Health and justice: A fundamental connection

– Professor Sir Michael Marmot, and Professor Dame Hazel Genn, University College London

One of the rationales for the long neglect of our justice system is that, in a tight fiscal environment, it just doesn’t rank as one of ‘the people’s priorities’ in the way that, say, health does. Certainly, if one looks at crude polling questions and reflects no further, one would form that view: a lot of voters would rank the NHS as their top priority, whereas virtually none would name, for instance, the civil courts. But as two experts on, respectively, health outcomes and the justice system, we both see fundamental connections between the two things, and reject any claim that public health can be advanced by neglecting justice: the opposite is true.

Despite, or perhaps more precisely because of, our very different professional backgrounds, we judged that it would be useful for us to come together for this piece and explain just how important the health/justice link looks when viewed from both sides. One of us chaired the World Health Organization (WHO) Commission on Social Determinants of Health, whose starkest conclusion was that social injustice is killing people. From this point of view, as the place where many of society’s problems have to get resolved, the justice system is a revealing crucible of many of the forces that drive health inequality; moreover, the law itself is an instrument that can ameliorate or exacerbate those forces’ power. The other one of us is a scholar of access to civil justice, whose keen practical interest in the workings of the system include serving on the Judicial Appointments Commission. From this perspective, what’s most striking are the many ways, for good and ill, that the legal and broader justice system shapes our well-being and our health. Get the system working well, and law and justice can be an efficacious health intervention.

A public health perspective: justice gaps and health divides

A child dying because of mould in the house. A child with special educational needs that are not being met. Youngsters in a gang engaged in anti-social behaviour, locked up as a result. An office cleaner paid less than the minimum wage with a zero–hours contract. Rough sleepers. A lonely pensioner, who scarcely ventures out because of fear of crime in the neighbourhood, whose main social contact is the care worker whose visits to attend to leg ulcers have become shorter and less regular. A young man stopped by the police because of the colour of his skin. Snacks of biscuits and crisps because anything healthier is too expensive.

These are all examples of the social determinants of health. These are, in turn, major causes of inequalities in health and all require social action. The two dominant reactions to inequalities in health are to exhort people to behave better and look after themselves, and to fix problems with the healthcare system. It is possible that the first might have a marginal impact, and the second is necessary. But neither will do much to reduce inequalities in health. Look at the UK over the last 15 years. Life expectancy did not improve, health inequalities increased, and health for the poorest people got worse. These alarming patterns could not be explained by people suddenly deciding to behave in unhealthy ways. Lack of access to healthcare may have made some things worse but is unlikely to be the root cause of the problems.

Inequalities in the way society is organised and operates are the real issue. After assessing and marshalling all the most instructive evidence, we emblazoned a bold summary statement on the back cover of the final report of the WHO Commission on Social Determinants of Health: “Social Injustice is killing people on a Grand Scale.”[ref] Commission on the Social Determinants of Health. 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. World Health Organization. Available from: https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1. [/ref] In parts of the world, bad laws sometimes play a part in cementing that injustice. Conversely, it is difficult to imagine that social justice can be achieved without the state operating, in some measure, to achieve the public good. A lot of the social welfare and other laws we have in Britain are (at least in theory) designed to secure that good by giving people important rights and entitlements. More generally, positive public actions often require legislation – and the law then becomes a mechanism to hold actors, public and private sector, to account.

Three examples of different sorts – covering virus control, criminal justice and day-to-day living conditions – all illustrate how the law and broader justice system are connected to health outcomes.

