This paper was motivated by the adverse results of a study that evaluated implementation of a structured health needs assessment tool in health visiting. It examines the conceptual basis of three approaches to needs assessment, exploring their relevance to the purpose of health visiting and their links with prioritizing, targeting and promoting health in practice. It is intended to help health visitors, their managers and service commissioners to explain and understand the different requirements and expectations in each approach.

British Government policy emphasizes that targeting and prioritizing are the means by which inequalities can be redressed and resources directed towards those in greatest need. Needs assessment processes are increasingly invoked as the mechanism through which health visiting services can best be deployed. Health visitors are expected to help identify service priorities and to target their efforts effectively and efficiently. Access to services and user empowerment are also important aspects of the NHS modernization agenda. These concepts are fundamental to health promotion, which has been the consistent underlying purpose of the health visiting service since its inception.

In this discussion paper, three approaches to needs assessment are unravelled, which focus on prioritizing, targeting and health promotion. It is suggested that these different purposes relate, in turn, to the expectations and requirements of public health, organizational efficiency and user empowerment. There are important benefits associated with each of the three approaches, but their underlying principles, purposes and requirements differ. Failure to appreciate such differences can lead to misunderstandings, confusion and even offence. A single instrument cannot successfully meet the expectations of all three approaches to needs assessment. Instead, a needs assessment system is necessary, to meet the contradictory requirements of public health, organizational efficiency and user empowerment.