- (Asadi-Lari et al., 2003) Coronary Heart Disease Nottingham Health Needs Assessment (NHNA) [developed by the authors] applied to 242 patients admitted to the Acute Cardiac Unit, Nottingham Self-reported need. Correlation between healthrelated quality of life (HRQL) and indicators of need. Comparison of HRQL and HNA domains means in various help needs (e.g. company, looking after patients). High correlation between physical needs and HNA physical score. More physical needs were detected in elderly and ischaemic patients compared with confirmed MI. No gender differences.
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- (Bansal et al., 2014) Mental Health Census 2001 + SMR04, Scotland. Sample: first hospitalisations between 1 May 2001 and 30 April 2008. Differences in admission rates. Poisson regression to calculate risk ratio of first admission adjusted for patient characteristics.
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- (Bebbington et al., 2003) Neurotic Disorders. British National Survey of Psychiatric Morbidity [n>10000]. Professional evaluation = contact with primary care physicians for psychiatric symptoms. Logistic regression. Contact with primary care due to mental health is more likely if the individual has more severe psychiatric symptoms, has difficulties in daily living activities, is female, has a physical illness, is not working, and is divorced/separated.
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- (Bien et al., 2013) Disability (in older people) EUROFAMCARE study, 200304: survey of family carers (FC) of older people (OP). Focus on cases where the OP has high levels of disability [n (UK) = 371]. Answer 'Yes' to question 'Would you like OP to have more help to meet this need?' This was a follow up question to 'Does OP have a need for help with any of these areas? Health needs, physical/personal needs, mobility needs, domestic needs'. Test for significant relationship between mean number of unmet care needs and the mean number of health and, separately, social services, by country.
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- (Di Bona et al., 2014) Mental Health Cohort patient data collected as part of the independent evaluation of the two Improving Access to Psychological Therapy (IAPT) demonstration sites, Doncaster and Newham, matched with patient questionnaires [n=363]. Access to service. Logistic regression to identify socio-demographic, clinical and service factors predictive of IAPT non-attendance.
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- (Higginbottom, 2006) A further study addressing the relationship between ethnicity and access to health care. This study is based on a survey that is more directed to understanding perceptions of service delivery than to relating the delivery of services to ethnicity or measuring unmet need. Overall not relevant to our brief.
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- (Judge et al., 2009) Hip and Knee Replacement Surgery English Longitudinal Study of Ageing (ELSA) + 2001 Census Dichotomous variable of whether or not the patient was in need of joint replacement. [1] Multilevel Poisson regression to estimate rates of need for hip/knee replacement by age, sex, deprivation, rurality, and ethnic mix using ELSA. [2] Combine regression model with stratified census population counts to produce small-area predictions of need. [3] Uncertainty in the predictions was obtained by taking a Bayesian simulationbased approach using WinBUGS software. Generally, need for joint replacement is lower in the South than in the North of England. Rates are also lower in a circle of affluent areas in England, Home Counties, areas that border or surround London. The geographic distribution of rates of need across districts of England is similar for both hip and knee replacement.
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- (Kessler, 2005) Palliative Care (Cancer) Public Health Mortality -cancer deaths of adults (≥ 18) registered in the twelve electoral wards of South Bristol between September 1999 and November 2002 [n=960]. Inequality in access -associations between social class and place of death. Logistic regression Individuals with unskilled occupations were less likely to die in hospice, but no other social class difference in place of death was found.
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- (Knowles et al., 2006) No specific condition.
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- (Nacul et al., 2007) Chronic obstructive pulmonary disease (COPD) Heath Survey for England 2001 [n=10749] Undiagnosed cases = compare the model estimates with the recorded prevalence of COPD. Logistic regression. Around 600,000 or nearly half of the 1.3 million COPD cases in England remain undiagnosed (no details on the paper on how that difference is distributed among population groups).
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- (Purandare et al., 2004) Mental Health Postal survey of managers of care homes (1) that have as residents older people with functional or organic mental illness requiring 24 hour nursing supervision/or over 65s with learning disabilities and (2) are classified as nursing/residential/or dual [n=1689] Perceived need vs. provision of old age psychiatrists (OPs). Multiple logistic regression Perceived inadequacy of service provision by OPs increases with the proportion of elderly residents that need psychiatric evaluation, infrequent visits by OPs, unavailability of geriatricians, lack of pharmacological advice and inability to refer patients directly to OPs.
