Health justice partnership: Access to justice meets health equity

Abstract

Access to justice research identifies how unmet legal need arises from and exacerbates disadvantage. In parallel, epidemiological research identifies the inequitable impact of social determinants on health. Health justice partnership (HJP) is an innovative response to this evidence: providing accessible legal help to individuals experiencing complex needs; building the capability of health and legal services to support these clients; and challenging systemic factors that contribute to social and health inequity. HJP offers a broader view of access to justice, demonstrating how the law and accessible legal help contribute to health and wellbeing outcomes, and are part of the shared challenge of responding to health and social inequity.

Access to justice, from the perspective of the individual

Historically, access to justice research has focused on the institutions of justice and the legal profession, paying particular attention to access to – and the cost and efficiency of – formal legal processes. However, a shift in focus in Australia and internationally to community-wide legal needs surveys has provided an alternative lens, framing access to justice from the perspective of citizens – identifying influential factors well out of sight of the formal institutions of justice. ¹

In 2012, the first Australia-wide legal needs survey (‘the LAW survey’) established that over one-fifth of people in Australia experience three or more legal problems a year. ² However, it found that legal problems were disproportionately experienced by people vulnerable to social disadvantage, particularly those with chronic ill-health or disability, single parents, the unemployed and people in insecure housing. ³ Legal issues were also found to cluster around ‘everyday life’ problems such as family breakdown, financial issues or poor-quality housing – problems which, if unresolved, can worsen or propel people into social and economic disadvantage. ⁴ Legal needs research further established that vulnerability to having multiple legal problems rises with increased indices of social disadvantage. ⁵ The LAW survey is consistent with other research in identifying the adverse impacts of legal issues, including income loss or financial strain, stress-related illness and physical ill health. ⁶ This pattern of the prevalence and inequity in the experience of legal problems has been consistent in legal needs surveys across the globe. ⁷

Viewing the same set of complex intersecting needs from another perspective, epidemiological research into the social determinants of health affirms and expands on the impact of social factors, including unresolved legal issues, on people’s lives. This extensive scholarship identifies the impact on people’s health of factors such as: insecure and poor-quality housing; ⁸ financial stress; ⁹ loss of employment; ¹⁰ family breakdown and family violence. ¹¹ The question to arise is the extent to which accessible, timely and appropriate legal assistance helps to alleviate those impacts.

Advice-seeking behaviour

Legal needs surveys have also highlighted the extent of people’s inaction in the face of legal issues, and the extent of barriers to their seeking help, and have provided insight into where people seek help. ¹² The 2012 LAW survey identified that nearly one in five Australians took no action for their legal problems. When they did seek advice, they were found to be more likely to ask a non-legal advisor, such as a health professional, than a lawyer. ¹³ A more recent study in Victoria identified that only 4 per cent of community members ‘did nothing’ and that a higher proportion of respondents compared to previous surveys (21 per cent) sought advice from legal services (13 per cent from private lawyers, 8 per cent from one or more public legal services). But the authors of this 2023 survey identified ‘[h]igher levels of inaction on the part of those on the lowest incomes and those not working because of poor health’, and higher levels of inaction for certain types of legal issues – including fines and other money related problems. ¹⁴

Barriers to seeking help from lawyers include: 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; previous poor experiences interacting with legal or other systems; concerns about the stress and possible repercussions of raising the issue; and the perceived and actual accessibility and costs of services. ¹⁵

The intersection of health and legal issues, in life and in services

Access to justice evidence identifies cohorts of people, including those with poor health, who are vulnerable to legal issues but not seeking help directly from lawyers. However, because legal issues tend to intersect with and impact upon other areas of their lives – particularly their health – people with unmet legal need are often in contact with health and community services, seeking assistance with the symptoms of these intersecting issues. ¹⁶

A recent survey of frontline workers in a national mental health organisation asked staff to identify legal issues that arise in their interactions with clients. ¹⁷ It found that 60 per cent of responding staff frequently saw clients experiencing legal issues relating to money (such as debts, fines, payday loans, mortgage stress). Other legal issues frequently seen among clients by staff were family/relationships (51 per cent of respondents), housing or tenancy (49 per cent) and social security issues (44 per cent), with family violence raised frequently by one third of respondents. All these issues were seen at least occasionally by more than 90 per cent of respondents. ¹⁸

