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Critical Public Health Vol. 18, No. 2, June 2008, 233–244

Rapid Needs Appraisal in the modern

NHS: potential and dilemmas

Ruth Balogh a*, Sandy Whitelaw

b and Jane Thompson

c

a St Martin’s College, University of Cumbria, Carlisle, UK;

b University of Glasgow, UK;

c Cumbria and Lancashire Strategic Health Authority, Preston, UK

This paper reports on our experience of undertaking a Rapid Appraisal of Health and Social Needs (RNA) in West Cumbria, UK. RNA aims to identify community-defined problems and to collect intelligence for action rather than simply for documentation. The broad nature of the study is summarised and we reflect critically on methodological and structural issues that arose. A number of inter-related themes were significant: the limitations of a ‘rapid’ approach; within an action frame, the implications that arose from focusing on locality capacity-building; the ability that commissioning organisations had in this public health domain; and the way in which such organisations tend to construct ‘needs’. These themes then are located in problematic contexts. Primarily, we were working with a fledgling NHS organisation, arguably set unrealistically high expectations to deliver innovative public health functions. Furthermore, the desire to see the NHS working more efficiently resulted in the expectation that the exercise should be done in a particular way—within a realist tradition of arriving at quick, simple and ‘definitive’ needs. We conclude by suggesting that if such work is to be meaningful then there needs to be a number of pre-cursors: an initial consensus on the nature of ‘need’; an agreement between commissioners and researchers around common frameworks and realistic expectations of the process; and finally, an acceptance of the importance of history in this work and the way histories of local inter-agency work reflect embedded forms of local knowledge. We suggest that NHS volatility means that much of this knowledge is often lost.

Keywords: participatory appraisal; capacity-building; inter-agency collaboration; partnerships; community profiling; health profiling; research commissioning

Introduction

This paper reports on our experience of undertaking a Rapid Appraisal of Health and Social Needs (RNA) in four localities in West Cumbria, UK. RNA approaches in the health field encompass a diversity of techniques, but according to Rifkin, Lewando-Hundt and Draper (2000) are distinctive in terms of: (i) intersectoral involvement; (ii) the direct participation of community members; and (iii) the use of iterative processes, that is, ‘repeating methods to gain new understanding and building on that understanding’ (Rifkin et al. 2000). Rapid Appraisal in general aims to identify the problems of

*Corresponding author. Email: [email protected]

ISSN 0958–1596 print/ISSN 1469–3682 online

� 2008 Taylor & Francis DOI: 10.1080/09581590701377010

http://www.informaworld.com

communities, particularly poor ones; and to collect information for action rather than for

documentation only (ibid.). A team of four external researchers from St Martin’s College, Carlisle carried out the

study on a part-time basis over a six-month period, each working in one of the four localities: three consisted of single electoral wards and the fourth consisted of two wards.

The policy drivers for the study came from two sources: first, the requirement for

contemporary health services to be based on the ‘needs’ of local populations (Percy-Smith

1996); and second, the allocation of new responsibilities of this type to the emergent

primary care-based health service organisations—Primary Care Groups (PCGs; which

subsequently became known as Primary Care Trusts). The project was commissioned by the local PCG, with funding originating from the North Cumbria Health Action Zone

(HAZ), an inter-sectoral initiative with a broad remit to promote positive change among

the most disadvantaged communities at individual, family, community and institutional

levels through a variety of mechanisms by placing a strong emphasis on neighbourhood

empowerment and capacity building, including the specific elements of developing social

and inter-organisational networks and effective leadership, understanding of community history and promoting a sense of community power and values (McLeroy et al. 2003,

Barnes et al. 2005). The project was thus commissioned and funded by two new

organisations created by the New Labour administration’s review of health services

in 1997 (The New NHS: Department of Health 1997, The NHS Plan; Department of

Health 1999). In the paper, we will summarise some aspects of the study, and critically

reflect on some of the methodological and structural issues that emerged whilst carrying it out.

