When life gets complex, people rarely experience problems in discrete and neat ways. Yet this is what service structures suggest, creating specialised silos that approach problems as though they are isolated and distinct.
Family violence issues can intersect with mental ill-health, and may impact or be impacted upon by housing, employment or money issues. Other illness or disability might be in the mix, as might discrimination, criminal law or family law issues.
Health justice partnership brings legal help into healthcare settings and teams to more effectively address intersecting health and legal problems in the lives of shared clients. Partnerships work in a number of ways. They provide integrated health and legal care for individual clients. At the system level they build the capability of health and legal practitioners and services to provide more holistic person-centred care. More broadly, health justice partnerships advocate for change which improves the health and wellbeing of communities.
In choosing to partner, legal services frame their intent around improved access to justice. Health services aim to address social issues that are impacting upon their patients’ health. Their shared intent is to improve the health and wellbeing of those disadvantaged by social and health inequity. Recognising the importance of shared goals as a principle of effective partnership (Partnership Brokers Association 2017), this paper explores wellbeing as one expressed outcome of health justice partnership.
Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health (Marmot, Goldblatt et al. 2010 p.15).
Health justice partnership brings legal help into healthcare settings and teams to address intersecting and accumulating health and legal problems in people’s lives. In Australia, health justice partnerships are commonly between public legal assistance services (such as legal aid commissions and community legal centres) and health services (such as community or family health services, mental health or alcohol and other drug services, Aboriginal Community Controlled Health Organisations (ACCHOs) and hospitals) (Forell and Nagy 2019).
Broadly, health justice partnership is a strategy that addresses both health equity (Marmot, Goldblatt et al. 2010) and access to justice goals (Council of Attorneys-General 2020) by services working together on health and legal issues that may hold people in disadvantage. Intersecting issues commonly addressed in health justice partnerships include mental health, family violence and family law, money issues and housing.
And yet each partner service brings its own expertise to address issues that a shared client may be facing, and its own lens on the difference that their help can make. Impact can look quite different if viewed solely and narrowly through these discrete professional lenses. Public legal services commonly view their outcomes in terms of access to assistance and legal issues addressed. Health services may view changes in terms of client or local population health and/or service efficiency outcomes. When services are working together with common clients but with no shared vision or framework, there is a risk that efforts may clash or undermine each other.
Health justice partnership also offers an opportunity to take a broader view of impact. First is the chance to consider the contribution each partner makes to the other’s goals. For instance, how the legal assistance may support health outcomes and how the health service may improve the capacity of an individual to achieve and sustain legal outcomes.
Second is the opportunity to identify how the goals – and the efforts – of health and legal partners align: how services can, together, improve the lives of the people they both support. This shared focus broadens the vision from ‘what can my efforts do to improve this legal outcome or health outcome’ to ‘what can we do together – and with the client – to make their life better?’
The challenge in stepping towards this broader focus is how to capture the difference that is made – above and beyond individual health or legal outcomes – in a way that is meaningful for both the partnering services and for the client. This paper explores the concept of client wellbeing as an outcome for health justice partnership, recognising how it aligns with a social determinants approach to public health and broadens our insight into the impact of legal help.
Individual wellbeing is broadly identified as ‘the quality and state of a person’s life’ (Linton, Dieppe et al. 2016), though there are different ways to define and measure it. Some focus on people’s internal state or mental health, while others focus more on the quality of or satisfaction with aspects of a person’s life: financial wellbeing, safety, future security. The focus is on satisfaction rather than happiness, because:
‘Whereas happiness tends to be more volatile and dependent on current mood, life satisfaction is generally more stable with respondents taking more long-term considerations into account when making such judgements’ (Wilkins, Botha et al. 2020).
Individual wellbeing is a concept that can and should be measured on multiple domains (Stiglitz, Sen et al. 2009), and can be assessed using both objective and subjective measures. Multi-dimensional measures of wellbeing recognise the complexity of factors that can make up wellbeing and provides an opportunity to explore how these interact. The Personal Wellbeing Index, for instance, explores subjective wellbeing across the domains of health, achieving in life, relationships, safety, community connectedness and future security.
While the breadth of wellbeing is part of its strength, this can also make it a challenging outcome to work with, given the range of available measures and the complexity of attributing outcomes to specific interventions. However, the potential of this concept as a focus for health justice partnership recommends it as worthy of further exploration and development.
