To determine Citizen's Advice Bureaux (CAB) and general practice staff perceptions on the impact of a CAB Health Outreach (CABHO) service on staff workload. To quantify the frequency of mental health issues among patients referred to the CABHO service. To measure any impact of the CABHO service on appointments, referrals and prescribing for mental health.

GPs and practice managers perceive that welfare rights services, provided by CAB, reduce practice staff workload, but this has not been quantified.

Interviews with practice managers and GPs hosting and CAB staff providing an advisory service in nine general practices. Comparison of frequency of GP and nurse appointments, mental health referrals and prescriptions for hypnotics/anxiolytics and antidepressants issued before and after referral to the CABHO service, obtained from medical records of referred patients.

Most GPs and CAB staff perceived the service reduced practice staff workload, although practice managers were less certain. CAB staff believed that many patients referred to them had mental health issues. Data were obtained for 148/250 referrals of whom 46% may have had a mental health issue. There were statistically significant reductions in the number of GP appointments and prescriptions for hypnotics/anxiolytics during the six months after referral to CABHO compared with six months before. There were also non-significant reductions in nurse appointments and prescriptions for antidepressants, but no change in appointments or referrals for mental health problems. The quantitative findings therefore confirmed perceptions among both CAB and practice staff of reduced workload and in addition suggest that prescribing may be reduced, although further larger-scale studies are required to confirm this.

To explore whether and how health visitors experience ethical tensions between the public health agenda and the need to be responsive to individual clients.

Current health policy in England gives health visitors a key role in implementing the government's public health agenda. Health visitors are also required by their Professional Code to respond to the health-related concerns and preferences of their individual clients. This may generate tensions.

A total of 17 semi-structured individual interviews covering participants’ experiences of implementing public health interventions and perceptions of the ethical tensions involved were conducted. Interviews were audio-recorded, transcribed and analysed thematically using a Framework approach.

Health visitors raised a number of ethical concerns, which they attributed to organisational resource allocation and the introduction of protocols and targets relating to public health goals. They did not always regard it as appropriate to raise topics that employing organisations had identified as public health priorities with particular clients for whom they were not priorities, or who had other more pressing needs. They noted that resources that were allocated towards reaching public health targets were unavailable for clients who needed support in other areas. Organisational protocols designed to monitor performance put pressure on health visitors to prioritise achieving targets and undermined their ability to exercise professional judgement when supporting individual clients. This had implications for health visitors’ sense of professionalism. Health visitors saw trusting relationships as key to effective health visiting practice, but the requirement to implement public health priorities, combined with a lack of resources in health visiting, eroded their ability to form these. Policies need to be evaluated with regard to their impact upon a broader range of processes and outcomes than public health goals. The erosion of health visitors’ professional values and ability to develop relationships with clients could have numerous adverse implications.