Details of the project

The proposal for RNA work in West Cumbria was agreed with West Cumbria PCG. Our first concern was to explore their understanding of ‘health needs’. Our own view was that a

‘capacity-building’ model (Henderson et al. 2004), rather than a ‘deficit’ model of need

would most closely reflect the aims of the HAZ, and we also recommended a broad

definition of ‘need’ encompassing social and community needs. Initial discussions

indicated general agreement, particularly on this latter issue that the PCG had already

discussed and specified as the focus of the RNA. We built into the project proposal a series of workshop-based meetings with what

we termed a ‘Working Group’ from the PCG. This had a range of related purposes: to

explore concepts of ‘need’ in more depth; to ensure that our interpretation of the brief

was fully explored and agreed; and for them to receive and contribute to our findings as

the study progressed. The group served a further purpose: by involving the PCG actively

in the process, their stake in the research was formally acknowledged and legitimated. We invited the PCG to convene the group and, in addition to four PCG Board members

and officers, the Chief Officer of the Community Health Council, a representative of

the Social Services Department, and a registrar in Public Health Medicine attached

to the Health Authority about to undertake a Masters dissertation in the same field were

invited. The PCG chose to commission four studies: three on the southern outskirts of

Whitehaven in the wards of Egremont North, Hensingham, and the town (two wards) of

Cleator Moor, and the fourth in the ward of Moorclose in South Workington. The

localities were chosen because they were part of the North Cumbria Health Action Zone

234 R. Balogh et al.

(HAZ) but were not the highest scoring wards on deprivation indicators and therefore not

otherwise in receipt of regeneration-linked funding. We agreed a research protocol that emphasised a participatory and iterative approach

according to the principles outlined earlier by Rifkin et al. (2000), setting out a sequence in which we would draw up a series of draft ‘health profiles’ to offer to local professionals,

agencies and residents as part of an ongoing process of discussion, revision and feedback,

ending with an agreed statement about health and social needs. We sought first of all to

find out what was already known about our localities in terms of public health

information, studies and reports. For each locality, we envisaged that this would form the

basis of the draft health profile that we would offer first to health professionals and agencies (including the Working Group) for checking, discussion, comment and

amendment, and then to local residents for similar scrutiny. We expressed the hope that

we would be able to canvass residents’ views in a public meeting format in each locality. We were aware from our own previous research and inquiry of the differences in the

way that ‘participation’ can be constructed (Balogh and Bond 1995, Whitelaw et al. 2003),

and the different roles that users of services can play in research (Balogh and Bond 1996). In terms of Arnstein’s ‘ladder of participation’ (Arnstein 1969), we acknowledged at the

outset that ‘citizen control’ would not be possible within the terms of the commission, but

were ready to explore what kind of participation on the level of ‘partnership’ could be

achieved. We operationalised ‘participation’ by proposing to consult with community

groups at an early stage; recommending the inclusion of a representative of the West

Cumbria Community Health Council on the Working Group (which was agreed); and further proposing to invite community members to comment on draft findings at a later

stage. In line with the tradition of RNA (Hawtin et al. 1994, Robinson and Elkan 1996),

we sought to ‘represent’ the views of each locality in terms of the breadth of the

constituencies we engaged with rather than their formal ability to represent the views

of others. Preparatory meetings of the ‘Working Group’ provided important and constructive

guidance on the initial direction for the work (and in the meeting at the conclusion of the

project this group also provided a link to implementation). When we entered the field,

however, we found that fixing dates for bringing together the ‘Working Group’ proved

impossible. Whilst disappointing and accepting that the absence of such personal contact

may have had some impact on the perceived worth of the data and the longer-term utility

or implementation, the expectation was perhaps in retrospect over-ambitious and a more realistic yet still engaging approach was arrived at. We replaced live discussion with a

‘Delphi’-type exercise (Linstone and Turoff 1975) that we felt offered a relatively quick

way of consulting with senior people and enabling them to see each other’s views without

meeting face to face. We anticipated that we would draw up Delphi tables consisting of a

list of recommendations for action based on existing information for each locality. In this

way, we wanted to involve participants by offering them information on a provisional basis and inviting their contributions. As indicated earlier, we also wanted to follow a

capacity-building approach rather than a deficit model and so when we came to frame our

statements we did so in terms of suggested actions rather than needs.