The implications for policy and practice

In their 2014 paper, Pleasence et al translated access to justice and legal needs evidence into policy and practice. They proposed that, to reach and effectively assist those most vulnerable to unmet legal need, legal assistance services needed to be: targeted to those most in need; joined-up with other services (non-legal and legal) to address intersecting issues; timely, to maximise utility of the service; and appropriate to the needs and capabilities of users. ¹⁹

These four features are interdependent. Services need to be joined up in recognition that, in life, complex issues do not sit neatly within single service silos. Legal and health issues, just to select two, can exacerbate each other and compromise the support offered by the other sector. Coordinated, collaborative support across sectors can help address this. Services need to match both the needs and the barriers facing those vulnerable to legal issues and provide enough active support to progress or resolve the issue. For this group of clients, legal information or advice only is unlikely to be enough; timely, trauma-informed legal support, including early intervention, can support better outcomes. And services need to be targeted to ensure those most in need can access this holistic support, and that the efforts and resources of services are located where they are most needed. ²⁰ Health justice partnership provides insight into how this looks in action, in both its opportunities and its challenges.

By addressing legal need in a health context, HJPs also provide an opportunity to demonstrate how legal help may contribute to health and wellbeing, providing a hook for discussing the value of funding legal assistance to a broader range of non-justice funders, for example, health.

Health justice partnership in Australia

Health justice partnerships (HJPs) are collaborations, most commonly between community-based legal services and health services, to embed legal help in community and health care settings to address unmet legal need. ²¹ Australian HJPs are found in services which are already accessed by people vulnerable to intersecting health and legal needs, such as those experiencing family violence, people experiencing mental health and/or alcohol and other drug issues, older people vulnerable to elder abuse, young people and Aboriginal and Torres Strait Islander people. By working together, partner services each build their capacity to support common clients in ways that they cannot achieve alone. In Australia, HJP settings include community health services, mental health services, hospitals, child and family hubs and Aboriginal Community Controlled Health Organisations. Legal partners are most commonly community legal centres or legal aid commissions. Some HJPs also involve pro bono support from private law firms, either providing direct services on site or through the community legal partner. ²²

Driven by emerging evidence around the experience of unmet legal need and its impact, HJP has been evolving as a movement in Australia since around 2012, noting there had been leading examples of this type of collaborative work for years prior. In particular, two studies into ‘medical-legal partnerships’, as HJPs are known as in the US, propelled the movement and led to the establishment of Health Justice Australia (HJA) in 2016, to support the practice and development of HJPs. ²³

When HJA first mapped ‘the health justice landscape’ in 2017, 48 partnerships were identified as providing legal help in health care settings, most in Victoria and New South Wales. ²⁴ The most recent count, in December 2023, identified more than 125 HJPs on the landscape, in all states and territories. ²⁵

How health justice partnership operates

HJP is not a fixed ‘model’ that is replicated in different places – rather, it is a strategy of working in partnership that is adapted to suit the needs of clients, the goals of the partnering services, available resources, existing service relationships and local infrastructure. As a result, no two partnerships are identical. However, broadly speaking, HJPs:

• provide timely accessible legal help to individuals most vulnerable to health-harming legal need;

• build the capacity and capability of health and legal services to holistically support clients with complex needs; and

• provide a vehicle to challenge systemic factors that contribute to social and health inequity and its impact.

Each of these is discussed, together with what is required for effective partnership and where there is scope for more impact.

Timely assistance to individuals

[L]egal services can mitigate many of the socio-economic determinants that disproportionately impact the health of low income and vulnerable groups by securing critical entitlements, by improving living conditions, by avoiding or diverting threats to employment, to family security, and many other health harming risks. ²⁶

To do this, legal services need to be accessible to those most vulnerable to these impacts. HJPs in Australia are reaching people experiencing complex legal needs. For instance, people experiencing family and domestic violence (FDV) are particularly vulnerable to multiple family, civil and criminal law issues, ²⁷ as are people experiencing mental health issues. ²⁸ A 2018 census of Australian HJPs found that, while only one-fifth specifically targeted FDV, people at risk of or experiencing FDV are seen in nearly 90 per cent of all partnerships. Similarly, one in six HJPs targeted support to those living with mental health conditions and/or addiction, yet more than 80 per cent indicated that at least ‘some’ of the people they served were experiencing mental health conditions and/or addiction. ²⁹