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- (Turner-Stokes et al., 2013) Long-term neurological conditions (LTnC) Questionnaires to patients discharged from specialist neurorehabilitation units within the London area over a 12-month period in 2010– 2011 [n=211] Using Needs and Provision Complexity Scale (NPCS), comparing 'needs' with 'gets' (levels of service provided). Met (or exceeded) Needs= NPCS-Gets ≥ NPCS Needs. Unmet Needs = NPCS-Gets < NPCS Needs. ‘Needs’ and ‘Gets’ were compared using non-parametric techniques (Wilcoxon Signed Rank tests). Needs for a personal enabler were significantly undermet, but the frequency of personal care for activities of daily living was provided at a level significantly above predicted need.
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- (Williams and Drinkwater, 2009) Radiotherapy Services Audit of radiotherapy waiting times conducted by the Royal College of Radiologists + administrative data. Access to radiotherapy = proportion of cancer patients receiving appropriate radiotherapy at least once during the treatment of their malignancy. Spearman’s rank coefficient to calculate correlation coefficients; this assumes a linear relationship. Variation in radiotherapy services across the UK measured by waiting times, access rates and dose fractionation. Deprivation negatively influences radiotherapy access rates.
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- A paper in the same general spirit as (Aspinall and London Health Observatory. Department of Health, 2004) and (Szczepura, 2005) with similar implications for RA. Inequity of access across ethnicity is not necessarily unmet need. Overall – informative of C and again suggesting a demand-side focus for unmet need in ethnic groups.  Judge, A., et al., Modeling the need for hip and knee replacement surgery. Part 2. Incorporating census data to provide small-area predictions for need with uncertainty bounds.
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- ACORN is a valid area-level deprivation measure, it agreed moderately well with IMD 2004 in its segmentation of the population. Regarding chlamydia positivity, ACORN and IMD2004 show similar gradients: the most ‘deprived’ (hard pressed) areas have higher positivity rates.
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- Aday, L. A. & Andersen, R. M. 1981. Equity of access to medical care: a conceptual and empirical overview. Medical Care, 19, 4-27.
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Allin, S., Grignon, M. & Le Grand, J. 2010. Subjective unmet need and utilization of health care services in Canada: what are the equity implications? Social Science & Medicine, 70, 465-72.
- Almond, P. & Lathlean, J. 2011. Inequity in provision of and access to health visiting postnatal depression services. Journal of Advanced Nursing, 67, 2350-62.
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- Asadi-Lari, M., Packham, C. & Gray, D. 2003. Unmet health needs in patients with coronary heart disease: implications and potential for improvement in caring services. Health & Quality of Life Outcomes, 1, 26.
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- Aspinall, P. J. & London Health Observatory. Department of Health 2004. Ethnic disparities in health and health care: a focused review of the evidence and selected examples of good practice: executive summary, London - 11-12 Cavendish Square, London W1G 0AN, London Health Observatory.
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- Austin, K. L., Power, E., Solarin, I., Atkin, W. S., Wardle, J. & Robb, K. A. 2009. Perceived barriers to flexible sigmoidoscopy screening for colorectal cancer among UK ethnic minority groups: a qualitative study. Journal of Medical Screening, 16, 174-9.
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- Bansal, N., Bhopal, R., Netto, G., Lyons, D., Steiner, M. F. & Sashidharan, S. P. 2014. Disparate patterns of hospitalisation reflect unmet needs and persistent ethnic inequalities in mental health care: the Scottish health and ethnicity linkage study. Ethnicity & Health, 19, 217-39.
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- Battersby, J., Flowers, J. & Harvey, I. 2004. An alternative approach to quantifying and addressing inequity in healthcare provision: access to surgery for lung cancer in the east of England. Journal of Epidemiology & Community Health, 58, 623-5.
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- Bebbington, P., Meltzer, H., Brugha, T., Farrell, M., Jenkins, R., Ceresa, C. & Lewis, G. 2003. Unequal access and unmet need: neurotic disorders and the use of primary care services. International Review of Psychiatry, 15, 115-22.
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- Bentley, C. 2014b. Considerations around Unmet Need. TAG/ACRA Workshop.
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- Bien, B., Mckee, K. J., Dohner, H., Triantafillou, J., Lamura, G., Doroszkiewicz, H., Krevers, B. & Kofahl, C. 2013. Disabled older people's use of health and social care services and their unmet care needs in six European countries. European Journal of Public Health, 23, 1032-8.
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- Boeing, L., Murray, V., Pelosi, A., Mccabe, R., Blackwood, D. & Wrate, R. 2007. Adolescent-onset psychosis: prevalence, needs and service provision. British Journal of Psychiatry, 190, 18-26.
