1/Efficiency: achieving maximum output for a given level of input

-HC systems depend substantially on public funding , governments require that these perform in a way that is consistent with societal objectives Proving efficiency means incr health benefits produced by health care pee unit cost

2/equity or social justice in the accessibility of health care to different groups in the population " fair opportunity for each individual to attain their full healthcare benefit with no avoidable obstacles "

Horizontal equity ;people with equal need having access to healthcare

Vertical equity people wig the greater needs having the highest priority Health car should also be humane

3/ Need Diff btw need for Health & need for health care Need for healthcare exists when an individual has an illness or disability for which there was an effective & acceptable treatment or care ( level of risk of illness/disability can be reduced by acceptable care)

Meeting greater needs with the same inputs /resources will mean greater expected benefit , thus pursuit of equity will also produce improvements in efficiency

Strategic analysis of population needs:

1/assessment of needs for HC involves info about expected benefits & harms, the nature & extent of expected benefits & harm can only be assessed for specific Cdx & interventions -research & consensus Dvt among techn experts

2/ diff people with diff Cdx can expect diff types of benefits & objective assessment of the relative value of these different types of benefit is impossible -planning of commissioning involves. Prioritisation of benefits & thus value judgements -matters for community Reps -Some believe tat this formulation medicalises need.

-difficulties Arise when same potential benefit cost more to realise in some groups than others as these situations efficiency gains mean equity losses & a balance has to struck between the two -where balance lies is a matter of community & political judgement

Trx decisions & appropriateness

-At The  time of decision, the outcome is uncertain thus trx decision made in basis of expected or predicted benefits /harm -data from research -these provide initial estimates w/c r later modified by clinical decision makers in light of onfo about particular pts -trx decisions are informed by guidelines -set out indications (ensures high enough benefit ) & contraindications ( ensures low enough expected harm) -based on research & consensus considers also affordability -a good context fir decision analysis is is one where clinical exper supplies probabilities & patient supplies value /utilities

Strategic intervention for equity & efficiency 

1/ leave it to the market

2/ leave it to providers 

Strategic intervention for equity & efficiency

1/leave it to the market but these

-are inequitable and inefficient because of the inverse r/ship btw capacity to benefit & capacity to pay

- do not provide for ;

a) consumer ignorance- most pts cannot make informed judgement about appropriateness

b) monopolistic providers

c) interventions with public benefits :immunisation benefit is for unimmunized as a result of general infection risk reduction

d) social concern for health of others

Streategic intervetionsfor equity and efficiency

1/ leave it to the market

2/ leave it to providers 

2/leave it to providers ( laissez-faire ) w/c requires clinical DM to do the following; 

a)-ensure efficient and equitable use of the resources currently available to them by providing appropriate, cost-effective care for the patients most likely to benefit; 

b)-seek to alter the levels and mix of resources available to them, if the current levels and mix are inconsistent with providing efficient and equitable care.

BUT

a)-some medical specialties and health care providers are more influential than others; 

b)-some patients are more clinically interesting than others; 

c)-the wide local variations in rates of prescribing, hospital admission and elective surgery suggest that there are unexplained (and inequitable) variations between clinical decision makers in their practice. 

Thus  need for strategic intervention i.e.:

Clinical decisions have to be supported or constrained by the effects of strategic decisions (by managers, planners and policy makers), who ensure that 

systems are in place that support: 

1 /Good access, so that people with health care needs are offered appropriate care, through: 

(a) referral guidelines; 

(b) outreach and screening systems; 

(c) levels of activity and resources that are consistent with appropriate good quality care for the population served; and 

2 /Sound clinical decisions, through 

(a) treatment guidelines; 

(b) information and audit systems. 

However the economic and politicalenvironment, which will affect levels of health, roll-out and acceptance of technical and organizational change, 

the general levels of resources available, and the priority given to different objectives. 

