Initiatives to teach doctors and lawyers how to work together are aimed at improving patient health
Initiatives to teach doctors and lawyers how to work together are aimed at improving patient health
Doctors and lawyers have traditionally had a rather strained relationship. But over the past few years Australia has been involved in developing a joint medical-legal initiative that is starting to improve these relations. Called health-justice partnerships, the idea is to address legal needs as a health issue by getting health and legal professionals working together. And the benefits can be considerable.
Imagine a child who is presenting with recurrent asthma which available treatments are struggling to stabilise. On questioning, it’s found the child lives in substandard housing with significant rising-damp problems, mould and cold, the family have had no luck getting the landlord to address the problems, and they can’t afford to move.
The mould and rising damp are major asthma triggers for the child, and removing them is the way of stabilising their condition. Enter a health justice partnership between the local GP and community legal centre. By working together, the lawyer is able to have the landlord held to account for the needed repairs, the child’s home environment significantly improves, and the GP is able to stabilise the child’s asthma on minimal medication.
Or think of a young person living in a rural or regional town who has accumulated a number of fines (for not wearing a helmet while riding a pushbike, having their feet on the seat on a bus). These have added up to several hundred dollars, which they have no means of paying. The apprenticeship they have managed to get in a business located out of town requires them to drive to work. But because the fines have remained unpaid the young person has their licence suspended (a practice currently operating in several Australian states, and one that replaced serving jail time for unpaid fines, which still happens in some states).
With no other means of getting to work they drive without a licence, get caught, accumulate more fines they can’t pay, and lose their job. Under increasing stress, they get kicked out of their house because they can’t afford the rent, get depressed, lose confidence, and start drinking to blunt their distress.
This young person is now homeless, depressed, defeated, and losing hope. On the insistence of a concerned friend, they reluctantly come to the local GP asking for help. What are our options? Prescribe anti-depressants? Refer them to a drug and alcohol program or counselling? Support their application for a Centrelink benefit?
Or address this young person’s legal needs. If this isn’t done, the situation has little prospect of improving. And any individually focused health approaches will likely, at best, simply prop them up in an untenable situation, and, at worst, leave them to fall even further into despair and dysfunction.
Doctors recognise the significance of social conditions on a patient’s health and well-being, but often feel helpless to intervenes. This is where health justice partnerships come into their own, and can be a powerful tool for facilitating real improvements in people’s lives.
The idea of legal needs as a social determinant of health has been bubbling along for some time. In the United States, the idea started to appear in the early 1990s through the efforts of Dr Barry Zuckerman, Chief of Paediatrics at Boston Medical Center, who recognised that a doctor and a lawyer working together had the best chance of keeping patients healthy. A key point noted by Dr Zuckerman was that people were much more likely to access a health professional than they were a legal one. Therefore, it made sense to harness this high level of health access to assist people with problems affecting their health that actually had a legal cause.
Coined medical-legal partnerships, the work of Dr Zuckerman and his colleagues started a movement that in 2006 resulted in establishment of a US National Center for Medical Legal Partnerships. The Center’s mission is:
“…to improve the health and well-being of people and communities by leading health, public health, and legal sectors in an integrated, upstream approach to combating health-harming social conditions.”
The centre believes the key is to have an integrated medical-legal approach to health and health care for patients and populations as part of mainstream practice. And the means of achieving this lies in:
- Transforming the focus of health care and legal practice from people to populations;
- Building and informing the evidence base to support the medical-legal partnership approach;
- Redefining inter-professional education with an emphasis on training health care, public health and legal professionals together.
This kind of thinking reflects the World Health Organisation’s recognition of the fundamental links between social, economic, environmental, political and cultural conditions, and human health. This is the so-called “new public health” in which responses to addressing individual human health needs are placed within this
The case of the child with asthma and the young person with depression demonstrate how these complex interrelationships affect health, and that the solution lies in addressing the underlying legalissues – although in a busy GP settings it might seem easier to write a script for an asthma medication or anti-depressant. We all know that feeling, and wish there was more we could do.