The global HIV/AIDS community has long recognised the importance of respect for human rights as fundamental to controlling infection and disease. Indeed, a global commission on HIV and the law reported in 2012. A 2018 supplement confirmed that AIDS remained a disease of the vulnerable, marginalised and criminalised.[ref] UNDP, HIV and Health Group. 2018. HIV and the Law: Risks, Rights & Health – 2018 Supplement. Available from: https://hivlawcommission.org/supplement/. [/ref] In general, laws that fail to protect sexual and reproductive rights, that fail to protect people with HIV and fail to protect the rights of women and girls were all antithetical to control of HIV and AIDS. Targeting of LGBT people and banning, harassing or vilifying relevant civil society organisations hindered efforts to control the virus. The Commission was especially critical of anti-sex work laws and laws perpetuating the war on drugs. The Commission saw the law as fundamental to meeting universal human rights obligations. Countries that did not have, and implement, laws that met human rights obligations made slower progress.­

All sorts of channels between health and the law flow through the criminal justice system. It has been shown globally that mental illnesses feature prominently among prisoners, as do infectious diseases.[ref] Favril, L, et al. 2024. Mental and physical health morbidity among people in prisons: an umbrella review. The Lancet Public Health 9, e250–e60. [/ref] A meta-analysis showed that mental illness is at least twice as common among prisoners as among the general population.[ref] Favril, L, et al. 2024. Mental and physical health morbidity among people in prisons: an umbrella review. The Lancet Public Health 9, e250–e60. [/ref] Of course, prison may cause, or make worse, mental illness. But the review found that a quarter of people who enter prison have alcohol use disorder and nearly 40% a drug use disorder. These problems are, themselves, strongly related to adverse childhood experiences which are, in turn, far more prevalent among those raised in deprivation.[ref] Bellis, MA, et al. 2014. Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. Journal of Public Health 36, 81–914. [/ref] These findings should lead in two linked directions: preventing mental illness in children as a step towards prevention of both crime and incarceration; and reducing the discrimination that leads to some groups being singled out for harsher treatment by the criminal justice system.

Deprivation is also more likely to put young people in contact with the police and the criminal justice system, as is membership of a minority ethnic group.[ref] Marmot, M, et al. 2024. Structural racism, ethnicity and health inequalities in London. Institute of Health Equity. [/ref] In the USA, Black Americans make up 37% of the population in jails or prisons, against 13% of the general population.[ref] Prison Policy Initiative. Updated 20 May 2025. Racial and ethnic disparities. Available from: https://www.prisonpolicy.org/research/racial_and_ethnic_disparities/. [/ref] A study in California used the excess incarceration rate of Black Americans, compared to White, as an indicator of structural racism – a force for health inequalities. In geographical areas with high structural racism by this measure, maternal morbidity after birth was high in Black and Hispanic or LatinX mothers.[ref] Hailu, EM, et al. 2024. Structural Racism, Mass Incarceration, and Racial and Ethnic Disparities in Severe Maternal Morbidity. JAMA Network Open 7, e2353626-e. [/ref]

The conditions of daily life were addressed in the 2010 Marmot Review, Fair Society Healthy Lives, and the Marmot Review 10 Years On.[ref] Marmot, M. 2010. Fair society, healthy lives: The Marmot review (available from: http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review); Institute of Health Equity. 2010. Strategic review of health inequalities in England post-2010; Marmot, M, et al. 2020. Health Equity in England: The Marmot Review 10 Years On. Institute of Health Equity. [/ref] We had initially six areas of recommendations, to which we have since added two. They are: give every child the best start in life; education; employment and working conditions; minimum income for healthy living; environmental conditions in which to live and work, including housing; taking a social determinants approach to prevention; tackling discrimination, racism and their health outcomes; pursuing environmental sustainability and health equity together.

In 2013, the English city of Coventry declared themselves a Marmot City.[ref] Coventry City Council. No date. Coventry, a Marmot City – the story so far. Available from: https://www.coventry.gov.uk/marmot-monitoring-tool/coventry-marmot-city-story-far. [/ref] They took our, then, six domains of recommendations and made them the basis for planning in the city involving local government, the health and care sector, voluntary and community services, other public services and the private sector. Greater Manchester followed to become the first Marmot City Region. We now have 50 Marmot places in England, Wales and Scotland.[ref] Institute of Health Equity. No date. Marmot Places. Available from: https://www.instituteofhealthequity.org/taking-action/marmot-places. [/ref] Scotland is developing a national strategy based on Marmot Principles.

