Need for redefining needs

In a sociological environment, Bradshaw defined need as: normative (distinguished by professionals, such as vaccination), felt (wants, wishes and desires), expressed (vocalised needs or how people use services) and comparative needs, which indicates that needs arising in one location may be similar for people with similar socio-demographic characteristics living in another location [6].

Bradshaw's typology of need creates a definition which is more practical for health service research workers, although it does not include the concept of cost containment. He recently argued that his taxonomy of need was constrained because of inherent problems with the concept of need.[7]

Some experts describe needs as 'instrumental' or fundamental to the achievement of a desirable goal [8] while others highlight a non-instrumental (or absolute) sense of needs[9, 10]. Baldwin [11] proposed a rather theoretical definition of need, that is a 'tension need' which implies a desire to compensate for some dis-equilibrium such as thirst due to fluid loss. He also proposed a 'teleological need' reflecting the gap between actual and desired status, such as a desire for coronary bypass surgery to improve both quality and longevity of life. This approach to need implies 'necessity to be explicit about whether it is effective, how effective it is and for whom' [4]. Baldwin considered teleological need to arise 'when the goal is not realised and there is a need of a certain thing when this is necessary for realising the goal' [11], which seems to be a characteristic attributable to any kind of need. While this definition usefully expounds the concept of need, a significant improvement in health services is unlikely without specific efforts to develop needs-oriented services.

Green and Kreuter considered need as 'whatever is required for health or comfort' [12], covering personal, social and environmental conditions, including family planning information, smoke-free zones, seat belt rules, and health 'hot lines' but appears ineffective in terms of 'life creativity' and cost-effectiveness. Doyal and Gough suggested 'objective needs', asserting that 'health needs' and 'autonomy' are not only two universal human needs, but also basic human rights [13], as some have previously claimed [9].

Cost containment is the focus of policy-makers' attention, therefore combining satisfactory services with cost-effectiveness could provide a solution to health care rationing issues. The most widely presented definition of need favoured by economists is 'the ability of people to benefit from health care provision' [14, 15]; in other words, 'need' exists only if there is a 'capacity to benefit' from a particular healthcare service.[10, 16] Need may be assumed to exist, therefore, when there is an effective treatment [17] or 'health gain'.[18] Ability to benefit from health care can be influenced by several factors including epidemiological aspects such as incidence and prevalence of disease and the effectiveness of interventions. Applying this definition, the outcomes of health interventions assume greater importance.

First of all, Culyer [10] proposes that 'capacity to benefit' (as an outcome measure) differs from needs (as a resource input), so these two concepts are measurable in different ways which do not necessarily match. Physical, physiological, and social benefits may be identified in individuals as well as groups or communities. In addition, the benefits of health care can be determined as improvement in clinical status, reassurance, supportive care, and relief of carers rather than a narrow medical definition in which merely objective, measurable clinical improvements are recorded. The rational result of this definition is that benefit from healthcare may be affected inversely by the severity of disease. For instance someone who suffers from mild symptoms of coronary heart disease may have a greater chance of being offered coronary bypass surgery than an older patient with severe 3-vessel coronary disease, whose life expectancy may not be extended greatly by surgery, on the grounds of having less capacity to benefit. Moreover, equity in access to healthcare is fundamental to the economists' definition, otherwise it might not be equitable. Also, this definition minimises the influence of lay people; focuses on "health care" rather than "health" contrary to Bradshaw's model [6]; and is concentrated on a causal model. This can be problematic when studying human behaviour based on complex interactions between: individual behaviour, social circumstances, cultural beliefs and genetic construction.[19] Furthermore it often leads to a belief that current services are the basis for healthcare needs assessment. [20] Even the supporters of the definition concede this, arguing that measured needs are only based on existing services.[15] On the other hand, this terminology is innovation-disoriented, that is it limits population healthcare needs to readily available services, ignoring potential needs arising from emerging health technologies. One example is the increased 'need' that followed the introduction of automatic implantable cardioverter defibrillators in late 1990s. Even so, individuals who have more 'capacity' to improve their health status or prevent deterioration might benefit more from healthcare provision -for example health professionals have more knowledge about their health/ill-health conditions, therefore may benefit from health services at higher levels.

Literature review reveals that cost effectiveness is already receiving greater emphasis, although there is no evidence that direct questioning of individuals to establish their health care requirements is being overlooked.

The Medical Research Council considers need to exist when a patient's functioning falls below -or threatens to fall below- some minimum specified level and there is a remediable cause. This definition takes into account the effectiveness of the care process and implies that a need is met 'when it has attracted some at least partly effective intervention'.[21] In a similar vein, Buchan et al defined health service needs as 'those for whom an intervention produces a benefit at reasonable risk and acceptable cost' [22]. This definition does incorporate effectiveness and cost-effectiveness.

A more reasonable definition of needs is 'the requirement of individuals to enable them to achieve, maintain or restore an acceptable level of social independence or quality of life, as defined by particular care agency or authority' [23]. Taking this definition into account, health authorities and other health-related organisations at local, regional, and national level set out to provide appropriate services to meet its population needs, targeting an acceptable level of social independence and improved quality of life. If assessing needs is being considered to change current healthcare services, [24] definitions that focus on 'maximum health' seem preferable.

A distinction needs to be made between individual and population-based health. Several approaches have been adopted as a proxy for assessing population's healthcare needs: mortality rates, [25‐28] socio-economic status[29], service utilisation,[30] or prevalence rates,[31] which are all at macro level. However, needs can be defined at micro level too, as demonstrated by the doctor-patient relationship, consultation with health professionals, or patients' healthcare needs at a local surgery or health centre. Both macro- and micro-health needs are important in different settings of health decision making.[10] Nevertheless, in routine clinical management, health professionals deal with rather wider aspects of healthcare needs than 'capacity to benefit', such as social support, informational needs and equipment for daily activities.

Demand for healthcare may also be affected by geographical variation [35, 36] and medical charges.[37] Healthcare providers too may constrain patients' ability to benefit from healthcare; for example, low-referring General Practitioners may fail to refer patients who need special care.[35] Hospital utilisation data cannot be assumed to be a valid proxy for need since hospital use is a product of many variables including service supply and clinical decision-making rather than population need[38]. These data more likely reflect patients' propensity to consult, the willingness of family doctors to refer, access to hospital beds and the availability of alternative facilities provided by the private sector.[39]