Anyone who has worked in medicine for any period of time knows this tension. The challenge has been having realistic and accessible options available to do this kind of upstream, causative engagement work.
Law and disorders
In September 2013 the Law and Justice Foundation of NSW released a seminal report on just how widespread and significant these kind of issues were in Australia. Called Law and disorders: illness/disability and the experience of everyday problems involving the law, this report, drawing on the considerable data generated by the Legal Australia-Wide (LAW) and legal needs surveys, demonstrated a compelling case for seeing legal needs as health needs. The report concluded that:
The findings confirm the existence of strong links between the experience of legal problems and long-term illness/disability. They show that the link strengthens as severity of illness/disability increases and that the associations are particularly strong for mental impairment…The findings provide overwhelming support for the potential utility of integrated legal, health and broader human services. 1
This awareness is not new, but this report, and others like it, bring a strong evidence base to the table to inform these issues. In 2008 The Lancet reported that “…virtually all legal needs (ranging from housing to domestic violence) are directly or proximally connected to health status.”2 And for a number of years, Australia has been working away at how to practically respond to this complex reality.
The Australian community and public law sectors have been doing this kind of connected health-legal needs work for a long time. However, it took an intrepid Victorian based community legal sector solicitor, Peter Noble, to gather the needed momentum to build the capacity to address these integrated issues. In 2012, Noble wrote a report on his time in the US investigating the medical-legal partnerships’ approach.3 This report led to establishment of the Australian Advocacy-Health Alliance, which was the initial iteration of the concept here.
Since then, this group of mainly lawyers, and a slowly growing number of health professionals, have partnered to create health-justice partnerships, the new name now settled on for this work in Australia.
Along with the Victorians, LegalAid NSW and community legal centres have been at the forefront of resourcing and actioning such initiatives, and they have established a highly effective community of practice to progress this work. In late 2015, the next step in this rapidly emerging process was achieved with establishment of the first National Centre for Health Justice Partnership in Australia.
This centre is supported by a private-public sector collaboration between Justice Connect, the national pro-bono policy, advocacy and service body, and the Clayton Utz Foundation, the charitable organisational support and social responsibility entity within Australian law firm Clayton Utz.
Awareness of the partnerships is still growing across the country with a much greater awareness needed by doctors. Although the Americans focused more on getting lawyers into hospital settings as part of the partnership model, Australia is taking a much broader approach. Here it’s recognised that the bulk of patients will access community-based services such as a GP, neighbourhood or community health centres, or a social service (for assistance with housing, employment, domestic violence etc). This requires creative thinking about how best to connect legal and health professionals.
Some responses to date have seen co-location of professionals in settings where this is possible – either in existing services or “pop up” ones that take a mix of professional services and expertise to where people are living, such as public-housing estates. Or through establishment of clear and accessible cross-referral mechanisms to maximise use of existing services. And more models are being developed as the partnerships gain traction.
The key is raising awareness of how legal needs can contribute to health problems. And, with the right engagement, that this is a readily addressable social determinant of health.
The days of working in isolated professional silos are going. The need for greater awareness, both in and between professions and services, is critical to meaningfully meeting our patients’ needs. The term used to describe this kind of practice is “wrap-around servicing” and it has a lot to offer.
GPs are in a unique position to engage with this approach. This is not about having to learn a whole new set of skills, but rather how to better utilise what is already there. Health-justice partnerships are a powerful tool we can add to our kit to really address our patients’ needs.
Dr Ursula King is Medical Editor of The Medical Republic, and a rural emergency practitioner (FACRRM)
1: Coumarelos, C., Pleasence, P., and Wei, Z. Law and Disorders: illness/disability and the experience of everyday problems involving the law. Justice Issues, The Law and Justice Foundation, Paper 17, Sept 2013, ISSN 1834-7266.
2: Zuckerman, B., Sandel, M, Lawton, E, Morton, S. Medical-legal partnerships: transforming healthcare. The Lancet. 8 November 2008; 372(9650): 1615-1617.
3: Noble, P. Advocacy-health alliances: better health through medical-legal partnership, 2012. Advocacy and Rights Centre, Bendigo.