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- Bruce, M., Gwaspari, M., Cobb, D. & Ndegwa, D. 2012. Ethnic differences in reported unmet needs among male inpatients with severe mental illness. Journal of Psychiatric & Mental Health Nursing, 19, 830-8.
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- Burt, J., Plant, H., Omar, R. & Raine, R. 2010. Equity of use of specialist palliative care by age: crosssectional study of lung cancer patients. Palliative Medicine, 24, 641-50.
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- Cooper, S. A., Mcconnachie, A., Allan, L. M., Melville, C., Smiley, E. & Morrison, J. 2011. Neighbourhood deprivation, health inequalities and service access by adults with intellectual disabilities: a cross-sectional study. Journal of Intellectual Disability Research, 55, 313-23.
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- Daniels, N. 1982. Equity of access to health care: some conceptual and ethical issues. Milbank Memorial Fund Quarterly - Health & Society, 60, 51-81.
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- Defining and measuring unmet need to guide healthcare funding: identifying and filling the gaps 15 Department of Health. 2015. Department of Health annual report and accounts 2014 to 2015 [Online]. Available: https://www.gov.uk/government/publications/department-of-health-annualreport -and-accounts-2014-to-2015 [Accessed].
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- Defining and measuring unmet need to guide healthcare funding: identifying and filling the gaps 25  Knowles, E., et al., Equity of access to health care. Evidence from NHS Direct in the UK. Journal of Telemedicine & Telecare, 2006. 12(5): p. 262-5. A recent study that uses a follow up survey of NHS Direct to assess the utilisation of this service and its variation across socio-economic groups. No clear measures of unmet need and so a study that falls into the general realm of variation in health care and is not central to our brief. Notable however in providing an illustration of how important mechanisms for health care access are. In this case, if there were unmet need it might correlate with access to a telephone – so it is not more health care that would be required but rather more communications infrastructure. Overall, not central to our brief but interesting in regards to B and C. Unmet need might be demanddriven and might be a need for something other than health care.
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- Defining and measuring unmet need to guide healthcare funding: identifying and filling the gaps 27 A.2. Details of UK empirical papers Ref. Condition Data Definition of (Unmet) Need Methodology Results (Almond and Lathlean, 2011) Postnatal depression 21 observations of health visitors visiting postnatal women (12 English and 9 Bangladeshi), interviews with 20 health visitors, 6 managers and 3 other personnel from one English PCT. Data collected between 2003 and 2005. Inequity in provision of postnatal depression assessment across ethnic groups. Documentary analysis. Analysis of interview data. Equality-based policy does not create equity in practice.
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- Defining and measuring unmet need to guide healthcare funding: identifying and filling the gaps 29 Ref. Condition Data Definition of (Unmet) Need Methodology Results (Battersby et al., 2004) Non-small cell lung cancers (NSCLC) NSCLC age-sex standardised incidence rates for PCTs in Norfolk, Suffolk, and Cambridgeshire, 1998 to 2000 Relation between incidence and procedures rates. Process Control Charts, based on the actual proportion of patients that receive surgery and on a higher arbitrary proportion. 3 of 17 PCTs lie outside (2 below, 1 above) the control limits based on the actual proportion of patients receiving surgery. 6 PCTs fall below the lower control limit and no PCTs lie above the upper control limit when using a higher proportion.
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- Defining and measuring unmet need to guide healthcare funding: identifying and filling the gaps 31 Ref. Condition Data Definition of (Unmet) Need Methodology Results (Cooper et al., 2011) Intellectual Disabilities (IDs) GP records and interviews with adults (≥ 16) with IDs in Greater Glasgow Health Board area + Census 2001 [n=1023]. Service utilization (consultation rates, health promotion services uptake and social supports). (1) Assess potential for nonparticipation bias using logistic regression models for participation in relation to year of birth, gender and deprivation score. (2) Examine the distributions of measures of consultation rates, health promotion service uptake and social supports in relation to these factors. (3) Repeat regression analyses, adjusting for type of accommodation and ability level. Health inequalities experienced by adults with IDs are not accounted for by the fact they are more likely to live in more deprived areas.
