The evidence supporting health justice partnership
Health justice partnerships (HJPs) embed legal help into healthcare services and teams. HJPs work to improve health and wellbeing for:
- individuals, through direct service provision in places that they access
- people and communities vulnerable to complex need, by integrating service responses around client needs and capability
- vulnerable populations through advocacy for systemic change to policies and practices that affect the social determinants of health.
The innovation of health justice partnership (HJP) has become a movement attracting interest from practitioners, researchers, policy-makers and funders. It is a movement driven by evidence arising from both socio-legal and socio-epidemiological research, which coalesces around shared client groups, intersecting need and integrated service responses.
Research into legal needs and access to justice (see Pleasence and Balmer 2014, Pleasence et al 2014; Coumarelos et al, 2012) has identified that:
- Over one-fifth of people in Australia experience three or more legal problems in a given year. While common across the community, legal problems are particularly prevalent among people experiencing social disadvantage, particularly those with chronic ill-health or disability, single parents, the unemployed and people in disadvantaged housing.
- Legal problems have been found to cluster, for instance around family breakdown, money issues or poor-quality housing, and often coexist with ‘everyday life’ problems.
- Legal needs are reported to have adverse impacts, including income loss or financial strain, stress-related illness and physical ill health.
- Those most vulnerable to legal need commonly face significant barriers to accessing legal help, including: not recognising that a problem has a legal solution; limited knowledge, skills and resources to respond to these problems; having other issues and priorities in their lives; concerns about the stress and possible repercussions of raising the issue; accessibility of services and cost.
- Nearly one in five Australians take no action for their legal problems. When they do seek advice, they are more likely to ask a non-legal advisor, such as a health professional, than a lawyer.
- Legal problems can both result from broader social problems and reinforce disadvantage.
A key rationale for legal services to provide assistance in healthcare settings is to better reach and assist those disproportionately burdened with legal need, but less likely to seek help directly from lawyers at all or in a timely way (Pleasence et al, 2014; Forell & McDonald et al, 2013; Coumarelos et al 2012).
From the health side, the HJP movement responds to evidence that:
… ‘a person’s health is determined by a lot more than high-quality healthcare services and personal behavior; it’s shaped by environment – where someone lives, works, plays and learns’ (Williamson, Trott & Regenstein, 2018).
Indeed, it is broadly estimated that:
‘genes, biology, and health behaviors together account for about 25% of population health. Social determinants of health represent the remaining three categories of social environment, physical environment/ total ecology, and health services/ medical care’ (NCHHSTP Social Determinants of Health, 2018, drawing upon Tarlov, 1999).
Critically, these environmental and social factors particularly impact upon the health and wellbeing of the same vulnerable communities identified in the legal needs research (see Williamson et al 2018; Bachrach, Pfister, Wallis & Lipson, 2014; CSDH, 2008). Such factors include access to resources and services (e.g. income, safe and secure housing, education), personal safety (e.g. safety from violence) and stressors such as loss of employment and debt (CSDH, 2008; see also Australian Institute of Health and Welfare, 2016 ch. 4). The identified impact of unmet social needs more broadly includes more illness, shorter life expectancy and increased healthcare spending (Bachrach et al, 2014, p.10; Australian Institute of Health and Welfare, 2016 ch. 4). Public health literature points to the key role of services and infrastructure beyond the health sector and the importance of integrated approaches to address health and wellbeing (e.g. WHO, 2013).
Thus, people are coming into health services with problems which may have health symptoms but broader social causes (Caper & Plunkett, 2015; Iacobucci 2014a & b; Popay, et al, 2007). Among these are issues that legal assistance services can address (Beardon & Genn, forthcoming; The Low Commission & Advice Service Alliance, 2015; Marple, 2015; Pleasence, Balmer & Buck, 2008).
Taken together, health and legal evidence points to common groups of people who:
- are vulnerable to complex life issues that have intersecting health and legal dimensions
- may not understand or respond to these problems as legal issues
- are less likely to have knowledge, skills, psychological readiness and resources to address these issues without support
- are more likely to seek help from people or services they know, commonly access and trust. Noting the nexus between chronic ill- health, disability and the experience of legal need, these places include health settings. However, depending on the client group, settings may also include welfare services, schools or local community centres
- may be driven to seek help or access services by crisis (medical, legal or otherwise)
- have health issues that are disproportionately affected by social and environmental factors, which are themselves shaped by law and policy
- will include some who are marginalised in their access to and uptake of any services.
The clients that health justice partnerships seek to assist
A central rationale for health and legal services coming together is to assist shared client groups with problems that have both health and legal dimensions (Williamson et al, 2018; Bachrach et al, 2014; Beeson et al, 2013). The assumption is that health and legal strategies pursued in partnership will have better outcomes than standard services provided in health and legal silos.
