Assessing population needs

The third step is to assess population needs. When assessing population-level needs for mental health services it is useful first to define 'need'. There is, at present, no consensus on how needs should be defined,(9) and who should define them.(19 The Oxford English Dictionary offers 'necessity, requirement and essential', and in a different sense 'destitution, distress, indigence, poverty or want'. These clusters of meanings overlap in so far as they define 'need' as a vital element which is lacking, and this chapter will use this sense as its point of departure. Stevens and Gabbay (1D have introduced the idea of treatability by defining need as 'the ability to benefit in some way from health care'. In general terms it is helpful to thinks in terms of the following definitions: need is what people benefit from, demand is what people ask for, and supply is what is provided.

Assessing the needs for services for a defined population is closely related to targeting, since the degree of stringency necessary in defining the highest priority group in any service will depend upon on three factors:

1. the overall rates of psychiatric morbidity in each local population;

2. the capacity of each local mental health service in terms of the number of cases which can be treated at any one time;

3. the degree to which these services effectively target the severely mentally ill.

A series of methods allows the measurement or the estimation of true (treated and untreated) prevalence, and the use of treated prevalence rates alone can produce a highly distorted picture of met and unmet needs at the population level. At the same time a population-based needs assessment only has value in terms of planning if it is more than an academic exercise, when it is an integral part of a programme of service development and reform.

In terms of assessing the needs of a population for mental health services we would also make the following preliminary remarks. First, there is no 'best' pattern of desired services, rather a reasonable balance of service components, which have a high 'degree-of-fit' to local circumstances. Second, in any local setting there will exist no 'correct' scale of provision, only reasonable estimates based on the best available data and which are periodically revised.

In practice, we propose a pragmatic strategy for the assessment of need, which consists of using the best information available in each particular area. As correctly indicated by Wing,(12)this process is not linear but should be viewed as a circular pathway that can be followed more than once, as indicated in Box5.

The feasibility of using epidemiological data may be limited because it will often be the case that no locally based epidemiological data are available. The only feasible strategy then is to make rough approximations by using the results of national or international epidemiological studies, and applying these overall, or diagnosis-specific, rates to the local area. In carrying out such an exercise, two important points need to be kept in mind. First, the comparative populations used for different geographical areas, and for the comparisons of actual and estimated needs, should be made quite clear. It may be a local total population of 100 000, for example, or the population aged between 18 and 65. In either case the denominator being used must be precisely specified. Second, the 'currency', or units of service provision, must be described in unambiguous terms. For instance, the numbers of psychiatric beds needed or provided per 100 000 populations may mean adult acute beds, with or without beds intended for patients aged over 65, or for people who are demented, or the total may include intensive care or forensic beds.

Simple estimates of the need for mental health services made from epidemiological data can be refined by weighting with sociodemographic variables to allow for factors such as social deprivation, which are closely associated with variations in morbidity of the more disabling forms of mental disorder.

This weighted population-based approach has been applied in Southern England (1. 14 and 15) and in Northern Italy, where other types of service activity data, such as day-care contact rates, were also entered as dependent variables into the model.(!6) Another example of this method, applied at the country level in England and Wales, is the Mental Illness Needs Index. (17) This is a composite weighting score that combines six census variables, and which has been used to predict expected capacities for inpatient and residential care services. T§b.!§...3. shows census (predictor) variables which have been found to be significantly correlated with psychiatric service utilization, most often hospital inpatient admission rates (outcome variables), in five different studies.

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