Key lessons from health and legal assistance services operating during the Covid19 pandemic that can help Australia build back better.
The year 2020 will go down in history as one of the toughest. In Australia, it began under a cloud of smoke from a horrendous bushfire season, during which 34 lives were lost, more than 3500 homes destroyed and 18 million hectares burned. Then, as the nation began surveying the aftermath of this destruction, Covid19 swept the globe.
Both were crises that affected people’s health, financial security and wellbeing. But for some, these effects were exacerbated by existing, underlying need. People who were already disadvantaged by insecure or overcrowded housing, by precarious employment, by exposure to stigma and discrimination, or who were unsafe in their own homes were hit hard by the health as well as the social and economic impacts of the pandemic.
2020 highlighted the deep, structural inequities that drive complex need and shape people’s experience of and resilience to crisis. It also shone a spotlight on the failings of service systems that operate from a single vantage point, such as the health or legal systems, when the reality for many people is that they experience multiple, intersecting problems concurrently.
More than ever before, the crises of this period demonstrated the importance of health, legal and other human services working together to collaborate around the needs of the people and communities they serve. Health justice partnership demonstrates how services did exactly that. Insights in this Report are drawn from health justice partnership practice and the work of health and legal assistance services more broadly.
In all the chaos and the challenges it produced, innovations and work arounds were being developed and lessons learned at all levels. Now, as we adjust to living with extreme weather events and pandemic, we need to capture the lessons of the past year: from failings to innovation that led to new and more effective responses; from impacts on individuals to those that were systemic.
Drawing on health and legal practitioner voices and community experience, this report shares lessons of collaboration to address complex health and legal needs among the people and communities, practitioners, services and governments facing the unprecedented crises of 2020.
Despite serious impacts on practitioner wellbeing, health justice partnership has helped health and legal assistance services to identify and respond to rapidly changing needs among the communities they serve through the successive crises of bushfire and pandemic.
For many people, the major environmental (bushfires) and health (Covid19) crises of 2020 exacerbated existing health, legal and social problems. Once the pandemic was declared and the public health response to socially distance or isolate was implemented, many parts of Australia entered a period of shutdown. While these shutdowns served the purpose of reducing the spread of Covid19, they also contributed to an increase in isolation; growing health, legal and social need; and a reduction in access to help as people put off otherwise-routine engagement with services.
Early on, health and legal assistance practitioners began reporting that clients and patients were staying away from services. This included services in our network who reported that older people among its cohort of regular patients were ‘not accessing “non-urgent” services for chronic disease’. By June 2020, the World Health Organization was reporting on the phenomenon that access to services for noncommunicable diseases, including chronic conditions such as cancers and Alzheimer’s disease, was declining due to the Covid19 pandemic. While the public commentary focused on this as a problem in healthcare, it extended to other service environments too. Legal assistance services reported that people were contacting them less frequently for non-urgent matters as the pandemic set in.
At the same time, there was an increase in the intensity of matters that some people were raising, particularly in relation to family violence, mental health and family law issues – the kinds of needs that health justice partnership responds to.
Health justice partnership is a response to the evidence that many people will experience three or more legal problems in a given year for which they often will not seek help from a lawyer. These legal problems include unstable or unhygienic public or rental housing; insecure employment; money problems like credit and debt or inadequate income support; stigma and discrimination; family violence and elder abuse. When people do seek help for these problems, they are more likely to do so in a setting of trust like a health service than to visit a lawyer, reflecting that these are issues that impact upon people’s health and wellbeing as well as their sense of justice.
The capability of services to respond rapidly to changing need in the community is not always matched by government, even when government’s ability to work at scale is critical.
Health and legal assistance services found they had to lead the change ahead of government policy in identifying appropriate and safe ways to meet their obligations and responding to changing need in the context of Covid19. By contrast to the agility of many health and legal assistance services who were connected to the communities they support, the slowness of government undermined its ability to respond to rapidly changing needs.