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- Defining and measuring unmet need to guide healthcare funding: identifying and filling the gaps 35 Ref. Condition Data Definition of (Unmet) Need Methodology Results (Orton et al., 2013) Diabetic Retinopathy (DR) Postal questionnaires, stratified (by district of residence, gender and age) sample of patients who had been invited for screening between 1st and 31st May 2010 [n=435]. DR screening uptake. Logistic regressions for nonresponse to invite associated with potential predictive variables. Multivariate models to identify predictors of non-attendance. Overall the under 40 age group more likely to be nonresponders than the over 80 age group but this effect was stronger in younger men than younger women and was stronger for people with type 1 diabetes than people with type 2 or unknown type of diabetes. Results show increasing odds of non-attendance with increasing deprivation.
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- Department of Health, 2004) above. This study is not of much relevance to our brief. It concerns only A. Defining and measuring unmet need to guide healthcare funding: identifying and filling the gaps 23  Hepworth, J., T. Bain, and M. van Driel, Hepatitis C, mental health and equity of access to antiviral therapy: a systematic narrative review. International Journal for Equity in Health, 2013. 12: p. 92. (Hepworth et al., 2013) Not relevant for our review. It is concerned with a particular treatment and whether clinical guidance is being followed. Overall – off-topic.
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- Di Bona, L., Saxon, D., Barkham, M., Dent-Brown, K. & Parry, G. 2014. Predictors of patient nonattendance at Improving Access to Psychological Therapy services demonstration sites. Journal of Affective Disorders, 169, 157-64.
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- Different patterns of mental health hospitalisation by ethnic group. Lower risk of psychiatric hospitalisation and compulsory treatment in the Other White British (mostly English compared to the White Scottish. Mixed Background, African and Chinese groups were at higher risk of being detained under the 2003 Act compared to the White Scottish.
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- Diwan, S. & Moriarty, D. 1995. A conceptual framework for identifying unmet health care needs of community dwelling elderly. Journal of Applied Gerontology, 14, 47-63.
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- Gwaspari, M. 2011. Unmet needs and antisocial personality disorder among Black African and Caribbean service users with severe mental illness. Ethnicity and Inequalities in Health and Social Care, 4.
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- Hawkins, N. M., Scholes, S., Bajekal, M., Love, H., O'flaherty, M., Raine, R. & Capewell, S. 2013. The UK National Health Service: delivering equitable treatment across the spectrum of coronary disease. Circulation. Cardiovascular Quality & Outcomes, 6, 208-16.
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- Hepworth, J., Bain, T. & Van Driel, M. 2013. Hepatitis C, mental health and equity of access to antiviral therapy: a systematic narrative review. International Journal for Equity in Health, 12, 92.
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- Higginbottom, G. M. A. 2006. African Caribbean hypertensive patients' perceptions and utilization of primary health care services. Primary Health Care Research and Development, 7, 27-38.
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- Home Office. 2015. Consultation on reform of police funding arrangements in England and Wales.
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-  Almond, P. and J. Lathlean, Inequity in provision of and access to health visiting postnatal depression services. Journal of Advanced Nursing, 2011. 67(11): p. 2350-62. This is a study focused on inequity of provision across predominantly ethnic groups. It is a very small scale study and does not address the identification of unmet need. Overall – not central to our brief.
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-  Asadi-Lari, M., C. Packham, and D. Gray, Unmet health needs in patients with coronary heart disease: implications and potential for improvement in caring services. Health & Quality of Life Outcomes, 2003. 1: p. 26. A study that utilises a patient survey to examine the nature of the health care that individuals report they need but are not receiving. For this small group of patients the results indicate that more social care, rather than medical treatment, is required. This fits under the heading of B in our framework and illustrates that poor outcome, or ‘illness’ alone might not establish unmet need for health care. 24 CHE Research Paper 141 Overall the evidence here is too limited to be of use in resource allocation, but the study usefully illustrates the issues that our framework encompasses under B.
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- ï‚· Austin, K.L., et al., Perceived barriers to flexible sigmoidoscopy screening for colorectal cancer among UK ethnic minority groups: a qualitative study. Journal of Medical Screening, 2009. 16(4): p. 174-9.
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-  Bansal, N., et al., Disparate patterns of hospitalisation reflect unmet needs and persistent ethnic inequalities in mental health care: the Scottish health and ethnicity linkage study. Ethnicity & Health, 2014. 19(2): p. 217-39. An example of the use of routine data to examine inequality in health care – this is focused on mental health care in Scotland. Another study that shows the abundance of research on inequalities in health care provision but does not link this to the needs or the populations under study. Therefore, a study of little value in informing about unmet need. Overall – provides more context in terms of A regarding mental health care. Otherwise not central to our brief.
