Linking medicine and law

The Low Commission is an independent group established to look at the future of social welfare advice and legal support post-legal aid cuts. One output that has gained most attention has been its report on The Role of Advice Services in Health Outcomes.

On one level this report is hardly revolutionary – social welfare advice providers like Citizens Advice have been working on an ad hoc basis with health and social care services for many years. The report looks at the evidence connecting social welfare law advice needs to the social determinants of ill-health; identifying how advice in healthcare settings can deliver benefits for patient health, reduce demand on the NHS and support individual wellbeing.

The research ranges over a variety of different projects and commissioning models, from Citizens Advice outreaches in GP surgeries, through specialist money and debt advice built into recovery pathways in hospital care settings, to wrap-around services in acute mental health trusts. The research also considers a range of other referral and partnership arrangements that enable health services to work with other agencies under the generic concept of ‘social prescription’.

Many of these projects are ‘win-win’ concepts for policymakers. These projects help the health system to deliver on wider objectives, such as joining up health and social care, managing long-term conditions in the community, tackling health inequalities and delivering public health strategies.

All of this gets one thinking about the wider connections between law and health needs, and also about debates around integration in the way that services are commissioned and delivered. In 2014, the Legal Action Group (with the support of a Law Society grant) commissioned ComRes to conduct a poll of GPs, which it published in a report called Healthy Legal Advice. Depending on problem type, up to 67% of GPs polled reported seeing increases in patients post-Legal Aid, Sentencing and Punishment of Offenders Act 2012. These patients ‘would have benefited from legal or specialist advice’ on social welfare law matters (debt, housing, employment, benefits, immigration and community care). Moreover, 88% reported that these issues had a negative impact on their patient’s health.

So not only are legal problems making people ill, but GP services are having to pick up the slack from the withdrawal of legal aid for social welfare law matters. The English and Welsh Civil and Social Justice Survey on legal needs among the public found that half of respondents who had experienced a legal problem suffered an adverse health consequence, including physical conditions and stress-related illnesses. Some 80% of those whose health was affected by their legal problem went on to visit their GP or other health service.

Looking more widely at both research and conceptual literature, from the 1980s a significant body of ‘therapeutic jurisprudence’ articles from US law schools began to emerge. These articles considered the impact of law on wellbeing and bridging with other disciplines, which has spilled over into practice contexts such as problem-solving courts, as well as providing a focus for law reformers. While the mixing of medical and legal concepts is not without its critics, therapeutic jurisprudence ideas have been a driver of innovation in common law jurisdiction systems, particularly in the medical-legal partnerships movement.

Medical-legal partnerships (MLPs) embed lawyers and paralegals alongside healthcare teams to detect, address and prevent health-harming social conditions for people and communities. The concept gained prominence in the US during the 1990s, when it was championed by the Boston Medical Centre, which recognised that lawyers could help patients navigate the complex systems that hold solutions to many social determinants of health. The MLP model has expanded from a single attorney service at Boston Medical Center to 292 partnerships with hospitals and healthcare services across the US.

Other jurisdictions have followed, most notably Australia with the Health-Justice Partnership between Bendigo Community Health Services and Loddon Campaspe Community Legal Centre. Other initiatives in Australia include West Heidelberg Community Legal Service’s long-term integration with Banyule Community Health, the NSW Cancer Council Legal Referral Service, and the Baker & McKenzie Cancer Patients’ Legal Clinic at the Peter MacCallum Cancer Institute.

Our chronic post-LASPO crisis in access to justice demands that we explore new thinking, approaches, and delivery models – and the medical-legal partnerships approach could offer one way forward. Policymakers have also long recognised that the barriers to access to justice are not just about legal aid policy but also concern issues of access, affordability, sustainability, and competitive innovation and product development in the wider legal services market. A key policy response under the last Labour government was the Legal Services Act, a deregulatory measure aimed at opening up the legal services market to non-lawyer alternative business structures.

The concept of ABS has perhaps not taken off to the full extent that its champions intended. But might there be another way to breath new life into it? In many respects, a parallel debate has been going on in the medical professions about their business and practice models, as successive governments have pushed different types of alternative provider medical services arrangements on to primary care professions. That is notwithstanding concerns that this approach risks diluting the professional ethos of traditional GP practice.

In the law too there have been fiercely contested debates on the role of regulation, the market, ethics, and professional and public service boundaries. The purpose of this article is not to take a position, but rather to point out that we are moving towards a regulatory environment in which there is no reason in theory why a legal business should not be able to own a medical practice contracting with the NHS – or, vice versa, why GP partnerships could not offer legal services under an ABS model.

Of course, I can see the potential myriad conflicts and incompatibilities. However, I make the point to illustrate that we have structures that could help make medical-legal partnerships a reality in England and Wales, and to encourage the Law Society to investigate this as a route to improving access to justice.

James Sandbach is advocacy and research manager at the Low Commission