The needs of the people the health system serves have been firmly at the heart of the movement towards integrated care; particularly for people with health problems that are not being met by existing services. But what about when the drivers of poor health lie in problems whose solutions fall beyond the health system?
Take Marnie, who was only 15 years old when she was diagnosed with cancer. The good news was that her cancer was treatable. The bad news: that the treatment would be long and invasive. So Marnie and her mum packed their things to leave their remote community while Marnie underwent treatment at a major hospital in the city.
After six months, Marnie had made great progress and her care team was ready to discharge her, but there was one thing stopping them. Marnie’s family home was badly affected by mould. It was so bad that her doctors were concerned her suppressed immune system couldn’t take it. Marnie’s family had been trying to get the mould fixed for months but their community housing provider never got around to it. Marnie was ready to leave hospital, but she couldn’t go home.
Luckily for Marnie, the hospital had a health justice partnership. This meant that a community sector lawyer worked on site at the hospital, as part of the healthcare team, to help patients with legal problems that impacted upon their health. Marnie and her mum were able to get free legal help to address their housing problem. The health justice lawyer wrote to the housing corporation that owned Marnie’s home, setting out its legal responsibility to provide safe and hygienic housing. The mould got fixed and Marnie and her mum could go home.
Ritchie had another example of non-medical problems affecting his health. Ritchie had recently come under a Guardianship order. In his mind, this meant Ritchie could no longer buy the things he needed around his house and this made him very stressed – so much so, that he attributed his recent stroke to the stress he was under. While he was recovering from that stroke, Ritchie’s rehabilitation team introduced him to their health justice lawyer. The lawyer helped Ritchie understand how a Guardianship order worked and, together, they were able to secure access to the funds Ritchie needed for his home repairs. Over time, the health justice lawyer got Ritchie’s Guardianship order overturned completely. In Ritchie’s own words, working with the lawyer as part of his stroke rehabilitation made him ‘feel like a human being again’ and able to get back ‘in control’ of his affairs and his life.
Our health system has become very good at recognising the underlying causes of poor health, like mouldy housing; or the stressors that exacerbate anxiety. But it doesn’t necessarily have the tools to fix those problems.
That’s why, across Australia, a quiet revolution is taking place that is transforming the way some of the most vulnerable people in our community are supported through their health services. In a movement that has been led by health and legal practitioners, health justice partnerships have seen community lawyers moving out of their offices and into hospitals and community health settings to address unmet, health-harming legal need.
Health justice partnerships have formed in response to a growing body of evidence that shows there are groups of people who are vulnerable to intersecting legal and health problems, but who are unlikely to turn to legal services for solutions. Over one-fifth of people in Australia experience three or more legal problems in a given year (Legal Australia Wide survey 2012). People often report multiple legal problems and these problems tend to cluster – such as family breakdown and money issues or problems centred around poor quality housing.
One in five of the most disadvantaged in our community take no action in response to their legal problems, for reasons including not recognising the issue as a legal problem, stress, time, cost, fear of damaging relationships and having bigger problems to deal with. When people do seek advice, they are more likely to ask a non-legal advisor, such as a health professional, than a lawyer. That’s why health justice partnerships make so much sense.
Health justice partnerships embed legal help into healthcare services and teams to improve health and wellbeing for:
- Individuals, through direct service provision in places that they access;
- People and communities vulnerable to complex need, by supporting services to integrate their responses and redesign their systems around client needs and capability;
- Vulnerable populations through advocacy for systemic change to policies which affect the social determinants of health.
Health justice partnerships support populations that are particularly at risk of poor health and unmet legal need, like people experiencing family violence, people at risk of elder abuse, Aboriginal and Torres Strait Islander people, culturally and linguistically diverse communities and people experiencing poverty.
Health justice partnerships provide legal support across a wide range of needs, such as:
- Advocating for public housing tenants needing repairs to address untreated mould, or having handrails and other aids installed so that people with mobility impairments can continue living independently in their own homes;
- Assisting people with accumulated fines or debt that cause stress or act as a barrier to meeting health costs like filling prescriptions;
- Advising on options for people experiencing family violence or elder abuse; and supporting their healthcare professionals to respond appropriately when they identify these needs among their patients.
While health justice partnerships have been evolving in this way in Australia only since 2012, they are modelled on the work of medical-legal partnerships that have been operating in the USA for over 20 years. Where Australia’s health justice partnerships have been driven mostly by community sector lawyers, in the US it was emergency department doctors who recognised that they could do nothing about preventable hospital admissions until they addressed the poor conditions of the housing that many of their asthmatic patients came from. The evolution of these integrated service models may have had different origins but they share the same objective: tackling the non-medical problems undermining people’s health, through collaboration between health teams who are more likely to see these problems among their patients, and the lawyers who can resolve them.
There are now over fifty services working to connect legal help with health care teams and settings across Australia. Already, we are seeing early indicators of the potential that health justice partnerships hold, leveraging this approach to service integration to resolve some of the longstanding and underlying barriers to better health. Domestic and family violence is one example. One-fifth of health justice partnerships have been established to tackle family violence specifically, recognising that people affected by family violence are often unable to access specialist services but are still engaged with the health system. Yet 9 out of 10 health justice partnerships have identified family violence as a problem among the people they see, irrespective of whether that was an intended focus for their partnership. This confirms the significant prevalence and impact of family violence across the community. But it also indicates that, while health services could provide a key pillar in improving systemic responses to addressing family violence, health professionals may need support to identify and respond appropriately to this problem among their patients. Mental health and elder abuse are other problems that health justice partnerships are showing early signs of being able to address.
How do we know all this? Through the work of Health Justice Australia, a national charity and centre of excellence supporting the expansion and effectiveness of health justice partnerships. In 2017 Health Justice Australia developed a foundational profile of the activity of health justice partnerships to date: where they are located, what organisations are involved in these partnerships, which legal problems are being addressed and for which patient populations. Informed by this research, we are now developing an outcomes framework that will support individual evaluations of health justice partnerships at the local level; while also enabling Health Justice Australia to analyse the value of health justice partnerships at a national, comparable level. Because in order for us to drive the effectiveness of this approach to integration, we need to know who it helps and how. Is it dependent on particular health settings; or priority populations? Are there particular approaches to integration that work better than others?
We also need to connect the growing interest in these partnerships with those driving the work to improve integration in other parts of the health and human service systems. That’s why Health Justice Australia has joined IFIC Australia as a knowledge partner, as we work to share the lessons from our own approach to integration and to learn from those exploring it in other ways. Ultimately, we have a shared interest: not to connect up different parts of the health and human service systems for its own sake, but to turn what is currently a labyrinth for many, into accessible and helpful services for the people those systems are here to serve.
Tessa Boyd-Caine, Chief Executive Officer, Health Justice Australia