Nigel Edwards On healthcare planning

Published: 22/04/2002, Volume II4, No. 5902 Page 17

How many times have you sat through an NHS presentation and heard the phrase, 'We have one of the 10 per cent most deprived electoral wards in the country'? Or perhaps the new variant that I heard recently, 'We have one of the most obese wards in the country'.

Even presenters from affluent areas generally manage to say they have some pockets of deprivation. And so what? Is this an excuse for why health outcomes or performance are poor, a bid for money or does it have some other relevance?

Looking at a population and noticing it is deprived may be useful for informing wider public health strategy with local government, and to target resources for community development.

But I think the constant use of these kind of phrases reveals a more serious problem with the epidemiological, public-health based approach to planning health services: it has largely failed to influence the planning of healthcare.

While there is little wrong with the technique, there is no way of translating its insights into language that connects with clinicians.

Knowing that a particular electoral ward has a high rate of deprivation is not very useful to the individual clinician. For a start, they may already be aware of this because they see the patients and where they live. Second, they treat individuals not electoral wards and it is not possible to move from general knowledge about the ward to the particular case of the individual.

What the clinician needs to know is that Ms Jones risks exacerbating her long-standing condition, and how to prevent this.

They also need to know about her individual circumstances, whether she lives alone etc, not the characteristics of the people who happen to share her postcode.

To connect to clinicians and to deal with the small number of patients that make high levels of demand, we need to move from generalised statements about the characteristics of populations to specific estimates of risk associated with individuals. Choice also means understanding what individuals want, rather than the average preferences of populations.

This implies a new set of actuarial analytical techniques, new data about individual risks and the development of costed pathways to create bottom-up population-based models. This can be built back into commissioning decisions, instead of relying on top-down generalisations that do not connect to clinicians.

The ongoing consultation on public health, which is based on an admission that current ideas are not working, suggests that some new approaches are required here, too. If we are going to borrow from insurance to plan healthcare, as suggested above, perhaps the techniques of communications and marketing should be plundered to supplement our approach to improving health.Many successful health improvement schemes avoid blanket approaches to populations and use segmentation, targeting and more individually tailored approaches, often supported by social entrepreneurs.We must not lose our public health skills, but maybe it is time to plunder the methodological toolboxes of other disciplines.

Nigel Edwards is policy director at the NHS Confederation.