Needs Assessment

Please also see our two guides to information published in 2010 by IMPRESS:

IMPRESS Guide to Information about Medicines Use

See also the NHS Atlas of Variation launched November 2010. In particular

Problems of the Respiratory System
Map 16: Directly standardised rate of emergency admissions in persons aged 18 years and over with asthma per 100,000 population by PCT page 54
Map 17: Rate of emergency admissions in persons aged 18 years and under with asthma per 100,000 population by PCT page 56
Map 18: Emergency bed-days per 1000 population weighted by chronic obstructive pulmonary disease (COPD) prevalence by PCT page 58.

This guide below was written in 2009 and whlist there are changes in the NHS In England about who the commissioners will be, the messages about how to integrate needs assessment remain valid.

It is primarily commissioners who are responsible for needs assessment. They have a statutory responsibility to work with their local authority to produce a Joint Strategic Needs Assessment (JSNA). Commissioners will also engage in more local work, often led by their Public Health Department, focussing on identifying inequalities in access to healthcare and in health outcomes. They are required, under the Public Service Agreement, to identify and find ways to reduce inequalities in life expectancy. That might, depending on local morbidity, include detailed work looking at long term conditions such as respiratory disease. To read more about needs assessment, see the IMPRESS paper on developing a service specification.

There can be an important role for clinicians, both practice-based commissioners, primary care practitioners and secondary care clinicians in contributing to this assessment of the local population's health. That is, typically, managers and commissioners have a faster turnover, and it is clinicians who have longer organisational memories, and knowledge and understanding of the local community. There is significant potential to share data, local audits and more qualitative data with commissioners to feed the needs assessment process.

For a real life example, please look at the January 2009 presentation from Salford PCT at the NHS Confederation's PCT Network conference and also at the webcast from the IMPRESS meeting in April 2009. It was reported bat the 2007 British Thoracic Society Winter Meeting (Roberts and Bakerly Benchmarking COPD across an inner city primary care organisation Thorax 2007 62 suppl III S134 ). The respiratory team used Read coded templates to collect data automatically from GP computer systems and combined it with QOF, public health, socio-economic deprivation and Hospital Episode Statistics (HES) data to create a city-wide COPD register. They then mapped COPD outcomes (QOF prevalence, COPD severity by lung function, hospital admissions and length of stay) by individual practice and Practice-based Commissioning group to identify areas of greatest need. They found a QOF prevalence of 2.3% n=5501, (range 0.1% – 4.7% across all practices); mean age of 68 years; 41% current smokers,12.5% never smoked; severity by FEV1% predicted values3: 50% mild, 30% moderate, 9% severe; 11% had an FEV1 %predicted value > 80% . They concluded that COPD prevalence was twice the national average and positively associated with deprivation; however, other factors such age and smoking status of the population were also important.

Starting with the vision
Before undertaking any detailed work on any parrticular population group, it would be helpful to understand the vision and aims in your region. Between 12 May - 5 June 2008 each NHS region published its vision as part of the Darzi review. Click here for the latest information from the Darzi review . See here for our deailed response to the Darzi team that has been well received by a number of audiences including SHAs and the Royal College of Physicians.

Predictive risk
The Kings Fund, together with New York University and Health Dialog has done significant work, that is now available to the NHS, on predicting who might be a user of hospital care; both those at risk of readmission, but also, moving further 'upstream', who might be a future user of hospital care unless services are put in place to support that individual to manage their care out of hospital. It includes a useful literature review of predictive risk, and an analsysis about why clinical judgement alone is insufficient.
Click here for PARR, PARR++ and the Combined Predictive Risk model.

This analysis has been used by a number of commissioners to populate the case loads of their Community Matrons or specialist teams for people with long term conditions. It has also been used for the development of innovative models such as the Vitual Ward by Croydon PCT. See http://www.croydon.nhs.uk/sections/frame.html?sec=182 Whilst this has not yet been evaluated formally, it has received significant media and commissioner attention, andt therefore it is worth understanding how it operates.