Collecting information in the four localities

Each academic member of the research team investigated one of the localities. Whilst

accepting the complex and varied nature of ‘participation’ (Murray 1999), we actively

Critical Public Health 235

sought to maximize opportunities for participating in existing fora as a way of collecting information, identifying informants and engaging with the communities. These experiences highlighted the different levels of participation that are attainable in this type of work. We reflect on this later but the following forms of engagement were achieved: attendance at regular health visitors’ meetings, Neighbourhood Forum meetings, and a Police and Community Liaison meeting. We found that a weekly scan of local newspapers was invaluable in providing us with many types of information pertaining to health and social issues in each locality, including details of significant meetings. We assembled existing information such as local health profiles devised by health visitors, the North Cumbria Health Improvement Plan, the Joint Review of Social Services, OFSTED reports on schools, and reports produced by the various organisations and agencies we visited. North Cumbria NHS Department of Public Health provided us with statistics for certain disease categories while the Cumbria County Council Information & Intelligence Unit provided us with Townsend Deprivation Indices (the composite score based on unemployment, car ownership, overcrowding, and levels of disability) along with some more contemporary data on some of these indices and specific material about unemployment, benefits uptake, etc. We were unable to obtain Townsend Health Indices (premature mortality, permanent sickness and disablement and low birthweight) (Townsend et al. 1988). This statistical information was ward-specific, but most of the other information we assembled was not. In this sense we were creating community ‘identities’ around the varied tangible dimensions (e.g. demographic and epidemiological data, levels of service provision) and symbolically constructed dimensions (e.g. interests, networks, social capital) of ‘community’ (Cohen 1982).

Building on local capacity and initiatives: specific experiences

Our experiences in the four localities proved to be contrasting in terms of the nature of existing capacity (see also Balogh 2007) and this affected fundamentally the direction that each of us took. These differences and their effects are summarised briefly below.

Egremont North

In this poorer end of the town of Egremont, it proved relatively easy to identify potential respondents. There was some history of community initiatives, connected with the local primary and secondary schools. The town’s secondary school was justly well known for its long-running community outreach work, and the primary school had begun to develop community education and other facilities (e.g. a breakfast club) on its premises. There were also people in Egremont considering how they might get access to Regeneration funding to combat a sense of decline in the town following the end of a period of expansion at the local British Nuclear Fuels Ltd Sellafield plant.

We were able to identify a sufficiently large and varied group of 33 respondents (covering primary and secondary education, housing, social services, environmental health, educational welfare, police, primary health care; elected representatives; voluntary sector including carers, playgroup, older people) to enable us to draw up a Delphi table of statements based on interviews, reports and statistics to circulate to the PCG Working Group and to some professionals. It also proved possible to convene a small meeting of residents to consider it further. This meeting was enhanced by a chance conversation with the person who opened up the meeting venue, which revealed that her wheelchair-bound

236 R. Balogh et al.

husband was waiting for her outside, that both were involved in a local disability support group, and that they were willing to contribute to the discussion.

Hensingham

Whilst being able to identify core demographic and epidemiological data for this ward, we found it relatively difficult to detect significant levels of symbolically constructed identities. It was a place that lacked a geographical centre, key services like a General Practice and Local Authority presence, any formal extensive community network or group or existing health needs assessment documentation. Rather, Hensingham appeared to be made up of relatively small and diverse pockets of communities separated by main roads and hills, with several workplaces and schools, dominated by the West Cumberland General Hospital, and hence a substantial transient population who were significant users of some facilities such as nursery schools. The only significant community facility in the area was a ‘Pensioners’ Hut’ which was well used but in a poor state of repair. One of the local primary school head teachers had, however, started a Community Action Group that looked set to provide a basis for regeneration activities, but was in its very early stages. The difficulty of establishing an identity for this ward both in terms of community and tangible intelligence or data meant that it was also difficult to summarise health and social needs among its residents, and in consequence our report was based on local interviews, reports and statistics relating to the area but no Delphi.

