Listening to local voices: adapting rapid appraisal to assess health and social needs in general practice

Introduction

The World Health Organisation's programme Health for All by the Year 2000 aims at giving everyone equal access to health care.1 As 2000 approaches many inequalities remain, and in the United Kingdom these are most notable in Scotland.2,3 The inequalities are directly related to socioeconomic and cultural factors that are not adequately addressed by the medically dominated model of health.4

The new NHS philosophy encourages patient choice and the tailoring of the process of care to benefit the consumer. But true participation of the public in decision making and evaluation of health care has been more difficult to promote in practice. Particularly in poorer areas, general practitioners need to work with community representatives, teachers, benefit rights workers, counsellors, and the local clergy to establish health education projects.5 The Cumberlege report also emphasised the need for services to be more sensitive to the requirements of individuals, families, and communities.6

At present few populations and communities are involved in planning primary care.7 Practice catchment areas have grown haphazardly so that identification with a defined neighbourhood and collaboration with local services is difficult. Gillam, Hastings, and the NHS Management Executive have called for a structure to involve local people in the purchasing process.*RF 8-10* We describe one method of listening to local voices. The method can be used for local neighbourhood planning and could provide a structured basis for practice sensitive local purchasing.

Methods

Rapid participatory appraisal is a research method that has been used in the United Kingdom to provide qualitative information, especially about deprived areas,11 but it is has not been used in planning primary care services. The general framework is based on the “health for all 2000” philosophy, and it has been adapted for use in health care.12 Rapid appraisal can focus on members of urban environments who are relatively deprived. It uses selected people with knowledge of the area (key informants) both to identify problems and to contribute to solutions. The team conducting the investigations and devising a plan of action is derived from various organisations and not just health workers.

The primary aims of rapid appraisal are to gain insight into a community's own perspective on its main needs; to translate these findings into action; and to establish an ongoing relationship between service purchasers, providers, and local communities. It is “rapid” in that the whole exercise can be done in two weeks if external researchers are used.

Information is collected on nine aspects. These are brought together to form an information pyramid (figure). The bottom layer defines the composition of the community, how it is organised, and its capacities to act. The second layer covers the socioecological factors that influence health. The next layer covers data on the existence, coverage, accessibility, and acceptability of services, which allows the effectiveness of present services to be evaluated and identifies what needs to be changed. The final layer is concerned with national, regional, and local policies that indicate whether the political leadership is committed to community participation in health. Data is collected from three main sources: existing written records about the neighbourhood, interviews with a range of informants, and observations made in the neighbourhood or in the homes of interviewees.

The scientific rigour and validity of the approach depends on the concept of triangulation, with data collection from one source being validated or rejected by checking it with data from at least two other sources or methods of collection. Through cross checking findings apparent differences may resolve themselves, and a coherent interpretation can be constructed.13 Instead of randomly selecting informants, people who are thought to be in the best position to understand the issues are chosen.14 People with a wide range of views are interviewed.

Results

The community had a large number of elderly people and single people. Newcomers to the area often had medical or social problems and tended to be younger. There was little sense of community identity. There were fewer services in Dumbiedykes than before the second world war. Most informants identified one volunteer worker and her community centre colleagues as the main community activists. A local counsellor commented on the lack of a heart or centre in the estate. Three house groups run by a nearby church gave social and spiritual support to some residents.

Common complaints about the physical environment included the hills in and out of the estate, the difficult steps, and generally poor access. Lack of play areas for toddlers and young children was also often mentioned. Dog fouling was a greater issue than vandalism or violence.

Many people found it hard to manage financially, especially elderly people, who often turned on an extra electric bar on their fire to keep the interviewers warm. Twenty six per cent of men and 11% of women were recorded as unemployed in the 1991 census. Nineteen per cent of houses were owner occupied compared with 60% in Lothian generally.

Perceived causes of ill health included unemployment, stress, dampness, poor diet and eating habits, and smoking. Drug misuse among the younger people and social isolation among elderly people were also felt to be problems. The main disease centred health problems in the estate were thought to be asthma, bronchitis, heart problems, and arthritis.

Some people, unaware of recent developments, wanted an increase in local educational services such as after school care, youth provision, and adult education classes or groups. Most people with children spoke favourably about a nearby youth project.

Initial comments about the primary care services were favourable. Complaints were made about long waiting lists for occupational therapy and chiropody and about a shortage of district nurses and auxiliaries to help with personal hygiene. It was sometimes hard to get an appointment with the local general practitioners. Queues at the accident and emergency department were thought to have got worse, as had arrangements for discharge from hospital.

The local social services were well known, well used, and appreciated. However, the non-local services were not well known, and many people expressed a wish for more information.

Informants had little knowledge about the patient's charter and the community care plan. Recent health policy interventions were thought by many to be cost cutting exercises.

We asked each informant for suggestions for change. The commonly recurring ideas were discussed in the two focus groups and a consensus list was drawn up (box).

Discussion

In contrast to the quantitative methods used by epidemiologists rapid appraisal offers very specific insights, helping to define what the problems are rather than how many people are affected by them. It helps identify the strength of feeling within the community on key issues.

We did not identify any previously unknown medical problems, but the team got a deeper understanding of the health and social problems in the neighbourhood. We were dismayed at the lack of knowledge about and uptake of some services while other services were overstretched. We plan to compare the needs identified in this study with the needs found by a postal survey instrument and by analysing primary care and hospital medical records.