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. 3The 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.

A community-based child mental health service was established for families of preschool children with emotional and behavioural problems in the children, psychosocial problems in the family or parenting difficulties. The intervention was home-based and conducted by health visitors and paediatric community medical officers trained in parent counselling, parenting issues and child behavioural management. The approach was based upon frameworks derived from counselling theory, with the intervention dependent upon the development of a trusting and respectful partnership with the parents. The aims were to promote and support the parents' own exploration of the identified problems, and to help them establish clear aims and effective problem management strategies. Ongoing supervision was provided by a clinical psychologist. The evidence indicated that the training course was acceptable to non-mental health professionals and effective in preparing them to work with psychosocial problems. The service was a feasible option for work at the community level; it was acceptable to both referrers and parents and beneficial for families living in a very deprived inner-city community.

There is substantial evidence that looked after children have extensive health needs and disabilities, that they have often missed out on routine health surveillance and health promotion before entry to care or accommodation, but that at present they receive little compensatory care. Harriet Ward, Helen Jones, Margaret Lynch and Tricia Skuse discuss these issues. They look at how frequent changes of placement and poor inter-agency communication exacerbate difficulties in gaining access to adequate health care, especially when children lack an advocate who takes proactive action on their behalf. The Department of Health has responded by issuing new Guidance that sets clear standards for service delivery, encourages children's participation, and ensures that health assessments recognise inequalities and take a holistic view of healthcare needs. The implementation of the Integrated Children's System should improve the quality and accuracy of health information concerning all children in need. New Regulations and Standards for foster care, a National Healthy Care Standard and, on a broader policy front, the National Service Framework for Children should all ensure better access to health care for this population. However, as the authors conclude, such measures will only be successful if inter-agency working can be improved through multi-disciplinary training and better co-ordinated structures for service delivery.