This paper outlines six reasons why individual wellbeing may be valuable as an expressed outcome of health justice partnership. It then discusses the measurement of wellbeing and the addition of wellbeing indicators as shared measures in health justice partnership. Beyond individual wellbeing is community wellbeing, which Marmot argues is as important as individual wellbeing when aiming to shift health inequity in society (Marmot, Goldblatt et al. 2010 p. 166). While this paper touches lightly upon community wellbeing, it also warrants further discussion for health justice partnerships that connect strongly with local communities.
Wellbeing as an outcome for health justice partnerships
1. Wellbeing puts people at the centre of service design, planning and accountability/learning
Person- or client-centred service design is identified in both healthcare and in legal assistance as a key strategy to better ensure that services are more appropriate to needs, capabilities and contexts of clients with more complex and intersecting issues (National Legal Assistance Partnership, 2020-25; Australian Commission on Safety and Quality in Healthcare, 2020; Pleasence, Coumarelos et al. 2014). Person-centred design involves engaging with users at all stages of the design process to ensure that services cater to their real-life needs and challenges.
One way to retain person-centred service delivery is to prioritise measures of service quality and utility that reflect value as it looks to those client groups. This is because what is measured in monitoring and evaluation often become a focus for decision-making. As Stiglitz, Sen & Fitoussi (2009) observed, ‘[w]hat we measure affects what we do and if our measures are flawed, decisions may be distorted’ (p. 7). If clients are involved in the design but the service is measured using an unrelated set of metrics (such as funder defined metrics), there is a risk that the focus skews away from value as seen through those clients’ eyes.
2. Wellbeing is a goal that matters to the people and communities that health justice partnerships address
Health justice partnership is a strategy to support people experiencing compounding health and legal issues. Among others, partnerships support people experiencing mental health problems, people facing domestic and family violence, and Aboriginal and Torres Strait Islander people grappling with multiple, intersecting health and justice needs.
When people are consulted about what they want from services and policies, common themes include holistic service delivery, improved wellbeing, and to be active partners in change towards wellbeing (agency and capability). For instance:
Vision 2030 reflects what we heard from Australians with a lived or living experience of mental illness, suicidality and those who love and care for them. It proposes a person-led system, where our social and emotional wellbeing is front and centre of every decision, and where we, as consumers and carers, partner and have choice in the shaping and delivery of our care and support (National Mental Health Commission 2020 p. 2).
Aboriginal Community Controlled Health Organisations in Australia lead knowledge and practice in the provision of person- and community-centred healthcare, focused on ‘whole-of-community self-determination and individual spiritual, cultural, physical, social and emotional wellbeing. Aboriginal health in Aboriginal hands’ (National Aboriginal Community Controlled Health Organisation 2019). Indigenous social and emotional wellbeing is becoming ‘increasingly prominent within Australian mental health policy and practice’, comprising the inter-related domains of body, mind and emotions, family and kinship, community, culture, Country, and spirituality (in Dudgeon, Bray et al. 2020 p. 3).
Taking the lead from community, the central objective of the Productivity Commission’s Indigenous Evaluation Strategy is ‘better lives for Aboriginal and Torres Strait Islander people’, with the overarching principle of the strategy ‘centring Aboriginal and Torres Strait Islander people, perspectives, priorities and knowledges’ (Productivity Commission 2020 p. 7). Recognising the diversity of views among different communities (see Yap and Yu, 2016), this necessarily means that Aboriginal and Torres Strait Islander people are at the centre of articulating what improved lives look like to them and their communities.
Services that understand and respond to what is important to the people they serve can better understand the range of factors that may (also) be influencing their clients’ (or communities’) wellbeing.
3. Wellbeing takes account of intersectionality in people’s lives
Multiple and intersecting problems can interact in ways that are complex to untangle. For this reason, a siloed focus on a single issue (supported by narrow outcome measures) can fail to take account of these other influences.
For instance, a singular focus on a legal outcome may miss the opportunity or need to address the intersecting impact of mental health issues, or indeed the positive impact that legal help may have on a person’s mental health. A focus on the whole person – in terms of their wellbeing – can lead to a more nuanced and contextualised view of these issues and the impact of strategies to address them.
4. Wellbeing provides a focus that can be shared across services and sectors
As a shared goal, wellbeing can break down departmental or jurisdictional silos. It recognises how different parts of our lives and experiences intersect (Hardoon, Hey et al. 2020 p. 7).
