An initiative is enabling people to improve their health by working with doctors to address unpaid fines
A NSW initiative is enabling people to improve their health by working with doctors to address debts from unpaid fines
Sometimes supporting people with their health needs requires a bit of lateral thinking. The NSW Work and Development Order scheme is one such example.
When thinking about “good guys” in the health system, State Debt Recovery isn’t one that immediately springs to mind. Neither may be the Department of Justice. But in NSW, these organisations have joined up with Legal Aid NSW and the Aboriginal Legal Service (NSW/ACT) to partner with doctors, and other health and service sector professionals, in an innovative program. And it’s changing peoples’ lives.
Established as a pilot between 2009 and 2011, the Work and Development Order scheme aimed to assist eligible people experiencing disadvantage to address their fines debt. It is a world-first approach focused on pragmatics and compassion – much in the same way as harm-minimisation programs such as needle and syringe exchanges are. And the program focuses on assisting rather than punishing vulnerable people struggling with a significant burden.
The key concept is to enable eligible people to work off their fines debt by participating in activities that will enhance their health. This may be through supported participation in unpaid work, or courses or treatment programs, by pairing with an approved organisation or health practitioner.
To be eligible, a person has to have either a mental illness, an intellectual disability or cognitive impairment, a serious addiction to drugs, alcohol or volatile substances, be homeless, or be experiencing acute economic hardship.
By linking up with an approved Work and Development Order provider (or sponsor), people can participate in activities based on their needs. These include: undertaking unpaid work in organisations such as a local recycling centre, landcare group, or charity; participating in a medical-treatment plan such as diabetes management or mental-health care; doing a literacy-skills course or engaging in financial counselling; completing drug or alcohol treatment; or undertaking structured mentoring.
Fines are worked off at different rates depending on the activity. For example, unpaid work reduces the debt by $30 for every hour worked. A medical or mental health treatment plan reduced the debt by up to $1000 a month, as long as the patient complies with the plan.
And the program took off.
By late 2011, the program was permanently instituted and rapidly grew. In the five years since, over 50,000 orders have been approved, with more than $60 million in fines debt being cleared. There are now over 1755 approved sponsor locations, made up of 805 not-for-profit organisations, 701 individual health practitioners, and 249 government services. Sponsors are located in NSW, Victoria, Queensland, and the ACT, although a person has to have fines debt accrued in NSW to be eligible.
A particular strength of the Work and Development Order program has been its successful partnering with Aboriginal services. Around 22% of current WDO participants are Aboriginal.
Such has been the success of the scheme in NSW, Victoria is now introducing its version called the Work and Development Permit scheme. And other states are investigating options to introduce similar models.
BREAKING THE CYCLE
“The ability for clients to undertake activities to work towards satisfying their debt is motivating… It’s a double win for the client. They get to work off their debt without being further financially compromised and they are more receptive to valuable interventions to address their significant barriers.”
– Work and Development Order provider
The most recent evaluation of the scheme by sponsors indicate significant benefits.
- 95% reported that Work and Development Orders reduce the level of stress and anxiety their clients feel about their fines debt
- 87% said the orders enabled their clients to address the factors that made it hard for them to pay or manage their debts in the first place
- 88% said they helped clients develop new skills and experience
- 86% felt that the orders improved client motivation to stay engaged with services and treatment
Also, 70% of sponsors had recognised the value of incorporating the orders into their regular operations. By increasing understanding of how fines debt further entrenched disadvantage, many of the participating organisations and individual service providers now ask their patients and clients about fines in their regular intake processes. This approach has been greatly appreciated by service users who may not have been aware of the scheme. And it gives service providers and health professionals an additional tool to assist their clients and patients.
Work and Development Order sponsors also reported that the option of an order provided a tool of engagement – an incentive – for their clients and patients, who might otherwise be reluctant to engage in counselling or treatment. A Work and Development Order was also an effective means of building rapport and develop trust, and improved peoples’ self-esteem and feelings of self worth.
People with a significant illness, disability, addiction, homelessness or economic hardship are often already trying to manage complex lives. The added burden of a fines debt can increase stress, which only exacerbates any health problems, and decreases their capacity to effectively engage in their lives and broader society.
This compounds an already reduced sense of self and results in yet more marginalisation in a downward spiral that the Work and Development Order scheme seeks to arrest. The program provides the opportunity to break this cycle through supported engagement in needed activities that genuinely improve wellbeing. The program also reinforces the profound link between legal needs and health outcomes. And offers doctors, along with other service sector professionals, a practical way of engaging with and addressing this complicated interrelationship.
WHERE DO GPs FIT IN?
Work and Development Orders and doctors are a great combination. Doctors see a significant number of people struggling under the weight of their complex lives. And we do not always feel equipped to assist patients with the wider, upstream, contributing factors that adversely affect their health.
Although health professionals have engaged as approved Work and Development Order providers, the number of GPs is still relatively small. Under the scheme, a health provider needs to be either a registered psychologist, registered nurse or medical practitioner. Increased awareness of the program and its benefits among GPs will hopefully assist increased uptake. Given the adverse health consequences experienced by people with legal problems – a significant aspect of which is unpaid fines – the benefits of the program are a win-win for GPs and their patients.
The Work and Development Order scheme is well-supported by a user-friendly online process. By negotiating the best option for patients under the program, a GP can offer patients an extra, and highly valued, incentive to stay engaged in their health care.
The patient receives the triple benefit of having an additional incentive to complete a needed health management plan, clearing their fines debt if they do, and reducing stress and increasing self-worth. And the GP has another means of encouraging and supporting patient engagement and participation in co-ordinated and ongoing healthcare that directly benefits the patient.
Because unpaid fines can lead to a driver’s licence suspension or car registration cancellation, participating in a Work and Development Order can also give a patient back their independence. This is a particularly significant benefit for people who live rurally and/or for those needing to use a car to take kids to school or get to work (or even keep a job where a licence is a prerequisite). Once a Work and Development Order is approved, all enforcement action stops and licence sanctions are lifted.
It is not necessary to prove that the person’s disability, impairment, illness, homelessness or hardship contributed to the person incurring the fine or penalty notice. However, where an application is made on the grounds of intellectual disability, cognitive impairment, mental illness, personality disorder or serious addiction to drugs, alcohol or volatile substances, the application should indicate that, in the view of the approved person, the person’s condition:
- Has contributed, or is contributing, to the person’s inability to pay the fine, or
- Because of the person’s condition, it is more appropriate for the person to undertake the work or activities proposed rather than pay the fine.
Work and Development Orders are an effective means of engaging some of our most vulnerable patients in treatment and support programs. Sometimes it is not medicine per se that best assists our patients, but rather finding ways to help them with their “whole health” needs.
Work and Development Orders enable doctors to do the job they are already doing with patients but with the benefit of additional gains for the patient. These gains are often critical to helping a vulnerable patient moving from a disempowered position to one where they can regain not just their physical health, but a sense of dignity, and control over, their lives.
And, when it comes to supporting patients with their healthcare, the orders brilliantly demonstrate how a carrot is much more effective than a stick.
Dr Ursula King is Medical Editor, The Medical Republic, and rural emergency practitioner (FACRRM)
References:
http://www.legalaid.nsw.gov.au/what-we-do/civil-law/work-and-development-order-service