Social justice is at the heart of all this activity, but it does not explicitly focus on the law. It could. The first case alluded to at the head of this section – the coroner declaring that two-year old Awaab Ishak died of a respiratory condition linked to black mould in his house – is a case in point. His parents, both immigrants from Sudan, had complained to their social landlord and had been told simply to paint over the mould. This tragedy garnered national headlines and led to change in the law around the responsibilities of social landlords to remedy hazards in their properties.[ref] Marmot, M, et al. 2024. Building Health Equity: the role of the property sector in improving health. Institute of Health Equity. [/ref]

Each of our domains of recommendations could involve the law in implementation and in holding those responsible to account. A recent international analysis shows how that could relate to work, focusing on workers in health and care.[ref] Kavanagh, MM RA, et al. 2024. Laws for health and care worker protection and rights: A study of 182 countries. PLOS Global Public Health 4. [/ref] WHO has developed a care compact for health and care workers. It includes, among many other things: protection against violence and harassment; protection against attacks in situations of war/vulnerability; and whistleblower protections. The care compact is not itself a legal document, but the authors of this study examined, for 182 countries, how well national legal frameworks aligned with the dimensions of the care compact. The study concluded that alignment is indeed possible, but there is some distance still to travel to use legal frameworks to protect workers in health and care.

Reduction of health inequalities is a matter of social justice.[ref] Marmot, M. 2015. The Health Gap. Bloomsbury. [/ref] There are alternative ways to think about this ideal – as discussed, for example, by the Harvard philosopher, Michal Sandel.[ref] Sandel, MJ. 2010. Justice: What’s the right thing to do? Farrar, Straus and Giroux. [/ref] The most pertinent concept is defined in terms of optimising freedoms. The freedom that matters for health is not the libertarian notion, but rather that version which Amartya Sen has championed: creating the conditions under which people enjoy the agency they need to live lives they have reason to value. A legal framework can be a guarantor of this sort of freedom – see the example of the care compact in the previous paragraph.

The justice system has much to offer in addressing the social determinants of health. Sadly, as Shameem Ahmad’s piece in this collection of essays eloquently testifies, one further casualty of a decade and more of austerity in the UK is erosion of the justice system’s capacity to perform this vital function. And yet not all is lost. Even in these difficult times, there are examples of pioneering practices in pursuing health through justice. And there is ample evidence that – with a little more focus, a few repairs and some extra investment – an awful lot more could be done.

A civil justice perspective: the law as a health intervention

The UK invests in a universal health service because it is understood that the health of citizens matters. Yet despite free and accessible treatment there are gross inequalities in the UK in health and well-being related to socio-economic status – the so-called ‘social gradient’.[ref] Marmot, MG, et al. 1991. Health inequalities among British civil servants: the Whitehall II study, The Lancet 337, 1387–1393. [/ref] People at the bottom of the pile die earlier and have more disability than those with higher status. There are well-documented explanations for this gradient – including income, housing, employment and education – which have a greater impact on health than individual biology or clinical care.[ref] See, for example: Public Health England. 2017. Health Profile for England, Chapter 6 Social Determinants of Health. Available from: https://www.gov.uk/government/publications/health-profile-for-england/chapter-6-social-determinants-of-health; Marmot, M. 2010. Fair society, healthy lives: The Marmot review (available from: http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review); Institute of Health Equity. 2010. Strategic review of health inequalities in England post-2010; The Academy of Medical Sciences. 2016. Improving the health of the public by 2040. Available from: https://acmedsci.ac.uk/file-download/41399-5807581429f81.pdf. [/ref]

What is urgently needed is evidence about the sort of interventions or innovations that might be effective at the individual level in mitigating the damage done by structural inequalities. To the extent that the mechanisms of intervention at the individual level are considered in public policy, they are too often focused narrowly on modifying health (or perhaps more precisely unhealthy) behaviours. From our respective perspectives of public health and justice research, we are both striving to get beyond that, to consider other measures that can be called in aid of improved health and well-being of individuals who are often at the sharp end all sorts of adverse social processes beyond their control.[ref] Popay, J, et al. 2007. Social problems, primary care and pathways to help and support: addressing health inequalities at the individual level. Part I: the GP perspective. J Epidemiol Community Health 61, 966–971. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2465599/. [/ref] The vast range of social protections and entitlements provided by law gives the civil justice system – which activates those entitlements – an important, and sometimes underappreciated, role to play here.