Moorclose

Although Moorclose was also perceived as lacking clear identity, we found it to be an active place compared with Hensingham, though somewhat overshadowed by its neighbouring ward at Westfield. However, residents attended the Moorclose & Westfield Neighbourhood Forum from both wards. We were able to participate by introducing the project and then making contact with potential contributors. Plans for regeneration in Workington were being drawn up and the participants at the Forum were keen to contribute and hoped to benefit. A local housing association had recently formed a residents’ association, and two local churches were also active in community development; one cited regular use by 25 different groups. It was possible to interview a sufficient range of respondents to draw up a Delphi and this was presented at a subsequent meeting of the Neighbourhood Forum for further discussion and priority setting. So in Moorclose we were able to develop a ‘health profile’ along the lines that we had initially hoped we could work.

Cleator Moor

In the two wards comprising the town of Cleator Moor we discovered that several health needs assessments had already taken place, some by local health visitors, others by a local housing association and one by a neighbourhood worker. We assembled this set of existing reports and digested the information from them into a Delphi format and called it ‘20 Steps to Health in Cleator Moor’. However, when we offered this to neighbourhood workers for comment, we quickly discovered that the existing assessments had already informed the development of a local plan for community development and regeneration activities. It seemed that not only had enough research already been carried out

Critical Public Health 237

unbeknown to the PCG, and there would be little value in any further work, but that the community had gone well beyond the stage of ‘needs assessment’ and had moved on through the planning cycle into an implementation phase. Indeed, it was suggested that a further exercise could be counter-productive. We had encountered an ‘over-researched’ community.

It became essential to re-think our strategy in view of an agreement with the PCG to include the collection of ‘primary’ information directly from residents, and so we consulted with the PCG Working Group about whether it would be acceptable for our report for this locality to take the form of a review of existing documentation. They agreed with this strategy, and our report for Cleator Moor was based solely on an analysis of secondary information, crosschecked against the various plans the community had already developed. Community agencies valued this low-level participatory approach and have continued to use it as a means of guiding and evaluating their progress towards achieving the ‘20 steps to health’.

Discussion

Taking a step back from the specific details of the work, a number of inter-related themes emerge as significant in a wider critical sense. We offer the following: (i) the limitations of a ‘rapid’ approach, (ii) the implications of focusing on capacity-building within the localities, (iii) the orientation and capacity of the commissioning organisations, and (iv) and their perception of ‘needs’ and their assessment.

Limitations of a ‘rapid’ approach

One of the central underlying expectations of RNA is that it can offer a quick and pragmatic response. In a cautionary tenor, Fazey suggests that policy makers/ commissioners, ‘can . . . expect too much in the time available’ (Fazey 2000, p. 172). On the other hand, some authors point to the difficulty of doing such work ‘rapidly’. Beebe (2000, p. 31), for example, raises the problem of RNA being done too quickly without the chance for the data to be collected and analysed rigorously, suggesting that this can be analogous to ‘research tourism’. This general notion is endorsed by a range of experiences within the literature: ‘we found that we could not implement the entire protocol . . . in a rapid manner’ (Archibald et al. 2000, p. 42); and ‘[we were working to an] impossibly short time frame’ (Manderson 2000, p. 45). These difficulties point to the need to be cautious in our expectations of what RNA can deliver. Power suggests, ‘we should not expect more from a rapid assessment than it can deliver . . . it is not a panacea’ (2000, p. 189). In general terms, our experiences were largely congruous with these. We also found that our ability to deliver useful information within a ‘rapid’ timeframe and along the lines of the approach of Rifkin et al. to RNA was closely associated to the extent of existing capacity in each of the localities. Where capacity was least well developed (in Hensingham), we were largely unable to formulate meaningful action-oriented statements and thus achieve comment and resolution in the given timeframe. On the other hand, where capacity was already well developed (in Cleator Moor), we were able to work entirely from existing needs assessments and thus progress could be accomplished readily within the time. However, there remains the question of whether Cleator Moor, where needs had already been well documented, was really a suitable candidate for a further study.

