Dr Amber Dar, Assistant Professor in Law
The root of health problems faced by children and families can be linked to non-medical factors, such as the condition of housing in which they reside, or environmental factors. Non-medical issues can have a profound impact on an individual’s health, and potentially other members of a family unit. Therefore, health professionals alone are not equipped to ‘treat’ every facet of the problem they identify and diagnose. Recent examples can illustrate the range of problems and concerns for child health and wellbeing, including the cases of Awaab Ishaq, Ella Adoo Kissi Debrah, and Matthew Richards.
Health and legal services provided by partnerships within a healthcare setting have the potential to better identify and respond to the needs of individuals, families and communities. These partnerships can help to address social and other determinants of health and failings confirmed in the ‘Marmot Review 10 Year On’ report. Such partnerships between health and legal services in England and other parts of the United Kingdom (UK) have increased in recent years. These collaborative initiatives often involve a partnership between different organisations working within the remit of health, welfare and/or legal services, to improve patient access to advice and support for non-medical issues. However, the structures through which these services are currently being provided lack clarity and cohesion. Social prescribing (SP) has its foundation in the National Health Service (NHS), whereas access to social welfare legal services and ‘health justice’, or ‘health justice partnerships’ (HJPs), are still the focus of research and evaluation, with support from the Legal Education Foundation. Social welfare legal services or HJPs can exist either within SP or independently of SP, and are often based within health settings. Concerns have been raised about whether those providing specialist services and advice within SP are suitably qualified to do so. Overall, it is unclear whether there is sufficient focus on child health and wellbeing to adequately address the needs of children, young people and their families in different communities and regions of England and other parts of the UK.
This lack of clarity presents difficulties, not only for existing practice and initiatives, but also to the prospect of expansion of service provision and sustainability based on an established framework and model underpinned by theory. This blog post will highlight the need to address shortcomings within existing structures that manage service provision, before advocating for greater investment to boost expansion and sustainability efforts, based on lessons that can be learnt from partnership models in other jurisdictions, namely Medical-Legal Partnerships (MLPs) in the United States (US) and Health Justice Partnerships (HJPs) in Australia. Shortcomings within existing structures include the need for greater clarity in SP and HJP initiatives, and confirming the extent to which theory underpins these initiatives, in order to establish a partnership framework and model to facilitate expansion across England (and potentially other parts of the UK), with a clear plan for sustainability.
Reduced costs for the NHS and government departments has been the focus of evaluation research questions, with the Ministry of Justice (MoJ) seeking to assess the impact and future potential of these integrated advice services. Different HJP models have been identified on the basis of structure, operation and service provision. Process evaluation has revealed findings about how HJPs are set-up, processes of referral and advice delivery, and variation in each of these aspects can contribute to inefficiencies. Eligibility and provision of legal aid has featured in the MoJ feasibility study and progress report, with consideration of how the scope of legal aid has been expanded to include certain matters pertaining to children and families. A pilot scheme and funding has been introduced to expand the scope of legal aid support for matters of housing, debt and welfare benefits in certain regions of England. The MoJ review of civil legal aid helps to examine the consequences of reduction in legal aid support, significantly limiting the provision of public funding of legal services ranging from advice and guidance to mediation and court representation. Whilst there is the possibility of a client meeting the requirements for Exceptional Case Funding (ECF), a MoJ Legal Means Test Review in 2022 proposed to increase thresholds of income and capital for legal aid eligibility and proposed that, for certain civil cases, there should be no means test at all. The situation for children and families still remains challenging and changes to the scope of legal aid have been recommended by organisations working to represent children and young people and/or those with parental responsibility.
There is little reference to theory informing the design and practice of partnerships between health and legal services, particularly existing partnerships recognised as HJPs in England. Theory of Change (ToC) is referred to in certain literature and resources, including the MoJ feasibility study, which speaks of advancing the existing HJP ToC. Broadly speaking, activities, their results, and the outcomes leading to impact, characterise a ToC. When tracing reference to theory or theoretical principles which underpin SP and HJP, amongst other influences rooted in medical sociology, the Ottawa World Health Organisation (WHO) Charter 1986 represents a significant milestone. There is increasing value attached to theory and theoretical approaches for how these can inform implementation and service provision in practice. Theories of implementation considered in a healthcare context, and for HJPs in particular, include Normalisation Process Theory (NPT) and the General Theory of Implementation (GTI), whereby GTI is described as extending NPT. The work of Central England Law Centre (CELC), which includes service provision they describe as a ‘HJP’, provides a useful example of how a ToC aims to be utilised and applied in England. The extent to which greater emphasis and reliance on theory, and devising a ToC, could (potentially) help to achieve a clearer system, framework and model in England and other parts of the UK requires further evaluation and research. The extent to which theory is given significance and prominence in the US and Australia can be considered when reviewing more established partnership models in these respective jurisdictions.
