Intended for healthcare professionals

Education And Debate

Children and the inverse care law

BMJ 1998; 316 doi: (Published 23 May 1998) Cite this as: BMJ 1998;316:1588
  1. Elspeth Webb, senior lecturer
  1. Department of Child Health, University of Wales College of Medicine, Cardiff CF4 4XN
  1. Correspondence to: Dr Webb

    It is over 25 years since Tudor Hart described the inverse care law. This states that “the availability of good medical care tends to vary inversely with the need for it in the population served.”1 Although Tudor Hart did not provide hard evidence to support his hypothesis, others have since. West and Lowe showed that for children's services need and provision were badly matched.2 Given the lack of strategic planning centred on children and the low priority given to the commissioning of children's services, this situation is unlikely to have changed.3

    The inverse care law also operates in terms of access to services. Those with least need of health care use the health services more, and more effectively, than do those with greatest need.4 This applies to preventive interventions as well as treatments. Health promotion based on providing information in standard formats to the population as a whole has had the greatest impact on people who are socially and economically advantaged.5

    Summary points

    Half a million socioeconomically deprived children and young people are marginalised within society in the United Kingdom

    Social exclusion is associated with poor health and very poor access to health services

    Addressing the needs of these young people ought to be a priority since poor health has implications for their adult health and welfare

    Strategies to improve their health care, with particular emphasis on the role of primary care, must be developed and implemented

    If Britain is to change its attitudes to children fundamentally, a children's rights commissioner must be appointed


    Over one third of the children in the United Kingdom grow up in conditions of socioeconomic deprivation. In consequence they experience poorer health than their more affluent peers.6 Within this socioeconomically deprived population exist several groups of children and young people who are profoundly marginalised—for example, homeless children, those in care, travellers, and refugees. They have both poor health and poor access to health services.714 Other groups, such as children from minority ethnic communities and adolescents, have poor access to services.1517 These young people are not in themselves inherently unhealthy, except if they are disadvantaged in some other way. They then face double or triple jeopardy.

    Homeless children

    The indifferent health and poor access to services of homeless people are well described.79 Official statistics, however, are available only for subgroups of this population, such as those housed by the local authority. In 1993, 149 410 households were accommodated by councils in England and Wales, 75% of which had dependent children.18 Those resident in women's aid refuges comprise a relatively unstudied subgroup of homeless people.19 In England and Wales over 35 000 children each year pass through these refuges, with an unknown but similar number referred on to other safe houses (personal communication, Women's Aid). It is not known how many children live on our streets; some are as young as 12. Every year 10 000 young people leave the care system, and a large but unknown proportion of them end up “living rough.”


    Travellers are often viewed as a subgroup of homeless people, but this view is both incorrect and unhelpful. It certainly does not reflect the profound discrimination these people experience within society. Traditional traveller communities in Britain include people of Roma extraction. Others have their origins in indigenous nomadic communities. Some of these are ancient, while others took to the road in later centuries—for example, during the Irish famine and the Highland clearances. Travellers were not included in the 1991 census. Estimates are based on Department of Environment figures for caravans on official sites. There are probably at least 50 000 travellers, 30 000 of whom are children. It is claimed that they have the poorest health of any minority community in the United Kingdom.11

    Latterly, so called “new age” travellers have adopted a nomadic lifestyle in response to different social pressures. They do not have rights of access to official sites, so their situation in respect of health and health care may be even worse than that of the traditional communities. They are an unstudied phenomenon, but they have not given up rights to statutory services. We continue to have a duty of care to their children.


    Refugee communities experience disadvantages at many levels. They share with other minority ethnic communities the experiences of racial discrimination, poverty, and poor access to services. 15 16 20 Over and above this, refugees and asylum seekers have great difficulty accessing services, particularly primary health care. 13 14 Disadvantageous factors that they meet after their arrival in the United Kingdom include racism, homelessness, language difficulties, uncertain residency status, and difficulties in adapting to peace. These factors are over and above the extreme trauma experienced by many refugees and the loss that pervades their lives—loss of home, parents, family, friends, culture, work, health. The population of young people in custody, another hugely disadvantaged group, includes over 70 young asylum seekers, many of whom arrived in Britain as unaccompanied minors.

    Children in care

    About 80 000 children are currently “looked after” in the United Kingdom, abandoned, unwanted, or removed from care of their parents. They may have been abused, neglected, or beyond parental control. Illness or disability in the child or parental illness, disability, or drug abuse may have precipitated family breakdown.21 These factors are associated with poverty. Thus, this is a group of children who are already vulnerable and disadvantaged before coming into the care of the local authority.


    Poverty and social exclusion combine to adversely affect the health and health care of at least half a million British children

    General interventions

    Responding to the healthcare needs of these groups requires the development of appropriate strategies. Given the emphasis currently placed on local planning and commissioning of health services, “plugging” them back into primary care is crucial. Fundholding, the attachment of health visitors to general practice, and targets linked to payment have led to an erosion of the public health role of the health visitors, the development of an inflexible system unable to respond to changing demography, and the advent of groups who are considered “budget unattractive”—too great a drain on resources. This has exacerbated the already poor access that these groups experience. Contracts for providing primary care to these communities should be agreed separately, and their immunisation and surveillance uptake rates should be excluded from calculations of general target attainments.

