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Podcast series from the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
Alastair Leyland:
Hello and welcome to 15 Minutes on Health Inequalities. Today our podcast is about evaluating the mental health impacts of Universal Credit. My name is Alastair Leyland, I'm at the MRC/CSO Social and Public Health Sciences Unit at the University of Glasgow. And with me today is.
Anna Pearce:
Anna Pearce, also from the Social and Public Health Sciences Unit.
Peter Craig:
And Peter Craig, I'm part of the team that's carrying out this evaluation of universal credit.
Alastair Leyland:
Thanks for coming. Peter. I wonder if you could start by explaining what Universal Credit is and what it's replacing.
Peter Craig:
Well universal credit’s a benefit for working age people. It was introduced under the 2012 Welfare Reform Act and it replaces six existing benefits and tax credits, things like job seekers allowance, the working tax credit and the child tax credit and housing benefit. And these benefits are collectively known as legacy benefits and the basic aim of Universal Credit is to encourage recipients to return to work by providing support and encouragement for job seeking, and by removing some of the disincentives that were there in the legacy benefits system because benefits were withdrawn very sharply as people increased their hours of work. And Universal Credit is supposed to smooth that out so that people don't lose so much. And it's being implemented in phases. Universal credit’s roll that area by area. It started with new claims for benefit by unemployed people and more recently, a process of what's called managed migration has started. And this is the transfer of existing claims for legacy benefits onto the new system. The whole process began in 2013. It was interrupted by the pandemic, but it's begun again and it's now expected to be complete by 2024.
Alastair Leyland:
OK, what aspects of Universal Credit are you evaluating?
Peter Craig:
Well, we'll be comparing the health of people receiving Universal Credit with the health of people receiving legacy benefits, and we'll be looking at the overall effects on health. But importantly, we're also trying to identify which features of Universal Credit are associated with better or worse health outcomes. So, we'll be asking people directly about their experiences of claiming Universal Credit and how they're managing while they're receiving the benefit. And on top of that, we'll be doing some simulation modelling and economic evaluation work to explore the implications of what would happen if we modify the policy. For example, by changing the amounts paid or the eligibility conditions or the way it's paid to people and so on.
Anna Pearce:
Thanks, Peter. So can you tell us why is it important to evaluate this?
Peter Craig:
Well, it's very broad because we know that income matters for health through its effects on living standards and you know, the ability of people to maintain a healthy lifestyle. But we also think that the way people obtain their income is important as well as the actual amount of income they have. So, income and benefits isn't necessarily seen by people in the same way as income from work is, and a stable income maybe more valuable to people than an uncertain one. Benefits can be managed in a way that either supports claimants, helps them to find work, or in a way that they find stressful or demeaning or difficult to manage. We are the first people to look at the effects of Universal Credit on health and there have already been a number of studies, including some by members of our team. And there’s been lots of other reports based on the experiences of claimants. And together these studies suggest that Universal Credit may have harmful effects on people's health. You know, some people find the process of claiming or meeting the entitlement conditions difficult or experience hardship for other reasons. What we want to do in our new study is to take a comprehensive look at the impact of Universal Credit on mental health across several years of the implementation process. And we also want to identify, you know, which specific features of the process of claiming or living on the benefit are associated with better or worse mental health or wellbeing amongst the recipients.
Anna Pearce:
OK. And why concentrate on mental health in particular?
Peter Craig:
Well, because we think these are the aspects of health that are most sensitive to change in the relatively short term as a result of the experience of claiming or living on Universal Credit. But in the qualitative study, we'll be able to look at other aspects of health that recipients themselves identify as important.
Alastair Leyland:
You've published a protocol for your evaluation and from that I can see there are several different components in it. Could you start by telling us about your comparison between the new recipients of Universal Credit and those on these legacy benefits?
Peter Craig:
Yes. So, we're treating the implementation of Universal Credit as a natural experiment. In other words, we're assuming that the phased approach to implementation that I mentioned will create broadly comparable groups of people who are receiving either the new benefit, Universal Credit, or one of the legacy benefits, depending whether they live in an area where Universal Credit has been implemented. And fortunately for us, the DWP publishes detailed information on the rollout process and we can combine this information on implementation with information that we can get from long running population surveys on people's health to compare changes in health amongst people who are getting Universal Credit with changes amongst people who remain on the legacy benefits. Obviously there's some quite strong assumptions involved here, but we can use other information from the surveys to test whether these groups are comparable and also whether the rollout process is effectively random. And even if these conditions aren't met, then there are some adjustments we can do using the survey data to make the comparisons more balanced. And that means that differences in health that we see between Universal Credit recipients and the people on legacy benefits in these adjusted comparisons can be attributed to the experience of receiving Universal Credit.