-Health care needs assessment is a systematic approach to ensure that the levels of activity and resources provided are consistent with equitable 

access to good quality care for the population served

-two broad approaches to needs assessment:

1/The corporate approach involves a process of adjustment subject to competing views and pressures.

2/Population-based approaches take as their 

starting point data on the population served and involve different combinations of data, assumptions, calculation and judgement.

-The aim is to provide estimates 

of need which are independent of current local levels of supply with a view to identifying any major gaps between actual provision and what is ‘needed’. 

-approach to determining the mix of services provided to a given population is through a process of adjustment in response to pressures for change. 

These pressures may come from clinical decision makers and from central policy makers, professional bodies, patients and representatives of the public.

-The process of balancing interests and pressures has been called ‘corporate needs assessment’. 

-it involves little  little " actual"assessment of needs

Advantages:

1/ close to what goes on in the absence of any attempt at rigorous analysis. It is possible to strengthen such processes by making them structured, 

open and transparent, and informed by data and analysis, rather than unaccountable and behind closed doors. 

2/It can be an incremental process (try a bit more here and a bit less there and see if that helps). The argument is that to improve equity and/or efficiency 

it is sufficient to identify the right direction to be moving at the current point in time, rather than the ideal or ultimate destination. This makes it less 

demanding of data and analysis than the population-based or ‘zero-based’ approaches. 

The problems with this approach are that: 

1/decisions tend to be driven by negotiation, and hence by power relationships, rather than what is actually efficient or equitable; 

2/interested parties rarely press for fewer resources; 

3/the aspects of care that gain attention tend to be driven by events and crises, rather than leadership based on strategic objectives or anticipation of 

problems; 

4/incremental processes can be very slow to adapt to environmental change. 

-

Population-based needs assessment

-all population based methods require some elements of value judgement

- coporate needs assess mostly used because 1/ few data  on w/c to base rigorous PBA, & 2/ processes and structures required to produce necessary judgements about indications & coverage are underdeveloped 

 theory is that the levels of care provided should depend on the characteristics of the population, and that the levels of resources needed will depend on the targetlevels of provision. The difficult 

part is to bridge the gaps 

Steps are;

1/ identify some population based norm or standard and 2/ apply this to the local population, 3/ determine what the local population should be -generally in terms of level of resources rather than activity

Adv: only the most basic data are required: 

the population size. but the value of the approach depends very much on where the norms or standards come from. They might be: 

1/national averages – this may be equitable in a narrow sense but may also be inefficient, as the average may be too high or too low to match actual population needs; 

2/policy targets – which may be either below or above the national average; the question then is, what is the justification for the policy? 

3/statements of the aspirations – of particular sectional interest groups (such as 

orthopaedic surgeons); 

4/expert or science-based – derived from the literature on epidemiology and clinical effectiveness; but

disadv 1/this may leave little room for responsiveness to local variations in priorities and patients’ attitudes, and to the availability of alternative forms of care and community support. 

2nd disadv of simple norms is that the size of a population is by no means the only determinant of its capacity to benefit from health care. Different 

populations experience different levels of sickness.

-Targeted or stratified standards based on specific groups represent one step forward in this respect. Age is a good predictor of prevalence for most conditions and age-specific standards are quite common. 

3rd disadvantage is that even if resources are provided in line with the norms, this does not imply horizontal equity (equal access for equal need). Providers will vary in the efficiency with which they convert their resources into services. 

A) Norms of Activity (e.g. national average rates of hip replacements)

 The advantages of this approach are: 

1/It provides a check on horizontal equity: equal access for equal needs. 

2/It is conceptually simple and can be done on a spreadsheet. 

3/It only needs data on activity rates from one standard population. So, for example, it can be used to check the equity within a population by applying the population rate to age structures of different subpopulations: different geographic areas, 

socio-economic or ethnic groups. 

4/It is possible to consider the effects on the levels of resources required of changes in utilization and changes in medical technology explicitly and separately. For example, in other areas of surgery the requirement for hospital beds has been 

reduced strikingly by innovations such as reducing lengths of stay, laparoscopic procedures and day surgery. 