Law as a determinant of health

Law is a crucial social determinant of health, critically influencing the framework in which individuals and populations live, face disease and injury, and eventually die.[ref] Parmet, W, et al. 2010. Social determinants, health disparities and the role of law. In Tobin-Tyler, E, et al (eds). Poverty, Health and Law, p. 21. [/ref] Practitioners are often ahead of the policymakers in getting on and fixing the missing link, by forging health–justice partnerships, often to impressive effect. One study of the roots and workings of such partnerships concluded that “Legal issues are embedded in most social determinants of health, making lawyers a necessary part of any strategy to address them, whether at the individual, local, or national level,” and insisted, too, on the need to deploy the law as a “lens” through which to make sense of “health promotion, disease prevention, and overall well-being”.[ref] Teitelbaum, J, & Lawton, E. 2017. The Roots and Branches of the Medical-Legal Partnership Approach to Health: From Collegiality to Civil Rights to Health Equity. Yale Journal of Health Policy, Law, and Ethics 17, 5. [/ref]

Public health theory highlights causal connections between social problems with a legal dimension and morbidity and mortality.[ref] Tobin-Tyler, E, et al. 2011. Housing: The Intersection of Affordability, Safety and Health. In Tobin-Tyler, E, et al (eds). Poverty, Health and Law. [/ref] The Pan-American Health Organization Commission on Equity and Health Inequalities (which one of us, Michael Marmot, chaired) took the next logical step for the field, stressing the role of legal and human rights mechanisms to safeguard health. As that Commission’s final report argued: the law can be a “counterbalance” to unequal power, and consequently, “legal redress provides a vital pathway to correct policies and practices that result in or deepen health inequities”.[ref] Commission of the Pan American Health Organization on Equity and Health Inequalities in the Americas. 2019. Just Societies: Health Equity and Dignified Lives. Available at: https://iris.paho.org/handle/10665.2/51571. [/ref] And yet legal remedies are not yet routinely considered by the medical sector as a vehicle for solving problems. By reaching across specialist silos, we can accelerate the change that’s needed.

If public policy has sometimes been slow to grasp the importance of justice in the protection of health, that reflects a far wider social lack of consciousness about law beyond crime and the criminal justice system. Representations of law in popular culture focus overwhelmingly on the drama of criminal, not civil, law and “for many people the law is the criminal law. Ordinary people do not routinely carry a distinction in their head”.[ref] Genn, H. 1997. Understanding Civil Justice. Current Legal Problems 50, 155–187. Available from: https://doi.org/10.1093/clp/50.1.155, p 159. [/ref] It is easy for everyone, including those working in healthcare and public policy, to forget how far the tentacles of the law reach into every aspect of social and economic life.

In reality, a vast range of social welfare law provision prescribes protective rights and entitlements to shield people facing challenging circumstances from precisely the sorts of factors known to harm health and well-being. Legal practitioners deal with individuals facing almost the full range of problems and crises that can affect health, including inadequate income, dangerous housing conditions, homelessness, debt, access to educational opportunities, threats of unemployment, family breakdown, discrimination, and more.

Law and legal services influence health at three different levels. At the national level, law-making can promote public health by measures such alcohol pricing and sugar tax. This is the level in which the public health world has most enthusiastically grasped the potential of law so far. At local level, a wide range of institutional and business policies and practices affect health through, to give just a few of many potential examples, the approach that is taken towards pollution, product standards and the treatment of staff. The law can make requirements in respect of such policies and practices, requirements which it then falls to the justice system to enforce. For example, the broad justice system ensures that public bodies comply with statutory responsibilities in relation to decision-making around health-promoting entitlements to services for poorer and vulnerable groups. Moreover, individual cases can act as a diagnostic tool for failed institutional policies, as exemplified after the death of toddler Awaab Ishak from the effects of unhealthy housing, a case already referred to above.[ref] No author. 2022. Awaab Ishak and the politics of mould in the UK. eClinicalMedicine 54, 10180. Available from: https://doi.org/10.1016/j.eclinm.2022.101801. [/ref] Note that these important and varied mechanisms will not work as they should unless underpinned by a courts system in which rights can be secured, disputes settled, and remedies imposed. In other words, the unhealthy figurative health of our tribunals and courts could have repercussions for the literal health of the community.