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-  Bebbington, P., et al., Unequal access and unmet need: neurotic disorders and the use of primary care services. International Review of Psychiatry, 2003. 15(1-2): p. 115-22. A study illustrating the use of national survey data to identify need and relate this to access to services, with a view to understanding any correlates of unmet need. The domain is mental health care. The potential proxies for unmet health care need are sex, age, marital status and employment status – so this study is illustrative of approaches that might prove valuable in RA. However there is no consideration of the reasons why need is not being met or whether increased resources would address unmet need.
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-  Bien, B., et al., Disabled older people's use of health and social care services and their unmet care needs in six European countries. European Journal of Public Health, 2013. 23(6): p. 1032-8. This is a multi-country study which does feature the UK, but at an aggregate level, and therefore not directly relevant to our brief. The measure of unmet need is survey based. The findings are that there tends to be greater unmet need where there is reliance on hospital-based over communitybased care. This offers some insight into B – the suggestion is that unmet need in this domain might be more addressed by social care than health care. Overall – rather peripheral but offers some insight into the need to take care in associating unmet need, with unmet need for health care. In this case the unmet need appears to be for more community-based support.
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-  Boeing, L., et al., Adolescent-onset psychosis: prevalence, needs and service provision. British Journal of Psychiatry, 2007. 190: p. 18-26. (Boeing et al., 2007) As (Torres et al., 2006) – study of mental health disease prevalence and incidence of treatment. Overall not sufficiently aligned with goals of our review to consider further. It deals with C alone.  Nacul, L.C., M. Soljak, and T. Meade, Model for estimating the population prevalence of chronic obstructive pulmonary disease: Cross sectional data from the health survey for England.
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-  Bruce, M., et al., Ethnic differences in reported unmet needs among male inpatients with severe mental illness. Journal of Psychiatric & Mental Health Nursing, 2012. 19(9): p. 830-8. Looks at variation in self-reported unmet need for severe mental illness care need ethnicity measures. Find White British have more unmet need in general. Overall – main issues are discussed in the context of (Aspinall and London Health Observatory.
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-  Burt, J., et al., Equity of use of specialist palliative care by age: cross-sectional study of lung cancer patients. Palliative Medicine, 2010. 24(6): p. 641-50. A study focused on the relationship between need and access – palliative care for lung cancer. It is this ratio that often serves as a metric of unmet need. In this study there is attention on what correlates with this ratio. Interestingly this study finds that observable population characteristics whilst associated with need, are NOT associated with unmet need, i.e. service provision is in some way matching to need. In terms of our framework this is a potentially important example of why A alone is not enough – we can measure disease incidence and note that it correlates with observable characteristics, but this does not mean there is unmet need that correlates with those characteristics.
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-  Cooper, S.A., et al., Neighbourhood deprivation, health inequalities and service access by adults with intellectual disabilities: a cross-sectional study. Journal of Intellectual Disability Research, 2011. 55(3): p. 313-23. A health inequality paper studying the relationship between diagnosis (of intellectual disability) and access to health care. Not directly applicable to our brief as no substantive discussion of need or unmet need. Finds no substantive evidence of health inequalities in respect of adults with intellectual disabilities. Overall – possibly notable in as much as suggests mental health is not like other health care in regards to inequity (and one might therefore infer not like other health care in respect of unmet need) but otherwise of little relevance.
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-  Gwaspari, M., Unmet needs and antisocial personality disorder among Black African and Caribbean service users with severe mental illness. Ethnicity and Inequalities in Health and Social Care, 2011. 4(1). (Gwaspari, 2011) (Comments based on abstract, paper needed to be paid for to view and was deemed marginal). This study uses a direct instrument approach to assess unmet need in the domain of mental health care. The study is very small (79 participants) and limited to two hospitals in London. Therefore not generalizable for purposes of RA. Overall – of value as an illustration of the direct elicitation of unmet need (A). Makes no attempt to attribute unmet need to demand or supply-side factors.
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- ï‚· Higginbottom, G.M.A., African Caribbean hypertensive patients' perceptions and utilization of primary health care services. Primary Health Care Research and Development, 2006. 7(1): p. 27-38.
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- ï‚· Joska, J., The assessment of need for mental health services. Social Psychiatry and Psychiatric Epidemiology, Darmstadt, 2005. 40(7). The focus here is mental health and this is a useful article for establishing the measurement of unmet need for mental health services. The article is a review and includes a lot of non-UK studies. The article captures a number of the elements of our conceptual framework and discussed (in relation to published studies) the problems in measuring unmet need especially the conflicting measures that arise from studying populations as compared with groups being treated. A key idea here is that, in this domain at least there is support for the idea that treatment (clinical) populations are not necessarily capturing unmet need.