    The Audit Commission recommended that services should be targeted at children in need.22 The welfare of these children should be as high on the agendas of departments of community child health as are child protection and developmental medicine. Consultants in community health should be key players and ensure that named health professionals within their departments have responsibility for these children. This may include hands-on care, audit, demography, training, and interagency working. It may be that a team including people from other disciplines is needed. Whether these named professionals are doctors or health visitors will depend on the needs of the group in question. They should carry their work beyond mere statutory obligations and be proactive. The appointment of a named professional for “adoption and fostering” has not in itself been enough to address the unmet needs of children in the care system. The model of a specialist health visitor serving groups with special needs of one sort or another is one that needs further exploration and development in the context of marginalised communities with poor access to health care.

    Acute services should work within a truly combined child health service that retains traditional paediatric values—that is, a “whole child” view that encompasses the family and social contexts of illness. These holistic values may be lost in hospital care that is increasingly based on specialties. Appropriate response demands health professionals who are familiar with the concepts underlying equal opportunities and non-discriminatory practice. This is an area that is currently neglected in medical education in Britain.

    Intersectorial working parties should address the needs of particular groups within a local context, with community development as a core ethos. They should not be merely advisory but have executive authority to develop and implement local strategies. Public health involvement is essential in addition to informed input from those who provide health care. Liaison with local authorities may lead to fruitful partnerships that can address the links between environment and health. Environmental improvements should be planned with the communities themselves, such as travellers and those in temporary accommodation. Local authority hostels should be safe environments that include provision for safe play and do not house children in the same buildings as Schedule 1 offenders (those with a previous conviction for an offence against a child). Particular hostels could be tailored for families with children or for those with a disabled or sick child.

    Specific interventions

    Children in refuges

    The key issue for children in refuges is violence. Over half are victims of violence. Nearly 75% have witnessed violence to their mothers first hand, including 10% who have witnessed sexual abuse or rape.23 These experiences are emotionally very damaging and must be addressed in any strategy. Clinical psychologists with experience in counselling after abuse need to develop links with refuges and support their child care workers.

    Children living rough

    Street children are marginalised in every way. As adolescents they are a hard to reach group. Their lifestyle makes the use of standard services difficult, and their often profound alienation and distrust of statutory and mainstream services preclude access to care. Many of them have been abused previously, and all of them risk violence, prostitution, and drug abuse. 24 25 Their needs are unique, and specific and imaginative strategies are needed. Mobile night-time clinics, for example, could provide services valued by the clients themselves, not just those that reflect professional priorities. In policy development, linking in with voluntary agencies such as Voices from Care would seem desirable.

    Refugees and asylum seekers

    Refugee children have unique needs ranging from tuberculosis prevention to the treatment of victims, and witnesses, of human rights abuses. Since these children often come from war torn areas they may have received no immunisations or child surveillance. At the very least, catch up surveillance and immunisation services should be provided.

    Responding to the emotional needs of these children is hampered by the broader issues of poor access to service. There are additional difficulties in providing psychological and psychiatric care to populations in whom the experience and the language of distress may be vastly different from our own, and for whom our models of psychosocial pathology and our treatment strategies are invalid.

    A survey of Somali refugees in Cardiff revealed a large number of children with important health problems whose life experience included violence, bereavement, separation, disruption, homelessness, and poverty.26 The authors believed that distress was exacerbated by the inappropriate responses of the statutory services to the arrival of these children—responses based on glib assumptions that they were developmentally intact and would slot easily into Western systems of education, health care, and welfare. An increase in Somali workers at all levels was essential for “culturally appropriate care” to be provided. The expertise within the refugee community was not tapped, partly because of regulations preventing professionals qualified in Somalia from working within our agencies except as interpreters and link workers. The refugees included doctors, nurses, pharmacists, and teachers who no doubt could have been invaluable. Some flexibility and imagination is necessary to allow skilled and experienced refugees to work in partnership with their Western counterparts.26


    The children discussed here experience the disadvantages of socioeconomic deprivation but face additional barriers to services as a result of their social marginalisation. There are nearly half a million of these children in the United Kingdom at any time (excluding street children and refugees, for whom reliable figures are not available). This is about 5% of the 12 million young people aged under 16 years. If disadvantaged children from minority ethnic communities are added, the figure is higher still—about 8% of the under 16 population of Great Britain belong to these communities and face a greater likelihood of living in poverty than do members of the ethnic majority. 20 27 Given what we know about the health status of all these groups, and the implications this has for adult health, strategies to address needs of these children must be a priority for central government and those charged with commissioning and providing health care.


    Responding to the plight of these children requires not just implementation of the measures described above but social and legislative change. The Criminal Justice and Public Order Act 1994, the Asylum and Immigration Act 1996, and the withdrawal of benefits to those aged under 18 have been detrimental to the health and welfare of children and young people.1129 We have a parliament that is not bound or inclined to consider the impact of its wider legislation on children, reflecting the marginalised status all children have in our political culture. It is one in which, in a mature Western democracy, politicians can propose curfews for teenagers as a solution to the symptoms of poverty and social exclusion, and cut benefits to lone parents to address the fiscal problems of the welfare state. Largely absent from the debate on cuts in benefits paid to single parents has been any assessment of its likely impact on the health and welfare of already disadvantaged children, or the acknowledgment of parenting as an important occupation. Britain needs a radical cultural change in its attitudes to children, a change that is unlikely to be achieved without the appointment of a children's rights commissioner.


    Funding: No additional funding.

    Conflict of interest: None.


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