Early impacts of Universal Credit: the tip of the iceberg?
Authors: Peter Craig, Srinivasa Vittal Katikireddi
Journal: The Lancet Public Health (2020)

Welfare systems are a fundamental determinant of population health and health inequalities, in high and low-income countries alike. They account for a substantial share of public expenditure,1EurostatGovernment expenditure on social protection.https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20190319-1Date accessed: February 7, 2020Google Scholar so their evaluation is an important focus for public health research. In addition to the adequacy of income transfers, aspects of administration and delivery, such as how claims are assessed, benefits are paid, and what conditions or sanctions are imposed, may also be important for health and wellbeing. Since 2012, the UK has been involved in a wholesale transformation of its welfare system, with the aim of removing the poverty and employment traps that hinder paid employment. Six existing benefits and tax credits for working age people have been combined into one, and substantial changes made to claiming and payment processes. The Department for Work and Pensions (DWP), the UK Government department that administers Universal Credit, has its own programme of evaluation. Although the 2012 Welfare Reform Act, which led to the new system, included provisions to enable randomised trials, these powers have only been used to evaluate variations in administration, such as how much support claimants receive with job-seeking,2Department for Work and PensionsUniversal credit: in work progression randomised controlled trial.https://www.gov.uk/government/publications/universal-credit-in-work-progression-randomised-controlled-trialDate: Oct 11, 2019Date accessed: February 4, 2020Google Scholar without any assessment of health impacts. However, there have been numerous reports of hardship associated with the transition to Universal Credit, from a variety of sources.3Statement on Visit to the United Kingdom, by Professor Philip Alston, United Nations Special Rapporteur on extreme poverty and human rights.https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=23881&LangID=EDate: Nov 16, 2018Date accessed: February 4, 2020Google Scholar, 4House of Commons Work and Pensions Select CommitteeUniversal Credit should "come with a health warning".https://www.parliament.uk/business/committees/committees-a-z/commons-select/work-and-pensions-committee/news-parliament-2017/universal-credit-chairs-comments-17-19/Date: July 23, 2019Date accessed: February 4, 2020Google Scholar, 5StepchangeProblem debt and the social security system.https://www.stepchange.org/policy-and-research/social-security-report.aspxDate: January, 2020Date accessed: February 4, 2020Google Scholar, 6Sosenko F Littlewood M Bramley G et al.State of hunger. A study of poverty and food insecurity in the UK.https://www.stateofhunger.org/wp-content/uploads/2019/11/State-of-Hunger-Report-November2019-Digital.pdfDate: November, 2019Date accessed: February 4, 2020Google Scholar The Government's response to such reports has been to emphasise the success of Universal Credit in encouraging unemployed people to return to work sooner. Sophie Wickham and colleagues' analysis7Wickham S Bentley L Rose T Whitehead M Taylor-Robinson D Barr B Effects on mental health of a UK welfare reform, Universal Credit: a longitudinal controlled study.Lancet Public Health. 2020; 5: e157-e164Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar of the effects of Universal Credit on unemployed recipients' mental health, using data from Understanding Society, a large, nationally representative longitudinal survey, is therefore an important and timely contribution to the debate. Universal Credit is being rolled out in a phased way, which lends itself to a natural experimental evaluation. Between 2013 and 2018 newly unemployed claimants received either Universal Credit or one of the former benefits depending on where they made their claim. Wickham and colleagues were able to compare unemployed survey respondents who might become exposed to Universal Credit at the time of their interview with respondents in the same areas who were in other employment situations (eg, employed, self-employed, retired). They find an 6·6 percentage point (95% CI 1·7–11·4) increase in psychological distress in the unemployed group, following exposure to Universal Credit, relative to their comparison group. Extensive testing of the assumptions underpinning this kind of difference-in-difference approach suggests that the findings represent an effect of exposure to Universal Credit rather than a reflection of differences between the two groups in other characteristics that may be associated with mental health problems. The finding of increased psychological distress, using a validated and widely used measure of mental health problems, is consistent with a recent study8Williams E Unemployment, sanctions and mental health: the relationship between benefit sanctions and antidepressant prescribing.J Social Policy. 2019; (published online Oct 25.)DOI:10.1017/S0047279419000783Crossref Scopus (2) Google Scholar analysing the effects of the sanctions regime introduced by the 2012 Welfare Reform Act on prescriptions for antidepressants and other research on the impacts of reforms targeted at lone parents.9Katikireddi SV Molaodi OR Gibson M Dundas R Craig P Effects of restrictions to Income Support on health of lone mothers in the UK: a natural experiment study.Lancet Public Health. 2018; 3: e333-e340Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar Several mechanisms might explain these adverse effects on mental health, including loss of income (there is a 5-week delay in the payment following a new claim), stress associated with negotiating the claims process, or the uncertainty created by sanctions and the strict conditions applied to eligibility for the benefit. There was little scope to explore such mechanisms in the present study, given the constraints of sample size and exposure data available in a survey with a much broader remit. Nevertheless, the findings have important policy implications. Universal Credit may be unique to the UK, but many of its features are common to welfare reforms in other countries, so Wickham and colleagues' findings have much wider implications for how welfare changes are evaluated; an exclusive focus on employment-related outcomes is clearly no longer adequate. Policymakers must take seriously the health effects of reforms of the kind associated with Universal Credit, which newly expose a large swathe of the population to an unfamiliar regime of sanctions and conditionality and to a claim process that for many is worryingly opaque and uncertain. So far, Universal Credit has been applied only to new claims from unemployed people. Although the timetable is evolving, over the next few years an estimated 5·5 million recipients of existing benefits and tax credits are due to be migrated to the new system.10Social Security Advisory CommitteeThe Draft Universal Credit (Managed Migration) Regulations.https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/753714/draft-universal-credit-managed-migration-regulations-2018-report.pdfDate: 2018Date accessed: February 17, 2020Google Scholar The impacts of this transition must be evaluated comprehensively and rigorously, using methods that can precisely identify the mechanisms by which effects occur, and the distribution of benefits and harms, as well as estimate overall costs and consequences. Universal Credit itself may be too big to fail11National Audit OfficeRolling out Universal Credit.https://www.nao.org.uk/report/rolling-out-universal-credit/Date: June 15, 2018Date accessed: February 4, 2020Google Scholar but there is much that can be done to mitigate the harms and enhance the positive impacts. Wickham and colleagues have provided an early indication of the potential impacts, but the legacy of the broader Universal Credit programme remains to be discovered. PC and SVK acknowledge funding from the Medical Research Council ( MC_UU_12017/13 and MC_UU_12017/15 ) and the Scottish Government Chief Scientist Office ( SPHSU13 and SPHSU15 ). SVK also notes funding from a NRS Senior Clinical Fellowship ( SCAF/15/02 ). We declare no other competing interests. Effects on mental health of a UK welfare reform, Universal Credit: a longitudinal controlled studyOur findings suggest that the introduction of Universal Credit led to an increase in psychological distress, a measure of mental health difficulties, among those affected by the policy. Future changes to government welfare systems should be evaluated not only on a fiscal basis but on their potential to affect health and wellbeing. Full-Text PDF Open Access