5/For some conditions, current activity rates are appropriate because virtually everyone with the condition receives care. so the method can be useful 

for estimating the effect of possible future changes in the population structure or in the resources needed to provide the service, as you have done here. e.g. people with ESRF are surviving longer, impact of this 

on extended survival on numbers needing dialysis? 

The disadvantages of this approach are: 

1/It is difficult to handle more than three or four explanatory or predictor variables. Also, age and sex may be poor predictors of the variable to be estimated. (Another approach is to estimate using regression equations. This allows many predictor 

variables, but requires data on many populations.) 

2/For procedures like elective surgery, it cannot be assumed that current levels of activity are appropriate. 

B) Epidemiologically-based needs assessment 

Epidemiology & norms for coverage :

 -behind the use if activity based norms there is a conceptual leap from population numbers to appropriate levels of health care utilization 

- e.g have epidemiological data on determinants of disease in population but not on determinants or indicators for trx 

-in thus situation there is a case for using epidem data to make 1/ estimates of prevalence & 2/make assumptions about proportion of prevalent  cases who will have the indications for treatment. This is called epidemiologically-based needs assessment 

Adv of this approach

-For some diseases good epidemiological data are available & almost all prevalent cases will require trx 

-It is possible to consider the effects of changes in disease prevalence & changes in medical technology 

Disadvantages 

- For some Cdx r/ship btw prevalence if disease & need for care is weak  

Evidenced based approach

whereas all population based methods (PBM) require some elements of value judgement, EB needs assessments unlike PBM ( & many others) make less sweeping assumptions but is very demanding of data & vulnerable to to choices about indications esp if threshold values are used

problems with the evidence-based approach

-it is very demanding of information; requires: 

(a) clear and accepted indications for treatment. The problem is that 1/ doctors often do not agree about indications. There is not enough research on subgroups and outcomes and many do not accept what research results there are. 2/Also indications for treatment should depend on expected outcomes and, in general, there will be very limited data on the outcomes of any particular hospital or doctor. The assumption has to be made that local services produce results similar to 

pooled research data or in line with expert consensus. 

(b) the local prevalence of people with these indications and information on who wants the 

treatment in question. Such local data as may be available usually 1/relate to levels of health care activity or disease, not indications for or acceptability of a procedure. 2/They may be subject to sampling error and bias. And while some conditions – 

such as fractures – are either present or not, many others, such as hypertension and diabetes, are defined by threshold values. Someone whose measurement is 

above this threshold value has the disease, and belowit they don’t.

In some cases the indication for treatment is severity of symptoms, defined as having a symptom 

score above a given level. In these situations the estimated numbers in a population needing health care can be highly sensitive to the choice of defining 

threshold. Furthermore, acceptability to the patient may depend on how the intervention is described. 

1 Health needs are gaps between actual and desired levels of health. Health care needs 

(some people call them requirements) arise when people with health needs can expect 

benefit from health care. Note that: 

a)health needs do not necessarily imply health care needs; but whether they do or not, they may also imply other kinds of intervention, particularly where risk reduction is required, such as health promotion and environmental controls; 

b)improvements in the effectiveness of health care creates new or increased health care needs; 

c)assessment of the relative need of a local population or group for a particular form of health care requires information on the amount of benefit its members can be expected to derive from it; and 

d)comparing different types of need for care is difficult because comparing benefits is difficult; in general there is no objectively correct answer to the question of which local population or group has the greatest health care needs. 

2/ Needs assessment involves estimates of the types and probabilities of benefit and harm that can be expected as a result of intervention.

Doctors and other experts are the best  source for these, informed by results of research studies, meta-analysis or expert consense. it also involves prioritisation of and value judgments about diff types of benefit;

-in matters of choice btw trx options, these are matters for pts concerned

- in matters of priorities btw care programmes- coomunity or it's rep involved in decision