Government departments do not necessarily have the capability to implement solutions in response to rapidly changing need. Poor capacity, including a lack of staff to provide advice on key issues as they emerged, created further challenges. In some cases, services could model solutions that government could then scale up for broader impact. But in other cases, services were left having to seek permission retrospectively for changes that had been necessitated by the crisis. This added further risk to an already difficult context, as services waited for policy to ‘catch up’ to the reality that these were not ‘normal times’.
One service working with people effected by alcohol and other drug addictions described how, overnight, they faced a dire situation for clients on methadone programs when their city went into a Covid19 shutdown. Methadone treatment is covered by strict guidelines directing that prescriptions need to be given in hard copy to a pharmacist; they can’t be faxed. There are also rules about ‘take-aways’ to manage the quantities of methadone that people have access to. When someone starts on a methadone program, they are required to visit their pharmacist on a daily basis. This gradually reduces over time as they are able to take treatments home to last days, initially, and then weeks.
When their city went into lockdown, this service wanted to fax scripts for clients who were known and trusted in order to reduce travel and therefore risk to clients, staff and pharmacists; and to extend the provision for take-aways, further reducing the risk of travel to clients and pharmacists.
Prior to Covid19, doing this would have led to an inquiry and potentially penalties but this was a situation without precedent. The service tried to contact the relevant government department to seek advice but could not raise anyone to discuss this situation. They ended up putting advice to the department in writing, endorsed by the doctors who deemed these actions essential for infection control and minimising risk and harm.
During the Covid19 shutdowns and prolonged working from home, legal practitioners also struggled to meet business-as-usual expectations about core elements of their practice, from assessing the capacity of clients to make decisions, to taking instructions and witnessing documents.
Thanks to advocacy by services on this issue, reforms were introduced to enable remote witnessing of documentation in at least two states. These reforms were time-limited and their future remains uncertain, even as the pandemic and consequent shutdowns continue. Yet they were reforms that both health and legal assistance practitioners reported making a significant difference to the wellbeing of their patients and clients, alleviating the stress and impact of unmet legal problems by addressing these problems as they arose.
The opportunity to tackle legal problems that people would not otherwise seek help for is a clear value of health justice partnership. But even as the crises of 2020 exacerbated multiple, intersecting health and legal needs, the slowness of policy-making hindered important efforts to meet these rapidly changing needs and placed further barriers in front of people needing help and the practitioners and services trying to provide it.
Access to information policies continued to be viewed in strict terms by policy-makers, limiting the sharing of information or speed with which information was shared. This included information about people who had tested positive for Covid19 and needed access to healthcare or pharmaceuticals during lockdowns.
Staff at one healthcare service encountered great difficulty following up Covid-positive tests within the community they served. At normal times, a healthcare provider would ask for a test and get the results back directly. But in the rush to set up Covid19 testing, there was no ‘clinical commissioner’ authorised to receive the test results. This meant that healthcare professionals could not access the information they needed to identify and provide care to patients who were Covid positive in the community.
To improve government responsiveness and community resilience during crisis, we need effective processes that identify and share lessons about what problems are emerging within communities and how best to respond to them by health, legal assistance and other service systems.
The 2019-2020 summer’s bushfires followed swiftly by the Covid19 global pandemic have demonstrated acutely how existing health, legal and social problems in people’s lives are exacerbated, and new problems emerge, in times of crisis and in its aftermath. And yet, as difficult as 2020 was for so many, it has also highlighted the critical role of health and legal assistance services that are accessible at the time, in the right places, and working in the ways that best support their communities.
Across the national network of health justice partnership it is clear that experiences of 2020 varied greatly. Some health justice partnerships were in communities that had been hit hard first by bushfires and then by the Covid19 lockdowns, such as Victorian border communities. This contrasted starkly with the experience of other participants, particularly those outside of Victoria and NSW, whose living and working environments were less significantly affected by each event. Despite these differences, there was shared learning across services about their ability to respond quickly to rapidly changing needs among the communities they serve and the community infrastructure that is needed to enable such responsiveness.