HJPs bring lawyers onsite and/or into health and community teams to assist people experiencing problems such as credit and debt, fines and payday loans, Centrelink, housing issues, family breakdown, family violence, child protection and minor crime. Health staff can directly connect their patients with HJP lawyers to address the legal issues that may be affecting, and being affected by, their health. HJP evaluations indicate how HJPs increase people’s access to income, benefits, safe and stable housing, and contribute to their health and wellbeing. ³⁰ In addition to more seamless holistic care, HJP clients also value the empowering impact of legal help, particularly those who have had power stripped from them, for instance through sexual violence and coercive control. ³¹

By embedding legal help into health care and other social and community services, an improvement to people’s health and wellbeing is felt beyond just that of the individual. HJP can respond to the compounding health, social and legal issues associated with poverty and complex disadvantage that, if unresolved, keep families and children in adversity and financial disadvantage. In the short term, this places families at risk of interaction with child protection systems. ³² In the long term, it is known that children growing up in adversity face poorer mental and physical health outcomes and higher likelihood of juvenile and criminal justice system involvement. ³³

Building the capability of service systems to address complex intersecting needs

While people with unmet legal need are accessing health and wellbeing services, staff of these services are not necessarily well-equipped to identify legal issues and connect clients to legal help. ³⁴ One set of health and social care providers acknowledged that (in services without HJP) ‘legal issues are underacknowledged and are often unmet’. ³⁵ In another study, staff identified the need for more connection with legal services to address legal issues affecting their clients who have mental health issues. ³⁶ In siloed services, lawyers can also struggle to manage client health issues that intersect with their legal issues. ³⁷

As a collaborative response, HJPs build the capability and capacity of health and legal practitioners and services to respond to complex intersecting need more effectively. Common activities of HJPs include:

• cross-disciplinary training (eg, about common legal issues or processes affecting shared clients);

• secondary consultation, whereby health staff can seek general information from the lawyer concerning a patient’s legal issue, and vice versa; and

• where appropriate, coordinated care for clients.

Underpinning these activities is the need for relationships and trust built between the health and legal practitioners, which are in turn strengthened by co-location, shared goals, shared activities and shared governance. ³⁸

By working together, health and legal partners each build their capacity to support clients, in ways that they cannot achieve alone, thereby enabling them to respond more effectively to the intersecting health, legal and social issues causing problems in people’s lives. Evaluations of HJPs also describe the reduced stress and improved job satisfaction for staff working in partnership. ³⁹

What it takes to partner, and the constraints of context

While there is strong evidence of the value of HJP for clients, and as a mechanism for person-centred care to address complex needs, it takes time and cross-sector commitment to build the shared understanding and goals, trust and relationships, structures and activities required to enable this collaborative service delivery. ⁴⁰

Effective HJP needs to be supported through administrative and funding structures that invest in building the capability and capacity of practitioners and services to undertake this change in the way they work. And yet, there is a recognised workforce crisis in the community legal sector around the recruitment and retention of staff, as there is across the broader health, social and community service landscapes. ⁴¹ Aboriginal and Torres Strait Islander community-controlled organisations, and services in rural, regional and remote areas, are disproportionately impacted. ⁴² Underpinning this crisis is inequity in remuneration across the legal sector, which is leading to frontline worker burnout and high staff turnover. ⁴³

The inconsistent and competitive nature of funding to the community legal assistance sector also impacts its ability to be innovative and collaborative. For instance, constraints on the scope of funding and remit can limit the type and level of support that legal services can offer. However, to effectively support people with complex intersecting need, legal services require the flexibility to provide assistance that may cross matter types, differing eligibility criteria and funding streams.

The innovation, led by practitioners seeking to better address complex intersecting needs, must be supported by cross-sector investment that supports the contribution of each to the shared challenge of addressing multiple disadvantage.

Challenging systemic factors that contribute to social and health inequity and its impact

Shah et al define policy advocacy as ‘actions associated with attempts to change policy or legislation’. ⁴⁴ A key element of the work of community legal centres has always been law reform and advocacy for access to justice and equitable laws and legal systems. As frontline services, they bear witness to the inequality and systemic issues that cause unmet legal need. Similarly, because of their joint knowledge of the social determinants of health, and the role of legal assistance, HJPs are uniquely positioned to advocate for reform to policies that cause health inequality and disadvantage more broadly. ⁴⁵