Alastair Leyland:
Just to follow up on that, is there an issue that any change could be disruptive and cause problems? So, the people on Universal Credit are changing and the people on legacy benefits aren't. So will you be able to look at that?
Peter Craig:
Yes, to some extent. So that we can look at the effects of Universal Credit in the few months after people have moved on to that, but then we can look at how their health changes over subsequent months or years post receipt, using later waves of the surveys that we’re using.
Anna Pearce:
What are you expecting to find when you look at the features of Universal Credit that are associated with health difficulties?
Peter Craig:
Well, I mentioned that a number of studies have already been done and several features of Universal Credit have been picked out in this research as possibly causing difficulties for some claimants. The five week wait for the first payment of benefits is one that often comes up, though loans are often made to bridge the gap. These loans have to be repaid through deductions from benefit payments later, which further reduces the amount of money that people have to live on and that's been quite controversial. Job search requirements that many Universal Credit claimants have to satisfy are thought to be more demanding than the requirements under the legacy system, and sanctions that are imposed when people, you know, fail to comply with these requirements, you know, can lead to further reductions in in benefits income. So, these are some of the things that we'll be looking at. Another feature of the new system is the online claims process, which you know, some people may find difficult to navigate without support, or they may find it hard to access support when they're claiming the benefits. We'll be looking at that as well. I mean, one issue that's already emerging from the qualitative interviews that we were doing last year is the effects of the cost of living crisis, you know, especially over the last few months. And this is obviously something that impacts most heavily on people on the lowest incomes. But it's important to bear in mind that experiences are likely to vary across the whole population of benefit recipients. Universal Credit’s meant to help people move into employment, and we're certainly finding in our interviews that that some recipients find the online process straight forward and that they really value the help that they're getting from their advisors in the DWP. And so we're interested in how experiences vary between different groups of claimants, such as young parents and couples, for example. When we design the qualitative study, and as we've been recruiting participants for it, we've been very careful to try and recruit them from a wide range of sources, not just from advice agencies where people might go when they’re having difficulty with their claim. And this is so that we can capture the widest possible range of experiences.
Alastair Leyland:
Yeah, interesting. You're looking at how claiming and managing Universal Credit might affect claimants’ health. What kind of health effects are you looking for and why might those differ from those claiming the legacy benefits?
Peter Craig:
As I mentioned, we're conducting qualitative interviews with Universal Credit recipients. We'll be doing these in the north of England and in Glasgow. We're using these to understand their experiences of claiming and living on Universal Credit, and these interviews are exploratory. So that interviewees can talk about the things that are most salient for them. Obviously, we've been guided by previous studies and what they found about sort of living on Universal Credit. And we've also been guided by talking to our public involvement and engagement partners and deciding where to start with these interviews. Though, importantly, the qualitative studies and the longitudinal one we’ll be reinterviewing some of the respondents a year or so after we first spoke to them to get a picture of how their experiences changed over the time. And we'll also be speaking to advice workers and frontline staff, we hope, from DWP job centres to get their perceptions as well. So, as with the quantitative study, we'll be focusing on mental health to begin with, but hopefully we'll be able to pick up effects on other aspects of people's health if respondents raise those things.
Anna Pearce:
Can you tell us a bit more about the modelling work you'll be doing and what are you looking for from this component?
Peter Craig:
So the plan is to develop something called a dynamic microsimulation model. We'll be basing our model on an existing income and welfare policy model, but we'll be adding in estimates of the relationship between Universal Credit receipt, recipients’ income, their employment and their health. And we'll use this model to try and simulate the effects on health of alternative implementation scenarios for Universal Credit. And we'll be comparing what happens under these scenarios with what we would expect to happen if we continue with legacy benefits or if we continued with Universal Credit as it's actually implemented. And so these alternative scenarios will include things like, you know, higher or lower levels of benefit, more or fewer deductions from benefits and so on. And so, under each of these scenarios, what we do is we take a synthetic population that matches the Great Britain population and we use the model to move it forward in in one year steps for up to 10 years so that we can compare the effects on health and health inequalities of the different policy choices as they evolve over this period.