Then thirdly, at an individual level, the law and justice system affects personal health in myriad ways. For starters, the law ‘prescribes’ the individual basic entitlements (in respect of income support, housing and so on) that should guard against social exclusion and destitution. It may also ‘prescribe’ additional support (in terms of care, say, or disability benefits) to those with the greatest burden of ill health. But vulnerable individuals will often fail to receive such entitlements. Legal advice and support is crucial in ensuring they get what they are due. This makes provision of that advice an important intervention. This form of intervention can have a preventative impact: when, for example, cancer patients are automatically offered legal advice on financial issues and employment rights, this can both support patients to work productively, when that might not otherwise have been sustainable.[ref] Jepson, R, et al. 2016. Theory Based Evaluation Of Long Term Conditions And Macmillan Benefit Advice Service In Queen Elizabeth University Hospital, Glasgow. Available from: http://www.scphrp.ac.uk/wp-content/uploads/2016/10/Evaluation-of-Long-Term-Conditions-Macmillan-Benefit-Service-by-Edin-Uni.pdf. [/ref] But law importantly has remedial impact, too, in seeing off individual immediate crises such as imminent eviction, loss of income, threatened job loss, family breakdown, domestic or elder abuse. In such ways and many more, law and legal services can be regarded as a health intervention: principally by improving the material well-being that supports physical and mental resilience.

Law as a remedy for poor health

We now have two decades of ‘access to justice’ research from around the world, which has elucidated many two-way links between citizens’ experience of legal issues and their health. Particular health-harming effects have been traced to unresolved socio-legal issues.[ref] Genn, H. 1999. Paths to Justice: What People Think and Do About Going to Law. Hart Publishing; Pleasence, P, et al. 2013. Paths to Justice: A Past, Present and Future Roadmap. Nuffield Foundation. [/ref] Every problem along the line of the justice system – lack of knowledge and understanding of rights, lack of advice about how to secure them, lack of avenues for resolution short of going to court, then heavy costs and long delays when a day in court is sought – will directly aggravate these effects. Moreover, individuals living with poor mental or physical health, as well as those who are poor or otherwise socially excluded, are more exposed to all sorts of problems, including difficulties navigating access to the benefit system; long-term indebtedness;[ref] Fitch, C, et al. 2011. The relationship between personal debt and mental health: a systematic review. Mental Health Review Journal 16, 153–66. Balmer, NJ, et al. 2010. Psychiatric morbidity and people’s experience of and response to social problems involving rights. Health and Social Care in the Community 18, 588–97; Balmer, N, et al. 2005. Worried sick: the experience of debt problems and their relationship with health, illness and disability. Social Policy and Society 5, 39–51. [/ref] and adverse housing circumstances.[ref] Tunstall, R, et al. 2013. The links between housing and poverty: an evidence review. Joseph Rowntree Foundation. [/ref] They are also more likely to have difficulty accessing support and advice for such issues.[ref] Finn, D, & Goodship, J. 2014. Take-up of benefits and poverty: an evidence and policy review. Centre for Economic & Social Inclusion; Pleasence, P, et al. 2008. The Health Cost of Civil‐Law Problems: Further Evidence of Links Between Civil‐Law Problems and Morbidity, and the Consequential Use of Health Services. Journal of Empirical Legal Studies 5, 351–373. Pleasence, P, et al. 2015. Health Inequality and Access to Justice: Young People, Mental Health and Legal Issues. Youth Access. Available from: https://www.youthaccess.org.uk/publications/research-evaluation/health-inequality-and-access-justice. [/ref]