HJP can leverage both health and legal expertise to advocate for reform to laws and policies that impact the health and wellbeing of communities, drawing upon their knowledge of the way these systems intersect and impact on the lives of their shared clients. The great strength of this approach is that it frames the solution to the problem (for example, poverty and inequality) as a shared challenge to which different sectors combine their unique expertise. ‘Health’ and ‘Social Services’ departments recognise the benefit of legal services to health outcomes, and vice versa. As Shah et al note,

collaboration between health care providers and legal teams increases the strength of advocacy efforts to shape policies on the social determinants of health that affect populations made vulnerable by social and economic policies. ⁴⁶

In the United States (US), Medical-Legal Partnerships have a more established history of conducting systemic advocacy to promote health and wellbeing than do HJPs in Australia. There are examples in the US of individual partnerships advocating for policy reform at both the local (community) level and at state and federal levels. ⁴⁷

In Australia, there are fewer examples of systemic advocacy or law reform being conducted by HJPs. The relative nascency of the movement, and a recognised funding and workforce crisis, reduce the capability of HJPs to engage in activity that extends beyond the provision of frontline services. ⁴⁸ However, there are striking examples where HJPs have advocated for localised service changes and broader systemic changes, particularly around family violence. In one example, HJP practitioners gave evidence to the Royal Commission into Family Violence in Victoria, ⁴⁹ which in turn led to partners working together around the development of the Strengthening Hospital Responses to Family Violence (SHRFV) toolkit. This example reflects the profile of HJP being founded by partners to work together around a social, health or legal issue that causes poverty and inequality at both the individual and systemic level.

In the wake of the national reckoning following the death of George Floyd in 2020, there has been an increase in the US in the number of Medical-Legal Partnerships that are centring racial justice and trying to build community power. ⁵⁰ There is an opportunity for HJPs to explore this evolution of practice, in support of the leadership and vast experience of First Nations peoples and other campaigners in advancing anti-racism in Australia.

Discussion: Access to justice as a tool for health and wellbeing

Enabling access to justice is about more than just resolving legal problems; it is about reducing social inequities that produce health inequities, breaking vicious cycles that ‘create and compound poverty, undermine socioeconomic development, and contribute to broader social inequality’. ⁵¹

Legal assistance services often identify the value of their work in terms of improved ‘access to justice’. HJP provides a perspective on the value of the law and legal help that takes us beyond ‘justice’ as an outcome, to access to justice as a tool for achieving health equity and reducing inequality.

This viewpoint is consistent with therapeutic jurisprudence, which explores how the law and legal practices can be used as a ‘therapeutic agent’ to influence health and wellbeing. ⁵² While broad areas of law have been analysed through the lens of therapeutic jurisprudence, in Australia it is perhaps most commonly translated into practice in the use of formal legal processes to support health outcomes – such as problem-solving courts, including drug courts. ⁵³ HJP, in contrast, is a strategy to intervene earlier – bringing legal help to people at a time and place that may help prevent the escalation of issues into health and/or legal crises, including court processes.

While the design and implementation of activities and processes will vary depending on the context in which an HJP operates, HJPs provide a pragmatic service strategy that address the complexity and fragmentation of service systems. HJPs increase access to justice through the provision of holistic services to people who are disproportionately experiencing financial disadvantage and inequality. For health partners, HJP increases the range of tools available to address socio-legal factors that impact upon their patients’ health and wellbeing. Patients benefit from coordinated accessible care for their inter-related legal, health and other social issues. Ultimately, HJP is an opportunity to collaborate and coordinate efforts to address the intersecting health and legal issues that can lead to, and entrench, disadvantage.

There is opportunity for collaboration in research too. Socio-legal and public health research have independently identified the impact of legal problems on people’s health, health systems, and health costs. ⁵⁴ Bringing this scholarship together around HJP provides an opportunity to explore legal help as part of the solution to complexity which includes intersecting, health-harming legal need. HJP provides an opportunity, for learning more about how legal help can have an impact, over and above improving people’s access to justice, but also the value of legal help as a health care initiative. This perspective is timely given the relative paucity of funding for public legal assistance. To attract broader interest, we need to be sharing the contribution that legal assistance can make, particularly to addressing complex need.

The capability of services and practitioners to partner also needs to be underpinned by adequate resourcing and investment. This investment should also extend to building the capability of HJP to advocate for reform to policies that underpin social and health inequity.

Through strategies like HJP, legal help can be rendered visible as a strategy to contribute to improved wellbeing at the individual level, more effective, holistic service provision at the service level, and social and health equity at the societal level.