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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." 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. 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.
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. 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.
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. 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.[7-14] Other groups, such as children from minority ethnic communities and adolescents, have poor access to services.[15-17] 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.
The indifferent health and poor access to services of homeless people are well described.[7-9] 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 not known how many children. Those resident in women's aid refuges comprise a relatively unstudied subgroup of homeless people. 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 house (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 …