From such research we have learned about the causal connection flowing from legal problems towards long-term illness or disability: the results can include acute and chronic stress, physical ill health and a cascade of social, family and employment crises in previously healthy people.[ref] Pleasence, P, et al. 2004. Civil Law Problems And Morbidity. Journal of Epidemiology and Community Health 58, 552–557. For an overview of evidence see: Coumarelos, C, et al. 2013. Law and Disorders: illness/disability and the experience of everyday problems involving law. Law and Justice Foundation, Paper 22. See also more recently work by Helen Rowe on the biology of poverty, available from: https://equalitytrust.org.uk/news/blog/guest-blog-eliminating-poverty-in-britain/. [/ref] Stressors experienced repeatedly or over a long period of time, including stressful living and working conditions, are associated with high blood pressure, development of diabetes, and ischemic heart disease. In cases such as asthma caused by poor social housing, legal services might be able to secure improved conditions and thereby exert a direct power to improve health that medical services cannot.

Also pertinent is the increasing attention rightly being paid to the impact of early life experiences, both in creating ill-health and in perpetuating cycles of deprivation. Children and adolescents exposed to adverse experiences run into many more physical and mental health problems as adults.[ref] Bellis, MA, et al. 2015. Measuring mortality and the burden of adult disease associated with adverse childhood experiences in England: a national survey. J Public Health 37, 445. [/ref] The kind of adverse experience that matters here could be something direct, like abuse, but can also be the toll that is taken by living in poor or insecure living conditions. Children growing up in chronically stressful environments can suffer harm to the development of their nervous, endocrine and immune systems, ultimately leaving them more susceptible to illness and more prone into engaging in health-harming behaviours, such as substance abuse. Early information and advice about entitlements to services and benefits and, for example, employment protection for expectant mothers within maternity services,[ref] See the work done by Maternity Action (https://maternityaction.org.uk/2025/01/maternity-action-shortlisted-for-the-lexisnexis-legal-awards/) and their Health Justice Partnerships (HJP) across north west England in collaboration with maternity services. It is the first of its kind in the UK with advice services embedded in the maternity services and available for women at the point of need. [/ref] can break cycles of deprivation by ensuring that the conditions into which children are born support healthy development and positive life chances.

However, ‘legal needs’ are not currently part of the routine language or practice of healthcare. This position could usefully change – and indeed, imaginative practitioners on both the legal and medical side are not waiting for scholars and theorists to tell them how, but getting on and showing how it can be done.

A holistic therapy: health-justice partnerships[ref] Much of the material in this section paraphrases a comprehensive review of the field undertaken for an international workshop on Health Justice Partnerships organised by Hazel Genn in November 2017. The background material was prepared by Charlotte Woodhead, Research Associate, NIHR CLAHRC North Thames, UCL. [/ref]

Given the links between civil justice and health it does not take a big leap of logic to imagine that collaboration between health services and social welfare legal advice could be valuable. Such health–justice partnerships have grown up at the grassroots in the UK, USA, Australia and Canada[ref] General information on such partnerships available from: https://www.ucl.ac.uk/health-of-public/research/ucl-health-public-communities/health-inequalities-community/health-justice-partnerships. On international experience see: Tobin-Tyler E, et al. 2023. Health Justice Partnerships: An international comparison of approaches to employing law to promote prevention and health equity. Journal of Law, Medicine & Ethics 51, 332–343. Available from: https://doi.org/10.1017/jme.2023.84. [/ref].[ref] For details on one recent partnership see the Central England Health Justice Partnership. Available from: https://www.centralenglandlc.org.uk/health-justice-partnership. [/ref]Such partnerships embed free legal advice in primary and acute healthcare settings with lawyers integrated into, or co-located with, the healthcare team: free legal advice is provided in healthcare settings to poor and vulnerable groups, with the express aim to address the social determinants of ill health.

