‘Inverse care’ and unmet need: How children in poorer areas are less likely to receive the right SEND diagnosis or provision

by Dr Tammy Campbell, Visiting Senior Fellow at CASE, and Director for Early Years at the Education Policy Institute.

A few years ago we ran an article from the Education Policy Institute that analysed data showing children with additional needs in deprived areas were more likely to be overlooked when it came to having their needs supported, than similar children in better-off areas. This finding has been furthered in new research from Dr Tammy Campbell also from the EPI and a visiting senior fellow at the Centre for Analysis of Social Exclusion (CASE) at the London School of Economics and Political
Science (LSE).

The new research examines relationships between families with children eligible for Free School Meals and the kind of support they receive for SEND. While a greater proportion of children eligible for FSM in deprived areas receive SEND provision, data shows what we have always believed - that they are less likely to have either Education, Health and Care Plans (EHCPs) or a correct diagnosis of specific conditions.

Dr Campbell explains her research:

Inequalities in SEND provision for primary children greater in less wealthy areas. By Dr Tammy Campbell

50 years ago, GP and researcher Dr Julian Tudor Hart, first wrote about the ‘inverse care law’ how ‘availability of good medical care tends to vary inversely with the need for the population served.’[1] Hart showed that people living in poorer and more deprived areas tend to become ill and disabled more often, and so require greater care from health services. But despite this, they receive the opposite: a lower level of service, not meeting their needs. Inequality persists to this day, and internationally[2].

Researching patterns in the 2000s, Francois Keslair and Sandra Mcnally found that the ‘inverse care law’ held for SEND provision, too. Children, particularly those from low-income families, had a higher chance of receiving a (pre-2014) Statement of Special Educational Needs if they lived in more affluent areas. They concluded it was, ‘more advantageous to be a poor child with special educational needs in a more affluent area,’ and suggested a ‘quota’ or ‘rationing’ of provision.[3]

Dr Tammy Campbell
Dr Tammy Campbell

SEND provision “rationing” continues

Earlier this year, during a session of Parliament’s Education Select Committee[4], MPs spoke of ‘huge high needs deficits’ in the resources meant to serve children with SEND in less wealthy areas. They proposed that ‘a massive rationing process’ is still going on, echoing Kalsair and Mcnally’s findings two decades ago.

In research published last month,[5] I explored whether recent national data shows us that ‘inverse care’ still exists in SEND services, with children’s needs being less likely to be met if they live in poorer areas. I use secure-access de-identified information from the National Pupil Database (NPD). This contains records for all children in state education in England. I examined the 4.5 million pupils in primary schools in January 2021. The Income Deprivation Affecting Children Index (IDACI) is my key measure. It tells us, ‘the proportion of all children aged 0 to 15 living in income-deprived families’ in a small local area.[6] The higher the IDACI score, the more families with children in the area have very low or no income.    

I found that pupils who are recorded with SEND in the NPD are less likely to have an Education, Health and Care Plan (EHCP), the more deprived the area in which they live.

  • About 17.5% have an EHCP in the most deprived areas, compared to 22% in the most affluent areas.
  • This gradient is steeper among children whose family is recorded as eligible for Free School Meals, meaning they have a low income.
  • This national data indicates that ‘inverse care,’ unmet need, and rationing still very much exist in the system that is supposed to serve children with SENDs and their families.

What kind of SEND are poorer children diagnosed with?

I also looked at the category of SEND with which a child is recorded in the National Pupil Database. Children living in deprived areas are more likely to be categorised with the most commonly attributed SEND ‘types’:

  • Speech, Language and Communication Needs;
  • Moderate Learning Difficulties; and Social,
  • Emotional and Mental Health Difficulties.

In contrast, those in more affluent areas are more likely to be recorded with conditions including:

  • autism,
  • specific learning difficulties (which include dyslexia, dyspraxia, and ADHD),
  • and sensory and physical conditions.

These patterns, and those for EHCPs hold when I accounted for individual low-income families and children’s reported ethnicity, home language and local authority of residence.

How do we interpret this?

We do need to be cautious with interpretation because these categories are recorded by schools in the NPD, rather than being taken from records from services external to schools. However, what these additional patterns may suggest are lower chances of access to diagnostic services in more deprived areas, and/or less recognition of and adaptation for specific conditions and disabilities within schools in these areas.

In sum, my findings indicate that there is unmet need for support and provision among children living in poorer areas, and that ‘inverse care’ continues to exist in SEND provision. They suggest that additional resourcing and funding is needed. However, the government’s recently revealed plans indicate that the opposite is on the cards: they intend to decrease spending, and reduce numbers of EHCPs.[7]

This is likely to hit children and families in deprived areas particularly hard, given the lack of support they already experience. Without radical revisions to the wider education system, this is a move in the wrong direction. It is likely to cause more harm and to deepen inequalities.

Read more: Dr Tammy Campbell (2023) ‘Inequalities in provision for primary children with special educational needs and / or disabilities (SEND) by local area deprivation.’ https://sticerd.lse.ac.uk/dps/case/cp/casepaper231.pdf


  1. https://sochealth.co.uk/national-health-service/public-health-and-wellbeing/poverty-and-inequality/the-inverse-care-law/
  2. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00243-9/fulltext
  3. https://www.researchgate.net/publication/242211473_Special_Educational_Needs_in_England_Final_Report_for_the_National_Equality_Panel
  4. https://committees.parliament.uk/oralevidence/13196/pdf/
  5. https://sticerd.lse.ac.uk/dps/case/cp/casepaper231.pdf
  6. https://opendatacommunities.org/def/concept/general-concepts/imd/idaci
  7. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1110657/Sustainable_high_needs_systems_guide_-_SV_and_DBV_updates_-_Oct22.pdf

About Dr Tammy Campbell

Dr Tammy Campbell is Visiting Senior Fellow at CASE, and Director for Early Years at the Education Policy Institute. This work was undertaken in her previous role as CASE Assistant Professorial Research Fellow, supported by a British Academy Postdoctoral Fellowship, under grant PF2\180019.

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