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- ï‚· Judge, A., et al., Equity in access to total joint replacement of the hip and knee in England: cross sectional study. BMJ, 2010. 341: p. c4092.
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-  Kovandzic, M., Access to primary mental health care for hard-to-reach groups: From 'silent suffering' to 'making it work'. Social Science and Medicine, 2011. 72(5). (Kovandzic, 2011) A similar focus to (Cooper et al., 2011) but more directly relevant to C. This is another study which indicates that demand-side factors are very important in the domain of mental health care. Overall – further support for the idea that there may be substantial demand-side explanations of unmet need (and therefore caution needed in jumping form measuring unmet need to building it into RA). In terms of our framework a topic C paper.
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- ï‚· Milner, P.C., et al., Inequalities in accessing hip joint replacement for people in need. European Journal of Public Health, 2004. 14(1): p. 58-62. This paper illustrates a survey based approach to establishing unmet need and the potential for proxying unmet need by characteristics some of which are already included in RA formulae. In terms of our overall framework, this paper therefore has elements of A, B and C. One point it confirms is that unmet need may already be proxied by measures of population that are included in RA. Overall this deals with only a single treatment (hip replacement) and offers only survey evidence. Furthermore it is hard to see it providing any new avenues to investigate for proxying unmet need.
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-  Miranda-Castillo, C., et al., Unmet needs, quality of life and support networks of people with dementia living at home. Health & Quality of Life Outcomes, 2010. 8: p. 132. (Miranda-Castillo et al., 2010) A study eliciting unmet need by direct survey methods but concerns a very small sample relies on patient reports and does not distinguish potential causes of unmet need. Overall – captured by our search but of little relevance to our brief.
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-  Orton, E., et al., Equity of uptake of a diabetic retinopathy screening programme in a geographically and socio-economically diverse population. Public Health, 2013. 127(9): p. 814-21. Concerned with the uptake of a screening programme and based on questionnaire. This is another study that is helpful in confirming the role of demand-side factors and the fact that it is not simply a deficit of services that leads to unmet need. As most surveys, it is based on small numbers and only considers one small area, therefore not easily generalizable for RA purposes. Overall – another study that emphasises C in our framework, but not extensive enough to be of value for RA.
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- ï‚· Purandare, N., et al., Perceived mental health needs and adequacy of service provision to older people in care homes in the UK: A national survey. International Journal of Geriatric Psychiatry, 2004. 19(6): p. 549-553. This paper is another survey based approach and so is concerned with directly measuring unmet need. The novelty is to capture a large population in a relatively small survey by targeting care home managers. Overall a potentially useful paper for illustrating how to directly elicit unmet need, but it does not proceed beyond A. It is measurement without attribution and there is no association between reported unmet need and observable proxies.
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-  Sheringham, J., et al., Monitoring inequalities in the National Chlamydia Screening Programme in England: added value of ACORN, a commercial geodemographic classification tool. Sexual Health, 2009. 6(1): p. 57-62. A study which in itself is quite niche but has potentially important implications for how tools to reflect unmet need might be developed. The study uses a commercial sociodemographic classification system to relate unequal access to services to a number of proxies that are richer than those usually adopted (including some more detailed proxies of socio-economic status – assets and relative poverty). This is illustrative of the kind of dataset that might be of value in D.
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- ï‚· Szczepura, A., Access to health care for ethnic minority populations. Postgraduate Medical Journal, London, 2005. 81(953). The commentary on this is really the same as for (Aspinall and London Health Observatory.
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- ï‚· Torres, A.R., et al., Obsessive-compulsive disorder: prevalence, comorbidity, impact, and helpseeking in the British National Psychiatric Morbidity Survey of 2000. American Journal of Psychiatry, 2006. 163(11): p. 1978-85. This study was picked up because of the disease area and it makes reference to unmet need. Its focus is really on establishing mental health disease prevalence in relation to treatment. Other than 20 CHE Research Paper 141 noting the distinction between failing to receive treatment and unmet need and the difficulty of distinguishing between lack of provision and unwillingness to access a service it does not offer any new evidence relevant to RA. Overall not sufficiently aligned with goals of our review to consider further. It deals with C alone.