The benefit of such partnerships includes solving immediate health-harming socio-legal crises; mitigating health-harming individual circumstances; and improving capability to deal with future problems. One study of such collaborations has argued that, when it comes to important determinants of health, “The most powerful lever at our disposal… is the law.”[ref] Teitelbaum, J, & Lawton, E. 2017. Roots and branches of MLPs. Yale Journal of Health Policy, Law and Ethics 17, 343–377, p377. [/ref] Taking a holistic approach to healthcare, these partnerships draw on legal practitioners with the skills to address the many health-harming social and economic needs.[ref] Ibid. [/ref] They are a promising practical means for making social welfare law part and parcel of the approach to improving the health of citizens. There is ever-more evidence and anecdote about the value of such partnerships not only to patients, but also to health professionals, such as GPs dealing with social problems.[ref] Woodhead, C, et al. 2017. Co-located welfare advice in general practice: a realist qualitative study. Health and Social Care in the Community 25, 1794–1804, p1794. [/ref]^,[ref] Popay, J, et al. 2007. Social problems, primary care and pathways to help and support: addressing health inequalities at the individual level. Part I: the GP perspective. J Epidemiol Community Health 61, 966–971. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2465599/. [/ref] The words of one GP in a partnership elucidate:

“We see a high proportion of social problems… I’d say there’s a social element to at least a third of the consultations that I deal with… It’s a lot easier to medicalise problems than to address social determinants… We have 10 minutes. We often have multiple problems to deal with… and sometimes it’s easier to ignore a problem than to try to take it on. … The co-location element [of the health-justice partnership] is important… Patients are really delighted when you say ‘We’ve got this service and it’s in the next room or it’s one floor up’. Patients really like that.” [ref] The quote was collated in a study of a Health–Justice partnership at a GP practice in Stratford. Although that study remains an unpublished research paper, it is described in Genn, H, & Beardon, S. 2021. Health Justice Partnerships: Integrating welfare rights advice with patient care. University College London. Available from: https://www.ucl.ac.uk/health-of-public/sites/health_of_public/files/health_justice_partnerships_integrating_welfare_rights_advice_with_patient_care.pdf. [/ref]

The development of health-justice partnerships in England can be traced back to the mid-1980s, when it was first suggested that GPs were well-placed to spot patients in financial difficulties but not to give them the advice on things like benefits that they needed to overcome these.[ref] Jarman, B. 1985. Giving advice about welfare benefits in general practice. BMJ 290, 522–524. [/ref]  But such progress as there has been has grown up from local initiatives and enterprising experiments. There has never been any concerted national policy or funding dedicated to this field. While there are now policies to encourage NHS collaborations with the voluntary and community sector aimed at addressing the social determinants of health,[ref] NHS. 2019. The NHS Long Term Plan. Available from https://www.longtermplan.nhs.uk/. [/ref]^, [ref] Department of Health and Social Care. 2021. Integration and Innovation: working together to improve health and social care for all. HM Government. [/ref] we have not yet seen the same recognition for role of the legal advice sector. The arts, exercise and all manner of community activities and groups loom larger in the ‘social prescribing’ discourse than legal advice.

Financial support for health-justice partnerships comes from various sources including charities, local authorities and the NHS, but such funding streams as exist are mostly short-term and unreliable, affecting the stability and longevity of the partnerships. A common reason for these partnerships to close is the money running out.[ref] Beardon, S, et al. 2024. Funding welfare rights advice services to work in partnership with healthcare. Available from: https://www.ucl.ac.uk/health-of-public/sites/health_of_public/files/hjp_funding_report.pdf. [/ref]

Civil justice as medicine for struggling health services

It is now generally accepted that an overwhelming proportion of health problems trace to social roots, rather than depending only on the biology of the individual in isolation. Exhausted health service staff need not fear being asked to fix social problems in isolation: only society as a whole can do that. And here’s the thing. If we can factor the law and justice system into our thinking about health in the right way, there should be less for medics to do, rather than more. Going right back to those crude polling questions about voter priorities which we invoked at the top of the paper – on which GPs and hospitals always rate highly, but courts and legal advice never register – recognising the damage that the inadequacies of legal support are doing to health service could be a way to reset the political discourse (or rather the lack of it) around civil law.

