In 1971 Tudor Hart believed that the people who most needed health services were the least likely to receive them, and that turns out to be true. His ‘Inverse Care Law’ is valid today. Since then Marmot and Wilkinson have identified that health is better at each step up the economic ladder AND that there is an equally direct relationship between health and social status. Soooo, the people who need health services most have the least financial resources and the least social resources. The social resources most implicit are control, stress and inclusion.

What I found in a small local study of people seeking free public counselling services surprised me even though I’ve been working as a counsellor and therapist for many years: the people seeking those services were very vulnerable. They were in social, emotional and psychological crises. One of my respondents had a daughter in her late teens who had memories of sexual abuse triggered and went into crisis. It took six weeks to get access to the sexual assault counsellor. The position was only filled halftime during staff leave and the casual staff member was unable to keep up. The intake/entry system being used relied on a landline answering machine. A period of phone tag ensued during which the young woman descended into self harm and required medical intervention.

It is very easy to exclude vulnerable people – they may be depressed or anxious, they may be conserving their phone credit or have difficulty with transport and they may not be very assertive. From the trauma and domestic violence literature we know that people who have suffered abuse or bullying become poor at valuing their own needs.They lose motivation and assertion. Any system that is not warm, welcoming, well known and pro-active will almost inevitably lock them out.

Services that; use call centres, are limited to cities and regional centres, that have security screens, limited parking, poor public transport, formal staff manners, and  intake interviews, assessments , and waiting periods before an engaged response are problematic. The research and evidence for this is well documented. Services with flexible entry, multi-disciplinary staff, co-located services, respectful, warm and non-hierarchical relationships and that are genuinely inclusive, are better at engaging those with the highest needs and vulnerabilities.

This needs consideration in the restructuring of primary health services and the entry systems that are to be used, for counselling services, but also for child and family, addictions, mental health and aged care. In the first instance how are we going to ensure that the complex jigsaw of non-government and private practitioner services are as visible and local as the Community Health Centres have been since the 1970s in towns and suburbs across the nation? Will this ever be a public discussion?