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-  Turner-Stokes, L., et al., The needs and provision complexity scale: A multicentre prospective cohort analysis of met and unmet needs and their cost implications for patients with complex neurological disability. BMJ Open, 2013. 3(2). Focus is on a tool (usually termed ‘instrument’?) for measuring met and unmet needs of a particular group of patients – in this instance those with complex neurological deficit. This seems to be more about the mix of services that patients received than about the overall level of provision and so seems marginal for RA. It does however illustrate one of a range of methods that can be used to elicit unmet need (i.e. illustrates the range of approach that are or can be taken for A). Overall – a further illustration of the mixture of methods available for A, but as we have emphasised establishing the extent of unmet need falls a good deal short of using such a measure in RA.
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- ï‚· Williams, M.V. and K.J. Drinkwater, Geographical variation in radiotherapy services across the UK in 2007 and the effect of deprivation. Clinical Oncology (Royal College of Radiologists), 2009. 21(6): p. 431-40.
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- In comparison with (Nacul et al., 2007) and (Judge et al., 2009) this study is concerned with country level variation – in this case the ‘need’ is that for radiotherapy services. The study does draw attention to the necessity of moving from need to unmet need by comparing service provision with the identified need – and finding variation in the treatment deficit that is correlated with some population characteristics. Thus there is more of an emphasis on B in this approach, so it might be used to illustrate how (Nacul et al., 2007) and (Judge et al., 2009) could be extended to be of more relevance to RA. However the geographic area of analysis in this study precludes any direct use in RA – and there is little consideration of issues C and D within our framework.
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- Joska, J. 2005. The assessment of need for mental health services. Social Psychiatry and Psychiatric Epidemiology, Darmstadt, 40.
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- Judge, A., Welton, N. J., Sandhu, J. & Ben-Shlomo, Y. 2009. Modeling the need for hip and knee replacement surgery. Part 2. Incorporating census data to provide small-area predictions for need with uncertainty bounds. Arthritis & Rheumatism, 61, 1667-73.
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- Judge, A., Welton, N. J., Sandhu, J. & Ben-Shlomo, Y. 2010. Equity in access to total joint replacement of the hip and knee in England: cross sectional study. BMJ, 341, c4092.
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- Kessler, D. 2005. Social class and access to specialist palliative care services. Palliative Medicine, 19.
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- Knowles, E., Munro, J., O'cathain, A. & Nicholl, J. 2006. Equity of access to health care. Evidence from NHS Direct in the UK. Journal of Telemedicine & Telecare, 12, 262-5.
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- Kovandzic, M. 2011. Access to primary mental health care for hard-to-reach groups: From 'silent suffering' to 'making it work'. Social Science and Medicine, 72.
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Martin, S., Rice, N. & Smith, P. C. 2008. Does health care spending improve health outcomes? Evidence from English programme budgeting data. Journal of Health Economics, 27, 826-842.
Martin, S., Rice, N. & Smith, P. C. 2012. Comparing costs and outcomes across programmes of health care. Health Economics, 21, 316-337.
- Mays, N. 1987. Measuring morbidity for resource allocation. British Medical Journal, 295.
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- Milner, P. C., Payne, J. N., Stanfield, R. C., Lewis, P. A., Jennison, C. & Saul, C. 2004. Inequalities in accessing hip joint replacement for people in need. European Journal of Public Health, 14, 58-62.
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- Miranda-Castillo, C., Woods, B., Galboda, K., Oomman, S., Olojugba, C. & Orrell, M. 2010. Unmet needs, quality of life and support networks of people with dementia living at home. Health & Quality of Life Outcomes, 8, 132.
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- Nacul, L. C., Soljak, M. & Meade, T. 2007. Model for estimating the population prevalence of chronic obstructive pulmonary disease: Cross sectional data from the health survey for England. Population Health Metrics, 5.
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- NHS England. 2014. Technical Guide to Clinical Commissioning Group and Area Team allocations 2014-15 and 2015-16 [Online]. Available: https://www.england.nhs.uk/2014/03/27/allocations-techguide / [Accessed].
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- Orton, E., Forbes-Haley, A., Tunbridge, L. & Cohen, S. 2013. Equity of uptake of a diabetic retinopathy screening programme in a geographically and socio-economically diverse population. Public Health, 127, 814-21.
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- Overall – a complement to (Burt et al., 2010) in establishing that need and unmet need may not correlate with need. And worth noting that this still is far short of the sort of evidence that our framework indicates would be necessary for RA.
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- Overall another confirmation of the fact that inequality of access is not sufficient for establishing unmet need that can be addressed through more health care resources. If there is an emerging theme from this strand of literature (the inequality of access across ethnicity) it is that the demandside seems very important. That argues that ethnicity may not be an appropriate proxy for unmet need in an RA context. As in (Aspinall and London Health Observatory. Department of Health, 2004) this informs regarding A but does not offer much more of practical significance to RA.