Information providers, and multiple data sets
The Eastern Region Public Health Observatory has developed a model for COPD prevalence. This incorporates new rates of smoking prevalence and has led to an increased estimate of COPD prevalence.

The Department of Health has also accredited a number of private companies, like Health Dialog and Dr Foster, to work with commissioners to provide them, under contract, with data analysis and information in its drive to develop World Class Commissioning. These companies use a number of data sets including not only HES data, but also primary care data, social care, education and criminal justice data.

Budgets

October 2010 update: the DH in England as part of its Rightcare workstream of the Quality, Innovation, Productivity and Prevention programme (QIPP) has issued to PCTs Health Investment Packs (HIPs) that analyse their expenditure by programme budget, and compare to outcomes using the SPOT tool (see IMPRESS guide to information).

The DH has produced useful comparative information at programme budget level. Programme Budgeting is a well-established technique for assessing investment in programmes of care (eg respiratory care) rather than services. All PCTs in England have submitted an annual programme budgeting return since 2003/4. So, for example, the latest figures available show that estimated England level gross expenditure by Respiratory Programme Budget for 2007/08 was £3.85 billion out of a total spend of £93.18bn; that is 4%. This compares to problems of circulation of £7.31 bn, or 7.8%. Programme budgets can compare relative growth of each programme, y ear on year. So, for example, nationally (England), respiratory programme budgets grew by 8.86% between 2006/07 and 2007/08 compared to problems of circulation wehre the comparative figure is 5.97%. See Jargon Buster Programme Budgeting for links.

Comparative data

The DH has produced disease management information toolkits that offer comparative data on hospital utilisation: PCT level data on emergency admissions, emergency bed days and length of stay and there is a paediatric asthma module that is regularly updated published here. NHS Comparators from the NHS Information Centre provides comparative data from QOF and SUS. IMPRESS has been given to show some examples of how this works. Click here.

The British Lung Foundation has recently worked with Experian and its Mosaic software that includes retail data sets to identify hot spots for COPD in its report Invisible Lives. This can pinpoint populations by postcode, down to clusters of about 15 households rather than (political) ward data that goes down to about 14,000 population. See below.

HES data wil remain the foundation of much needs assessment work by the commissioner and therefore it must be firstly the clinician's role to check for accuracy. For example, the NHS Institute has produced its Opportunity Locator that analyses HES data by ambulatory codes, to produce for PCTs the opportunities for shifting care out of hospital - either by admission avoidance or by step down care. Have a look at your PCT data at http://www.institute.nhs.uk/opportunitylocator/default.aspx.

Commercial firm CHKS Ltd published summary findings in the Health SErvice Journal Jan 2010 analysis of hospital admissions showing a 6.0 per cent growth in emergency and elective admissions in the year to March 2009 and that the growth varies from PCT to PCT by as much as 28 per cent. There is an atlas and a Report Are hospital admissions out of control?

For several useful publications on coding using HRG4 and the implications for provider clinicians and commissioners, please look at a very useful and practical commentary on the respiratory tariffs and Guide to Respiratory Coding by Dr Steve Connellan.

The National COPD Resources and Outcomes Project [NCROP] Incorporating the National COPD audit 2008

Please see the Royal College of Physicians Clinical Effectiveness and Evaluation Unit web page on the 2008 audit . It also gives details of previous audits that could be used as a benchmark. The 2008 audit will be the first to include primary care data systematically. For details on the NCROP peer review programme that is looking at 4 aspects of hospital care:

Non-invasive ventilation
Pulmonary rehabilitation
Early discharge schemes
Provision of oxygen services and also
information about the provision of palliative care services for people with COPD

click here.

COPD Needs Assessment – Invisible Lives, British Lung Foundation
Click here

Experience of BME patients with COPD: Picker Report
Click here

NHS Comparators
Click here

Social Care

The NHS Information Centre now has a range of social care information available and National Adult Social Care Intelligence Service The NHS Number is increasingly being used as the common identifier across health and social care, which will assist common assessment of personal care needs and supporting commissioners to plan for services.