Health and legal services partner to better address the range of issues experienced by shared clients. Through health justice partnership, legal services are better able to reach and assist clients with unmet legal needs who would otherwise not seek legal help; and health services are better able to access legal solutions to address issues affecting patient health which lie beyond healthcare responses. Clients seek help for problems affecting their lives.
Again, a person’s wellbeing provides a common and person-centred focus for shared impact. In a health justice partnership, a shared focus on client wellbeing supports consideration of how health and legal strategies may be timed, sequenced or aligned to best assist the whole client. In short, it provides a more holistic outcome for integrated service delivery.
When measuring wellbeing, a number of or multi-dimensional wellbeing measures provide more insight than single measures, allowing consideration of how shared efforts made may (or may not) contribute to different aspects of a person’s wellbeing. However, in general, making connections between specific interventions and changes in wellbeing is a key challenge. This and other measurement issues are discussed further below.
5. Health justice partnerships address wellbeing
In addition to the health services provided, the types of problems typically addressed by health justice partnership – such as family law and family violence, money issues, housing quality and security, employment – are among social factors known to affect health and wellbeing.
Where these problems intersect and compound in people’s lives, wellbeing is further diminished. For instance, a recent New Zealand study explored the clustering of inequity in health, social welfare and crime. The study identified that those with the highest need in any one domain tested also reported low life satisfaction scores. ‘Individuals who belonged to three or more high-need groups [in mid-life], reported a level of life satisfaction one standard deviation lower than individuals who belonged to no high-need group’ (Richmond-Rakerd, D’Souza et al. 2020 p. 260).
Separately the experience of legal problems has been found to be associated with reduced feelings of wellbeing, with subjective wellbeing decreasing as the number of legal issues increases.
While we know that life satisfaction (subjective wellbeing) varies as people’s economic and social circumstances change (Western and Tomaszewski 2016) and that lower life satisfaction is linked to greater income inequality (OECD 2020 p. 12), there is less evidence about:
- how legal help affects wellbeing
- how strategies in one sector contribute to outcomes in other sectors (e.g. health strategies on legal outcomes and legal strategies on health outcomes)
- the value of collaborative efforts to address health and legal outcomes and to improve wellbeing.
Health justice partnerships provide an opportunity to explore these empirical questions.
6. Wellbeing provides a benchmark or point of comparison
The specific factors that influence wellbeing can vary between people and communities. However, the feeling of wellbeing has been described as ‘…a common currency, allowing us to compare very different determinants and interventions’ (Hardoon, Hey et al. 2020 p.30).
The uptake and appropriate implementation of wellbeing as an outcome measure by health justice partnerships may offer opportunities to: explore the impact of variation between health justice partnership models on this shared metric; pool outcome data to examine the collective impact of health justice partnerships; and to compare these to other strategies that also describe their impact in terms of wellbeing.
Increasingly wellbeing is being used as a measure and point of comparison for progress globally, nationally, at the community and at the program level. For instance, wellbeing has been promoted by economists and policy makers as an alternative to gross domestic product as a lens through which to assess the difference that government and its services are making to improve lives (Hardoon, Hey et al. 2020, New Zealand Treasury 2020, OECD 2020). This is reflected in the third of the United Nations’ Sustainable Development Goals which focuses on ‘good health and well-being’. Governments around the world are starting to explicitly target, value and report wellbeing as a national goal, with 34 out of 35 OECD countries now gathering ‘life evaluation’ data (reflective assessment on a person’s life) as part of their national statistics (Durand 2018, Exton and Shinwell 2018). National progress on a range of objective and subjective wellbeing measures can be compared using the OECD’s Better Life Index.
In Australia, a range of standard data collections identify various aspects of wellbeing, together with subjective wellbeing (life satisfaction) scores. These include:
- Household, Income and Labour Dynamics in Australia (HILDA) Survey (Wilkins, Botha et al. 2020)
- National Aboriginal and Torres Strait Islander Social Survey (Australian Bureau of Statistics 2019)
- General Social Survey (Australian bureau of Statistics 2020a)
- People Matter Survey (workplace wellbeing)(NSW Public Service Commission 2020)
- Partner Violence – In Focus: Crime and Justice Statistics (Australian Bureau of Statistics 2020b).
As a result, points of comparison that can be used for benchmarking include average life satisfaction scores, together with some relevant objective wellbeing measures for the Australian population as well as various demographic subgroups. This allows us to explore questions such as whether health justice partnerships, compared to other strategies, are reaching people experiencing poorer wellbeing across a range of domains; and if and how services together are contributing to a difference in wellbeing for those people.
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