Populations that are particularly at risk of poor health and justice outcomes include people living with disability or chronic health conditions, people experiencing domestic and family violence, people at risk of elder abuse, Aboriginal and Torres Strait Islander peoples, culturally and linguistically diverse communities and people experiencing poverty.
Noting that social and environmental factors (including legal issues) will also affect those who do not access any services, community-wide impact is likely to require more than individual assistance. Additional strategies may include service system redesign, and advocacy for policy change around factors which impact upon the social determinants of health (Bachrach et al, 2014; Gyorki, 2013; Noble, 2012; CSDH, 2008).
References for supporting evidence
Advice Services Alliance, and The Low Commission. 2015. ‘The Role of Advice Services in Health Outcomes: Evidence review and mapping study.’ UK.
Australian Institute of Health and Welfare. 2016. ‘Australia’s health 2016.’ In Australia’s health series. Canberra.
Bachrach, D, H Pfister, K Wallis, and M Lipson. 2014. ‘Addressing Patients’ Social Needs: An emerging business case for provider investment.’ The Commonwealth Fund, United States of America
Beardon S, and Genn, H. 2018 forthcoming. ‘Mapping social welfare advice in healthcare settings.’ University College London Centre for Access to Justice & the Legal Education Foundation, London.
Beeson, T, BD McAllister, and M Regenstein. 2013. ‘Making the Case for Medical-Legal Partnerships: A Review of the Evidence.’ School of Public Health and Health Services, Washington DC.
Caper, K, and J Plunkett. 2015. ‘A very general practice: How much time do GPs spend on issues other than health?’ In Citizens Advice policy briefings: Public services in a constrained spending environment. Citizens Advice, London.
Commission on Social Determinants of Health. 2008. ‘Closing the gap in a generation: Health equity through action on the social determinants of health.’ Geneva.
Coumarelos, C, D Macourt, HM McDonald, Z Wei, R Iriana, and S Ramsey. 2012. ‘Legal Australia-Wide Survey: Legal need in Australia.’ Law and Justice Foundation of NSW, Sydney.
Forell, S, HM McDonald, S Ramsey, and SA Williams. 2013. ‘Review of Legal Aid NSW outreach legal services. Stage two report: evolving best practice in outreach – insights from experience.’ Law and Justice Foundation of NSW, Sydney.
Gyorki, L. 2013. ‘Breaking down the silos: Overcoming the practical and ethical barriers of integrating legal assistance into a healthcare setting.’
Iacobucci, G. 2014a. ‘GPs increasingly have to tackle patients’ debt and housing problems’, British Medical Journal, 349.
Iacobucci, G. 2014b. ‘GPs’ workload climbs as government austerity agenda bites’, British Medical Journal, 349.
Marple, K. 2015. ‘Framing Legal Care as Healthcare: A guide to help civil legal aid practitioners message their work to health care audiences.’ Milken Institute School of Public Health, The George Washington University, Washington DC.
NCHHSTP Social Determinants of Health Centers for Dis¬ease Control and Prevention, available at https:// www.cdc.gov/nchhstp/socialdeterminants/faq.html (last visited October 24, 2018).
Noble, P. 2012. ‘Advocacy-Health Alliances: Better health through medical-legal partnership.’ Final Report of
the Clayton Utz Foundation Fellowship. Bendigo.
Pleasence, P, and NJ Balmer. 2014. ‘How People Resolve ‘Legal’ Problems: A report to the Legal Services Board.’ Legal Services Board, United Kingdom.
Pleasence, P, NJ Balmer, and A Buck. 2008. ‘The Health Cost of Civil-Law Problems: Further evidence of links between civil-law problems and morbidity, and the consequential use of health services’, Journal of Empirical Legal Studies, 5: 351-74.
Pleasence, P, C Coumarelos, S Forell, and HM McDonald. 2014. ‘Reshaping legal assistance services: building on the evidence base: a discussion paper.’ Law and Justice Foundation of NSW, Sydney.
Popay, J, U Kowarzik, S Mallinson, S Mackian, and J Barker. 2007. ‘Social problems, primary care and pathways to help and support: addressing health inequalities at the individual level. Part 1: the GP perspective’, Journal of Epidemiology & Community Health, 61: 966-71.
Tarlov, A. and St. Peter, R. 1999. Society and Population Health; A Reader. Volume II: A State Perspective, The New Press, New York.
Williamson, A, J Trott, and M Regenstein. 2018. ‘Health Center-Based Medical-Legal Partnerships: Where they are, how they work, and how they are funded.’ Milken School for Public Health, George Washington University, Washington DC.
World Health Organization. 2013 The economics of the social determinants of health and health inequalities: a resource book. World Health Organization, Switzerland
World Justice Project. 2018. ‘Global Insights on Access to Justice: Findings from the World Justice Project general population poll in 45 countries.’ World Justice Project, Washington DC.
