If the goal of mental health services is to improve quality of life, then best available evidence indicates that the patient’s perspective on their unmet needs should drive care planning.

Assessing needs

In this section we identify specific approaches to assessing needs.

(a) Individual-level needs assessment measures

Several standardized approaches to the assessment of patient-level need have been developed, primarily in the United Kingdom. These have shown a transition along a continuum, from an initial focus on assessment of need as an objective state to be defined by experts following careful assessment, towards those which emphasize the subjective nature of needs assessment.

The earliest standardized needs assessment measure was the Medical Research Council Needs for Care Assessment (NFCAS).⁽³⁰⁾ The NFCAS assesses the need for further action by health care professionals, and links identification of a need with a predefined list of actions. This raises two problems. First, the emphasis on identifying available interventions which would be at least partly effective is problematic, given the complexities of deciding that a treatment has not worked. Second, updating the list of actions has proved problematic. However, as Bebbington notes, ‘the inevitable value judgements inherent in the procedure have the virtue of being public and consequently accessible to argument’.⁽³¹⁾ An important variation of the NFCAS is the Cardinal Needs Schedule (CNS),⁽³²⁾ which also considers patient willingness to accept help and level of carer concern. Training is needed for using both the NFCAS and the CNS, and they are primarily used for research purposes.

At the other end of this continuum are needs assessment measures which emphasize individual difference and the subjective nature of need. The AVON Mental Health Measure was developed by service users, and assesses physical, social, behaviour, access, and mental health domains.⁽³³⁾ It can take up to 20 min for completion by the patient and 5 min by the staff, and its development has emphasized external validity over other psychometric properties. The Carers and Users Experience of Services (CUES) was developed by service users and staff, and assesses 16 domains: the place you live, money situation, the help you get, the way you spend time, your relationships, social life, information/advice, access to services, choice of mental health services, relationship with mental health workers, consultation and contact, advocacy, stigma, any treatment, access to physical health services, and relationship with physical health workers.⁽³⁴⁾ Completion can take up to 30 min. Neither AVON nor CUES have become widely used in mental health services.

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