While NHS GPs struggle to meet the increased demand of an ageing population and rise in multi-morbidity,[ref] Royal College of General Practitioners. 2018. Spotlight on the 10 High Impact Actions. Available from: https://mvda.info/sites/default/files/field/resources/RCGP-spotlight-on-the-10-high-impact-actions-may-2018.pdf, p6. [/ref] a lot of their time is being consumed by non-medical social problems or medical problems with a social cause. Even a decade ago, the time GPs spent on social issues that are not principally about health were already estimated at a cost to the health service of almost £400 million a year. The top categories of non-medical issues involved were found to be personal relationship problems, housing, unemployment/work related issues and welfare benefits.[ref] Caper, K, & Plunkett, J. 2015. A Very General Practice: How much time do GPs spend on issues other than health? Citizens Advice. Available from: https://www.citizensadvice.org.uk.cach3.com/Global/CitizensAdvice/Public%20services%20publications/CitizensAdvice_AVeryGeneralPractice_May2015.pdf. [/ref] Patient demand for such ‘non-health’ work places extra strains on GPs and their practices, particularly in deprived areas, and so exacerbates health inequalities.[ref] Bloomer, E, et al. 2012. The impact of the economic downturn and policy changes on health inequalities in London. UCL Institute of Health Equity. [/ref] GPs report that patient health, GP workload and practice staff time have been adversely affected by greater patient financial hardship.[ref] Baird, B, et al. 2016. Understanding pressures in general practice. The King’s Fund; Iacobucci, G. 2014. GPs’ workload climbs as government austerity agenda bites. British Medical Journal g4300. Available from: http://www.bmj.com/content/349/bmj.g4300; Iacobucci, G. 2014. GPs increasingly have to tackle patients’ debt and housing problems. British Medical Journal 349, g4301. Available from: http://www.bmj.com/content/349/bmj.g4301. [/ref] Recent data collected directly from GPs suggested one in five GP appointments (amounting to 200,000 consultations every day) are taken by ‘patients’ with non-medical issues such as seeking advice about debts, relationships or housing.[ref] ‘Smart flow’ can provide GPs with information about high service use (Data Care Solutions. No date. Around 200,000 GP consultations every day are spent on non-medical issues. Available from https://web.archive.org/web/20250318131045/https://www.datacaresolutions.co.uk/news/around-200000-gp-consultations-every-day-are-spend-on-non-medical-issues). [/ref] And the issues for the NHS don’t stop with family doctors’ surgeries. In 2024 the Red Cross published a report on high intensity users of A&E departments and concluded that deprivation was driving repeat emergency hospital visits.[ref] British Red Cross. 2024. Seen and Heard. Available from: http://www.redcross.org.uk/-/media/documents-indexed/seenheardreport2024.pdf. [/ref]

Conclusion: a silo that cannot stand

Having examined the gap between justice and health from both sides, it is plain that the traditional division between them is damaging and confusing and cannot be allowed to stand. One of the central lessons of public health scholarship is, as we have explained, that social injustice is making people sick and ultimately costing lives. The right framework of laws and social entitlements, together with effective and accessible courts and tribunals that empower citizens to secure their rights, is one important means of moving towards social justice and thereby bolstering health. From the point of view of civil justice practice and advice, we can see that the law touches upon virtually every imaginable health-harming social problem – from poor housing to debt, to unfairly withheld medical services. To optimise population health, reduce health inequalities and relieve the crisis in primary care, something more than increased expenditure on treating disease is needed. The need is for a truly strategic approach addressing all the social causes of health problems.[ref] The Health Foundation. 2017. Healthy Lives for people in the UK, p12. [/ref]

The Labour government’s talk of making a “pivot” towards prevention in the NHS could be taken as a nod in that direction. But many other governments have made similar noises before. If this is to become a real shift backed by serious interventions and a suitably rewired health service – the sort of shift that might stand a real chance of making the health service work better – then the law and justice system will need to be a big part in making it happen.

The Nuffield Foundation has commissioned this project, but the views expressed are those of the authors and not necessarily the Foundation.