238 R. Balogh et al.

In the case of Hensingham, the level of local participation was low, and an extended time-frame might have improved this. In Moorclose, where we were most successful in delivering within the agreed project expectations, our time-frame happened to coincide with relatively well-attended Neighbourhood Forum meetings—where capacity was developing as a result of regeneration initiatives—and local participation was higher than in the other three localities.

The literature also identifies the need for a formalised framework for RNA (Power 2000), including the development of an infrastructure that identifies key partners, and creates an appropriate steering group to work with a research team. Our Working Group represented an attempt to bring together relevant agencies to make a direct contribution to the RNA process, but the need for the project to begin immediately—and hence within its own ‘rapid’ time-frame—precluded the possibility of this group ever meeting with the regularity it needed. Significantly, Trautmann et al. (2000, p. 60) identify ‘a need for extensive co-operation between different agencies and organisations as a prerequisite for developing effective assessment and interventions’ and the literature on community and inter-sectoral development work also emphasises the importance of ‘contact’ time (Dockery 1996, Backet-Milburn and MacHardy 1998). Our experiences lead us to believe that where such extensive co-operation does not already exist, the work required to build it is likely to be time-consuming at least in terms of ‘elapsed’ time (that is, in timetabling meetings for contributions, feedback etc) and unlikely to fit the context of being ‘rapid’.

Capacity within the localities

As already suggested, we found widely varying levels of existing capacity within the four localities. Optimally, Moorclose and Egremont North had a sufficient but not over- developed infrastructure that offered both initial scope but ample potential for further development. For contrasting reasons, Cleator Moor and Hensingham did not offer such favourable circumstances. At one extreme, Cleator Moor already had an existing infrastructure and our work was taking place in a situation where capacity had not only been developed, but had moved beyond the ‘needs assessment’ phase of the planning cycle. Inter-sectoral work was well established but health sector input was limited. Our response to this was to re-frame our locality profile as a summary of existing needs, offering it as a potential evaluation tool—i.e. for use at the end of a planning cycle, and to advocate for greater health sector involvement. In Hensingham, existing groups or structures were limited and our ability to enable inter-sectoral input and participation from community members was correspondingly limited. The rapidity involved in this type of work to some extent presumes or requires the existence of some infrastructure or capacity within which the needs assessment process can operate, particularly if the work is based upon ‘capacity- building’ approach.

The orientation and capacity of the commissioning organisations

It has been widely observed that the UK NHS has experienced relatively acute and enduring organisational change since 1983 and that there has been an acceleration of this trend (e.g. Powell 2000). Within this context, two features of the commissioning and funding organisations (the PCT and HAZ) were significant.

Both were at formative stages of their development, establishing core organisational structures, functions and processes and coming to terms with the range of demands being

Critical Public Health 239

placed upon them (of which public health was one relatively minor one). This context was

made more problematic in the sense that Primary Care Groups were evolving from groups

with relatively limited remits towards becoming Primary Care Trusts with significantly

greater (but as yet only partially defined) responsibilities. More specifically, it was clear that they were in their very early stages of

operationalising the extended ‘public health’ role (particularly that in needs assessment)

envisaged of them in post 1997 policy directives. The pursuit of public health work within

primary care in general terms has been seen as problematic; for example, Heller, Edwards,