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- Population Health Metrics, 2007. 5(8). This is a study that illustrates an approach that might be useful in moving towards evidence-based proxies for RA. It establishes models for predicting COPD – this establishes need. It is a strong evidence-based approach. A next step could be to relate the estimated need against service provision. Our framework however is useful precisely because it indicates how much further work would be required; establishing whether lack of service provision or unwillingness to access is the cause, and testing whether some of the elements of the model exhibit sufficient variation across geographic areas to be practical proxies of unmet need amenable to greater health care provision.
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- Purandare, N., Burns, A., Challis, D. & Morris, J. 2004. Perceived mental health needs and adequacy of service provision to older people in care homes in the UK: A national survey. International Journal of Geriatric Psychiatry, 19, 549-553.
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- Rice, N. & Smith, P. C. 2001. Capitation and Risk Adjustment in Health Care Financing: An International Progress Report. Milbank Quarterly, 79, 81-113.
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- Sheringham, J., Sowden, S., Stafford, M., Simms, I. & Raine, R. 2009. Monitoring inequalities in the National Chlamydia Screening Programme in England: added value of ACORN, a commercial geodemographic classification tool. Sexual Health, 6, 57-62.
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- Significant differences between ethnic groups with respect to total number of self-reported needs and unmet needs (Burt et al., 2010) Lung Cancer Cross-sectional survey of lung cancer patients attending chest or oncology outpatient clinics at four NHS Trusts in south London between June 2006 and April 2007 [n=252]. Need for specialist palliative care (SPC), using health-related quality of life (HRQL) as an indicator. Multivariate analyses. Use of SPC is related to metastatic disease, global quality of life, and treating clinic.
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- Significant predictors of IAPT first session non-attendance by patients were: lower non-risk score on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM); more frequent thoughts of ‘being better off dead’ (derived from the CORE-OM); either a very recent onset of common mental health disorder (1 month or less) or a long term condition (more than 2 years); and site 32 CHE Research Paper 141 Ref. Condition Data Definition of (Unmet) Need Methodology Results (Hawkins et al., 2013) Coronary Disease Myocardial Ischemia National Audit Project + General Practice Research Database. Differences in treatment. Age-adjusted descriptive comparisons. No socioeconomic gradients in the treatment of coronary artery disease, but treatment levels still under national targets.
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- Szczepura, A. 2005. Access to health care for ethnic minority populations. Postgraduate Medical Journal, London, 81.
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- Torres, A. R., Prince, M. J., Bebbington, P. E., Bhugra, D., Brugha, T. S., Farrell, M., Jenkins, R., Lewis, G., Meltzer, H. & Singleton, N. 2006. Obsessive-compulsive disorder: prevalence, comorbidity, impact, and help-seeking in the British National Psychiatric Morbidity Survey of 2000. American Journal of Psychiatry, 163, 1978-85.
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- Total needs and unmet needs of asylum seekers were very high compared with the three reference populations. The most prominent needs were social, but just over half had unmet needs related to psychotic symptoms (Milner et al., 2004) Hip Replacement Random samples from the age-sex registers of Wiltshire (7,900) and Sheffield (7,100) Health Authorities, stratified by disadvantage using the Townsend Index of Material Deprivation. Need for the intervention was determined by an adapted version of the index of severity of osteoarthritis of the hip. Compare need to services used. Multiple logistic regression Unmet need for hip replacement in those aged over 65 is relatively common (3.4%).
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- Turner-Stokes, L., Mccrone, P., Jackson, D. M. & Siegert, R. J. 2013. The needs and provision complexity scale: A multicentre prospective cohort analysis of met and unmet needs and their cost implications for patients with complex neurological disability. BMJ Open, 3.
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- Williams, M. V. & Drinkwater, K. J. 2009. Geographical variation in radiotherapy services across the UK in 2007 and the effect of deprivation. Clinical Oncology (Royal College of Radiologists), 21, 43140. Defining and measuring unmet need to guide healthcare funding: identifying and filling the gaps 17 A. Appendices A.1. Paper by paper commentaries We can summarise our framework as indicating that, in order to be of real use in RA formulae it is necessary first to: A. elicit evidence of unmet need from disparity of outcome/reports, then B. establish how much can be attributed to unmet healthcare need, then C. establish whether that is supply or demand side driven, and then D. link that to observable correlates which are capable (and usefully vary) of being included in formula.
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