Stephanie Morris

We provide new evidence on the mental health and healthcare utilisation impacts of the roll-out of Universal Credit, one of the most significant welfare reforms in Europe in recent decades. Designed to simplify the benefit system and strengthen work incentives by merging six means-tested programmes into a single payment, Universal Credit also introduced features that may adversely affect mental health. Exploiting the plausibly exogenous, staggered geographical introduction of Universal Credit across England between 2013 and 2018, we implement a difference-in-differences design using comprehensive small-area administrative data on clinically recorded mental health and related healthcare utilisation. We find adverse effects of Universal Credit exposure on population mental health: a 0.10 standard-deviation increase in clinically diagnosed depression prevalence and a 0.06 standard-deviation rise in antidepressant prescribing, alongside a smaller 0.03 standard-deviation increase in mental health-related hospital admissions and attendances. In natural units, these correspond to approximately 113,742 additional cases of diagnosed depression, 29,993 extra hospital admissions and attendances, and 1.29 million additional antidepressant prescriptions annually by 2018. Results are robust across specifications, sensitivity analyses, spatial aggregation, and alternative estimators. Because outcomes are measured at the small-area level, our estimates capture population-wide effects that combine direct impacts on Universal Credit recipients with spillovers to non-recipients. Indicative valuations imply sizeable associated quality-of-life losses and direct healthcare costs of approximately £2.84 billion per year. These findings show that welfare reforms can generate substantial mental health externalities, and that the health and healthcare-system consequences of social policy belong squarely within its design and evaluation.

We provide new evidence on the mental health and healthcare utilisation impacts of the roll-out of Universal Credit, one of the most significant welfare reforms in Europe in recent decades. Designed to simplify the benefit system and strengthen work incentives by merging six means-tested programmes into a single payment, Universal Credit also introduced features that may adversely affect mental health. Exploiting the plausibly exogenous, staggered geographical introduction of Universal Credit across England between 2013 and 2018, we implement a staggered difference-in-differences design using comprehensive small-area administrative data on clinically recorded mental health and related healthcare utilisation. We find substantial adverse effects of Universal Credit exposure: a 0.10 standard-deviation increase in clinically diagnosed depression prevalence, a 0.03 standard-deviation increase in mental health-related hospital admissions and attendances, and a 0.06 standard-deviation rise in antidepressant prescribing. In natural units, these correspond to approximately 113,742 additional cases of diagnosed depression, 29,993 extra hospital admissions and attendances, and 1.29 million additional antidepressant prescriptions annually by 2018. Results are robust across specifications, sensitivity analyses, spatial aggregation, and alternative estimators. Because outcomes are measured at the small-area level, our estimates capture population-wide effects that combine direct impacts on Universal Credit recipients with spillovers to non-recipients. Indicative valuations imply sizeable associated quality-of-life losses and direct healthcare costs of approximately £2.84 billion per year. These findings highlight that welfare reforms can generate substantial mental health externalities and underscore the importance of incorporating health and healthcare system consequences into social policy design and evaluation.

Universal Credit radically changes the welfare system for working age adults in the UK. Although aiming to simplify the benefit system, its implementation has been widely criticised and the rollout beset with difficulties and delays, negatively affecting the lives of many claimants. Drawing on findings from a qualitative study of Universal Credit claimants and staff supporting them in North East England, we critically reflect on the process of co-producing a play for a public audience with Cap-a-Pie theatre company, artists, public partners, voluntary and community sector organisations and academics. We draw on reflections from stakeholders involved in the creative process and audience members’ responses to a filmed reading of extracts from the play. We explore the pitfalls, setbacks and successes of co-producing a theatre performance to communicate research findings and inform and enrich public discourse about Universal Credit. The arts are a vital part of the public health landscape, but the potential utility of theatre remains underexplored as a tool to stimulate debate about the effects of welfare reform. We aim to contribute to debates about the challenges of co-production and social value of using arts-based methods in public health to address inequalities and promote social justice. We explore the extent to which collaborations between researchers, public, policy and practice partners, and theatre makers can raise awareness of the effects of Universal Credit, challenge negative attitudes about Universal Credit claimants, and stimulate debate about the adequacy of social security in the UK.