Patterson and Elhassan (2003, p. 158) have noted that relationships between public health

and primary care have historically been ‘relatively weak’. These observations are supported by the likes of Wirrmann and Carlson (2005), Chapman et al. (2004), Walshe

et al. (2004) who argue that such instability has led to failures in respectively: creating

effective public health leadership, achieving clarity in what should be considered a ‘public

health’ role; achieving a unified workforce dealing with public health work in a systematic

and on-going basis; and developing public health skills across the workforce via

appropriate training and continuing professional development. As such, Walshe et al. (2004) conclude that there is a perception that PCTs have ‘not fulfilled their public health

responsibilities’ (p. 871). Our own experiences confirm research that identifies organisational barriers to

effective community engagement (Smithies and Webster 1998, Pickin 2002). Although the

PCG expressed broad sympathies with the concepts we were using for our RNA and in no

way could specific blame be attributed to them, a range of deep-seated problems arose in both the actual execution of the project and achieving a legacy for it. First, the very fact

that external researchers were commissioned to do this work precluded the possibility

of fostering embedded public health skills and knowledge within the organisations.

Policy-makers within the PCG and HAZ seemed insufficiently well-informed about local

community matters (e.g. to help them select localities which could have most benefited

from needs assessments) and nor did capacity for the full range of inter-sectoral work appear well-established. Second, even within a scenario that sought to leave behind such

expertise as a legacy, the ‘busyness’ of those involved with a multitude of other more

immediate management tasks meant that this was not possible.

Perceptions of ‘need’

The practically grounded and pragmatic nature of RNA is strongly stressed, so any critical

review would inevitably have to pose the questions, ‘what types of need were identified’

and ‘to what extent did these differ to those that might have been identified in other ways’? In relation to types of needs, there is a general acceptance that they are complex and

multi-faceted, and that they are also constructed (Bradshaw 1972, Doyal 1992, Sheaf 1996,

Stevens and Raferty 1997, Henderson 2000, Pickin et al. 2002). In summary, types of need can be characterised as existing between two broad poles ranging from on the one hand as

relatively unambiguous objective ‘absolutes’, usually expressed in quantitative terms and

relating to specific health problems or need for medical/health care and intervention

(‘deficits’) and on the other (as preferred of our approach) a more complex comparative

concept that can be expressed in qualitative terms and be couched in more constructive terms—‘solutions’ that focus on an examination of community capacity and resources

within the wider social domain (Pickin and St. Leger 1993, Hawtin et al. 1994, de Koning

and Martin 1996).

240 R. Balogh et al.

In our project, most of the needs we identified were of this latter type, but we did

identify some need along the former lines too and examples are provided in Table 1. It is

worth noting that our only example of a need for medically defined services occurred in

Hensingham, where capacity was least well-developed, and that in Cleator Moor, where

capacity was best developed, no such needs were articulated. In the latter case, the closest

approximation was a need for preventive work, for example, ‘provide home safety

equipment and accident prevention programmes for older people’ (Balogh Beattie et al.

2000). A further dimension along which the assessment process may be framed lies within the

notion of a ‘visible’ need for existing service provision [what McKeganey (2000) terms

‘the problem of induction’] or an attempt to seek out new needs with a view to developing

more innovative responses (Sheaf 1996). In this sense, the magnitude of change offered

by needs assessment can vary, ranging from a conservative re-allocation within

existing narrowing defined health services to a more radical model that recognises the

potential to re-distribute resources between sectors and address wider prerequisites for

health (Pickin and St. Leger 1993). Again, as other researchers have found in exploring

lay perceptions of need (e.g. Popay et al. 2003) we were able to identify relatively

innovative needs that existed beyond pre-conceived traditional health services, as indicated

in Table 1.

Table 1. Illustrative examples of ‘‘need’’ identified in the RNA.

