It’s official: legal aid cuts are making people ill


James SandbachIf we look at all the major improvements in the UK’s population health over the past couple of centuries, it is hard to solely ascribe these to advances in medical science or even our landmark ‘free at the point of use’ NHS developed in the 20th century. Much bigger social policy interventions have also played a role – sanitation, slum clearance, smog-busting laws, free school meals, and so on. Indeed, Professor Sir Michael Marmot, the grand master of social epidemiology, undertook a study for the UN which suggested a direct correlation between the generosity of a country’s social protection policies and key health indicators.

Of course, the case for big public health interventions is well accepted by policy makers in some areas such as fluoridation, banning smoking in public places, the sugar tax, or minimum alcohol pricing. But in other areas, both environmental and social drivers of ill-health are being overlooked, despite overwhelming research and evidence. Common legal problems, like dealing with rogue landlords, unfair benefit sanctions, aggressive bailiffs, relationship breakdown or exploitative employers, have huge negative impacts on population health. The more that we look at the health issues of those with legal needs, the more we find that not only do legal problems make people ill, but GP services have been picking 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 per cent of those whose health was affected by their legal problem went on to visit their GP or other health service.

In 2014, the Legal Action Group commissioned ComRes to conduct a poll of GPs published in a report called Healthy Legal Advice. Depending on problem type, up to 67 per cent 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 per cent reported that these issues had a negative impact on their patients’ health. The Low Commission then undertook a more extensive evidence review, drawing on 140 research studies in the field, as well as a more detailed analysis of process, models and outcomes in 58 integrated health and welfare advice services in primary care, mental health, secondary and tertiary care settings.

The clear conclusion from this research was that welfare rights advice produces real benefits for patient health, especially where advice services work directly with NHS care providers. Not only did it find mounting evidence that unresolved social welfare law problems make people ill – with an especially strong debt and mental health link – but also corresponding evidence that welfare advice provided in health care settings, such as GP surgeries, impacts positively on health and well-being – including lowering stress, improving sleep, stabilising relationships and housing. So legal advice can indeed be good for your health. But it can also be good for the NHS: where advice services are routinely located in primary care settings (such as, in Derbyshire) the Low Commission’s research has found that the time spent by GPs on benefits issues can be cut by 15 per cent, as well as reducing repeat appointments and prescriptions.

Integrating legal and welfare advice into the health system may also provide the key to reinventing NHS models of primary care delivery. Under traditional clinical models, usually a GP will have only one of three options in dealing with a patient’s pathway to recovery – referring to a hospital for admission, referring to consultant for a specialist consultation, or making out a prescription for drugs to take to the pharmacy. However, under new “social prescribing” approaches championed by Sir Sam Everington – founder of the Bromley by Bow Centre – and other reforming clinicians, GPs can prescribe services such as health training, debt or legal advice, or a direct referral through to other appropriate care, support or skills and employment services.

Taking this a step forwards, while there is much in the US healthcare system that we would not wish to emulate, there are some interesting innovations in embedding lawyers and paralegals alongside healthcare teams to detect, address and prevent health-harming social conditions for people and communities. The model of Medical Legal Partnerships was first championed by the Boston Medical Centre, recognising that lawyers can 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 the Boston Medical Center to 292 partnerships with hospitals and healthcare services across the US. Here in the UK, the NHS faces huge challenges over funding, workforce planning, managing longevity and co-morbidities and increasing demands, from mental issues to dementia, diabetes, stress-related illness and obesity. There is much policy talk of greater integration between health, community and social care, and greater priority for mental health – but not much action. I would suggest a good starting point would be embedding welfare advice within our primary care system.

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