Medicine and the law are not traditional bedfellows, but is it possible that a lawyer could be good for your health?
At The Alfred Hospital, for the first time anywhere in the country, pro bono legal advice is being provided to patients under the auspices of the hospital at the same time as medical treatment.
The Michael Kirby Centre at Monash University is running the pilot program, which involves a solicitor attending the hospital for two and half days each week and working with patients referred by The Alfred’s social work department.
Legal issues addressed range from excessive parking fines to immigration disputes, tenancy issues and domestic violence.
“It’s not specific to wills, or superannuation. It’s for all concurrent legal problems that patients have when they present”, the hospital’s general counsel, Bill O’Shea, says.
“We’re the first to take it on for the full range. Whatever legal issues come in the door, we deal with them.”
The hospital provides office space and logistical support for the solicitor from legal firm Maurice Blackburn, who works on the cases pro bono.
Importantly, a memorandum of understanding between the law firm and the hospital specifically prohibits Maurice Blackburn dealing with medical negligence or complaints against The Alfred.
Mr O’Shea says that even before the program was formally launched by former justice of the High Court, Michael Kirby, in March this year, the potential benefits in terms of patient outcomes were evident.
He describes a patient suffering a terminal illness whose complex legal issues were put in order quickly.
“There were all sorts of issues —– including ones involving the family court — which we were able to resolve. And the patient, who had a very short time to live, was actually able to feel some comfort in the fact that these had been dealt with, after not feeling entirely confident beforehand that they could have been. That was a terrific outcome.”
Legal need
The 2012 Legal Australia-Wide (LAW) survey of Australians’ legal needs found that there was a clear correlation between people’s health and their problems with the law. Those with the greatest number of legal issues were most likely to be suffering multiple morbidities.
Some legal problems will obviously lead to bad health such as illegal drug use, domestic violence or unsafe rental housing.
In other cases, health problems cause their own legal difficulties, such as how to arrange early access to superannuation for dealing with serious illness, guardianship issues, or problems related to the nature of particular diseases such as HIV. It can be a vicious circle with tragic consequences.
The same 2012 survey, which incorporated 20 000 respondents, showed that people experiencing legal issues often didn’t consult with lawyers or advocates but would go elsewhere, perhaps to a health care provider, a banker or a friend, to share their concerns.
Incredibly, close to one in five people with legal issues had chosen to seek help from their doctor before consulting a lawyer.
Initiatives to address this, through the co-location of medical and legal services such as The Alfred medical–legal clinic, are slowly beginning to appear, with Victorian groups leading the way.
Medicare for lawyers?
“The reality is that ill health does not occur in a vacuum. By and large it is a product of social circumstances”, Dr Fiona Lander says.
A graduate in law as well as medicine, Dr Lander brings both perspectives to the concept of health.
A casual hospital medical officer at Austin Health and graduate lawyer with Corrs Chambers Westgarth, she is a big fan of greater collaboration between lawyers and doctors in the interest of patients.
“Legal problems are one of the social circumstances that we need to address in order to ensure that we’re looking at the whole person and trying to improve health holistically”, Dr Lander says.
It comes down to the social determinants of health.
“The reality is that the social determinants that influence people’s health negatively are the same determinants that land people in jail or with $20 000 of public transport fines, or with disputes over housing.
“These things are not isolated from each other.”
Until recently, Dr Lander was coordinator of the Advocacy Health Alliance (AHA) network at Victoria’s peak body for pro bono legal services, Justice Connect.
Founded by Peter Noble (see box), the AHA network is helping to foster a small number of advocacy–health alliances, otherwise known as medical–legal partnerships, within Victoria, including in Bendigo, St Kilda and The Royal Women’s Hospital.
Each of these is providing access to free legal services through a health provider, made possible with the generous support one of the state’s law firms.
The arrangements take legal services to the people that need them, although none in quite so comprehensive a way as at The Alfred.
Dr Lander points to grand rounds in psychiatry as one realm where having a lawyer present could be of real value to providing effective multidisciplinary treatment for vulnerable patients.
“The real key to this is early intervention. It’s picking up these issues before they snowball into warrants for arrest or a major court case.
“The ideal set-up would be having a lawyer as a part of that multidisciplinary team, either funded by the government, in the case of public services, or potentially funded as any other allied health practitioner or nurse practitioner would be funded in a community setting.
“Maybe the dream is to have Medicare line items for lawyers!”
Bill O’Shea says no one involved is looking for reimbursement from the health system yet but he doesn’t dismiss the concept.
“Who knows? Psychologists can claim from Medicare and that’s improving people’s mental health and wellbeing and dealing with psychological issues. It’s not that different if you deal with their accumulated parking fines or their gambling problem.
“Maybe the saving to the community would justify a Medicare item number.”
He is optimistic that the evaluation of The Alfred pilot program will be positive and that the Board may choose to continue the work. Other hospitals in Victoria are watching with interest, he says.
Meanwhile, in the wards at The Alfred, Dr Allen Cheng is an infectious diseases physician whose patients are frequently dealing with legal problems associated with HIV.
He says that the hospital’s new legal service is already changing his approach to his patients’ legal difficulties.
“For a fair few patients, their legal problems are front and centre in their minds even though they may be in the hospital with a medical problem.
“I can look after their medical problem, but their legal problems do need to be addressed and while patients are being seen at the hospital is probably as good a time as any to try and work these problems out.”
And the health outcomes? He has no doubt that the new ability to address legal problems onsite will improve patients’ health outcomes.
*For those interested in being part of an advocacy–health alliance, Justice Connect is about to publish a toolkit outlining how to set one up. Phone 03 8636 4400 or visit www.justiceconnect.org.au.
New alliances
Bendigo community lawyer Peter Noble was the founder of the Advocacy Health Alliance Network and is credited by many with introducing the concept of advocacy–health alliances in the Australian context.
The coordinator of Bendigo’s Loddon Campaspe Community Legal Centre (LCCLC) says he saw the benefits of links between law and medicine in his own experiences with clients.
“Observing that legal issues seemed to impact on people’s wellbeing and their health, I was interested to understand that relationship better and to see how that had been explored internationally.”
Mr Noble’s investigations led him to the medical–legal partnership movement in the United States.
It began at the Boston Children’s Hospital and has been credited with reducing the lengths of hospital stays and re-presentations at emergency.
The model justifies itself cost-wise within the American health care system due to the insurance savings it can create and there are now more than 300 such collaborations across the country.
The US model has three points of focus:
- Looking at individual legal interventions that can be made to improve a person’s welfare. Examples of scenarios that might be dealt with include a woman who experiences domestic violence whose tenancy has been terminated, or someone who has a consumer problem which affects his or her welfare.
- Looking at institutional change within the service provider or the health provider — that is, looking at the training of health providers to better identify legal issues that affect their clients’ wellbeing. LCCLC have a training package arranged with staff at Bendigo Community Health. Women’s Legal Services NSW recently produced a program for general practitioners on identifying family violence and making referrals for family support.
- Looking at systemic change — observing, through client interactions, a systemic problem that needs to be addressed, including unhealthy environments. This larger systemic perspective aligns well with the classic public health approach.
- Annabel McGilvray