Alastair Leyland:
The last component you have is health economics. What are you investigating in this and why?
Peter Craig:
Well we’ll be doing two different kinds of economic evaluation. One's a kind of retrospective evaluation using an approach known as cost consequence analysis. And in this piece of work, we'll be comparing the costs and consequences of implementing Universal Credit against the cost and consequences of staying on the legacy benefits. And the advantage of using this kind of approach is that we can include a very wide range of outcomes, whether or not we can express them in in monetary terms, so we'll be looking at things like and health and well-being, income, employment, economic productivity, use of health and care services and so on. But we'll also do a second kind of study, a prospective study. And this will be a cost benefit analysis of measures that might be taken to mitigate any of the health harms that we identify as being associated with Universal Credit. And we'll be using the same 10-year time frame in this prospective study as we are for the modelling study.
Anna Pearce:
And when are you likely to have results?
Peter Craig:
Well, we already have some. We've got some results from a work package or part of the study that looked at changing patterns of advice seeking connection and Universal Credit claims. And we've got some early findings from our first round of quantitative interviews as well. The advice seeking results are already available as a preprint, and we just sent in corrections for a journal paper that should be out very soon. Early in January, as it happens, we presented some of the findings from the first round of qualitative interviews and we did this to policymakers and analysts at the DWP. And we’ve also published a paper about our approach to engaging benefit recipients in the study. So, we're already on track but it's still early day.
Anna Pearce:
Oh I hope you'll come back and tell us more about the results when the work’s a bit further along.
Peter Craig:
Well, I'd be glad to ideally with other members of the team who can talk in much more detail about some of the subtleties of the qualitative research and the modelling and so on. But I should say now that as well as publishing the findings in journal articles and reports as we go along, we’ll be presenting them back to claimants and to people who support Universal Credit claimants, for example, advice workers and so on, and also to policymakers and analysts in governments. Right from the start of the study, right from the planning stage, we've been trying to work closely with claimants and claimant organisations. They've been helping us. for example, to make sure that we ask the right questions in our qualitative study. And we also have representatives of the Citizens Advice Network, Child Poverty Action Group and the DWP on the advisory group for the studies. So, we’re well linked in with people who are directly involved with these benefits, and we'll be using that for the dissemination of the findings as well.
Alastair Leyland:
Great. As you'll know, we always ask what implications this work has for health inequalities.
Peter Craig:
Well, universal credits are means tested benefit, so by definition claimants are people on relatively low incomes and this means that the policies that affect their health will have a relatively large impact on health inequalities. Much more so than policies that mainly affect the health of people on more or less average incomes. And in the cost consequence parts of the economic evaluation that I was speaking about, we’ll be comparing the distribution effects of UC with the distribution effects of the legacy benefits. So, we will be looking explicitly at implications for health inequalities. Another thing that's important to remember is that very large numbers of people rely on Universal Credit. In March 2021, for example, there were over 5,000,000 households receiving Universal Credit. So that, even if the effects that we find are quite small at an individual level, they can add up to a very substantial effect on population health and on health inequalities across the whole population.
Alastair Leyland:
OK. Do you think that policy could change as a result of this? Will you be able, for example, to propose alternatives?
Peter Craig:
Well, the policy certainly can change and big changes were introduced at the start of the pandemic. Although many of them have now been reversed. Clearly there could be further changes in the future. Whether they're likely or not is a political question and so that's hard to speculate about. And in our study, we'll be looking at the kinds of changes that are likely to have the greatest health benefit. And I should perhaps say that you know the question we're interested in is not really whether there should be Universal Credit or nothing. I mean the key question is that you know, given that in the UK, as in most of the high-income countries, you know, we do have income related benefits. The question we want to ask is how can such benefits be designed and implemented in ways that improve rather than harm health, while meeting their other aims, such as helping people to find work or preventing poverty. So, in our modelling work and in the economic evaluation work, we'll be aiming to provide policymakers with really quite detailed evidence about the health implications of changes that they might make to the delivery of Universal Credit or to the design of the benefit. And of course, all our findings will be available freely to anybody who wants to use them to get involved in the debate about the future of Universal Creidt.
Anna Pearce:
Right. Well, I think that's us. So, just to finish by saying thank you, Peter, for joining us today. Thanks to everyone listening. You can find the link to the project called paper that we've been discussing today in the podcast notes. These and other podcasts in our series can be found on the major platforms by searching for 15 Minutes on Health Inequalities.