Background: Link worker social prescribing enables health-care professionals to address patients’ non-medical needs by linking patients into various services. Evidence for its effectiveness and how it is experienced by link workers and clients is lacking. Objectives: To evaluate the impact and costs of a link worker social prescribing intervention on health and health-care costs and utilisation and to observe link worker delivery and patient engagement. Data sources: Quality Outcomes Framework and Secondary Services Use data. Design: Multimethods comprising (1) quasi-experimental evaluation of effects of social prescribing on health and health-care use, (2) cost-effectiveness analysis, (3) ethnographic methods to explore intervention delivery and receipt, and (4) a supplementary interview study examining intervention impact during the first UK COVID-19 lockdown (April–July 2020). Study population and setting: Community-dwelling adults aged 40–74 years with type 2 diabetes and link workers in a socioeconomically deprived locality of North East England, UK. Intervention: Link worker social prescribing to improve health and well-being-related outcomes among people with long-term conditions. Participants: (1) Health outcomes study, approximately n = 8400 patients; EuroQol-5 Dimensions, five-level version (EQ-5D-5L), study, n = 694 (baseline) and n = 474 (follow-up); (2) ethnography, n = 20 link workers and n = 19 clients; and COVID-19 interviews, n = 14 staff and n = 44 clients. Main outcome measures: The main outcome measures were glycated haemoglobin level (HbA_1c; primary outcome), body mass index, blood pressure, cholesterol level, smoking status, health-care costs and utilisation, and EQ-5D-5L score. Results: Intention-to-treat analysis of approximately 8400 patients in 13 intervention and 11 control general practices demonstrated a statistically significant, although not clinically significant, difference in HbA_1c level (–1.11 mmol/mol) and a non-statistically significant 1.5-percentage-point reduction in the probability of having high blood pressure, but no statistically significant effects on other outcomes. Health-care cost estimates ranged from £18.22 (individuals with one extra comorbidity) to –£50.35 (individuals with no extra comorbidity). A statistically non-significant shift from unplanned (non-elective and accident and emergency admissions) to planned care (elective and outpatient care) was observed. Subgroup analysis showed more benefit for individuals living in more deprived areas, for the ethnically white and those with fewer comorbidities. The mean cost of the intervention itself was £1345 per participant; the incremental mean health gain was 0.004 quality-adjusted life-years (95% confidence interval –0.022 to 0.029 quality-adjusted life-years); and the incremental cost-effectiveness ratio was £327,250 per quality-adjusted life-year gained. Ethnographic data showed that successfully embedded, holistic social prescribing providing supported linking to navigate social determinants of health was challenging to deliver, but could offer opportunities for improving health and well-being. However, the intervention was heterogeneous and was shaped in unanticipated ways by the delivery context. Pressures to generate referrals and meet targets detracted from face-to-face contact and capacity to address setbacks among those with complex health and social problems. Limitations: The limitations of the study include (1) a reduced sample size because of non-participation of seven general practices; (2) incompleteness and unreliability of some of the Quality and Outcomes Framework data; (3) unavailability of accurate data on intervention intensity and patient comorbidity; (4) reliance on an exploratory analysis with significant sensitivity analysis; and (5) limited perspectives from voluntary, community and social enterprise. Conclusions: This social prescribing model resulted in a small improvement in glycaemic control. Outcome effects varied across different groups and the experience of social prescribing differed depending on client circumstances. Future work: To examine how the NHS Primary Care Network social prescribing is being operationalised; its impact on health outcomes, service use and costs; and its tailoring to different contexts. Trial registration: This trial is registered as ISRCTN13880272. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme, Community Groups and Health Promotion (grant no. 16/122/33) and will be published in full in Public Health Research; Vol. 11, No. 2. See the NIHR Journals Library website for further project information.

Introduction The UK social security system is being transformed by the implementation of Universal Credit (UC), which combines six existing benefits and tax credits into a single payment for low-income households. Despite extensive reports of hardship associated with the introduction of UC, no previous studies have comprehensively evaluated its impact on mental health. Because payments are targeted at low-income households, impacts on mental health will have important consequences for health inequalities. Methods and analysis We will conduct a mixed methods study. Work package (WP) 1 will compare health outcomes for new recipients of UC with outcomes for legacy benefit recipients in two large population surveys, using the phased rollout of UC as a natural experiment. We will also analyse the relationship between the proportion of UC claimants in small areas and a composite measure of mental health. WP2 will use data collected by Citizen’s Advice to explore the sociodemographic and health characteristics of people who seek advice when claiming UC and identify features of the claim process that prompt advice-seeking. WP3 will conduct longitudinal in-depth interviews with up to 80 UC claimants in England and Scotland to explore reasons for claiming and experiences of the claim process. Up to 30 staff supporting claimants will also be interviewed. WP4 will use a dynamic microsimulation model to simulate the long-term health impacts of different implementation scenarios. WP5 will undertake cost–consequence analysis of the potential costs and outcomes of introducing UC and cost–benefit analyses of mitigating actions. Ethics and dissemination We obtained ethical approval for the primary data gathering from the University of Glasgow, College of Social Sciences Research Ethics Committee, application number 400200244. We will use our networks to actively disseminate findings to UC claimants, the public, practitioners and policy-makers, using a range of methods and formats. Trial registration number The study is registered with the Research Registry: researchregistry6697.