Key here was the lack of opportunity to communicate directly to government and other decision-makers about emerging problems and how best to solve them, from communities and the services working with them. Where conduits did exist, they were insufficient for the scale and scope of need. Australia has benefited from existing infrastructure, including medical research institutes and expertise in immunology and epidemiology, in our response to Covid19. While some of this infrastructure has evolved to meet the current challenge, some of it builds on decades of work, for instance Australia’s internationally leading contribution to fighting the HIV pandemic.
Similarly, community infrastructure that supports strong, resilient communities cannot be built overnight. Enabling our capability to respond to the health, legal and social impacts of crises at this scale requires sustained investment in our health, legal assistance and social services; and in the mechanisms for community engagement with these services and with their policy, political and funding decision-makers.
Throughout 2020, health, legal assistance and other services were identifying solutions to community need as it evolved and changed. Yet there were inadequate mechanisms to relay those solutions; to translate them to different community contexts; to ensure their benefits were shared. Testing ideas with and learning from these services can support improved responses at a systemic level in the future, as the following insights from their work demonstrate.
- Developing the mechanisms that enable communities and services to communicate directly about emerging problems and solutions to them would improve the quality of advice and decisionmaking in response to crises in the future.
- The cost of failing to develop these mechanisms will include the crises that are brought on or prolonged in the lives of people living with multiple and intersecting health, legal and other needs, such as those experiencing family violence, mental illhealth or living with chronic illness.
- While these mechanisms are important for all communities, they are also important for addressing inequities between communities. For instance in regional hubs and border communities, for whom centralised decision-making can have a disproportionately harmful effect if it fails to understand the impacts of its decisions at a local level.
The effectiveness of community infrastructure can make or break how a community fares during crisis and its aftermath. Yet in many cases, this effectiveness relies upon the trusted relationships between decisionmakers and the people affected by their decisions; and among the health, legal and other service settings that help people with their problems on a daily basis.
Short-term cycles that prioritise political opportunity over long-term resilience have missed opportunities to invest adequately in these forms of community infrastructure and have masked the inadequacy of existing infrastructure and trust in it. In doing so, these processes can undermine community preparedness for crises like those experienced in 2020, when they should instead be building it.
As we work to build back after the crises of 2020, our ability to achieve long-term social as well as economic impact will rely on how well we can build community resilience and confidence. Investing adequately in community-level infrastructure and the relationships that support its effectiveness would make a key contribution to this impact and provide the foundation for effective conduits to inform decision-making in response to future crises and their aftermath.
Amid calls to ‘build back better’, recovery from the successive crises of 2020 is underway. Both the bushfires and the pandemic were unprecedented challenges. It is not surprising, therefore, that there were failings in response. But there were also examples of incredible innovation and surprising workarounds that met rapidly changing needs.
There is much to learn if we want to build back better. What worked and what did not? What needs to change and how best should we change it? As we adjust to living with pandemic and the constant risk of extreme weather events, we need to capture the lessons of 2020. Those lessons include failure, but also innovation and new and more effective responses. And, as first bushfire and then pandemic exacerbated existing vulnerabilities to health and legal need, lessons were learned about complexity and how it impacts, at both individual and systemic levels.
For our own priorities at Health Justice Australia, these experiences point directly to the need for systems-level change in how we design and deliver our health and legal assistance services. We need to reshape health and legal service systems, putting the communities these services support at their centre to respond better to the complex, intersecting health and legal problems that hold people in disadvantage.
We need to hear from a range of perspectives encompassing community experience and that of the health, legal assistance and other services responding to that experience. And we need responsive mechanisms that ensure decision-makers are well informed about this experience in government, philanthropy and elsewhere.