Health and legal systems can vary significantly between jurisdictions, however the challenges vulnerable citizens face can be very similar, particularly problems rooted in social determinants of child health. There is some reference to ToC and reliance on principles and values within the literature, however again, this appears minimal. Whilst the US MLP landscape has developed considerably over the years, it is the National Centre for Medical Legal Partnership’s (NCMLP) collaboration with Health Outreach Partners (HOP) that appears most firmly rooted in theory. The US MLP model supports partnerships dedicated to vulnerable ‘groups’, responding to the need for specific paediatric service provision and more specialist services for chronic disease in children, diagnosis and management of diabetes, intellectual and developmental disabilities, special education needs, mental health advocacy, child welfare, and more recently, psychosocial factors. Government organisations in the US have also responded to additional challenges faced by those residing in rural communities. The COVID-19 pandemic, followed by new variants of the virus, and the lasting effects of ‘long COVID’ experienced by some, are amongst contemporary concerns for health and wellbeing. However, there remains debate about agreed and accepted definitions for critical concepts such as ‘disability’ and ‘long COVID’, and the timeframe considered to equal or determine a diagnosis of ‘long COVID’.
Particular features of the Australian HJP model should be reviewed to help consider what aspects could be implemented within an established UK model underpinned by theory. Processes of consultation, the working practice of professionals, and their focus on the concept of ‘wellbeing’ are amongst features which merit further review and examination. The role of Health Justice Australia (HJA) as the national centre and charity, and their ToC, could provide useful guidance and direction. Their funding structures may usefully inform plans for sustainability at a national level, in view of the recent announcement regarding legal sector funding to commence in July 2025, based on a ‘National Access to Justice Partnership’.
Once a suitable partnership model has been identified, for England, and potentially other parts of the UK, a process to expand and strategically develop service provision should be agreed. This will require secure funding programmes and committed funding sources for the short and longer term. To drive expansion of service provision and a plan for sustainability, the role of higher education and professional regulation should be rightly acknowledged to devise the necessary support structures. The potential of US law school law clinics and law students supporting US MLPs has been considered in the US, and there are ongoing efforts to build more specialist provision on this basis. Examples of clinical legal education in the UK can also provide guidance, whereby existing examples of collaboration and pilot projects with higher education (HE) institutions could contribute to a partnership template, with the potential to expand beyond law and medicine to other disciplines. It will be imperative to define the role of HE, whether that can be done on the basis of existing collaborative practice and pilot projects, or whether this needs further consideration alongside or within a theoretical framework that should underpin a UK partnership model. The vital role of legal and medical professional regulation to support collaborative practice in different jurisdictions must be clearly outlined, and the extent to which the US example can provide a sound example should be considered.
The issues I have outlined help to ‘map’ a way forward. Improving existing partnership service provision could be a necessary first step, or a strategy for improvement could be ‘mapped’ alongside a plan to facilitate and fund expansion, with a proposal for sustainability. Two final suggestions that go beyond the scope of this research. Firstly, further (related) research should be conducted to help evaluate the feasibility of ‘therapeutic’ clinical research recruitment in partnership settings. Eligible patients who are suffering from a particular illness or condition should be the focus of any such recruitment. Further research should help to determine whether such research recruitment potential is currently being considered in practice, and if not, could this be introduced into a screening process without violating any ethical commitments or guidelines. Secondly, (and arguably a more pressing issue to address), further (related) research should be conducted to evaluate the extent to which a partnership model can assist in matters of child protection, in line with provisions of the Children Act 1989 (CA 1989) and safeguarding the welfare of a relevant child. This further research would not only be valuable in its own right, but would strengthen the case for establishing a consistent partnership model with an adequate plan for sustainability.