IF you spend a couple of hours with clients and staff down in the drug health services ward at the Royal Prince Alfred Hospital (RPA) in Sydney, you will quickly learn that drugs aren’t the only problem.
When patients present themselves to RPA, through the door can come harrowing stories of domestic violence, homelessness, and the loss of children to the hands of the state. These are the stories of the hard-lived experiences of society’s most vulnerable, working hard to keep their often otherwise positive lives on track.
Substance misuse, it seems, is often the small tip of the iceberg. What drags below is the weight of a history lived in the margins of society and the baggage that comes with it. For Australia’s Indigenous populations, this can be intergenerational cycles of trauma.
Dealing with the underlying causes – the iceberg that allows them to manifest – is a more complex task.
At RPA, the patients are cared for by multidisciplinary teams made up of highly experienced medical, nursing and allied health professionals. Each day they care, treat and navigate the complex needs of their patients – not just their acute health needs – but their psychosocial needs and importantly what is needed to enable a patient to return home safely and with support. It is true that often there are significant and complex legal hurdles for patients which are real barriers to their safety and wellbeing.
In May 2015, Redfern Legal Centre (RLC) and Sydney Local Health District (SLHD) united to establish New South Wales first hospital-based Health Justice Partnership (HJP) at RPA, providing legal assistance as a preventive health measure for vulnerable people at the same time that they accessed care and health services with a focus on improving Aboriginal health. Referrals to the HJP come from all areas of the RPA, including Aboriginal liaison officers, social work staff and nursing staff.
While the legal and medical professions may seem like strange bedfellows, it has been well established that legal issues have the potential to cause or compound health problems.
The social determinants of medical and health issues are not always isolated from a patient’s legal issues. This is particularly true for vulnerable populations, such as Indigenous women, as the two are often inextricably linked.
Disputes or threats of eviction over housing, and in some cases the possibility of homelessness, are examples of the social determinants that patients often present with in health care settings. This can lead to health issues, including substance misuse, physical violence and mental health problems. The legal expertise that this partnership brings to the multidisciplinary team at RPA is reaping huge benefits for patients and their families.
While a doctor alone cannot remedy a patient’s housing situation, and in some cases even the very best social worker cannot remove the legal barrier, a lawyer can, preventing legal and medical issues from snowballing into a crisis. In this sense, the partnership is an agile and collaborative approach to early intervention.
Often vulnerable people are reluctant to seek out legal assistance or do not know how to do it. They face barriers based on previous negative experiences with the law and justice system, the potential costs involved and a genuine lack of understanding that legal advocacy could solve their issues.
In the first 6 months of its existence, the partnership between RLC and RPA assisted 62 clients at RPA. Prior to contact with the partnership, 80% of clients surveyed as part of an evaluation of the service did not know their issue was a legal one.
Half of the patients were victims of domestic violence, while other legal advice given related to family law, criminal and police complaints, tenancy, debt and child protection issues. Often, clients presented with more than one legal and health need. The partnership has meant the legal team with the hospital’s multi-disciplinary team can do more.
The partnership is now a core service of RLC practice; such has been the success in providing access to justice to vulnerable populations.
The partnership has also impressed RPA. Health professionals are reaping the benefits provided by the partnership, with 88% of RPA hospital staff stating they are more able to holistically assist their patients now that they can better respond to the social, economic and legal issues that impact on their health and wellbeing.
Unlike in traditional outreach services, Sue-Ellen, a solicitor with RLC, is not an occasional drop-in lawyer who looks awkward in a waiting room. She is integrated into the hospital system as if she were an RPA staff member.
This is crucial because it allows Sue-Ellen to build key working relationships with clients, nursing staff, social workers and Aboriginal liaison officers, to both assist them and receive referrals.
Sue-Ellen is provided with in-kind assistance from RPA, which includes her own office space, hospital computer, phone line, email address and administration support. She works closely with Professor Paul Haber (Clinical Director, Drug Health Service), Elaine Doherty, NUM Drug Health Services and George Long, Director Aboriginal Health.
This core integration is central to Sue-Ellen’s ability to drive the partnership on the ground in conjunction with the senior RPA staff members, with whom she shares key relationships.
While the partnership has had strong early results, dark days are looming.
Harsh Commonwealth Government funding cuts to the community legal sector threaten to force the closure of this and other services in NSW. RLC currently redirects core funding to top up a grant from the Gandevia Foundation to sustain the service until the end of the financial year.
In the absence of commitment from the government, the story of what happens to the vulnerable people who access the service beyond the funding shortfall will rest on the generosity of the community.
It is a hard pill to swallow at a time where there is public demand for better preventive health care and legal protection, particularly in the shadow of Australia’s brutal epidemic of domestic violence.
Despite the challenges, RLC and RPA have ambitious plans for the future of the partnership.
Funding is being sought for a scientifically rigorous and detailed evaluation of the service, the first publishable study of its kind in Australia, to provide a comprehensive insight into the service’s ability to alleviate the negative social determinants of health affecting vulnerable populations.
The rigorous evaluation will provide a platform to approach and convince government funders to sustain and cement the partnership, providing a pathway to expand and improve the service it delivers.
This will mean more solicitors integrated in the hospital system and, ultimately, more patients receiving access to justice, with the aim of improving their quality of life and ultimately their health and wellbeing.
At the coalface, the partnership provides a window of opportunity to intervene before a patient’s problems reach a crisis point.
The Health Justice Partnership model appears to be contagious as the movement gains momentum. Following the RLC lead, a number of other law firms and organisations in NSW are in the process of establishing their own partnerships, on top of a number of established partnerships in Victoria.
This builds on the recent appointment of Dr Tessa Boyd-Caine as CEO of the National Centre for Health Justice Partnerships, a body tasked to support the health and legal professions to develop transformative and thriving health–justice partnerships.
The success in the US and the outcomes that have been achieved here in a short period of time put a strong case for the model to be the future of holistic health service delivery to Australia’s most vulnerable.
Legal advice in a hospital setting may not be the ordinary prescription for a patient’s health problems, but based on the evidence, it is proving to be a great addition to the multidisciplinary care provided by our hospitals and the dedicated staff who work in the team.
Christopher Hills is a volunteer policy officer assisting the CEO of Redfern Legal Centre. He also works with the Australian Human Rights Commission in Investigation and Conciliation Services.