Needs for health services (‘deficit’ model)

Needs defined as building on existing capacity

Hensingham Improve access to a range of services for children (health visitors, dental services, speech therapy, child psychology)

Consult young people to assess their needs and to seek funding to renovate the Community Centre

Provide a GP service Develop a debt counselling service and community loans scheme

Egremont North Reduce waiting times for assessment of homes for adaptations by occupational therapists

Provide support for parenting in a form acceptable to local parents

Provide a small number of beds for people (especially older people) who need temporary nursing care

Improve access to recreation for all children and young people, taking account of special needs

Moorclose Increase the availability of speech therapy services in primary schools

Develop breakfast, after-school and holiday clubs for children in Moorclose

Reduce the waiting times to access the Child & Family Consultation Unit and Educational Welfare Services

Find ways for young people to have a voice in local community and service developments

Cleator Moor Provide a family centre (crèche, respite/support for parents, coun- selling on domestic violence)

Run a well-man’s group, to offer stress management, keep fit, healthy eating, CHD advice

Note: From Balogh et al. (2000).

Critical Public Health 241

Conclusion

Although this study was conducted a number of years ago, these reflections remain relevant to current public health contexts. We were unable to return to the field to review

its use, but in initial inquiries, we obtained some evidence that it informed local decision-

making, e.g. in the development of a local Family Centre at Cleator Moor, and in the

regeneration of the towns of Egremont and Workington. The following themes combine to reflect aspects of the circumstances in which this

RNA exercise was undertaken: essentially that we were working with new and developing

organisations with relatively high expectations from the centre being placed upon them to

deliver in a range of relatively innovative public health functions. Furthermore, the desire to see the NHS working in a more efficient and functional way resulted in the expectation

that the rapid needs assessment exercise should be carried out in a particular way—

essentially, within a realist tradition of arriving at a quick and simple ‘definitive’

description of ‘needs’. Perhaps, what is at the heart of this discussion is a fundamental divergence in views of

what RNA is. On the one hand there is a relatively functional and modest perception

of it as a context specific exercise where a limited set of options are offered in relation

to a specific health problem. Here, community-based groups have a relatively low level of participation in the research (e.g. the construction of questions, potential breadth

of options). On the other hand, there are those who have proposed more ambitious

expectations: Greig and Kershnar (2000), for example, talk of the purpose of Rapid Action

Research (a related technique also relying on short time-scales) being to ‘mobilise the involvement of affected communities in a more informed dialogue . . . the value of RAR

lies less in its rapidity than in its explicit integration of assessment and response’ (ibid.). Our research reinforces, in the case of external commissions, the value of

commissioners and researchers developing and agreeing common frameworks and realistic expectations of the nature of needs assessment processes. This necessarily involves

commissioners in making a contribution to such projects beyond the act of commissioning

them, and for research briefs and protocols to provide for the discussions this approach

demands. Such processes must also recognise the on-going work that may need to be done to enlist the support of the increasingly wide range of agencies involved in inter-sectoral

working at a local level. The benefits of a ‘capacity-building’ approach to needs assessment are well

documented (de Koning and Martin 1996, Henderson et al. 2004), but perhaps not as widely appreciated as they might be within the NHS. Although ‘rapid’ approaches have

become accepted in some quarters within the NHS (Ong et al. 1991, Murray et al. 1994,

Henderson et al. 2004), our findings suggest that the emphasis on speed may detract

from the potential for such needs assessments to contribute to capacity-building and deeper community sensitive change. Within the context where we were working, the

particular strengths of the ‘rapid’ approach seemed to derive more from the

participatory methods it employed and the ability it had to develop networks and promoting a sense of community power and values than from its speed of delivery and

from its ability to identify emergent issues rather than discrete findings reflecting existing

patterns of health service provision. In this sense, participation should also be seen as

an indefinite concept that requires on-going work that seeks to maximise the representativeness of it (Murray 1999).

Perhaps the most important finding from our four RNAs, however, concerns one

significant aspect of community capacity, the importance of history, and the way in which,

242 R. Balogh et al.

at local level, the histories of local inter-agency work—its successes and its failures—

represent quite deeply embedded forms of local knowledge. The lack of stability in NHS

structures and the current trend for rapid movement of personnel within and between

sectors can mean that much of this knowledge is not readily available to the newly

appointed senior managers of young organisations. The Primary Care Trusts are still

developing their role in public health, yet with further re-organisations currently in

progress, the prospects for stability seem remote.

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